髌上入路髓内钉治疗胫骨干骨折的研究进展

陈水林 孙贵才

髌上入路髓内钉治疗胫骨干骨折的研究进展

陈水林 孙贵才

胫骨骨折；骨折固定术，内；髓内钉；髌上入路；综述

胫骨干骨折是四肢骨折中最为常见的一种[1]，约占全身骨折的 13.7%[2]。由于髓内钉具有微创、固定强度高、术后并发症及再手术率低，目前成为胫骨干骨折的首选治疗方案[3-6]。与传统入路 ( 髌韧带及髌韧带旁入路 ) 相比，髌上入路胫骨髓内钉的置入具有易操作、适应证更广及术后并发症发生率更低等优势[7-13]。笔者就近年来髌上入路髓内钉固定治疗胫骨干骨折安全性的研究进展及其与传统入路的对比研究作一综述，为今后相关研究提供参考。

一、髌上入路胫骨髓内钉固定治疗胫骨干骨折的安全性

髌上入路髓内钉固定治疗胫骨干骨折最早由 Cole[14]提出，通过分析 1 例 80 岁胫骨干骨折患者病情最后选择髌上入路髓内钉固定治疗并取得理想的术后效果。有研究指出髌上入路是半伸膝位的一种改良的胫骨髓内钉手术入路，具有手术时间短，术后膝关节疼痛发生率低，骨折畸形愈合较少见等优点[10-12]。付备刚等[15]指出髌上入路胫骨髓内钉内固定治疗胫骨干骨折具有复位固定操作简单、术中透视方便和术后并发症少等优点，尤其适用于近远干骺端、多节段、小腿软组织条件差及合并同侧股骨骨折等特殊类型胫骨骨折的手术治疗。但有反对者认为髌上入路胫骨髓内钉置入会增加髌股关节面压力导致髌股关节面损伤，同时有可能损伤膝关节内重要软组织结构及增加关节内感染的风险。Glebke 等[16]通过一具尸体研究发现髌上入路髓内钉固定治疗胫骨干骨折时髌股关节面的压力为 3.83×103kPa ( 1 kPa＝7.52 mm Hg )，低于造成软骨细胞损伤标准的 4.5×103kPa，故得出髌上入路胫骨髓内钉并不会造成髌股关节面的损伤的结论。这结论在 Eastman等[17]的尸体研究中也得到证实。同样，Gaines 等[18]研究发现髌上入路胫骨髓内钉不仅不会增加髌股关节面损伤的风险，而且膝关节重要软组织结构损伤发生率更低。Beigang[19]通过 23 例髌上入路髓内钉固定治疗胫骨干骨折患者并平均随访 15.5 个月后得出髌上入路胫骨髓内钉治疗胫骨干骨折是安全、有效、利于早期康复并且无不良并发症的结论，同时，Mitchell 等[20]指出髌上入路胫骨髓内钉的置入并不会增加关节内感染的风险。

二、髓内钉固定治疗胫骨干骨折髌上入路与传统入路的对比

髓内钉固定治疗胫骨干骨折髌上入路与传统入路的对比主要有术中指标 ( 手术时间、术中 X 线放射时间、出血量 ) 及术后评分及并发症发生率等方面。

1. 术中指标：巩金鹏等[21]通过临床研究指出两种入路方式在手术时间、住院天数及术中出血量的比较中，差异无统计学意义；Courtney 等[22]通过随机对照实验发现，两种入路方式在手术时间上差异无统计学意义，但髌上入路能明显减少术中 X 线放射时间，且差异有统计学意义；Sun 等[23]通过随机对照实验指出两种入路方式在手术时间、住院天数及术中出血量的比较中的差异无统计学意义，同时证实了髌上入路能明显减少术中 X 线放射时间；同样傅升培[24]通过随机对照实验对 98 例胫骨骨折患者分析指出两种入路方式在手术时间、住院天数及术中出血量的比较中的差异无统计学意义；王等[25]通过回顾 68 例胫骨干骨折患者病例后分析指出髌上入路能明显减少术中出血量及 X 线放射时间。

2. 术后评分：巩金鹏等发现术后 24 周髌上入路较传统入路优良率高、髌上入路具有更高的 Lysholm 膝关节评分及术后患侧膝前疼痛发生率更低，差异均有统计学意义；Sun 等通过随机对照实验证实了术后 24 周髌上入路具有更高的 Lysholm 膝关节评分，同时髌上入路具有更高的 SF-36 physical 和更低 VAS 评分，差异均有统计学意义，但 ROM 及 SF-36 physical 差异无统计学意义；Courtney 等发现两种入路方式在术后 Oxford Knee Score 比较中，差异无统计学意义；傅升培发现术后 9 个月髌上入路组患者膝关节 HSS 评分及 Lysholm 评分均优于髌下入路组，差异有统计学意义；同时王等也发现术后 9 个月髌上入路具有更高的膝关节 HSS 评分及 Johner-Wruhs 评分，差异均有统计学意义。

3. 术后并发症：( 1 ) 慢性膝前区疼痛是传统入路胫骨髓内钉术后最常见并发症，病因不明，有研究指出，可能主要与髌韧带完整性破坏、膝关节内结构损伤、隐神经髌下支损伤等因素有关[26-28]。孙和炎等发现髌上入路胫骨髓内钉术后膝关节前区疼痛发生率不足 5%；解冰等[29]采用髌上入路髓内钉固定治疗胫骨近端骨折患者 16 例，随访2 年未出现膝关节疼痛；Courtney、Sun、Chan、王及王惠等[22-23,25,30-31]分别通过髌上入路及传统入路对比发现，髌上入路术后膝关节前区疼痛发生率低，差异有统计学意义。( 2 ) 骨折术后成角畸形 胫骨近端 1 / 3 骨折及胫骨多段骨折，传统入路胫骨髓内钉植入时，患膝需过曲位，由于髌腱的牵拉及骨折端的不稳定，使得复位及固定困难，术后容易造成成角畸形[32-33]。Courtney 等发现髌上入路可以减少矢状面成角，差异有统计学意义；Avilucea 等[34]同样指出髌上入路可以减少冠状面及矢状面成角，与传统入路相比，差异有统计学意义。

综上所述，胫骨干骨折常由高能量损伤所致，由于胫骨前方肌肉组织较少，暴力损伤后容易造成开放性骨折，软组织损伤、污染等，不仅影响传统入路开口，而且增加切口不愈合、感染的风险[35]，髌上入路是一个很好的选择方案。同时，与传统入路比较，髌上入路具有操作方便，术中放射时间短，术后并发症发生率少及优良率高等优势。但髌上入路植入髓内钉经哪种手术方式移除仍具有争议，同时需要外科医生操作熟练，避免髌股关节面损伤，再加上手术费用贵，患者不容易接受。目前仍需要更多的大型对比性研究来给临床一个合理的建议，但从临床满意效果来讲，髌上入路胫骨髓内钉值得在临床上推广使用。

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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 南昌大学第四附属医院骨科

孙贵才，Email: 13657000633@139.com

2016-12-31 )

( 本文编辑：李慧文 )