肘关节恐怖三联征中桡骨小头HotchkissⅢ型骨折的处理策略选择:内固定或置换?

How to treat the Hotchkiss⁃typeⅢradial head fracture in“terrible triad of elbow”cases:open reduction and internal fixation or radial head prosthetic replacement?

目的探讨保留桡骨小头内固定和桡骨小头假体置换治疗肘关节恐怖三联征中桡骨小头HotchkissⅢ型骨折的临床疗效,并为该类骨折的处理策略选择提供科学依据。方法对在我院行手术治疗的23例伴桡骨小头HotchkissⅢ型骨折的恐怖三联征患者的临床资料行回顾性分析,对患者就桡骨小头的处理方式进行分组,其中10例行保留桡骨小头的切开复位内固定者为内固定组,13例行桡骨小头切除后行桡骨小头假体置换者为置换组。对所有患者行至少1年,结合手术相关指标、肘关节功能评分、成本⁃效益分析、患者满意度及生活质量等综合分析两种方案处理恐怖三联征中桡骨小头HotchkissⅢ型骨折的医疗、经济效益并作比较评价。结果手术时间内固定组长于置换组(P<0.05),切口长度、术后当天疼痛评分两组无统计学差异(P>0.05),术后1年复查,患者Mayo肘关节功能评分示,置换组总分优于内固定组(P<0.05),其中其肘关节疼痛、功能范围恢复均优于内固定组(P<0.05),但两组稳定性、日常活动完成情况评分对比数据无统计学差异(P>0.05),两组患者治疗质量⁃效益分析显示,内固定组治疗费用低于置换组(P<0.05),治疗效益、患者满意度均高于置换组(P<0.05),术后1年生活质量对比两组数据差异无统计学意义(P>0.05)。结论两种方法均能有效治疗TTE中该类复杂骨折,从而恢复肘关节日常功能,改善生活质量。桡骨小头置换术创伤较小,功能改善较优,但内固定术治疗效益及患者满意度更高。

Objective To explore the clinical outcomes for Hotchkiss-type Ⅲ radial head fracture in "terrible triad of the elbow"(TTE) cases treated with two surgical methods,namely,open reduction and internal fixation(ORIF) and radial head prosthetic replacement(RHPR).Methods Twenty-three TTE cases with Hotchkiss-type Ⅲ radial head fracture,identified from a prospective database,were divided into two groups base on the treatment of radial head fracture. Twenty-three of them underwent the fixation with microplate and the others were treated with RHPR. All the patients were followed for at least one year,and outcomes were assessed and compared base on operation-related situations,the Mayo elbow function score,the cost-effect analysis,satisfaction score and life quality score.Results There were no significant differences in mean incision length and intraday VAS between the two groups,but the operation time was shorter for RHPR than ORIF(72.15±4.95 vs 83.60.±7.93,P<0.001). For Mayo score in one-year follow-up after the operation,the total score,pain score and range of motion were all better for RHPR than ORIF(91.15±6.81 vs 79.50±10.39,P=0.004,39.23±7.59 vs 31.50±8.51,P=0.032,18.85±2.19 vs 16.00±3.16,P=0.019),but no significant difference were found in stability or activity of daily life. The ORIF group yield better benefit-index in the cost-effect analysis because they consume much less than the RHPR(21.96±3.00 vs. 19.13±1.55,P=0.008,3.63±0.26 vs. 4.77±0.21,P<0.001),and they also shows a better mean satisfaction-score(100.60±4.84 vs. 92.69±4.91,P=0.001). But no significant difference was found in daily life quality questionnaire between the two groups.Conclusion ORIF and RHPR were both effective in reconstruction and recovering elbow function when used to treat Hotchkiss-type Ⅲ radial head fracture in TTE cases. RHPR showed better outcomes in terms of Mayo score,but ORIF showed better benefit-index and satisfaction score.