倒置髓内钉结合内侧微创钢板治疗C2、C3型股骨远端骨折的疗效

Efficacy analysis of inverted intramedullary nail combined with medial minimally invasive plate in treatment of type C2 and C3 distal femoral fractures

目的探讨倒置髓内钉结合内侧微创钢板固定治疗AO分型c2、c3型股骨远端复杂骨折的临床疗效。方法采用回顾性病例对照研究分析2015年1月-2017年1月收治的38例股骨远端复杂骨折患者临床资料，其中男22例，女16例；年龄24～72岁[（45．6±2．5）岁]。骨折AO分型：c2型24例，c3型14例。均为新鲜闭合性骨折。伤后至手术时间4～16d，平均7．5d。根据手术方式分为外侧股骨髁单钢板固定组（单钢板组，20例）和倒置髓内钉结合内侧微创锁定钢板固定组（锁定钢板组，18例）。比较两组手术时间、术中出血量、早期负重时间、骨折愈合时间、术后美国特种外科医院（HSS）评分、生活活动能力（Barthel指数）及术后并发症情况。结果患者均获随访10～24个月[（12．2±1．8）个月]。单钢板组手术时间为（110．5±35．4）min，锁定钢板组为（116．7±42．3）min（P〉0．05）。单钢板组术中出血量为（450．5±120．7）ml，锁定板组为（455．2±130．4）ml（P〉0．05）。单钢板组早期负重时间为（28．5±8．6）d，锁定钢板组为（18．7±4．9）d（P〈0．01）。单钢板组骨折愈合时间为（8．5±2．2）个月，锁定钢板组为（6．5±1．6）个月（P〈0．01）。术后1，6，12个月膝关节功能HSS评分，锁定钢板组明显优于单钢板组（P〈0．01）。术后6，12个月Barthel指数评分，锁定钢板组明显优于单钢板组（P〈0．01）。术后两组均未发生感染。锁定板组未发生内固定失败、膝内外翻、下肢外旋畸形或脂肪栓塞等并发症；单钢板组发生钢板断裂2例，膝关节外翻1例，膝关节内翻2例（P〈0．01）。结论与单钢板固定比较，倒置髓内钉结合内侧微创锁定钢板固定治疗AO分型c2、c3型股骨远端复杂骨折，具有负重时间早、骨折愈合率高、功能恢复好、并发症少等优点，是治疗该类型骨折较为理想的选择。

Objective To investigate the clinical efficacy of inverted intramedullary nail combined with medial minimally invasive plate in treatment of type C2 and C3 distal femoral fractures. Methods A retrospective case control study was conducted on 38 patients with complex distal fractures of the femur treated from January 2015 to January 2017. There were 22 males and 16 females, aged 24-72 years [ （45.6±2.5）years]. AO fracture classification was type C2 in 24 patients and type C3 in 14. All of them were fresh closed fractures. The time duration from injury to operation was 4-16 days （ average, 7.5 days）. Based on the different surgical methods, the patients were divided into lateral single platefixation group （single plate group, 20 patients） and inverted intramedullary nail combined with medial minimally invasive locked plate fixation group （locked plate group, 18 patients）. The two groups were compared in terms of operation condition, early weight bearing time, fracture healing time, postoperative complications, postoperative knee function and activity of living. Hospital for Special Surgery （HSS） score was used for evaluating postoperative knee function and Barthel index for activity of living. Results The patients were followed up for 10-24 months [ （ 12. 2±1. 8 ） months ]. The operation duration was （ 110.5 ± 35.4） min for single plate group and （ 116.7 ± 42.3 ） min min for locked plate group （ P 〉 0.05 ）. Intraoperative blood loss in single plate group was [ （450.5 ± 120.7 ） ml ] and [ （455.2± 130.4）ml] in locked plate group （P 〉 0.05 ）. The early weight bearing time in single plate group was （28.5± 8.6） days and 18.7 ± 4.9 （P 〈 0.01 ） days in the locked plate group. The fracture healing time in single plate group was （8.5± 2.2） months, and [ （6.5± 1.6 ） months ] in locked plate group （ P 〈 0. 01 ）. After 3 weeks, 6 months and 12 months, HSS scores of knee joint function of the locked plate group was significantly better than that of single plate group （ P 〈 0.01 ）. At 6 months and 12 months after operation, Barthel index score of locked plate group was significantly better than that of single plate group （ P 〈 0.01 ）. No infection occurred in two groups after operation. There were no complications such as internal fixation failure, knee valgus, external rotation deformity or fat embolism in locked plate group. There were two cases of internal fixation failure, one knee eversion, and two knee varus in single plate group （P 〈 0.01 ）. Conclusion Compared with single plate fixation, the therapeutic method of inverted intramedullary nail combined with medial minimally invasive locked plate has the advantages of early weight bearing time, quick recovery, better function restoration and fewer complications, and hence is a preferable choice for treatment of type C2 and C3 complex distal femoral fractures.