持续被动活动在股骨远端骨折术后的临床疗效

Clinical effect of continuous passive motion after distal femoral fractures

目的研究持续被动活动(continuous passive motion,CPM)在股骨远端骨折(distal femoral fracture,DFF)术后的临床疗效。方法前瞻性选择2019年1月—2021年12月于眉山市中医医院骨外科行内固定治疗的DFF患者98例,其中男性61例,女性37例;年龄24~70岁,平均48.6岁;致伤原因:道路交通伤55例,高处坠落伤38例,摔伤5例。依据随机数字表法分为CPM组(49例)和对照组(49例)。对照组术后行常规活动康复;CPM组术后行CPM,术后2d行患侧踝关节屈伸运动、肌肉舒缩锻炼,术后3d开始于持续被动功能练习器上进行CPM,出院后继续行CPM直至完全弃拐活动。观察两组下地行走时间、骨折愈合时间、完全弃拐活动时间等术后恢复指标;术后6个月膝关节支撑位触地即时、支撑末期的最大伸膝肌力矩及最大内屈角等生物力学指标,活动度、稳定性、疼痛及股四头肌力量等膝关节功能指标,术前、术后6周全血高切黏度、血细胞比容、血浆粘度及血小板黏附率等血液流变学指标。统计术后并发症发生情况。结果两组均随访6个月。经临床观察,CPM组下地行走时间、骨折愈合时间、完全弃拐活动时间均短于对照组[(11.3±1.4)d vs.(17.7±2.0)d、(12.5±1.4)周vs.(14.8±1.7)周、(16.5±1.9)周vs.(19.3±2.2)周],P<0.001。术后6个月,CPM组膝关节支撑位触地即时、支撑末期最大伸膝肌力矩均大于对照组[(22.60±2.53)Nm vs.(19.20±2.15)Nm、(18.91±2.05)Nm vs.(17.55±1.96)Nm],触地即时、支撑末期最大内屈角均小于对照组[(3.52±0.37)°vs.(4.70±0.49)°、(6.51±0.68)°vs.(7.61±0.79)°],P<0.05。术后6个月,CPM组膝关节活动度、稳定性、疼痛及股四头肌力量评分均高于对照组[(21.05±2.42)分vs.(17.89±1.93)分、(21.87±2.38)分vs.(18.65±2.14)分、(38.05±3.21)分vs.(35.27±3.83)分、(8.92±0.93)分vs.(7.28±0.74)分],减分项目评分低于对照组[(-0.98±0.09)分vs.(-1.20±0.14)分],P<0.001。术后6周,CPM组全血高切黏度、血细胞比容、血浆粘度及血小板黏附率水平均低于对照组[(2.28±0.24)mPa·s vs.(2.96±0.32)mPa·s、(3.38±0.36)%vs.(4.09±0.43)%、(1.58±0.17)mPa·s vs.(1.72±0.19)mPa·s、(51.72±5.33)%vs.(64.39±6.70)%],P<0.001。CPM组感染、内固定不良事件及疼痛等术后并发症发生率低于对照组(6.1%vs.20.4%,P<0.05)。结论CPM可有效缓解DFF患者术后疼痛,纠正异常血液流变学,加快骨折愈合,促进患肢生物力学及膝关节功能恢复,减少术后并发症,有助于患者术后康复。

Objective To investigate the clinical effect of continuous passive motion(CPM)after distal femoral fractures(DFF).Methods A total of 98 patients with DFF who received internal fixation in the Department of Orthopedics,Meishan Traditional Chinese Medicine Hospital from Jan.2019 to Dec.2021 were prospectively included in this study.There were 61 male and 37 female aged 24-70 years,mean 48.6 years.The injury causes were traffic accidents in 55 cases,falls from height in 38 and falls in 5.Patients were divided into CPM group and control group using a random number table(n=49 for each group).After internal fixation,the control group experienced routine rehabilitation,and CPM group received CPM:flexion and extension exercises as well as muscle contraction exercises of the affected ankle joint at 2 d after surgery;CPM exercises on machine since 3 d after surgery and continued after discharge until patients can walk freely without crutches.Related parameters were observed,i.e.,(1)postoperative recovery indexes,such as the time needed for off-bed walking,fracture healing and no-crutch activities;(2)biomechanical indexes at 6 months after surgery,such as the maximum knee extensor moment and maximum internal flexion angle at the start(touchdown)and end of knee support position posture;(3)knee functional indexes,such as range of motion,stability,pain and quadriceps muscle strength;and(4)hemorheological indexes before and 6 d after surgery,such as the whole blood high shear viscosity(WBHSV),hematocrit(HCT),plasma viscosity(PV)and platelet adhesion rate(PAD).Postoperative complications were also recorded.Results Patients were followed up for 6 months.Clinical observation showed that the CPM group had much earlier off-bed walking(d,11.3±1.4 vs.17.7±2.0),fracture healing(week,12.5±1.4 vs.14.8±1.7)and no-crutch activities(week,16.5±1.9 vs.19.3±2.2,all P<0.001).At postoperative 6 months,the maximum knee extensor moment(Nm)were larger in CPM group than in control group,at the time points of both start(22.60±2.53 vs.19.20±2.15)and end(18.91±2.05 vs.17.55±1.96)of knee support position posture,while the maximum internal flexion angle was smaller(3.52°±0.37°vs.4.70°±0.49°;6.51°±0.68°vs.7.61°±0.79°,all P<0.05).Moreover the CPM group had much higher score for knee range of motion(21.05±2.42 vs.17.89±1.93),stability(21.87±2.38 vs.18.65±2.14),pain(38.05±3.21 vs.35.27±3.83)and quadriceps muscle strength(8.92±0.93 vs.7.28±0.74),and lower score for subtractive items(-0.98±0.09 vs.-1.20±0.14,all P<0.001).At postoperative 6 weeks,the levels of WBHSV(mPa·s,2.28±0.24 vs.2.96±0.32),HCT(3.38%±0.36%vs.4.09%±0.43%),PV(mPa·s,1.58±0.17 vs.1.72±0.19)and PAD(51.72%±5.33%vs.64.39%±6.70%)were much lower in CPM group than in control group(all P<0.001).Besides,the incidence of postoperative complications such as infection,internal fixation adverse events and pain was lower in CPM group than in control group(6.1%vs.20.4%,P<0.05).Conclusion CPM can effectively relieve postoperative pain in patients with DFF,correct abnormal hemorheology,accelerate fracture healing,promote biomechanical recovery of the affected limb and functional recovery of the knee joint,reduce postoperative complications,and thus contributing to better postoperative rehabilitation.