髓内钉附加小钢板或阻挡钉治疗胫骨近段骨折比较

Intramedullary nailing combined with adjunct plate or blocking screw for proximal tibial fractures

[目的]比较传统入路髓内钉附加小钢板或阻挡钉治疗胫骨近段骨折的治疗效果。[方法]2013年1月~2017年1月,36例未累及膝关节的胫骨近段骨折患者纳入本前瞻性研究,采用随机数字表法将患者分为两组。其中,19例采用髓内钉附加小钢板固定,17例采用髓内钉附加阻挡钉治疗。比较两组围手术期、随访和影像资料。[结果]36例患者均顺利完成手术,术中无血管、神经损伤。钢板组在手术时间、术中透视次数显著优于阻挡钉组(P<0.05);但钢板组在手术耗材费用和平均住院时间方面显著不及阻挡钉组(P<0.05)。两组患者随访12~24个月,平均(15.62±4.71)个月。两组患者下地行走时间、完全负重时间的差异无统计学意义(P>0.05)。末次随访时,两组膝关节活动度、Johner-Wruhs术后功能评级的差异无统计学意义(P>0.05),而在膝前痛方面,两组差异无统计学意义(P>0.05)。影像方面,术后钢板组残余侧方移位、前后移位、冠状面成角和矢状面成角均显著小于阻挡钉组(P<0.05)。至末次随访时,两组患者均达到影像学骨性愈合,两组间骨折愈合时间的差异无统计学意义(P>0.05)。所有患者均未见内固定物松动、移位。[结论]无论采用传统入路髓内钉附加小钢板或阻挡钉技术治疗胫骨近段骨折均可取得满意疗效;采用附加钢板虽费用高,但可达到更好的下肢力线恢复。

[Objective]To compare the traditional approach of intramedullary nail with an extra plate versus the nail combined with blocking screws for proximal tibia fractures without the knee involved.[Methods]From January 2013 to January2017,a total of 36 patients who suffered from proximal tibial fractures unaffecting the knee were enrolled into this prospective study,and divided into two groups by random number table method.Of them,19 patients received an interlocking intramedullary nail combined with an extra plate for internal fixation of the fractures(the plate group),while the remaining 17 patients had fractures fixed with the nail combined with blocking screws(the screw group).The perioperative,follow-up and radiographic data were compared between the two groups.[Results]All the 36 patients underwent operation smoothly without iatrogenic neurovascular injuries.The plate group proved superior the screw group regarding to operation time and intraoperative X-ray exposure(P<0.05),nevertheless the former was inferior to the latter in implant cost and hospital stay(P<0.05).The follow-up period lasted for 12~24 months with a mean of(15.62±4.71)months.There were no statistically significant differences in the time to return ambulation and the time to full weight-bearing activity between the two groups(P>0.05).At the latest follow up,no statistically significant differences were found between the two groups regarding knee range of motion and Johner-Wruhs grades for clinical consequences(P>0.05).In terms of anterior knee pain,the difference between the two groups was not statistically significant(P>0.05).In respect of radiographic assessment,the plate group had significantly less residual malalignment than the screw group,including anteroposterior and lateral displacements,as well as angulations in coronal and sagittal planes(P<0.05).To the latest follow up,all patients in both group got bony healing of the fractures without a statistical difference in fracture healing time between them(P>0.05),and no loosening or breaking of the implants were showed on images in anyone of them.[Conclusion]Both the nail plus plate and nail plus blocking screw do achieve satisfactory clinical outcomes for proximal tibial fractures unaffecting the knee.By comparison,the nail combined with plate facilitates to regain and maintain better alignment of the leg regardless of higher implant cost.