胫骨远端逆行髓内钉内固定治疗胫骨远端近踝部骨折

Treatment of proximal malleolar fracture of distal tibia with retrograde intramedullary nail fixation

目的观察胫骨远端逆行髓内钉内固定治疗胫骨远端近踝部骨折的临床疗效。方法对40例成人胫骨进行三维CT检查,测量胫骨远端后内侧后翻角度、扭转高度、置钉安全区高度等解剖学指标。依托人体骨骼模型解剖数据库研制出符合国人胫骨远端近踝部骨骼解剖特点的胫骨远端逆行髓内钉及其配套器械。回顾性分析2019年6月至2023年6月于第九〇九医院接受逆行髓内钉内固定治疗的胫骨远端近踝部骨折患者25例,男18例、女7例,年龄(41.3±10.8)岁(范围22~65岁)。以样本量1∶1根据性别和年龄进行配对,匹配同期接受顺行髓内钉内固定治疗的胫骨远端近踝部骨折患者25例,男20例、女5例,年龄(41.2±9.4)岁(范围19~60岁)。观察复位质量、术后Baird-Jackson评分、美国骨科足踝学会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分、踝关节活动范围及并发症情况。结果所有患者均顺利完成手术并获得随访,随访时间为(14.4±3.5)个月(范围12~24个月)。逆行髓内钉组术中出血量和住院时间为(33.12±7.38)ml和(10.32±1.75)d,小于顺行髓内钉组的(49.04±10.22)ml和(13.16±2.69)d,差异有统计学意义(P<0.05)。逆行髓内钉组复位质量优23例、良2例,顺行髓内钉组优17例、良8例,逆行髓内钉组复位质量优的占比高于顺行髓内钉组,差异有统计学意义(χ^(2)=4.500,P=0.034)。逆行髓内钉组术后3个月Baird-Jackson评分和AOFAS踝与后足评分分别为(85.6±2.5)分和(85.8±3.3)分、均小于术后1年的(95.3±3.1)分和(95.8±3.6)分,差异有统计学意义(P<0.05)。顺行髓内钉组术后3个月Baird-Jackson评分和AOFAS踝与后足评分分别为(85.1±3.3)分和(86.1±2.5)分,均小于术后1年的(95.2±2.7)分和(94.9±3.5)分,差异有统计学意义(P<0.05)。两组术后3个月和术后1年的Baird-Jackson评分和AOFAS踝与后足评分组间比较差异无统计学意义(P>0.05)。末次随访时两组患者无一例出现踝关节僵硬、神经血管损伤、下肢深静脉血栓形成、内固定感染或断裂等并发症。结论胫骨远端逆行髓内钉内固定治疗胫骨远端近踝部骨折复位质量满意,术后关节功能恢复好,有助于术后早期康复。

Objective To observe the clinical effect of retrograde distal tibial intramedullary nail fixation in the treatment of proximal ankle fracture of the distal tibia.Methods A three-dimensional CT examination of 40 adult tibias was performed to measure anatomical indicators such as the posterior medial posterior torsion angle of the distal tibia,the height of torsion,and the height of the safety zone for nail placement.Based on the anatomy database of the human skeleton model,a retrograde distal tibial nail and its supporting instruments were developed in accordance with the anatomical characteristics of the distal tibia and the proximal ankle of Chinese people.From June 2019 to June 2023,a total of 25 patients with distal tibial proximal ankle fractures treated with retrograde intramedullary nail internal fixation in the 909th Hospital were retrospectively analyzed.There were 18 males and 7 females,aged 41.3±10.8 years(range,22-65 years).The sample size was 1:1 matched according to gender and age.Twenty-five patients with distal tibial proximal ankle fractures who underwent antegrade intramedullary nail fixation during the same period were matched,including 20 males and 5 females,aged 41.2±9.4 years(range 19-60 years).The reduction quality,postoperative Baird-Jackson score,American Orthopaedic Foot and Ankle Society(AOFAS)ankle and hindfoot score,ankle range of motion and complications were observed.Results All patients were successfully operated and followed up for 14.4±3.5 months(range,12-24 months).The intraoperative blood loss and hospitalization time in retrograde intramedullary nail group were 33.12±7.38 ml and 10.32±1.75 d,less than 49.04±10.22 ml and 13.16±2.69 d in antegrade intramedullary nail group,and the difference was statistically significant(P<0.05).The reduction quality was excellent in 23 cases and good in 2 cases in the retrograde intramedullary nail group,and was excellent in 17 cases and good in 8 cases in the anterograde intramedullary nail group.The proportion of excellent reduction quality in the retrograde intramedullary nail group was higher than that in the anterograde intramedullary nail group,and the difference was statistically significant(χ^(2)=4.500,P=0.034).The Baird-Jackson score and AOFAS ankle and hindfoot score in the retrograde intramedullary nail group were 85.6±2.5 and 85.8±3.3 at 3 months after operation,lower than those at 1 year after operation 95.3±3.1 and 95.8±3.6,and the difference was statistically significant(P<0.05).The Baird-Jackson score and AOFAS ankle and hindfoot score of the antegrade intramedullary nail group were 85.1±3.3 and 86.1±2.5 at 3 months after operation,lower than 95.2±2.7 and 94.9±3.5 at 1 year after operation,and the difference was statistically significant(P<0.05).There was no significant difference in Baird-Jackson score and AOFAS ankle and hindfoot score between the two groups at 3 months and 1 year after operation(P>0.05).At the last follow-up,there was no ankle stiffness,neurovascular injury,deep vein thrombosis,infection or breakage of internal fixation in the two groups.Conclusion The treatment of distal tibial proximal ankle fractures with retrograde intramedullary nail fixation has satisfactory reduction quality,good postoperative function recovery,and is helpful for early postoperative rehabilitation.