机器人辅助逆行弹性髓内钉微创手术治疗移位锁骨中段骨折的临床应用研究

doi:10.3969/j.issn.1006-7795.2024.05.002

首都医科大学学报

机器人辅助逆行弹性髓内钉微创手术治疗移位锁骨中段骨折的临床应用研究

张玉富¹,谭杰¹,张曦公²,韩啸¹,李艳超³,公茂琪¹,黄强¹,蒋协远^1*

1.首都医科大学附属北京积水潭医院创伤骨科,北京 100035;2.北京大学第四临床医学院北京积水潭医院创伤骨科,北京 100035; 3.首都医科大学附属北京积水潭医院康复医学科,北京 100035

收稿日期:2024-06-24
通讯作者: 蒋协远 E-mail:jxy0845@sina.com
基金资助:
国家重点研发计划项目(2022YFC2407500), 北京市JST科研基金资助项目(2023OSR-GCZX202204)。

Clinical application of robot-assisted and retrograde elastic intramedullary nail in the minimally invasive treatment of displaced midshaft clavicle fractures

Zhang Yufu¹, Tan Jie¹, Zhang Xigong², Han Xiao¹ , Li Yanchao³, Gong Maoqi¹, Huang Qiang¹ , Jiang Xieyuan^1*

1. Department of Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China; 2. Peking University Fourth School of Clinical Medicine and Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Beijing 100035, China; 3.Department of Rehabilitation Medicine, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China

Received:2024-06-24
Supported by:
This study was supported by National Key Research and Development Program of China (2022YFC2407500), Beijing JST Research Funding (2023OSR-GCZX202204).

摘要/Abstract

摘要： 目的评估机器人辅助逆行弹性髓内钉治疗移位型锁骨中段骨折的临床效果。方法 2022年12月1日至2023年5月31日在首都医科大学附属北京积水潭医院诊断为移位型锁骨中段骨折的60例患者纳入本前瞻性研究。所有手术均由一名经验丰富的外科医生使用新型天玑（TiRobot）机器人系统进行导航和规划最佳逆行髓内钉入点和轨迹。记录患者人口统计学资料和术中参数。分别于术后2周、4周、6周、8周、12周、6个月和12个月，进行临床随访。由一名骨科医生评估骨折愈合时间，一名康复治疗师评估包括Constant Murley肩功能(CM)评分、手臂、肩部和手部快速残疾(quick Disabilities of the Arm, Shoulder and Hand,q-DASH)评分、疤痕美容评定量表(Scar Cosmesis Assessment and Rating，Scar)和视觉模拟量表(Visual Analogue Scale，VAS)评分。结果 60例患者锁骨骨折根据AO分型，A型16例，B型26例，C型18例。平均手术时间为(53.47±21.63) min，50例患者闭合复位，10例局部有限切开复位。所有患者均得到随访，随访时间为(60.50±6.69)周。骨折愈合时间为(7.43±2.19)周。与健侧相比，锁骨短缩率明显好转，由术前6.44%±5.00%显著改善至术后2.09%±2.95%(P<0.01)。肩部活动恢复运动范围时间为(9.13±2.20)周，恢复运动锻炼时间为(12.73±2.39)周。所有患者均对瘢痕满意，瘢痕评分为(9.80±0.48)分。CM评分在2周、6周、6个月时分别为53.67±9.52、83.22±6.28、97.85±2.60。q-DASH评分在2周、6周、6个月时分别为33.17±5.37、17.07±5.37、11.42±0.69。5例(8.33%)患者出现钉尾突出引起皮肤疼痛刺激，1例(1.67%)出现短暂性神经丛刺激，术后28周消失。结论机器人辅助逆行弹性髓内钉是一种安全、微创的治疗移位型锁骨中段骨折的手术，具有愈合快、美观性好、功能预后好、并发症少等优点。

关键词: 锁骨骨折, 机器人, 导航, 髓内钉

Abstract: Objective To evaluate the clinical efficacy of robot-assisted retrograde intramedullary nail in the treatment of midshaft clavicle fractures. Methods All patients who were diagnosed with displaced midclavicular fractures at Beijing Jishuitan Hospital, Capital Medical University from December 1, 2022 to May 31, 2023 and met the inclusion and exclusion criteria were included in this prospective study. All procedures were navigated and planned by an experienced surgeon using the new TIANJI robotic system for optimal retrograde intramedullary nail entry points and trajectories. The demographics and intraoperative parameters of the patients were recorded. Clinical follow-up was performed at 2 week, 4 week, 6 week, 8 week, 12 week, 6 month and 12 month, respectively. Fracture healing time was assessed by an orthopedic surgeon and a rehabilitation therapist with the Constant Murley Shoulder (CM) score, quick Disabilities of the Arm, Shoulder and Hand (q-DASH) score for the arm, shoulder, and hand, the Scar Cosmesis Assessment and Rating (Scar) Scale, and the Visual Analogue Scale (VAS). Results A total of 60 patients ［48 males and 12 females, aged （32.97±11.26） years］ were included. Injury causes: 18 cases fell while walking, 32 cases fell while riding electric or motorcycle, 4 cases were injured by car, and 6 cases were injured in sports. According to AO classification, there were 16 cases of type A, 26 cases of type B and 18 cases of type C. The operation time was （53.47±21.63） min, with closed reduction in 50 cases and local limited open reduction in 10 cases. All patients were followed up for (60.50±6.69)week. The fracture healing time was （7.43±2.19）week. Compared with the healthy side, the clavicle shortening rate was significantly improved from (6.44±5.00)% before surgery to (2.09±2.95)% after surgery (P<0.01). The recovery range time of shoulder activity was (9.13±2.20) week, and the recovery exercise time was （12.73±2.39）week. All patients were satisfied with the Scar, and the Scar score was 9.80±0.48. CM scores at 2 week, 6 week and 6 month were 53.67±9.52, 83.22±6.28 and 97.85±2.60, respectively. q-DASH scores at 2 week, 6 week, and 6 month were 33.17±5.37, 17.07±5.37, and 11.42±0.69, respectively. Skin pain caused by nail protrusion occurred in 5 cases (8.33%), and transient nerve plexus irritation occurred in 1 case (1.67%), which disappeared 28 week after operation. Conclusion Robot-assisted retrograde elastic intramedullary nail is a safe and minimally invasive surgery for the treatment of displaced midshaft clavicle fractures, with the advantages of fast healing, good aesthetics, good functional prognosis and few complications.

Key words: clavicle fracture, robot, navigation, intramedullary nail

中图分类号:

张玉富, 谭杰, 张曦公, 韩啸, 李艳超, 公茂琪, 黄强, 蒋协远. 机器人辅助逆行弹性髓内钉微创手术治疗移位锁骨中段骨折的临床应用研究[J]. 首都医科大学学报, doi: 10.3969/j.issn.1006-7795.2024.05.002.

Zhang Yufu, Tan Jie, Zhang Xigong, Han Xiao , Li Yanchao, Gong Maoqi, Huang Qiang , Jiang Xieyuan. Clinical application of robot-assisted and retrograde elastic intramedullary nail in the minimally invasive treatment of displaced midshaft clavicle fractures[J]. Journal of Capital Medical University, doi: 10.3969/j.issn.1006-7795.2024.05.002.

参考文献

［1］Postacchini F, Gumina S, De Santis P, et al. Epidemiology of clavicle fractures［J］. J Shoulder Elbow Surg, 2002, 11(5): 452－456.
［2］Rowe C R. An Atlas of anatomy and treatment of midclavicular fractures［J］. Clin Orthop Relat Res, 1968, 58: 29－42.
［3］Andersen K, Jensen P O, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling［J］. Acta Orthop Scand, 1987, 58(1): 71－74.
［4］von Rüden C, Rehme-Rührl J, Augat P, et al. Evidence on treatment of clavicle fractures［J］. Injury, 2023, 54 Suppl 5: 110818.
［5］Frima H, van Heijl M, Michelitsch C, et al. Clavicle fractures in adults; current concepts［J］. Eur J Trauma Emerg Surg, 2020, 46(3): 519－529.
［6］Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients［J］. Acta Orthop, 2005, 76(4): 496－502.
［7］Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up［J］. J Shoulder Elbow Surg, 2004, 13(5): 479－486.
［8］Hill J M, McGuire M H, Crosby L A. Closed treatment of displaced middle-third fractures of the clavicle gives poor results［J］. J Bone Joint Surg Br, 1997, 79(4): 537－539.
［9］Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial［J］. J Bone Joint Surg Am, 2007, 89(1): 1－10.
［10］Trivellas M, Wittstein J. Midshaft clavicle fractures: when is surgical management indicated and which fixation method should be used?［J］. Clin Sports Med, 2023, 42(4): 633－647.
［11］Hoogervorst P, van Dam T, Verdonschot N, et al. Functional outcomes and complications of intramedullary fixation devices for Midshaft clavicle fractures: a systematic review and meta-analysis［J］. BMC Musculoskelet Disord, 2020, 21(1): 395.
［12］Kabelitz N, Kabelitz M, Frima H, et al. Lateral approach for intramedullary nailing of displaced midshaft clavicle fractures; a retrospective cohort study［J］. Eur J Trauma Emerg Surg, 2022, 48(2): 1263－1270.
［13］田伟. 我国智能骨科手术体系的建立及应用［J］. 骨科临床与研究杂志, 2020, 5(3): 129－130.
［14］Smekal V, Deml C, Irenberger A, et al. Length determination in midshaft clavicle fractures: validation of measurement［J］. J Orthop Trauma, 2008, 22(7): 458－462.
［15］Constant C R, Murley A H. A clinical method of functional assessment of the shoulder［J］. Clin Orthop Relat Res, 1987(214): 160－164.
［16］Mintken P E, Glynn P, Cleland J A. Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain［J］. J Shoulder Elbow Surg, 2009, 18(6): 920－926.
［17］Kantor J. The SCAR (scar cosmesis assessment and rating) scale: development and validation of a new outcome measure for postoperative scar assessment［J］. Br J Dermatol, 2016, 175(6): 1394－1396.
［18］Hong P, Liu R K, Rai S, et al. Plating versus elastic stable intramedullary nailing for displaced pediatric midshaft clavicular fractures［J］. J Orthop Traumatol, 2022, 23(1): 42.
［19］Millett P J, Hurst J M, Horan M P, et al. Complications of clavicle fractures treated with intramedullary fixation［J］. J Shoulder Elbow Surg, 2011, 20(1): 86－91.
［20］Eichinger J K, Balog T P, Grassbaugh J A. Intramedullary fixation of clavicle fractures: anatomy, indications, advantages, and disadvantages［J］. J Am Acad Orthop Surg, 2016, 24(7): 455－464.
［21］张玉富, 谭杰, 公茂琪, 等. 应用天玑骨科机器人导航辅助治疗双侧锁骨中段骨折的临床观察［J］. 骨科临床与研究杂志, 2023, 8(2): 118－121.
［22］Frigg A, Rillmann P, Perren T, et al. Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications［J］. Am J Sports Med, 2009, 37(2): 352－359.
［23］Zhu Y R, Hu J P, Zhan T C, et al. Refracture after plate removal of midshaft clavicle fractures after bone union-incidence, risk factors, management and outcomes［J］. BMC Musculoskelet Disord, 2023, 24(1): 308.