內(nèi)側(cè)入路治療脛骨平臺骨折時對鵝足不同處理方法的預(yù)后分析
發(fā)布時間：2018-08-03 10:32
【摘要】：目的:膝關(guān)節(jié)作為人體下肢三大負(fù)重關(guān)節(jié)之一,是全身關(guān)節(jié)中滑膜面積最大的關(guān)節(jié),滑膜反應(yīng)也最明顯。膝關(guān)節(jié)是人體較大且復(fù)雜的屈曲關(guān)節(jié)。它所受到的應(yīng)力大,結(jié)構(gòu)穩(wěn)定而又靈活。由于膝關(guān)節(jié)負(fù)重大,運動多,且由于膝關(guān)節(jié)滑膜廣泛位于肢體較表淺的部位,最易受到損傷和感染。所有膝關(guān)節(jié)損傷當(dāng)中,脛骨平臺骨折嚴(yán)重影響了膝關(guān)節(jié)的功能及其穩(wěn)定性。近年來,高能量損傷所致的脛骨平臺骨折呈日益增加的趨勢,且隨著我國社會步入邁入老齡化,患病人數(shù)逐年增多,但往往處理中等能量所致的脛骨平臺骨折時,多采用手術(shù)治療。因此,為了患者術(shù)后更好的日常生活,保護膝關(guān)節(jié)傷后周圍軟組織及患者術(shù)后肢體功能恢復(fù)情況的重要性越來越受到人們的關(guān)注。一般來說,因為Schatzker I型、II型及III型骨折僅涉及脛骨平臺外側(cè)關(guān)節(jié)面,僅需外側(cè)入路手術(shù)即可對其進行良好固定,治療較簡單。而對于高能量損傷所致的Schatzker IV型損傷,臨床上多采用內(nèi)側(cè)手術(shù)入路,至于更加復(fù)雜的Schatzker V型,甚至VI型骨折,常常需要使用內(nèi)側(cè)入路合并外側(cè)入路手術(shù)治療,以達(dá)到良好的治療效果。但脛骨平臺骨折內(nèi)側(cè)入路手術(shù)切口多平行于脛骨近端的后內(nèi)側(cè)緣,作為膝關(guān)節(jié)重要組成部分的鵝足,位于縫匠肌、股薄肌及半腱肌的聯(lián)合腱止點與脛骨內(nèi)側(cè)副韌帶之間,恰好位于切口處。因此,在手術(shù)過程中,術(shù)者不可避免的需要面對處理鵝足的問題。骨折復(fù)位之后,鵝足多被切斷、牽開或直接放置內(nèi)固定物鋼板,但并沒有相關(guān)研究或文獻(xiàn)明確指出,術(shù)中如何處理鵝足,對病人術(shù)后患肢功能恢復(fù)效果最佳。有鑒于此,本研究通過應(yīng)用三種不同的處理鵝足方法,根據(jù)患者術(shù)后3個月,6個月及1年的HSS膝關(guān)節(jié)功能評分互相比較,以評估那種處理方法其臨床療效最佳。方法:取河北醫(yī)科大學(xué)第三醫(yī)院從2012年9月至2014年3月收治的45例存在脛骨平臺內(nèi)側(cè)骨折的患者。納入標(biāo)準(zhǔn):1)患者年齡25歲-55歲之間;2)所有患者均為新鮮閉合性骨折,并且其受傷后2周內(nèi)接受手術(shù)治療;3)術(shù)前檢查均未發(fā)現(xiàn)患有糖尿病、甲狀腺功能亢進以及嚴(yán)重的心、肺、肝、腎功能不全等內(nèi)科疾病及血栓患者。男31例,其中1例為雙側(cè)脛骨平臺骨折,另一患肢診斷為Schatzker II型骨折;女14例。平均40.3歲。左側(cè)26例,右側(cè)19例。按Schatzker分類:IV型32例,V型11例,VI型2例。致傷原因:高處墜落傷31例,交通傷11例,其他3例。所有患者治療內(nèi)側(cè)脛骨平臺骨折時,均選擇切開復(fù)位,采用鎖定鋼板內(nèi)固定手術(shù)治療,取仰臥位,患膝屈曲20°左右,應(yīng)用氣囊止血帶加壓止血。取內(nèi)側(cè)切口,自膝關(guān)節(jié)內(nèi)側(cè)間隙上方5cm起,沿脛骨干縱軸向遠(yuǎn)側(cè)延伸至關(guān)節(jié)間隙下8~10cm。沿皮膚切口切開淺筋膜,充分暴露鵝足肌腱.其中A組15例術(shù)中切斷鵝足,骨折解剖復(fù)位,放置內(nèi)固定物后,予以鵝足7#手術(shù)線縫合,重建修復(fù);B組15例術(shù)中予以骨膜起子及彎鉗細(xì)心分離鵝足,充分牽拉保護,在不影響骨折固定復(fù)位的情況下,將鋼板置于鵝足下方。最后C組15例術(shù)中不分離切斷鵝足,直接將鋼板放置于鵝足上方,予以復(fù)位固定。待內(nèi)側(cè)骨折被糾正后,Schatzker V型及VI型骨折再以外側(cè)手術(shù)入路處理外側(cè)合并骨折。檢測下肢力線和膝關(guān)節(jié)穩(wěn)定性,逐層縫合切口并放置引流。所有患者于術(shù)后第2~3天均拔除引流,開始在不負(fù)重狀態(tài)下的適當(dāng)膝關(guān)節(jié)功能鍛煉。術(shù)后8~10周開始部分負(fù)重鍛煉,定期復(fù)查膝關(guān)節(jié)正側(cè)位X線。待其局部無疼痛及叩痛并且X線提示骨折愈合后,開始完全負(fù)重鍛煉�；颊咝g(shù)后3個月、6個月、12個月隨訪復(fù)查,評估骨折愈合情況、并發(fā)癥發(fā)生情況及膝關(guān)節(jié)關(guān)節(jié)功能恢復(fù)情況,以HSS膝關(guān)節(jié)功能評分為標(biāo)準(zhǔn)。住院期間及隨訪資料通過統(tǒng)計學(xué)分析進行比較。結(jié)果:住院期間患者身體情況指標(biāo)無明顯差異,都為健康成人。隨機分為A、B、C三組,其中A組患者為鵝足修復(fù)重建組,B組為分離鵝足,牽拉保護組,C組為直接安放鋼板,壓迫鵝足組。以患者術(shù)后3個月、6個月、12個月HSS膝關(guān)節(jié)功能評分為標(biāo)準(zhǔn)來評估膝關(guān)節(jié)的功能恢復(fù)情況,根據(jù)患者對疼痛、功能、活動度、肌力、屈曲畸形、穩(wěn)定性和減分項目等方面進行評分,根據(jù)患者術(shù)后1年復(fù)查得到的HSS評分確定術(shù)后恢復(fù)效果。術(shù)后三個月復(fù)查結(jié)果,A組平均HSS評分為69.96,B組平均HSS評分為75.00,C組平均HSS評分為68.33,兩兩比較,A組與B組及B組與C組均數(shù)標(biāo)準(zhǔn)差對比有統(tǒng)計學(xué)意義,P0.05。證明術(shù)后短期3個月復(fù)查,B組處理鵝足的方式優(yōu)于A組與C組,而A組與C組間無明顯差異。術(shù)后六個月復(fù)查結(jié)果,A組平均HSS評分為81.92,B組平均HSS評分為86.06,C組平均HSS評分為79.00,兩兩比較,B組與C組均數(shù)標(biāo)準(zhǔn)差對比有統(tǒng)計學(xué)意義,P0.05;而A組與C組之間無統(tǒng)計學(xué)意義,P0.05。證明術(shù)后6個月復(fù)查,B組處理鵝足的方式優(yōu)于C組,而A組與C組及A組與B組間互相比較,無明顯區(qū)別。術(shù)后1年患者復(fù)查,A組平均HSS評分為85.42,B組平均HSS評分為87.20,C組平均HSS評分為81.13,兩兩比較,B組與C組均數(shù)標(biāo)準(zhǔn)差對比,P=0.05;而A組與C組之間無統(tǒng)計學(xué)意義,P0.05。證明術(shù)后12個月復(fù)查,三組處理方式對患者膝關(guān)節(jié)功能恢復(fù)則無明顯區(qū)別。所有45例患者,除A組一例患者于六個月復(fù)查時脫漏,其他患者都獲得了12個月以上的隨訪,隨訪期間骨折均得到愈合,C組1例患者出現(xiàn)鵝足滑膜炎。經(jīng)統(tǒng)計學(xué)分析,患者術(shù)后1年復(fù)查,A組患者HSS評分,總14例,優(yōu)11良2可1差0。B組患者總15例,優(yōu)12良2可1差0,C組患者總15例,優(yōu)10良1可3差1,根據(jù)統(tǒng)計學(xué)卡方檢驗,P0.99,無明顯統(tǒng)計學(xué)差異。因此,根據(jù)術(shù)后長期效果,三組處理方式對于患者的術(shù)后功能恢復(fù)并未有明顯區(qū)別。但就本組研究來看,B組相對于A組與C組預(yù)后優(yōu)良率明顯稍高(93.33%92.86%73.33%)。結(jié)論:本研究通過分析在以內(nèi)側(cè)手術(shù)入路治療脛骨平臺內(nèi)側(cè)骨折時,比較三種不同的術(shù)中處理鵝足方式,根據(jù)其術(shù)后3個月,6個月及1年的HSS膝關(guān)節(jié)功能評分可以發(fā)現(xiàn),術(shù)中予以患者分離鵝足,牽拉保護,術(shù)后短期內(nèi)可有效促進患者膝關(guān)節(jié)功能恢復(fù),減少疼痛,提高了患者術(shù)后生活質(zhì)量。所以我們可以認(rèn)為,對于Schatzker IV、V型及VI型脛骨平臺的治療,充分保護鵝足,是最合適的選擇,為患者術(shù)后功能恢復(fù)創(chuàng)造了有利條件。
[Abstract]:Objective: as one of the three heavy joints of the lower limbs of the lower limbs of the human body, the knee joint is the largest joint in the synovial membrane and the most obvious synovial reaction. The knee joint is the large and complex flexion joint of the human body. It is subjected to large stress, stable and flexible structure. Because of the large knee joint, many movements, and wide position of the knee joint synovium. The fracture of the tibial plateau seriously affects the function and stability of the knee joint in all knee joint injuries. In recent years, the fracture of the tibial plateau caused by high energy damage is increasing, and the number of diseases is increasing year by year as our society enters the aging process, but the number of patients is increasing year by year. Surgical treatment is often used when treating fractures of the tibial plateau caused by moderate energy. Therefore, the importance of protecting the soft tissue and the recovery of limb function after the injury of the knee joint is becoming more and more important for the better daily life of the patients. Generally speaking, the Schatzker I, II and III fractures are only the only ones. The lateral articular surface of the tibial plateau involves a good fixation and simple treatment with the lateral approach. For the Schatzker IV type injury caused by high energy damage, the medial approach is often used clinically. As for the more complex Schatzker V, or even the VI type fracture, the medial approach is often required to be used with the lateral approach. The medial approach of the tibial plateau fracture is mostly parallel to the posterior medial edge of the proximal tibia. As an important part of the knee joint, the surgical incision is located between the sartorius muscle, the combined tendon of the gracilis and the semitendinosus and the medial tibial collateral ligament, which happens to be located at the incision. Therefore, the operation is over. In the course, the operator inevitably needs to face the problem of treating goose foot. After the reduction of fracture, the goose foot is cut off, and the internal fixation plate is placed directly or directly, but there is no related research or the literature clearly points out that how to deal with goose foot in the operation is the best for the patient's limb function recovery after operation. In view of this, three kinds of methods are applied in this study. Different methods of handling the goose foot were compared to each other according to the HSS knee joint function score of the 3 months, 6 months and 1 years after the operation to assess the best clinical effect of the treatment. Methods: 45 patients with the medial tibial plateau fracture from September 2012 to March 2014 were treated by the third Hospital of Hebei Medical University. 1) All patients were 25 years old -55 years old and 2) all patients were fresh closed fracture and underwent surgical treatment within 2 weeks after injury; 3) no diabetes, hyperthyroidism and severe heart, lung, liver, renal dysfunction and other internal medical diseases and thrombus patients were found before operation. 31 cases were male and 1 of them were bilateral tibial plateau fractures. One limb was diagnosed as Schatzker II type fracture, 14 female cases, average 40.3 years old, left 26 cases and right 19 cases. According to Schatzker classification: IV type 32 cases, V type 11 cases, VI type 2 cases. The cause of injury: high falling injury 31 cases, traffic injury 11 cases, other 3 cases. All patients were treated with open reduction and locking plate internal fixation operation when treating medial tibial plateau fracture. Treatment, take the supine position, the knee flexion 20 degrees about 20 degrees, use the airbag tourniquet pressure hemostasis. Take the medial incision, from the medial space of the knee joint above the medial space of the knee joint, extending the longitudinal axis of the tibia shaft to the distal part to the joint space and opening the superficial fascia along the skin incision and exposing the tendon of the goose foot fully. Among them, 15 cases of A group cut off the goose foot and dissection the fracture anatomic reduction. After placing the internal fixator, the goose foot was sutured and repaired by 7# operation line. In group B, 15 cases were treated with periosteum and bending forceps to separate the goose foot carefully. The plate was placed under the goose foot without affecting the fixed reduction. In the final group, 15 cases in group C were not separated from the goose foot, and the steel plate was placed directly above the goose foot. Reposition and fixation. After the medial fracture was corrected, Schatzker V and VI type fractures were treated with lateral surgical approach to treat the lateral combined fracture. The stability of the lower limb force line and knee joint was detected, the incision was sutured and the drainage was placed by layer. All patients removed the drainage on day 2~3 after the operation and began to exercise appropriate knee joint function under the condition of no weight negative. 3 months, 6 months and 12 months after 3 months, 6 months, and 12 months follow-up examination, the patients were followed up to evaluate the fracture healing, complications and knee joint function recovery, HSS The score of knee joint function was the standard. During the period of hospitalization and follow-up data, the results were compared by statistical analysis. Results: there were no significant differences in physical condition between patients during hospitalization and healthy adults. They were randomly divided into three groups: A, B, C, of which group A patients were goose foot repair and reconstruction group, B group was separated goose foot, traction protection group, and C group was directly placed steel plate, The functional recovery of the knee joint was evaluated by the 3 months, 6 months and 12 months HSS knee joint function score of the patients. The patients were scored according to the patients' pain, function, activity, muscle strength, flexion deformity, stability and subtraction, and the HSS score of the patients after 1 years' reexamination was determined after the operation. The results were three months after the operation, the average HSS score in group A was 69.96, the average HSS score in group B was 75, the average HSS score in group C was 68.33, and 22 was compared. The comparison of the standard difference between the A group and B group and B group and C group was statistically significant. The average HSS score in group A was 81.92, the average HSS score in group B was 86.06, the average HSS score in group C was 79, and the comparison of the standard difference between the B group and C group was statistically significant, but there was no statistical significance between the B group and the C group, while the A group and the C group were not statistically significant, and the P0.05. proved 6 months after the operation, and the way to deal with goose feet was better than that of the group. There was no significant difference between group A and group C and group A and group B. The average HSS score in group A after 1 years of operation was 85.42, the average HSS score in group B was 87.20, the average HSS score of group C was 81.13, 22 was compared, and there was no statistical difference between the B group and the C group, but there was no statistical significance between the group and the group, three after 12 months of review, three, three. There was no significant difference between the group treatment and the recovery of the knee joint function. All 45 cases, except one case in group A, were missed at six months, and all the other patients were followed up for more than 12 months. All the fractures were healed during the follow-up period, and 1 patients in group C had the synovitis of goose foot. After statistical analysis, the patients were rechecked for 1 years after 1 years and the patients in group A were reexamined. HSS score, total 14 cases, excellent 11 good 2 1 poor 0.B patients total 15 cases, excellent 12 good 2 to 1 difference 0, C group of 15 patients, excellent 10 good 1 can be 3 difference 1, according to statistical chi square test, P0.99, no significant statistical difference. The good prognosis of group B was slightly higher than that of group A and C (93.33%92.86%73.33%). Conclusion: in this study, three different methods of handling goose foot were compared in the treatment of medial tibial plateau fracture by medial surgical approach. The HSS knee function score of 6 months and 1 years after the operation was found to be found during the operation. It can effectively promote the recovery of the knee joint function, reduce the pain and improve the quality of life after operation, so we can think that it is the most suitable choice for the treatment of Schatzker IV, V type and VI type tibial plateau to fully protect the goose foot, which creates a favorable article for the postoperative recovery of the patients' function. Pieces.
【學(xué)位授予單位】：河北醫(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
本文編號：2161470
[Abstract]:Objective: as one of the three heavy joints of the lower limbs of the lower limbs of the human body, the knee joint is the largest joint in the synovial membrane and the most obvious synovial reaction. The knee joint is the large and complex flexion joint of the human body. It is subjected to large stress, stable and flexible structure. Because of the large knee joint, many movements, and wide position of the knee joint synovium. The fracture of the tibial plateau seriously affects the function and stability of the knee joint in all knee joint injuries. In recent years, the fracture of the tibial plateau caused by high energy damage is increasing, and the number of diseases is increasing year by year as our society enters the aging process, but the number of patients is increasing year by year. Surgical treatment is often used when treating fractures of the tibial plateau caused by moderate energy. Therefore, the importance of protecting the soft tissue and the recovery of limb function after the injury of the knee joint is becoming more and more important for the better daily life of the patients. Generally speaking, the Schatzker I, II and III fractures are only the only ones. The lateral articular surface of the tibial plateau involves a good fixation and simple treatment with the lateral approach. For the Schatzker IV type injury caused by high energy damage, the medial approach is often used clinically. As for the more complex Schatzker V, or even the VI type fracture, the medial approach is often required to be used with the lateral approach. The medial approach of the tibial plateau fracture is mostly parallel to the posterior medial edge of the proximal tibia. As an important part of the knee joint, the surgical incision is located between the sartorius muscle, the combined tendon of the gracilis and the semitendinosus and the medial tibial collateral ligament, which happens to be located at the incision. Therefore, the operation is over. In the course, the operator inevitably needs to face the problem of treating goose foot. After the reduction of fracture, the goose foot is cut off, and the internal fixation plate is placed directly or directly, but there is no related research or the literature clearly points out that how to deal with goose foot in the operation is the best for the patient's limb function recovery after operation. In view of this, three kinds of methods are applied in this study. Different methods of handling the goose foot were compared to each other according to the HSS knee joint function score of the 3 months, 6 months and 1 years after the operation to assess the best clinical effect of the treatment. Methods: 45 patients with the medial tibial plateau fracture from September 2012 to March 2014 were treated by the third Hospital of Hebei Medical University. 1) All patients were 25 years old -55 years old and 2) all patients were fresh closed fracture and underwent surgical treatment within 2 weeks after injury; 3) no diabetes, hyperthyroidism and severe heart, lung, liver, renal dysfunction and other internal medical diseases and thrombus patients were found before operation. 31 cases were male and 1 of them were bilateral tibial plateau fractures. One limb was diagnosed as Schatzker II type fracture, 14 female cases, average 40.3 years old, left 26 cases and right 19 cases. According to Schatzker classification: IV type 32 cases, V type 11 cases, VI type 2 cases. The cause of injury: high falling injury 31 cases, traffic injury 11 cases, other 3 cases. All patients were treated with open reduction and locking plate internal fixation operation when treating medial tibial plateau fracture. Treatment, take the supine position, the knee flexion 20 degrees about 20 degrees, use the airbag tourniquet pressure hemostasis. Take the medial incision, from the medial space of the knee joint above the medial space of the knee joint, extending the longitudinal axis of the tibia shaft to the distal part to the joint space and opening the superficial fascia along the skin incision and exposing the tendon of the goose foot fully. Among them, 15 cases of A group cut off the goose foot and dissection the fracture anatomic reduction. After placing the internal fixator, the goose foot was sutured and repaired by 7# operation line. In group B, 15 cases were treated with periosteum and bending forceps to separate the goose foot carefully. The plate was placed under the goose foot without affecting the fixed reduction. In the final group, 15 cases in group C were not separated from the goose foot, and the steel plate was placed directly above the goose foot. Reposition and fixation. After the medial fracture was corrected, Schatzker V and VI type fractures were treated with lateral surgical approach to treat the lateral combined fracture. The stability of the lower limb force line and knee joint was detected, the incision was sutured and the drainage was placed by layer. All patients removed the drainage on day 2~3 after the operation and began to exercise appropriate knee joint function under the condition of no weight negative. 3 months, 6 months and 12 months after 3 months, 6 months, and 12 months follow-up examination, the patients were followed up to evaluate the fracture healing, complications and knee joint function recovery, HSS The score of knee joint function was the standard. During the period of hospitalization and follow-up data, the results were compared by statistical analysis. Results: there were no significant differences in physical condition between patients during hospitalization and healthy adults. They were randomly divided into three groups: A, B, C, of which group A patients were goose foot repair and reconstruction group, B group was separated goose foot, traction protection group, and C group was directly placed steel plate, The functional recovery of the knee joint was evaluated by the 3 months, 6 months and 12 months HSS knee joint function score of the patients. The patients were scored according to the patients' pain, function, activity, muscle strength, flexion deformity, stability and subtraction, and the HSS score of the patients after 1 years' reexamination was determined after the operation. The results were three months after the operation, the average HSS score in group A was 69.96, the average HSS score in group B was 75, the average HSS score in group C was 68.33, and 22 was compared. The comparison of the standard difference between the A group and B group and B group and C group was statistically significant. The average HSS score in group A was 81.92, the average HSS score in group B was 86.06, the average HSS score in group C was 79, and the comparison of the standard difference between the B group and C group was statistically significant, but there was no statistical significance between the B group and the C group, while the A group and the C group were not statistically significant, and the P0.05. proved 6 months after the operation, and the way to deal with goose feet was better than that of the group. There was no significant difference between group A and group C and group A and group B. The average HSS score in group A after 1 years of operation was 85.42, the average HSS score in group B was 87.20, the average HSS score of group C was 81.13, 22 was compared, and there was no statistical difference between the B group and the C group, but there was no statistical significance between the group and the group, three after 12 months of review, three, three. There was no significant difference between the group treatment and the recovery of the knee joint function. All 45 cases, except one case in group A, were missed at six months, and all the other patients were followed up for more than 12 months. All the fractures were healed during the follow-up period, and 1 patients in group C had the synovitis of goose foot. After statistical analysis, the patients were rechecked for 1 years after 1 years and the patients in group A were reexamined. HSS score, total 14 cases, excellent 11 good 2 1 poor 0.B patients total 15 cases, excellent 12 good 2 to 1 difference 0, C group of 15 patients, excellent 10 good 1 can be 3 difference 1, according to statistical chi square test, P0.99, no significant statistical difference. The good prognosis of group B was slightly higher than that of group A and C (93.33%92.86%73.33%). Conclusion: in this study, three different methods of handling goose foot were compared in the treatment of medial tibial plateau fracture by medial surgical approach. The HSS knee function score of 6 months and 1 years after the operation was found to be found during the operation. It can effectively promote the recovery of the knee joint function, reduce the pain and improve the quality of life after operation, so we can think that it is the most suitable choice for the treatment of Schatzker IV, V type and VI type tibial plateau to fully protect the goose foot, which creates a favorable article for the postoperative recovery of the patients' function. Pieces.
【學(xué)位授予單位】：河北醫(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
【引證文獻(xiàn)】
相關(guān)會議論文 前1條
1 梅永良;;AO-BO理念及MO概念在骨折中的應(yīng)用[A];2007年貴州省醫(yī)學(xué)會骨科學(xué)分會學(xué)術(shù)年會論文匯編[C];2007年
，本文編號：2161470
本文鏈接：http://sikaile.net/yixuelunwen/waikelunwen/2161470.html
最近更新
教材專著
