环状韧带重建修复对治疗儿童陈旧性孟氏骨折的疗效分析

目的 探讨环状韧带的重建、修复对陈旧性孟氏骨折预后的影响.方法 采用多中心回顾性方法,收集2011年1月至2015年12月于各中心治疗的儿童陈旧性孟氏骨折患儿,通过病历查询及随访的方式获取资料,记录患儿的性别、年龄、首诊时间、手术年龄、骨折分型、复位方式、是否尺骨截骨、手术入路和肘关节功能等数据,用SPSS19.0软件进行统计学分析.结果 最终有59例患儿纳入本次研究,术后随访6个月～3年,平均22个月.其中,男35例,女24例;年龄2～14岁,平均7.8岁.Bado分型:Ⅰ型45例,Ⅱ型2例,Ⅲ型12例.行肱桡关节切开复位59例,其中采用B0yd's切口35例,Kocher's切口10例,Henry's切口14例.行环状韧带重建(重建组)45例,环状韧带修补(修复组)14例.行尺骨截骨59例,其中48例内固定,包括:钢板39例、克氏针9例;采用外固定架11例.根据Kim's评分标准,重建组:优18例,良13例,一般8例,差6例,优良率为68.9％(31/45);修复组:优9,良3例,一般1例,差1例,优良率为85.7％(12/14).两组患儿术前的一般资料及优良率比较,差异无统计学意义(P＞0.05).重建组术前旋前活动度为(67.2±6.7)度,末次随访时旋前活动度为(75.8±7.5)度,手术前后比较,差异有统计学意义(t=9.745,P＜0.05).修复组术前旋前活动度为(70.6±9.2)度,末次随访时旋前活动度为(79.1±8.9)度,手术前后比较,差异有统计学意义(t=8.347,P＜0.05).在患儿受伤后1年以内,修复组的优良率为90％％(9/10)明显高于重建组81.3％(26/32),组间比较,差异有统计学意义(P＜0.05).修复组采用Henry's切口,重建组采用Boyd's、Kocher's切口.修复组在手术时间、切口长度及术中出血量(82.6±5.7)min、(5.3±1.2)cm和(32.6±6.8)ml]上,均较重建组(95.6±6.8)min、(8.2±0.9)cm和(56.1±9.7)ml]有明显优势,差异有统计学意义(P＜0.05).结论 肘前切口采用修补残余环状韧带的方法治疗儿童陈旧性孟氏骨折具有符合伤前解剖结构、方法简单、创伤小等优势,值得进一步探讨和推广.

Comparison of reconstruction versus reposition of annular ligament for neglected Monteggia fracture in children

Objective To compare the clinical efficacies of reconstruction and reposition of annular ligament for neglected Monteggia fracture in children.Methods For this multi-center retrospective study,the clinical and follow-up data were reviewed for 59 children with neglected Monteggia fracture from January 2011 to December 2015.The relevant parameters included gender,age,time from injury to operation,operative age,fracture type,reduction approach,ulnar osteotomy,operative approach and elbow function.And the epidemiological data were analyzed with SPSS 19.0.Results Among them,there were 35 boys and 24 girls with an average age of 7.8 (2-14) years.According to the Bado's classification scheme,the clinical types were Ⅰ (n =45),Ⅱ (n =2) and Ⅲ (n =12).Open reduction and ulnar osteotomies were performed for all cases.The operative approaches included Boyd's (n =35),Kocher's (n =10) and Henry's (n-=14).Annular ligaments were reconstructed (reconstruction group,n =45) and repaired (reposition group,n =14).Fixation was via plates (n =39),k-wires (n =9) and external fixation (n =11).The mean follow-up period was 22 (6-36) months.Based upon the Kim's criteria,the outcomes were excellent (n =18),good (n =13),fair (n =8) and poor (n =6) in reconstruction group versus excellent (n =9),good (n =3),fair (n =1) and poor (n =1) in reposition group.No significant inter-group differences existed in general profiles and excellent & good rate (P＞ 0.05).Pronation activity of reconstruction and reposition group at the last follow-up (75.8° ± 7.5°、79.1° ± 8.9°) obviously improved as compared with preoperatively (67.2° ± 6.7°,70.6° ± 9.2°).There were significant differences (reconstruction group:t =9.745,P＜0.05;reposition group:t =8.347,P＜0.05).The inter-group differences had no statistical significance (t =0.912,P＞0.912).But in patients of time from injury to operation within 1 year,excellent & good rate was 90％ (9/10) in reposition group versus 81.3％ (26/32) in reconstruction group.The difference was significant (P＜ 0.05).The average operative duration (reconstruction group:95.6 ± 6.8 min vs reposition group:82.6 ± 5.7 min),length of incision (reconstruction group:8.2 ± 0.9 cm,vs reposition group:5.3 ± 1.2 cm) and intraoperative blood loss (reconstruction group:56.1-± 9.7 ml vs reposition group:32.6 ± 6.8 ml) were significantly different between two groups (P ＜ 0.05).Conclusions For neglected Monteggia fracture,reposition of interposed annular ligament is both effective and mini-invasive due to anatomic and mechanical advantages of native ligament without an uncertainty of reconstruction accuracy.