看神奇的打结技术，在髌骨骨折复位中的妙用！

髌骨粉碎性骨折如何将碎骨块拼接并维持复位，仍是一个难题。既往众多研究关注于如何固定骨折块，包括克氏针张力带、空心钉、钢板、髌骨爪等，但关于如何将粉碎骨块进行复位的研究较少。

通常，复位髌骨骨折需切开骨膜，进行拼接，但容易导致骨块旋转、游离，增加拼接难度。关于缝线辅助复位固定的方法已经在肱骨近端骨折维持骨块复位中应用广泛，因此，有学者将Nice结应用于髌骨粉碎骨块的复位与维持，取得了良好效果，研究结果发表在Injury上。

Purpose（目的）

评估应用Nice结辅助复位技术治疗移位粉碎性髌骨骨折的术中和术后早期临床疗效。

[Purpose: To evaluate intraoperative and early postoperative clinical outcomes using the Nice knot as an auxiliary reduction technique in displaced comminuted patellar fractures.]

Methods（方法）

本研究回顾了39例单侧闭合移位粉碎性髌骨骨折患者接受切开复位内固定术(ORIF)，其中采用Nice结(NK组，24例)或传统复位(TR组，23例)技术。记录术中手术时间和围手术期血红蛋白。术后临床结果采用VAS评分、膝关节活动范围和Böstman量表进行测量，影像学结果用于评估骨折愈合情况。还评估了包括感染、骨不愈合、植入物松动、骨块移位和内植物疼痛在内的并发症。

[Methods: Thirty-nine patients with unilateral closed displaced comminuted patellar fractures received open reduction and internal fixation (ORIF), utilizing either Nice knot (the NK group, 24 patients) or traditional reduction (the TR group, 23 patients) techniques, were retrospectively reviewed in this study. Intra-operative surgical time and peri-operative hemoglobin were recorded. Post-operative clinical outcomes were measured using visual analgesic score, range of motion of the knee joint and the Böstman scales, and radiographic outcomes were used to evaluate fracture healing. Complications including infection, bone non-union, implant loosening, fragment displacement and painful hardware were also assessed.]

附：常规髌骨骨折复位需切开骨折表面骨膜，将骨折线完全暴露，但缺乏骨膜附着的骨块很容易游离，导致无法辨认原有位置。在使用Nice时，只需暴露主要骨折块，然后在髌骨两侧韧带中开口，将所有骨块包裹在一个“口袋”中，然后从两侧开口中置入缝线打结。下图为Nice结示意图。

图1：Nice结辅助髌骨骨折复位示意图。

附：Nice结的打法在付中国教授《骨科缝线与打结》一书中有详细记录，见下图示：

NIce结打结第一步

NIce结打结第二步

NIce结打结第三步

Results（结果）

住院记录显示NK组的手术时间(32.6分钟)明显短于TR组(63.9分钟)。与TR组(189.1毫升)相比，NK组(64.7毫升)术中失血量也显著减少。NK组和TR组的患者分别平均随访12.9个月和12.5个月。NK组的愈合率为100% (24/24)，TR组为91.3% (21/23)。在TR组中，有两例骨折不愈合，包括一个感染引起的骨折不愈合。两组患者在最后一次随访时的VAS评分、膝关节活动范围或Böstman评分均无差异。

[Results: In-hospital records indicated significantly shorter surgical duration (32.6 min) in the NK group than in the TR group (63.9 min). Intraoperative blood loss was also significantly decreased in the NK group (64.7 ml) compared to the TR group (189.1 ml). Patients in the NK and TR groups were followed for mean of 12.9 months and 12.5 months respectively. The union rate was 100% (24/24) in the NK group and 91.3% (21/23) in the TR group. In the TR group, there were two non-unions, including one infected non-union. There was no difference in the visual analgesic score, the range of motion of the knee joint or the Böstman scale at last follow-up between the two groups.]

图2：Nice结术中手术图。A.髌骨粉碎骨折；B.Nice复位后；C.透视见复位良好；D.克氏针张力带固定。

图3：典型病例2

Conclusion（结论）

滑动的、自稳定的Nice结与手术时间减少、术中失血减少以及治疗移位髌骨骨折的满意术后结果相关。未来的研究需要确保这些发现在其他机构的患者群体中的普遍性。

[Conclusion: The sliding, self-stabilizing Nice knot was associated with reduced surgical time, decreased intraoperative blood loss, and satisfactory postoperative outcomes in the treatment of displaced patellar fractures. Future studies are needed to ensure the generalizability of these findings to additional patient populations at other institutions.]

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