单锁定钢板内固定联合自体髂骨植骨治疗全膝关节置换术后RorabeckⅡ型股骨远端假体周围骨折的疗效

Effect of single locked‑plate internal fixation combined with autogenous iliac bone graft in the treatment of Rorabeck type II periprosthetic distal femoral fracture after total knee arthroplasty

目的探讨单锁定钢板内固定联合自体髂骨植骨治疗全膝关节置换(TKA)术后RorabeckⅡ型股骨远端假体周围骨折(PDFF)的疗效。方法采用回顾性病例系列研究分析2016年1月至2020年12月解放军联勤保障部队第九四〇医院收治的13例伴严重骨质疏松(T值≤‑2.5 SD)的初次TKA术后RorabeckⅡ型PDFF患者临床资料,其中男4例,女9例;年龄65~85岁[(75.2±6.5)岁]。患者均行单锁定钢板内固定联合自体髂骨植骨术。术后给予抗骨质疏松治疗及早期规范的关节功能康复锻炼。记录手术时间、术中出血量;比较术前、术后3,6,12个月膝关节活动度;比较术后3,6,12个月美国特种外科医院(HSS)膝关节功能评分,评估膝关节功能恢复情况;比较术前、术后6,12个月骨密度,评估抗骨质疏松治疗效果;观察并发症发生情况。结果患者均获随访12~72个月[(43.2±19.9)个月]。手术时间为90~135 min[(103.8±12.6)min]。术中出血量为100~250 ml[(150.0±45.6)ml]。术前、术后3,6,12个月膝关节活动度分别为(114.6±7.8)°、(90.4±8.0)°、(97.3±4.8)°、(98.1±6.3)°(P均<0.05)。术后3,6,12个月HSS膝关节功能评分分别为(80.2±2.2)分、(84.6±2.9)分、(87.3±3.3)分(P均<0.05)。术后12个月膝关节功能优10例,良3例,优良率为100%。术前、术后6,12个月骨密度T值分别为(-3.8±0.6)SD、(-3.4±0.6)、(-2.9±0.6)SD(P均<0.05)。1例患者出现骨折不愈合,行二次自体髂骨复合骨形态发生蛋白‑2(rhBMP‑2)植骨术后骨折愈合良好;3例患者出现下肢静脉血栓,经口服利伐沙班片后均治愈;1例患者出现膝关节轻度屈伸受限,经股神经阻滞麻醉下手法松解及功能康复后改善。结论对于TKA术后RorabeckⅡ型PDFF,采用单锁定钢板内固定联合自体髂骨植骨,手术时间短,术中出血少,膝关节活动度及功能恢复满意,骨密度显著提高。

Objective To investigate the efficacy of single locked‑plate internal fixation combined with autologous iliac bone graft in the treatment of Rorabeck type II periprosthetic distal femural fracture(PDFF)after total knee arthroplasty(TKA).Methods A retrospective case series study was made on 13 patients suffering from Rorabeck type II PDFF after primary TKA together with severe osteoporosis(T value≤‑2.5 SD)admitted to 940th Hospital of Joint Logistics Support Force of PLA from January 2016 to December 2020,including 4 males and 9 females,aged 65‑85 years[(75.2±6.5)years].All patients were treated with single locked‑plate internal fixation combined with autologous iliac bone graft.Anti‑osteoporosis and early standardized joint function rehabilitation were undertaken postoperatively.The operation time and intraoperative blood loss were recorded.The range of motion of knee joint was compared before operation,at postoperative 3,6 and 12 months and at the last follow‑up.The Hospital for Special Surgery(HSS)knee score was assessed at postoperative 3,6 and 12 months and at the last follow‑up to evaluate the recovery of knee joint function.The bone mineral density was reexamined at postoperative 6 months and 12 months to evaluate the therapeutic effect of anti‑osteoporosis.Complications were detected as well.Results All patients were followed up for 12‑72 months[(43.2±19.9)months].The operation time was 90‑135 minutes[(103.8±12.6)minutes],with the intraoperative blood loss of 100‑250 ml[(150.0±45.6)ml].The range of motion of knee joint was(114.6±7.8)°,(90.4±8.0)°,(97.3±4.8)°and(98.1±6.3)°before operation and at postoperative 3,6 and 12 months(all P<0.05).The HSS knee score was(80.2±2.2)points,(84.6±2.9)points and(87.3±3.3)points at postoperative 3,6 and 12 months(all P<0.05).The knee joint function was excellent in 10 patients and good in 3 at postoperative12 months,and the excellent and good rate was 100%.The T value of bone mineral density was(-3.8±0.6)SD,(-3.4±0.6)SD and(-2.9±0.6)SD preoperatively and at postoperative 6 months and 12 months(all P<0.05).One patient experienced nonunion and was cured after secondary autologous iliac bone grafting combined with recombinant human bone morphogenetic protein‑2(rhBMP‑2)bone grafting.Three patients developed venous thrombosis of lower limbs and were cured with oral administration of rivaroxaban.One patient had mild knee flexion and extension limitation and was improved after manual release under femoral nerve block anesthesia and subsequent functional rehabilitation.Conclusion For patients with Rorabeck type II PDFF after TKA,single locked‑plate internal fixation combined with autologous iliac bone graft has advantages of short operation time,few intraoperative bleeding,satisfactory knee range of motion and functional recovery as well as significant improvement of bone mineral density.