Department of Orthopaedic Surgery, MetroHealth Medical Center, affiliated with Case Western Reserve University School of Medicine, Cleveland, OH, USA.
J Orthop Trauma. 2012 Mar;26(3):178-83. doi: 10.1097/BOT.0b013e31823924df.
Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative studies suggest more malalignment and nonunions with nails. Some studies have reported knee pain after tibial nailing. However, plates may be associated with soft tissue complications, such as infections or wound-healing problems. The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail. We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence, each of which would adversely affect functional outcome scores.
Randomized prospective study.
Level 1 trauma center.
PATIENTS/PARTICIPANTS: One hundred four patients with extra-articular distal tibia shaft fractures (OTA 42), mean age of 38 years (range, 18-95), and mean Injury Severity Score of 14.3 (range, 9-50).
Patients were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large fragment medial plate (n = 48).
Ability to work was evaluated after a minimum of 12 months, with mean of 22 months. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed.
Mean MFA was 27.5, and mean total FFI was 0.26; P < 0.0001 versus an uninjured reference population. Sixty-one of 64 patients (95%) employed at the time of injury had returned to work, although 31% had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. Forty percent of all patients described some persistent ankle pain, and 31% had knee pain after nailing, versus 32% and 22%, respectively after plating. Both knee and ankle pain were present in 27% with nails and 15% with plates (P = 0.08), and rates of implant removal were similar after nails versus plates. Patients with malunion ≥5 degrees were more likely to report knee or ankle pain (36% vs 20%, P < 0.05). Except 1 patient with knee pain when kneeling, none reported modifying activity because of persistent knee or ankle pain, although knee and ankle pain were more frequent in the unemployed (P = 0.03). Unemployed patients requested implant removal more frequently (24% vs 9.2%, P = 0.07) and continued to report pain afterward. Although FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, Injury Severity Score, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all Ps < 0.004) and in patients who remained unemployed (P < 0.0001). All 4 patients with work-related injuries had returned to employment but had worse FFI scores (P = 0.01).
Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. No patients reported unemployment because of their tibia fracture, but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores.
对于移位的胫骨远端骨折，无论是使用钢板还是髓内钉固定，手术治疗都能取得可靠的效果。对比研究表明髓内钉固定更容易出现对线不良和不愈合。一些研究报告了胫骨钉固定后膝关节疼痛。然而，钢板可能与软组织并发症相关，如感染或伤口愈合问题。本研究旨在评估胫骨骨干骨折采用钢板或髓内钉治疗后的功能结果。我们假设胫骨钉固定后膝关节疼痛更常见，钢板固定后与植入物突出相关的疼痛更常见，这两种情况都会对功能结果评分产生不利影响。
随机前瞻性研究。
1 级创伤中心。
患者/参与者：104 例关节外胫骨骨干骨折（OTA 42）患者，平均年龄 38 岁（范围，18-95 岁），平均损伤严重程度评分 14.3（范围，9-50）。
患者随机接受经皮扩髓髓内钉（n = 56）或标准大接骨板（n = 48）治疗。
至少随访 12 个月（平均 22 个月）后评估患者的工作能力。完成足部功能指数（FFI）和肌肉骨骼功能评估（MFA）问卷。
平均 MFA 为 27.5，平均总 FFI 为 0.26；与未受伤的参考人群相比，均为 P < 0.0001。64 例受伤时就业的患者中，61 例（95%）已恢复工作，尽管 31%因受伤而改变了工作性质。3 例患者无法找到工作。没有因胫骨骨折而失业的报告。40%的患者描述了持续性踝关节疼痛，31%的患者在髓内钉固定后出现膝关节疼痛，而分别有 32%和 22%的患者在钢板固定后出现膝关节疼痛。胫骨钉固定后膝关节和踝关节疼痛均存在的患者占 27%，钢板固定后膝关节和踝关节疼痛均存在的患者占 15%（P = 0.08），且钢板和髓内钉的植入物取出率相似。对线不良≥5°的患者更可能报告膝关节或踝关节疼痛（36%比 20%，P < 0.05）。除 1 例患者在跪着时出现膝关节疼痛外，没有患者因持续性膝关节或踝关节疼痛而改变活动，尽管失业患者（P = 0.03）更频繁地报告膝关节和踝关节疼痛。失业患者更频繁地要求取出植入物（24%比 9.2%，P = 0.07），并在之后继续报告疼痛。虽然 FFI 和 MFA 评分与钢板或髓内钉固定无关，开放性骨折、骨折类型、多发伤、损伤严重程度评分或年龄无关，但膝关节或踝关节疼痛存在时（均 P < 0.004）以及失业患者（P < 0.0001）时，MFA 和 FFI 评分更差。所有 4 例与工作相关的损伤患者均已恢复工作，但 FFI 评分更差（P = 0.01）。
与未受伤人群相比，胫骨骨折后的平均 MFA 和 FFI 评分表明存在明显的残余功能障碍。钢板或髓内钉固定后，轻度踝关节或膝关节疼痛很常见，但大多数患者的疼痛并不影响活动。对线不良与膝关节和踝关节疼痛均有关，胫骨钉固定后膝关节和踝关节疼痛的发生率呈上升趋势。没有患者因胫骨骨折而失业，但失业患者更频繁地描述膝关节和踝关节疼痛，且功能结果评分最差。
