关节镜下与切开复位内固定手术治疗胫骨平台Schatzker Ⅲ型骨折血清炎症因子变化对预后的影响

Effect of changes of inflammatory factors on prognosis of tibia plateau Schatzker Ⅲ fractures treated under arthroscopic or open reduction and internal fixation

目的:探讨关节镜下与切开内固定手术治疗胫骨平台骨折Schatzker Ⅲ型骨折血清炎症因子变化对预后的影响。方法:回顾性分析2013年11月至2016年11月治疗的30例胫骨平台Schatzker Ⅲ型骨折患者的临床资料,根据手术方式不同分为微创组和对照组,每组15例。微创组采用关节镜下内固定治疗,男8例,女7例;年龄20~50(35.0±14.6)岁;受伤至手术时间7~15(11.0±4.1) d。对照组采用开放手术内固定治疗,男7例,女8例;年龄18~48(33.0±13.6)岁;受伤至手术时间6~14(10.0±3.4) d。比较两组患者手术时间、切口长度、失血量、术后负重时间和骨折愈合时间,分别于术后3 d、6及12个月时检查血清炎症因子IL-1β、IL-6、TNF-α水平;观察术后并发症情况;术后6、12个月采用Lysholm膝关节功能评分进行临床疗效评价。结果:两组患者均获得随访,两组随访时间比较差异无统计学意义(P>0.05)。微创组手术时间、切口长度、术中出血量、术后负重时间、骨折愈合时间及并发症发生例数分别为(80.3±9.7) min、(4.2±1.0) cm、(102.2±26.4) ml、(30.0±10.0) d、(70.0±5.0) d、0例,对照组分别为(90.3±9.1) min、(10.5±1.1) cm、(221.1±46.8) ml、(50.0±15.0) d、(90.0±6.0) d、2例;两组比较差异有统计学意义(P<0.05)。术后6个月微创组Lysholm评分89.2±5.1高于对照组80.1±3.1;术后6个月微创组Lysholm评分中肿胀、下蹲、疼痛评分高于与对照组(P<0.05);术后12个月两组Lysholm各单项评分及总分比较差异无统计学意义(P>0.05)。术后3 d、6个月时微创组血清炎症因子IL-1β、IL-6、TNF-α分别为[(52.1±20.1) pg/L、(0.9±0.1) pg/L],[(56.1±20.1) pg/L、(1.1±1.3) pg/L],[(28.3±2.5) pg/L、(8.4±1.5) pg/L],对照组分别为[(64.8±9.1) pg/L、(8.1±2.1) pg/L],[(65.8±12.3) pg/L、(9.1±5.3) pg/L],[(38.5±2.3) pg/L、(26.5±1.4) pg/L];两组各时间点比较差异有统计学意义(P<0.05)。两组术后12个月IL-1β、IL-6、TNF-α比较差异无统计学意义(P>0.05)。术后3 d炎症因子IL-1β[OR=1.279,95%CI(1.047,1.512),P<0.05],IL-6[OR=1.687,95%CI (1.478,1.888),P <0.05],TFN-α[OR=2.096,95%CI (1.863,2.316),P <0.05]水平是术后6个月Lysholm评分的独立危险因素。结论:关节镜下与开放手术内固定治疗胫骨平台Schatzker Ⅲ型骨折均可获得良好的治疗效果。微创组能够缩短手术时间,减少术中失血量,创伤更小,减轻术后炎症反应,降低术后并发症发生率,能够更快地恢复患者的膝关节功能。

Objective:To explore changes of inflammatory factors on prognosis of tibia plateau Schatzker Ⅲ fractures treated under arthroscopic or open reduction and internal fixation.Methods:From November 2013 to November 2016,clinical data of 30 patients with tibia plateau Schatzker Ⅲ fractures were retrospectively analyzed,and divided into minimally invasive group and control group according to different surgical methods 15 patients in each group.Minimally invasive group were treated by arthroscopic internal fixation,including 8 males and 7 females,aged from 20 to 50 years old with an average of(35.0±14.6) years old,the time from injury to operation ranged from 7 to 15 days with an average of(11.0±4.1) days.Control group were treated by open reduction and internal fixation,including 7 males and 8 females,aged from 18 to 48 years old with an average of(33.0±13.6) years old,the time from injury to operation ranged from 6 to 14 days with an average of(10.0±3.4) days.Operation time,length of incision,blood loss,postoperative loading time and fracture healing time,complications were compared between two groups.Level of IL-1β,IL-6,TNF-α were detected at 3 days,6 months and 12 months after operation,Lysholm knee function score at 6 and 12 months were compared between two groups.Results:All patients were followed up,but there was no significant difference in following-up between two groups.Operation time,length of incision,blood loss,postoperative loading time,fracture healing time and cases of complications in minimally invasive group were(80.3±9.7) min,(4.2±1.0) cm,(102.2±26.4) ml,(30.0±10.0) d,(70.0±5.0) d and 0 case respectively;while in control group were(90.3±9.1) min,(10.5±1.1) cm,(221.1±46.8) ml,(50.0±15.0) d,(90.0±6.0) d and 2 cases respectively;there were significant difference between two groups.Lysholm score in minimally invasive group 89.2±5.1 was higher than that of control group 80.1±3.1;and score of swelling,squat and pain in minimally invasive group was higher than that of control group at 6 months after opertaion.While there were no significant difference in each items and total score of Lysholm score between two groups at 12 months after operation.Level of IL-1β,IL-6,and TNF-α in minimally invasive group at 3 days and 6 months were [(52.1±20.1) pg/L,(0.9±0.1) pg/L],[(56.1±20.1) pg/L,(1.1±1.3) pg/L] and [(28.3±2.5) pg/L,(8.4±1.5) pg/L] respectively;while in control group were [(64.8±9.1) pg/L,(8.1±2.1) pg/L],[(65.8±12.3) pg/L,(9.1±5.3) pg/L] and [(38.5±2.3) pg/L,(26.5±1.4) pg/L] respectively;there were statistically difference in level IL-1β,IL-6 and TNF-α between two groups at 3 days and6 months after operation;while there was no difference at 12 months after operation(P>0.05).Inflammatory cytokines level at3 days after operation IL-1β [OR=1.279,95%CI(1.047,1.512),P<0.05],IL-6 [OR=1.687,95%CI(1.478,1.888),P<0.05],TFN-α[OR=2.096,95%CI(1.863,2.316),P<0.05] was an independent risk factor for Lysholm knee function score at 6 months after operation.Conclusion:Arthroscopic surgery and open surgery also could obtain good clinical effects in treating tibia plateau Schatzker Ⅲ fractures.Arthroscopic internal fixation could shorten operation time,lessen the mount of blooding with minimally invasive,lower occurrence of postoperative complications,faster recovery of knee function.