钉板联合固定在不稳定股骨非峡部骨折治疗中的意义

The significance of combined fixation in the treatment of unstable non-isthmus fractures of the femur

目的探讨钉板联合固定治疗伴有蝶形骨块的股骨非峡部骨折的临床疗效及相关适应证,为临床手术方案选择提供参考。方法回顾性研究2017年6月至2020年6月苏州大学附属太仓医院收治的62例伴有蝶形骨块的股骨非峡部骨折患者,按照术式分为单纯髓内钉组(37例)和钉板联合固定组(25例)。单纯髓内钉组均单独采用股骨交锁髓内钉固定,钉板联合固定组采用股骨交锁髓内钉联合辅助钢板固定。观察两组患者的手术时间、术中出血量、骨折愈合时间、术后首次直腿抬高时间、术后1 d及术后1周的VAS疼痛评分、术后1周及术后1年的膝关节屈曲度、术后1年PPMS功能评分及愈合相关不良事件发生率的差异。骨折稳定性相关指标主要动态观察患肢旋转角度的变化、患肢冠状位的成角畸形、蝶形骨块的位移程度及术后1年骨折愈合的RUST评分。结果患者随访24~35个月,平均(28.18±3.02)个月。两组的手术时间比较,差异无统计学意义(P>0.05);单纯髓内钉组的术中出血量低于钉板联合固定组,骨折愈合时间长于钉板联合固定组,差异具有统计学意义(P<0.05)。两组在首次直腿抬高时间及术后VAS评分方面比较,差异无统计学意义(P>0.05);单纯髓内钉组术后1周的膝关节屈曲明显优于钉板联合固定组(P<0.05),而在术后1年膝关节屈曲比较差异无统计学意义(P>0.05);两组术后1年PPMS评分比较,差异无统计学意义(P>0.05)。单纯髓内钉组发生骨不连4例,其中1例同时发生断钉,愈合相关不良事件发生率为10.8%(4/37);钉板联合固定组骨不连1例,愈合相关不良事件发生率为4%(1/25);两组比较差异无统计学意义(P>0.05)。单纯髓内钉组术后1周及术后1年存在股骨旋转畸形角度≥10°者均显著高于钉板联合固定组,差异有统计学意义(P<0.05)。两组术后1周冠状位畸形角度≥5°者,差异无统计学意义(P>0.05),但术后1年单纯髓内钉组冠状位畸形角度≥5°远高于钉板联合固定组,差异有统计学意义(P<0.05)。单纯髓内钉组术前蝶形骨块平均位移距离为(16.51±3.48)mm,钉板联合固定组为(15.52±4.16)mm(P>0.05),术后1周单纯髓内钉组蝶形骨块平均移位距离(14.35±3.99)mm,钉板联合固定组为(5.08±2.14)mm(P<0.05)。术后1年两组骨折愈合RUST评分比较,差异无统计学意义(P>0.05)。结论对于伴有蝶形骨块的不稳定股骨非峡部骨折,钉板联合固定可提高复位质量并增加术后稳定性,愈合相关不良事件发生率低于单纯髓内钉固定。

Objective To explore the clinical efficacy and related indications of combined fixation with intramedullary nail and plate for the treatment of unstable non-isthmus femoral fractures with butterfly bone fragment,providing reference for the selection of clinical surgical schemes.Methods A retrospective study was conducted on 62 patients with non-isthmus femoral fractures accompanied by butterfly bone fragment,who were admitted to Taicang Hospital Affiliated to Suzhou University from June 2017 to June 2020.They were divided into simple intramedullary nail group(37 cases)and combined fixation with intramedullary nail and plate group(25 cases),according to the inclusion and exclusion criteria.The simple intramedullary nail group was fixed with intramedullary nails alone,while the combined fixation group was fixed with intramedullary nails combined with plates.The surgical time,intraoperative bleeding,time for first straight leg lift after surgery,VAS pain score on the first day and one week after surgery,knee joint flexion at one week and one year after surgery,and fracture healing time,PPMS functional score and incidence of healing related adverse events at 1 year after surgery were observed in both groups.Changes in the rotation angle of the affected limb,angular deformity of the coronal position of the affected limb,degree of displacement of the butterfly bone fragment,and the RUST score of fracture healing one year after surgery was dynamically observed to evaluate stability.Results The patients were followed up for an average of 24-35 months,with an average of(28.18±3.02)months.There was no statistically significant difference in surgical time between the two groups(P>0.05).The intraoperative bleeding volume in the intramedullary nail group was significantly lower than combined fixation group,and fracture healing time in the intramedullary nail group was significantly longer than combined fixation group(P<0.05).There was no statistical difference between the two groups in first straight leg elevation time and postoperative VAS score(P>0.05).The flexion angle in the intramedullary nail group was significantly better than combined fixation group at 1 week post operation(P<0.05),but there was no statistically significant difference at 1 year post operation(P>0.05).There was no significant difference in PPMS score at 1 year post operation between the two groups(P>0.05).Four cases of bone non union occurred in the simple intramedullary nail group,of which 1 case also experienced nail breakage.The incidence of healing related adverse events was 10.8%(4/37).There was 1 case of bone nonunion in the nail plate combined fixation group,with an overall incidence of adverse events of 4%(1/25)(P>0.05).The incidence of femoral rotation deformity angle≥10°in the simple intramedullary nail group was significantly higher than that in combined fixation group at 1 week and 1 year post-operation,and the difference was statistically significant(P<0.05).There was no statistically significant difference(P>0.05)between the two groups with a coronary deformity angle of≥5°1 week post-operation,but the coronary deformity angle of≥5°in the simple intramedullary nail group was much higher than that in combined fixation group 1 year post-operation,and the difference was statistically significant(P<0.05).The average displacement distance of the butterfly bone fragment before surgery in the intramedullary nail group was(16.51±3.48)mm,while in the combined fixation group it was(15.52±4.16)mm(P>0.05),but the distance was(14.35±3.99)mm in the intramedullary nail group and(5.08±2.14)mm in the combined fixation group one week post operation(P<0.05).Conclusion For unstable non-isthmus femoral fractures with butterfly bone fragment,combined fixation with intramedullary nail and plate can improve reduction quality and increase postoperative stability.Moreover,the incidence of adverse events related to fracture healing is lower than that of simple intramedullary nail fixation.