230,,,,,,,,, (,200021) : 采用手法闭合复位结合 MIPPO 技术经皮锁定接骨板固定与常规小腿下段前外侧入路切开复位内固定治疗胫骨中下段骨折, 比较两种方法的临床效果 :2009 年 3 月至 2013 年 5 月, 治疗并获得随访的 124 例胫骨中下段骨折, 其中男 89 例, 女 35 例 ; 左侧 53 例, 右侧 71 例 ; 年龄 21~81 岁, 平均 (48.62±8.93) 岁 ; 摔伤 94 例, 车祸伤 30 例微创组 66 例, 男 48 例, 女 18 例 ; 平均年龄 (47.72±9.23) 岁 ;29 例合并腓骨 ( 或外踝 ) 骨折 ; 根据 AO 分型,A 型 45 例,B 型 12 例,C 型 9 例 ; 受伤至手术时间平均 1.9 d; 采用手法闭合复位技术结合 MIPPO 治疗常规组 58 例, 男 41 例, 女 17 例 ; 平均年龄 (49.08±9.66) 岁 ;26 例合并腓骨 ( 或外踝 ) 骨折 ; 根据 AO 分型,A 型 41 例,B 型 10 例,C 型 7 例 ; 受伤至手术时间平均 2.3 d; 采用常规小腿下段前外侧入路切开复位内固定治疗所有患者为闭合性骨折 : 微创组手术切口 (7.34±1.42) cm, 常规组 (21.82±2.35) cm, 微创组较常规组切口小 ; 微创组手术时间 (44.48±10.00) min, 常规组 (59.42±11.84) min, 微创组手术时间较常规组短随访时间 10~24 个月, 平均 15.2 个月微创组 65 例在术后 15~ 20 周骨折愈合,1 例发生骨折延迟愈合, 予补肾续骨中药口服后愈合, 术后均未出现伤口处表皮感染 皮肤裂开及骨外露 ; 常规组 4 例出现伤口裂开 感染, 致钢板外露,3 例出现骨不连并再次手术, 其余骨折均愈合良好随访过程中未出现钢板及螺钉松动 断裂及骨折再移位等现象按照 Johner-Wruhs 功能评定标准, 微创组疗效优于常规组 : 手法闭合复位结合 MIPPO 技术治疗胫骨中下段骨折, 结合了传统正骨手法与现代骨科的优点, 既保护了软组织, 将手术程序简化, 创伤降到最小, 又能获得较坚强的内固定, 保证踝关节的早期功能活动, 具有软组织创伤小 血运破坏少 固定可靠等优点, 是治疗胫骨中下段骨折的一种有效方法, 也符合微创生物学内固定观点 胫骨骨折 ; 骨折固定术, 内 ; 手法, 骨科 ; 病例对照研究 DOI:10.3969 / j.issn.1003-0034.2015.03.009 Case control study on close reduction combined with minimally invasive percutaneous plate osteosynthesis for the treatment of distal fracture of tibial shaft LIU Yin wen,zheng Yu xin,wang Xue zong,zhang Hu,SUN Mu zheng, WEI Xiao en,gu Xin feng,kuang Yong,ZHANG Lei,SHEN Zi liang,zhan Hong sheng,and SHI Yin yu. Shi s Center of Orthopaedics and Traumatology,Shuguang Hospital Affiliated to Shanghai University of TCM,Shanghai 200021,China ABSTRACT Objective:To compare the effects of close reduction combined with minimally invasive percutaneous plate osteosynthesis for distal fracture of tibial shaft. Methods:From March 2009 to May 2013,there were 124 patients (89 males and 35 females,30 of them were injured in a traffic accident and 94 were falling down in daily life,the ages ranging from 21 to 81 years old) who suffered from distal fracture of tibial shaft. Sixty six patients (48 males and 18 females,45 cases of type A,12 cases of type B and 9 cases of type C) were treated with close manipulative reduction combined with minimally invasive percutaneous plate fixation. After close reduction,a minimal incision was made and a anatomic plate was inserted just along the medial tibia periostea,and then the fracture was fixed without fracture exposure. The other 58 patients (41 males and 17 females, 41 cases of type A,10 cases of type B and 7 cases of type C) were treated with conventional open reduction and internal fixation. Length of the incision,operating time,early postoperative pain (recorded using the Visual Analog Scale score) and the outcome results(recorded using the evaluation standard of Johner-Wruhs) were compared. Results:The length of incision was meanly(7.34±1.42) cm in MIPPO group and(21.82±2.35) cm in ORIF group; operation time was (44.48±10.00) min in MIP- PO group and (59.42±11.84) min in ORIF group. The postoperative radiographs verified good position of all screws and satis- : ( :100508); ( :ZYSNXD-CC-HPGC-JDD-001) ; ( :041); ( :ZY3-DCCX-3-3004); ( :2014LP096A) Fund program:provided by National TCM Tramotology and Orthopedics Key Discipline(No. 100508) : E mail:shgsyjs@139.com Corresponding author:zhan Hong sheng E mail:shgsyjs@139.com
231 factory bone fracture reduction in both groups. All the patients were followed up,and the duration ranged from 10 to 24 months (mean 15.2 months) in both groups. In MIPPO group,only one patient had delayed union and got union after Chinese herb therapy. The other 65 patients got bony union during 15 to 20 weeks. While in ORIF group,3 patients suffered from nonunion and received reoperation with bone grafting,and 4 patients got bone infection. Conclusion:Treatment of distal fracture of tibial shaft,combined with close reduction and MIPPO technique,has the advantages such as less invasion,less damage of blood supply,simplified procedure of operation and higher union rate,which is an ideal methods and is accordant to the biological demand. KEYWORDS Tibial fractures; Fracture fixation,internal; Manipulation,orthopedic; Case control studies Zhongguo Gu Shang / China J Orthop Trauma,2015,28(3):230-234 www.zggszz.com 1, Tab.1 Comparison of clinical data of patients with tibia ; fractures before treatment between two groups, ( ) AO ( ) 8 20 60~ ( ) (x 軃 ±s, ) A B C 80, 66 48 18 47.72±9.23 45 12 9, 58 41 17 49.08±9.66 41 10 7 [1], 2009 3 - χ 2 =0.516 t=-1.510 Z=0.089 P - 0.472 2013 5, 0.124 0.929 [2] MIPPO, 66, 58 1. 2. 1,,,, 1 1. 1 124, 89, 35 ;53, 71 ;21~81,(48.62±8.93) ; 94, 30 66, 48, 18 ; (47.72±9.23) ;29 ( ) ; AO :A 45,B 12, C 9 ; 1.9 d 58, 41, 17 ; (49.08±9.66) ;26 ( ) ; AO :A 41, B 10,C 7 ; 2.3 d C X, 1 2~3 cm,,, 1,,,C X, 1,, 4~5 0.6 cm,, 4~5 X ;,, CT,,,, 2,, 66 ; 1. 2. 2 1.0 cm,, 58, ( 1), 1. 2,, 1,,,,
232 1. 2. 3 2. 1 2 d, 20% 3 32~56 min, 2, (44.48±10.00) min; ( +)6.4~, 1.5 8.2 cm,(7.34±1.42) cm, 3~4,X, 1 3 d, 1. 3, 3 1 3 d VAS VAS, 2 6 12 Tab.3 Comparison of operation time,length of incision and pain between two groups of patients with tibia fractures 6 12 X, VAS (x 軃 ±s, ) ( ) (x 軃 ±s,min) (x 軃 ±s,cm) ;6,6~9, 1 3 9 Johner-Wruhs [3] 66 44.48±10.00 7.34±1.42 4.41±0.54 2.89±0.22 ( 2) 58 59.42±11.84 21.82±2.35 5.03±0.58 3.26±0.46 t - -5.577-42.085-1.768-1.250 Tab.2 2 Johner-Wruhs P - 0.000 0.000 0.115 0.247 Evaluation standard of tibia fracture(johner- Wruhs) / ( ) 2~5 6~10 >10 / ( ) 0~5 6~10 11~20 >20 ( ) 0~5 6~10 11~20 >20 (mm) 0~5 6~10 11~20 >20 >80% >75% <75% >75% >50% <50% >75% >50% <50%, 2. 2, ;1, 6, [4], 1 X ; 65 15~20, ; 4~6,7, 4,,3, ; Johner-Wruhs [3], 55, 9, 2 ( 1-2); 41, 7, 3, 7 ; (Z=-1.968,P=0.049) 1. 4 3 SPSS 16.0,, ±,, χ 2,, VAS, t ;AO Johner-Wruhs,,, α=0.05, 2, 10~24, 15.2 X,,,
233 1a 1b 1c 1d 1e 1f 1,,48, 1a. X 1b. 1c. X, 1d. 1e,1f. 1 X, Fig.1 A 48 year old male patient with fractures of distal tibia and fibula neck 1a. Preoperative AP X ray showed spiral fracture of distal tibia and fibula neck 1b. AP view of leg monitored under C arm after close reduction showed that fracture was anatomically reduced 1c. Postoperative lateral and AP X ray films showed that tibia fracture was nearly anatomically reduced and well fixed 1d. Mini incision of the leg 1e,1f. One year after operation,ap and lateral X ray films showed disappearance of fracture line and formation of callus 2 2a 2b 2c 2d 2e,,25, 2a. X 2b,2c. X 2d. 2e. 1 X Fig.2 A 25 years old male patient with fractures of distal tibia and fibula 2a. Preoperative lateral and AP X ray films showed spiral fracture of distal tibia and fibula 2b,2c. Postoperative AP and lateral X ray films showed the tibia fracture was nearly anatomically reduced 2d. Mini incision of the leg 2e. One year after operation,lateral and AP X ray films showed disappearance of fracture line, MIPPO [6-7],, MIPPO, [5] MIPPO,,,,,, [8],,,,, MIPPO,
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