GSH钉内固定治疗股骨下段及下端骨折

2001-2004年,我科使用GSH钉（股骨髁上髓内钉）内固定治疗股骨下段及下端骨折,取得满意疗效,报道如下。     

Stress analysis of the distal locking screws for femoral interlocking nailing.

In femoral locked nailing, the distal locking screws are vulnerable to mechanical failure. Biomechanical studies have shown that the stress on these screws is substantially affected by the fit of the nail in the medullary canal. In this study, a "closed form" mathematical model based on elastic beam-column theory was developed to investigate how the nail-cortical contact, which was simulated by a linear elastic foundation, affected the stress on the distal locking screws. Providing data for the model was a construct of a fractured femur with an intramedullary locked nail loaded by an eccentric vertical load. The stress on the locking screw was analyzed as a function of the distance from the fracture to the locking screw in the distal fragment under two situations: with and without nail-cortical contact in the distal fragment. With nail-cortical contact, the screw stress decreased as the length of nail-cortical contact and the distance between the distal locking screw and the fracture site increased, but this stress contrarily increased when the nail reached the femoral region at which the screw length increased. The screw stress was much higher without nail-cortical contact than with contact and continued to increase as the nail was inserted further. The mathematical model developed here can be a convenient means of rapid stress evaluation and parametric analysis for locked femoral nailing. It may be used to improve the design of interlocking nails and surgical technique.     

多向锁定带锁髓内钉顺行固定股骨远端骨折

 目的 总结多向锁定股骨带锁髓内钉(multi-interlocking femoral intramedullary nail, MIFIN)顺行固定股骨远端骨折的方法和疗效。方法 回顾性分析2003年1月至2011年12月,应用MIFIN治疗股骨远端骨折43例患者资料,男29例,女14例;年龄21～78岁,平均35.5岁;左侧20例,右侧23例;新鲜骨折40例,陈旧性骨折3例;开放性骨折5例,闭合性骨折38例。AO分型：A1型12例,A2型11例,A3型7例,C1型6例,C2型4例,C3型3例;闭合复位10例,切开复位33例。结果43例患者中,除3例陈旧性骨折和9例髓腔较小的患者经扩髓后穿入MIFIN外,余31例均未扩髓穿钉。术后1～4周,行无痛膝关节功能锻炼。43例患者均获得随访,随访时间为19.3～57个月,平均33.5个月。骨折均完全愈合,愈合时间为 4.3~25 个月,平均 6.2 个月。术后美国特种外科医院膝关节功能评分为55～97分,平均85.2分;其中优26例,良7例,可6例,差4例,优良率为76.74%(33/43)。正位X线片示下肢力线外翻＜ 4° 8例,4°～6° 30例,＞6° 5例。侧位X线片示膝关节伸直位均在0°;屈曲超过90° 38例,70°～90° 3例,45°～70° 2例。结论 顺行MIFIN固定股骨远端骨折疗效满意,可避免两次膝关节开放手术的损伤,降低膝关节粘连、功能障碍和感染率。     

Placement of the distal locking screws of the femoral intramedullary nail without radiation

An H-shaped device was invented to facilitate placement of the distal interlocking screws during closed femoral nailing. Eleven sound cadaveric femurs were experimentally nailed before the application of the device in 15 patients with a femoral shaft fracture. In all experimental cases the insertion of the distal screws proved to be easy. In 11 of 15 patients with a femoral fracture, distal locking was achieved using the H-device. These primary results should stimulate further clinical application of the device.     

Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union

Distal third tibial fractures are prone to non-union following tibial nail insertion. The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws. Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed. Our results showed that 80% of non-unions in distal third fractures had only one distal locking screw compared to 20% who had two distal locking screws. This is statistically significant (p<0.01). We therefore conclude that two distal locking screws are essential for distal third fractures.     

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.     

Limb malalignment and functional outcome after antegrade versus retrograde intramedullary nailing in distal femoral fractures

BACKGROUND: Torsional malalignment and mechanical axis deviation (MAD) are worrisome complications after nailing of distal femoral fractures. Variable, sometimes contradictory, reports about these problems have been published. METHODS: In a retrospective nonrandomized study, 41 patients (mean age, 44.5 years) with distal third femoral fractures that were operatively treated using either antegrade (20 cases) or retrograde (21 cases) intramedullary nailing during a period of 2 years have been reviewed. Goniometric measurement was done using a navigated ultrasound examination whereas functional evaluation and return to sports were assessed using Merle d'Aubigné functional grading system and Tegner and Lysholm activity score. RESULTS: There was no difference in femoral length, torsion, or MAD between patients treated using antegrade nails and those treated with a retrograde nail. There was a greater limitation of knee motion with retrograde nailing and of hip motion with antegrade nailing. The functional grading and activity evaluation showed, however, no difference between both groups. CONCLUSIONS: The study cohort showed that no treatment method had proved an advantage over the other regarding limb geometry or the functional outcome. The proper operative indication, intraoperative control, and the surgeon's experience seem to be more important in this regard than the nailing technique.     

Anatomical study of the placement of proximal oblique locking screws in intramedullary tibial nailing

Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing.     

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。     

Post-traumatic torsional differences and functional tests following antegrade or retrograde intramedullary nailing of the distal femoral diaphysis

Previous studies have compared the functional outcome and torsional differences following closed intramedullary nailing of femoral fractures. Rotational deformity following intramedullary nailing may cause symptoms and require surgical correction by osteotomy. Until now studies were designed to evaluate the correct torsional differences by examining every patient following antegrade or retrograde femoral nailing. The series included 13 women and 28 men, average age 44.5 years, who suffered a fracture of the distal femoral diaphysis. Postoperatively we established the diagnosis by three-dimensional determination of the torsion and length of the lower extremities by ultrasound measurement. Furthermore, we performed the clinical examination according to the Tegner and Lysholm score and the Merle d'Aubigne score. There were no significant differences in torsional deformity and length found. The functional outcome showed no significant differences between the two groups. The functional examination exhibited a reduction of flexion in knee motion in the retrograde group. In the antegrade group the motion of the hip was decreased. A correlation between the functional outcome and the torsional deformity was not found.The possible advantage of positioning by using the retrograde femoral nail was not verified.     

交锁髓内钉远端锁入可吸收螺钉治疗胫骨骨折

目的比较交锁髓内钉远端锁入可吸收螺钉与锁入金属锁钉静力型固定在治疗胫骨骨折中的临床效果。方法采用交锁髓内钉远端锁入可吸收螺钉固定治疗25例胫骨骨折患者（试验组）,检测骨折愈合及并发症情况,并与同期锁入金属锁钉静力型固定28例胫骨骨折（对照组）的随访结果进行比较。结果患者均获得随访,时间4~13个月。骨折愈合时间：试验组为13~16（14.28±0.94）周,对照组为14~18（15.89±1.13）周,差异有统计学意义（P〈0.01）。结论交锁髓内钉远端锁入可吸收螺钉比锁入金属锁钉静力型固定更有利于胫骨骨折愈合。     

计算机导航下交锁髓内钉的远端螺钉交锁

目的报道计算机导航技术应用于交锁髓内钉远端交锁螺钉固定效果。方法6例股骨、4例胫腓骨骨折，交锁髓内钉置入后，只需要一次C臂X线机透视定位，存计算机导航下完成远端交锁螺钉的固定。结果10例全部在导航下完成交锁髓内钉的远端交锁，平均透视时间为10s。结论计算机导航手术用于交锁髓内钉的远端固定十分有效，可避免机械引导器的误差。     

有限切开复位逆行交锁髓内钉治疗股骨下段骨折

2003年1月～2007年12月,我科采用有限切开复位逆行交锁髓内钉治疗股骨下段骨折26例,疗效满意,报道如下.     

Femoral nailing with transverse locking screws through the femoral neck

We treated 55 patients with subtrochanteric or comminuted femoral fractures with a transverse locking femoral nail (Alta, Howmedica). This nail was positioned more cephalad than usual so that at least one fixation screw was located in the femoral neck or head. Forty-seven fractures (20 subtrochanteric and 27 diaphyseal) were available for follow-up averaging 12 months (3-35). The time to radiographic healing averaged 7 months (3-21). There was one delayed union, one non-union, two superficial infections, one broken proximal screw, one compartment syndrome of the thigh, and one peroneal nerve palsy. There were no femoral neck fractures, avascular changes of the femoral head, or gluteal irritation at the most recent follow up. The described technique appears safe and effective, is technically easy, and avoids intra-articular screws.     

Fracture strain and stability with additional locking screws in intramedullary nailing: a biomechanical study

BACKGROUND: We studied the effect of additional locking screws on fracture strain and stability in tibial intramedullary nailing. METHODS: We drilled an additional diaphyseal locking hole into 8-mm solid tibial nails 185 mm from the proximal end of the nail, and locked it proximally and distally. An osteotomy was produced 4.5 cm distal to the additional hole, and the construct loaded axially, in flexion, extension, and torsion. The nails were also tested for their fatigue strength. RESULTS: With the additional locking screw, strain increased proximally during loading in neutral and flexion. Strain decreased on loading in extension. The extra locking screw decreased strain close to the osteotomy site in all loading positions. A significant reduction in angular motion at the osteotomy site occurred with the addition of the extra locking screw. The nails survived the fatigue test, although the stress increased around the additional locking hole CONCLUSIONS: Nails with additional locking options, by altering strain and motion at the fracture site, may have the clinical potential to affect fracture healing.     

逆行交锁髓内钉治疗股骨远端骨折

目的 总结应用逆行交锁髓内钉（GSH）治疗股骨远端骨折的疗效。方法采用GSH内固定术治疗股骨远端骨折34例。结果34例获6～35个月随访,髓内钉固定理想,骨折对位、对线良好,均获愈合,采用Merchan等膝关节功能评分标准,优31例,良3例。结论 GSH内固定术治疗股骨远端骨折疗效较好,是治疗股骨远端骨折的首选方法。     

带锁髓内钉治疗股骨干骨折与远端安锁定位装置

目的：总结带锁髓内钉治疗股骨干骨折的临床经验，改进远端锁钉瞄准器，方法：股骨干骨折32例中，新鲜骨折25例，陈旧性骨折7例，采用闭合穿钉治疗11例，半开放穿钉12例，开放穿钉9例，设制髓内钉定位孔及安锁定位装置。结果：本组病例随访6－23个月，平均12个月骨折均已愈合，按Klemm功能恢复分级评定；优21例，良9例，中2例，远端锁钉瞄准器改进后手术使用30例，无锁钉放置失败，一次交锁成功29例，结论：（1）应用带锁髓内钉固定，对闭合复位困难的股骨干新鲜骨折，采用半开放穿钉术，效果良好，（2）改进后的远端锁钉瞄准器无需X线引导，锁钉准确可靠。