【摘要】：目的:脛骨下段骨折是臨床上較常見(jiàn)的骨折之一,多由高能量損傷所致。由于脛骨下段骨性解剖結(jié)構(gòu)特殊、軟組織覆蓋較少及血運(yùn)較差,骨折后易導(dǎo)致骨折延遲愈合、不愈合的發(fā)生[1]。因此在治療脛骨下段骨折的過(guò)程中,有效的保護(hù)骨折斷端血運(yùn)、減少對(duì)軟組織及骨外膜的損傷是提高臨床治療效果的關(guān)鍵。交鎖髓內(nèi)釘固定和鎖定加壓鋼板固定是目前脛骨下段骨折較為常用的兩種手術(shù)內(nèi)固定方式,但其優(yōu)劣尚存爭(zhēng)議。本課題的研究目的是比較交鎖髓內(nèi)釘與鎖定加壓鋼板治療脛骨下段骨折的臨床療效,為以后手術(shù)方式的選擇提供依據(jù)。方法:回顧性分析2013年5月至2015年11月我院收治的94例脛骨下段骨折患者為研究對(duì)象。男55例,女39例。年齡在21~64歲之間,平均年齡為(40.9±3.1)歲。骨折按照AO分型:A型骨折38例,B型27例,C型29例。合并有腓骨骨折31例;將所有患者隨機(jī)分為A、B兩組,A組共51例行交鎖髓內(nèi)釘內(nèi)固定術(shù),B組共43例行鎖定加壓鋼板內(nèi)固定術(shù)。兩組患者在年齡、性別、骨折分型、合并傷等一般資料方面相比差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05,Table 1),具有可比性。比較觀察兩組患者的術(shù)中及術(shù)后療效。手術(shù)中由同一組人員記錄切口長(zhǎng)度、手術(shù)時(shí)間、術(shù)中出血量術(shù)中等相關(guān)數(shù)據(jù),隨訪嚴(yán)格記錄患者骨折的愈合時(shí)間及患肢術(shù)后效果。術(shù)后康復(fù)訓(xùn)練由我院康復(fù)科同一組康復(fù)技師進(jìn)行指導(dǎo)。術(shù)后第1天開始臥床行膝、踝關(guān)節(jié)功能練習(xí),隔日換藥,預(yù)防感染,術(shù)后2周拆除縫線;同時(shí)出院后積極鼓勵(lì)患者進(jìn)行膝關(guān)節(jié)、踝關(guān)節(jié)功能鍛煉,此時(shí)禁止負(fù)重;視骨折愈合情況術(shù)后第6-10周才開始部分負(fù)重,待骨折愈合后,才能完全負(fù)重。所有患者術(shù)后均獲得18~24個(gè)月隨訪。組間比較術(shù)后4周,8周,12周,半年,1年,2年患的骨折愈合程度及并發(fā)癥的發(fā)生情況。術(shù)中及術(shù)后隨訪所得數(shù)據(jù)用SPSS19.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析比較,P0.05認(rèn)為差異具有統(tǒng)計(jì)學(xué)意義。結(jié)果:所有患者術(shù)后均進(jìn)行18~24個(gè)月時(shí)間隨訪,平均21.3個(gè)月,經(jīng)隨訪所得結(jié)果顯示。兩組患者組間相比較,A、B組在手術(shù)時(shí)間和手術(shù)治療效果兩方面,差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05,Table 2);A組(髓內(nèi)釘組)患者術(shù)中出血量、骨折愈合時(shí)間均低于B組(鎖定加壓鋼板組),差異有統(tǒng)計(jì)學(xué)意義(P0.05,Table 2)。結(jié)論:通過(guò)本研究可得出,鎖定加壓鋼板內(nèi)固定術(shù)為傳統(tǒng)治療脛骨下段骨折的手術(shù)方式,其操作簡(jiǎn)單,固定效果好,但此方法為切開復(fù)位,術(shù)中需將骨折端充分暴露,對(duì)骨折處周圍軟組織損傷較大,破壞了血運(yùn),容易導(dǎo)致局部皮膚壞死、患肢功能障礙。與鋼板組相比,髓內(nèi)釘組的術(shù)后效果更令人滿意,髓內(nèi)固定可有效減輕對(duì)骨外膜及軟組織的損傷,最大程度的減小手術(shù)切口及減少術(shù)中出血量,降低其術(shù)后并發(fā)癥的發(fā)生率,縮短其骨折愈合的時(shí)間。
[Abstract]:Objective: the distal tibia fracture is one of the most common fractures, mostly caused by high energy injury. Because of the special bone anatomical structure of the lower tibia, less soft tissue covering and poor blood circulation, the fracture is prone to delayed union and nonunion. Therefore, in the treatment of distal tibial fractures, the key to improve the clinical treatment is to effectively protect the blood flow at the broken end of the fracture and reduce the injury to the soft tissue and the epineurium. Interlocking intramedullary nail fixation and locking compression plate fixation are two common internal fixation methods for distal tibial fractures, but their merits and demerits remain controversial. The purpose of this study was to compare the clinical efficacy of interlocking intramedullary nail and locking compression plate in the treatment of distal tibial fractures. Methods: from May 2013 to November 2015, 94 patients with distal tibial fractures were retrospectively analyzed. There were 55 males and 39 females. The average age was (40.9 鹵3.1) years. According to AO classification, 38 cases were type A fractures, 27 cases were type B fractures and 29 cases were type C fractures. 31 patients with fibula fracture were randomly divided into group A (51 cases) and group B (43 cases). There was no significant difference in age, sex, fracture classification and combined injury between the two groups (P 0.05 Table 1). The results of intraoperative and postoperative treatment were compared between the two groups. The length of incision, the time of operation and the amount of blood lost during the operation were recorded by the same group. The time of fracture healing and the postoperative effect of the affected limb were recorded strictly after follow up. Postoperative rehabilitation training was directed by the same group of rehabilitation technicians in our hospital. On the first day after operation, the patients were kept in bed, ankle function was practiced, dressing was changed every other day, infection was prevented, suture was removed 2 weeks after operation, patients were encouraged to exercise knee joint and ankle joint function after discharge from hospital, and weight-bearing was prohibited. Partial weight loading was only started 6-10 weeks after fracture healing, and full weight loading was achieved after fracture healing. All patients were followed up from 18 to 24 months after operation. The degree of fracture healing and the incidence of complications were compared between groups at 4 weeks, 8 weeks, 12 weeks, 6 months, 1 year and 2 years after operation. SPSS19.0 software was used to analyze and compare the data of intraoperative and postoperative follow-up. P0.05 showed that the difference was statistically significant. Results: all patients were followed up for 18 ~ 24 months (mean 21.3 months). There was no significant difference between the two groups in the time of operation and the effect of operation (P0.05Table 2). In group A (intramedullary nail group), the amount of intraoperative bleeding and the time of fracture healing were lower than those in group B (locking compression plate group), and the difference was statistically significant (P0.05 table 2). Conclusion: this study shows that locking compression plate internal fixation is a traditional operative method for the treatment of distal tibial fractures. The operation is simple and the fixation effect is good, but this method is open reduction, and the fracture ends should be fully exposed during the operation. The soft tissue around the fracture is damaged, which leads to local skin necrosis and limb dysfunction. Compared with the plate group, the intramedullary nail group had more satisfactory postoperative results. Intramedullary fixation could effectively reduce the injury to the periosteum and soft tissue, minimize the operative incision and decrease the amount of intraoperative bleeding, and reduce the incidence of postoperative complications. Shorten the time of fracture healing.
【學(xué)位授予單位】：承德醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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