張海森 劉暢 梁東啟 王懷良 裴寶靜 劉輝 劉穎
[摘要] 目的 考察AO/ASIF-43 A3型脛骨遠端骨折采用跟骨前突置釘外固定架固定的臨床療效。 方法 選取2013年1月~2018年1月在河北省滄州市中心醫(yī)院骨科采用跟骨前突置釘外固定架固定的AO/ASIF-43 A3型脛骨遠端骨折患者36例,對其相關資料進行回顧性分析。所有病例均伴有腓骨遠端骨干骨折,且脛腓骨遠端骨折均為閉合性骨折。術中于跟骨后內側及載距突前側約1 cm置入骨折遠側端外固定釘,采用后外側切口鋼板內固定腓骨骨折。術后4周開始訓練踝關節(jié)屈伸,每周放松外架1次。記錄手術時間、術中出血量、骨折愈合時間以及圍術期并發(fā)癥等數(shù)據。對患者進行為期18個月術后隨訪,臨床療效的評價采用Maryland評分、Lowa踝關節(jié)評分和疼痛視覺模擬(VAS)評分。 結果 平均手術時間(42.6±23.8)min,平均術中出血量(149.5±28.6)mL,平均住院時間(9.2±2.9)d。術后出現(xiàn)腓骨切口淺表炎性反應1例(2.8%),外固定釘?shù)栏腥?例(2.8%),經相應處理后均愈合。所有病例均未發(fā)生血管、神經損傷并發(fā)癥,總體圍術期并發(fā)癥發(fā)生率為5.6%。所有病例均經術后18個月隨訪。所有病例均獲得骨折愈合,無復位丟失出現(xiàn)。患者Lowa踝關節(jié)評分與VAS評分術后各時間點整體比較,差異無統(tǒng)計學意義(P > 0.05)?;贛aryland評分的整體優(yōu)良率為88.9%。 結論 跟骨前突置釘閉合復位外固定架技術在AO/ASIF-43 A3型脛骨遠端骨折損傷早期是一種可供選擇的治療方法,該方法臨床療效良好,固定可靠,并發(fā)癥發(fā)生率低。
[關鍵詞] 早期手術;跟骨前突;外固定架;脛骨遠端骨折
[中圖分類號] R687.3? ? ? ? ? [文獻標識碼] A? ? ? ? ? [文章編號] 1673-7210(2020)05(c)-0084-04
Clinical effect of external fixator pinning in anterior process of calcaneus for treatment of AO/ASIF 43.Type A3 distal tibial fractures
ZHANG Haisen1? ?LIU Chang1? ?LIANG Dongqi2? ?WANG Huailiang3? ?PEI Baojing3? ?LIU Hui4? ?LIU Ying5
1.Department of Sports Medicine, Cangzhou Central Hospital, Hebei Province, Cangzhou? ?061001, China; 2.Department of Pain Management, Cangzhou Central Hospital, Hebei Province, Cangzhou? ?061001, China; 3.Department of the Second of Orthopedics, Cangzhou Central Hospital, Hebei Province, Cangzhou? ?061001, China; 4.Department of Orthopedics, Mumendian Hospital of Qing County, Hebei Province, Qing County? ?062650, China; 5.Operating Room, Cangzhou People′s Hospital, Hebei Province, Cangzhou? ?061001, China
[Abstract] Objective To investigate clinical effect of the external fixator pinning in anterior process of calcaneus for treatment of AO/ASIF 43.Type A3 distal tibia fracture. Methods Thirty-six patients of AO/ASIF 43.Type A3 distal tibia fracture fixed by external fixator pinning in anterior process of calcaneus in the Department of Orthopedics, Cangzhou Central Hospital, Hebei Province from January 2013 to January 2018 were selected, and the relevant data were retrospectively analyzed. All cases were associated with fracture of shaft of distal fibula, and all fractures of distal tibia and fibula were closed fractures. During the operation, the distal end of the fracture was fixed with an external pin about 1 cm in the posterior medial side of the calcaneus and the anterior side of the sustentaculum of talus of calcaneus, and internal fixation of fracture of shaft of distal fibula was fixed with a posterolateral incision plate. Ankle flexion and extension training began 4 weeks after the operation, and relaxed the external fixator once a week. The operative time, intraoperative blood loss, fracture healing time and perioperative complications were recorded. The patients were followed up for 18 months after the operation. The clinical efficacy was evaluated by Maryland score, Lowa ankle joint score, and visual analogue scale (VAS) score. Results The average operative time was (42.6±23.8) min, the average intraoperative blood loss was (149.5±28.6) mL, and the average length of stay was (9.2±2.9) d. After the operation, one patient (2.8%) had superficial inflammatory reaction of fibula incision and one case (2.8%) had infection of external pin hole, and all healed after corresponding treatment. No vascular and nerve injury complications occurred in all cases. The overall incidence rate of perioperative complications was 5.6%. All cases were followed up for 18 months after the operation. Fracture healing was achieved in all cases without reduction loss. There were no statistically significant differences between the overall Lowa ankle score and VAS score at each postoperative time point (P > 0.05). According to the Maryland score, the good rate of the curative effect was 88.9%. Conclusion The closed reduction and external fixator pinning in anterior process of calcaneus is an alternative treatment method in the early stage of AO/ASIF 43.Type A3 distal tibia fracture injury, which has good clinical efficacy, reliable fixation and low complication rate.
[Key words] Early operation; Anterior process of calcaneus; External fixator; Distal tibia fracture
脛骨遠側干骺端復雜粉碎性脛骨遠端骨折的AO/ASIF分型為43-A3型[1]。針對該類復雜損傷的手術治療,目前的主流觀點為[2-4],損傷早期可實施外架固定,以便避免發(fā)生軟組織并發(fā)癥。外固定架治療既可降低軟組織并發(fā)癥風險,又能實現(xiàn)骨折的穩(wěn)定固定。采用傳統(tǒng)外固定架技術治療脛骨遠端骨折時,骨折遠端兩枚固定針均置于跟骨后內側,容易出現(xiàn)外固定釘松動等問題。2013年以來,河北省滄州市中心醫(yī)院(以下簡稱“我院”)采用改良的跟骨前突置釘外固定架技術治療AO/ASIF-43 A3型脛骨遠端骨折36例,取得了滿意的臨床效果?,F(xiàn)報道如下:
1 資料與方法
1.1 一般資料
回顧性分析2013年1月~2018年1月在我院骨科就診的36例AO/ASIF-43 A3型脛骨遠端骨折患者的臨床資料。病例均采用跟骨前突置釘外固定架進行治療。所有病例均單側肢體損傷,均伴有腓骨遠端骨干骨折,且為脛腓骨遠端閉合性骨折?;颊呔趽p傷早期(傷后<12 h)接受外固定支架治療,并作為最終性固定方式?;颊叩哪挲g26~59歲,平均(39.6±12.9)歲;其中男22例,女14例;在損傷病因方面,車禍16例,跌倒傷12例,跌落傷8例;根據軟組織損傷Tscherne分級[5],Ⅰ級20例,Ⅱ級14例,Ⅲ級例2例。本研究經我院醫(yī)學倫理委員會批準,患者均于入選研究前簽署知情同意書。
1.2 手術方法
同一組醫(yī)師實施手術,術中患者腰麻,取平臥位。首先經皮于脛骨前內側、骨折近端置入2枚外固定針,然后經皮由內向外于跟骨后角置入第3枚外固定針。最后于跟骨載距突向前1 cm做一0.5 cm切口,采用血管鉗鈍性分離深層至骨面,置入套筒,由內向外穿過兩層骨皮質置入第4枚外固定針。外固定架安裝后延長加壓裝置,適度牽開骨折斷端。之后采用后外側切口復位、鋼板內固定腓骨骨折,恢復肢體長度。骨折復位方法為閉合徒手復位或克氏針經皮撬撥,術中根據骨折對位、對線需要放松或延長外固定架。C臂透視確認骨折復位情況,滿意后擰緊外架。
1.3 術后處理
患肢術后抬高,適度冰敷。術后4周開始訓練踝關節(jié)屈伸,放松外架、每周1次。根據X線片復查情況,術后4~8周確定是否患肢負重活動,骨折愈合后拆除外固定架,外架去除后扶持雙拐部分負重4周,之后逐步完全負重。
1.4 觀察指標與評估方法
記錄手術時間、術中出血量、骨折愈合時間、圍術期數(shù)據及并發(fā)癥情況。對患者進行為期18個月隨訪,在術后隨訪中,臨床療效的評估采用Lowa踝關節(jié)評分[6]、Maryland評分[7]和疼痛視覺模擬(visual analogue scale,VAS)評分[8],骨折愈合情況及復位維持的評價應用常規(guī)正側位X線片。
1.5 統(tǒng)計學方法
采用SPSS 13.0統(tǒng)計學軟件對所得數(shù)據進行分析,計量資料采用均數(shù)±標準差(x±s)表示,采用單因素方差分析,計數(shù)資料采用百分率表示。以P < 0.05為差異有統(tǒng)計學意義。
2 結果
2.1 圍術期一般資料
平均手術時間(42.6±23.8)min,平均術中出血量(149.5±28.6)mL,平均住院時間(9.2±2.9)d。典型病例影像見圖1。
2.2 術后并發(fā)癥情況
術后發(fā)生腓骨切口淺表炎性反應1例(2.8%),加強換藥后炎癥得到控制,但切口愈合不良,鋼板外露,考慮鋼板放置偏前,骨折愈合未受影響,內固定物在術后半年后取出,切口愈合無感染。術后并發(fā)外固定釘?shù)栏腥?例(2.8%),經擴創(chuàng)及釘?shù)酪骱蟾腥镜靡钥刂?,去除外固定支架后釘?shù)烙狭己谩g期未發(fā)生血管、神經損傷并發(fā)癥。整體圍術期并發(fā)癥發(fā)生率為5.6%。
2.3 隨訪數(shù)據
所有患者術后均獲18個月的隨訪?;颊吖钦劬@愈合,平均愈合時間為(3.6±1.4)個月。隨訪中輕度跛行7例,所有患者均未發(fā)生外固定針松動、斷釘、斷板,復位丟失等并發(fā)癥情況。Lowa踝關節(jié)評分與VAS評分術后各時間點整體比較,差異無統(tǒng)計學意義(P > 0.05)。見表1。在術后18個月隨訪時,基于Maryland評分的整體優(yōu)良率為88.9%,其中優(yōu)19例,良13例,中4例。
3 討論
脛骨遠側干骺端復雜粉碎性骨折在AO/ASIF分型中屬于43-A3型[1]。切開復位內固定技術具有較高的切口并發(fā)癥發(fā)生率[9],而髓內釘固定手術中經常面臨遠端鎖釘置的困難[10]。這類損傷雖然可采用經皮鋼板橋接固定技術,但在損傷早期施術仍然面臨局部軟組織并發(fā)癥的風險[3]。目前,多數(shù)學者認為[2-4],為了降低軟組織并發(fā)癥風險,“損傷控制理論”適用于AO/ASIF-43 A3型脛骨遠端骨折的損傷早期,之后才可實施內固定技術,但卻可導致患者的住院時間延長,相關住院花費增加。相比傳統(tǒng)鋼板內固定技術,外固定架對軟組織條件要求低,可以顯著縮短患者住院時間、減少患者治療費用[11-20]。臨床實踐中,我院采用一種改良的閉合復位外架固定方式治療這類復雜損傷,并在本研究中回顧分析了其初步臨床效果。本研究中36例患者均于傷后12 h內實施手術,避免了傳統(tǒng)內固定延期手術的長時間等待問題。只有1例(2.8%)術后并發(fā)外固定釘?shù)栏腥?,可見軟組織并發(fā)癥問題并不高。
以往報道的外固定架技術固定脛骨遠端骨折時,骨折遠端兩枚固定針均置于跟骨后內側,導致外固定釘易松動,且“非三角形”的幾何形態(tài)不利于骨折的穩(wěn)定固定[12-13]。相比傳統(tǒng)外固定架遠端置釘技術,本研究改良置釘方式的優(yōu)勢體現(xiàn)在:①骨折斷端固定的幾何形態(tài)為“三角形”,更利于維持骨折固定的穩(wěn)定性;②該置釘技術基本不干擾距骨的血供,因此不會增加距骨壞死的風險。
需要指出的是,作為一種跨關節(jié)固定方式,該外固定架技術可能導致踝關節(jié)僵硬[15,21-22]。為了降低跨關節(jié)外固定架的關節(jié)僵硬風險,手術4周之后,本研究每周放松外固定架1次以訓練踝關節(jié)屈伸活動。術后18個月的Lowa踝關節(jié)評分達(85.5±6.8)分,總體療效滿意。另外,在理論上,跟骨前突置釘存在踝管內神經、血管結構的損傷風險[20-24],為了避免該并發(fā)癥的發(fā)生,本研究術中采用經皮切口,然后采用將血管鉗鈍性分離直至骨面這一方法,所有病例均未發(fā)生血管、神經損傷并發(fā)癥。
本研究的不足之處如下,首先,本組多數(shù)病例的術前軟組織損傷情況較輕,以Tscherne Ⅰ、Ⅱ級為主,在Tscherne Ⅲ級損傷早期實施外架固定技術,其軟組織并發(fā)癥發(fā)生風險如何尚需進一步臨床研究證實。另外,本研究為一項小樣本隊列研究,回顧性研究證據級別較低,因此該手術方式的安全性及可靠性尚需進一步研究檢驗。最后,本研究的隨訪時間尚短,需進一步追蹤觀察患者的遠期踝創(chuàng)傷性關節(jié)炎的發(fā)生情況。
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(收稿日期:2019-08-27? 本文編輯:顧家毓)