两种髓内棒内固定联合Ilizarov外固定和包裹式自体髂骨植骨治疗儿童先天性胫骨假关节的效果比较

Comparison of two different intramedullary rods combined with Ilizarov external fixation and wrapped autologous iliac bone grafting for the treatment of congenital tibial pseudarthrosis in children

目的:比较可延伸髓内棒内固定与Williams髓内棒固定联合Ilizarov外固定和包裹式自体髂骨植骨治疗儿童先天性胫骨假关节的初期临床效果。方法:回顾性收集2013年1月至2020年12月湖南省儿童医院骨科收治的60例经联合手术治疗的CrawfordⅣ型先天性胫骨假关节患儿的临床资料。根据手术内固定方式不同分为可延伸髓内棒组(30例)和Williams髓内棒组(30例)。可延伸髓内棒组男12例,女18例,年龄为(33.6±6.3)个月(范围:18~44个月);Williams髓内棒组男10例,女20例,年龄(47.8±8.6)个月(范围:36~66个月)。术后1、3、6、9和12个月分别复查胫腓骨正、侧位X线片及双下肢全长X线片,比较两组患儿的临床治疗效果。组间比较采用独立样本t检验、χ^(2)检验或Fisher确切概率法。结果:两组患儿均顺利完成手术,术后随访时间均>2年,可延伸髓内棒组随访(49.5±6.4)个月,Williams髓内棒组(53.7±10.5)个月。可延伸髓内棒组胫骨假关节断端初期骨愈合时间为(5.1±0.8)个月,Williams髓内棒组为(5.0±0.6)个月,差异无统计学意义(t=0.584,P=0.562);可延伸髓内棒组术后初期骨愈合率为93.3%(28/30),Williams髓内棒组为96.7%(29/30),组间比较差异无统计学意义(χ^(2)=0.351 P=0.554);可延伸髓内棒组术后再骨折率为20.0%(6/30),Williams髓内棒组为16.7%(5/30);可延伸髓内棒组术后双下肢肢体不等长6例(20.0%),肢体长度差为(2.5±1.4)cm(范围:1.5~5.2 cm),Williams髓内棒组8例(26.7%),肢体长度差为(2.8±1.4)cm(范围:1.8~6.0 cm);术后胫骨近端外翻畸形可延伸髓内棒组4(13.3%)例,外翻角度范围为(12.5±4.9)°(范围:7°~18°),Williams髓内棒组3(10.0%)例,外翻角度为(15.0±6.0)°(范围:9°~21°);术后踝关节外翻畸形可延伸髓内棒组2(6.7%)例,外翻角度为(11.5±4.9)°(范围:8°~15°),Williams髓内棒组4(13.3%)例,外翻角度为(14.8±6.2)°(范围:6°~20°);可延伸髓内棒组术后患儿膝关节与踝关节活动正常,无受限,可延伸髓内棒移位4例。Williams髓内棒组术后患儿踝关节活动僵硬30例,髓内棒固定位置无移位。两组患儿术后并发症比较差异均无统计学意义(P值均>0.05)。结论:在儿童先天性胫骨假关节联合手术中应用可延伸髓内棒和Williams髓内棒两种内固定方式均可达到有效的内固定效果,术后初期骨愈合率均较高,术后并发症发生率无差异。两种内固定方式各有优势与缺陷,可根据患儿自身特点选择合适的内固定方式进行固定。

Objective To compare the initial clinical efficacy of extensible intramedullary rod fixation and Williams intramedullary rod fixation combined with Ilizarov external fixation and wrapped autologous iliac bone grafting in the treatment of congenital tibial pseudarthrosis in children.Methods A retrospective analysis was conducted on the clinical data of 60 children with CrawfordⅣtype congenital pseudarthrosis of the tibia treated with combined surgery at the Orthopedics Department of Hunan Children′s Hospital from January 2013 to December 2020.According to different internal fixation methods,patients were divided into the extensible intramedullary rod group(30 cases)and the Williams intramedullary rod group(30 cases).There were 12 males and 18 females in the extendable intramedullary rod group,aged(33.6±6.3)months(range:18 to 44 months),while there were 10 males and 20 females in the Williams intramedullary rod group,aged(47.8±8.6)months(range:36 to 66 months).The anteroposterior and lateral views of tibia and fibula and the full length anteroposterior film of both lower limbs were examined to compare the clinical treatment effects of the two groups at 1-,3-,6-,9-,and 12-month after surgery.Independent sample t-test,χ^(2) test or Fisher exact test was used for inter group comparison,respectively.Results Both groups of children underwent surgery successfully,with postoperative follow-up time greater than 2 years.The extensible intramedullary rod group was followed up for(49.5±6.4)months,while the Williams intramedullary rod group was followed up for(53.7±10.5)months.The initial bone healing time between the broken ends of the tibial pseudarthrosis was(5.1±0.8)months in the extensible intramedullary rod group and(5.0±0.6)months in the Williams intramedullary rod group.There was no statistically significant difference between the two groups(t=0.584,P=0.562).The initial postoperative bone healing rate of the extensible intramedullary rod group was 93.3%(28/30),while that of the Williams intramedullary rod group was 96.7%(29/30).There was no statistically significant difference between the groups(χ^(2)=0.351 P=0.554).The postoperative fracture rate of the extensible intramedullary rod group was 20.0%(6/30),while that of the Williams intramedullary rod group was 16.7%(5/30);Six cases(20.0%)in the extensible intramedullary rod group had unequal limb lengths in both lower limbs after surgery,with a limb length difference of(2.5±1.4)cm(range:1.5 to 5.2 cm).Eight cases(26.7%)in the Williams intramedullary rod group had a limb length difference of(2.8±1.4)cm(range:1.8 to 6.0 cm);After surgery,there were 4 cases(13.3%)of proximal tibial valgus deformity in the extensible intramedullary rod group,with an valgus angle range of(12.5±4.9)°(range:7°to 18°),and 3 cases(10.0%)in the Williams intramedullary rod group,with an valgus angle of(15.0±6.0)°(range:9°to 21°).There were 2 cases(6.7%)of ankle valgus deformity in the extensible intramedullary rod group,with an valgus angle of(11.5±4.9)°(range:8°to 15°),and 4 cases(13.3%)in the Williams intramedullary rod group,with an valgus angle of(14.8±6.2)°(range:6°to 20°).The postoperative activities of the knee and ankle joints in the extensible intramedullary rod group were normal and unrestricted,with 4 cases of extensible intramedullary rod displacement.In the Williams intramedullary rod group,there were 30 cases of postoperative ankle joint stiffness and no displacement of the fixation position of the intramedullary rod.There was no statistically significant difference in postoperative complications between the two groups of children(all P>0.05).Conclusions The use of both extensible intramedullary rods and Williams intramedullary rods in the combined surgery for congenital tibial pseudarthrosis in children can achieve effective internal fixation results.The initial postoperative bone healing rate is high,and there is no difference in the incidence of postoperative complications between groups.Both internal fixation methods have their own advantages and disadvantages,and suitable internal fixation methods can be selected based on the characteristics of the patient.