腓骨中下段骨折并下胫腓分离髓内钉与钢板固定比较△（开放获取）

Intramedullary nailing versus plate for middle and distal fibular fracture complicated with inferior tibiofibular separation

摘要:

[目的] 比较髓内钉与钢板治疗腓骨中下段骨折并下胫腓联合分离的临床疗效。[方法] 回顾性分析 2020 年 1 月— 2022 年 12 月在本院内固定联合下胫腓 TightRope 固定治疗腓骨中下段骨折并下胫腓联合分离 40 例患者的临床资料，依据医患沟通结果， 20 例采用髓内钉固定，另外 20 例采用钢板固定。比较两组围手术期、随访及影像结果。[结果]两组手术均顺利完成。髓内钉组手术时间 [(117.1±24.5) min vs (147.2±26.6) min, P＜0.001]、切口长度 [(4.1±1.7) cm vs (6.9±3.5) cm, P=0.003]、术中失血量 [(175.8±26.4) mL vs (199.4±22.5) mL, P=0.004] 和术中透视次数 [(5.7±1.2) 次 vs (7.1±1.5) 次, P=0.002]、切口愈合等级 [例, 甲/乙/ 丙, (20/0/0) vs (16/4/0), P=0.035]、下地行走时间 [(3.5±1.2) d vs (5.1±1.7) d, P＜0.001]、住院时间 [(9.6±4.8) d vs (14.6±5.3) d, P=0.003] 均显著优于钢板组。随访时间平均（13.0±0.6）个月。髓内钉组完全负重活动时间 [(68.2±5.1) d vs (75.8±8.8) d, P=0.003] 显著早于钢板组。术后 1 个月及末次随访时，髓内钉组的 VAS 评分 [(3.4±0.9) vs (4.5±1.0), P＜0.001; (0.5±0.3) vs (1.0±0.6), P=0.002]、AOFAS 评分 [(76.5±5.3) vs (70.1±6.1), P＜0.001; (92.8±3.1) vs (89.3±4.2), P=0.005] 均显著优于钢板组。术后 1 个月髓内钉组的跖屈-背伸 ROM [(32.9±5.6)° vs(27.8±4.9)°, P=0.004] 显著优于钢板组。影像方面，髓内钉组骨折复位质量不及钢板组（P＜0.05），但骨折愈合显著优于钢板组（P＜0.05）。末次随访时，髓内钉组的内侧净间隙（medial clear space, MCS）、胫腓净间隙（tibiofibular clear space, TFCS）显著优于钢板组（P＜0.05）。[结论]髓内钉联合 TightRope 固定是治疗腓骨中下段骨折并下胫腓联合分离的优选方案。

Abstract:

[Objective] To compare the clinical efficacy of intramedullary nailing (IN) versus plate combined with TightRope for middle and distal fibular fractures complicated with inferior tibiofibular separation. [Methods] A retrospective study was done on 40 patients who had middle and distal fibular fracture complicated with inferior tibiofibularseparation treated by internal fixation and tibiofibular TightRope fixation in our hospital from January 2020 to December 2022. According to doctor-patient communication, 20 patients were fixed with the INl, while the other 20 patients were fixed with the plate. The documents of perioperative period, follow-up and imaging were compared between the two groups. [Results] All patients in both groups had operation performed successfully. The IN group proved significantly superior to the plate group in terms of operation time [(117.1±24.5) min vs (147.2±26.6) min, P＜0.001], incision length [(4.1±1.7) cm vs (6.9±3.5) cm, P=0.003], intraoperative blood loss [(175.8±26.4) mL vs (199.4±22.5) mL, P=0.004], intraoperative fluoroscopy times [(5.7±1.2) times vs 7.1±1.5) times, P=0.002], incision healing grade [A/B/C, (20/0/0) vs (16/4/0), P=0.035], ambulation time [(3.5±1.2) days vs (5.1±1.7) days, P＜0.001] and hospital stay [(9.6±4.8) days vs (14.6±5.3) days, P=0.003]. The average follow-up time was of (13.0±0.6) months, and the IN group resumed full weight-bearing activity significantly earlier than the plate group [(68.2±5.1) days vs (75.8±8.8) days, P=0.003]. The IN group was significantly better than the plate group in terms of the VAS score [(3.4±0.9) vs (4.5±1.0), P＜0.001; (0.5±0.3) vs (1.0±0.6), P= 0.002], AOFAS score [(76.5±5.3) vs (70.1±6.1), P＜0.001; (92.8±3.1) vs (89.3±4.2), P=0.005] 1 month after surgery and at the last follow-up, additionally, the plantar flexion-dorsal extension ROM [(32.9±5.6)° vs (27.8±4.9)°, P=0.004] 1 month postoperatively. Regarding imaging, the IN had poorer fracture reduction quality than the plate group (P＜0.05), but the IN group got fracture healing significantly better than the plate group (P＜0.05). However, the IN group proved significantly superior to the plate group in terms of the medial clear space (MCS) and tib-iofibular clear space (TFCS) at the latest follow-up (P＜0.05). [Conclusion] Intramedullary nailing combined with TightRope fixation might be the better choice for the treatment of the middle and distal fibula fractures complicated with inferior tibiofibular separation.