胫骨骨折--扩髓和不扩髓髓内钉比较

关于这个主题的文献质量不高，因此很难得出一个结论，究竟是扩髓钉还是不扩髓钉的效果更好。这个报告提示：对于开放或闭合性胫骨骨折，两种治疗方法在骨愈合率和并发症上没有统计学差异，建议对患者的功能和生活质量进行更深入和详细的评价和分析研究。     

Tibial fractures Reamed versus unreamed intramedullary nailing

AMEDLINEsearchwasperformedtoidentifystudiespublishedfromJanuary1997toNovember2003com-paringreamedintramedullary(IM)nailingwithun-reamedIMnailingfortibialfractures.Fromalistof16articles,threerandomizedclinicaltrialscomparingreamedIMnailingtounreamedIMnailingwereidentified.Weincludedstudiesexaminingbothopenandclosedtibialfractures.Weexcludedanalysesofnonrandomizedtrials.StudiesStudy1KeatingJF,OBrienPJ,BlachutPA,etal(1997)Lockingintramedullarynailingwithandwithoutreamingforopenfractur…     

Extending the indications of intramedullary nailing with the Expert Tibial Nail

Numerous modifications in nail and screw design have led to the development of the Expert Tibial Nail. It enables the surgeon to further extend the spectrum of fractures eligible for intramedullary nailing. In the proximal metaphysis spongious bone screws achieve an optimized purchase in the cancellous bone. Multidirectional interlocking screws ensure that alignment can be well maintained and stability preserved in short proximal or distal tibial segments. The end cap achieves angular stability between the proximal oblique screw and the nail. These changes in implant design enhance the stability of the bone-nail construct and reduce the risk for secondary malalignment. The results of our prospective case series demonstrate favorable results and extended indications, compared to standard tibial nails.     

Tibial unreamed intramedullary nailing using schanz screws in displaced diaphyseal segmental fractures

Reduction and manipulation using percutaneously fixated Schanz screws and unreamed intramedullary nailing facilitates fracture reduction, promotes early weight bearing, and decreases complications such as nonunion, malalignment, in failure.     

Chronic sepsis following intramedullary nailing of femoral fractures

We reviewed 12 patients with chronic drainage after intramedullary nailing of a femoral shaft fracture. The fractures tended to be the result of high-speed trauma and were frequently comminuted. Six were open fractures and six were closed injuries. All but one had been managed initially with the open nailing technique, exposing the fracture site. In six cases we left the nail in place until bone union occurred, an average of 33 months after injury, removing the hardware thereafter. The remaining six patients, each with bone sequestra at the fracture site, underwent nail removal, debridement of nonviable bone, and external fixation followed by bone grafting; this group took 37 months to heal. There was one persistent nonunion in each group. Drainage did not cease in either group until the nail and all sequestra had been removed. There was an average of 4.3 cm of shortening, but no angulation greater than 10 degrees. Six patients were left with less than 45 degrees of knee flexion and only five had 100 degrees or more of knee flexion.     

Tibial shaft malunion treated with reamed intramedullary nailing: a revised technique

Thirty-seven consecutive adult tibial shaft malunions which had not undergone surgical treatment were prospectively treated with reamed intramedullary nailing. Indications for this treatment modality included a malunion of a tibial shaft which had only been conservatively treated, lesion level fitting for traditional or locked reamed intramedullary nail fixation, less than 2 cm shortening, and without evidence of deep infection at present. The malunions were treated with fibulotomy, closed wedge tibial osteotomy, open reaming of the marrow cavity, stable reamed intramedullary nail stabilization with or without supplementation, and cancellous bone grafting. Thirty-four (92%) patients were followed up for at least 1 year (range 1.0–4.3 years), and all achieved a solid union. The union period was 5.8±0.8 months. Complications included 2 (6%) patients with deep infection and 1 (3%) with cortical perforation. However, all 3 patients recovered completely after adequate management. In conclusion, a reamed intramedullary nail is an ideal instrument for tibial shaft malunions in indicated cases. Good exposure of the bony segments to ream the marrow cavity precisely can avoid cortical perforation. Gentle dissection of the soft tissues may lower the infection rate. Concomitant cancellous bone grafting can improve the union rate. Received: 13 April 1999     

Porosity of rat femora following intramedullary reaming and nailing

The present study evaluated cortical porosity and thickness of intact rat femora 12 weeks after intramedullary reaming and nailing. The right femora were reamed and received either flexible polyacetal nails or rigid stainless steel nails. A third group was reamed but not nailed. The left femora were used as controls. The anterior cortical wall was analyzed at the mid-diaphyseal level. Neither reaming nor reaming combined with nailing influenced porosities with a diameter less than 10 microns. For larger pores, polyacetal nailing doubled the porosity, whereas steel nails increased porosity by a factor of 4.5. A slightly increased porosity was observed for the reamed group. Reduced cortical thickness was found in both nailed groups, whereas cortical thickness was increased in the reamed group compared with the control side. Implantation of rigid and flexible intramedullary nails in rat femora increased porosity along the anterior cortical wall.     

Hip fractures following intramedullary nailing fixation for femoral fractures

IntroductionProximal peri-implant femoral fractures occur following intramedullary nailing (IMN) fixation for trochanteric, femoral shaft, and distal femoral fractures. However, analyses of secondary hip fractures (SHFs) using large clinical samples are lacking. Therefore, we aimed to report the incidence and clinical outcomes of SHF after nailing fixation (IMN or cephalomedullary nailing [CMN]) for overall femoral fractures. In addition, we focused on IMN for femoral shaft fractures and investigated the risk factors for SHF.MethodsThis multicenter, retrospective, cohort study included 2,293 patients aged > 60 years who underwent nailing fixation for femoral fractures. The primary outcome was the incidence of SHF. In the assessment of clinical outcomes, we evaluated reoperation and the regaining of walking ability following SHF management. In addition, we conducted multivariable logistic regression analyses to examine the association between risk factors and SHF.ResultsSeventeen (0.7%) patients had SHFs, including 12 femoral neck fractures and 5 trochanteric fractures. Antegrade IMN was the most common type of nailing fixation. Multivariable analysis demonstrated that the absence of femoral head fixation was significantly associated with the incidence of SHF following IMN for femoral shaft fractures (odds ratio, 17.0; 95% confidence interval, 1.9–2265.7; p=0.006). In the assessment of clinical outcomes, there were two reoperations (16.7%) in the secondary femoral neck fracture group. Patients with secondary trochanteric fractures tended to have a lower probability of regaining walking ability than those with secondary femoral neck fractures (20% vs. 50%).ConclusionsIn this multicenter study, the incidence of SHF after nail fixation for femoral fractures was 0.7%. The absence of femoral head fixation was significantly associated with SHF, and the clinical outcomes were poor. Therefore, femoral head fixation at the initial IMN fixation for femoral fractures may be a fixation option for surgeons to consider as an SHF prevention measure.     

Malrotation following reamed intramedullary nailing of closed tibial fractures

Background:

Rotational malalignment after intramedullary tibial nailing is rarely addressed in clinical studies. Malrotation (especially >10°)of the lower extremity can lead to development and progression of degenerative changes in knee and ankle joints. The purpose of this study is to determine the incidence and severity of tibial malrotation after reamed intramedullary nailing for closed diaphyseal tibial fractures.

Materials and Methods:

Sixty patients (53 males and 7 females) with tibial diaphyseal fracture were included in this study. The mean age of the patients was 33.4±13.3 years. All fractures were manually reduced and fixed using reamed intramedullary nailing. A standard method using bilateral limited computerized tomography was used to measure the tibial torsion. A difference greater than 10° between two tibiae was defined as malrotation.

Results:

Eighteen (30%) patients had malrotation of more than 10°. Malrotation was greater than 15° in seven cases. Good or excellent rotational reduction was achieved in 70% of the patients. There was no statistically significant relation between AO tibial fracture classification and fibular fixation and malrotation of greater than 10°.

Conclusions:

Considering the high incidence rate of tibial malrotation following intramedullary nailing, we need a precise method to evaluate the torsion intraoperatively to prevent the problem.     

髌上入路胫骨髓内钉治疗胫骨近端骨折

目的:探讨膝关节半伸直位髌上入路胫骨髓内钉治疗胫骨近端骨折的临床疗效。方法:2013年1月至2014年1月共收治胫骨近端骨折16例,男14例,女2例;年龄26～57岁,平均42.2岁。所有患者为单侧闭合骨折,采用膝关节半伸直位髌上入路META-NAIL胫骨髓内钉内固定治疗。记录手术时间、术后并发症、骨愈合时间、胫骨力线和膝关节活动范围,并采用视觉模拟评分法(visual analogue scale,VAS)和Lysholm膝关节评分评定手术疗效。结果:所有16例患者手术时间65～95 min,平均(75.7±8.3) min.无明显围手术期并发症发生。所有患者获随访,时间12～24个月,平均(15.6±8.1)个月。15例获得Ⅰ期骨愈合,平均骨愈合时间(3.6±1.8)个月(3～5个月).末次随访时,所有患者胫骨力线良好,无膝前疼痛。患侧膝关节屈伸活动范围平均(124.4±18.8)°,健侧(127.5±16.7)°。Lysholm膝关节评分77～92分,平均86.4±12.3.结论:膝关节半伸直位髌上入路胫骨髓内钉治疗胫骨近端骨折,术中复位及固定操作方便,术后并发症少,患肢功能恢复良好,临床疗效满意。     

Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures

Introduction  

This study was designed to evaluate the incidence of femoral malrotation in bilateral femoral shaft fractures.     

Long-term functional outcome following intramedullary nailing of femoral shaft fractures

BackgroundThe management of femoral shaft fractures using intramedullary nailing is a popular method. The purpose of this study was to evaluate the long-term functional outcome after antegrade or retrograde intramedullary nailing of traumatic femoral shaft fractures. We further determined predictors of these functional outcome scores.MethodsIn a retrospective study, patients with a femoral shaft fracture but no other injuries to the lower limbs or pelvis were included. A total of 59 patients met the inclusion criteria. Functional outcome scores (Short Musculoskeletal Functional Assessment (SMFA), Western Ontario and McMaster University Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and the Lysholm knee function scoring scale) were measured at a mean of 7.8 years (±3.5 years) postoperatively. The Visual Analogue Scale (VAS) was used to determine pain complaints of the lower limb.ResultsThe range of motion (ROM) of the hip and knee joints was comparable between the injured and uninjured leg, regardless of the nailing technique. Correlation between ROM and the final outcome scores was found to be fair to moderate. Even years after surgery, 17% of the patients still reported moderate to severe pain. A substantial correlation was observed between VAS and the patient-reported outcome scores. The most significant predictor of functional outcome was pain in the lower limb.ConclusionsOur findings suggest that the ROM of hip and knee returns to normal over time, regardless of the nailing method used. However, pain in the lower limb is an important predictor and source of disability after femoral shaft fractures, even though most patients achieved good functional outcome scores.     

髓内钉内固定术后感染

髓内钉内固定术后感染,尤其是深部感染,是髓内钉技术最严重的并发症之一,具有病因复杂、早期诊断困难、难以彻底治愈、易复发等特点.该文就髓内钉内固定术后感染的病因、诊断方法及治疗方法作一综述.