逆行和顺行交锁髓内钉治疗股骨干骨折的比较研究

目的比较逆行和顺行交锁髓内钉治疗股骨干骨折的愈合率和并发症。方法前瞻性地研究应用闭合扩髓交锁髓内钉技术治疗新鲜股骨干骨折72例，其中逆行钉治疗34例，顺行钉治疗38例。所有72例患者均进行了1次以上的随访，随访时间平均19个月（6～31个月）。结果逆行钉组中32例骨折愈合，延迟愈合3例，畸形愈合4例；顺行钉组35例骨折愈合，延迟愈合5例，畸形愈合3例。排除术前即有膝关节疼痛的病例，术后患侧膝关节疼痛者逆行钉组24例，顺行钉组9例；排除术前即有髋关节疼痛的病例，术后患侧髋关节疼痛者逆行钉组1例，顺行钉组6例。结论在骨折愈合方面，两种治疗方法无显著性差异。逆行钉治疗术后有较多的膝关节并发症而顺行钉治疗术后有较多的髋关节并发症。     

逆行交锁髓内钉治疗股骨髁间粉碎性骨折12例

目的探讨股骨逆行交锁髓内钉治疗股骨髁间粉碎性骨折的效果。方法应用股骨逆行交锁髓内钉治疗12例股骨髁间粉碎型骨折,随访全部病例并进行临床效果评定。结果经6~20个月随访,12例骨愈合良好。结论股骨逆行交锁髓内钉具有操作简便、固定牢靠等优点,是治疗股骨髁间粉碎性骨折较理想的内固定器械。     

Prospective comparison of retrograde and antegrade femoral intramedullary nailing

OBJECTIVE: To prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures. DESIGN: Prospective, randomized. SETTING: Urban Level 1 trauma center. PATIENTS: One hundred consecutive femoral shaft fractures. Fifty-four nails inserted retrograde and forty-six inserted antegrade. INTERVENTION: Ten-millimeter antegrade or retrograde nail inserted for a femoral shaft fracture after reaming. OUTCOME MEASUREMENTS: A comparison of the outcomes after antegrade and retrograde nailing of the femur. Data were collected for analysis on comminution, set-up and starting point times, open grade, location of fracture, injury severity score, body mass index, time to union, knee pain and motion, hip and thigh pain, and nail to intramedullary canal diameter difference. A linear regression model was employed. RESULTS: Knee motion was 120 degrees in all but one knee in each group. The antegrade nailed femurs healed faster than those treated retrograde (A = 14.4, R = 18.1 weeks, p = 0.0496). More patients required dynamization for union in the retrograde insertion group (17 percent versus 5 percent, p = 0.10, NS). In a linear regression model, a nail-to-canal-diameter difference and retrograde nailing had an association with an increased time to union. Knee pain was equal in both groups; however, thigh pain was higher in the antegrade group (p = 0.0108). All of the antegrade nailed femurs healed (100 percent), and 98 percent (one nonunion) of the retrograde femurs healed after secondary procedures. CONCLUSIONS: Both antegrade and retrograde nailing yielded high union rates. Each insertion technique has its own advantages and disadvantages. The two insertion modes appear to be relatively equal for the treatment of femoral shaft fractures.     

Antegrade Versus Retrograde Locked Intramedullary Nailing for Femoral Fractures: Which Is Better?

Abstract Background: Locked intramedullary nailing or interlocking nailing (ILN) is a proven mode of treatment for femoral shaft fractures. It can be inserted via the antegrade or retrograde approach. Retrograde approach is technically less demanding especially if the patient is overweight. But there are concerns with regard to the violation of the knee and its effect on subsequent knee function. Methods: We studied consecutive cases of femoral shaft fractures treated with locked intramedullary nailing at the Penang General Hospital, from 1st June 2004 to 1st June 2005. We looked at radiological and clinical union rates, union of fractures, alignment of the operated limb, and the knee function, using the Thoresen scoring system. Results: There were a total of 77 cases of femoral interlocking nails during the study period. Forty-two cases were antegrade nails and 35 cases were retrograde nails. Both groups of patients eventually achieved union of the fracture and retrograde nailing group showed significantly earlier union rate (p = 0.032). There is no significant difference between both groups, in regards to knee pain, swelling, and range of motion as well as postnailing femoral alignment. Conclusions: Both methods of nailing achieved excellent union rates with good alignment of the limb. Contrary to popular belief, we found that retrograde nailing does not give rise to a higher rate of knee complications. Therefore, we strongly recommend this approach of nailing as it is technically less demanding.     

逆行和顺行置髓内钉治疗股骨干骨折的疗效比较

目的比较逆行和顺行置髓内钉治疗股骨干骨折的临床疗效。方法将57例股骨干骨折患者按置钉方式的不同分为对照组(经大转子顺行置髓内钉治疗,25例)和观察组(经股骨髁逆行置髓内钉治疗,32例)。比较两组术中透视次数、手术时间、术中出血量、骨折愈合时间、术后6个月Harris评分。结果患者均获得随访,时间7~12个月。手术时间、术中出血量观察组明显短(少)于对照组(P<0.05);术中透视次数、骨折愈合时间以及术后6个月Harris评分两组比较差异均无统计学意义(P>0.05)。结论逆行和顺行置髓内钉治疗股骨干骨折均能取得满意的临床疗效,但逆行置髓内钉具有手术操作简单、无需使用牵引床、手术时间短、术中出血量少等优点,更利于基层医院使用。     

Retrograde versus antegrade nailing of femoral shaft fractures

OBJECTIVES: To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05). INTERVENTION: Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques. MAIN OUTCOME MEASURES: Union, delayed union, nonunion, malunion, and complication rates. RESULTS: After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05). CONCLUSIONS: Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.     

Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases

Subtrochanteric femur fractures commonly present with predictable displacement because of the deforming muscle forces acting upon the proximal femur. For this reason, successful closed reduction and femoral nailing can be a technically demanding procedure. Open reduction prior to nail placement has been advocated to improve and maintain anatomic fracture alignment. The purpose of this study was to evaluate the results of patients with closed subtrochanteric femur fractures treated with open reduction and a reamed antegrade statically locked intramedullary nail. An initial query of our database identified 154 patients who had sustained a subtrochanteric femur fracture over the defined study period. Ninety-six patients had adequate radiographic and clinical follow-up. Fifty-six (58%) patients were treated with open reduction and nail placement. There were no wound complications or infections and all patients went on to successful osseous union. There was no loss of reduction and a final coronal and sagittal plane deformity of <5 degrees in 55 of 56 (98%) patients. Open reduction of closed subtrochanteric femur fractures followed by intramedullary nailing leads to high union rates with rare complications.     

Unreamed Nailing of Diaphyseal and Metaphyseal Fractures of the Femur

Background: Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. Patients and Methods: A prospective series of 63 patients were treated with three different unreamed nailing and interlocking techniques selected according to the predominant fracture location. Median age of the 30 women and 33 men was 39 (17–97) years. High-energy injuries had occurred in 37 patients. Antegrade nailing and interlocking with standard technique was used in 29 diaphyseal fractures, antegrade nailing and placement of the proximal locking device to the femoral head was performed in eleven proximal fractures with involvement of the intertrochanteric region, and retrograde nailing and standard interlocking was done in 23 mainly distal fractures. Results: We encountered two types of major mechanical complications: angular malalignment and protrusion of the nail into the knee joint following compression in the fracture. Angular malalignment was found in four fractures. One midshaft fracture was fixed in a valgus reduction. Varus malalignment and loss of fixation occurred in two high subtrochanteric fractures after proximal locking with a spiral blade. In another midshaft fracture redisplacement in varus occurred. Compression in the fracture with protrusion of the nail by 2–10 mm into the knee joint following retrograde nailing was observed in six osteoporotic patients. Only two of these patients had significant knee problems. The median time to union – 4 months – did not differ significantly between the fixation groups. Conclusions: Thus, there are still problems after nailing very proximal and distal fractures. Most postoperative complications were seen after retrograde nailing of distal fractures, but the consequences of fixation failure in very proximal fractures were worse. Nevertheless, a protocol that takes advantage of the different options for nail introduction and locking depending on the fracture location seems promising. Received: January 6, 2002; revision accepted: October 8, 2002 Correspondence Address Karl Akke Alberts, MD, PhD, Department of Orthopedics, Karolinska Hospital, 17176 Stockholm, Sweden, Phone (+48/8) 517-70000, Fax -72695, e-mail: akke.alberts@ks.se     

股骨交锁髓内钉手术并发股骨颈骨折

目的探讨股骨交锁髓内钉手术并发股骨颈骨折的原因。方法回顾分析7例因股骨干骨折行交锁髓内钉手术而并发股骨颈骨折患者的影象学资料、内固定材料、手术操作过程、术后行走锻炼、下肢功能及骨折愈合情况。结果3例由器械因素及操作不当引起,2例因漏诊隐匿股骨颈骨折导致,2例系术后过早行走锻炼所致。并发的股骨颈骨折分别以股骨重建钉或斯氏针内固定,5例闭合复位,2例开放复位。平均随访35个月(15~48个月),7例骨折均愈合,未发现股骨头坏死,下肢功能恢复满意。结论杜绝隐匿股骨颈骨折的漏诊、规范熟练的手术操作及术后适当的延迟负重行走是减少该类并发症的关键。     

Does fixation of femoral fractures using retrograde intramedullary nailing cause long-term knee pain: a systematic review of the literature

Aim  To perform a systematic review of the literature to discover if knee pain was a common complication in patients who underwent retrograde intramedullary fixation for femoral fractures and whether the pain persisted beyond fracture union and soft tissue healing. Materials and methods  The literature search revealed eight articles which fit the inclusion criteria. These series were then compared and articles critiqued to allow conclusions to be drawn. Three articles compared antegrade and retrograde nails and five articles reviewed results of retrograde fixation only. Results  Retrograde intramedullary nailing produced knee pain in 40–53% of patients compared with 20% in antegrade fixations during follow-up. These figures however, dropped substantially by final follow-up to 23–24% for retrograde and 12.5% for antegrade. Thirty-seven per cent of knee pain post operatively was associated with prominent metal work the majority of which resolved if the metal was removed. Conclusion  Retrograde intramedullary nailing for femoral fractures is associated with higher rates of anterior knee pain than antegrade nailing. Many cases of knee pain can be prevented with proper technique avoiding prominent metal work and many more cases settle in time with no intervention.     

股骨重建钉治疗股骨干合并同侧髋部骨折适应证探讨

目的探讨股骨重建钉治疗股骨干合并同侧髋部骨折的手术适应证。方法根据入选标准和排除标准,回顾2001年1月至2011年1月收治的股骨干合并同侧髋部骨折病例15例,其中男14例,女1例;年龄21~64岁,平均35.5岁。通过比较术前、术后即刻、术后1、3、6和12个月的临床和影像学随访结果,评估骨折愈合情况和并发症,分析股骨重建钉治疗股骨干合并同侧髋部骨折的最佳适应证。结果全部病例获得随访,随访时间14~48个月,平均27.8个月。13例股骨干骨折一期获得骨性愈合,愈合时间(6.2±4.1)个月,14例股骨颈骨折一期获得骨性愈合,愈合时间(5.4±2.9)个月。合并症:1例股骨远端骨折由于狭部限制,重建钉过细,局部旋转不稳定,并发肥大性骨不连;1例股骨中段骨折延迟愈合;2例股骨干旋转畸形愈合;1例股骨颈头下型骨折不愈合。末次随访时进行Friedman-Wyman评定,优12例,良2例,差1例,优良率93.3%。结论股骨重建钉适用于绝大部分股骨干骨折合并髋部骨折,尤其是股骨颈基底部骨折合并股骨干近端或狭部骨折。但对于股骨颈头下型、难复位的股骨颈骨折合并股骨干远端骨折,股骨重建钉并非最佳的治疗方案。     

Retrograde interlocking intramedullary nailing under arthroscopy for supracondylar femoral fracture

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Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial

BACKGROUND: A variety of devices have been used in the treatment of supracondylar femoral fractures. The condylar blade plate relies on the principles of open reduction, absolute stability and interfragmentary compression to achieve union. The technique of retrograde nailing uses indirect reduction of the metaphyseal fracture component, offering relative stability and a less invasive approach. Randomized comparison of these common methods of fixation has not been reported. METHODS: Twenty-two patients with 23 supracondylar femur fractures were recruited from two regional trauma centres over a 26-month period and randomized to receive either a retrograde intramedullary nail fixation (IM group, 12 fractures) or a fixed-angle blade plate fixation (BP group, 11 fractures). The groups were followed for 12-36 months. The primary outcome measures were revision surgery and general health. RESULTS: Three patients in the IM group required revision surgery for the removal of implant components. No reoperations occurred in the BP group. There was a trend towards greater pain in the IM group, although there was no statistically significant difference in the scores for any of the SF-36 domains. CONCLUSION: Both distal femoral nailing and blade plating give good outcomes. There is a trend for patients undergoing retrograde nailing to complain of more pain and to require revision surgery for removal of implants.     

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures

Introduction Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures. Materials and methods Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture. Results The average time for union of femoral shaft fractures was 27.3 (14–60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8–12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman–Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. Conclusion Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.This study was conducted at Kyungpook National University Hospital, Daegu, South Korea. The authors have and will not receive any financial benefit in association with the present paper.     

Management of subtrochanteric femoral fractures and metastases using long proximal femoral nail

We report our initial experience with a new reconstruction nail, the long proximal femoral nail (L.PFN), in the treatment of subtrochanteric femoral fractures and metastases. We performed 52 L.PFN in 49 patients over a period of 18 months with an average follow-up period of 47.7 weeks. Group I consisted of 24 patients, who had L.PFN for traumatic subtrochanteric femoral fractures. Group II consisted of 25 patients, who had L.PFN for femoral metastases and pathological fractures. (Three bilateral.) In nine patients in group I, the fracture was extending to the intertrochnateric region with involvement of the piriformis fossa. Eight patients in group I had open reduction and cerclage cabling of the fracture prior to L.PFN. All the traumatic fractures in group I had united with an average time to union of 19.4 weeks. In eight operations there were technical difficulties with the insertion of proximal locking screws. Five patients in our series had complications but we had no mechanical failures of the implant. L.PFN is a reliable implant for subtrochanteric femoral fractures and metastases. We also showed that open reduction and cerclage cabling of unstable subtrochanteric fractures prior to nailing was not detrimental to fracture healing in our series.     

交锁髓内钉治疗股骨和胫腓骨骨折

目的探讨交锁髓内钉治疗股骨和胫腓骨骨折的疗效：方法对47例（51肢）股骨和胫腓骨骨折采用交锁髓内钉固定,分析临床疗效。结果随访7～36个月,骨折全部愈合,功能恢复良好,效果满意。结论交锁髓内钉治疗股骨和胫腓骨骨折具有适应证广、创伤小、固定牢靠等优点,可作为股骨和胫骨干骨折的首选治疗方法。应严格掌握适应证及手术时机,熟练掌握操作技术。     

静力型交锁髓内钉动力化治疗下肢骨干骨折延迟愈合

目的 探讨静力型交锁髓内钉动力化治疗下肢骨干骨折延迟愈合的效果。方法 对27例骨折应用静力型交锁髓内钉固定后的股骨和胫骨骨干延迟愈合患者，行近侧或远侧锁钉取出术进行动力化治疗。其中股骨干延迟愈合17例，胫骨干延迟愈合10例。结果 随访7—48个月，平均19．5个月。术后3—7个月(平均3．3个月)获临床愈合。无感染、断钉、关节损伤和内固定取出后再骨折。结论 静力型改为动力型是治疗交锁髓内钉固定后股骨和胫骨骨干延迟愈合的有效方法。应用时注意选择适当的手术时机，选择取出锁钉也要得当。     

带锁髓内钉治疗股骨骨折骨不连

目的探讨带锁髓内钉治疗股骨骨折骨不连的治疗效果。方法对23例股骨骨折骨不连患者采用带锁髓内钉内固定治疗,术后早期应用CPM机锻炼。结果23例均获6～24个月随访,术后12～19周,平均16．3周骨折愈合。患肢膝关节功能较术前明显改善。结论带锁髓内钉是治疗股骨骨折骨不连较理想的方法。     

The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature

The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.     

逆行性可膨胀髓内钉治疗股骨干骨折

目的探讨逆行性可膨胀髓内钉在股骨干中段及中下段骨折治疗中的临床疗效。方法对9例股骨干中段及中下段骨折患者采用逆行性可膨胀髓内钉进行内固定。结果 9例均获随访,时间10～18个月。骨折均愈合,时间2～6个月。膝关节功能按Lysholm评分为74～94分,优6例,良2例,可1例。结论逆行性可膨胀髓内钉治疗股骨中段及中下段骨折创伤小,关节功能恢复较快。