手术与非手术治疗创伤性连枷胸合并胸骨骨折的疗效比较

摘要

目的 观察比较手术内固定与非手术治疗创伤性连枷胸合并胸骨骨折的临床疗效.方法 回顾分析2007年1月-2014年1月创伤性连枷胸合并胸骨骨折患者102例的临床资料,根据治疗方法不同分为手术组(71例)和非手术组(31例).手术组根据内固定材料的不同分为纯钛爪型肋骨接骨板内固定组(Ⅰ组,22例)、多孔钛板螺钉内固定组(Ⅱ组,20例)及镍钛记忆合金胸肋骨固定组(Ⅲ组,29例).非手术组采用肋骨牵引治疗.比较手术组和非手术组临床疗效,以及不同内固定方式的手术情况.结果 手术组治疗24,72 h的心率(HR)[(100.4±9.5)次/min、(92.1±9.9)次/min]、平均动脉压(MAP)[(97.7±14.5) mmHg、(112.5±15.2) mmHg]及中心静脉压(CVP)[(7.8 ±3.7)cmH2O、(6.2±2.9)cmH2O]明显优于非手术组[HR:(105.2 ±10.1)次/min、(102.1±9.2)次/min,MAP:(91.0±13.3) mmHg、(93.1±13.8) mmHg,CVP:(9.4±3.8) cmH2O、(9.1±3.2) cmH2O] (P ＜0.05).手术组住ICU时间[(5.1±0.8)d]、呼吸机使用时间[(4.5±1.0)d]、住院时间[(14.6±3.5)d]均显著低于非手术组[(9.3±1.1)d、(8.2±1.4)d、(23.3±4.4)d](P＜0.01);且出院后2个月手术组潮气量(VT)[(0.52±0.04)L]、深吸气量(IC)[(1.99±0.45)L]、用力肺活量(FVC)[(3.52 ±0.51)L]、肺总量(TLC)[(5.41 ±0.82)L]及第1秒用力呼气容积(FEV1)[(2.80 ±0.43)L]均明显优于非手术组[(0.40 ±0.03)L、(1.22 ±0.33)L、(2.44 ±0.42)L、(3.72 ±0.56)L、(1.95 ±0.50)L] (P ＜0.01).Ⅱ组在手术时间[(38.8±9.2)min]、术中出血量[(43.5±7.6)ml]及伤口日引流量[(10.9±1.1)ml]方面均显著优于Ⅰ组[(62.5±10.1)min、(100.0±10.5)ml、(26.8 ±3.1)ml]、Ⅲ组[(49.3±9.6) min、(61.4±8.3) min、(19.8±1.6)ml](P＜0.01).结论 创伤性连枷胸合并胸骨骨折应尽早行手术内固定治疗,以减少并发症的发生;多孔钛板螺钉内固定相对具有较好的临床疗效.%Objective To compare the efficacy of internal fixation with non-operative treatment of traumatic flail chest combined with sternal fracture.Methods A retrospective review was made on 102 patients with traumatic flail chest combined with sternal fracture treated from January 2007 to January 2014.There were 71 patients in operation group and 31 patients in non-operation group.Operation group was allocated to pure titanium rib plating (Group Ⅰ,22 cases),porous titanium screw fixation (Group Ⅱ,20 cases),and nickel-titanium memory alloy sternal rib plating (Group Ⅲ,29 cases).Rib traction was performed in non-operation group.Clinical results and incidence of complications were compared between the two groups.Results At 24 and 72 hours,operation group was superior over non-operation group with regard to HR [(100.4 ± 9.5) times/min vs (105.2 ± 10.1) times/min,(92.1 ± 9.9) times/min vs (102.1 ± 9.2) times/min],MAP [(97.7 ± 14.5) mmHg vs (91.0 ± 13.3) mmHg,(112.5 ± 15.2) mmHg vs (93.1 ± 13.8)mmHg] and CVP [(7.8 ±3.7)cmH2O vs (9.4 ±3.8)cmH2O,(6.2 ±2.9)cmH2O vs (9.1 ±3.2) cmH2 O] (P ＜ 0.05).Duration in ICU [(5.1 ± 0.8) days vs (9.3 ± 1.1) days],ventilation time [(4.5 ±1.0)days vs (8.2 ± 1.4)days],hospitalization time [(14.6 ±3.5)days vs (23.3 ±4.4)days] and incidence of complications were significantly lower in operation group than in non-operation group (P ＜ 0.05).Two months after discharge,tidal volume (VT) [(0.52 ±0.04)L vs (0.40 ±0.03)L],inspiratory capacity (IC)[(1.99 ±0.45)L vs (1.22 ±±0.33)L],forced vital capacity (FVC) [(3.52 ±0.51)L vs (2.44 ±0.42)L],total lung capacity (TLC) [(5.41 ±0.82)L vs (3.72 ±0.56)L] and forced expiratory volume in one second (FEV1) [(2.80 ± 0.43) L vs (1.95 ± 0.50) L] showed significantly better results in operation group than in non-operation group (P ＜ 0.05).Operation time,intraoperative bleeding and daily drainage volume were (38.8 ±9.2)min,(43.5 ±7.6)ml and (10.9 ± 1.1)ml in Group Ⅱ versus (62.5 ± 10.1)min,(100.0 ± 10.5) ml and (26.8 ±3.1)ml in Group Ⅰ and (49.3 ±9.6)min,(61.4 ±8.3)min and (19.8 ±1.6)ml in Group Ⅲ (P ＜ 0.01).Conclusion For traumatic flail chest combined with sternal fracture,the internal fixation should be done as early as possible so as to reduce incidence of complications.Relatively,porous titanium screw fixation has better clinical outcome.