带锁髓内针治疗下肢长骨骨不连52例临床分析/

2019-05-11 07:05:03

骨折 fracture cases 髓内 nail



下肢股骨,胫骨骨折是常见的骨折,其中股骨骨折占全部骨折总量的6%,胫骨骨折占13.7%。由于它们血供特点,功能特点,骨不连是股骨、胫骨骨折术后常见的并发症,据统计,骨不连发生率约占8%-10%。往往需要再次手术治疗。自从1940年Kuntscher介绍髓内针术,创立了髓内夹板的生物力学原则以来,髓内针技术取得了长足的发展,特别是20世纪70年代带锁髓内针的出现,增加了锁钉,具有抗旋转及抗压缩能力。在20世纪70年代中期就有髓内针治疗长骨骨干骨不连的成功报道。随着髓内针技术的发展,髓内针设计更加合理,材料质量的提高,特别是扩髓带锁髓内针,可以提供稳定而且顺应骨折愈合机理的固定,使用其治疗下肢股骨、胫骨骨不连被越来越多的学者接受。
目的:
2000年1月至2005年10月本院自使用扩髓带锁髓内针治疗股骨、胫骨骨不连病人52例。通过对这些病例进行回顾性分析。来探讨使用扩髓带锁髓内针治疗股骨、胫骨骨不连的临床治疗效果,以及术前、术中、术后的注意事项及处理方法。
方法:
选择吉林大学中日联谊医院自2000年1月至2005年10月应用扩髓带锁髓内针治疗股骨、胫骨骨不连患者52例,男性45例,女性7例。年龄24-61岁,平均35.6岁。股骨25例,胫骨27例。原固定方式:钢板内固定术后29例,髓内针固定16例,外固定架4 例,石膏固定3例。按X线分型:肥大性骨不连22例,骨端正常型骨不连15例,骨端萎缩型15例。根据AO分型,A型15例,B型16例,C型21例。首次术前为开放骨折的有24例,按照Gustilo分型,I型6例,II型8例,III型10例。患者受伤或上次手术距本次手术时间9-26个月,平均13.7个月。本次手术均采用有限切口切开复位,扩髓,静力锁定加植骨术。
结果:
手术切口均一期愈合,住院时间21-32天,平均24天。术后平均随访21.3个月,(4-56个月)。51均达到骨折愈合,愈合率98.1%,平均愈合时间6.1个月。(2.5-11.5个月)。骨折愈合标准:X线片显示连续骨痂通过骨折线,骨折局部无疼痛及压痛,无纵向扣击痛,能够全部负重。其中一例因术后过早下地负重,导致锁钉断裂,手术更换锁钉后,4个月后骨折愈合。所有病例均未发生深部感染、未发生皮肤坏死,骨筋膜综合症,无主钉折弯、断裂,无骨折畸形愈合、肢体短缩等并发症,关节功能及下肢功能较术前有较明显改善。根据Kolment评定标准,膝关节功能优良率94.2%。
结论:
应用带锁扩髓髓内针治疗股骨、胫骨骨不连,有较明显的优点,(1)带锁髓内针具有良好的生物学特性,在骨组织与针体之间提供均匀的应力分布,有良好的抗旋转、抗压缩作用,保持骨折端的稳定性,同时可保证肢体长度,防止肢体短缩。(2)带锁髓内针为中轴固定,不存在应力遮挡作用。符合生物学固定原理。(3)扩髓后,使髓腔内径与髓内针更加适应,同时放入直径更大的髓内针,增加髓腔与髓内针的接触面积并提高了髓内针的强度,为骨折端提供了更好的稳定性。(4)扩髓是一种新的组织损伤,其产生的生物刺激效应能使机体释放大量促骨折愈合的生物因子,刺激骨痂的生长,促进骨折愈合。(5)扩髓产生的骨屑与纤维组织组成的混合物,起到内植骨的作用。(6)使用髓内针固定,可早期进行功能锻炼,可避免关节僵硬、骨质疏松、肌肉废用性萎缩等并发症。

关键词: 长骨,骨不连,植骨,带锁髓内针,扩髓



Objective:
We evaluated the effectiveness of nonunion of femoral or tibial shaft fracture treated with reamed intramedullary interlocking nail by reviewing 52 cases from January 2000 to October 2005.And to approach the indication, methods and announcement and treatment before operation, during operation and after operation.
Document and Metheds:
The 52 patients with nonunion of femoral or tibial shaft fracture dealt with reamed intramedullary interlocking nail were selected since January 2000 to October 2005 in the China-Japan Union hospital of Jinlin Universicity.. there are 45 males and 7 females in the cases. The age is between 24 to 61 and the average age is 35.6. 25 cases of femoral femoral shaft fracture and 27 cases of tibial are selected. In primary treatment, 29 cases were fixed by plate, 16 cases were fixed by intramedullary nail, 4 cases were fixed by external fixator, 3 cases were fixed by plaster. The cases are classifacted by X ray, hypertrophic nonunion,22 cases, atrophic nonunion,15 cases, malnourished nonunion,15 cases. According to AO type, A type has 12 cases, B type has 17 cases, C type has 23 cases. The open fracture are typed with Gustilo, I type has 7 cases, II type has 17 cases, III type has 23 cases. The last operations are 9-26 months ago, average 13.7 months. All cases were treated by a limited open reduction, fixation of reamed intramedullary interlocking nail and bone graft.
Conclusion:
All the operative incisions were primary healing, the length of stay was 21-32 days, average 24 days. All cases were followed –up for average of 21.3 months, ranging from 4 to 56 months. 51 cases healed up well within 11.5 months, average 6.1 months.,the rate of healing is 98.1%. The standard of union of fracture: X-ray display bony callus pass the fracture line, the region of fracture don’t feel pain and tendemess, and the pain of length wise beating, the patients can weight loading in full. The lockpin of one case disrupted for prematuritily weight loading. We change the lockpin, found union of fracture after 4 months. All the cases did not found the complications of deep part infection, necrosis of skin, syndrome of bone anadesma, bending or breakage of lockpin, malunion, limb shortening, and so on. The function of article and lower limb manifest improved to compare with preoperative. With the standard of Kolment , the rate of fineness of the function of knee joint was 94.2%.
Conclusion:
To treat nonunion of femoral or tibial shaft fracture with reamed intramedullary interlocking nail has apparente merit. (1)Interlocking nail has good bionomics, it can give aequalis stress distribution between bone tissue and nail body, has good effect of anti-screw and anti-compression,and it can remain the stability of bone fracture, the length of the limbs. (2)Interlocking nail is central axis fixation, has not effect of stress dodge, is coincidence with the principle of biology. (3)After reamed, the inner diameter of cavum medullare accommodate with nail better, the nail of bigger diameter can be put in. it add the contact surface between the cavum medullare and nail, increase the intensity, offer the better stability of the fracture. (4)The reamed intramedullary nail cause the new tissue damage, the biostimulation make the organism release generous catagmatic biological factors. The factors make the bony callus develop well, encourage the union of fracture. (5)The mixture of bone and fibrous tissue which is made by reamed intramedullary nail has the effect of reamed intramedullary bone graft. (6)With the fixation of intramedullary nail, the patients can do the functional exercise in earlier period, avoid the complication ,such as stiffness of joint, bone rarefaction atrophy of disuse, and so on.


Key words: long bone; nonunion; bone graft;
intramedullary interlocking nail; reamed