本文選題：脛骨髓內(nèi)釘 + 髕上入路　； 參考：《吉林大學》2015年碩士論文

【摘要】：目的：探討三種不同近端手術(shù)入路經(jīng)交鎖髓內(nèi)釘(IMN)固定治療脛骨的手術(shù)時間、出血量、愈合時間以及術(shù)后膝關(guān)節(jié)疼痛發(fā)生率及膝關(guān)節(jié)功能效果，并分析導致術(shù)后相關(guān)并發(fā)癥的因素，為以后手術(shù)方式的選擇及研究提供依據(jù)并分享一些手術(shù)技巧及功能鍛煉方面的經(jīng)驗及體會。 方法：回顧性研究2012年8月至2014年11月期間，我院骨科創(chuàng)傷學組診治的脛骨骨折患者經(jīng)篩選后得到58例。所有患者均為高能量損傷，包括車禍傷、砸傷、高空墜落傷)均采用國產(chǎn)或進口交鎖髓內(nèi)釘，直徑8-10mm.長度280-360mm，男34例，女24例。年齡16—63周歲，平均年齡48.5歲。外傷原因：車禍傷32例，跌倒砸傷15例，高空墜落傷11例。將58例患者按手入路分為A、B、C三組，A組經(jīng)髕韌帶入路組患者28名，B組經(jīng)髕韌帶旁入路患者13名，C組經(jīng)髕上入路組患者17名。每組都記錄相應(yīng)手術(shù)時間、出血量等，住院期間開始在醫(yī)師指導下進行早期功能鍛煉。術(shù)后根據(jù)復(fù)查、隨訪都記錄愈合時間，有無感染、骨筋膜室綜合癥、骨不連等并發(fā)癥，并應(yīng)用相同的膝關(guān)節(jié)運動功能評價標準評估術(shù)后膝關(guān)節(jié)功能和相關(guān)并發(fā)癥的發(fā)生率。平均隨訪18個月（最短12個月，最長20個月）。骨折1-7天內(nèi)行手術(shù)治療。排除標準:陳舊性骨折、病理性骨折、合并膝關(guān)節(jié)損傷或骨性關(guān)節(jié)炎。統(tǒng)計學方法:應(yīng)用SPSS18.0軟件進行數(shù)據(jù)處理，資料用均數(shù)加減標準（X±S）表示，數(shù)據(jù)比較采用方差分析，P＜0.05差異有統(tǒng)計學意義。 結(jié)果：對手術(shù)中相關(guān)指標如手術(shù)時間，出血量等進行記錄并分析，對患者定期復(fù)查、電話、二次手術(shù)取出內(nèi)固定裝置等方式隨訪，隨訪內(nèi)容包括術(shù)后相關(guān)節(jié)間段的影像學資料以及是否存在膝前疼痛、膝關(guān)節(jié)活動范圍、日常生活恢復(fù)水平。絕大多數(shù)骨折均達到臨床愈合標準，愈合時間為75-85天，平均81天，有1例出現(xiàn)了骨不連，考慮原因為閉合復(fù)位不理想，鎖釘位置偏移。有1例行“經(jīng)髕韌帶入路”的患者術(shù)后銅綠假單胞菌感染，經(jīng)一期手術(shù)清創(chuàng)、氟喹諾酮類藥物抗炎治療一周后傷口愈合，未拔出髓內(nèi)釘。經(jīng)髕韌帶入路組共10例出現(xiàn)術(shù)后膝關(guān)節(jié)輕中度疼痛；經(jīng)髕韌帶旁入路組共8例出現(xiàn)術(shù)后膝關(guān)節(jié)輕中度疼痛，經(jīng)髕韌帶入路組共4例出現(xiàn)術(shù)后膝關(guān)節(jié)輕中度疼痛。術(shù)后膝關(guān)節(jié)評分三組患者為83-95，平均91分，，1例開放性骨折的患者開放創(chuàng)口較小為皮膚擦傷，經(jīng)清創(chuàng)控制感染后行髕上入路髓內(nèi)釘固定，術(shù)后未出現(xiàn)了切口及創(chuàng)口的表面感染，在常規(guī)換藥2周后切口愈合。根據(jù)術(shù)后膝關(guān)節(jié)同意功能評分標準評分，58例患者中優(yōu)47例，良10例，中1例，差0例，總的優(yōu)良率為98.2%。按照骨術(shù)中出血量B組與A、C組P＜0.05，差別有統(tǒng)計學意義，B組與A組P0.05，差別無統(tǒng)計學意義，即經(jīng)髕韌帶入路和經(jīng)髕上入路比經(jīng)髕旁入路髓內(nèi)釘內(nèi)固定治療脛骨骨折書中出血量少。手術(shù)時間指標A組與B組、A組與C組間相較P0.05，差別無統(tǒng)計學意義，B組與C組P0.05，差別無統(tǒng)計學意義，即經(jīng)髕韌帶入路、經(jīng)髕上入路和經(jīng)髕旁入路髓內(nèi)釘內(nèi)固定治療脛骨骨折手術(shù)時間無明顯差異。愈合時間及術(shù)后感染、骨不連、骨筋膜室綜合癥發(fā)生率指標A、B、C三組P＞0.05，差別無統(tǒng)計學意義，即三組住院時間、骨折愈合時間及術(shù)后相關(guān)并發(fā)癥無明顯差別。術(shù)后疼痛等功能評分A組與B組、A組與C組間相較P＜0.05，差別具有統(tǒng)計學意義，B組與C組P0.05，差別無統(tǒng)計學意義，即經(jīng)髕韌帶入路比較經(jīng)髕上入路和經(jīng)髕旁入路髓內(nèi)釘內(nèi)固定治療脛骨骨折術(shù)后膝前痛發(fā)生率高。經(jīng)髕韌帶組一例患者術(shù)中擴髓操作不當導致髕韌帶撕裂，經(jīng)韌帶縫合線縫合后術(shù)后出現(xiàn)明顯膝前疼痛及功能障礙。其余無明顯手術(shù)意外出現(xiàn)。 結(jié)論：隨著理論的進步與科學的發(fā)展，使用髓內(nèi)釘治療脛骨或合并腓骨骨折逐漸成為大家的共識，并取得了良好的臨床效果，對于相關(guān)手術(shù)入路及手術(shù)體位、術(shù)后相關(guān)并發(fā)癥的研究仍有分歧。和經(jīng)髕韌帶途徑相比，經(jīng)髕韌帶旁途徑和髕上途徑治療脛骨骨折膝關(guān)節(jié)功能評分更高和膝關(guān)節(jié)疼痛發(fā)生率更低；和髕韌帶途徑和髕上途徑相比，經(jīng)髕韌帶旁途徑出血較多，除此外，三者在手術(shù)時間、愈合時間指標上無差異。術(shù)中精細的操作、軟組織的保護及重建非常有利于預(yù)后。
[Abstract]:Objective: To explore the operative time, bleeding volume, healing time, the incidence of knee joint pain and the effect of knee joint function after three different proximal surgical approach interlocking intramedullary nail (IMN) fixation, and to analyze the factors leading to the postoperative complications and to provide the basis for the selection and study of the methods of hand operation and to share some of them. Experience and understanding of surgical skills and functional exercises.
Methods: from August 2012 to November 2014, 58 cases of tibial fractures in the Department of orthopedics of our hospital were screened. All patients were treated with high energy injury, including car accident injury, injury, high altitude falling injury, both domestic or oral interlocking intramedullary nail, diameter 8-10mm. length 280-360mm, male 34 cases, female 24 cases. Age 1. 6 to 63 years old, the average age of 48.5 years. The cause of trauma: accident injury 32 cases, fall and crush 15 cases, high altitude fall 11 cases. 58 patients were divided into A, B, C three, group A, 28 by patellar ligament entry group, 13 by patellar ligament approach in group B and 17 in group of patellar approach group in group C. Each group recorded the corresponding operation time, bleeding volume. In the period of hospitalization, early functional exercise was conducted under the guidance of the physician. After the reexamination, the healing time was recorded, the complications such as infection, osteofascial compartment syndrome, bone nonunion were recorded, and the incidence of postoperative knee function and related complications was evaluated with the same knee motion function evaluation criteria. The average follow-up was 18 months. The shortest 12 months, the longest 20 months). Surgical treatment within 1-7 days of fracture. Exclusion criteria: old fracture, pathological fracture, knee joint injury or osteoarthritis. Statistical method: data processing with SPSS18.0 software, data using mean number addition and subtraction standard (X + S), data comparison using variance analysis, P < 0.05 difference statistics Significance.
Results: the related indexes such as the operation time and the amount of bleeding were recorded and analyzed. The patients were reviewed regularly, the telephone and the internal fixation devices were taken out of the two operation. The follow-up contents included the imaging data of the inter articular segment after the operation, the existence of pain in the knee, the range of knee joint activity, and the level of daily life. Most fractures reached the standard of clinical healing, with a healing time of 75-85 days, an average of 81 days, and 1 cases of bone nonunion. Considering the reasons for closed reduction and locking position, 1 cases of Pseudomonas aeruginosa infection after the "patellar ligament approach" were treated after one stage operation debridement and fluoroquinolones for one week after anti-inflammatory treatment. The wound healing, unpulled intramedullary nail. 10 cases of mild and moderate pain in the knee joint after the patellar ligament approach group, 8 cases of mild and moderate pain in the knee joint after the patellar ligament approach group, and 4 cases of mild and moderate pain in the knee joint after the patellar ligament approach. The score of the knee joint was 83-95, 91 and 1 open after the operation. The patients with sexual fracture were less open wound and skin bruise, with intramedullary nail fixation after debridement control, and no surface infection of incision and wound after operation. The incision healed after 2 weeks of conventional change. According to the score of the knee joint agreement function score, 58 patients were excellent in 47 cases, good in 10 cases, 1 in 1 cases, and 0 cases in general. The good rate was 98.2%. in group B and A in bone operation, and P < 0.05 in group C. The difference was statistically significant. There was no statistical difference between group B and A group P0.05, that is, there was less bleeding in the treatment of tibial fracture by patellar ligament approach and patellar approach by intramellar intramedullary nail internal fixation. There was no significant difference in the difference between the B group and the C group P0.05. There was no significant difference between the patellar ligament approach, the patellar approach and the intramapellar intramedullary nail internal fixation for the treatment of tibial fracture. The healing time and postoperative infection, bone nonunion, and the incidence of osteofascial compartment syndrome were A, B, C three, P > 0.05, and there was no statistical difference. Meaning, there was no significant difference between the three groups of hospitalization time, fracture healing time and postoperative complications. Postoperative pain scores in group A and group B, group A and group C were P < 0.05, the difference was statistically significant. There was no statistical difference between group B and C group P0.05, that is, comparing the patellar approach to the patellar approach and the intramedullary intramedullary nail by patellar approach. There is a high incidence of anterior knee pain in the fixed treatment of tibial fracture. A patient with patellar ligament is unsuitable to tear the patellar ligament during the operation. After suture of the ligamentous suture, there is obvious anterior knee pain and dysfunction after the suture of the ligamentous suture.
Conclusion: with the progress of theory and the development of science, intramedullary nail is gradually becoming a common understanding in the treatment of tibia and fracture of the fibula, and good clinical results have been achieved. There are still differences in the study of related surgical approaches, surgical position and postoperative complications. The knee joint function score of the tibial fracture is higher and the incidence of knee joint pain is lower. Compared with the patellar approach and the patellar approach, there are more bleeding than the patellar approach. Besides, there are no differences in the time of the operation and the time of healing. The fine exercises in the operation, the protection and reconstruction of the soft tissue are very beneficial to the prognosis in the three cases.
【學位授予單位】：吉林大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R687.3

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