摘要
目的 探讨"三位一体"策略在多发骨创伤救治中的临床价值.方法 采用回顾性病例系列研究分析2013年6月至2023年5月上海交通大学医学院附属新华医院、海军军医大学第一附属医院收治的1267例多发骨创伤患者的临床资料,其中男862例,女405例;年龄18～93岁[(55.2±19.8)岁].合并伤:失血性休克632例,创伤性湿肺274例,颅脑损伤135例,腹盆腔出血116例,气胸89例,尿道损伤13例,膀胱破裂8例.患者均采用"三位一体"多发骨创伤救治策略,将救治全程分为急救期、重建期和康复期.急救期以稳定症状、抢救生命为宗旨;重建期以恢复解剖、复位结构为核心;康复期以中西协同、功能重建为目标.统计所有患者术后30 d内全因病死率、骨折愈合时间;末次随访时Constant-Murley肩关节功能评分、Mayo肘关节功能评分、Gartland-Werley腕关节功能评分、Harris髋关节功能评分、美国特种外科医院(HSS)膝关节功能评分和美国足踝外科协会(AOFAS)踝-后足功能评分的优良率和所有关节功能评分的总优良率;术前及术后6个月36条目简明健康量表(SF-36)评分,包括生理机能、生理职能、躯体疼痛、一般健康、生命力、社会功能、情感职能和精神健康8个维度;术后并发症发生率.结果 患者均获随访6～18个月[(10.2±4.2)个月].急性期(术后30d内)病死率为2.37％,其中失血性休克导致死亡12例,创伤性脑损伤导致死亡10例,多器官功能障碍综合征(MODS)导致死亡6例,肺部感染导致死亡2例.骨折愈合时间为3.8～18个月[(11.5±4.2)个月],其中89.49％的患者在术后12个月内获得骨性愈合,8.93％的患者在术后18个月内获得骨性愈合,1.58％的患者经历二次手术.内固定失效和骨不连患者骨折愈合时间分别延长至(10.2±2.2)个月和(13.7±3.3)个月.末次随访时所有患者Constant-Murley肩关节功能评分、Mayo肘关节功能评分、Gartland-Werley腕关节功能评分、Harris髋关节功能评分、HSS膝关节功能评分和AOFAS踝-后足功能评分的优良率分别为83.93％、90.24％、94.12％、85.57％、88.46％、92.31％,所有关节功能评分的总体优良率达89.11％.术后6个月所有患者SF-36评分在生理机能、生理职能、躯体疼痛、一般健康、生命力、社会功能、情感职能和精神健康8个维度的得分分别为(74.4±8.6)分、(44.7±14.4)分、(77.4±10.9)分、(68.4±18.2)分、(72.5±16.0)分、(76.8±8.7)分、(49.9±17.6)分、(72.8±17.9)分,均明显高于术前的(63.4±12.7)分、(30.9±17.4)分、(56.4±18.0)分、(55.4±24.7)分、(53.5±21.0)分、(55.8±24.3)分、(36.9±24.0)分、(58.8±21.6)分(P＜0.01).214例(16.89％)患者术后出现不同程度并发症,其中肺部感染118例(9.31％),下肢深静脉血栓50例(3.95％),压力性损伤26例(2.05％),内固定失效12例(0.95％),骨不连8例(0.63％).结论 "三位一体"策略针对多发骨创伤全程管理、个性化治疗、实现整体康复,可降低患者病死率,缩短骨折愈合时间,改善关节功能和生活质量,降低并发症发生率.
Abstract
Objective To explore the clinical value of a trinity strategy for the treatment of multiple orthopedic trauma.Methods A retrospective case series study was conducted to analyze the clinical data of 1 267 patients with multiple orthopedic trauma admitted to Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the First Affiliated Hospital of Navy Medical University from June 2013 to May 2023,including 862 males and 405 females,aged 18-93 years[(55.2±19.8)years].Associated injuries included hemorrhagic shock in 632 patients,traumatic wet lung in 274,cranial injuries in 135,abdominal and pelvic bleeding in 116,pneumothorax in 89,urinary injury in 13,and vesical rupture in 8.All the patients were treated with the trinity strategy and the treatment process was divided into the phases of first aid,remodeling,and rehabilitation.The first aid phase focused on stabilizing symptoms and saving lives;the remodeling phase centered on restoring the anatomical structure and alignment;the rehabilitation phase aimed for functional recovery through the integration of both Western and traditional Chinese medicine.The all-cause mortality within 30 days after surgery and fracture healing time were calculated;the excellent and good rates of Constant-Murley shoulder score,Mayo elbow score,Gartland-Werley wrist score,Harris hip score,Hospital for Special Surgery(HSS)knee score and the American Orthopedic Foot&Ankle Society(AOFAS)ankle-hindfoot score at the last follow-up and the overall excellent and good rate of all joint function scores were measured.The short form health survey(SF-36)scores were collected preoperatively and at 6 months postoperatively,including 8 aspects such as physical functioning,physical role,bodily pain,general health,vitality,social functioning,emotional role,and mental health.The incidence of postoperative complications was recorded.Results All the patients were followed up for 6-18 months[(10.2±4.2)months].The mortality rate during the acute phase(within 30 days after surgery)was 2.37％with 12 deaths due to hemorrhagic shock,10 due to traumatic brain injury,6 due to multiple organ dysfunction syndrome(MODS),and 2 due to pulmonary infection.The average fracture healing time averaged 3.8-18 months[(11.5±4.2)months],with 89.49％of the patients having bone union within 12 months after surgery,8.93％having bone union within 18 months after surgery,and 1.58％undergoing reoperation.For the patients with internal fixation failure and nonunion,the average healing time was extended to(10.2±2.2)months and(13.7±3.3)months respectively.At the last follow-up,the excellent and good rates of Constant-Murley shoulder score,Mayo elbow score,Gartland-Werley wrist score,Harris hip score,HSS knee score,and AOFAS ankle-hindfoot score were 83.93％,90.24％,94.12％,85.57％,88.46％,and 92.31％respectively,with an overall excellent and good rate of 89.11％.At 6 months after surgery,the SF-36 scores of all the patients in the eight dimensions,including the physical functioning,physical role,bodily pain,general health,vitality,social functioning,emotional role,and mental health were(74.4±8.6)points,(44.7±14.4)points,(77.4±10.9)points,(68.4±18.2)points,(72.5±16.0)points,(76.8±8.7)points,(49.9±17.6)points,and(72.8±17.9)points,significantly improved compared with those before operation[(63.4±12.7)points,(30.9±17.4)points,(56.4±18.0)points,(55.4±24.7)points,(53.5±21.0)points,(55.8±24.3)points,(36.9±24.0)points,(58.8±21.6)points](P＜0.01).Complications of different degrees occurred in 214 patients(16.89％),including lung infections in 118 patients(9.31％),lower extremity deep vein thrombosis in 50(3.95％),pressure injuries in 26(2.05％),internal fixation failure in 12(0.95％),and nonunion in 8(0.63％).Conclusions The trinity strategy provides whole-process management,personalized treatment,and overall rehabilitation for multiple orthopedic trauma.It can decrease mortality,shorten fracture healing time,improve joint function and quality of life,and reduce the incidence of complications.
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