Search

COMPARISON OF TWO SURGICAL METHODS FOR ASEPTIC NONUNIONS OF FEMORAL SHAFT FRACTURES AFTER FEMORAL NAILING

Objective To compare the outcomes between intramedullary nail change and augmentation plating with a retained intramedullary nail for aseptic nonunion of femoral shaft fractures after femoral nailing, and to analyze the cause so as to guide the clinical application. Methods Between June 2001 and June 2011, 28 patients with aseptic nonunion of femoral shaft fractures after femoral nailing were treated with intramedullary nail change (11 patients, group A) and augmentation plating with a retained intramedullary nail (17 patients, group B), and the clinical data were analyzed retrospectively. There was no significant difference in age, gender, smoking, location of fracture, Association for the Study of Internal Fixation (AO/ASIF) classification, type of injury, associated injury, type of nonunion, and time of nonunion between 2 groups (P gt; 0.05). The patients were followed up by imaging and the clinical function at regular intervals to observe the callus growth and the recovery condition of the affected limb function, and clinical curative effectiveness was evaluated by Tohner-Wrnch standard. Results The operation time, intraoperative bleeding volume, and intraoperative erythrocyte-transported volume in group A were significantly higher than those in group B (P lt; 0.05). There was no significant difference in postoperative drainage volume and hospitalization days between 2 groups (P gt; 0.05). All the incisions healed by first intention, and no nerve and blood vessel injury occurred. All patients were followed up 18.6 months on average (range, 12-36 months). All cases obtained bone union, and time of clinical and radiological bone healing in group B was significantly shorter than those in group A (P lt; 0.05). During follow-up, no following complication occurred: deep incision infection, injuries of blood vessels and nerves, loosening and breakage of internal fixation, loss of reduction, angulated and rotational malunion. According to Tohner-Wrnch standard at last follow-up, the results were excellent in 6 cases, good in 3 cases, and poor in 2 cases, with an excellent and good rate of 81.8% in group A; the results were excellent in 12 cases, good in 5 cases, with an excellent and good rate of 100% in group B; and difference was significant between 2 groups (Z= — 2.623, P=0.021). Conclusion Augmentation plating with a retained intramedullary nail is an ideal treatment for aseptic nonunion of femoral shaft fractures after femoral nailing and can achieve satisfactory clinical outcomes because it has simpler operation, shorter operation time, less blood loss, and less trauma than intramedullary nail change.

股骨干骨折術后不愈合25例臨床分析

【摘 要】 目的 總結股骨干骨折術后不愈合的原因及再手術方法。 方法 1999 年2 月－ 2007 年1 月，收治股骨干骨折術后不愈合患者25 例。男18 例，女7 例；年齡27 ～ 61 歲，平均42 歲。車禍傷14 例，墜落傷6 例，跌摔傷5 例。股骨干骨折部位：上段4 例，中段18 例，下段3 例。原固定方法：國產加壓鋼板內固定12 例，進口AO 加壓鋼板內固定4 例，髓內釘固定7 例，外固定架固定2 例。入院X 線片檢查無連續骨痂，骨折線明顯。骨折至本次手術時間8 ～ 16 個月。術中采用AO 股骨交鎖髓內釘固定16 例，AO 加壓鋼板內固定7 例，AO 單管單臂架外固定2 例。 結果 患者術后切口均Ⅰ期愈合。25 例均獲隨訪6 ～ 14 個月，平均9.4 個月。骨折愈合時間為4 ～ 12 個月，平均7.2 個月。根據Tohner-Wrnch 標準證定臨床療效；優14 例，良9 例，差2 例，優良率92%。 結論 采用恰當內固定方式、術中操作仔細、術后進行正確功能鍛煉是治療股骨干骨折術后不愈合的關鍵。

克氏針提拉復位髓內釘固定治療粉碎性股骨干骨折

目的 總結克氏針提拉閉合復位、交鎖髓內釘內固定治療粉碎性股骨干骨折的臨床療效。 方法 2008 年4 月－ 2010 年3 月，采用克氏針提拉閉合復位、交鎖髓內釘內固定治療新鮮粉碎性股骨干中段骨折23 例。其中男19 例，女4 例；年齡27 ～ 55 歲，平均35 歲。致傷原因：交通事故傷18 例，重物砸傷5 例。左側10 例，右側13 例。骨折按Winquist-Hansen 分級：Ⅰ級11 例，Ⅱ級6 例，Ⅲ級3 例，Ⅳ級3 例。受傷至手術時間2 ～ 5 d。 結果 手術時間40 ～ 90 min，平均55 min；術中出血量100 ～ 500 mL，平均310 mL。術后切口均Ⅰ期愈合。23 例均獲隨訪，隨訪時間13 ～ 30 個月，平均16 個月。X 線片示22 例骨折愈合良好，愈合時間8 ～ 17 個月，平均13 個月；1 例Ⅳ級骨折患者因活動過多，骨折愈合遲緩，經予以制動4 個月后愈合。無深靜脈血栓形成、斷釘、感染等并發癥發生。末次隨訪時按劉興炎等股骨干骨折療效評定標準，獲優22 例，良1 例，優良率達100%。 結論 克氏針提拉閉合復位交鎖髓內釘內固定治療粉碎性股骨干骨折，手術方法簡便、并發癥少、骨折愈合率高。

交鎖髓內釘治療股骨干骨折

目的 總結交鎖髓內釘治療股骨干骨折的臨床經驗。方法 2000年6月~2004年6月，收治股骨干骨折35例，男21例，女14例；年齡16～69歲，平均31.5歲。其中車禍傷19例，摔傷6例，工地外傷3例，墜落傷7例。開放性骨折13例，Anderson分型Ⅰ型8例，Ⅱ型5例；閉合性骨折22例。新鮮骨折于傷后4 h~5 d、陳舊性骨折于傷后25~56 d入院。35例均采用交鎖髓內釘治療。結果 35例獲隨訪6~49個月。術后達骨性愈合25例(71.4%)，平均愈合時間5.4個月，12~16個月取出內固定；4~8個月臨床愈合9例(25.7%)；5個月骨折延遲愈合1例，經取出上端橫行鎖釘，改為動力型髓內釘固定4個月后骨性愈合。隨訪期內無感染，髓內釘無折彎和折斷，無畸形愈合；鎖釘折斷與退出各1例。35例功能鍛煉后，髖、膝關節功能均基本恢復正常。結論 交鎖髓內釘能防止肢體短縮和旋轉，骨折固定牢靠，愈合率高，是治療股骨干骨折的首選內固定方法。

BIOMECHANICAL IMPACT OF OBLIQUE LOCKING PLATE ON FIXATION OF FEMORAL SHAFT FRACTURES

ObjectiveTo investigate the biomechanical influence of the oblique locking plate on the fixation of femoral shaft fracture. MethodsForty imitation artificial femur model with mechanical properties similar to human femur were selected and randomly divided into groups A, B, C, and D, 10 in each group; the femur fracture model was made by transverse osteotomy at 15 cm and 17 cm below the lesser trochanter of the femur and fixed with locking plate with 12 holes and cortical bone screws. The plate was placed in the middle of the longitudinal axis of the femur in group A, and was placed at 5, 10, and 15° angle axis in groups B, C, and D respectively. The axial compression, three-point bending, torsion tests were carried out to measure the strain. ResultsWith the compressive load and bending load increasing, the medial and lateral strains were significantly increased in each group (P<0.05); but no significant difference was found in strains under compressive load and bending load among 4 groups (P>0.05). With increasing torque, the strain was significantly increased in each group (P<0.05). At 10 N·m torque, there was no significant difference in the strain values among 4 groups (P>0.05); the strain value was significantly higher in groups C and D than groups A and B (P<0.05) and in group D than group C (P<0.05) at torque of 20 and 50 N·m, but no significant difference was found between groups A and B (P>0.05). ConclusionUnder different stress, the strain will be significantly increased when the plate is placed at >10° angle axis.

Ilizarov external fixation without bone graft for atrophic femoral shaft nonunion

Objective To explore the effectiveness of Ilizarov external fixation without bone graft in the treatment of atrophic femoral shaft nonunion. Methods The clinical data of 12 patients with atrophic femoral shaft nonunion admitted between October 2010 and January 2017 were retrospectively analyzed. There were 8 males and 4 females, aged from 24 to 61 years, with an average age of 41.7 years. The nonunion sites located in the middle and upper femur in 7 cases and in the distal femur or supracondylar in 5 cases. The disease duration ranged from 1 to 9 years, with an average of 3.7 years. Previous operations ranged from 1 to 9 times, with an average of 2.8 times. The original fixator was removed, the fracture end of nonunion was debrided, and Ilizarov external fixator was installed. In patients with the length of bone defect less than 4 cm, direct compression fixation was performed during operation; in patients with limb shortening more than 2.5 cm, proximal femoral osteotomy and bone lengthening components were required to prepare limb lengthening after operation; all patients did not receive bone graft. The wearing time of external fixator, clinical bone healing time of nonunion fracture end, and complications were recorded. The effectiveness was evaluated by Paley’s nonunion evaluation criteria. Results All patients were followed up 24-50 months, with an average of 30 months. Bony union was achieved in all 12 cases with a healing time of 6.0-23.5 months (mean, 11.5 months). The wearing time of external fixator ranged from 7 to 25 months, with an average of 13.5 months. At last follow-up, according to Paley’s nonunion evaluation criteria, the results were excellent in 6 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 83.3%. Sagittal angulation deformity of femur more than 7° occurred in 4 cases, with no significant effect on knee extension function, and no special treatment such as osteotomy was performed. Two patients had shorter limbs (>2.5 cm) after operation and were replaced by high shoes; 4 patients with trans-knee fixation lost knee joint mobility of 10-30° after operation; 10 cases of needle tract infection occurred, of which 4 cases with infection and loosening of fixed needle were replaced and re-fixed after needle extraction, the remaining 6 cases of infection without loosening of fixed needle were controlled by local dressing change, needle nursing, and oral cephalosporin anti-inflammatory drugs. No complications such as deep infection and vascular nerve injury occurred. Conclusion Ilizarov external fixation has a high healing rate for atrophic femoral shaft nonunion, which is relatively minimally invasive and can avoid bone grafting. Its preliminary effectiveness is exact, and it is also effective for patients who have experienced multiple failed operations. It is necessary to pay attention to the nursing and rehabilitation training after external fixation.

Reamed versus Nonreamed Intramedullary Nailing for Femoral Fractures: A Systematic Review

Objective　To evaluate the effectiveness of reamed versus nonreamed intramedullary nailing for femoral fractures. Methods　Randomized controlled trials (RCTs) and clinical controlled trials (CCTs) were identified from MEDLINE (1966-2004.5), EMBASE (1966-2004.5), Cochrane Library (Issue 2, 2004), Cochrane Musculoskeletal Injuries Group Database (2004.5), and CBM disc (1979-2004.5). We handsearched Chinese Journal of Orthopaedy (from establishment to May 2004) and Orthopaedic Journal of China (from establishment to May 2004) . RCTs and CCTs were included. Data were extracted by two reviewers with designed extraction form. RevMan 4.2.3 software was used for data analysis. Results　Five RCTs and two CCTs were included. The combined results of meta-analysis showed that reamed intramedullary nailing for femoral fractures can reduce the rate of nonunion (RR=0.38, 95%CI 0.17 to 0.83, P=0.01) and the rate of implant failure (RR=0.42, 95%CI 0.20 to 0.89, P=0.02). Conclusions　Compared with nonreamed intramedullary nailing for femoral fractures, reamed intramedullary nailing can reduce the rates of nonunion and implant failure. However, the relation between reaming or pulmonary complications, the time of union, infection, malunion, operative time, and blood loss needs further study.

股內收肌群痙攣致老年嚴重骨質疏松患者股骨干再骨折一例

交鎖髓內釘動力化治療股骨干骨折不愈合

目的 總結交鎖髓內釘動力化固定對骨折愈合的影響，分析動力化固定后可達到正常愈合的類型。 方法回顧性分析2005年6月－2010年8月30例初始行靜力鎖定后再行動力化固定患者臨床資料。男25例，女5例；年齡18～60歲，平均34歲。股骨干骨折26例，轉子下骨折4例。均為閉合損傷。根據AO分型：A1型2例，A2型2例，A3型1例，B1型5例，B2型6例，B3型2例，C1型8例，C2型4例。根據骨折或不愈合端的力學穩定性和生物活性分型：穩定/增生型8例、穩定/萎縮型5例、不穩定/增生型9例、不穩定/萎縮型8例。于初次靜力釘術后6～18周，平均14周后行髓內釘動力化固定。 結果術后患者切口均Ⅰ期愈合。30例均獲隨訪，隨訪時間6～18個月，平均12個月。24例骨折于動力化固定后3～6個月完全愈合，4例于7～11個月延遲愈合，2例不愈合。3例不穩定/萎縮型患者出現明顯股骨短縮，1例不穩定/萎縮型患者出現旋轉移位。 結論髓內釘動力化治療股骨干骨折不愈合療效確切，但不穩定/萎縮型患者行動力化固定術后并發癥較多。

Effects of Rehabilitation Education and Training Interventions on Perioperative Patients with Femoral Shaft Fractures

【摘要】　目的　探討康復宣教與訓練等干預手段對股骨干骨折患者圍手術期的影響。　方法　2010年6月－2011年3月收治股骨干骨折患者90例，其中男48例，女42例；年齡17~58歲，平均38歲。開放性骨折28例，閉合性骨折62例。股骨骨折部位:上1/3骨折33例，中1/3骨折35例，下1/3骨折20例，多段骨折2例。橫形骨折20例，斜形骨折30例，粉碎性骨折40例。將90例患者隨機分為康復組（46例）和對照組（44例）。對照組采用骨科術前常規處理，康復組采用骨科術前常規處理加康復宣教與訓練。　結果　康復組住院時間為（5.35±1.27） d，對照組為（7.67±1.85） d，兩組比較差異有統計學意義（Plt;0.05）。 康復組治療后發生并發癥7例，對照組16例，康復組并發癥發生率（15.2%）明顯低于對照組（36.4%），差異有統計學意義（Plt;0.05）。治療后5 d，康復組療效獲優35例，良6例，可3例，差2例，優良率89.1%；對照組獲優25例，良5例，可12例，差2例，優良率68.2%；兩組療效比較差異有統計學意義（Plt;0.05）。　結論　康復宣教與訓練能預防與改善股骨干骨折圍手術期臥床引起的并發癥，減輕患者腿部疼痛及腫脹，縮短圍手術期時間，使患者能盡早手術，加快住院床位周轉，提高患者生活質量。【Abstract】　Objective　To explore the effects of rehabilitation education and training interventions on perioperative patients with femoral shaft fractures.　Methods　A total of 90 patients with femoral shaft fractures were selected from June 2010 to March 2011, including 48 males and 42 females aged from 17 to 58 years (mean 38 years). In these 90 patients, open fracture was in 28 and closed fracture was in 62. Fracture site: upper 1/3 fracture was in 33, middle 1/3 fracture was in 35, lower 1/3 fracture was in 20 and multiple fractures was in 2. There were transverse fractures in 20 patients, oblique fractures in 30 patients and comminuted fractures in 40 patients. All of the patients were randomly divided into experimental group (46 patients) and control group (44 patients). The patients in the control group underwent the routine treatment before the orthopedic surgery; besides the routine treatment, the patients in the experimental group were given the rehabilitation education and training before the orthopedic surgery.　Results　The hospital duration in the rehabilitation group was (5.35±1.27) days while in the control group was (7.67±1.85) days, the difference was statistically significant (Plt;0.05). There were 7 cases who had complications in rehabilitation group compared with 16 patients in the control group; the incidence of the complications in the rehabilitation group (15.2%) was significantly lower than that in the control group (36.4%) (Plt;0.05). After the treatment for 5 days, the therapeutic effect in rehabilitation group were excellent in 35 cases, good in 6 cases, middle in 3 cases and poor in 2 cases (with the good rate of 89.1%); while in the control group were excellent in 25 cases, good in 5 cases, middle in 12 cases and poor in 2 cases (with the good rate of 68.2%); the difference was significant between the two groups (Plt;0.05).　Conclusion　Rehabilitation education and training could prevent the perioperative complications in patients with femoral shaft fracture, decrease the pain and edema, speed up the turnover of hospital beds, and improve the patients’ quality of life.