弹性髓内钉固定儿童长度不稳与稳定胫骨干骨折

Elastic stable intramedullary nails for length unstable and stable tibial shaft fractures in children

摘要:

[目的] 比较弹性髓内钉 （elastic stable intramedullary nail, ESIN） 固定儿童长度不稳定与稳定胫骨干骨折的临床效果。[方法] 回顾性分析 2016 年 1 月—2021 年 11 月收治于本院采用弹性髓内钉治疗的 84 例胫骨干骨折患儿资料，其中，不稳定骨折 32 例，稳定骨折 52 例。比较两组围手术期、随访及影像结果。[结果]两组患儿手术时间、切口总长度、术中失血量、切口愈合等级、住院时间的差异均无统计学意义（P＞0.05），不稳定组术中透视次数显著多于稳定组 [(12.4±1.5) 次 vs (10.3± 1.7) 次, P＜0.05]。随访时间平均 （13.3±2.3） 个月，两组患者恢复术后完全负重时间的差异无统计学意义 （P＜0.05）。随术后时间推移，两组 AOFAS 评分、踝背伸-跖屈 ROM 均显著增加（P＜0.05）。相应时间点，两组 AOFAS 评分和踝背伸-跖屈 ROM 的差异均无统计学意义（P＞0.05），末次随访时，两组 Johner-Wruh 评级的差异无统计学意义（P＞0.05），两组患者步态和下蹲活动均正常。影像方面，与术前相比，术后两组胫骨对位对线、双侧胫骨长度差（leg length discrepancy, LLD）和胫骨成角均显著改善 （P＜0.05）。术后即刻不稳定组胫骨对位对线 [优/良/差, (9/18/5) vs (33/18/1), P＜0.05]、双胫骨长度差 [(2.1±2.2) mm vs (0.7± 1.3) mm , P＜0.05] 均显著不及稳定组，两组胫骨成角的差异无统计学意义（P＞0.05）；末次随访时，两组上述指标的差异均无统计学意义（P＞0.05）。两组影像骨折愈合时间的差异无统计学意义（P＞0.05）。[结论]ESIN 是治疗学龄期长度稳定胫骨干骨折患儿安全有效的方法，同样适用于长度不稳定型骨折，虽然术后长度不稳定型骨折短缩的可能性较大，但过度生长会代偿最终的下肢长度差异。

Abstract:

[Objective] To compare the clinical outcomes of the elastic stable intramedullary nail (ESIN) for fixation of length unstable tibial shaft fractures versus stable counterparts in children. [Methods] A retrospective study was conducted on 84 children who received ESIN for tibial shaft fractures in our hospital from January 2016 to November 2021. Among them, 32 children suffered from unstable frac- ture, while the remaining 52 children were of stable fracture. The perioperative, follow-up and imaging data were compared between the two groups. [Results] Although there were no significant differences in operation time, total incision length, intraoperative blood loss, inci- sion healing and hospital stay between the two groups (P＜0.05), the unstable group had significantly more intraoperative fluoroscopy than the stable group [(12.4±1.5) times vs (10.3±1.7) times, P＜0.05]. All patients in both groups were followed up for (13.3±2.3) months on a mean, and there was no a significant difference in the time to return full weight-bearing activity between the two groups (P＞0.05). The AO- FAS scores and ankle dorsal extension- plantar flexion ROM significantly increased in both groups over time postoperatively (P＜0.05), which proved not statistically significant between the two groups at any time points accordingly (P＞0.05). In addition, there was no a signifi- cant difference in Johner-Wruh scale between the two groups at the latest follow-up (P＞0.05), with normal gait and squat activity in all chil- dren in both groups. Radiographically, there were significant improvements in tibial alignment, leg length discrepancy (LLD) and tibial an- gulation in both groups postoperatively compared with those preoperatively (P＜0.05). The unstable group proved significantly inferior to the stable group in terms of tibial alignment [excellent/good/poor, (9/18/5) vs (33/18/1), P＜0.05], and LLD [(2.1±2.2) mm vs (0.7±1.3) mm, P＜ 0.05], despite that there was no statistical significance in tibia angulation between the two groups immediately postoperatively (P＞0.05).However, all differences in the above indexes became not statistically significant between the two groups at the latest follow-up (P＞0.05). There was no significant difference in fracture healing time on images between the two groups (P＞0.05). [Conclusion] ESIN, a safe and ef- fective for the length stable tibial shaft fractures in school-age children, is also suitable for the length unstable fractures. Although there is a greater possibility of postoperative shortening in length unstable fractures, the overgrowth can compensate for the final difference in lower limb length.