肘关节恐怖三联征中桡骨小头HotchkissⅢ型骨折的处理策略选择：内固定或置换?

doi:10.3969/j.issn.1009-976X.2020.04.021

摘要/Abstract

摘要： 目的探讨保留桡骨小头内固定和桡骨小头假体置换治疗肘关节恐怖三联征中桡骨小头Hotchkiss Ⅲ型骨折的临床疗效,并为该类骨折的处理策略选择提供科学依据。方法对在我院行手术治疗的23例伴桡骨小头HotchkissⅢ型骨折的恐怖三联征患者的临床资料行回顾性分析,对患者就桡骨小头的处理方式进行分组,其中10例行保留桡骨小头的切开复位内固定者为内固定组,13例行桡骨小头切除后行桡骨小头假体置换者为置换组。对所有患者行至少1年,结合手术相关指标、肘关节功能评分、成本-效益分析、患者满意度及生活质量等综合分析两种方案处理恐怖三联征中桡骨小头Hotchkiss Ⅲ型骨折的医疗、经济效益并作比较评价。结果手术时间内固定组长于置换组（P<0.05）,切口长度、术后当天疼痛评分两组无统计学差异（P>0.05）,术后1年复查,患者Mayo肘关节功能评分示,置换组总分优于内固定组（P<0.05）,其中其肘关节疼痛、功能范围恢复均优于内固定组（P<0.05）,但两组稳定性、日常活动完成情况评分对比数据无统计学差异（P>0.05）,两组患者治疗质量-效益分析显示,内固定组治疗费用低于置换组（P<0.05）,治疗效益、患者满意度均高于置换组（P<0.05）,术后1年生活质量对比两组数据差异无统计学意义（P>0.05）。结论两种方法均能有效治疗TTE中该类复杂骨折,从而恢复肘关节日常功能,改善生活质量。桡骨小头置换术创伤较小,功能改善较优,但内固定术治疗效益及患者满意度更高。

关键词: Hotchkiss Ⅲ, 桡骨小头置换术, 内固定术, 型骨折, 恐怖三联征

Abstract: Objective To explore the clinical outcomes for Hotchkiss-type Ⅲ radial head fracture in “terrible triad of the elbow” （TTE） cases treated with two surgical methods, namely, open reduction and internal fixation （ORIF） and radial head prosthetic replacement （RHPR）. Methods Twenty-three TTE cases with Hotchkiss-type Ⅲ radial head fracture, identified from a prospective database, were divided into two groups base on the treatment of radial head fracture. Twenty-three of them underwent the fixation with microplate and the others were treated with RHPR. All the patients were followed for at least one year, and outcomes were assessed and compared base on operation-related situations, the Mayo elbow function score, the cost-effect analysis, satisfaction score and life quality score. Results There were no significant differences in mean incision length and intraday VAS between the two groups, but the operation time was shorter for RHPR than ORIF （72.15±4.95 vs 83.60.±7.93, P<0.001）. For Mayo score in one-year follow-up after the operation, the total score, pain score and range of motion were all better for RHPR than ORIF （91.15±6.81 vs 79.50±10.39, P=0.004, 39.23±7.59 vs 31.50±8.51, P=0.032, 18.85±2.19 vs 16.00±3.16, P=0.019）, but no significant difference were found in stability or activity of daily life. The ORIF group yield better benefit-index in the cost-effect analysis because they consume much less than the RHPR （21.96±3.00 vs. 19.13±1.55, P=0.008, 3.63±0.26 vs. 4.77±0.21, P<0.001）, and they also shows a better mean satisfaction-score （100.60±4.84 vs. 92.69±4.91, P=0.001）. But no significant difference was found in daily life quality questionnaire between the two groups. Conclusion ORIF and RHPR were both effective in reconstruction and recovering elbow function when used to treat Hotchkiss-type Ⅲ radial head fracture in TTE cases. RHPR showed better outcomes in terms of Mayo score, but ORIF showed better benefit-index and satisfaction score.

Key words: terrible triad of the elbow, prosthetic replacement, hotchkiss-type Ⅲ, open reduction and internal fixation, radial head fracture

中图分类号:

R683.41

郑伟坤, 汤俊芬, 戈涛, 蔡维山. 肘关节恐怖三联征中桡骨小头HotchkissⅢ型骨折的处理策略选择：内固定或置换?[J]. 岭南现代临床外科, 2020, 20(04): 496-502.

ZHENG Wei-kun, TANG Jun-fen, GE Tao, CAI Wei-shan. How to treat the Hotchkiss-type Ⅲ radial head fracture in “terrible triad of elbow”cases：open reduction and internal fixation or radial head prosthetic replacement?[J]. Lingnan Modern Clinics in Surgery, 2020, 20(04): 496-502.

参考文献

[1] 侯召猛,陈彦华. 手术治疗肘关节恐怖三联征疗效分析[J]. 中国矫形外科杂志,2019,27(9):853-855.
[2] Hotchkiss RN.Displaced fracture of radial head:Internal fixation or excision?[J]. J Am Acad Orthop Surg, 1997, 5(1): 1-10.
[3] McKee MD, Pugh DM, Wild LM, et al. Standard surgical protocol to treat elbow dislocation with radial head and coronoid fractures [J]. J Bone Joint Surg, 2005, 87suppl 1(Pt 1): 22-32.
[4] Flinkkilä T, Kaisto T, Sirniö K, et al.Short-to-mid term results of metallic press-fit radial head arthoplasty in unstable injuries of the elbow[J]. J Bone Joint Surg Br, 2012, 94(6): 805-810.
[5] 马文明, 董启榕, 茅永涛, 等. Madison Ⅲ型桡骨头骨折的治疗选择 (附35例临床分析)[J]. 苏州大学学报 (医学版), 2011, 31(1): 146-147.
[6] 吴加东, 卞化, 沈孝天, 等. 肘关节恐怖三联征合并肱骨远端骨折的手术治疗[J]. 中华肩肘外科杂志, 2017, 5(3): 194-198.
[7] Shepard MF, Markolf KL, Durbar AM. Effects of radial head excision and distal radial shortening on load-sharing in cadaver forearms [J]. J Bone Joint Surg Am, 2001, 83-A(1): 92-100.
[8] 王思成, 刘祥飞, 杨国庆. 桡骨小头置换与切开复位内固定: 治疗桡骨小头骨折谁更有优势?[J].中国组织工程研究, 2014, 18(13): 2031-2036.
[9] Ring D, Hannouche D, Jupiter JB.Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow[J]. J Bone J Surg Am, 2004, 29(3): 470-480.
[10] Ring D, Quintero J, Jupiter JB.Open reduction and internal fixation of fractures of the radial head[J]. J Bone Joint Surg Am, 2002, 84(10): 1811-1815.
[11] Chen X, Wang SC, Cao LH, et al.Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable multi-fragment radial head fracture[J]. Int Orthop, 2011, 35(7): 1071-1076.
[12] Leigh WB, Ball CM.Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow[J]. J Shoulder Elbow Surg, 2012, 21(10): 1336-1341.
[13] 代杰志, 柴益民. Madison Ⅲ型桡骨头骨折的治疗研究进展[J]. 国际骨科学杂志, 2016, 37(3): 145-148.
[14] Duckworth AD, Wickramasinghe NR, Clement ND, et al.Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal?[J]. Clin Orthop Relat Res, 2014, 472(7): 2136-2143.
[15] 孙利华. 药物经济学[M]. 第2版. 北京: 中国医药科技出版社, 2010: 52.