發(fā)布時間：2018-05-23 20:39

  本文選題：脛骨骨折 + 髓內(nèi)釘�。� 參考：《大連醫(yī)科大學(xué)》2015年碩士論文

【摘要】：背景:髓內(nèi)釘治療脛骨近端骨折有成角畸形的問題,1996年Tornetta和Collins發(fā)明了一個新的入路,在膝關(guān)節(jié)半伸直位,切開膝關(guān)節(jié)囊,最初是在髕骨兩側(cè)的髕旁入路插入髓內(nèi)釘,作為改良術(shù)式中的一種,髕上入路切口具有避免過多分離髕腱旁軟組織的優(yōu)點。反對者認(rèn)為該點進(jìn)針增加了髕股關(guān)節(jié)間壓力,損傷髕股關(guān)節(jié)面引發(fā)髕股關(guān)節(jié)炎以及術(shù)后髕前疼痛的問題。但是關(guān)于髕上入路和髕下入路療效差別尚缺乏足夠的數(shù)據(jù)統(tǒng)計分析。目的:比較髓內(nèi)釘內(nèi)固定治療脛骨骨折髕上入路和髕下入路的臨床療效比較。方法:回顧大連醫(yī)科大學(xué)附屬第一醫(yī)院2012年9月至2014年9月收治的應(yīng)用脛骨髓內(nèi)釘治療的42例脛骨骨折病例,男24例,女18例;年齡18-50歲,平均(33.7±7.7)歲。新鮮骨折40例,陳舊骨折2例。骨折類型:根據(jù)A0的Muller分類法:42A1型8例,42A2型22例,42B1型7例,42B2型例,42C1型1例。兩組性別、年齡、骨折部位、骨折類型比較差異無統(tǒng)計學(xué)意義(PO.05),具有可比性。分為兩組,A組是采用的髕上入路髓內(nèi)釘內(nèi)固定的病例,B組是采用的髕下入路髓內(nèi)釘固定的病例。結(jié)果:獲隨訪6個月一2.5年,術(shù)中出血量比較髕上入路組術(shù)中出血60~260 mL,平均112.6 mL;髕下入路組術(shù)中出血80~240 mL,平均121.7 mL。兩組出血量比較無顯著性差異(P0.05)。手術(shù)時間比較髕上組手術(shù)時間65-110分鐘,平均81分鐘;對照髕下組手術(shù)時間60-120分鐘,平均89分鐘。兩組手術(shù)時間比較無顯著性差(P0.05)。髕前痛發(fā)生率髕上組1例,髕下組6例,發(fā)生率分別為5%和27%,共7例術(shù)后出現(xiàn)膝關(guān)節(jié)疼痛,主要為膝前切口淺層疼痛。還有2例出現(xiàn)踝關(guān)節(jié)內(nèi)側(cè)疼痛。兩組患者髕前痛發(fā)生率比較有顯著性差異(P0.05)。骨折愈合時間:髕上入路組18例骨性愈合,2例骨延遲愈合,行動力化3個月后達(dá)到骨性愈合。至末次隨訪無骨折再次移位;內(nèi)固定物無松動、移位或斷裂;也未發(fā)現(xiàn)內(nèi)固定周圍骨折現(xiàn)象。髕下入路組19例骨性愈合,2例骨折延遲愈合,1例動力化3個月后達(dá)骨折愈合。另1例骨折不愈合,二期行自體骨植骨內(nèi)固定后愈合。骨折I期愈合率髕上組和髕下組分別為90%和86.4%,兩組骨折臨床愈合率比較無顯著性差(P0.05)。X線投照次數(shù),髕上入路手術(shù)投照次數(shù)13-32次,平均17次,髕下入路鎖釘投照次數(shù)18-52次,平均31次。兩組投照次數(shù)比較有顯著性差異(P0.05)手術(shù)操作人員:髕上入路組4--8人,平均6.2人。髕下入路組5--9人平均6.7人,兩組手術(shù)操作人員配備比較無顯著性差異(P0.05)。治療結(jié)果兩組術(shù)后均得到隨訪,隨訪時間術(shù)后0.5年至2.5年,平均1.4年,術(shù)后12月Johner-Wuchs評分78-100分,優(yōu)30例,良8例,中2例,差2例,優(yōu)良率達(dá)90%。其中髕上組優(yōu)為14例,良為4例,中為1例,差為1例。優(yōu)良率達(dá)分別為90%。而髕下組優(yōu)為16例,良4例,中為1例,差為1例,優(yōu)良率91%,兩組術(shù)后優(yōu)良率比較無顯著性差(P0.05)。結(jié)論:脛骨骨折應(yīng)用髓內(nèi)釘治療,在膝前痛發(fā)生率和放射線曝光次數(shù)方面髕上入路比髕下入路有明顯的優(yōu)勢。
[Abstract]:Background: in 1996, Tornetta and Collins invented a new approach for the treatment of angular deformities of proximal tibial fractures with intramedullary nailing. In 1996, a new approach was developed, in which the knee joint capsule was cut open at the half extension of the knee joint, and the intramedullary nail was initially inserted into the parrapatellar approach on both sides of the patella. As one of the improved surgical procedures, the suprapatellar approach has the advantage of avoiding excessive separation of the peripatellar soft tissue. Opponents said the needle added to the pressure between the patellofemoral joint, patellofemoral joint surface injury caused patellofemoral arthritis and postoperative prepatellar pain problems. However, the difference between the suprapatellar approach and the subpatellar approach is not statistically significant. Objective: to compare the clinical efficacy of intramedullary nail fixation in the treatment of tibial fracture via superior patellar approach and subpatellar approach. Methods: 42 cases of tibial fractures treated with tibial intramedullary nail from September 2012 to September 2014 in the first affiliated Hospital of Dalian Medical University were retrospectively reviewed, including 24 males and 18 females, aged 18-50 years with an average age of 33.7 鹵7.7 years. Fresh fracture 40 cases, old fracture 2 cases. Fracture types: according to the Muller classification of A0, 8 cases of type 42A2 were classified as type 42A2, 7 cases of type 42B1 were classified as type 42B2, and 1 case of type 42C1. There was no significant difference in sex, age, fracture site and fracture type between the two groups. Two groups were divided into two groups: group A was treated with suprapatellar intramedullary nail fixation and group B was treated with infrapatellar intramedullary nail fixation. Results: during the follow-up period from 6 months to 2.5 years, the amount of intraoperative bleeding was compared with that in the suprapatellar approach group with a mean of 112.6 mL (60 ~ 260mL), while in the infrapatellar approach group, the intrapatellar hemorrhage was 80 ~ 240mL (mean 121.7 mL). There was no significant difference in blood loss between the two groups (P 0.05). The operative time was 65-110 minutes (mean 81 minutes) in the suprapatellar group and 89 minutes (60-120 min) in the control group. There was no significant difference in operation time between the two groups (P 0.05). The incidence of prepatellar pain was 1 in the suprapatellar group and 6 in the subpatellar group. The incidence was 5% and 27% respectively. There were 7 cases of postoperative knee pain, mainly superficial pain in the anterior genicular incision. There were also 2 cases of medial ankle pain. There was significant difference in the incidence of prepatellar pain between the two groups (P 0.05). Fracture healing time: 18 cases of bony union and 2 cases of delayed union of bone in suprapatellar approach group. No redisplacement of fracture, no loosening, displacement or rupture of internal fixator, and no fracture around internal fixation were found at the last follow-up. In the subpatellar approach group, 19 cases of bone healing and 2 cases of delayed fracture healing were achieved after 3 months of dynamic healing. Another case of nonunion was treated with autogenous bone grafting and internal fixation. The rate of fracture healing was 90% in the suprapatellar group and 86.4% in the subpatellar group, respectively. There was no significant difference in the clinical healing rate between the two groups. The number of radiographs taken in the suprapatellar approach was 13-32, with an average of 17, and the number of the locking nails in the subpatellar approach was 18-52. The average is 31. There was a significant difference between the two groups in the number of radiographs (P 0.05): the supracrapatellar approach group consisted of 4-8 patients with an average of 6.2 people. The average number of 5 to 9 patients in the subpatellar approach group was 6.7, and there was no significant difference between the two groups in operating personnel. Results the two groups were followed up for 0.5 to 2.5 years (mean 1.4 years). Johner-Wuchs score was 78-100 points in 12 months after operation. Excellent 30 cases, good 8 cases, medium 2 cases, poor 2 cases, the excellent and good rate was 90%. In the suprapatellar group, 14 cases were excellent, 4 cases were good, 1 case was middle, and 1 case was poor. The excellent and good rate was 90% respectively. In the subpatellar group, 16 cases were excellent, 4 cases were good, 1 case was moderate, and 1 case was poor. The excellent and good rate was 91. There was no significant difference in the excellent and good rate between the two groups. Conclusion: the treatment of tibial fracture with intramedullary nail has obvious advantages over infrapatellar approach in the incidence of anterior knee pain and the times of radiation exposure.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3

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