关节镜辅助与切开复位内固定治疗髌骨骨折的疗效对比分析

Comparative Analysis Curative Effect of Arthroscopy and Open Reduction in Treatment of Patellar Fracture

摘要: 目的：探讨关节镜辅助微创与切开复位内固定治疗髌骨骨折临床效果。方法：2007年6月~2011年10月，关节镜辅助与切开复位Cable-pin固定治疗髌骨骨折病例，选择骨折类型相似的两组各30例进行疗效对比分析。两组患者受伤至手术时间为2~5天，平均3.5天。均为新鲜闭合骨折。关节镜手术组常规膝关节镜检查，伴有半月板损伤4例，股骨髁软骨面损伤5例均I期处理，严重韧带损伤予二期处理。在关节镜监视下进行复位和Cable-pin微创固定，损伤的股四头肌扩张部予镜下修补。切开组常规行切开整复骨折，Cable-pin固定。结果：1) 用T检验比较两组患者手术时间及术后第3天疼痛评分情况，均有统计学差异。关节镜组手术时间较切开组长，而术中出血量及术后疼痛评分均有所减低。2) 两组患者术后3个月X线片示骨折均愈合。关节镜组：均无切口及关节感染、皮肤坏死或创口延迟愈合。2例后期出现关节面塌陷1 mm~1.5 mm，均为伴有冠状面骨折的Rockwood V型。1例出现髌骨关节面1 mm分离，Rockwood V型。术后3个月Bostman评分：优24例，良5例，差1例。此期主要表现为股四头肌萎缩，肌力不够及膝关节主动伸屈功能较差。术后6个月Bostman评分：优26例，良4例。此期不适表现为劳累后疼痛及肿胀，上下楼及深蹲不适。切开组：2例在院期间切口愈合不良，1例3周后切口感染，再次清创引流后3周痊愈，未影响骨折愈合。术后3个月Ｘ线片示骨折均愈合。1例后期出现关节面塌陷2 mm，伴有冠状面骨折的Rockwood V型。1例钢缆松动，关节面轻度分离1 mm。术后3个月Bostman评分：优19例，良8例，差3例。此期不适表现为手术疤痕牵拉不适，股四头肌萎缩，肌力不够及膝关节僵硬。术后6个月Bostman评分：优24例，良5例，差1例。此期不适表现为深蹲时髌前疤痕牵拉感，关节活动弹响，打软腿，关节僵硬，劳累后疼痛及肿胀，上下楼及深蹲不适等。3) 用X²检验比较两组患者术后3个月膝关节屈伸活动范围，显示关节镜组与切开组活动范围有显著差异，关节镜组优于切开组。4) 两组患者正常工作生活平均时间，镜下组和切开组分别为(75 ± 15) d和(110 ± 15) d。结论：两种手术方式均能较好治疗髌骨骨折，中长期疗效相似。与传统切开复位手术相比关节镜辅助下治疗髌骨骨折，可以微创进行骨折的精确复位和固定，早期发现和处理关节内其他结构损害，应用多种镜下技术相结合能较好修复扩张部。术后局部疼痛轻，在早期功能康复方面具有一定优势。但应按骨折类型慎重选择病例。

Abstract:  Objective: Comparative analysis curative effect of arthroscopy and open reduction in treatment of patellar fracture. Method: We’ve treated closed patellar fractures with Cable-pin in arthroscopy and open reduction since July 2007 till October 2011. Divide the cases into two groups with classification of fracture, and 30 cases every group. The patients were operated 2 - 5 days after injury (3.5 days in average). Arthroscopy group: we routinely exam the joint under arthroscopy and find 4 meniscus injury and 5 femoral condyle cartilage injury, and then proceed reduction and internal fixation closely inspected under arthroscopy were operated with MIPO technique using Cable-pin. Patellar tears were also treated under arthroscopy, so did the meniscus injury and femoral condyle cartilage injury. A severe ligament injury requires secondary intervention. Result: 1) Compared average operation time and grading the wound ached NO. 3 day after operation with variance. Arthroscopy group have longer time, fewer amount of bleeding and grading the wound ached. 2) All X rays showed healed fracture 3 months after operation. Arthroscopy group: there was no evidence of infection, necrosis or delayed healing. Bostman Score after 3 month counted for 24 excellent, 5 good and 1 bad. Major situation were atrophy of quadriceps femoris, weak, and compromised active extension of keen joint. Bostman Score after 6 month counted for 26 excellent, 4 good. Major situation in this period were pain and swelling after exercises and irritation of subcutaneous internal fixation device. Open reduction group: There was 2 cases poor wound healing and 1 cases wound infection. Bostman Score after 3 month counted for 19 excellent, 8 good and 3 bad. Major situation were atrophy of quadriceps femoris, weak, and compromised active extension of keen joint. Bostman Score after 6 month counted for 24 excellent, 5 good and 1 bad. Major situation in this period were pain and swelling after exercises and irritation of subcutaneous internal fixation device. 3) With X² test compared between the two groups were 3 months after knee flexion range of activity, display arthroscopy group and open reduction group activity area have significant differences, arthroscopy group is better than the open reduction group. 4) Two groups of patients with normal work and life average time, arthroscopy group is (75 ± 15) d and open reduction group is (110 ± 15) d. Conclusion: Long term of curative effect is good of arthroscopy and open reduction in treatment of patellar fracture. Arthroscopy can achieve precise reduction and internal fixation of fracture, early discovery and treatment of other joint structure injury. Various type of patellar fracture can be well handled by different internal fixation instrument. The variety of technology with arthroscopy can treat retinaculum tear cutaneously. But key is cautious select cases with fracture type.