芯钻髓内钉治疗股骨干闭合骨折的并发症防治

目的:总结芯钻髓内钉治疗闭合股骨干骨折的并发症,并探讨其处理策略。方法:2014年8月至2018年6月,215例股骨干闭合骨折患者采用闭合复位芯钻髓内钉内固定,男129例,女86例;年龄18～62(44.2±10.6)岁;受伤到手术时间3～21 d。其中102例A型骨折,82例B型骨折,31例C型骨折。记录手术时间、术中出血量、住院时间、骨折愈合时间及末次随访膝关节功能HSS评分。并发症观察包括:术中医源性骨折,芯钻断裂,芯钻打卷,术后感染和骨折不愈合等。结果:患者手术时间为(63.2±15.6) min,术中出血量为(150.0±34.5) ml。手术切口均达甲级愈合,所有患者获得随访,时间(18.5±3.2)个月,住院时间(4.3±1.2) d,骨折愈合时间(5.6±2.3)个月。末次随访时膝关节HSS评分90.3±4.7。发生相关并发症37例,发生率为17.2%。其中芯钻相关并发症13例(6.0%),包括芯钻断裂5例(2.3%),采用远端切开取出断裂芯钻1例,股骨开槽取出4例;芯钻打卷8例(3.7%),远端切开剪断内芯,完整取出,改徒手置钉。常规髓内钉类似的并发症:术中医源性骨折12例(5.6%):骨折端劈裂10例,髓内钉远端周围骨折2例。骨折端发生劈裂患者判断其稳定性良好未行处理,远端周围骨折患者术中辅助钢板固定;术后迟发性感染1例(0.4%),清创更换外固定并进行骨搬移后愈合;骨折不愈合11例(5.1%),其中肥大型骨不连7例(3.3%),采用附加钢板后愈合;萎缩性骨不连4例(1.9%),附加钢板加植骨后愈合。结论:芯钻髓内钉治疗股骨干闭合骨折临床疗效佳,并发症包括芯钻相关的并发症及常规髓内钉类似的并发症,精确术前评估、术中仔细操作及术后尽早对症处理可有效降低相关并发症的发生。

Prevention and treatment of complications in the treatment of femoral shaft closed fracture with core drilling intramedullary nail

Objective: To summarize the complications of core drilling intramedullary nail in the treatment of femoral shaft closed fracture and explore the treatment strategy.Methods: From August 2014 to June 2018,a total of 215 patients with closed femoral shaft fractures were treated with closed reduction core drill intramedullary nail,including 129 males and 86 females,aged from 18 to 62 years,with an average of (44.2±10.6) years old. The time from injury to operation was 3 to 21 days. There were 102 cases of AO type A fracture,82 cases of AO type B fracture and 31 cases of AO type C fracture. The time of operation,the amount of blood loss during operation,the duration of hospitalization,the time of fracture healing and the HSS score of knee joint function at the last follow-up were recorded. The observation of complications included:iatrogenic fracture,core drill broken,core drill twist,postoperative infection,and fracture nonunion.Results: The average operation time was (63.2±15.6) min and intraoperative blood loss was (150.0±34.5) ml. All the incisions reached grade A healing. Patients were follow-up for a mean of (18.5±3.2) months,the average hospital stay was (4.3±1.2) days,and the average fracture healing time was (5.6±2.3) months. At the final follow-up,the average HSS score of knee joint was 90.3±4.7. Related complications occurred in 37 cases(17.2%). The core drill related complications occurred in 13 cases(6.0%),including core drill broken in 5 cases(2.3%),core removal in 1 case and slotting in 4 cases;core drill twist in 8 cases(3.7%). After the core was cut,the core was removed. Similar complications of conventional intramedullary nail:iatrogenic fracture was performed in 12 cases(5.6%),including 10 cases of fracture end split and 2 cases of distal perimedullary fracture of intramedullary nail. The patients with cleavage at the fracture end were not treated after judging their stability,and the patients with fracture around the distal end of the intramedullary nail were fixed with auxiliary steel plate during operation;1 case(0.4%) with delayed infection after operation,debridement and external fixation was replaced and healed after bone transfer; fracture nonunion occurred in 11 cases (5.1%),of which 7 cases (3.3%) were hypertrophic nonunion and healed with additional plate. Atrophic nonunion occurred in 4 cases (1.9%),which healed after additional steel plate and bone graft.Conclusion: Core drilling intramedullary nail is an effective method for the treatment of closed femoral shaft fracture,and the complications include core drill related complications and conventional intramedullary nail similar complications. Accurate preoperative evaluation,careful operation during operation and early postoperative symptomatic treatment can effectively reduce the occurrence of related complications.