【作者】 王伟；

【导师】 吴希瑞；

【作者基本信息】 河北医科大学 ， 外科学， 2012， 硕士

【摘要】 目的：随着交通及体育事业的迅速发展，髌骨骨折患者呈上升趋势。对于髌骨骨折，临床上最常用的治疗方法是克氏针钢丝张力带固定，其优点是其优点是操作简单、价格低廉、符合生物力学、固定可靠、适用于各种类型的髌骨骨折，但其也有一些不足，如：钢丝结刺激皮肤，术后钢丝断裂、松动，骨折愈合后需二次手术取出等。近年来随着生物医学工程的发展,可吸收内置物逐渐应用于临床，一些学者认为应用可吸收线张力带固定髌骨骨折可避免钢丝张力带的各种不足。据文献报道多名学者应用不同的可吸收线张力带固定法治疗髌骨骨折取得了较好的临床疗效。本实验通过对髌骨横断骨折模型，应用4种可吸收线张力带与克氏针钢丝张力带进行比较，测试可吸收线张力带的稳定性，为临床医师选择髌骨骨折的治疗方式提供理论依据。方法：取4个成人尸体膝关节标本，将髌骨制成简单横断骨折模型，因所测试的内固定方法相近，测试后髌骨标本不会被破坏，因此髌骨标本可反复利用多次。将膝关节标本的股骨端与胫骨端分别固定于自制夹具上，保持膝关节屈曲36°。首先将髌骨骨折解剖复位，而后依次应用：两种单独应用可吸收线构筑张力带固定法、克氏针可吸收线张力带固定法、克氏针可吸收线张力带结合髌骨胫骨结节环扎术固定法、克氏针钢丝张力带固定法，共五种方法对每个髌骨标本进行固定，应用生物力学机对股四头肌进行牵拉，记录髌骨骨折内固定失败时的牵张力大小，规定骨折端分离2.0mm为内固定失败。结果：在内固定失败时各内固定组承受的牵张力大小分别为:(A组)第一种单独应用可吸收线构筑张力带固定法166.500±6.350N；(B组)第二种单独应用可吸收线构筑张力带固定法226.250±6.500N；(C组)克氏针可吸收线张力带固定法228.500±19.226N；(D组)克氏针可吸收线张力带结合髌骨胫骨结节可吸收线环扎术固定法425.500±18.734N；(E组)克氏针钢丝张力带固定法480.750±15.370。B组与C组之间比较，结果无统计学意义（p＞0.05）;B、C组与A组、D组、E组之间两两比较，结果均有统计学意义（p＜0.05）结论：1各内固定组的稳定性：克氏针钢丝张力带固定法＞克氏针可吸收线张力带结合髌骨胫骨结节可吸收线环扎术固定法＞克氏针可吸收线张力带固定法＝第二种单独应用可吸收线张力带固定法＞第一种单独应用可吸收线张力带固定法。2第一种可吸收线张力带法稳定性差，不宜单独应用于髌骨骨折的治疗。3第二种可吸收线张力带法与克氏针可吸收线张力带法，稳定性不足以支持膝关节的早期功能练习，如应用则建议术后早期行石膏托外固定。4克氏针钢丝张力带固定法的稳定性最好，克氏针可吸收线张力带结合髌骨胫骨结节可吸收线环扎术固定法次之，两种固定方法均可承受425牛以上的股四头肌牵张力及同时产生的髌股关节作用力，术后可早期行膝关节不负重功能锻炼。5髌骨胫骨结节可吸收线环扎术可辅助治疗髌骨骨折。6可吸收线虽具有较好的生物学特性，但对于髌骨骨折来说，其无法提供骨折端静态加压，其弹性形变较钢丝大，因此固定的稳定性欠佳，不建议用可吸收线替代钢丝治疗髌骨骨折，其主要适用于髌骨骨折的辅助固定。如应用可吸收线张力带治疗髌骨骨折，则需加用髌骨胫骨结节可吸收线环扎术进行保护。更多还原

【Abstract】 Objective: In recent years, with the development of transport and sportcareer, the incidence of patella fracture has been increasing. For patellafracture, the most widely used method is K-wire and tension band wiringfixation.The advantage of K-wire and tension band wiring fixation method issimple、cheap price、conforming to biomechanics、relatively stable、applicableto all types of patellar fracture;however, there are also some disadvantagessuch as steel nodular skin irrigation、wire loose or break、stell wire has to beremoved after the healing of fracture,and so on. In recent years, absorbableimplants gradually applied to clinic with the development of BiomedicalEngineering. Some scholars believe that the application of tension bandabsorbable suture for patella fracture can avoid various defects of tensionband wiring， and some scholars used different kinds of tension bandabsorbable suture in the treatment of patella fractures and achieved goodtherapeutic effect according to literature.This experiment based on transversefracture of the patella model respectively using K-wire and tension bandwiring and four kinds of tension band absorbable suture,a total of fivetreatment methods for biomechanical comparison.the stability was tested toprovide a theoretical basis for clinicians to choose the treatment of patellafracture.Method: The transverse fracture model of the patella was made in4keenjoints of adult cadaveric.The test methods of fixation were Similar, patellaspecimens were not destroyed after test, thus the patella specimens could bereused.The femur and the tibia of the specimen were fixed on the homemadeclamp,the femur was parallel to the ground and the knee was flexed36°.First,the patella fracture was anatomically reducted,then each of the patellaspecimens were sequentially fixed with five methods: two kinds of tension band absorbable suture、K-wire and tension band absorbable suture、K-wireand tension-band absorbable suture combined with patella and tibial tuberclecerclage by absorbable suture, K-wire and tension band wiring.The quadricepsfemoris of specimens were pulled by CSS-44020biomechanics machine,andthe tensile strength was recorded when the internal fixation was failure.Wedefined that the internal fixation was failure when the separation distance ofthe patella fracture was2mm under tension.Result: The tensile strength of each group when the internal fixation wasfailure:(group A)the first kind of tension band absorbable suture:166.500±6.350N；(group B)the second kind of tension band absorbable suture:226.250±6.500N；(group C)K-wire and tension band absorbable suture:228.500±19.226N；(group D)K-wire and tension-band absorbable suture combined withpatella and tibial tubercle cerclage by absorbable suture:425.500±18.734N；(group E)K-wire and tension band wiring:480.750±15.370N.There were statistical significances(p＜0.05) in comparison between anytwo groups except between group B and group C.Conclusions：1The stability of internal fixation groups: K-wire and tension band wiring＞K-wire and tension-band absorbable suture combined with patella and tibialtubercle cerclage by absorbable suture＞K-wire and tension band absorbablesuture＝the second kind of tension band absorbable suture＞the first kind oftension band absorbable suture.2The stability of the first kind of tension band absorbable suture is poor,should not be used for the treatment of patellar fracture3The stability of the second kind of tension band absorbable suture andK-wire and tension band absorbable suture are not sufficient to support the early functional exercises of the knee. If these two fixtion methods areapplied,we propose a plaster external fixation postoperative.4The stability of the K-wire and tension band wiring is better than K-wire andtension-band absorbable suture combined with patella and tibial tuberclecerclage by absorbable suture, these two fixtion methods can withstand thetension of quadriceps femoris more than425N,and withstand the patello-femoral pressure at the same time. If these two fixtion methods are applied，the patients can take early functional exercise of the knee postoperative.5Patella and tibial tubercle cerclage by absorbable suture can be used for aadjuvant treatment of patellar fracture.6Although the absorbable suture has good biological characteristics, but forpatellar fracture, it cannot provide static compression at both ends of the fract-ure,and it is more flexible, so the stability of fixation with absorbable suture isnot enough.we do not recommend to use absorbable suture instead of steelwire for the treatment of patellar fracture, it is mainly applied to the assistedfixation of patella fracture. If the tension band absorbable suture was applied,patella and tibial tubercle cerclage by absorbable suture must be used forprotection.更多还原