摘要
目的 探讨儿童先天性胫骨假关节(congenital pseudarthrosis of the tibia,CPT)经联合手术治疗骨愈合后再骨折可能的临床原因.方法 回顾性收集2007年1月至2016年8月在湖南省儿童医院骨科接受联合手术治疗的142例CPT患儿中骨愈合后再骨折的患儿56例,男35例、女21例,年龄(38.0±9.2)个月(范围18～66个月).记录术后胫骨假关节是否完全愈合、有无外伤史诱发因素、腓骨状态完整与否及胫骨髓内棒整体是否在胫骨髓腔内四种因素下发生再骨折例数,采用单因素logistic回归分析检验四种因素与胫骨假关节骨愈合后再骨折的相关性.结果 142例术后随访时间为(81.7±10.8)个月(范围60～120个月),骨愈合后随访时间均＞5年.术后胫骨假关节完全愈合和部分愈合者再骨折例数分别为48、8例;术后有外伤史与无外伤史者再骨折例数分别为50、6例;术后腓骨完整与腓骨不完整再骨折例数分别为7、49例;骨愈合后髓内棒整体在胫骨髓腔内与跨踝关节固定者再骨折例数分别为44、12例.单因素logistic回归分析结果示术后胫骨假关节部分愈合[OR=0.255,95％CI(0.107,0.605),P=0.002]、胫骨再骨折有外伤史诱因[OR=36.458,95％CI(13.332,99.701),P＜0.001]、腓骨不完整[OR=0.267,95％CI(0.108,0.661),P=0.004]及髓内棒整体在胫骨髓腔内[OR=2.640,95％CI(1.224,5.695),P=0.013]与骨愈合后再骨折相关.再骨折发生于骨愈合后≤1、1～3、3～6、≥6年的例数及构成比分别为 5 例、9％(5/56),14 例、25％(14/56),22 例、39％(22/56),15 例、27％(15/56),差异有统计学意义(x2=11.569,P=0.009).随着随访时间延长,骨愈合后再骨折病例增多,大多发生于骨愈合后1年以上.94例髓内棒整体在胫骨髓腔内与48例跨踝关节固定者中骨愈合后分别发生再骨折44例(47％,44/94)、12例(25％,12/48),再骨折发生率的差异有统计学意义(x2=6.327,P=0.018).髓内棒整体在胫骨髓腔内者髓内棒移位的发生率达100％.结论 术后胫骨假关节部分愈合、有外伤史诱发因素、腓骨不完整状态及髓内棒推入胫骨内是影响CPT经联合手术治疗骨愈合后再骨折发生的可能的危险因素;假关节骨愈合后胫骨髓内棒整体不宜推入胫骨髓腔内,可造成胫骨髓内棒固定不稳定而产生髓内棒移位或再骨折.
Abstract
Objective To explore the possible risks of re-fracture after bone healing in children with congenital pseudar-throsis of the tibia,who were treated with combined surgery.Methods 56 children(35 males and 21 females,with an average age of 38.0±9.2 months ranging from 18 to 66 months)with re-fracture after bone healing were retrospectively enrolled from Janu-ary 2007 to August 2016,during which a total of 142 children with CPT underwent combined surgical treatment in the orthopedics department of Hunan Children's Hospital.Complete healing of the tibial pseudarthrosis,trauma after surgery,breakage of fibula,and the distal end of the tibial intramedullary rod located in the tibial medullary cavity or not were hypothesized as 4 risk factors.Univariate logistic regression analysis was conducted to investigate the correlation between these factors and re-fractures after tibi-al pseudarthrosis healing.Results The average follow-up was 81.7±10.8 months ranging from 60 to 120 months with at least 5 years after bone healing.For complete or partial healing of the tibial pseudarthrosis after surgery,the number of re-fractures was 48 and 8,respectively;For with or without a history of trauma,the number of re-fractures was 50 and 6,respectively;for with an in-tact or broken fibula after surgery,the number of re-fractures was 7 and 49,respectively;For entry or no entry of the intramedul-lary rod into the tibial medullary cavity,the number of re-fractures was 44 and 12,respectively.The results of univariate logistic re-gression analysis showed that partial healing of the tibial pseudarthrosis after surgery[OR=0.255,95％CI(0.107,0.605),P=0.002],history of trauma[OR=36.458,95％CI(13.332,99.701),P＜0.001],incomplete fibula[OR=0.267,95％CI(0.108,0.661),P=0.004],and intramedullary rod insertion into the tibial medullary cavity[OR=2.640,95％CI(1.224,5.695),P=0.013]were as-sociated with re-fracture after bone healing.The number and proportion of cases with recurrent fractures occurring ≤1,1-3,3-6,≥6years after bone healing were 5 cases,9％(5/56),14 cases,25％(14/56),22 cases,39％(22/56),15 cases,and 27％(15/56),respectively,the difference was statistically significant(x2=11.569,P=0.009).With the extension of follow-up time,the number of cases of re-fractures after bone healing increases,mostly occurring more than one year after bone healing.There were 44 cases(47％,44/94)and 12 cases(25％,12/48)of re fractures after bone healing in 94 cases of distal intramedullary rods in the tibial medullary cavity and 48 cases of cross ankle joint fixation,respectively.The difference in the incidence of re-fractures was statisti-cally significant(x2=6.327,P=0.018).The incidence of intramedullary rod displacement in cases where the distal end of the intra-medullary rod is located within the tibial medullary cavity was 100％.Conclusions Factors of partial healing of the tibial pseud-arthrosis,a history of trauma,incomplete status of the fibula after surgery,and intramedullary rod's entry into the tibia were risk factors for re-fracture after bone healing treated with combined surgery for CPT.After the healing of the tibial pseudarthrosis,it is not advisable to push the tibial intramedullary rod into the tibial medullary cavity,which can cause unstable fixation of the tibial intramedullary rod and result in displacement,and even affect the development of the tibial mechanical axis or the occurrence of re-fractures.
基金项目
儿童骨科学湖南省重点实验室专项(2023TP1019)
维普
万方数据