多维交叉锁定钢板治疗转子下骨折髓内钉固定术后骨不连

Treatment of nonunion after intramedullary nailing for subtrochanteric fractures with multi-dimensional cross locking plate-Ⅱ

目的比较多维交叉锁定钢板(multi-dimensional cross locking plate-Ⅱ,MDC-LP-Ⅱ)和锁定加压钢板(locking compression plate,LCP)作为附加钢板在股骨转子下骨折髓内钉固定术后骨不连中的治疗效果。方法回顾性分析2019年1月至2021年1月于解放军总医院第四医学中心骨科医学部治疗的23例股骨转子下骨折髓内钉术后骨不连患者资料。根据使用附加钢板类型分为MDC-LP-Ⅱ组和LCP组。MDC-LP-Ⅱ组12例,男10例、女2例,年龄(36.83±12.61)岁,体质指数(body mass index,BMI)为(25.09±2.37)kg/m^(2);与末次手术间隔(12.25±2.93)个月,既往接受手术次数(1.33±0.65)次;肥大性骨不连5例、萎缩性骨不连7例,骨不连断端缺损长度(1.19±0.78)cm。LCP组11例,男9例、女2例,年龄(30.55±8.85)岁,BMI为(26.74±5.05)kg/m^(2);与末次手术间隔(12.82±4.40)个月,既往接受手术次数(1.36±0.96)次;肥大性骨不连5例、萎缩性骨不连6例,骨不连断端缺损长度(1.20±0.57)cm。比较两组患者的切口长度、附加钢板长度、置入螺钉数量、双皮质螺钉数量、术中出血量、输血量、骨不连愈合时间及Harris髋关节功能评分、下肢功能评分(lower extremity functional scale,LEFS)和健康调查简表-36(the medical outcomes study item short from health survey-36,SF-36)生活质量评分。结果23例患者均获得随访,MDC-LP-Ⅱ组随访时间为(14.17±2.55)个月,LCP组为(14.45±3.75)个月,差异无统计学意义(t=0.22,P=0.834)。MDC-LP-Ⅱ组手术切口长度(7.25±2.01)cm、附加钢板长度(9.25±0.62)cm、置入螺钉数量(7.17±0.94)个、双皮质螺钉数量(7.17±0.94)个、术中出血量(279.17±169.84)ml、输血量(166.67±187.05)ml,LCP组分别为(15.45±4.72)cm、(15.51±2.38)cm、(5.09±0.95)个、(1.82±1.72)个、(481.82±227.24)ml、(685.45±299.95)ml,差异均有统计学意义(P<0.05)。术后6个月,MDC-LP-Ⅱ组骨折愈合率为100%,LCP组为64%(7/11),差异有统计学意义(P=0.037);术后12个月,LCP组愈合率达到91%(10/11),两组差异无统计学意义(P=0.478)。末次随访时MDC-LP-Ⅱ组Harris和LEFS评分分别为(92.83±8.04)分和(74.92±6.68)分,高于LCP组的(83.36±9.89)分和(66.27±7.68)分,差异均有统计学意义(P<0.05)。SF-36评分方面,MDC-LP-Ⅱ组在生理功能、躯体疼痛、一般健康状况、生命活力和心理健康评分均高于LCP组(P<0.05)。两组患者均未发生与使用MDC-LP-Ⅱ或LCP固定的相关并发症。结论在保留原有髓内钉的基础上,与LCP相比,使用MDC-LP-Ⅱ作为附加钢板治疗股骨转子下骨折髓内钉术后骨不连可以在更小的操作范围内有效增强断端的稳定性,减少手术创伤,保护局部血供,骨折断端愈合速度更快,患者下肢功能恢复和生活质量更佳。

Objective To compare treatment effect of the new multi-dimensional cross locking plate-Ⅱ(MDC-LP-Ⅱ)and locking compression plate(LCP)as additional plates in the treatment of nonunion after intramedullary nailing treatment of subtrochanteric fractures.Methods A retrospective analysis was performed on 23 patients with nonunion after subtrochanteric fractures treated with intramedullary nails from January 2019 to January 2021.According to the type of additional plate,it was divided into MDC-LP-Ⅱgroup and LCP group.There were 12 patients in MDC-LP-Ⅱgroup,including 10 males and 2 females,with an age of 36.83±12.61 years,a body mass index(BMI)of 25.09±2.37 kg/m^(2),the time from the last operation to this treatment was 12.25±2.93 months,the number of previous operations was 1.33±0.65,5 cases of hypertrophic nonunion,7 cases of atrophic nonunion,and the length of bone nonunion defect was 1.19±0.78 cm.In the LCP group,there were 11 cases,9 males and 2 females,aged 30.55±8.85 years,BMI was 26.74±5.05 kg/m^(2),a time of 12.82±4.40 months after the last operation,the number of previous operations was 1.36±0.96,5 cases of hypertrophic nonunion,6 cases of atrophic nonunion,and the length of bone nonunion defect was 1.20±0.57 cm.The incision length,additional plate length,number of screws,number of bicortical screws,intraoperative blood loss,blood transfusion,healing time of nonunion,Harris hip score,lower extremity functional scale(LEFS)and the medical outcomes study item short from health survey-36(SF-36)were compared between the two groups.Results All 23 patients were followed up.The follow-up time of MDC-LP-Ⅱgroup was 14.17±2.55 months,and that of LCP group was 14.45±3.75 months,with no significant difference(t=0.22,P=0.834).In MDC-LP-Ⅱgroup,the incision length was 7.25±2.01 cm,the plate length was 9.25±0.62 cm,the number of screws was 7.17±0.94,the number of bicortical screws was 7.17±0.94,the intraoperative blood loss was 279.17±169.84 ml,and the blood transfusion was 166.67±187.05 ml.In LCP group,the incision length was 15.45±4.72 cm,the plate length was 15.51±2.38 cm,the number of screws was 5.09±0.95,the number of bicortical screws was 1.82±1.72,the intraoperative blood loss was 481.82±227.24 ml,and the blood transfusion was 685.45±299.95 ml.There were significant differences in incision length(P<0.05),plate length(P<0.05),number of screws(P<0.05),number of bicortical screws(P<0.05),intraoperative blood loss(P<0.05),and blood transfusion volume(P<0.05)between the two groups.The fracture healing rate was 100%in MDC-LP-Ⅱgroup and 64%in LCP group at 6 months after operation,and the difference was statistically significant(P<0.05).At 12 months after operation,the healing rate of LCP group was 91%,and the difference was not statistically significant(P=0.478).The Harris score 92.83±8.04 and LEFS 74.92±6.68 at the last follow-up in MDC-LP-Ⅱgroup and the Harris hip score 83.36±9.89 and LEFS 66.27±7.68 at the last follow-up in LCP group were significantly different between the two groups(P<0.05).In terms of SF-36,scores of physical function,physical pain,general health status,vital vitality and mental health of MDC-LP-Ⅱgroup were higher than those of LCP group.No complications related to the use of MDC-LP-Ⅱor LCP fixation were observed in both groups.Conclusion On the basis of preserving the original intramedullary nail,MDC-LP-Ⅱcompared with LCP as additional plates in the rebuilding of nonunion after intramedullary nailing treatment of subtrochanteric fractures,it can effectively enhance the stability of the broken ends in a much smaller operating range,reduce the surgical trauma,protect the local blood supply and accelerate the healing of the broken end of the fracture.The patients who received MDC-LP-Ⅱtreatment had better lower limb function recovery and quality of life.