Abstract
目的
分析空心螺钉联合克氏针张力带、空心螺钉联合锚钉、改良1/3管型钢板3种内固定方式治疗青少年胫骨结节撕脱骨折(avulsion fracture of tibial tubercle,AFTT)的疗效。
方法
回顾分析2018年1月—2023年9月收治且符合选择标准的19例青少年AFTT患者临床资料。根据内固定方式不同,将患者分为A组(8例,空心螺钉联合克氏针张力带)、B组(6例,空心螺钉联合锚钉)、C组(5例,改良1/3管型钢板)。3组患者年龄、性别、侧别、致伤原因、Ogden分型及受伤至手术时间等基线资料比较差异均无统计学意义(P>0.05)。记录并比较3组术后1个月膝关节活动度、膝关节负重时间、膝关节正常活动时间、末次随访时美国特种外科医院(HSS)评分;记录骨折有无移位、术后1个月骨折线是否模糊、有无骨骺发育异常以及有无切口感染等并发症。
结果
3组患者住院时间比较差异无统计学意义(P>0.05)。所有患者均获随访,随访时间10~24个月,平均14.3个月;3组间随访时间比较差异无统计学意义(P>0.05)。患者手术切口均愈合良好,无软组织激惹及骨折不愈合发生,随访期间未见患肢短缩畸形,无骨骺发育异常。A组术后1个月膝关节活动度及住院费用均优于B、C组,骨折愈合时间、膝关节负重时间、膝关节正常活动时间优于C组,C组住院费用优于B组,差异均有统计学意义(P<0.05);其余各指标组间两两比较差异无统计学意义(P>0.05)。A组术后1个月骨折线均模糊,骨折端接触紧密,无骨折移位发生;B、C组各有2例术后1个月骨折线清晰,C组1例出现骨折端轻度移位;除B组1例术中出现骨折块劈裂外,其余两组术中骨折块均无劈裂。3组间术后1个月骨折线模糊情况、骨折移位情况及术中骨块劈裂情况比较差异均无统计学意义(P>0.05)。末次随访时3组患者膝关节HSS评分均获优、良,3组间比较差异无统计学意义(P>0.05)。
结论
空心螺钉联合克氏针张力带技术治疗青少年AFTT疗效可靠,具有稳定骨折端、加速骨折愈合康复、早期可行膝关节功能锻炼、降低住院费用等优点。
Keywords: 胫骨结节撕脱骨折, 克氏针张力带, 空心螺钉, 钢板, 锚钉, 内固定
Abstract
Objective
To analyze the effectiveness of three internal fixation methods, namely hollow screw combined with Kirschner wire tension band, hollow screw combined with anchor nail, and modified 1/3 tubular steel plate, in the treatment of avulsion fracture of tibial tubercle (AFTT) in adolescents.
Methods
Between January 2018 and September 2023, 19 adolescent AFTT patients who met the selection criteria were admitted. According to different internal fixation methods, patients were divided into group A (8 cases, hollow screw combined with Kirschner wire tension band), group B (6 cases, hollow screw combined with anchor nail), and group C (5 cases, modified 1/3 tubular steel plate). There was no significant difference in the baseline data of age, gender, side, cause of injury, Ogden classification, and time from injury to operation among the three groups (P>0.05). The range of motion (ROM), weight-bearing time, normal activity time of knee joint, and the hospital for special surgery (HSS) score at last follow-up were recorded and compared among the three groups. Recorded whether the fracture was displaced, whether the fracture line was blurred at 1 month after operation, whether there was epiphyseal dysplasia, and whether there was incision infection and other complications.
Results
There was no significant difference in hospital stay between the groups (P>0.05). All patients were followed up 10-24 months, with an average of 14.3 months; there was no significant difference between the groups (P>0.05). All the incisions healed well without soft tissue irritation or fracture nonunion, and no limb shortening deformity or epiphyseal dysplasia was found during follow-up. At 1 month after operation, the knee joint ROM and hospitalization expenses in group A were better than those in groups B and C, the fracture healing time, knee joint weight-bearing time, and normal activity time of knee joint were better than those in group C, and the hospitalization expenses in group C were better than those in group B, with significant differences (P<0.05); there was no significant difference in the other indicators between the groups (P>0.05). In group A, the fracture line was blurred 1 month postoperatively, the fracture ends were in close contact, and there was no fracture displacement; in groups B and C, the fracture line was clear in 2 cases, and 1 case in group C had slight fracture displacement; except for 1 case in group B, there was no fracture split in the other two groups. There was no significant difference in the incidences of blur of fracture line, fracture displacement, and intraoperative bone split between the groups at 1 month after operation (P>0.05). At last follow-up, the HSS scores of knee joints in the three groups were excellent and good, and there was no significant difference between the groups (P>0.05).
Conclusion
Hollow screw combined with Kirschner wire tension band technique is effective in treating adolescent AFTT, which has the advantages of stabilizing fracture, accelerating fracture healing and rehabilitation, early feasible knee joint functional exercise, and reducing hospitalization expenses.
Keywords: Avulsion fracture of tibial tubercle, Kirschner wire tension band, hollow screw, steel plate, anchor nail, internal fixation
胫骨结节撕脱骨折(avulsion fracture of tibial tubercle,AFTT)是临床少见损伤,仅占儿童骨折的0.4%~2.7%,不足骨骺损伤的1%,好发于13~17岁青少年,男女比例为10∶1[1-3]。胫骨结节是伸膝装置的重要组成部分,AFTT治疗的主要目的是恢复膝关节伸膝机制、复位固定关节面、修复相关合并损伤[4]。治疗方式不当会增加膝关节功能障碍、骨折端移位及骨折愈合不良风险[3]。因此,选择合适的治疗方式对AFTT预后尤为重要。
Watson-Jones依据骨折线是否通过胫骨近端骺板及有无累及关节面,将AFTT分为Ⅰ~Ⅲ型[1]。Ogden为描述骨折移位程度,在Watson-Jones分型基础上将每型又分为A、B 2个亚型,A型骨折端无移位,B型骨折端移位或为粉碎性骨折[5]。目前,手术治疗是大部分AFTT的首选治疗方案,内植物选择主要有空心螺钉、克氏针、钢丝张力带、钢板、带线锚钉等[6-8]。然而,各种内固定方式存在诸多弊端,例如单枚空心螺钉强度较差,多枚空心螺钉拧入时骨折块易劈裂;克氏针易失效;钢丝张力带固定强度弱且骨骺远端易向前方成角;钢板螺钉固定创伤较大且螺钉存在骺板损伤风险[3,6]。此外,上述内固定方式均不具有抵抗股四头肌收缩牵拉骨折块的能力,内固定易失效,且不利于软组织修复,患者早期无法行膝关节功能锻炼。因此,现有单一内固定方式无法解决上述问题,不同内固定方式联合应用可能是治疗AFTT的有效方案。
现回顾分析2018年1月—2023年9月我们采用空心螺钉联合克氏针张力带、空心螺钉联合锚钉、改良1/3管型钢板3种内固定方式治疗的19例青少年AFTT患者临床资料,探讨分析3种内固定方式临床疗效差异,为临床选择手术方式提供参考。报告如下。
1. 临床资料
1.1. 一般资料
患者纳入标准:① 膝关节正侧位X线片及CT三维重建示胫骨结节撕脱,骨皮质连续性中断;② 闭合性骨折;③ 采用切开复位内固定治疗;④ 年龄<18岁。排除标准:① 合并胫骨结节骨骺炎病史;② 合并胫骨平台及胫骨干骨折;③ 随访资料缺失。
2018年1月—2023年9月共19例患者符合选择标准纳入研究。根据内固定方式不同,将患者分为A组(8例,空心螺钉联合克氏针张力带)、B组(6例,空心螺钉联合锚钉)、C组(5例,改良1/3管型钢板)。3组患者年龄、性别、侧别、致伤原因、Ogden分型及受伤至手术时间等基线资料比较差异均无统计学意义(P>0.05)。见表1。
表 1.
Comparison of baseline data of three groups of patients
3组患者基线资料比较
基线资料 Baseline data |
A组 Group A |
B组 Group B |
C组 Group C |
统计量 Statistical value |
P值 P value |
年龄(x±s,岁) | 14.50±1.69 | 14.57±1.62 | 13.80±1.30 | F=0.474 | 0.631 |
性别(男/女,例) | 7/1 | 5/1 | 5/0 | - | 0.650 |
侧别(左/右,侧) | 5/3 | 4/3 | 3/2 | - | 0.978 |
受伤至手术时间(x±s,d) | 3.25±0.71 | 3.57±0.79 | 3.40±0.89 | F=0.315 | 0.734 |
Ogden分型(ⅠB/ⅡA/ⅡB/ⅢA/ⅢB,侧) | 1/1/2/2/2 | 0/1/2/3/1 | 2/1/2/0/0 | - | 0.182 |
致伤原因(剧烈运动伤/摔伤/交通事故伤,例) | 6/1/1 | 6/1/0 | 3/1/1 | - | 0.804 |
1.2. 手术方法
患者于全身麻醉后取仰卧位,常规消毒、铺巾,驱血后充气止血。以骨折端为中心作一长7~10 cm纵切口,显露骨折端,清除骨折端血肿及机化肉芽组织,直视下复位骨折端,克氏针临时固定。A组:骨折端复位满意后,取2枚2.0 mm克氏针固定骨折近端,进针点位于骨折块中上1/3两侧且在同一水平面,2枚克氏针穿过髌腱后斜行向前下方平行进针;另使用1枚4.0 mm空心螺钉(大博医疗科技股份有限公司)加压固定骨折块远端,空心螺钉与2枚克氏针呈“三点固定”;使用克氏针于骨折远端2 cm处电钻钻孔,取双股钢丝行“8”字加压固定,剪除多余长度克氏针,折弯,冲洗止血后关闭切口。见图1。
图 1.
Schematic diagram of hollow screw combined with Kirschner wire tension band in the treatment of AFTT
空心螺钉联合克氏针张力带治疗AFTT手术操作示意图
a、b. 股四头肌强力收缩致AFTT;c. 克氏针联合空心螺钉“三点固定”增加骨折端稳定性;d. 空心螺钉避免骨骺远端向前方成角,张力带将拉力转化为压应力,对抗股四头肌牵拉同时加压骨折端
a, b. AFTT caused by strong contraction of quadriceps femoris; c. Kirschner wire combined with hollow screw “three-point fixation” increased the stability of fracture end; d. The hollow screw prevented the distal end of the epiphysis from opening forward, and the tension band converted the tension into compressive stress, which resisted the traction of the quadriceps femoris and pressurizes the fracture fragment
B组:根据骨折块大小,使用1~2枚4.0 mm空心螺钉加压固定骨折端,充分显露髌腱附着点;使用2枚带线锚钉(强生公司,美国)自骨折块两侧编织髌韧带,稳定骨折端,冲洗止血后关闭切口。针对Ogden Ⅲ型骨折,若骨折复位后胫骨关节面骨折端仍不稳定,在A、B组内固定方式中,可采用2枚及以上空心螺钉予以固定。
C组:取合适长度的1/3管型钢板(大博医疗科技股份有限公司),自钉孔处剪断,残端预弯呈勾形,将钢板预弯处置于胫骨结节骨折块近端,并向钢板施加向下的拉力,交替应用普通螺钉及锁定螺钉加压胫骨结节骨折端,至钢板服帖,冲洗止血后关闭切口。
1.3. 术后处理及疗效评价指标
术后3组处理方法一致。定期清洁换药,患肢行可调节支具外固定4~6周;术后2周内膝关节屈曲30° 位固定,采用个体化、渐进式关节功能康复锻炼方案,每周增加20°~40°。术后1、2、3、6个月门诊定期复查膝关节正侧位X线片,明确骨折愈合情况,指导膝关节康复锻炼。
记录并比较3组术后1个月膝关节活动度、膝关节负重时间、膝关节正常活动时间、末次随访时美国特种外科医院(HSS)评分;记录骨折有无移位、术后1个月骨折线是否模糊、有无骨骺发育异常,以及有无切口感染等并发症。
1.4. 统计学方法
采用SPSS27.0统计软件进行分析。计量资料经Shapiro-Wilk检验,均符合正态分布,数据以均数±标准差表示,组间比较采用单因素方差分析,两两比较采用LSD检验;计数资料组间比较采用Fisher确切概率法;等级资料比较采用Wilcoxon秩和检验。检验水准取双侧α=0.05。
2. 结果
3组患者住院时间比较差异无统计学意义(P>0.05)。所有患者均获随访,随访时间10~24个月,平均14.3个月;3组间随访时间比较差异无统计学意义(P>0.05)。患者手术切口均愈合良好,无软组织激惹及骨折不愈合发生,随访期间未见患肢短缩畸形,无骨骺发育异常。A组术后1个月膝关节活动度及住院费用均优于B、C组,骨折愈合时间、膝关节负重时间、膝关节正常活动时间优于C组,C组住院费用优于B组,差异均有统计学意义(P<0.05);其余各指标组间两两比较差异无统计学意义(P>0.05)。A组术后1个月骨折线均模糊,骨折端接触紧密,无骨折移位发生;B、C组各有2例患者术后1个月骨折线清晰,C组有1例患者出现骨折端轻度移位,予以支具固定患肢、延迟负重时间、减少膝关节活动,于术后14周骨折达临床愈合。除B组1例患者术中出现骨折块劈裂外,其余两组患者术中骨折块均无劈裂。3组间术后1个月骨折线模糊情况、骨折移位情况及术中骨块劈裂情况比较差异均无统计学意义(P>0.05)。末次随访时3组患者膝关节HSS评分均获优、良,3组间比较差异无统计学意义(P>0.05)。见表2、3,图2~4。
表 2.
Comparison of outcome indicators between groups
3组患者结局指标比较
结局指标 Outcome indicator |
A组 Group A |
B组 Group B |
C组 Group C |
P值 P value |
住院时间(x±s,d) | 6.25±1.04 | 6.29±0.76 | 6.40±1.14 | 0.963 |
随访时间(x±s,月) | 14.00±3.02 | 14.29±2.22 | 14.80±5.59 | 0.926 |
骨折愈合时间(x±s,周) | 8.13±0.84 | 9.14±1.57 | 10.40±2.19 | 0.047 |
术后1个月膝关节活动度(x±s,°) | 97.50±3.78 | 89.29±6.08 | 86.00±10.84 | 0.020 |
膝关节正常活动时间(x±s,周) | 17.38±1.41 | 18.86±2.55 | 21.20±2.68 | 0.019 |
膝关节负重时间(x±s,周) | 5.25±1.04 | 5.43±0.98 | 6.80±1.10 | 0.041 |
住院费用(x±s,万元) | 0.67±0.04 | 1.13±0.09 | 0.82±0.07 | <0.001 |
HSS评分(优/良/差,侧) | 8/0/0 | 6/1/0 | 4/1/0 | 0.740 |
术后1个月骨折线模糊(是/否,侧) | 8/0 | 5/2 | 3/2 | 0.168 |
骨折移位(是/否,侧) | 0/8 | 0/7 | 1/4 | 0.452 |
术中骨块劈裂(是/否,侧) | 0/8 | 1/6 | 0/5 | 0.376 |
表 3.
Pairwise comparison of outcome indicators between groups
3组患者结局指标两两比较
结局指标 Outcome indicator |
A组 vs B组 Group A vs group B |
B组 vs C组 Group B vs group C |
A组 vs C组 Group A vs group C |
|||||
效应值(95%CI) Effect value (95%CI) |
P值 P value |
效应值(95%CI) Effect value (95%CI) |
P值 P value |
效应值(95%CI) Effect value (95%CI) |
P值 P value |
|||
骨折愈合时间(周) | MD=−1.02(−2.67,0.63) | 0.211 | MD=−1.26(−3.13,0.61) | 0.174 | MD=−2.28(−4.10,−0.45) | 0.017 | ||
术后1个月膝关节活动度(°) | MD=8.21(0.76,15.66) | 0.033 | MD=3.29(−5.14,11.71) | 0.422 | MD=11.50(3.29,19.71) | 0.009 | ||
膝关节正常活动时间(周) | MD=−1.48(−3.87,0.91) | 0.208 | MD=−2.34(−5.05,0.36) | 0.085 | MD=−3.83(−6.46,−1.19) | 0.007 | ||
膝关节负重时间(周) | MD=−0.18(−1.30,0.95) | 0.742 | MD=−1.37(−2.64,−0.10) | 0.036 | MD=−1.55(−2.79,−0.31) | 0.017 | ||
住院费用(万元) | MD=−0.46(−0.54,−0.38) | <0.001 | MD=0.31(0.22,0.40) | <0.001 | MD=−0.15(−0.23,−0.06) | 0.002 |
图 2.
A 15-year-old male patient with right AFTT in group A (Ogden type ⅡA)
A组患儿,男,15岁,右侧AFTT(Ogden ⅡA型)
a、b. 术前CT三维重建及矢状位平扫;c、d. 术后即刻正侧位X线片;e、f. 术后1个月正侧位X线片示骨折线模糊,骨折端接触紧密;g、h. 术后3个月正侧位X线片示骨折端愈合良好;i、j. 术后6个月正侧位X线片示骨折端愈合良好,内固定无失效;k、l. 术后1年取出内固定装置后正侧位X线片示骨折愈合,骨折线消失
a, b. Preoperative CT three-dimensional reconstruction and sagittal plain scan; c, d. Anteroposterior and lateral X-ray films at immediate after operation; e, f. Anteroposterior and lateral X-ray films at 1 month after operation showed that the fracture line was blurred and the fracture ends were in close contact; g, h. Anteroposterior and lateral X-ray films at 3 months after operation showed that the fracture end healed well; i, j. Anteroposterior and lateral X-ray films at 6 months after operation showed that the fracture end healed well and the internal fixation did not fail; k, l. Anteroposterior and lateral X-ray films after removal of the internal fixator at 1 year after operation showed that the fracture healed and the fracture line disappeared
图 4.
A 13-year-old boy with left AFTT (Ogden type ⅡB)
C组患儿,男,13岁,左侧AFTT(Ogden ⅡB型)
a、b. 术前CT三维重建及矢状位平扫;c、d. 术后即刻正侧位X线片示骨折端对位对线佳;e、f. 术后1个月正侧位X线片示骨折端无移位,骨折线模糊;g、h. 术后3个月正侧位X线片示骨折端愈合良好;i、j. 术后个8月正侧位X线片示骨折端愈合良好,内固定无失效;k、l. 术后8个月取出内固定物后正侧位X线片示骨折愈合,骨折线消失
a, b. Preoperative CT three-dimensional reconstruction and sagittal plain scan; c, d. Anteroposterior and lateral X-ray films at immediate after operation showed that the fracture end was well aligned; e, f. Anteroposterior and lateral X-ray films at 1 month after operation showed that the fracture end was not displaced and the fracture line was blurred; g, h. Anteroposterior and lateral X-ray films at 3 months after operation showed that the fracture end healed well; i, j. Anteroposterior and lateral X-ray films at 8 months after operation showed that the fracture healed well and the internal fixation did not fail; k, l. Anteroposterior and lateral X-ray films after removal of the internal fixator at 8 months after operation showed that the fracture healed and the fracture line disappeared
图 3.
A 12-year-old boy with bilateral AFTT (Ogden type ⅢA on the left, Ogden type ⅢB on the right) in group B
B组患儿,男,12岁,双侧AFTT(左侧Ogden ⅢA型,右侧Ogden ⅢB型)
a~c. 术前CT三维重建及矢状位平扫;d~f. 术后即刻正侧位X线片示骨折端对位对线佳,关节面平整;g、h. 术后3个月侧位X线片示骨折端愈合良好;i、j. 术后8个月侧位X线片示骨折端愈合良好,内固定无失效;k、l. 术后8个月取出内固定物后侧位X线片示骨折愈合,骨折线消失
a-c. Preoperative CT three-dimensional reconstruction and sagittal plain scan; d-f. Anteroposterior and lateral X-ray films at immediate after operation showed that the fracture end was well aligned and the articular surface was flat; g, h. Lateral X-ray films at 3 months after operation showed that the fracture end healed well; i, j. Lateral X-ray films at 8 months after operation showed that the fracture end healed well and the internal fixation did not fail; k, l. Lateral X-ray films after removal of the internal fixator at 8 months after operation showed that the fracture healed and the fracture line disappeared
3. 讨论
青少年胫骨结节骨骺线尚未闭合,骺板及周围骨膜产生的附着力较薄弱。跳跃、起跑等剧烈活动引起股四头肌强力收缩,并对胫骨结节产生巨大瞬时牵引力,当牵引力超过附着力时,即可导致AFTT。AFTT治疗方式的选择主要取决于骨折类型及损伤程度[2-3,9]。除少数无移位或轻微移位(<2 mm)的Ogden ⅠA、ⅠB和ⅡA型骨折外,大部分AFTT需行手术治疗,以恢复膝关节伸膝机制、复位固定关节面,必要时修复合并损伤[10-11]。Pretell-Mazzini等[6]报道,336例AFTT患者中88%进行了手术治疗,其中切开复位内固定术占手术方式的98%。然而,目前对于手术方式及内固定物的选择尚未达成共识。尽管相关报道显示,99.8%的AFTT患者经治疗后可获得良好骨折愈合效果,不同内固定方式似乎与骨折愈合无明显相关性[3,12];然而,骨折愈合并非AFTT预后的唯一评判标准,早期膝关节功能康复同样是AFTT预后的重要影响因素[13-14]。
理想的内固定方式需同时具备坚强固定及抵抗股四头肌牵拉力的能力,消除骨折端不稳定因素,为膝关节早期功能康复提供有利基础[15]。现有单一内固定方式存在诸多弊端,不同内固定方式联合应用可能是治疗AFTT的有效方案。Matsuo等[16]采用单枚空心螺钉联合锚钉技术治疗AFTT,实现了骨折端加压,减少骨折端应力;但是单枚螺钉固定存在骨折端不稳定及内固定失效隐患,且锚钉缝线缝合于骨折端远端,应力仍集中于胫骨结节处。Park等[10]采用空心螺钉联合张力带技术治疗AFTT,疗效满意,但其仅使用张力带固定胫骨结节骨折端,空心螺钉则用于固定胫骨关节面,胫骨结节撕脱处仍为单一内固定方式固定,骨折端固定强度弱,且不具备减小骨折端应力的能力。在此基础上,Kothari等[13]使用克氏针张力带替代张力带内固定,然而上述问题仍无法有效解决。
胫骨结节是伸膝装置的重要组成部分,同时也是应力集中部位。因此,针对AFTT的治疗,增加胫骨结节骨折端固定强度、减小骨折端应力是手术治疗关键[17]。在上述报道基础上,我们尝试对手术方式进行改进。① 采用空心螺钉联合克氏针张力带技术对AFTT进行固定,2枚克氏针斜行向前下方平行进针,与胫骨干长轴线成锐角,克氏针进针点均位于髌腱内。空心螺钉固定于胫骨结节中远端,解决张力带加压后导致的骨骺远端向前方成角问题;2枚克氏针联合空心螺钉“三点固定”可增加骨折端稳定性;克氏针联合张力带可最大化将拉应力转化为压应力,对抗股四头肌牵拉的同时对髌腱及骨折端产生即刻加压效果,为早期膝关节功能康复提供有利基础。② 采用空心螺钉联合锚钉技术对AFTT进行固定,使用2枚空心螺钉固定胫骨结节骨折端,锚钉缝线缝合于髌腱止点处,而非骨折端远端,减小骨折端局部应力。③ 采用改良1/3管型钢板技术对AFTT进行固定,1/3管型钢板可塑性强,将预弯处固定于胫骨结节骨折近端及髌韧带处,达到骨折端加压及减小应力目的,且内固定不通过骺线,避免骨骺损伤。
本研究结果表明,空心螺钉联合克氏针张力带技术可提供足够的内固定强度,实现骨折端加压,减小骨折端局部应力,加速骨折愈合并促进AFTT患者早期功能康复。A组在骨折愈合时间、术后1个月膝关节活动度、膝关节正常活动时间、负重时间方面均优于C组。因内固定方式及术后康复方案不同,既往关于AFTT功能预后的报道存在较大差异。Pretell-Mazzini等[6]发现,约98%的AFTT患者平均术后22周恢复膝关节完全活动范围,94%患者平均术后29周恢复受伤前相同运动水平。另有研究报道,采用张力带技术治疗的AFTT患者术后4~8周达到膝关节完全活动范围,平均术后3个月恢复至伤前运动水平[18]。本研究结果显示,A组术后(17.38±1.41)周恢复膝关节正常活动,术后1个月膝关节活动度达(97.50±3.78)°。与其他内固定方式相比,空心螺钉联合克氏针张力带技术的显著优势在于可最大化将股四头肌产生的拉应力转化为对骨折块的压力,单枚空心螺钉增加骨折端稳定性,当膝关节早期功能锻炼时,骨折端接触更加紧密,稳定骨折端的同时促进骨折愈合[4,10]。本研究随访结果显示,A组术后1个月骨折线均模糊、骨折愈合良好,术后(8.13±0.84)周骨折端均愈合,随访期间骨折端均未发生移位。此外,胫骨结节撕脱骨块较小,多枚空心螺钉拧入时骨折块易劈裂,单枚空心螺钉联合2枚克氏针固定可减少骨折块碎裂风险,增加加压面积。
本研究中,B、C组同样取得了良好治疗效果,末次随访时膝关节HSS评分优良率100%,且骨折端均愈合;但这两种内固定方式骨折端固定强度有待进一步加强,术后早期功能锻炼仍存在骨折端移位风险。尽管锚钉缝线缝合于髌腱止点处可减小骨折端局部应力,但仍需术者对于缝合端张力进行评估,若缝合端张力较小,则难以保证骨折端固定强度;较大的缝合端张力虽可提供足够的内固定强度,但髌韧带短缩同样影响膝关节早期功能康复效果。此外,二期手术常无法取出金属锚钉,造成异物残留。针对Ogden Ⅲ型骨折,改良1/3管型钢板技术无法对胫骨关节面进行有效固定。因此,我们不建议Ogden Ⅲ型患者采用改良1/3管型钢板技术治疗。
综上述,空心螺钉联合克氏针张力带技术治疗青少年AFTT疗效可靠,具有稳定骨折端、加速骨折愈合康复、早期可行膝关节功能锻炼、降低住院费用等优点。但本研究样本量较少,结果存在偏倚,仍需扩大样本量进一步研究;此外,3种内固定方式减小骨折端应力情况也有待进一步力学分析。
利益冲突 在文章撰写过程中不存在利益冲突;经费支持不影响文章观点和对研究数据客观结果的统计分析及其报道
伦理声明 研究方案经蚌埠医科大学伦理委员会批准(2020013)
作者贡献声明 王照东、段克友:手术方案设计、实施及论文撰写;刘亚军、徐陈、朱仲廉:查阅文献、整理分析数据;官建中:论文审阅并参与观点形成
Funding Statement
安徽省自然科学基金面上项目(2408085MH235);安徽省重点科研平台开放课题研究项目(AHTT2023B003)
Natural Science Foundation of Anhui Province (2408085MH235); Anhui Province Key Research Platform Open Project Research Project (AHTT2023B003)
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