Bonnevialle P, Cauhepe C, Alqoh F, Bellumore Y, Rongières M, Mansat M
Service d'Orthopédie-Traumatologie, Hôpital Purpan, place Dr. Baylac, 31059 Toulouse Cedex.
Rev Chir Orthop Reparatrice Appar Mot. 2000 Oct;86(6):598-607.
A retrospective series of 40 patients who underwent simultaneous intramedullary nailings for bilateral femoral shaft fractures was analyzed. The aim of our study was to verify that simultaneous nailing without reaming does not increased risk of fat embolism and to assess clinical and radiological outcome.
This series included 27 men and 13 women, mean age 27.8 years, who underwent first intention intramedullary nailing between 1986 and February 1999. Thirty-two patients had multiple fractures. Mean ISS was 23 (range 9 to 59). Among the 80 femoral shaft fractures, 15 were open fractures, 3 were associated with sciatic paralysis, and 4 were complicated by an interruption of the femoral vessels. The AO classification was: type A=44; type B=25; type C=11. Mean delay to simultaneous centromedullary nailing was 3. 8 days: surgery was performed on the day of arrival for 25 patients. General anesthesia was used in all cases with respiratory assistance (FIO(2) =50 to 100 p. 100). Mean nail diameter was 11.6 (range 10-14). Gurd criteria and PaO(2) were followed to assess pulmonary function. Clinical and radiological outcome was assessed using the modified Thorensen criteria.
Preoperatively, PaO(2) was< 87 mmHg in 8 patients. Four of these patients showed a discrete drop off and three improved well above the normal level. Only one patient experienced an important decrease but did not develop respiratory distress. Among the 32 patients with a normal level preoperatively, PaO(2) remained in the normal range in 18, fell to a limit level but below 87 mmHg in 4, and showed a substantial drop off of 46 to 172 mmHg in 10. Two of these 10 patients developed respiratory distress due to fat embolism which was fatal in one case. One other patient died in the immediate postoperative period of an undetermined cause. All of the other patients recovered normal gas levels within a few hours or days. There were four cases of phlebitis, including one with pulmonary embolism, one case of respiratory distress by pulmonary superinfection, and one case of septicemia. Both femoral fracture sites became infected in one patient. Malunion occurred in two cases. Two vascular repairs of the femoropopliteal axis were unsuccessful, leading to above knee amputations. Thirty-four patients have been examined after a minimal 12 months follow-up (mean 30 months). Outcome was excellent for 48 femurs, good for 10 and fair for 10.
This continuous series of simultaneous bilateral femoral shaft intramedullary nailings appears to be the only such report to date. The clinical and radiological outcomes were comparable with those achieved in one-side femoral fractures. The risk of fat embolism is inevitable after long bone fractures. Many factors favoring the risk are recognized, the most important being delay to fixation. Reaming creates excessive pressure in the medullary canal and could thus contribute to the risk. The presence of an associated chest trauma is not a formal contraindication if effective hematosis is preserved as evidenced by the blood gases.
Simultaneous nailing of bilateral femoral shaft fractures can be performed if blood gases remain acceptable and minimal reaming is used.
对40例同时行双侧股骨干骨折髓内钉固定术的患者进行回顾性分析。本研究的目的是证实不扩髓的同时固定不会增加脂肪栓塞的风险，并评估临床和影像学结果。
该系列包括27例男性和13例女性，平均年龄27.8岁，于1986年至1999年2月接受一期髓内钉固定术。32例患者为多发骨折。平均损伤严重度评分（ISS）为23分（范围9至59分）。在80个股骨干骨折中，15例为开放性骨折，3例伴有坐骨神经麻痹，4例合并股血管中断。AO分类为：A型 = 44例；B型 = 25例；C型 = 11例。同时行中心髓内钉固定的平均延迟时间为3.8天：25例患者在入院当天进行手术。所有病例均采用全身麻醉并辅以呼吸支持（吸入氧浓度（FIO₂）= 50%至100%）。平均钉直径为11.6（范围10至14）。采用Gurd标准和动脉血氧分压（PaO₂）评估肺功能。使用改良的Thorensen标准评估临床和影像学结果。
术前，8例患者的PaO₂< 87 mmHg。其中4例患者PaO₂有轻微下降，3例改善至正常水平以上。仅1例患者出现显著下降，但未发生呼吸窘迫。在术前PaO₂水平正常的32例患者中，18例患者的PaO₂维持在正常范围内，4例降至临界水平但低于87 mmHg，10例患者的PaO₂大幅下降46至172 mmHg。这10例患者中有2例因脂肪栓塞发生呼吸窘迫，其中1例死亡。另1例患者在术后即刻因不明原因死亡。所有其他患者在数小时或数天内恢复正常气体水平。发生4例静脉炎，包括1例合并肺栓塞，1例因肺部感染导致呼吸窘迫，1例败血症。1例患者双侧股骨骨折部位均发生感染。2例发生骨不连。2例股腘血管修复术失败，导致膝上截肢。34例患者在至少12个月（平均30个月）的随访后接受检查。48个股骨的结果为优，10个股骨为良，10个股骨为可。
这一连续的双侧股骨干同时髓内钉固定系列似乎是迄今为止唯一的此类报告。临床和影像学结果与单侧股骨干骨折的结果相当。长骨骨折后脂肪栓塞的风险是不可避免的。许多增加风险的因素已被认识到，其中最重要的是固定延迟。扩髓会在髓腔内产生过高压力，因此可能增加风险。如果血气显示有效的血液灌注得以维持，合并胸部创伤并非绝对禁忌证。
如果血气仍可接受且采用最小限度的扩髓，双侧股骨干骨折可同时进行固定。
