不同内固定手术时机治疗复杂胫骨平台骨折伴筋膜间隔综合征患者术后康复疗效观察

Observation of the curative effect of internal fixation at different times in the treatment of complex tibial plateau fractures with osteofascial compartment syndrome

目的 探讨不同内固定手术时机对复杂胫骨平台骨折伴筋膜间隔综合征(osteofascial compartment syndrome,OCS)患者功能康复的影响。方法 收集2019年1月至2020年1月兰溪市人民医院复杂胫骨平台骨折伴OCS患者64例,根据手术时机不同分为A组(4~48h,n=17)、B组(49h至5d,n=13)、C组(6~8d,n=24)和D组(≥9d,n=10),比较各组患者手术时间、术中出血量、总住院时间、软组织覆盖时间、关闭切口时间、骨折愈合时间,术后并发症,并比较及记录四组胫骨平台力学指标[胫骨平台内翻角(tibia plateau angle,TPA)、外侧后倾角(posterior slope angle,PA)]及纽约特种外科医院膝关节功能评分(hospital for special surgery knee score,HSS)。结果 A组患者手术时间、住院时间均显著短于B、C、D组(P<0.05),术中出血量显著少于B、C、D组(P<0.05);B、C、D组患者手术时间、术中出血量比较,差异无统计学意义(P>0.05)。住院时间:B组<C组<D组,差异有统计学意义(P<0.05);各组患者软组织覆盖时间、关闭切口时间、骨折愈合时间、并发症发生率比较,差异无统计学意义(P>0.05);A组患者术后并发症最高23.53%,D组术后并发症最低10.00%。术后即刻,各组患者胫骨平台TPA与PA比较,差异均无统计学意义(P>0.05);术后3、12个月,各组间TPA、PA比较,差异无统计学意义(P>0.05)。术后1、3个月,A组患者HSS评分显著高于B、C、D组(P<0.05)。术后6、12个月,各组HSS评分比较,差异无统计学意义(P>0.05)。B、C、D组患者各时间点HSS评分比较,差异无统计学意义(P>0.05)。术后12个月,4组患者膝关节功能优良率比较,差异无统计学意义(P>0.05)。结论 尽管伤后4~48h行手术可显著缩短手术时间和住院时间,减少术中出血量,降低短期HSS评分,但伤后6~8d的术后并发症较少,随着伤后49h至8d行手术,术后并发症呈时间延长而有减少趋势,但从远期疗效来看,建议对复杂胫骨平台骨折伴OCS患者以伤后6~8d进行治疗为宜,此时局部软组织肿胀基本消退且出现皮肤皱纹,术后并发症较少。

Objective To investigate the effect of different surgical timings on functional rehabilitation of patients with complex tibial plateau fractures complicated with osteofascial compartment syndrome(OCS).Methods A total of 64 patients with tibial plateau fractures complicated with OCS were enrolled divided into group A(4-48h,n=17),group B(49h-5d,n=13),group C(6-8d,n=24)and group D(≥9d,n=10)according to the timing of surgery,the perioperative conditions(operation time,intraoperative blood loss,total hospital stay,soft tissue coverage time,incision closure time,fracture healing time)and postoperative complications were compared among the groups.Tibia plateau angle(TPA),posterior slope angle(PA)and New York Hospital for special surgery knee score(HSS)in 4 groups were recorded and compared.Results Compared with group B,C,D,the operation time,intraoperative blood loss and hospital stay in group A were significantly reduced(P<0.05).There was no significant difference in operation time and intraoperative bleeding volume in groups B,C and D(P>0.05).Hospitalization time:group B<group C<group D,the difference was statistically significant(P<0.05).There was no statistical difference in the time of soft tissue coverage,incision closure and fracture healing incidence of complications in 4 goups(P>0.05).There was no loosening or breakage of the internal fixation in 4 groups.There were significant differences in the incidence of postoperative complications in 4 groups(P>0.05).The lowest postoperative complications in group D were 10.00%,and the highest in group A were 23.53%.Immediately after operation,There was no significant difference in the TPA and PA of the tibial plateau in 4 groups(P>0.05).After surgery 3 and 12 months,there was no statistical significant difference between the groups(P>0.05).At 12 months after operation,there was no significant difference in the excellent and good rate of knee joint function in 4 groups(P>0.05).At 1 and 3 months after operation,the HSS score of group A was significantly higher than that of group B,C,D(P<0.05).At 6 and 12 months after operation,there was no significant difference in HSS score in 4 groups(P>0.05).Conclusion Although 4-48h operation can significantly reduce the operation time,intraoperative bleeding,hospital stay and short-term HSS score,there are few postoperative complications 6-8d after injury.With 49h-8d after injury,the postoperative complications tend to decrease,but in the long term,it is recommended that patients with complex tibial plateau fractures and OCS should be treated 6-8d after injury,when local soft tissue swelling basically subsides and skin wrinkles appear,postoperative complications are less.