Chen Chin-En, Ko Jih-Yang, Wang Jun-Wen, Wang Ching-Jen
Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Kaohsiung Memorial Hospital, Kaohsiung Medical Center, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan, Republic of China.
J Trauma. 2003 Aug;55(2):338-44. doi: 10.1097/01.TA.0000035093.56096.3C.
The management of infection after intramedullary nailing of the femoral shaft fracture remains a challenge to orthopedic surgeons. The dilemma confronting surgeons concerns the removal or retention of the nail in the presence of infection.
The authors treated 23 infections after intramedullary nailing for femoral fractures. All fractures were unhealed at presentation. All patients were followed for at least 1 year after the infection. Acute infection occurred in 13 patients, subacute infection in 5, and chronic infection in 5. The patients were divided into two groups on the basis of the method of the initial treatment. In group I (12 patients), the intramedullary nails were retained, and there were 11 men and 1 woman, with an average age of 36 years (range, 15-55 years). In group II (11 patients), the nails were removed at the time of debridement and the fractures were stabilized with external fixation, and there were nine men and two women, with an average age of 44 years (range, 25-69 years).
In group I, all fractures healed within an average period of 9 months (range, 5-15 months) after surgical debridement. There was no recurrence of infection at an average follow-up of 25 months (range, 12-76 months). In group II, seven fractures healed within an average of 10 months (range, 4-24 months) after treatment. At an average follow-up of 33.8 months (range, 12-79 months), infected nonunion was noted in two patients. More complications occurred in group II patients in comparison with group I patients. Limited range of motion of the knee joint was usually encountered if a fracture was stabilized with external fixation for a prolonged period of time.
Retention of the intramedullary nail is performed if the fixation is stable and the infection is under control. External fixation is most suitable for uncontrollable osteomyelitis or infected nonunion. Staged bone grafting is usually necessary when a bone defect is present.
股骨干骨折髓内钉固定术后感染的处理仍然是骨科医生面临的一项挑战。外科医生面临的两难困境在于，在存在感染的情况下，是取出还是保留髓内钉。
作者对23例股骨干骨折髓内钉固定术后感染患者进行了治疗。所有骨折在就诊时均未愈合。所有患者在感染后至少随访1年。13例患者发生急性感染，5例为亚急性感染，5例为慢性感染。根据初始治疗方法将患者分为两组。第一组（12例患者）保留髓内钉，其中男性11例，女性1例，平均年龄36岁（范围15 - 55岁）。第二组（11例患者）在清创时取出髓内钉，骨折采用外固定架固定，其中男性9例，女性2例，平均年龄44岁（范围25 - 69岁）。
第一组，所有骨折在手术清创后平均9个月（范围5 - 15个月）内愈合。平均随访25个月（范围12 - 76个月）时感染无复发。第二组，7例骨折在治疗后平均10个月（范围4 - 24个月）内愈合。平均随访33.8个月（范围12 - 79个月）时，2例患者出现感染性骨不连。与第一组患者相比，第二组患者发生的并发症更多。如果长时间采用外固定架固定骨折，通常会出现膝关节活动范围受限。
如果固定稳定且感染得到控制，则保留髓内钉。外固定最适合于无法控制的骨髓炎或感染性骨不连。存在骨缺损时通常需要分期植骨。
