腕关节镜辅助下经皮克氏针固定治疗腕舟骨新鲜骨折

Wrist arthroscopy-assisted percutaneous Kirschner wire fixation for fresh scaphoid fractures

目的比较腕关节镜辅助下经皮克氏针固定和透视下闭合复位经皮空心钉内固定治疗腕舟骨新鲜骨折的疗效。方法采用回顾性病例对照研究分析2009年4月-2016年1月收治的34例腕舟骨新鲜骨折患者临床资料，其中男23例，女11例；年龄21—44岁，平均28．9岁。右侧21例，左侧13例。按照Herbert腕舟骨骨折分型：B2型25例，B3型9例。受伤至手术时间1—13d，平均3．2d。根据手术方式不同，分为关节镜辅助下经皮克氏针内固定组（A组，16例）和透视下闭合复位经皮空心钉内固定组（B组，18例）。A组中4例采用镜下自体髂骨植骨，3例镜检发现舟月韧带损伤予以I期克氏针固定舟月关节。比较两组手术时间、住院时间、骨折愈合时间及末次随访时视觉模拟评分（VAS）、上肢功能障碍评定量表（DASH）评分、改良Mayo腕关节功能评分和并发症情况。结果患者术后均获随访6～12个月，平均7．5个月。A、B两组手术时间分别为（52．3±11．2）min和（42．5±9．7）min（P〈0．01），住院时间分别为（3．9±1．4）d和（4．1±1．5）d（P〉0．05），骨折愈合时间分别为（11．8±1．4）周和（13．2±2．4）周（P〈0．05）。末次随访时A、B两组VAS分别为（1．1±0．6）分和（1．8±0．7）分（P〈0．01），DASH评分分别为（14．1±5．3）分和（17．2±7．8）分（P〉0．05），改良Mayo腕关节功能评分分别为（92．1±6．6）分和（85．4±7．5）分（P〈0．05）。A组1例发生早期克氏针松动；B组1例发生骨折不愈合，1例残留舟月不稳定（P〉0．05）。结论对于有移位的新鲜腕舟骨骨折，采用腕关节镜辅助下经皮克氏针固定治疗，较透视下闭合复位经皮空心钉内固定更能够缩短手术时间，促进骨折愈合，减轻疼痛，改善腕关节功能。

Objective To compare the efficacy of percutaneous Kirschner wire fixation assisted by wrist arthroscopy and percutaneous hollow screw fixation under fluoroscopy in the treatment of scaphoid fresh fractures. Methods A retrospective case control study was conducted on the clinical data of 34 patients with scaphoid fresh fractures admitted from April 2009 to January 2016, including 23 males and 11 females, aged 21-44 years, with an average of 28.9 years. There were 21 cases on the right side and 13 cases on the left side. According to the classification of Herbert scaphoid fractures, there were 25 cases of type B2 and nine cases of type B3. The duration from injury to operation was 1-13 d, with an average of 3.2 d. According to the different surgical methods, the patients were divided into arthroscopic assisted percutaneous Kirschner wire fixation group （Group A, 16 cases） and percutaneous hollow screw fixation under fluoroscopy group （Group B, 18 cases）. In Group A, four cases were treated with autogenous iliac bone graft, and three cases with scapholunate ligament injury were treated with fixation of scaphoid joint with stage I Kirschner wire. The operation time, hospitalization time, bone healing time, visual analogue scale （VAS） , disabilities of arm, shoulder and hand score （DASH）, modified Mayo wrist function score, and complications were compared between the two groups. Results The patients were followed up for 6-12 months, averaging 7.5 months. The operation time of Group A and Group B was （52.3 ± 11.2 ） minutes and （ 42.5 ± 9.7 ） minutes, respectively （ P 〈 0.01 ）, hospitalization time was （3.9 ± 1.4） d and （4.1 ± 1.5） d respectively （P 〉 0.05 ） , bone healing time was （ 11.8 ± 1.4） weeks and （ 13.2 ± 2.4） weeks respectively （ P 〈 0.05 ）, VAS was （ 1.1 ± 0.6） points and （ 1.8 ± 0.7 ） points respectively （P 〈 0.05 ） , DASH score was （ 14.1 ± 5.3 ） points and （ 17.2 ± 7.8 ） points respectively （P〉0.05）, and modified Mayo wrist score was （92. 1 ±6. 6） points and （85. 4 ±7. 5）points respectively （ P 〈 0.05 ）. One case of early Kirschner wire loosening occurred in Group A, and one case of nonunion and another of residual scapholunate instability were found in Group B. Conclusion For fresh scaphoid fractures with displacement, percutaneous Kirschner wire fixation assisted by wrist arthroscopy can shorten operation time, promote fracture healing, relieve pain, and improve wrist joint function compared with percutaneous hollow screw fixation under fluoroscopy.