加速康复外科理念在Gustilo Ⅰ型及Ⅱ型肱骨远端开放骨折中的应用

Application of enhanced recovery after surgery in treating Gustilo type I&II open distal humeral fractures

比较加速康复外科(ERAS)的急诊手术与分期手术在治疗GustiloⅠ型及Ⅱ型肱骨远端开放骨折的疗效及并发症。方法回顾性分析2013年7月—2017年6月北京积水潭医院创伤骨科收治的22例GustiloⅠ型与Ⅱ型肱骨远端骨折患者的临床资料,其中男性18例,女性4例;年龄(42.5±13.0)岁,年龄范围14~65岁。根据治疗方式不同分为两组:急诊手术组(n=6),急诊清创后直接行内固定术治疗;分期手术组(n=16),急诊行清创缝合术,等待软组织条件好转后行二期内固定术治疗。比较两组患者急诊至手术等待时间、禁食水时间、手术时间、术中出血量、住院时间及术后第1、3、6、12个月及2018年6月进行末次门诊随访时肘关节活动范围、梅奥肘关节功能评分(MEPS)、二次手术率和并发症情况。正态分布且方差齐性的计量资料以均数±标准差(Mean±SD)表示,两组间比较采用独立样本t检验;不符合正态分布的计量资料以[M(P25,P75)]表示,两组间比较采用秩合检验。计数资料组间比较采用χ^2检验或Fisher确切概率法。结果急诊手术组和分期手术组患者的急诊至手术等待时间分别是[5.1(4.5,7.3)h]、[160.0(102.9,221.2)h],P<0.001;禁食水时间分别是[5.1(4.5,7.3)h]、[12.1(9.7,13.2)h],P<0.001;住院时间分别是[5.5(5.0,6.5)d]、[11.5(9.0,13.0)d],P=0.001。两组比较差异有统计学意义。两组患者在手术时间[3.0(2.0,3.6)h、2.6(2.0,3.4)h]、术中出血量[75.0(25.0,225.0)ml、100.0(100.0,200.0)ml]、活动范围[155.0(141.3,155.0)°、155.0(143.8,155.0)°]、MEPS[95.0(83.8,100.0)分、90.0(80.0,100.0)分]、二次手术率(分别为33.3%,31.2%)、并发症发生率(分别为83.3%,68.7%)等方面差异均无统计学意义(P>0.05)。结论ERAS的快速急诊手术措施治疗GustiloⅠ型与Ⅱ型开放性肱骨远端骨折可以显著缩短患者急诊就诊至手术等待时间、禁食水时间及住院时间,可与分期手术取得相似的临床疗效,故对于GustiloⅠ型和Ⅱ型开放性肱骨远端骨折患者推荐行急诊手术措施治疗。

Objective To compare the function outcome and complication of emergency operation and staged operation with enhanced recovery after surgery (ERAS) for Gustilo type I &II open distal humeral fractures. Methods Retrospective analysis of 22 patients with Gustilo type Ⅰ&Ⅱ open distal humeral fractures who were treated in Department of Orthopeaedic Trauma, Beijing Jishuitan Hospital from July 2013 to June 2017 was conducted. There were 18 males and 4 females,aged (42.5±13.0) years, with an age range of 14-65 years. According to different treatment methods, all patients were divided into two groups: emergency operation group (n=6), direct internal fixation after emergency debridement;staged operation group (n=16), emergency debridement and suture, performed the second period of fixed treatment after the soft tissue condition to improve. Patient′s waiting time from emergency to surgery, fasting time, surgery time, intra-op blood loss, hospital stay time, elbow range of motion, Mayo elbow performance score (MEPS), secondary surgery rate and complication at the last outpatient visit at 1, 3, 6, 12 and June 2018, post-operatively were recorded. The measurement data of normal distribution and homogeneity of variance were expressed as mean ± standard deviation (Mean±SD), and the independent sample t test was used for comparison between the two groups;the measurement data not conforming to the normal distribution were expressed as [M(P25, P75)].The rank sum test was used for comparison between the two groups. Comparison of count data between the two groups was performed by χ2 test or Fisher exact probability method. Results The time from emergency to surgery of emergency group and staged group was [5.1(4.5,7.3) h],[160.0(102.9,221.2) h], respectively, P<0.001. Fasting time was [5.1(4.5,7.3) h],[12.1(9.7,13.2)h],P<0.001. Hospital stay time was [5.5(5.0,6.5) d],[11.5(9.0,13.0) d], P=0.001. These differences were significant. Surgery time was [3.0(2.0,3.6) h, 2.6(2.0,3.4) h]. Intra-op blood loss was [75.0(25.0,225.0)ml, 100.0(100.0,200.0)ml]. Elbow range of motion was [155.0(141.3,155.0)°, 155.0(143.8,155.0)°]. MEPS was [95.0 (83.8, 100.0) scores, 90.0 (80.0, 100.0) scores]. Secondary surgery rate was(33.3% vs. 31.2%). Complication rate was (83.3% vs. 68.7%). These differences were not significant (P>0.05). Conclusions ERAS′s quick emergency surgery for Gustilo type I&II open distal humeral fractures significantly reduces the waiting time from emergency to surgery, fasting time and hospital stay time. Function outcome is comparable to the staged group. Therefore, emergency surgical procedures are recommended for patients with Gustilo typeⅠ&Ⅱ open distal humeral fractures.