Selvakumar K, Saw K Y, Fathima M
Med J Malaysia. 2001 Dec;56 Suppl D:24-8.
Intramedullary nailing is an accepted procedures for femoral fractures gives uniformly good results. Various methods of intramedullary fixation have been practiced in the past. Recently intramedullary fixation without reaming has come into vogue. Preservation of the endosteal blood supply, less blood loss and quicker union have been the alleged benefits of not reaming the medullary canal. This study is a prospective randomised study conducted to compare intramedullary nail fixation of closed femoral fractures with and without a reaming procedure to assess the validity of the above assumptions. One hundred and two consecutive cases of skeletally mature patients with closed fracture of femoral shaft were randomised into two groups, i.e. Reamed (52) and Unreamed (50). The average follow-up was 36 weeks (range 28-86 weeks). Average time taken for various stages of the operation and total operating time were longer in the reamed group (109.9 min vs 78.6 min) and the blood loss was also increased (320 mls vs. 190 mls). Bridging and callus formation were seen to occur earlier in the reamed group compared to the unreamed enabling the patients in the reamed group to return to normal functions earlier. Limb length discrepancy and rotational alignment measured clinically and with CT scan did not however show any significant difference between the two methods. Nails used in this study group were notably of a smaller diameter and of shorter length when compared to those used in the western population highlighting the difference in the femur in the Asian population. Complications were notably more in the unreamed group where these were screw breakage (3/50) delayed unions (9/50) and non-unions (4/50). In the reamed group however there were only delayed union (2/50) and all fractures eventually united without any implant failure. We conclude that closed, reamed, antegrade insertion of an intramedullary nail is the treatment of choice in femoral shaft fractures, especially those involving the distal 1/3. The unreamed procedure should be reserved for certain exceptions, such as in polytrauma, where a shorter operative time and less blood loss is desired.
髓内钉固定术是治疗股骨骨折的一种公认方法，效果普遍良好。过去曾采用过多种髓内固定方法。近来，不扩髓的髓内固定术开始流行。保留骨内膜血供、减少失血和更快愈合被认为是不扩髓髓腔的好处。本研究是一项前瞻性随机研究，旨在比较闭合性股骨干骨折行扩髓与不扩髓髓内钉固定术，以评估上述假设的有效性。102例连续的骨骼成熟的股骨干闭合性骨折患者被随机分为两组，即扩髓组（52例）和不扩髓组（50例）。平均随访36周（范围28 - 86周）。扩髓组手术各阶段的平均时间和总手术时间更长（109.9分钟对78.6分钟），失血量也增加（320毫升对190毫升）。与不扩髓组相比，扩髓组的桥接和骨痂形成更早，使扩髓组患者能更早恢复正常功能。然而，临床测量及CT扫描的肢体长度差异和旋转对线在两种方法之间未显示出任何显著差异。与西方人群使用的髓内钉相比，本研究组使用的髓内钉直径明显更小、长度更短，突出了亚洲人群股骨的差异。不扩髓组的并发症明显更多，包括螺钉断裂（3/50）、延迟愈合（9/50）和不愈合（4/50）。然而，扩髓组仅有延迟愈合（2/50），所有骨折最终均愈合，无任何植入物失败。我们得出结论，闭合性、扩髓、顺行插入髓内钉是股骨干骨折尤其是累及远端1/3骨折的首选治疗方法。不扩髓手术应保留用于某些特殊情况，如多发伤，此时需要较短的手术时间和较少的失血量。
