陳水林 孫貴才

髕上入路髓內(nèi)釘治療脛骨干骨折的研究進(jìn)展

陳水林 孫貴才

脛骨骨折；骨折固定術(shù)，內(nèi)；髓內(nèi)釘；髕上入路；綜述

脛骨干骨折是四肢骨折中最為常見的一種[1]，約占全身骨折的 13.7%[2]。由于髓內(nèi)釘具有微創(chuàng)、固定強度高、術(shù)后并發(fā)癥及再手術(shù)率低，目前成為脛骨干骨折的首選治療方案[3-6]。與傳統(tǒng)入路 ( 髕韌帶及髕韌帶旁入路 ) 相比，髕上入路脛骨髓內(nèi)釘?shù)闹萌刖哂幸撞僮?、適應(yīng)證更廣及術(shù)后并發(fā)癥發(fā)生率更低等優(yōu)勢[7-13]。筆者就近年來髕上入路髓內(nèi)釘固定治療脛骨干骨折安全性的研究進(jìn)展及其與傳統(tǒng)入路的對比研究作一綜述，為今后相關(guān)研究提供參考。

一、髕上入路脛骨髓內(nèi)釘固定治療脛骨干骨折的安全性

髕上入路髓內(nèi)釘固定治療脛骨干骨折最早由 Cole[14]提出，通過分析 1 例 80 歲脛骨干骨折患者病情最后選擇髕上入路髓內(nèi)釘固定治療并取得理想的術(shù)后效果。有研究指出髕上入路是半伸膝位的一種改良的脛骨髓內(nèi)釘手術(shù)入路，具有手術(shù)時間短，術(shù)后膝關(guān)節(jié)疼痛發(fā)生率低，骨折畸形愈合較少見等優(yōu)點[10-12]。付備剛等[15]指出髕上入路脛骨髓內(nèi)釘內(nèi)固定治療脛骨干骨折具有復(fù)位固定操作簡單、術(shù)中透視方便和術(shù)后并發(fā)癥少等優(yōu)點，尤其適用于近遠(yuǎn)干骺端、多節(jié)段、小腿軟組織條件差及合并同側(cè)股骨骨折等特殊類型脛骨骨折的手術(shù)治療。但有反對者認(rèn)為髕上入路脛骨髓內(nèi)釘置入會增加髕股關(guān)節(jié)面壓力導(dǎo)致髕股關(guān)節(jié)面損傷，同時有可能損傷膝關(guān)節(jié)內(nèi)重要軟組織結(jié)構(gòu)及增加關(guān)節(jié)內(nèi)感染的風(fēng)險。Glebke 等[16]通過一具尸體研究發(fā)現(xiàn)髕上入路髓內(nèi)釘固定治療脛骨干骨折時髕股關(guān)節(jié)面的壓力為 3.83×103kPa ( 1 kPa＝7.52 mm Hg )，低于造成軟骨細(xì)胞損傷標(biāo)準(zhǔn)的 4.5×103kPa，故得出髕上入路脛骨髓內(nèi)釘并不會造成髕股關(guān)節(jié)面的損傷的結(jié)論。這結(jié)論在 Eastman等[17]的尸體研究中也得到證實。同樣，Gaines 等[18]研究發(fā)現(xiàn)髕上入路脛骨髓內(nèi)釘不僅不會增加髕股關(guān)節(jié)面損傷的風(fēng)險，而且膝關(guān)節(jié)重要軟組織結(jié)構(gòu)損傷發(fā)生率更低。Beigang[19]通過 23 例髕上入路髓內(nèi)釘固定治療脛骨干骨折患者并平均隨訪 15.5 個月后得出髕上入路脛骨髓內(nèi)釘治療脛骨干骨折是安全、有效、利于早期康復(fù)并且無不良并發(fā)癥的結(jié)論，同時，Mitchell 等[20]指出髕上入路脛骨髓內(nèi)釘?shù)闹萌氩⒉粫黾雨P(guān)節(jié)內(nèi)感染的風(fēng)險。

二、髓內(nèi)釘固定治療脛骨干骨折髕上入路與傳統(tǒng)入路的對比

髓內(nèi)釘固定治療脛骨干骨折髕上入路與傳統(tǒng)入路的對比主要有術(shù)中指標(biāo) ( 手術(shù)時間、術(shù)中 X 線放射時間、出血量 ) 及術(shù)后評分及并發(fā)癥發(fā)生率等方面。

1. 術(shù)中指標(biāo)：鞏金鵬等[21]通過臨床研究指出兩種入路方式在手術(shù)時間、住院天數(shù)及術(shù)中出血量的比較中，差異無統(tǒng)計學(xué)意義；Courtney 等[22]通過隨機對照實驗發(fā)現(xiàn)，兩種入路方式在手術(shù)時間上差異無統(tǒng)計學(xué)意義，但髕上入路能明顯減少術(shù)中 X 線放射時間，且差異有統(tǒng)計學(xué)意義；Sun 等[23]通過隨機對照實驗指出兩種入路方式在手術(shù)時間、住院天數(shù)及術(shù)中出血量的比較中的差異無統(tǒng)計學(xué)意義，同時證實了髕上入路能明顯減少術(shù)中 X 線放射時間；同樣傅升培[24]通過隨機對照實驗對 98 例脛骨骨折患者分析指出兩種入路方式在手術(shù)時間、住院天數(shù)及術(shù)中出血量的比較中的差異無統(tǒng)計學(xué)意義；王等[25]通過回顧 68 例脛骨干骨折患者病例后分析指出髕上入路能明顯減少術(shù)中出血量及 X 線放射時間。

2. 術(shù)后評分：鞏金鵬等發(fā)現(xiàn)術(shù)后 24 周髕上入路較傳統(tǒng)入路優(yōu)良率高、髕上入路具有更高的 Lysholm 膝關(guān)節(jié)評分及術(shù)后患側(cè)膝前疼痛發(fā)生率更低，差異均有統(tǒng)計學(xué)意義；Sun 等通過隨機對照實驗證實了術(shù)后 24 周髕上入路具有更高的 Lysholm 膝關(guān)節(jié)評分，同時髕上入路具有更高的 SF-36 physical 和更低 VAS 評分，差異均有統(tǒng)計學(xué)意義，但 ROM 及 SF-36 physical 差異無統(tǒng)計學(xué)意義；Courtney 等發(fā)現(xiàn)兩種入路方式在術(shù)后 Oxford Knee Score 比較中，差異無統(tǒng)計學(xué)意義；傅升培發(fā)現(xiàn)術(shù)后 9 個月髕上入路組患者膝關(guān)節(jié) HSS 評分及 Lysholm 評分均優(yōu)于髕下入路組，差異有統(tǒng)計學(xué)意義；同時王等也發(fā)現(xiàn)術(shù)后 9 個月髕上入路具有更高的膝關(guān)節(jié) HSS 評分及 Johner-Wruhs 評分，差異均有統(tǒng)計學(xué)意義。

3. 術(shù)后并發(fā)癥：( 1 ) 慢性膝前區(qū)疼痛是傳統(tǒng)入路脛骨髓內(nèi)釘術(shù)后最常見并發(fā)癥，病因不明，有研究指出，可能主要與髕韌帶完整性破壞、膝關(guān)節(jié)內(nèi)結(jié)構(gòu)損傷、隱神經(jīng)髕下支損傷等因素有關(guān)[26-28]。孫和炎等發(fā)現(xiàn)髕上入路脛骨髓內(nèi)釘術(shù)后膝關(guān)節(jié)前區(qū)疼痛發(fā)生率不足 5%；解冰等[29]采用髕上入路髓內(nèi)釘固定治療脛骨近端骨折患者 16 例，隨訪2 年未出現(xiàn)膝關(guān)節(jié)疼痛；Courtney、Sun、Chan、王及王惠等[22-23,25,30-31]分別通過髕上入路及傳統(tǒng)入路對比發(fā)現(xiàn)，髕上入路術(shù)后膝關(guān)節(jié)前區(qū)疼痛發(fā)生率低，差異有統(tǒng)計學(xué)意義。( 2 ) 骨折術(shù)后成角畸形 脛骨近端 1 / 3 骨折及脛骨多段骨折，傳統(tǒng)入路脛骨髓內(nèi)釘植入時，患膝需過曲位，由于髕腱的牽拉及骨折端的不穩(wěn)定，使得復(fù)位及固定困難，術(shù)后容易造成成角畸形[32-33]。Courtney 等發(fā)現(xiàn)髕上入路可以減少矢狀面成角，差異有統(tǒng)計學(xué)意義；Avilucea 等[34]同樣指出髕上入路可以減少冠狀面及矢狀面成角，與傳統(tǒng)入路相比，差異有統(tǒng)計學(xué)意義。

綜上所述，脛骨干骨折常由高能量損傷所致，由于脛骨前方肌肉組織較少，暴力損傷后容易造成開放性骨折，軟組織損傷、污染等，不僅影響傳統(tǒng)入路開口，而且增加切口不愈合、感染的風(fēng)險[35]，髕上入路是一個很好的選擇方案。同時，與傳統(tǒng)入路比較，髕上入路具有操作方便，術(shù)中放射時間短，術(shù)后并發(fā)癥發(fā)生率少及優(yōu)良率高等優(yōu)勢。但髕上入路植入髓內(nèi)釘經(jīng)哪種手術(shù)方式移除仍具有爭議，同時需要外科醫(yī)生操作熟練，避免髕股關(guān)節(jié)面損傷，再加上手術(shù)費用貴，患者不容易接受。目前仍需要更多的大型對比性研究來給臨床一個合理的建議，但從臨床滿意效果來講，髕上入路脛骨髓內(nèi)釘值得在臨床上推廣使用。

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Research progress of suprapatellar approach with intramedullary nails for the treatment of tibia shaft fractures

CHEN Shui-lin, SUN Gui-cai. Department of Orthopedics, the fourth Hospital affiliated to Nanchang University,Nanchang, Jiangxi, 330000, China

SUN Gui-cai, Email: 13657000633@139.com

s】 Tibia fracture is the most common one among the long bone fractures. The treatment included open reduction and internal fixation ( ORIF ), minimally invasive plate osteosynthesis ( MIPO ), external fixator and intramedullary nailing ( IMN ). The technology of tibia intramedullary nailing was first put forward by Kuntscher.Intramedullary nailing ( IMN ) was preferred for most tibia shaft fractures, because of its advantage of minimal surgical dissection with appropriate preservation of blood supply, with fewer complications and re-operations. Classic approach of tibia intramedullary nailing was conducted either through or near the patellar tendon. Both technologies required a hyperflexed knee, which was easy to cause the proximal tibia fracture angulation deformity. The rate of chronic anterior knee pain was reported varying from 10% to 70%, with an average of 50%. A semi-extended suprapatellar approach was described, with advantages of shorter operation time, lower incidence rate of postoperative knee pain and fracture malunion. However, some considered the suprapatellar approach may increase the patellofemoral joint surface pressure which may cause the damage of patellofemoral joint surface, or injurg of important soft tissue structures such like meniscus within the knee joint. This review summarizes the researches on the suprapatellar approach with intramedullary nails for the treatment of tibia shaft fractures.

Tibial fractures; Fracture fixation, internal; Intramedullary nailing; Suprapatellar approach;Review

10.3969/j.issn.2095-252X.2017.11.010

R683.4, R687.3

330000 南昌大學(xué)第四附屬醫(yī)院骨科

孫貴才，Email: 13657000633@139.com

2016-12-31 )

( 本文編輯：李慧文 )