杠杆重建平衡理论分析锁骨骨折术后内固定失效的原因

Analysis of the internal fixation failure after clavicular fractures by lever reconstruction balance theory

目的基于Medline、万方等数据库,对锁骨骨折内固定失效的可能原因进行分析,为未来治疗提供参考。方法对Medline、Embase、Pubmed、PQDT、万方、中国知网、维普等数据库进行手工检索,获得锁骨骨折内固定失效的相关文献。研究对象为国内、外自2001年1月至2021年1月已发表的锁骨骨折内固定术后并发症的个案报道、论著和综述,对数据筛选提炼,将符合纳入及排除标准者作为研究对象。观察终点为锁骨骨折术后内固定断裂、畸形、松动或穿出。根据文献提供的文字描述或图片,记录观察指标并进行描述性统计分析。结果本研究共纳入17篇文献,65例患者符合纳入与排除标准,其中43例采用钢板螺钉、22例采用弹性髓内钉固定,有25例患者出现内固定松动(38.5%)、11例发生内固定穿出(16.9%)、33例发生内固定形变或断裂(50.8%);在观察终点,有31例发生骨折再移位(47.7%)、26例骨折不愈合(40%)、2例形成假关节(3%)。结论经过对上述结果的分析比较,结合杠杆重建平衡理论,笔者认为锁骨骨折内固定后重建了新的杠杆系统,多数锁骨骨折可以采用保守治疗。对于移位较大或粉碎严重的骨折,仍需手术治疗,内固定长度选择应依据骨折线位置而定,使支点两端内固定长度相同,动力臂与阻力臂相等,达到杠杆远端、近端及支点的三点平衡。同时术后应尽量避免过早康复运动,防止并发症的发生。该理论可以指导未来骨折治疗的原则、内植物的选择研发、康复方案,并有效减少临床并发症,为锁骨骨折乃至全身其他部位骨折的治疗提供了新思路、新方向。

Background Clavicular fractures are common,accounting for 2.6%-10%of all adult fractures.Approximately 80%of the fractures were located in the middle shaft of the clavicle,among which 48%were associated with displacement,and 19%were associated with comminution.Generally,clavicular fractures are treated conservatively,but for displaced or severely comminuted fractures,surgery should be considered.The traditional surgical treatment method is mainly plate fixation,and locking plate is widely used with good functional result.However,postoperative internal fixation failure includes loosening,deformation,fracture,etc.,and the postoperative revision rate reached 6.9%-16.7%,especially for wedge or comminution fractures that directly affects the stability of internal fixation.Currently,intramedullary nail has been gradually recognized in the treatment of clavicle fracture,with the advantages such as small incision and good blood supply protection.However,some studies have reported related complications,in which the incidences of fracture,deformation or displacement of intramedullary nailing reached 5%-10%.As far as we know,there are no specific studies on the mechanism and biomechanical causes of such complications,as well as relevant theories to guide the selection of internal fixator type and length.Objective To investigate and analyze the causes of internal fixation failure after clavicular fractures by lever reconstruction balance theory.Methods This study conducted a manual search on MEDLINE,EMBASE,PubMed,PQDT,Wanfangdata,CNKI,QCVIP and other databases,and the research objects were domestic and foreign case reports,publications and reviews of complications after internal fixation of clavicular fracture published from January 2001 to January 2021,and those who met the inclusive and exclusive criteria were selected.The end points were plate fracture,deformity,loosening or perforation after internal fixation of clavicle fractures.The observation indicators were recorded according to the text description or pictures provided by the literatures.Results A total of 17 literatures were included in this study,among which 65 cases met the inclusive criteria,with 43 cases fixed with plates and 22 cases fixed with elastic intramedullary nails.There were 25 patients of internal fixation loosening(38.5%),11 patients of internal fixation penetration(16.9%),and 33 patients of internal fixation deformation or fracture(50.8%).At the end point,31 cases(47.7%)had fracture redisplacement,26 cases(40%)had nonunion,and 2 cases(3%)had pseudo-articulation.Conclusion A new lever system was reconstructed after internal fixation of clavicular fracture,and the selection of internal fixation length should be determined according to the position of fracture line.The internal fixation length at both ends of fulcrum should be the same with equal power arm and resistance arm,so as to achieve a three-point balance of distal clavicle,fulcrum and proximal clavicle.In the meanwhile,early rehabilitation exercise should be avoided as far as possible to prevent the occurrence of complications.This theory can guide the principle of clavicular fracture treatment,the selection and development of internal fixators,and rehabilitation programs,and effectively reduce clinical complications,providing a new idea and direction for the treatment of clavicle fracture and even other parts of the body fractures in the future.