微创皮质截骨联合髓内钉固定治疗陈旧性胫腓骨骨折

Minimally invasive cortical osteotomy and intramedullary nailing for old tibiofibular fractures

摘要:

[目的] 观察微创皮质截骨联合髓内钉固定治疗陈旧性胫腓骨骨折的临床效果。[方法] 2021 年 10 月—2023 年 2 月，本科对 13 例骨折端存在不同程度畸形的 3 周以上陈旧性胫腓骨骨折患者行手术治疗。术中行骨折端小切口皮质截骨，松解周围软组织，牵引恢复胫骨力线和长度，随后常规进行髌上入路髓内钉固定。评价临床和影像资料。[结果]13 例患者均顺利完成手术，术中均无重要血管神经损伤。随访 12 个月以上，临床骨折愈合时间（7.8±1.5）个月，随术前、术后 3 个月和末次随访的时间推移，VAS 评分 [(5.7±1.7) 分, (1.6±0.7) 分, (1.2±0.4) 分, P＜0.001]、HSS 评分 [(54.1±7.0) 分, (87.7±2.7) 分, (91.5±2.7) 分, P＜0.001]、膝伸屈 ROM [(92.3±9.3)°, (121.3±25.8)°, (130.6±17.6)°, P＜0.001]、踝 AOFAS 评分 [(69.5±4.6), (88.0±2.9), (99.5±0.8), P＜ 0.001] 均显著改善。随访过程中，所有患者均无再骨折，无翻修手术。影像方面，随时间推移，患者胫骨对线显著改善 [例, 优/良/ 差, (0/0/13), (4/9/0), (10/3/0), P＜0.001]，双侧胫骨长度差显著缩小 [(7.3±5.3) mm, (1.3±1.0) mm, (0.4±0.3) mm, P＜0.001]。术后骨痂形成时间为（7.0±1.5）周，至末次随访时，13 例患者均达到完全骨折愈合塑形，均无内固定物松动或断裂。[结论]骨折处小切口截骨可有效辅助陈旧性胫骨骨折复位和髓内钉固定，微创操作，对骨折端血运影响小，取得满意临床结果。

Abstract:

[Objective] To observe the clinical consequence of minimally invasive cortical osteotomy combined with intramedullary nailing in the treatment of old tibiofibular fractures. [Methods] From October 2021 to February 2023, 13 patients had old tibiofibular fractures over 3 weeks with varying degrees of deformity at the fracture site treated surgically in our department. During the operation, two small incisions were made for cortical osteotomy performed at the fracture site with the surrounding soft tissues released for restoration of the tibial alignment and length. Subsequently, intramedullary nailing was performed through the suprapatellar approach. The clinical and imaging data were evaluated. [Results] All the 13 patients had the operations performed successfully without injury to major blood vessels or nerves. The followup was conducted for more than 12 months, and the clinical fracture healing time was of (7.8±1.5) months in a mean. The VAS [(5.7±1.7) score, (1.6±0.7) score, (1.2±0.4) score, P＜0.001], HSS [(54.1±7.0) score, (87.7±2.7) score, (91.5±2.7) score, P＜0.001], knee flexion-extension ROM [(92.3±9.3)°, (121.3±25.8)°, (130.6±17.6)°, P＜0.001], and ankle AOFAS [(69.5±4.6) score, (88.0±2.9) score, (99.5±0.8) score, P＜ 0.001] all significantly improved over time preoperatively, 3 months postoperatively and at the latest follow-up. During the follow-up period, no patients had re-fracture or revision surgery. As for imaging, the tibial alignment significantly improved [n, excellent/good/poor, (0/0/13), (4/ 9/0), (10/3/0), P＜0.001], while the tibial length discrepancy between both sides significantly decreased over time [(7.3±5.3) mm, (1.3±1.0) mm, (0.4±0.3) mm, P＜0.001]. The continuous callus remodeling time was (7.0±1.5) weeks after surgery. By the last followup, all 13 patients achieved complete fracture healing and remodeling, without loosening or breakage of the internal fixation implants. [Conclusion] This small incision osteotomy at the fracture site does effectively assist in the reduction and intramedullary nailing of old tibial fractures with advantages of minimally invasive operation and little impact on the blood supply at the fracture site, and achieves satisfactory clinical outcome.