不同入路髓内钉内固定在胫骨骨折中应用效果的对照研究

Comparative Study on the Effect of Different Approaches of Intramedullary Nail Internal Fixation in Tibial Fractures

目的:通过对照研究探讨不同入路髓内钉内固定对胫骨骨折患者并发症、骨性标志物及预后等指标的影响,以期寻找一种更为安全有效治疗方案。方法:回顾性分析2018年2月至2020年2月我院125例胫骨骨折患者临床资料,依据治疗方案不同分为髌上组(n=63)、经髌韧带组(n=62)。经髌韧带组采取经髌韧带入路髓内钉内固定,髌上组采取髌上入路手术。比较两组围术期手术指标、并发症与术前、术后1d、3d炎症因子[白细胞介素-1β(Interleukin-1β,IL-1β)、C反应蛋白(C-reactive protein,CRP)、肿瘤坏死因子-α(Tumor necrosis factor-α,TNF-α)]、术前、术后2周、4周骨性标志物[骨钙素(Osteocalcin,BGP)、降钙素(Calcitonin,CT)、总骨Ⅰ型前胶原氨基端延长肽(Total Nterminal propeptide of type I procollagen,Total-PINP)、β-胶原降解产物(β-C-terminal telopeptide of type I collagen,β-CTX)]水平、术前、术后3个月、6个月、12个月膝关节活动度(屈膝、伸膝最大角度)、美国特种外科医院(American Special Surgery Hospital,HSS)评分系统、Johner-Wruhs评分标准(Johner wruhs scoring system,Johner-Wruhs)评分。结果:髌上组骨折愈合时间较经髌韧带组短,术中透视次数、术后3 d视觉模拟评分量表(Visual analogue scale,VAS)评分较经髌韧带组低(P<0.05);髌上组术后1d、3d血清IL-1β、CRP、TNF-α与术后2周、4周Total-PINP、β-CTX水平均低于经髌韧带组,术后2周、4周血清BGP、CT水平均高于经髌韧带组(P<0.05);髌上组术后并发症发生率为7.94%,低于经髌韧带组的22.58%(P<0.05);髌上组术后3个月、6个月、12个月屈膝、伸膝最大角度均大于经髌韧带组,HSS、Johner-Wruhs评分均高于经髌韧带组(P<0.05)。结论:应用髌上入路髓内钉内固定治疗胫骨骨折可减轻术后疼痛感,促进骨性标志物水平改善与骨折愈合,提升膝关节活动度、膝关节功能及临床功能,降低并发症,且机体炎症反应较轻,整体效果优于经髌韧带入路手术。

Objective:To explore the effects of different approaches of intramedullary nailing on complications,bone markers and prognosis of patients with tibial fracture,in order to find a safer and effective treatment.Methods:A retrospective analysis of the clinical data of 125 tibial fracture patients in our hospital from February 2018 to February 2020 was divided into suprapatellar group(n=63)and transpatellar ligament group(n=62)according to different treatment plans.The transpatellar ligament group was fixed with intramedullary nail via the transpatellar ligament approach,and the suprapatellar approach was adopted for the suprapatellar group.The perioperative indicators and complications of the two groups were compared with the inflammatory factors[Interleukin-1β(IL-1β)and C-reactive protein(C-reactive protein,CRP)before and 1 d and 3 d after the operation),tumor necrosis factor-α(Tumor necrosis factor-α,TNF-α)],bone markers[osteocalcin(BGP),calcitonin(Calcitonin,CT),Total Nterminal propeptide of type I procollagen(Total-PINP),β-C-terminal telopeptide of type I collagen(β-CTX)]levels,Knee motion(maximum angle of knee flexion and extension)before operation,3 months after operation,6 months after operation,12 months,American Special Surgery Hospital(HSS)scoring system,Johner-Wruhs scoring standard(Johner wruhs scoring system,Johner-Wruhs)scoring.Results:The fracture healing time of the suprapatellar group was shorter than that of the transpatellar ligament group,and the number of intraoperative fluoroscopy and the 3 d visual analogue scale(VAS)scores were lower than those of the transpatellar ligament group(P<0.05).The levels of serum IL-1β,CRP,TNF-αand Total-PINP andβ-CTX levels in the suprapatellar group at 1 and 3 days after operation were lower than those in the transpatellar ligament group at 2 and 4 weeks after operation.The levels of serum BGP and CT at 2 and 4 weeks after operation were higher than those in the transpatellar ligament group(P<0.05).The postoperative complication rate in the suprapatellar group was 7.94%,which was lower than 22.58%in the transpatellar ligament group(P<0.05).The maximum angles of knee flexion and extension in the suprapatellar group were higher than those in the transpatellar ligament group at 3 months,6 months,and 12 months after surgery.HSS and Johner-Wruhs scores were higher than those in the transpatellar ligament group(P<0.05).Conclusion:The suprapatella approach intramedullary nail internal fixation for tibial fractures can reduce postoperative pain,promote the improvement of bony markers and fracture healing,improve the range of motion,knee function and clinical function of the knee joint,and reduce complications.In addition,the body's inflammatory response is mild,and the overall effect is better than that of transpatellar ligament approach surgery.