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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 795 -801. doi: 10.3877/cma.j.issn.1674-134X.2023.06.006

临床论著

髌上入路和髌旁外侧入路髓内钉治疗胫骨骨折疗效比较
刘瀚忠, 黄生辉, 万俊明, 李家春, 舒涛†()   
  1. 518107　深圳，中山大学附属第七医院骨科
    518111　深圳大学附属华南医院骨科
  • 收稿日期:2023-07-03 出版日期:2023-12-01
  • 通信作者: 舒涛

Efficacy comparison in treatment of tibial fractures with intramedullary nails via suprapatellar and lateral parapatellar approaches

Hanzhong Liu, Shenghui Huang, Junming Wan, Jiachun Li, Tao Shu†()   

  1. Department of Orthopedics of Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China
    Department of Orthopedics of Southern Hospital of Shenzhen University, Shenzhen 518111, China
  • Received:2023-07-03 Published:2023-12-01
  • Corresponding author: Tao Shu
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刘瀚忠, 黄生辉, 万俊明, 李家春, 舒涛. 髌上入路和髌旁外侧入路髓内钉治疗胫骨骨折疗效比较[J]. 中华关节外科杂志(电子版), 2023, 17(06): 795-801.

Hanzhong Liu, Shenghui Huang, Junming Wan, Jiachun Li, Tao Shu. Efficacy comparison in treatment of tibial fractures with intramedullary nails via suprapatellar and lateral parapatellar approaches[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(06): 795-801.

目的

比较髌上入路和髌旁外侧入路治疗胫骨骨折的疗效。

方法

回顾性分析2018年10月至2022年2月中山大学附属第七医院和深圳大学附属华南医院骨科收治的86例胫骨骨折患者资料。纳入标准：采用髌上和髌旁外侧入路髓内钉治疗；术后随访≥12个月；18岁以上60岁以下。排除标准：病理性骨折；软组织条件差的开放性骨折；合并同侧股骨骨折；有活动性感染；有其他膝关节功能障碍、手术史及神经损伤；有早期膝骨关节炎；严重的重要脏器疾病及精神疾病。所有患者均予以髓内钉内固定治疗，其中髌上入路的44例，髌旁外侧入路的42例。比较二种手术方法在手术时长、术中出血量，术中C臂曝光次数、骨折愈合时间、特种外科医院评分(HSS)及Lysholm评分等方面的差异。计量资料的比较采用两独立样本t检验，计数资料的比较采用卡方检验。

结果

二者手术时长、术中出血量、骨折愈合时间、术后HSS及Lysholm评分差异均无统计学意义(均为P>0.05)。术中C臂曝光次数，髌上入路组明显多于髌旁外侧入路组，差异具有统计学意义(t＝5.907，P<0.05)。

结论

髌上入路和髌旁外侧入路髓内钉治疗胫骨干骨折，均能有效恢复膝关节关节功能，有效避免膝前疼痛，值得临床推广应用，但髌上入路存在进入关节腔副损伤的争议、术中C臂透视次数较多及取出内固定需额外切口。

关键词: 胫骨骨折, 骨折固定术，髓内, 骨钉
Objective

To compare efficacy of suprapatellar and lateral parapatellar approaches in the treatment of tibial fractures.

Methods

A total of 86 tibial fracture patients admitted to the Department of Orthopedics of Seventh Affiliated Hospital of Sun Yat-sen University and Southern Hospital of Shenzhen University, from October 2018 to February 2022 were retrospectively analyzed. Inclusion criteria: tibial fractures treated with intramedullary nailing using the patellar and lateral entry approaches; follow-up period≥12 months; age between 18 and 60 years. Exclusion criteria: pathological fractures; open fractures with poor soft tissue conditions; concomitant ipsilateral femoral fractures; active infection; other knee joint dysfunctions, surgical history, and nerve injuries; early knee osteoarthritis; severe vital organ diseases, and mental disorders. The patients were all treated with intramedullary nailing. Among the patients, 44 patients were operated via suprapatellar approach, while the other 42 patients were operated via lateral parapatellar approach. The operation time, intraoperative blood loss, the number of C-arm exposures, fracture healing time, Hospital for Special Surgery (HSS), and Lysholm score were compared between the two groups. The measurement data were analyzed by two-independent t test, and the enumeration data were analyzed by chi-square test.

Results

There was no statistically significant difference in the duration of surgery, intraoperative blood loss, fracture healing time, HSS and Lysholm scores after operation between the two groups (all P>0.05). The suprapatellar approach group presented more C-arm exposures during surgery than the lateral parapatellar approach group, the difference was statistically significant (t=5.907, P<0.05).

Conclusions

The intramedullary nail fixation with suprapatellar approach or the parapatellar lateral approach for the treatment of tibial fractures can effectively restore knee joint function and effectively avoid anterior knee pain, which is worthy of clinical application. However, there is a controversy regarding potential intra-articular damage when using the suprapatellar approach. Additionally, this approach requires more frequent intraoperative C-arm fluoroscopy and may need additional incisions for removing internal fixation.

Key words: Tibial fractures, Fracture fixation, intramedullary, Bone nails
表1 髌上入路组和髌旁外侧入路组术前一般资料
Table 1 General data of the suprapatellar approach group and parapatellar lateral approach group before surgery
组别Groups 例数Number of cases 性别(例)Gender 年龄[岁，(±s)]Age (year) 伤侧(例)Injured side 受伤至手术时间[d，(±s)]Time from injury to surgery 闭合或开放(例)Open or closed fractures
男Male 女Female 左Left 右Right 闭合Closed 开放Open
髌上入路组Suprapatellar group 44 35 9 43.6±12.8 18 26 4.2±1.5 32 12
髌旁外侧入路组Lateral parapatellar group 42 32 10 45.7±13.5 20 22 3.9±1.8 32 10
统计值Statistical value   χ2＝0.141 t＝0.741 χ2＝0.392 t＝0.841 χ2＝0.135
P值   >0.05 >0.05 >0.05 >0.05 >0.05
组别Groups 例数Number of cases 致伤机制(例)Causes of trauma AO/OTA分型(例)AO/OTA fracture classification
车祸Traffic accident 压砸伤Crush injury 扭伤Sprain 41A 42A 42B 42C
髌上入路组Suprapatellar group 44 23 14 7 6 11 17 10
髌旁外侧入路组Lateral parapatellar group 42 20 16 6 4 13 18 7
统计值Statistical value     χ2＝0.373     χ2＝1.079    
P值     >0.05     >0.05    
表2 两组患者的手术时长、术中出血量、住院时间(±s)
Table 2 Operation duration, intraoperative blood loss, and length of hospital stay of the two groups
组别Groups 例数Number of cases 手术时长(min)Operation duration 术中出血量(ml)Blood loss 骨折愈合时间(个月)Fracture healing time(month) 术中曝光次数(次)Number of C-arm exposures(time)
髌上入路组Suprapatellar group 44 81.7±12.4 124.1±12.1 11.7±4.2 15.4±2.5
髌旁外侧入路组Lateral parapatellar group 42 83.2±14.5 119.5±11.4 12.1±3.1 12.3±2.3
t值   0.516 1.813 0.501 5.907
P值   >0.05 >0.05 >0.05 <0.001
表3 两组患者术后HSS和Lysholm评分(±s)
Table 3 HSS and Lysholm scores of the two groups after surgery
组别Groups 例数Number of cases HSS评分 Lysholm评分
术后6个月Six months after surgery 术后12个月12 months after surgery 术后6个月Six months after surgery 术后12个月12 months after surgery
髌上入路组Suprapatellar group 44 82±8 87±7 85±3 93±4
髌旁外侧入路组Lateral parapatellar group 42 82±8 88±8 85±4 94±5
F值   时间：20.95，组间：0.968，交互：0.148 时间：180.8，组间：1.119，交互：0.091
P值   时间：<0.001，组间>0.05，交互：>0.05 时间：<0.001，组间：>0.05，交互：>0.05
图1 右侧胫腓骨骨折病例X线图像及术后右下肢外观。图A为术前右小腿正位X线片，示胫骨中段横行骨折、腓骨中段粉碎性骨折；图B为右胫骨术中透视正侧位图像，沿套筒置入导针后到达胫骨外侧隆突内侧的起点，侧位示其位于关节面的前方；图C为术后右胫腓骨正侧位X线片，示髓内钉植入后胫骨骨折复位满意；图D为术后右下肢外观，示右膝手术切口为髌上取约4 cm左右纵形切口
Figure 1 X ray images and right lower limb appearance after operation of the patient with right tibiofibular fractures. A is the anteroposterior view of right focil in X-ray image, showing transverse fracture of the tibia and communicated fracture of fibula; B is the C-arm fluoroscopic images of right knee at anteroposterior and lateral positions during the surgery, showing that after inserting the guide pin along the sleeve, the guide pin reached the starting point on the inner side of the tibial tuberosity, and was precisely positioned just anterior to the joint surface; C is the anteroposterior and lateral views of right focil in X-ray image after surgery, showing a satisfactory realignment and reduction of the right tibiofibular fractures, following the implantation of intramedullary nail; D is right lower limb appearance after surgery, showing the longitudinal surgical incision about 4 cm on the right knee, above the patella
图2 左侧胫骨及踝关节骨折术前术后X线片及术后左下肢外观。图A为左侧胫骨术前正侧位X线片，示左胫骨中下断螺旋形骨折，内侧可见蝶形骨块；图B为术后复查左胫腓骨正侧位X线片，示髓内钉植入后胫骨骨折复位满意；图C为术后患者左膝手术切口，外侧髌旁取约4 cm左右斜形切口
Figure 2 X ray images and left lower limb appearance after operation of the patient with left tibial and ankle fractures. A is the anteroposterior and lateral views of left tibia in X-ray image, showing spiral fracture in the mid-lower region of the left tibia, with an butterfly-shaped bone fragment at medial of tibia; B is the anteroposterior and lateral views of left tibia in X-ray image after surgery, showing a satisfactory reduction of the right tibial fracture, following the implantation of intramedullary nail; C is the appearance of left lower limb after surgery, showing the oblique surgical incision about 4 cm on left knee beside the patella at lateral side
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