Comparison of Therapeutic Effects of Intramedullary Nail Fixation of Tibial Fractures Through Different Approaches and Analysis of the Causes of Postoperative Knee Pain
Department of Orthopaedics，Jingmen People’s Hospital
摘要目的 比较髌上与髌下两种入路行髓内钉固定治疗胫骨干骨折的疗效，探讨不同入路对胫骨骨折治疗的效果差异，分析术后膝前疼痛的原因。方法 回顾性分析荆门市人民医院自2019年1月至2022年12月应用髓内针治疗的胫骨干骨折共143例。髌上入路(A组)74例，其中男39例，女35例；年龄34~55岁，平均(41.56±3.24)岁。髌下入路(B组)69例，其中男35例，女34例；年龄30~56岁，平均(40.56±5.54)岁。比较两组手术时间、术中失血量、术后48 h隐性失血量、住院天数、术中X线透视次数、术后不同时期疼痛视觉模拟评分(visual analogue scale，VAS)、美国特种外科医院(hospital for special surgery，HSS)膝关节评分、Lysholm评分、膝关节活动度(range of motion，ROM)。结果 患者术后均获随访，随访时间7~10个月，平均(8.31±1.21)个月。所有患者均顺利完成手术，术中均无血管、神经损伤，术后除3例出现小腿肌间静脉血栓，其余患者均未发生深部组织感染、内固定失效、皮肤坏死骨髓炎等严重并发症。两组患者术中出血、住院时间、骨愈合时间比较差异无统计学意义(P＞0.05)；术后1、3个月随访HSS评分比较，差异无统计学意义(P＞0.05)；术后6个月随访HSS评分比较A组优于B组，差异有统计学意义(P＜0.05)。手术时间、术中X线透视次数A组明显少于B组，差异有统计学意义(P＜0.05)。两组术后1、3、6个月ROM比较差异无统计学意义(P＞0.05)，术后3、6个月Lysholm评分A组优于B组，差异有统计学意义(P＜0.05)。术前、术后1、3个月运动状态VAS评分比较差异无统计学意义(P＞0.05)，术后第6个月A组VAS评分低于B组，差异有统计学意义(P＜0.05)。结论 两种入路行髓内钉治疗胫骨骨折均安全、可靠，可取得良好的手术效果，但髌上入路更具优势。术中减少医源性损伤、适度的尾帽突出、术后持续的功能锻炼能降低膝关节疼痛发生率。
Objective To compare the therapeutic effects of intramedullary nail fixation using suprapatellar and infrapatellar approaches in the treatment of tibial shaft fractures and explore the differences in the effectiveness of different approaches in the treatment of tibial fractures，and analyze the causes of postoperative anterior knee pain.Methods A retrospective analysis was conducted on 143 cases of tibial shaft fractures treated with intramedullary nails at Jingmen People’s Hospital from January 2019 to December 2022.74 cases underwent suprapatellar approach were included in Group A.There were 39 males and 35 females in group A.The patients aged 34~55 years，with an average age of (41.56±3.24)years.In group B，69 cases were treated through the infrapatellar approach.There were 35 males and 34 females and the patients aged 30 to 56 years，with an average age of (40.56±5.54)years.After surgery，all patients were followed up for 6 months to compare the surgical time，intraoperative blood loss，occult blood loss at 48 hours after surgery，length of hospital stay，intraoperative X-ray fluoroscopy frequency，visual analog scale(VAS) for pain at different postoperative stages，hospital for special surgery(HSS) knee joint score，Lysholm score，and range of motion(ROM) between the two groups.Results All patients were followed up for 7 to 10 months，with an average of (8.31±1.21)months.All patients successfully completed the surgery without any vascular or nerve damage during the operation.Except for 3 cases of intramuscular venous thrombosis in the calf after surgery，all other patients did not experience serious complications such as deep tissue infection，internal fixation failure，skin necrosis，and osteomyelitis.There was no statistically significant difference in intraoperative bleeding，hospital stay，and bone healing time between the two groups of patients (P＞0.05).There was no statistically significant difference (P＞0.05) in HSS scores between postoperative follow-up at 1 and 3 months.After 6 months of follow-up，the HSS score of Group A was better than that of Group B，and the difference was statistically significant (P＜0.05).The surgical time and intraoperative Xray fluoroscopy frequency in Group A were significantly less than those in Group B，and the difference was statistically significant (P＜0.05).There was no statistically significant difference in ROM between the two groups at 1，3，and 6 months after surgery (P＞0.05).The Lysholm score of Group A was better than that of Group B at 3 and 6 months after surgery，and the difference was statistically significant (P＜0.05).There was no statistically significant difference (P＞0.05)in the VAS scores of preoperative and postoperative 1 and 3 months.On the 6th month after surgery，the VAS score of Group A was lower than that of Group B，and the difference was statistically significant (P＜0.05).Conclusion Both approaches for intramedullary nail treatment of tibial fractures are safe and reliable，and can achieve good surgical results.But the suprapatellar approach has more advantages.Reducing iatrogenic injuries during surgery，moderate tailcap protrusion，and continuous postoperative functional exercise can reduce the incidence of knee joint pain.
廖云健，黄佳，尤加锐，李孝新，黄平，袁华兵，胡锐. 不同入路行胫骨骨折髓内钉固定的疗效比较及术后膝部疼痛原因分析[J]. 实用骨科杂志, 2023, 29(12): 1081-.
Liao Yunjian，Huang Jia，You Jiarui，Li Xiaoxin，Huang Ping，Yuan Huabing，Hu Rui. Comparison of Therapeutic Effects of Intramedullary Nail Fixation of Tibial Fractures Through Different Approaches and Analysis of the Causes of Postoperative Knee Pain. sygkzz, 2023, 29(12): 1081-.
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