三种内固定方式治疗股骨中远端内侧粉碎性骨折的疗效比较

Efficacy comparison of three different internal fixations in treating medial cortical comminuted fractures of the medial distal femur

目的评价单钢板、髓内钉与双钢板治疗股骨中远端内侧粉碎性骨折的临床疗效。方法采用回顾性病例对照研究分析2012年11月-2016年10月收治并获得完整随访的63例股骨中远端内侧粉碎性骨折患者临床资料。根据内固定种类分组，19例股骨干中下段内侧粉碎性骨折分为两组：单钢板组11例，其中男4例，女7例，平均57．5岁；髓内钉组8例，其中男5例，女3例，平均56．4岁。44例股骨远端内侧粉碎性骨折分为三组：单钢板组14例，其中男6例，女8例，平均57．6岁；髓内钉组9例，其中男5例，女4例，平均56．6岁；双钢板组21例，其中男14例，女7例，平均55．1岁。分别比较各组骨折愈合率、骨折愈合时间、组间及组内术后即刻及末次随访时股骨远端外翻角（DFVR）或股骨角、组间DFVR及股骨角变化量、术后并发症发生率。结果63例患者获随访6—37个月，平均13．4个月。19例股骨干中下段内侧粉碎性骨折中，单钢板组和髓内钉组的骨折愈合率、骨折愈合时间、组间及组内术后即刻及末次随访时DFVR、DFVR变化量比较，差异均无统计学意义（P〉0.05）。在术后并发症方面，两组间不愈合率、感染率、内固定失败率和畸形愈合率差异均无统计学意义（P〉0．05）。但单钢板组总的不良事件发生率[46％（5／11）]显著高于髓内钉组[0（0／8）]（P〈0．05）。44例股骨远端内侧粉碎性骨折中，两两比较单钢板组、髓内钉组和双钢板组的骨折愈合率、骨折愈合时间及术后即刻股骨角差异均无统计学意义（P〉0．05）。髓内钉组末次随访时股骨角[（80．80±2．93）。]显著小于单钢板组[（85．28±5．89）°]和双钢板组[（83．55±3．51）°]（P〈0．05）。髓内钉组组内术后即刻及末次随访时股骨角差异无统计学意义（P〉0．05），单钢板组和双钢板组组内术后即刻及末次随访时股骨角差异有统计学意义（P〈0．05）。髓内钉组股骨角变化量[（0．25±1．95）°]显著小于单钢板组[（4．03±3．78）°]和双钢板组[（2．60±2．24）。]（P〈0．05）。在术后并发症方面，三组的不愈合率、感染率、内固定失效率差异均无统计学意义（P〉0．05）。单钢板组畸形愈合率[36％（5／14）]显著高于双钢板组[14％（3／21）]（P〈0．05）。单钢板组总的不良事件发生率[50％（7／14）]显著高于双钢板组[14％（3／21）]（P〈0．05）。结论在骨折愈合率和愈合时间上，三种固定方式没有明显差异。对于股骨干中下段内侧粉碎性骨折和未累及关节面的股骨远端骨折，髓内钉固定要优于锁定钢板固定。对于累及关节面的股骨远端内侧皮质粉碎性骨折，双钢板固定是更优选择。

Objective To evaluate the clinical efficacy of single plate, double plates, and intramedullary nail in treating medial cortical comminuted fractures of the medial distal femur. Methods A retrospective case control study was conducted on 63 cases of medial cortical comminuted fractures of the medial distal femur treated from November 2011 through October 2016. According to the type of internal fixation, 19 cases of middle and distal shaft fractures were divided into the single plate group （n = 11 ） comprising four males and seven females, aged averagely 57.5 years, and intramedullary nail group （ n = 8） comprising five males and three females, aged averagely 56.4 years. Forty-four cases of distal femoral fractures were divided into the single plate group （n = 14） comprising six males and eight females, aged averagely 57.6 years, intramedullary nail group （ n = 9） comprising five males and four females, aged averagely 56.6 years, and double plates group （ n = 21 ） comprising 14 males and seven females, aged averagely 55.1 years. The rate and period of racture healing, distal femoral valgus resection （ DFVR）, femoral angle, change of DFVR and femoral angle, and complications were compared within and between groups. Results All the cases were followed up for 6-37 months （mean, 13.4 months）. Of 19 cases of middle and distal shaft fractures, there were no statistically significant differences in fracture healing rate and period, DFVR after operation and at the last follow-up, and the amount of change of DFVR between the single plate and double plates group （ P 〉 0. 05 ）. With respect to postoperative complications of the two groups, no significant difference was found for the rate of nonunion, infection, internal fixation failure, and mal union （P 〉 0. 05）. However, the incidence rate of adverse events in single plate group （46%） was significantly higher than that in intramedullary nail group （0） （P 〈0. 05）. Of the 44 cases of distal femoral fractures, the pairwise comparisons among three groups showed no statistically significant differences in fracture healing rate, healing period, and the post operative femoral angle （ P 〉 0.05 ）. The femoral angle at the last follow-up in intramedullary nail group was （ 80.80 ± 2.93）°, significantly lower than （85.28 ±5.89） °in single plate group and （ 83.55 ± 3.51 ） ° in double plates group （ P 〈 0.05 ）. Within the intramedullary nail group, no significant difference was found between the femoral angle immediately after operation and at the last follow-up （ P 〉 0.05 ）, but significant difference was detected in both single plate group and double plates group （ P 〈 0. 05 ）. The amount of change of the femoral angle in intramedullary nail group [ （0.25 ± 1.95 ） ° ] was significantly lower than （ 4.03 ±3.78 ） ° in single plate group and （2. 60 ± 2.24） ° in double plates group （ P 〈 0. 05 ）. With respect to post operative complications in the three groups, no significant difference was found for the rate of nonunion, infection, internal fixation failure, and malunion （ P 〉 0. 05 ）. The malunion rate in single plate group （ 36% ） was significantly higher than that in double plates group （ 14% ）. The incidence rate of adverse events in single plate group （ 50% ） was significantly higher than that in double plates group （ 14% ） （ P 〈 0. 05 ）. Conclusions Three internal fixations have similar clinical results in fracture healing rate and period. For medial cortical eomminuted middle and distal shaft fractures, and distal femoral fractures without involving articular surface, intramedullary nail has better results than locking plate. For medial cortical comminuted distal femoral fractures involving articular surface, double plates fixation might be a better option.