髌上入路和髌旁内侧入路髓内钉固定治疗胫骨多段骨折的疗效比较

Comparison of effectiveness of tibial intramedullary nailing fixation via suprapatellar approach and medial parapatellar approach in treatment of multiple tibial fractures

目的比较膝关节半伸直位髌上入路与髌旁内侧入路髓内钉固定治疗胫骨多段骨折的临床疗效。方法回顾分析2018年7月—2022年12月收治且符合选择标准的43例采用髓内钉固定治疗的胫骨多段骨折患者临床资料,其中23例采用膝关节半伸直位髌上入路(A组),20例采用膝关节半伸直位髌旁内侧入路(B组)。两组患者性别、年龄、致伤原因、受伤至手术时间、骨折国际内固定研究协会/美国骨创伤协会(AO/OTA)分型及术前疼痛视觉模拟评分(VAS)、膝关节活动度(range of motion,ROM)等基线资料比较差异均无统计学意义(P>0.05)。记录并比较两组患者手术时间、术中失血量、切口长度、术中透视次数及骨折愈合时间,统计两组术后4、8、12周膝关节VAS评分及ROM,观察术后并发症发生情况;末次随访时采用Lysholm评分评价膝关节功能。结果两组患者均顺利完成手术,术中无神经、血管损伤等并发症发生,术后所有切口均Ⅰ期愈合。两组手术时间、术中失血量、术中透视次数比较差异均无统计学意义(P>0.05);但B组手术切口长于A组,差异有统计学意义(P<0.05)。两组患者均获随访,随访时间12~30个月,平均21.1个月。术后随时间延长,两组膝关节VAS评分均逐渐降低,ROM逐渐增加,各时间点间差异均有统计学意义(P<0.05);术后4、8周B组VAS评分低于A组,差异有统计学意义(P<0.05),其余时间点两组间比较膝关节VAS评分及ROM差异均无统计学意义(P>0.05)。两组骨折均愈合,愈合时间比较差异无统计学意义(P>0.05)。随访期间无内固定物松动、断裂及骨折复位丢失等并发症发生。末次随访时,B组膝关节Lysholm评分显著优于A组,差异有统计学意义(P<0.05)。结论膝关节半伸直位髌上入路与髌旁内侧入路髓内钉固定治疗胫骨多段骨折均可获得满意疗效,髌旁内侧入路术后早期膝关节疼痛症状更轻,远期膝关节功能更优。

Objective To compare the effectiveness of intramedullary nailing fixation via suprapatellar approach and medial parapatellar approach in semi-extended position in the treatment of multiple tibial fractures.Methods The clinical data of 43 patients with multiple tibial fractures treated with intramedullary nailing fixation between July 2018 and December 2022 were retrospectively analyzed,including 23 patients treated with suprapatellar approach in semi-extended position(group A)and 20 patients with medial parapatellar approach in semi-extended position(group B).There was no significant difference in gender,age,cause of injury,time from injury to operation,AO/Orthopaedic Trauma Association(AO/OTA)classification,preoperative visual analogue scale(VAS)score,and range of motion(ROM)of the knee joint between the two groups(P>0.05).The operation time,intraoperative blood loss,incision length,intraoperative fluoroscopy frequency,and fracture healing time were recorded and compared.The VAS score and ROM of the knee joint were analyzed at 4,8,and 12 weeks after operation,and the incidence of postoperative complications was observed;knee function was evaluated by Lysholm score at last follow-up.Results The operations were successfully completed in both groups,and there was no complication such as nerve and blood vessel injury during operation,and all incisions healed by first intention.There was no significant difference in operation time,intraoperative blood loss,and intraoperative fluoroscopy frequency between the two groups(P>0.05),but the incision length in group B was significantly longer than that in group A(P<0.05).Patients in both groups were followed up 12-30 months,with an average of 21.1 months.The VAS score decreased and ROM increased gradually in both groups with time after operation,showing significant differences between different time points(P<0.05).The VAS score of group B was significantly lower than that of group A at 4 and 8 weeks after operation(P<0.05);there was no significant difference in VAS score and ROM between the two groups at other time points(P>0.05).There was no significant difference in fracture healing time between the two groups(P>0.05).During the follow-up,there was no complication such as internal fixator loosening,breakage,and loss of fracture reduction.At last follow-up,the Lysholm score in group B was significantly better than that in group A(P<0.05).Conclusion Both the suprapatellar approach and the medial parapatellar approach in semi-extended position can achieve satisfactory results in the treatment of multiple tibial fractures.The medial parapatellar approach has lower symptoms of early knee pain and better long-term function.