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膝关节是人体最为复杂的关节,较易发生损伤。胫骨平台骨折(tibial plateau fracture,TPF)是较为常见的关节内骨折,影响胫骨平台功能和稳定性的骨折通常需要手术治疗。TPF的特征在于关节面的劈裂和严重压缩[1],导致关节面不同程度的移位和膝关节周围结构的严重破坏[2]。TPF术后并发症发生率为4%~27%[3-4],其中骨性关节炎(osteoarthritis,OA)严重影响膝关节功能,同时也增加了治疗和康复成本[5]。本文就TPF术后继发OA的影响因素作一探讨。
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2组性别、年龄、骨折分型、损伤暴力程度、吸烟与饮酒史、手术时间、出血量、植骨情况、住院总时间差异均无统计学意义(P>0.05), 2组围手术期时间差异有统计学意义(P < 0.05)(见表 1)。
因素 继发OA组
(n=17)非OA组
(n=62)χ2 P 性别 男 10(58.8) 33(53.2) 0.17 >0.05 女 7(41.2) 29(46.8) 年龄/岁 ≤55 8(47.1) 37(59.7) 0.87 >0.05 >55 9(52.9) 25(40.3) 骨折分型/型 Ⅰ 2(11.8) 4(6.5) Ⅱ 5(29.4) 18(29.0) Ⅲ 3(17.6) 5(8.1) 3.00 >0.05 Ⅳ 1(5.9) 10(16.1) Ⅴ 4(23.5) 17(27.4) Ⅵ 2(11.8) 8(12.9) 损伤暴力程度 低能量 11(64.7) 47(75.8) 0.37* >0.05 高能量 6(35.3) 15(24.2) 吸烟史 否 17(100.0) 50(80.6) 2.52* >0.05 是 0(0.0) 12(19.4) 饮酒史 否 17(100.0) 52(83.9) 1.85* >0.05 是 0(0.0) 10(16.1) 手术时间/h <3 14(82.4) 49(79.0) 0.002* >0.05 ≥3 3(17.6) 13(21.0) 出血量/mL <400 15(88.2) 53(85.5) 0.01* >0.05 ≥400 2(11.8) 9(15.5) 植骨情况 不植骨 6(35.3) 21(33.9) 0.01 >0.05 植骨 11(64.7) 41(66.1) 住院总时间/d ≤14 6(35.6) 28(45.2) 0.53 >0.05 >14 11(64.7) 34(54.8) 围手术期时间/d >7 9(52.9) 15(24.2) 5.21 < 0.05 ≤7 8(47.1) 47(75.8) *示矫正χ2值 表 1 TPF术后继发OA的单因素分析[n;百分率(%)]
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单因素分析仅围手术期时间具有统计学意义,将P值调整至0.15,选取吸烟、围手术期时间和饮酒因素进行多因素分析,采用二分类logistic回归评估吸烟、围手术期时间和饮酒因素对研究对象发生继发性OA的影响。最终得到logistic模型具有统计学意义(χ2=15.16, P < 0.01),该模型能够正确分类79.0%的研究对象。模型的敏感度为88.7%,特异度为47.1%,阳性预测值为85.9%,阴性预测值为53.3%。回归分析显示,围手术期超过7 d是继发性OA发生危险因素(P < 0.01),是7 d内实施手术治疗病人的5.77倍(见表 2)。
变量 B SE Waldχ2 P OR 95%CI 吸烟 19.228 9 573.634 0.000 >0.05 224 106 373.4 0.000 0.000 饮酒 18.566 1 0138.25 0.000 >0.05 115 632 127.6 0.000 0.000 围手术期时间 1.752 0.621 7.962 < 0.01 5.766 1.707 19.469 表 2 TPF术后继发OA的多因素logistic回归分析
胫骨平台骨折术后继发骨性关节炎的影响因素分析
Analysis of influencing factors of secondary osteoarthritis after operation of tibial plateau fracture
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摘要:
目的探讨手术治疗胫骨平台骨折继发骨性关节炎(OA)的影响因素。 方法选择经手术治疗胫骨平台骨折病人79例,分为继发骨性关节炎组17例,非继发骨性关节炎组62例,单因素和logistic回归分析手术治疗胫骨平台骨折继发OA的危险因素。 结果2组性别、年龄、骨折分型(schatzker分型)、损伤暴力程度、吸烟与饮酒史、手术时间、出血量、植骨情况、住院总时间差异无统计学意义(P>0.05),围手术期时间差异有统计学意义(P < 0.05)。Logistic回归分析显示,围手术期超过7 d是继发性OA发生危险因素。 结论围手术期的时间长度可以间接反映骨折吸收能量强度、软组织破坏情况,以及围手术对症处理的效果等综合情况,是术后继发OA的重要影响因素。 Abstract:ObjectiveTo explore the influencing factors of secondary osteoarthritis (OA) after operation of tibial plateau fracture. MethodsSeventy nine patients with tibial plateau fracture treated with operation were selected and divided into secondary OA group (n=17) and non-secondary OA group(n=62).The risk factors of secondary OA to surgical treatment of tibial plateau fracture were analyzed by single factor and logistic regression analysis. ResultsThere were no significant difference in gender, age, fracture classification (Schatzker type), degree of injury violence, smoking and drinking history, operation time, bleeding volume, bone grafting and total hospitalization days (P>0.05)between the two groups, but there was significant difference in perioperative days (P < 0.05).Regression analysis showed that perioperative period of more than 7 days was a risk factor for secondary OA. ConclusionsThe duration of perioperative period can indirectly reflect the energy absorption intensity of fracture, the destruction of soft tissue, and the effect of perioperative symptomatic treatment.It is an important influencing factor of postoperative secondary OA. -
Key words:
- tibial plateau fracture /
- secondary osteoarthritis /
- influencing factor
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表 1 TPF术后继发OA的单因素分析[n;百分率(%)]
因素 继发OA组
(n=17)非OA组
(n=62)χ2 P 性别 男 10(58.8) 33(53.2) 0.17 >0.05 女 7(41.2) 29(46.8) 年龄/岁 ≤55 8(47.1) 37(59.7) 0.87 >0.05 >55 9(52.9) 25(40.3) 骨折分型/型 Ⅰ 2(11.8) 4(6.5) Ⅱ 5(29.4) 18(29.0) Ⅲ 3(17.6) 5(8.1) 3.00 >0.05 Ⅳ 1(5.9) 10(16.1) Ⅴ 4(23.5) 17(27.4) Ⅵ 2(11.8) 8(12.9) 损伤暴力程度 低能量 11(64.7) 47(75.8) 0.37* >0.05 高能量 6(35.3) 15(24.2) 吸烟史 否 17(100.0) 50(80.6) 2.52* >0.05 是 0(0.0) 12(19.4) 饮酒史 否 17(100.0) 52(83.9) 1.85* >0.05 是 0(0.0) 10(16.1) 手术时间/h <3 14(82.4) 49(79.0) 0.002* >0.05 ≥3 3(17.6) 13(21.0) 出血量/mL <400 15(88.2) 53(85.5) 0.01* >0.05 ≥400 2(11.8) 9(15.5) 植骨情况 不植骨 6(35.3) 21(33.9) 0.01 >0.05 植骨 11(64.7) 41(66.1) 住院总时间/d ≤14 6(35.6) 28(45.2) 0.53 >0.05 >14 11(64.7) 34(54.8) 围手术期时间/d >7 9(52.9) 15(24.2) 5.21 < 0.05 ≤7 8(47.1) 47(75.8) *示矫正χ2值 表 2 TPF术后继发OA的多因素logistic回归分析
变量 B SE Waldχ2 P OR 95%CI 吸烟 19.228 9 573.634 0.000 >0.05 224 106 373.4 0.000 0.000 饮酒 18.566 1 0138.25 0.000 >0.05 115 632 127.6 0.000 0.000 围手术期时间 1.752 0.621 7.962 < 0.01 5.766 1.707 19.469 -
[1] MENGHI A, MAZZITELLI G, MARZETTI E, et al.Complex tibial plateau fractures:a retrospective study and proposal of treatment algorithm[J].Injury, 2017, 48(Suppl 3):S1. [2] SOHN HS, YOOH YC, CHO JW, et al.Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures[J].J Orthopaedic Trauma, 2015, 29(2):91. doi: 10.1097/BOT.0000000000000170 [3] BASQUES BA, WEBB ML, BOHL DD, et al.Adverse events, length of stay, and readmission after surgery for tibial plateau fractures[J].J Orthop Trauma, 2015, 29(3):e121. [4] RUFFOLO MR, GETTYS GF, MONTIJO HE, et al.Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions[J].J Orthop Trauma, 2015, 29(2):85. doi: 10.1097/BOT.0000000000000203 [5] ROBBACH BP, FAYMONVILLE C, MüLLER LP, et al.Quality of life and job performance resulting from operatively treated tibial plateau fractures[J].Unfallchirurg, 2016, 119(1):27. doi: 10.1007/s00113-014-2618-z [6] ROHRA N, SURI HS, GANGRADE K.Functional and radiological outcome of Schatzker type V and VI tibial plateau fracture treatment with dual plates with minimum 3 years follow-up:a prospective study[J].J Clin Diagn Res, 2016, 10(5):RC05. [7] ELSOE R, LARSEN P, NIELSEN NP, et al.Population-based epidemiology of tibial plateau fractures[J].Orthopedics, 2015, 38(9):e780. [8] ALBUQUERQUE RP, HARA R, PRADO J, et al.Epidemiological study on tibial plateau fractures at a level I trauma center[J].Acta Ortop Bras, 2013, 21(2):109. doi: 10.1590/S1413-78522013000200008 [9] MARTíNEZ-RONDANELLI A, ESCOBAR-GONZáLEZ SS, HENAO-ALZATE A, et al.Reliability of a four-column classification for tibial plateau fractures[J].Int Orthop, 2017, 41(9):1881. doi: 10.1007/s00264-017-3543-x [10] KRAPPINGER D, STRUVE P, SMEKAL V, et al.Severely comminuted bicondylar tibial plateau fractures in geriatric patients:a report of 2 cases treated with open reduction and postoperative external fixation[J].J Orthop Trauma, 2008, 22(9):652. doi: 10.1097/BOT.0b013e318188d6a2 [11] OLADEJI LO, WORLEY JR, CRIST BD.Age-related variances in patients with tibial plateau fractures[J].J Knee Surg, 2019, 33(6):611. [12] MELLEMA JJ, DOORNBERG JN, MOLENAARS RJ, et al.Traumaplatform Study Collaborative & Science of Variation Group.Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures[J].Injury, 2016, 47(4):944. doi: 10.1016/j.injury.2015.12.022 [13] KFURI M, SCHATZKER J.Revisiting the Schatzker classification of tibial plateau fractures[J].Injury, 2018, 49(12):2252. doi: 10.1016/j.injury.2018.11.010 [14] FREEMAN K, MICHALSON JL, ANDERSON DD, et al.Tibial plateau fractures:a new rank ordering method for determining to what degree injury severity or quality of reduction correlate with clinical outcome[J].Iowa Orthop J, 2017, 37:57. [15] EVANGELOPOULOS D, CHALIKIAS S, MICHALOS M, et al.Medium-term results after surgical treatment of high-energy tibial plateau fractures[J].J Knee Surg, 2019, 33(4):394. [16] LI J, ZHU Y, LIU B, et al.Incidence and risk factors for surgical site infection following open reduction and internal fixation of adult tibial plateau fractures[J].Int Orthop, 2018, 42(6):1397. doi: 10.1007/s00264-017-3729-2 [17] CHAN G, ILIOPOULOS E, JAIN A, et al.Infection after operative fixation of tibia plateau fractures.A risk factor analysis[J].Injury, 2019, 50(11):2089. doi: 10.1016/j.injury.2019.06.022 [18] TRIKHA V, GABA S, AGRAWAL P, et al.CT based management of high energy tibial plateau fractures:A retrospective review of 53 cases[J].J Clin Orthop Trauma, 2019, 10(1):201. doi: 10.1016/j.jcot.2017.11.005 [19] ELLSWORTH HS JR, DUBIN JR, SHAW CM, et al.Second place award immediate versus delayed operative treatment of low-energy tibial plateau fractures[J].Curr Orthop Pract, 2016, 27(4):351. doi: 10.1097/BCO.0000000000000390 [20] 王国旗, 张里程, 唐佩福.胫骨平台骨折的治疗策略与进展[J].中华骨科杂志, 2016, 36(18):1202.