Retrograde femoral nailing:Indications and techniques

Intramedullary nailing is the treatment of choice for fractures of the femoral shaft. Newer nail designs have allowed the orthopaedic surgeon to use a more “implant specific” approach to treating these fractures. Antegrade nailing is efficacious for the treatment of subtrochanteric and femoral diaphyseal fractures. Retrograde nailing has been shown to be equally effective in the treatment of fractures of the femoral shaft and very advantageous for distal one-third and supracondylar fractures. In addition, retrograde femoral nailing has been able to improve he treatment of femoral shaft fractures associated with other combined musculoskeletal injuries, The surgical technique although straightforward may be greatly improved by the understanding of the subtleties of this procedure.     

The use of a revision femoral stem to manage a distal femoral periprosthetic fracture in a well-fixed total knee arthroplasty

Managing very distal femoral periprosthetic fracture above a total knee arthroplasty (TKA) is a difficult problem. When a cruciate sacrificing TKA is used, bone stock around the implant is compromised and, therefore, can limit fixation options. We present technique using the revision system femoral stem for the PFC Sigma TKA (Depuy; Leeds, England) to stabilize this particular type of fracture.     

Closed retrograde retrieval of the distal broken segment of femoral cannulated intramedullary nail using a ball-tipped guide wire

Background:

Extracting broken segments of intramedullay nails from long bones can be an operative challenge, particularly from the distal end. We report a case series where a simple and reproducible technique of extracting broken femoral cannulated nails using a ball-tipped guide wire is described. This closed technique involves no additional equipment or instruments.

Materials and Methods:

Eight patients who underwent the described method were included in the study. The technique involves using a standard plain guide wire passed through the cannulated distal broken nail segment after extraction of the proximal nail fragment. The plain guide wire is then advanced distally into the knee joint carefully under fluoroscopy imaging. Over this wire, a 5-millimeter (mm) cannulated large drill bit is used to create a track up to the distal broken nail segment. Through the small knee wound, a ball-tipped guide wire is passed, smooth end first, till the ball engages the end of the nail. The guide wire is then extracted along with the broken nail through the proximal wound.

Results:

The method was successfully used in all eight patients for removal of broken cannulated intramedullary nail from the femoral canal without any complications. All patients underwent exchange nailing with successful bone union in six months. None of the patients had any problems at the knee joint at the final follow-up.

Conclusion:

We report a technique for successful extraction of the distal fragment of broken femoral intramedullary nails without additional surgical approaches.     

关节镜下微创逆行髓内钉治疗股骨髁上骨折

目的评价关节镜下微创逆行髓内钉治疗股骨髁上骨折不愈合的疗效。方法 2003年10月至2008年7月行关节镜下微创逆行髓内钉治疗不愈合的股骨髁上骨折12例,均行自体髂骨植骨。结果随访8~64个月（平均32.4个月）,12例骨折术后复位良好,临床愈合时间6个月,功能满意。HSS评分,优10例,良1例,中1例,优良率91.67%。结论较之于传统内固定及LISS,关节镜下逆行髓内钉治疗不愈合的股骨髁上骨折创伤小,骨折端血运破坏小,愈合率高,恢复快,可显著改善膝关节功能,疗效满意。     

可膨胀髓内钉Fixion系统治疗四肢骨折

目的：可膨胀髓内钉Fixion^TM系统是髓内钉固定理念和技术的革新,本文探讨这一新技术在治疗四肢骨折中的方法和临床效果,以及临床应用过程中的一些体会。方法：自2004年8月至2005年1月,21例骨折病人采用Fixion^TM系统治疗。男16例,女5例,年龄21～75岁。1例为开放伤,3例为骨折不愈合,1例病理性骨折。应用部位为胫骨干5例;股骨干7例;肱骨干4例;股骨近端5例。结果：本组21例伤口全部一期愈合,手术时间35～210min,平均90min。术中出血30～1500ml,平均出血量280ml,术中平均透视4．9次。X线片示股骨干、胫骨干骨折术后4周均有骨痂出现,骨折术后临床和影像学愈合时间为：胫骨干骨折12周,股骨干骨折10周,肱骨骨折12周,股骨近端骨折10周。无感染、脂肪栓塞、深静脉血栓、骨折不愈合、肢体短缩及旋转畸形发生。结论：可膨胀髓内钉根据髓腔解剖特点呈沙漏样固定,应力分布更为均匀;节省了扩髓和锁钉的操作,减少了创伤、手术时间、医生和病人接受的X线剂量和感染率;轴相弹性固定加快了骨折愈合时间。在掌握好适应证和正确操作的前提下,Fixion^TM系统治疗四肢骨干骨折和股骨近端骨折有比传统交锁髓内钉更好的效果,尤其适用于骨质疏松病人的治疗。     

Use of a retrograde femoral nail in a patient with McCune-Albright syndrome

McCune-Albright Syndrome is a rare condition characterized by endocrine abnormalities, precocious puberty, pigmented skin lesions and polyostotic fibrous dysplasia with consequent fractures and limb deformity. Patients with this syndrome might have had multiple operations on a limb and might also have extensive internal fixation in-situ. We review the case of a 41-year-old woman with McCune-Albright syndrome, who presented with a pathological fracture of her left femur below a long plate and screws. Our management of this challenging problem included the use of a retrograde femoral nail, which, because of the need to retain pre-existing internal fixation, had to be locked proximally through a hole in a femoral plate. This technique, combined with reaming, and thus bone grafting of the fracture, and also perioperative infusions of pamidronate, allowed an early recovery and return to premorbid function for the patient. In the present study we detail our technique and discuss its advantages over other possible methods of treatment.     

扩髓带锁髓内钉治疗股骨骨折不愈合24例报告

目的 评价扩髓带锁髓内钉治疗股骨骨折不愈合的临床疗效。方法 1998年9月一2001年12月对24例股骨骨折不愈合患者采用扩髓带锁髓内钉进行治疗，行开放复位、扩髓和植骨。采用X线检查及膝关节活动度对结果进行评价。结果 随访6—28个月，平均12．5个月，所有病例均骨性愈合，愈合时间12—28周，平均22周；无感染、脂肪栓塞综合征、再骨折及断钉等并发症发生。随访膝关节活动度优16例，良6例，可l例，差l例。结论 股骨骨折不愈合的主要原因为内固定方式选择及治疗不当，固定技术不完善。使用扩髓带锁髓内钉治疗股骨骨折不愈合，具有内固定可靠，便于膝关节早期功能锻炼等优点。同时粉碎颗粒状骨移植可促进骨折愈合，临床应用效果满意。     

Treatment of distal femoral nonunion and delayed union by using a retrograde intramedullary interlocking nail

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逆形交锁髓内钉内固定治疗狭部以远股骨干骨折的临床评价

[目的]评价逆行交锁髓内钉（RIIN）内固定治疗狭部以远股骨干骨折的临床疗效。[方法]对1999年10月～2005年1月使用RIIN治疗37例（39肢）狭部以远股骨干骨折的疗效进行回顾性分析，其中开放性骨折8肢，闭合性骨折31例，均行静力固定。[结果]随诊8～24个月，平均15个月。发生浅表感染2肢。39肢均达骨性愈合，骨折愈合时问9-20周，平均15周。无深部感染、畸形愈合、主钉及锁钉断裂等并发症发生。Merchan功能评定优良率94．9％。[结论]RIIN内固定治疗狭部以远股骨干骨折具有良好的生物力学性能，骨折愈合率高且并发症少，严格操作规程和术后早期积极功能锻炼是治疗成功的关键。     

关节镜下逆行带锁髓内钉治疗股骨远端A型骨折疗效探讨

目的: 比较两种内固定治疗股骨远端A型骨折的不同疗效。方法: 1999年 6月~2003年 12月本院共收治股骨远端A型骨折患者 46例, 采用关节镜下逆行带锁髓内钉 (GSH钉 ) 内固定 28例, 采用动力髁螺钉 (DCS)内固定 18例。结果: 术后随访 6~54个月, 平均 18个月。两组在手术时间、术中出血、住院时间、骨折完全愈合时间、关节功能恢复时间有显著性差异 (P<0 .01 )。膝关节功能按Kolment评定标准, 其中髓内钉组优良率 89 .2%;动力髁组优良率 72. 2%。结论: 关节镜引导股骨逆行带锁髓内钉手术时间短、出血少, 最大程度地保留了关节部位解剖与功能的完整性, 不仅对膝关节损伤小, 并可同时发现及处理膝关节内的损伤或病变, 治疗结果优于动力髁螺钉, 值得提倡。     

股骨近端防旋转髓内钉治疗老年股骨粗隆间骨折的疗效分析

目的探讨股骨近端防旋转髓内钉（proximal femoral nail anti-rotation,PFNA）治疗老年股骨粗隆间骨折的临床疗效。方法从2009年6月至2011年6月,采用PFNA治疗老年股骨粗隆间骨折患者82例,记录手术时间、术中出血量等指标,观察骨折的愈合及并发症发生情况,利用Harris评分对患者的功能恢复进行评估。结果手术时间35.0-70.0min,平均（50.7±13.4）min;术中出血100.0-250.0mL,平均（165.5±29.7）mL。随访时间为12-24个月,骨折临床愈合时间12.0-21.0周,平均（15.3±3.6）周。术后有2例患者伤口浅表感染经扩创换药治愈,无褥疮、伤口深部感染或骨髓炎发生。截至末次随访,82例患者骨折全部愈合,无内固定松动及切割现象,无颈干角变小。参照Harris疗效评定标准：优65例,良14例,可3例,优良率96.3%。结论PFNA治疗股骨粗隆骨折操作简单、手术创伤小、固定可靠、并发症少,有利于患者早期负重行走,是治疗老年股骨粗隆间骨折的理想方法。     

非扩髓闭合交锁髓内钉治疗股骨干骨折

目的　观察与分析闭合非扩髓交锁髓内钉技术治疗股骨干骨折的临床疗效与优点。方法　应用闭合非扩髓交锁髓内钉技术治疗新鲜股骨干骨折 2 83例。 2 83例患者均进行了 1次以上随访 ,随访时间为 3个月～ 4年 (平均随访时间 30个月 )。结果　骨折愈合时间 9～ 15周 ,平均 12周。术后3个月时 ,膝关节伸屈活动已与伤前相仿 ,无一例发生感染 ,无患肢疼痛、肿胀或关节僵硬等并发症。2 4例C型骨折中有 3例患肢短缩 1cm ,2例患肢轻度内翻 ,但成角 <7° ,1例交锁髓内钉在远端交锁螺钉孔处发生断裂。结论　闭合非扩髓交锁髓内钉内固定手术创伤小、保留了骨折处的血肿、不剥离骨折周围软组织、较少破坏骨内膜血供 ,为骨折愈合提供了良好的条件。同时 ,可进行早期功能锻炼 ,从而可防止关节肿胀、僵硬等骨折并发症发生 ,是目前治疗股骨干骨折较为理想的方法     

附加钢板治疗髓内钉固定后股骨肥大性骨不连

目的:探讨附加钢板治疗髓内钉固定后股骨肥大性骨不连的安全性和有效性。方法:自1998年4月至2008年6月,应用附加钢板治疗9例髓内钉固定后股骨肥大性骨不连,男8例,女1例;年龄21～54岁,平均32岁。1例为股骨上1/3,5例为股骨中1/3,3例为股骨下1/3。采用4～6孔钛合金限制接触性窄动力接骨板,4～6枚皮质骨螺钉固定。6例骨不连间隙大于5mm,4例采用单纯髂骨植骨,2例固骼生和髂骨混合植骨。3例小于5mm,1例植入固骼生,2例将修整的骨痂重新植入。术后保护性负重防止主钉断裂失效,逐渐恢复术前活动水平,术后1、3、6、12个月临床与影像学随诊。结果:6例取髂骨植骨或固骼生混合植骨患者,手术时间60～120min,出血量100～300ml;另3例单纯植入固骼生或骨痂植入患者,手术时间40～100min,出血量60～100ml。供骨区疼痛4例,3例1个月内缓解,1例3个月后缓解,无感染、钢板螺钉松动、断裂等。平均愈合时间8个月,5例术后6～11个月取出髓内钉和钢板。结论:附加钢板有效改善局部旋转不稳定,是治疗髓内钉固定后股骨肥大性骨不连的有效方法之一。     

带锁髓内钉治疗股骨干骨折合并股骨颈及转子间骨折或转子下粉碎骨折

目的应用带锁髓内钉治疗股骨干骨折合并同侧股骨颈骨折及转子间骨折或转子下粉碎骨折。方法在1996年7月～1998年11月收治的16例复杂股骨骨折中,股骨干骨折合并同侧股骨颈骨折3例,合并转手间骨折4例,转子下粉碎骨折9例。其中10例应用国产加长型Gamma钉,6例使用Russell－Taylor股骨重建钉固定。结果所有病例随访6～22个月,平均11个月。除1例股骨干骨折合并同侧股骨颈骨折患者术后7个月出现股骨头坏死外,其余15例骨折均愈合,平均愈合时间5．5个月,患肢关节功能优良。经此方法治疗后可早期活动关节及功能锻炼、手术创伤小、切口小、固定可靠、骨折愈合率高。结论　　对股骨干骨折合并同侧股骨颈骨折及转手间骨折或转子下粉碎骨折的治疗,带锁髓内钉具有明显优势。     

外固定架辅助髓内钉技术治疗股骨畸形和股骨干骨折不愈合

目的 探讨外固定架辅助髓内钉(fixator assist nailing,FAN)技术治疗股骨畸形、股骨干骨折不愈合伴畸形和畸形愈合的疗效.方法 回顾性分析在2008年1月至2011年12月采用FAN技术治疗8例股骨干骨折不愈合伴畸形、3例维生素D抵抗性佝偻病性股骨畸形、2例股骨干骨折畸形愈合.男11例,女2例;年龄16～50岁,平均33岁.10例采用一期手术,3例采用二期手术.12例采用单边外固定架,1例采用环形外固定架.8例采用顺行髓内钉,5例采用逆行髓内钉.2例患者采用自体髂骨植骨,1例骨痂剪碎后植骨.结果 12例患者获得完整随访,随访时间12～48个月,平均21个月.7例股骨干骨折不愈合的患者骨折在术后3～6个月愈合,平均3.8个月.5例股骨畸形行截骨术的患者截骨端在术后3～5个月(平均3.5个月)愈合.根据Paley评分标准,9例为优,2例为良,1例为可.术前下肢不等长(48.2±23.0) mm,术后为(27.3±24.6) mm,肢体长度增加4.6～41.0 mm(平均23.3 mm).术前机械轴偏向(27.5±24.4) mm,术后(6.3±8.3) mm.未发生感染和神经、血管损伤.结论 FAN技术结合了外固定架安全、微创、便于调节,可准确矫正畸形优点和髓内钉固定患者依从性高特点,可有效地治疗代谢性骨病引起的股骨畸形、股骨干骨折不愈合伴畸形和畸形愈合.     

股骨髁上交锁髓内钉治疗股骨髁上骨折

目的总结股骨髁上交锁髓内钉治疗股骨髁上骨折的疗效.方法对13例股骨髁上交锁髓内钉治疗股骨髁上骨折进行回顾性分析.结果13例均在4～8个月愈合,无交锁钉松动、折弯、断裂情况,患肢膝关节功能恢复满意.结论股骨髁上交锁髓内钉治疗股骨髁上骨折具有骨折复位好、固定坚强、可早期活动关节及骨折愈合率高等优点,是一种较为理想的方法.     

顺行交锁髓内钉在股骨远端骨折的应用

目的探讨髓腔延长顺行交锁髓内钉治疗股骨远端骨折的临床疗效。方法在X线片上测量髁间窝高度,估算髓内钉可达到股骨远端的最远距离,采用髓腔延长顺行交锁髓内钉治疗股骨远端骨折18例。结果18例获8个月~2年的随访,3~4个月后X线片显示骨折愈合。无畸型愈合、无感染、未发现断钉及松动现象。按Merchan功能标准评定:优9例,良6例,可3例。结论髓腔延长顺行交锁髓内钉治疗股骨远端骨折具有创伤小、术中出血少、稳定性好、关节功能恢复快、骨折愈合率高等优点。     

TRIGEN股骨髓内钉在股骨骨折中的应用

目的探讨TRIGEN股骨髓内钉在股骨骨折中的应用效果。方法对54例股骨骨折患者采用TRIGEN股骨髓内钉治疗,记录髓内钉远端锁钉时间、透视次数、一次锁钉成功率及骨折愈合时间。结果54例均获得随访,时间8~36个月。患者骨折均愈合,愈合时间3~14个月。均无伤口感染、血管神经损伤。Sureshot远端瞄准系统远端锁钉时间为142~412 s,一次锁钉成功率为97.2%,透视次数为1~6次。结论TRIGEN股骨髓内钉治疗股骨骨折治疗效果满意,具有损伤小、固定简便、并发症少等优点;Sureshot远端瞄准系统一次锁钉准确率高、操作时间短、放射量小。     

A biomechanical study on flexible intramedullary nails used to treat pediatric femoral fractures

Flexible intramedullary nails have been indicated to treat femoral fractures in pediatric patients. The purpose of this study was to examine the stability of simulated transverse fractures after retrograde intramedullary flexible nail fixation. Various nail diameter combinations were tested using composite femurs in bending, torsion, and a combined axial/bending test where a vertical compressive force was applied to the femoral head. The cross-sectional percent area fill of the nails within the femurs was also determined. In 4 point bending, the greatest repair stiffness was 12% of the intact stiffness. In torsion, the greatest stiffness was 1% of the intact stiffness for either internal or external rotation. The greatest repair stiffness was 80% of the intact stiffness for a compressive load applied to the femoral head. Nail combinations with single nail diameters greater than 40% of the mid-shaft canal width, as measured from an AP radiograph, prevented the fracture from being reduced and left a posterior gap. Flexible intramedullary nails may be of value in the treatment of pediatric femoral fractures, but care must be taken to insert nails that are correctly sized for the canal and to protect the healing fracture from high torsional and bending loads.     

闭合复位交锁髓内钉固定治疗股骨干骨折

目的探讨闭合复位交锁髓内钉治疗股骨干骨折的疗效。方法对32例股骨干骨折应用闭合复位交锁髓内钉治疗，均闭合复位顺行置钉。结果所有患者随访6～26个月，术后复位满意，骨折平均愈合时间12周，术后均愈合良好，无主钉或锁钉断裂，无肢体短缩、功能障碍、感染。结论闭合复位交锁髓内钉是治疗股骨干骨折的一种创伤小、并发症少、骨愈合时间短、术后患者恢复好的内固定方法。