纯钛肋骨接骨板内固定治疗肋骨骨折:与保守治疗的疼痛对照分析
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摘要
背景:大量数据表明,手术复位内固定相较保守治疗更具优势。遗憾的是,由于许多临床医生对肋骨骨折治疗的最新理念了解不足,再加上目前尚缺乏高级别临床证据,导致手术在肋骨骨折治疗中的作用还存在诸多争议。目的:探讨纯钛肋骨接骨板在肋骨骨折内固定中对疼痛的治疗效果。方法:选取多发肋骨骨折患者共187例,根据手术与否分为2组,手术组79例,对照组108例进行保守治疗。手术组在双腔气管插管静脉复合麻醉下行胸腔镜辅助多点小切口或直接单切口开放纯钛肋骨接骨板内固定术,手术均在伤后1周内完成,其中伤后3 d内完成者68例,占86%,伤后3-7 d内完成者11例,占14%。收集2组骨折根数、处数、是否伴发血气胸以及是否放置胸管;手术组收集术前1d、术后第1天、第2天的疼痛评分,对照组收集伤后第1天、第2天疼痛评分。2组指标进行统计学对比分析。结果与结论:①2组均无死亡患者。手术组2例出现术后切口感染,长期换药后发现窦道与接骨板相通,分别于术后34d及42d取出接骨板,伤口愈合。其余患者均顺利出院或胸部情况稳定后继续其他外伤治疗;②手术组79例患者骨折根数468根,平均(5.92±2.17)根;骨折处数547处,平均(6.92±2.91)处。非手术组108例患者骨折根数373根,平均(3.45±1.38)根;骨折处数382处,平均(3.54±1.54)处。2组骨折根数与骨折处数比较,差异有显著性意义(P均<0.01);③所有对照组患者疼痛评分908个,疼痛评分2.86±0.36;所有手术组患者术后疼痛评分400个,疼痛评分2.13±0.41,差异有显著性意义(P <0.01),说明手术组患者疼痛较非手术组明显减轻;④2组单日疼痛评分比较,手术组低于对照组(P <0.05);手术组患者术后第1天疼痛评分高于术后第2天,差异有显著性意义(P <0.01);⑤结果表明,伤后1周以内应用纯钛肋骨接骨板内固定治疗肋骨骨折具有减轻疼痛的效果。
BACKGROUND: Existing studies have shown that open reduction and internal fixation is superior to the conservative treatment. However, due to the poor understanding of new concept of rib fracture and lack of high-quality evidence, the application in the treatment of rib fracture remains controversial.OBJECTIVE: To investigate the effect of titanium rib plate fixation in the treatment of rib fracture on pain relief.METHODS: One hundred and eighty-seven cases of rib fractures were selected, and then allocated into surgical(n=79) and conservative(n=108) groups. The surgical group was given thoracoscopy-assisted small incision or traditional incision pure titanium rib plate fixation under anesthesia with double lumen tube and artery and central vein catheterized. All surgeries were completed within 1 week after trauma, 68 cases completed within 3 days(86%), and 11 cases were completed within 3-7 days(14%). The number and parts of rib fractures,hemopneumothorax and chest tube placement were recorded. The pain scores in the surgical(preoperative 1 day, postoperative 1 and 2 days)and conservative(1 and 2 days post-injury) groups were detected and compared.RESULTS AND CONCLUSION:(1) No case died in both groups. There were two cases of incision infection in the surgical group, and the sinus canal communicated with the plate after long-term dressing. The plate was removed at postoperative 34 and 42 days, and the wound was healed. The remaining patients discharged successfully or underwent other trauma treatment.(2) There were 468(5.92±2.17 mean)fractured ribs in the surgical group, and 382 fractured parts(6.92±2.91 mean). There were 373(3.45±1.38 mean) fractured ribs in the conservative group, and 382 fractured parts(3.54±1.54 mean). There was significant difference in the number and parts of rib fracture between two groups(both P < 0.01).(3) The pain score showed significant difference between conservative(908, 2.86±0.36) and surgical(400, 2.13±0.41) groups(P < 0.01), suggesting that the pain was significantly alleviated in the surgical group compared with the conservative group.(4) The single day score in the surgical group was significantly lower than that in the conservative group(P < 0.05). In the surgical group, the pain score at postoperative 1 day was significantly higher than that at postoperative 2 days(P < 0.01).(5) In summary, pure titanium rib plate fixation can effectively alleviate the pain of rib facture within 1 week after trauma.
BACKGROUND: Existing studies have shown that open reduction and internal fixation is superior to the conservative treatment. However, due to the poor understanding of new concept of rib fracture and lack of high-quality evidence, the application in the treatment of rib fracture remains controversial.OBJECTIVE: To investigate the effect of titanium rib plate fixation in the treatment of rib fracture on pain relief.METHODS: One hundred and eighty-seven cases of rib fractures were selected, and then allocated into surgical(n=79) and conservative(n=108) groups. The surgical group was given thoracoscopy-assisted small incision or traditional incision pure titanium rib plate fixation under anesthesia with double lumen tube and artery and central vein catheterized. All surgeries were completed within 1 week after trauma, 68 cases completed within 3 days(86%), and 11 cases were completed within 3-7 days(14%). The number and parts of rib fractures,hemopneumothorax and chest tube placement were recorded. The pain scores in the surgical(preoperative 1 day, postoperative 1 and 2 days)and conservative(1 and 2 days post-injury) groups were detected and compared.RESULTS AND CONCLUSION:(1) No case died in both groups. There were two cases of incision infection in the surgical group, and the sinus canal communicated with the plate after long-term dressing. The plate was removed at postoperative 34 and 42 days, and the wound was healed. The remaining patients discharged successfully or underwent other trauma treatment.(2) There were 468(5.92±2.17 mean)fractured ribs in the surgical group, and 382 fractured parts(6.92±2.91 mean). There were 373(3.45±1.38 mean) fractured ribs in the conservative group, and 382 fractured parts(3.54±1.54 mean). There was significant difference in the number and parts of rib fracture between two groups(both P < 0.01).(3) The pain score showed significant difference between conservative(908, 2.86±0.36) and surgical(400, 2.13±0.41) groups(P < 0.01), suggesting that the pain was significantly alleviated in the surgical group compared with the conservative group.(4) The single day score in the surgical group was significantly lower than that in the conservative group(P < 0.05). In the surgical group, the pain score at postoperative 1 day was significantly higher than that at postoperative 2 days(P < 0.01).(5) In summary, pure titanium rib plate fixation can effectively alleviate the pain of rib facture within 1 week after trauma.
引文
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[14]Brasel KJ,Moore EE,Albrecht RA,et al.Western Trauma Association Critical Decisions in Trauma:Management of rib fractures.J Trauma Acute Care Surg.2017;82(1):200-203.
[15]王黎红,何华.癌症疼痛的评估及护理对策[J].中华护理杂志,2000,35(8):489-490.
[16]Garra G,Singer AJ,Taira BR,et al.Validation of the Wong-Baker Faces Pain Rating Scale in pediatric emergence depatment patiens.Acad Emerg Med.2010;17(1):50-54.
[17]李晖,黄青青,苏美仙.护室机械通气病人镇静水平的准确性[J].中华麻醉学杂志,2009,29(5):443-445.
[18]Kuchyn IL.Anesthesiological support of surgical intervention onclavicular osteosynthesis in patients with multiple rib fractures.Klin Khir.2013;(12):58-60.
[19]Lee JB,Park HN,Ko WK,et al.Poly(L-Iactic acid)/hydroxyapatite nanocylinders as nanofibrous structure for bone tissue engineering scaffolds.J Biomed Nanotechnol.2013;9(3):424-429.
[20]李高阳.纯钛肋骨接骨板和钛镍记忆合金环抱器在肋骨骨折内固定中的生物力学比较[D].石家庄:河北医科大学,2016.
[21]刘锦源,戚晓通,陈广明.肋骨爪形接骨钛板治疗多发性肋骨骨折的临床分析[J].外科研究与新技术,2018,7(1):28-30.
[22]陈晶.镍钛环抱式接骨器内固定对多发肋骨骨折患者术后VAS评分及并发症发生率的影响[J].山西职工医学院学报,2018,28(2):17-19.
[23]郝懿,吴骏,王立杰,等.预成型肋骨锁定钛板与钛镍记忆合金环抱器治疗多发性肋骨骨折的疗效比较[J].中国胸心血管外科临床杂志,2018,25(5):397-400.
[24]滕继平,杨志胤,程佑爽,等.两种肋骨骨折内固定材料的生物力学性能比较[J].创伤外科杂志,2014,16(1):54-57.
[2]Sharma OP,Oswanski MF,Jolly S,et al.Perils of rib fracturs.Am Surg.2008;74(4):310-314.
[3]Leinicke JA,Elmore L,Freeman BD,et al.Operative management of rib fractures in the setting of flail chest:a systematic review and meta-analysis.Ann Surg.2013;258(6):914-921.
[4]Brasel KJ,Moore EE,Albrecht RA,et al.Western Trauma Association Critical Decisions in Trauma:Management of rib fractures.J Trauma Acute Care Surg.2017;82(1):200-203.
[5]Simon B,Ebert J,Bokhari F,et al.Management of pulmonary contusion and flail chest:an Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg.2012;73(5 Suppl 4):S351-S361.
[6]肖代顺,韩以杰,阚奇伟.罗哌卡因肋间局部浸润麻醉肋骨骨折内固定术效果观察[J].局部手术学杂志,2011,20(3):274-275.
[7]陈翔.肋骨骨折的保守治疗和手术对比[J]世界最新医学信息文摘,2018,18(37):67-68.
[8]梁锐宇,梁锦崧,饶新辉,等.内固定手术与保守疗法在多发肋骨骨折治疗中的应用效果对比[J].中国当代医药,2018,25(10):83-85.
[9]乔贵宾,陈刚.创伤性肋骨骨折的处理:广东胸外科行业共识(2017年版)[J].中国胸心血管外科临床杂志,2018,25(5):362-366.
[10]Tanaka H,Yukioka T,Yamaguti Y,et al.Surgical stabilization of internal pneumatic stabilization?A prospective randomized study of management of severe flail chest patients.J Trauma.2002;52(4):727-732.
[11]Granetzny A,Abd El-Aal M,Emam E,et al.Surgical versus conservative treatment of flail chest.Evaluation of the pulmonary status.Interact Cardiovasc Thorac Surg.2005;4(6):583-587.
[12]Marasco SF,Davies AR,Cooper J,et al.Prospective randomized controlled trial of operative rib fixation in traumatic flail chest.J Am Coll Surg.2013;216(5):924-932.
[13]Dehghan N,de Mestral C,McKee MD,et al.Flail chest injuries:areview of outcomes and treatment practices from the National Trauma Data Bank.J Trauma Acute Care Surg.2014;76(2):462-468.
[14]Brasel KJ,Moore EE,Albrecht RA,et al.Western Trauma Association Critical Decisions in Trauma:Management of rib fractures.J Trauma Acute Care Surg.2017;82(1):200-203.
[15]王黎红,何华.癌症疼痛的评估及护理对策[J].中华护理杂志,2000,35(8):489-490.
[16]Garra G,Singer AJ,Taira BR,et al.Validation of the Wong-Baker Faces Pain Rating Scale in pediatric emergence depatment patiens.Acad Emerg Med.2010;17(1):50-54.
[17]李晖,黄青青,苏美仙.护室机械通气病人镇静水平的准确性[J].中华麻醉学杂志,2009,29(5):443-445.
[18]Kuchyn IL.Anesthesiological support of surgical intervention onclavicular osteosynthesis in patients with multiple rib fractures.Klin Khir.2013;(12):58-60.
[19]Lee JB,Park HN,Ko WK,et al.Poly(L-Iactic acid)/hydroxyapatite nanocylinders as nanofibrous structure for bone tissue engineering scaffolds.J Biomed Nanotechnol.2013;9(3):424-429.
[20]李高阳.纯钛肋骨接骨板和钛镍记忆合金环抱器在肋骨骨折内固定中的生物力学比较[D].石家庄:河北医科大学,2016.
[21]刘锦源,戚晓通,陈广明.肋骨爪形接骨钛板治疗多发性肋骨骨折的临床分析[J].外科研究与新技术,2018,7(1):28-30.
[22]陈晶.镍钛环抱式接骨器内固定对多发肋骨骨折患者术后VAS评分及并发症发生率的影响[J].山西职工医学院学报,2018,28(2):17-19.
[23]郝懿,吴骏,王立杰,等.预成型肋骨锁定钛板与钛镍记忆合金环抱器治疗多发性肋骨骨折的疗效比较[J].中国胸心血管外科临床杂志,2018,25(5):397-400.
[24]滕继平,杨志胤,程佑爽,等.两种肋骨骨折内固定材料的生物力学性能比较[J].创伤外科杂志,2014,16(1):54-57.