半伸膝位髌旁关节外入路髓内钉内固定治疗胫骨干骨折

Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach

目的探讨半伸膝位髌旁关节外入路髓内钉内固定治疗胫骨干骨折的疗效。方法2018年7月—2019年9月,应用半伸膝位髌旁关节外入路髓内钉内固定治疗22例胫骨干骨折患者。男15例,女7例;年龄25~68岁,平均46.4岁。致伤原因:摔伤7例,交通事故伤14例,重物砸伤1例。闭合性骨折16例,开放性骨折6例。胫骨干骨折AO分型:42-A1型4例,42-A2型2例,42-A3型3例,42-B2型3例,42-B3型4例,42-C1型2例,42-C2型3例,42-C3型1例。合并腓骨骨折20例。受伤至手术时间2~15 d,平均7.5 d。记录骨折愈合时间、术后并发症及膝前痛发生情况,末次随访时采用Lysholm评分评价膝关节功能。结果手术时间50~140 min,平均85 min。术后2例切口有渗出,经对症处理后愈合;其余患者切口均Ⅰ期愈合。患者均获随访,随访时间8~23个月,平均14.9个月。X线片复查示骨折均愈合,愈合时间12~20周,平均14.4周。4例(18.18%)患者出现膝前痛。随访期间均未出现髌股关节不稳定表现。末次随访时,膝关节功能Lysholm评分为85~100分,平均94.3分。结论半伸膝位髌旁关节外入路髓内钉内固定治疗胫骨干骨折,既能对骨折有效固定,又能避开髌下入路植钉存在的骨折端再次移位、多发膝前痛等问题,是一种有效的治疗方法。

Objective To investigate the effectiveness of intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach for tibial shaft fracture.Methods Between July 2018 and September 2019,22 patients with tibial shaft fracture treated with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach.There were 15 males and 7 females,with an average age of 46.4 years(range,25-68 years).The fractures were caused by falling in 7 cases,by traffic accident in 14 cases,and by a heavy object in 1 case.Sixteen patients were closed fractures and 6 were open fractures.According to the AO classification,there were 4 cases of 42-A1 type,2 cases of 42-A2 type,3 cases of 42-A3 type,3 cases of 42-B2 type,4 cases of 42-B3 type,2 cases of 42-C1 type,3 cases of 42-C2 type,and 1 case of 42-C3 type.Twenty cases complicated with fibular fractures.The time from injury to operation was 2-15 days(mean,7.5 days).The fracture healing time,complications,the incidence of anterior knee pain during the follow-up were observed;and knee joint functions were evaluated by Lysholm score at last follow-up.Results The operation time was 50-140 minutes(mean,85 minutes).Two cases experienced incision exudation which healed after symptomatic treatment.The incisions of other patients healed by first intention.All patients were followed up 8-23 months(mean,14.9 months).X-ray films reexamination showed that all fractures healed with the healing time of 12-20 weeks(mean,14.4 weeks).Four patients(18.18%)experienced the anterior knee pain.No patellofemoral instability was observed during the follow-up period.Lysholm score of knee function was 85-100(mean,94.3)at last follow-up.Conclusion Application of the intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach is effective for tibial shaft fractures,which can not only realize the effective fixation of the fracture,but also avoid the adverse factors including re-displacement and anterior knee pain in the application of the intramedullary nailing fixation via the sub-patellar approach.