發(fā)布時(shí)間：2018-04-13 01:35

  本文選題：鋼板 + 髓內(nèi)釘　； 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：研究背景目前,髓內(nèi)釘技術(shù)已經(jīng)廣泛應(yīng)用在臨床的骨科手術(shù)中,效果也很確切,但是用來(lái)治療脛骨多段骨折仍存在失敗的幾率。國(guó)內(nèi)外的學(xué)者已經(jīng)就固定失敗的原因做了比較全面的闡釋,但對(duì)二次手術(shù)的指導(dǎo)性卻鮮有報(bào)道。有學(xué)者認(rèn)為,既然髓內(nèi)釘內(nèi)固定手術(shù)失敗,那么二次手術(shù)換用鋼板固定應(yīng)該是最佳選擇,然而,分析種種髓內(nèi)釘固定失敗的原因,很多的骨折不愈合并不是髓內(nèi)釘造成的,而且髓腔在擴(kuò)髓之后髓內(nèi)釘是否依然有效存在爭(zhēng)議【1】。因此,在髓內(nèi)釘固定失敗后,需要對(duì)補(bǔ)救治療方式進(jìn)行指導(dǎo),才能完善整個(gè)髓內(nèi)釘?shù)膬?nèi)固定體系,給患者帶來(lái)福音。目的探討脛骨多端骨折髓內(nèi)釘固定后骨折不愈合的治療方式,并對(duì)不同類(lèi)型的骨折不愈合翻修方式的療效進(jìn)行對(duì)比分析,為該疾病的診治提供更好的診療基礎(chǔ)及術(shù)前指導(dǎo)依據(jù)。方法對(duì)鄭州大學(xué)第一附屬醫(yī)院骨外科2004年1月至2017年3月治療的25例脛骨多段骨折髓內(nèi)釘固定后骨折不愈合的患者資料進(jìn)行回顧性分析。所選患者均在骨折髓內(nèi)釘固定失敗后接受后續(xù)治療,平均既往手術(shù)次數(shù)1.5次,其中男性14例,女性11例,年齡20-50歲,平均年齡36.5歲,左側(cè)13例,右側(cè)12例,均為脛骨多端或粉碎骨折髓內(nèi)釘術(shù)后。入院患者完善術(shù)前準(zhǔn)備,手術(shù)時(shí)機(jī)成熟后進(jìn)行手術(shù)治療。將接受二次手術(shù)治療的病人分為2組,A組15人,二次手術(shù)前有3人存在膝關(guān)節(jié)畸形,接受了取出原有髓內(nèi)釘,采用雙鋼板固定的手術(shù);B組10人,二次手術(shù)前有3人存在膝關(guān)節(jié)畸形,接受了更換新的髓內(nèi)釘?shù)氖中g(shù)。兩組患者均在術(shù)中視情況適當(dāng)植骨,以促進(jìn)骨折愈合。術(shù)后長(zhǎng)期進(jìn)行隨訪,觀察并記錄骨折愈合患者的人數(shù),在骨折不愈合的病理分型、形態(tài)分型和部位等方面對(duì)A、B兩組患者骨折的愈合率進(jìn)行統(tǒng)計(jì)學(xué)分析,從而對(duì)二次手術(shù)方式療效進(jìn)行評(píng)價(jià)。結(jié)果患者住院時(shí)間14.3±3.5天,平均12.5天。術(shù)后所有患者均獲得6-12個(gè)月(平均8.3個(gè)月)的隨訪,隨訪期間患者均無(wú)其余外傷或者死亡之情況。患者定期復(fù)查的X光片均可見(jiàn)有明顯的骨痂形成,骨折存在愈合跡象。對(duì)于肥大型骨折不愈合兩種手術(shù)方式愈合率無(wú)明顯差異(P0.05),而萎縮性骨折不愈合時(shí)A組的愈合率要高于B組(P0.05);當(dāng)骨折不愈合發(fā)生脛骨上半段時(shí),A組的愈合率高于B組(P0.05),發(fā)生在脛骨下半段時(shí)A組的愈合率要低于B組(P0.05);對(duì)于簡(jiǎn)單的橫斷、斜形骨折不愈合,A、B兩組的骨折愈合率沒(méi)有明顯的差異(P0.05),而對(duì)于存在旋轉(zhuǎn)、多部分的復(fù)雜骨折不愈合,A組的愈合率要高于B組(P0.05)。結(jié)論脛骨多段骨折髓內(nèi)釘固定不愈合時(shí),雙鋼板固定在萎縮性骨不愈合、上半段骨折不愈合及復(fù)雜骨折不愈合等方面具有顯著優(yōu)勢(shì);而脛骨下半段的簡(jiǎn)單肥大骨折不愈合時(shí),更換髓內(nèi)釘具有顯著優(yōu)勢(shì)。可以在臨床上作為術(shù)前指導(dǎo)依據(jù)。
[Abstract]:Background at present, intramedullary nail technology has been widely used in clinical orthopedic surgery, the effect is also very accurate, but there is still a probability of failure in the treatment of tibial fractures.Scholars at home and abroad have made a comprehensive explanation of the reasons for the failure of fixation, but there are few reports on the guidance of secondary surgery.Some scholars believe that, since intramedullary nail internal fixation failed, then secondary surgery should be the best choice for plate fixation. However, by analyzing the causes of various failure of intramedullary nail fixation, many nonunion fractures are not caused by intramedullary nail.And whether intramedullary nail is still effective after reaming is controversial [1].Therefore, after the failure of intramedullary nail fixation, it is necessary to guide the remedial treatment to improve the internal fixation system of the whole intramedullary nail and bring good news to the patients.Objective to explore the treatment methods of nonunion of tibial fractures after fixation with intramedullary nail, and to compare and analyze the curative effect of different types of revision methods of fracture nonunion, so as to provide a better basis for diagnosis and treatment and guidance before operation for the diagnosis and treatment of this disease.Methods from January 2004 to March 2017, 25 cases of nonunion of tibial fractures treated with intramedullary nail fixation in the first affiliated Hospital of Zhengzhou University were retrospectively analyzed.All the patients received follow-up treatment after the failure of intramedullary nail fixation. The average number of previous operations was 1.5, including 14 males and 11 females, aged 20-50 years, with an average age of 36.5 years, left 13 cases and right 12 cases.All of them were treated with multiple tibia or comminuted intramedullary nail.The preoperative preparation was improved and the operative time was ripe for surgical treatment.The patients were divided into two groups: group A (n = 15) and group A (n = 15). There were 3 patients with knee joint malformation before the second operation, and 10 patients in group B were treated with intramedullary nail removal and double plate fixation.Three people had knee deformities prior to secondary surgery and underwent surgery to replace new intramedullary nails.The patients in both groups received proper bone grafting during operation to promote fracture healing.After long-term follow-up, the number of fracture healing patients was observed and recorded. The rate of fracture healing in group A B was statistically analyzed in terms of pathological classification, morphological classification and site of nonunion.Therefore, the curative effect of secondary operation was evaluated.Results the hospitalization time was 14.3 鹵3.5 days, with an average of 12.5 days.All patients were followed up for 6 to 12 months (average 8.3 months).The X-ray films showed obvious callus formation and fracture healing.There was no significant difference in the healing rate between the two surgical methods for the nonunion of fat large fractures, but the healing rate of group A was higher than that of group B when the nonunion of atrophic fractures occurred, and the healing rate of group A was higher than that of group B when the nonunion of fracture occurred in the upper half of tibia.The healing rate of group A was lower than that of group B at the lower half of tibia.There was no significant difference in fracture healing rate between group A and group A, but the rate of union in group A was higher than that in group B for complex nonunion with rotation.Conclusion double plate fixation has significant advantages in atrophic bone nonunion, upper half fracture nonunion and complex fracture nonunion, while in simple hypertrophic fracture of the lower half of the tibia, it has significant advantages in nonunion of multiple tibial fractures with intramedullary nail fixation.Replacement of intramedullary nails has significant advantages.It can be used as the basis of preoperative guidance in clinic.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R687.3

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