手法复位鱼嘴钳经皮固定与切开复位钢板内固定治疗胫骨平台骨折的比较研究

目的:比较分析手法复位鱼嘴钳经皮固定与切开复位钢板内固定治疗胫骨平台骨折的临床疗效.方法:将纳入研究的237例胫骨平台骨折患者随机分为2组,采用手法整复鱼嘴钳经皮固定126例,采用切开复位钢板内固定111例.其中SchatzkerⅠ型30例,Ⅱ型41例,Ⅳ型71例,Ⅴ型95例.记录并比较2组患者的膝关节疼痛、行走能力、伸膝、关节活动度、关节稳定性评分及膝关节功能总分情况.记录并比较2组患者的关节面塌陷、髁部变宽、膝关节内外翻畸形评分及膝关节X线总分情况.参照Rasmussen胫骨髁部骨折膝关节功能评分标准及Rasmussen胫骨髁部骨折复位解剖学评分标准评定2组患者的疗效.结果:手法复位鱼嘴钳经皮固定组:拆除鱼嘴钳时间1.5 ～2.5个月,中位数2个月；去除钢针时间2.5～4.5个月,中位数3.5个月;10例于术后7d至3个月出现针道流液、局部皮肤发红,经换药处理后愈合,无窦道、骨髓炎形成；126例中有122例得到随访,3例失访脱落,1例合并糖尿病剔除；随访时间1～4年；骨折愈合时间3～6个月,中位数4.8个月.切开复位钢板内固定组:12例术后出现局部皮肤感染、坏死,10例经换药处理后治愈,2例部分钢板外露,经换药、皮瓣移位后治愈.111例中有103例得到随访,6例失访脱落,2例纳入后未接受本试验剔除；随访时间1～4年；骨折愈合时间3～9个月,中位数6.9个月；内固定取出时间为术后12～ 21个月,中位数为术后15.3个月.2组患者的膝关节疼痛、行走能力、伸膝、关节活动度、关节稳定性评分及膝关节功能总分比较,差异均无统计学意义(t=1.655,P=0.200;t =0.153,P=0.696；=0.860,P=0.355；t =0.691,P=0.407；t=1.697,P=0.194；t=1.845,P=0.176).2组患者的关节面塌陷、髁部变宽、膝关节内外翻畸形评分及膝关节X线总分比较,差异均有统计学意义,切开复位钢板内固定组膝关节X线评分高于手法复位鱼嘴钳经皮固定组(t =8.695,P=0.004;t =9.601,P=0.002;t=11.493,P =0.001；t =7.935,P=0.005).2组患者膝关节功能比较,差异无统计学意义(Z=-0.236,P =0.814)；2组患者骨折复位效果比较,切开复位钢板内固定组优于手法复位鱼嘴钳经皮固定组(Z=-3.223,P =0.001).结论:对于SchatzkerⅠ、Ⅱ、Ⅳ、Ⅴ型胫骨平台骨折患者而言,与手法整复鱼嘴钳经皮固定相比,手术切开复位内固定具有骨折复位效果好的优势,但是二者对患者膝关节功能的疗效相当.二者各有优缺点,术者应根据自身操作技能水平及医院条件等综合考虑,选择适当的固定方式.

Comparison study on the curative effects between manipulative reduction and percutaneous fixation with fish-lip pincers and open reduction and internal fixation with plate in tibial plateau fracture

Objective:To compare and analyze the clinical curative effects between manipulative reduction and percutaneous fixation with fish-lip pincers and open reduction and internal fixation with plate in tibial plateau fracture.Methods:Two hundred and thirty-seven patients with tibial plateau fracture enrolled into the study were randomly divided into 2 groups.One hundred and twenty-six patients were administrated with manipulative reduction and percutaneous fixation with fish-lip pincers,while the others were administrated with open reduction and internal fixation with plate.Thirty patients with SchatzkerⅠtibial plateau fracture,41 patients with SchatzkerⅡtibial plateau fracture,71 patients with SchatzkerⅣ tibial plateau fracture and 95 patients with SchatzkerV tibial plateau fracture were enrolled into the study.Such scores as knee pain,walking ability,knee extension,range of motion(ROM),joint stability and total scores of knee joint function were recorded and compared between the 2 groups.Such scores as collapse of articular facet,broaden of condyles,varus-valgus deformity of knee joint and total scores of X-ray for knee joint were recorded and compared between the 2 groups.The curative effects were evaluated according to Rasmussen scoring standards of knee joint function for tibial condyles fracture and Rasmussen scoring standards of anatomyfor tibial condyles fracture reduction.Results:For manipulative reduction and percutaneous fixation with fish-lip pincers group:time of removing fish-lip pincer is 1.5-2.5 months with median time of 2 months.Time of removing steel needle is 2.5-4.5 months with median time of 3.5 months.Ten cases with needle passage fluids and local skin redness were found from 7 days to 3 months after operation,while they were healed after dressing change without forming sinus and osteomyelitis.Among the 126 cases,122 cases were followed up,3 cases were lost to follow-up and 1 case was rejected for diabetes.Follow-up time was 1-4 years.Fracture healing time was 3-6 months with median time of 4.8 months.For open reduction and internal fixation with plate group:Twelve cases with local skin infection and necrosis were found,among which 10 cases were healed after dressing change,2 cases with partly steel exposure were healed after dressing change and flap transposition.Among the 111 cases,103 cases were followed up,6 cases were lost to follow-up and 2 cases were rejected for refusing to accept this test.Follow-up time was 1-4 years.Fracture healing time was 3-9 months with median time of 6.9 months.Time of removing internal fixation is 12-21 months with median time of 15.3 months after operation.There was no statistical difference in scores of knee pain,walking ability,knee extension,joint ROM,joint stability and total scores of knee joint function between the 2 groups(t=1.655,P=0.200;t=0.153,P=0.696;t=0.860,P=0.355;t=0.691,P=0.407;t=1.697,P=0.194;t=1.845,P=0.176).There was statistical difference in scores of collapse of articular facet,broaden of condyles,varus-valgus deformity of knee joint and total scores of X-ray for knee joint between the 2 groups,X-ray scores of internal fixation group were higher than those of percutaneous fixation group(t=8.695,P=0.004;t=9.601,P=0.002;t=11.493,P=0.001;t=7.935,P=0.005).There was no statistical difference in knee joint function between the 2 groups(Z=-0.236,P=0.814).Fracture reduction effect of open reduction and internal fixation with plate was better than that of manipulative reduction and percutaneous fixation with fish-lip pincers(Z=-3.223,P=0.001).Conclusion:Compared with the method of manipulative reduction and percutaneous fixation with fish-lip pincers,open reduction and internal fixation with plate has the advantage of better fracture reduction effect on patients with SchatzkerⅠ,Ⅱ,ⅣandⅤtibial plateau fractures,while the 2 methods have the similar curative effects on knee joint function.Considering the 2 methods have their own advantages and disadvantages,the performers should select the proper fixation method according to their own operation skill levels and hospital conditions.