摘要目的 探讨髓内钉治疗股骨干骨折,术中干预Ⅱ度及以上移位的骨折块对股骨干骨折愈合的疗效。方法 采用回顾性病例对照研究分析2016年2月至2020年2月连云港市第一人民医院收治的115例股骨干骨折伴蝶形骨折块患者临床资料,其中男58例,女57例;年龄17~68岁,平均(39.0±11.9)岁;右侧62例,左侧53例。致伤原因:车祸伤71例,高处坠落18例,骑车摔倒12例,压砸伤等其他14例。受伤到手术时间平均(5.0±2.4)d。根据是否术中干预蝶形骨折块,分为干预组:Ⅱ度移位患者34例,Ⅲ度移位患者14例,Ⅳ度移位患者11例;对照组:Ⅱ度移位患者30例,Ⅲ度移位患者16例,Ⅳ度移位患者10例。比较各组骨折愈合率、愈合时间、完全负重时间以及术后9个月的改良股骨X线愈合评分(modified radiological union scale for femur,mRUSF)。结果 术后115例患者均获随访,随访时间9~24个月,平均(15.2±3.8)个月。在Ⅱ度移位病例中,干预组的骨折愈合率、愈合时间、完全负重时间以及术后9个月的mRUSF评分均优于对照组(P<0.05);在Ⅲ度移位病例中,干预组的骨折愈合率、愈合时间、完全负重时间以及术后9个月的mRUSF评分均优于对照组(P<0.05);在Ⅳ度移位病例中,干预组的骨折愈合率、完全负重时间以及术后9个月的mRUSF评分优于对照组(P<0.05)。结论 髓内钉治疗股骨干骨折,术中对Ⅱ度、Ⅲ度、Ⅳ度移位的骨折块进行干预,减小骨折块移位程度至Ⅰ度,有利于股骨骨折愈合。
Abstract:Objective To investigate the effect of intramedullary nail on femoral shaft fracture healing by intervening the displaced fracture fragments with degree Ⅱ and above during operation.Methods A retrospective case-control study was conducted to analyze the clinical data of 115 patients with femoral shaft fracture with butterfly fracture admitted to the First People's Hospital of Lianyungang from February 2016 to February 2020,including 58 males and 57 females,62 right and 53 left.The age ranged from 17 to 68 years,with an average of (39.0±11.9)years.There were 71 cases of a traffic accident,18 cases of a fall from height,12 cases of a cycling fall,14 cases of crushing or other according to the cause of injury.The time from injury to surgery was (5.0±2.4)days.According to whether butterfly fracture fragments were intervened during surgery,patients were divided into the intervention group and control group.Interention group had 34 patients with grade Ⅱ displacement,14 patients with grade Ⅲ displacement and 11 patients with grade Ⅳ displacement.The control group had 30 patients with grade Ⅱ displacement,16 patients with grade Ⅲ displacement,and 10 patients with grade Ⅳ displacement.The fracture healing rate,healing time,full weight-bearing time,and the modified Radiological Union Scale for Femur(mRUSF) at 9 months at 9 months after surgery were compared between the groups.Results All 115 patients were followed up for 9~24 months,with an average of (15.2±3.8)months.In cases of grade Ⅱ displacement,the fracture healing rate,healing time,full weight-bearing time,and mRUSF score at 9 months after surgery in the control group were superior to those in the intervention group(P<0.05).In cases of grade Ⅲ displacement,the fracture healing rate,healing time,full weight-bearing time,and mRUSF score at 9 months after surgery in the control group were superior to those in the intervention group(P<0.05).In cases of grade Ⅳ displacement,the fracture healing rate,full weight-bearing time,and mRUSF score at 9 months after surgery in the control group were superior to those in the intervention group(P<0.05).Conclusion During the treatment of femoral shaft fractures with intramedullary nails,intraoperative intervention should be used on the displaced fragments of grade Ⅱ,Ⅲ,and IV to reduce the degree of fragment displacement to grade Ⅰ,which is beneficial to femoral fracture healing.
[1]Lee JR,Kim HJ,Lee KB.Effects of third fragment size and displacement on non-union of femoral shaft fractures after locking for intramedullary nailing[J].Orthop Traumatol Surg Res,2016,102(2):175-181.
[2]Pihlajamaki HK,Salminen ST,Bostman OM.The treatment of nonunions following intramedullary nailing of femoral shaft fractures[J].J Orthop Trauma,2002,16(6):394-402.
[3]Salminen ST,Pihlajamki HK,Avikainen VJ,et al.Population based epidemiologic and morphologic study of femoral shaft fractures[J].Clin Orthop Relat Res,2000(372):241-249.
[4]Santolini E,West RM,Giannoudis PV.Leeds-genoa non-union index:a clinical tool for asessing the need for early intervention after long bone fracture fixation[J].Int Orthop,2020,44(1):161-172.
[5]Lin SJ,Chen CL,Peng KT,et al.Effect of frag mentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail[J].Injury,2014,45(4):752-756.
[6]Vicenti G,Carrozzo M,Caiaffa V,et al.The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing:a radiological study[J].Int Orthop,2019,43(1):193-200.
[7]林庆荣,杨明辉,侯志勇.中国创伤骨科患者围手术期静脉血栓栓塞症预防指南(2021)[J].中华创伤骨科杂志,2021,23(3):185-192.
[8]刘洋.交锁髓内钉固定治疗股骨干骨折的体会[J].中国医药指南,2009,7(8):90.
[9]Litrenta J,Tornetta P,Mehta S,et al.Determination of radiographic healing:An assessment of consistency using RUST and modified RUST in metadiaphyseal fractures[J].J Orthop Trauma,2015,29(11):516-520.
[10]Plumarom Y,Wilkinson BG,Willey MC,et al.Sensitivity and specificity of modified RUST score using clinical and radiographic findings as a gold standard[J].Bone Joint Open,2021,2(10):796-805.
[11]Misir A,Yildiz KI,Kizkapan TB,et al.Reliability of RUST and modified RUST scores for evaluation of union in pediatric and adult femoral shaft fractures[J].Acta Orthop Trauma Turc,2021,55(2):127-133.
[12]Nakamura A,Akahane M,Shigematsu H,et al.Cell sheet transplantation of cultured mesenchymal stem cells enhances bone formation in a rat nonunion model[J].Bone,2010,46(2):418-424.
[13]梁志勇,李华壮,赵光宗,等.髓内钉内固定治疗股骨干多段骨折[J].中国矫形外科杂志,2018,26(4):375-377.
[14]Wiss DA,Fleming CH,Matta JM,et al.Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail.[J].Clin Orthop Relat Res,1986(212):35-47.
[15]Claes L,Eckert-Hübner K,Augat P.The effect of mechanical stability on local vascularization and tissue differentiation in callus healing[J].J Orthop Res,2002,20(5):1099-1105.
[16]Lienau J,Schell H,Duda GN,et al.Initial vascularization and tissue differentiation are influenced by fixation stability[J].J Orthop Res,2005,23(3):639-645.
[17]Hamahashi K,Uchiyama Y,Kobayashi Y,et al.Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments:a retrospective analysis of risk factors for delayed union[J].Trauma Surg Acute Care Open,2019,4(1):e203.
[18]毛国庶,周敏,李晓明,等.第三骨块对股骨干骨折髓内钉固定后骨愈合效果的影响[J].中国组织工程研究,2021,25(15):2405-2409.
[19]王雪兵,李力更,吴志新,等.股骨干骨折交锁髓内钉内固定移位骨块对骨折愈合的影响[J].创伤外科杂志,2017,19(8):574-577.
[20]Yoon YC,Song HK,Han JS,et al.Antegrade nailing in femoral shaft fracture patients-comparison of outcomes of isolated fractures,multiple fractures and severely injured patients[J].Injury,2021,52(10):3068-3074.
[21]Mundy GR.Nutritional modulators of bone remodeling during aging[J].Am J Clin Nutr,2006,83(2):427-430.
[22]Burc H,Atay T,Demirci D,et al.The Intramedullary Nailing of Adult Femoral Shaft Fracture by the Way of Open Reduction is a Disadvantage or Not?[J].Indian J Surg,2015,77(Suppl 2):583-588.
[23]Ehlinger M,Niglis L,Favreau H,et al.Vascular complication after percutaneous femoral cerclage wire[J].Orthop Trauma Surg Res,2018,104(3):377-381.
[24]Devendra A,Avinash M,Chidambaram D,et al.Vascular injuries due to cerclage passer:Relevant anatomy and note of caution[J].J Orthop Surg (Hong Kong),2018,26(1):614422904.