微创和传统切开复位内固定治疗桡骨远端不稳定骨折的疗效比较

Effectiveness comparison between minimally invasive surgery and traditional open reduction internal fixation in treatment of unstable distal radial fractures

目的比较微创经皮掌侧植入和传统切开(Henry入路)复位锁定钢板内固定治疗桡骨远端不稳定骨折的临床疗效。方法将2013年10月—2014年12月收治的符合选择标准的56例桡骨远端不稳定骨折患者纳入研究,随机分为微创组(26例)和传统组(30例),分别采用微创经皮掌侧植入和传统Henry入路切开复位斜T型锁定钢板内固定治疗。两组患者性别、年龄、侧别、致伤原因、骨折分型及受伤至手术时间等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。记录两组患者切口长度、手术时间、术中出血量及住院时间、骨折愈合时间;术后3个月桡骨茎突长度、掌倾角、尺偏角与术前的差值;术后4周及3个月腕部疼痛视觉模拟评分(VAS),患侧腕关节屈伸范围、前臂旋转范围及握力占健侧的百分比(分别记为FS%、FR%和HG%);术后3个月采用上肢功能评定表(DASH)评分评价腕关节功能。结果微创组患者切口长度、手术时间、术中出血量及住院时间均显著优于传统组(P<0.05)。两组患者术后切口均Ⅰ期愈合。患者均获随访,随访时间10~16个月,平均12.6个月。两组均无桡动脉损伤、螺钉过长或进入关节间隙发生。微创组1例术后发生正中神经一过性刺激症状,1个月后完全恢复;传统组2例术后出现肌腱刺激疼痛症状,取出钢板后缓解。两组骨折愈合时间及手术前后桡骨茎突长度、掌倾角及尺偏角差值比较,差异均无统计学意义(P>0.05)。术后4周微创组VAS评分明显低于传统组,FS%、FR%、HG%明显高于传统组,差异均有统计学意义(P<0.05);而术后3个月两组间上述指标比较,差异均无统计学意义(P>0.05)。术后3个月微创组DASH评分明显低于传统组,差异有统计学意义(t=–5.308,P=0.000)。患者对术后切口美观感评价微创组明显优于传统组。结论微创经皮掌侧植入锁定钢板治疗桡骨远端不稳定骨折具有创伤小、切口隐蔽、腕关节功能恢复快等优点,患者易于接受。

Objective To compare the effectiveness of minimally invasive percutaneous internal fixation and traditional open reduction via Henry approach and internal fixation in the treatment of unstable distal radial fractures.Methods Fifty-six patients with unstable distal radial fractures that met the selection criteria between October 2013 and December 2014 were randomly divided into minimally invasive group（26 cases） and traditional group（30 cases）. They were treated with oblique T-shaped locking plate internal fixation via minimally invasive percutaneous approach or traditional Henry approach. There was no significant difference in gender, age, side, causes of injury, fracture classification, and time from injury to operation between 2 groups（P〈0.05）. The length of incision, operation time,intraoperative blood loss, hospitalization time, and fracture healing time were recorded in 2 groups. The difference of the length of the radial styloid process, the volar tilting angle, and the ulnar inclining angle between at 3 months postoperatively and preoperation were compared between 2 groups. The visual analogue scale（VAS） score, the percentage of the lateral wrist flexion and extension range, forearm rotation, and the hand grip strength（recorded as FS%, FR%, and HG%, respectively） were compared between 2 groups at 4 weeks and 3 months postoperatively. The wrist function was evaluated through the disability of arm-shoulder-hand（DASH） scores at 3 months postoperatively. Results The length of incision, operation time, intraoperative blood loss, and hospitalization time in minimally invasive group were significantly less than those in traditional group（P〈0.05）. The incisions of 2 groups were all achieved primary healing. All patients were followed up 10-16 months（mean, 12.6 months）. There was no radial artery injury, screw too long, or screw entering the joint space. In minimally invasive group, 1 patient had the symptoms of median nerve irritation after operation, and recovered completely at 1 month; in traditional group, there were 2 cases of tendon irritation after operation. There was no significant difference in the fracture healing time, the difference of the length of the radial styloid process, the volar tilting angle, and the ulnar inclining angle between at 3 months postoperatively and preoperation between 2 groups（P〈0.05）. At 4 weeks after operation, the VAS score in minimally invasive group was significantly less than that in traditional group, and the FS%, FR%, and HG% were significantly higher than those in traditional group（P〈0.05）. There was no significant difference in above indicators between 2 groups at 3 months after operation（P〈0.05）.The DASH score in minimally invasive group was significantly less than that in traditional group at 3 months after operation（t=–5.308, P=0.000）. The patient＇s aesthetic evaluation of postoperative wound in minimally invasive group was better than in traditional group. Conclusion For treatment of unstable distal radial fractures, the metacarpal minimally invasive internal fixation has the advantages of smaller wound, incisional concealment, and quicker recovery of wrist joint.