Hansen Matthias, El Attal René, Blum Jochen, Blauth Michael, Rommens Pol Maria
Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum Worms, Worms, Germany.
Oper Orthop Traumatol. 2009 Dec;21(6):620-35. doi: 10.1007/s00064-009-2010-2.
Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare. Early functional aftercare to maintain joint mobility. Good bony healing in closed and open fractures.
All closed and open fractures of the tibia and complete lower leg fractures (AO 42). Certain extraarticular fractures of the proximal and distal tibia (AO 41 A2/A3; AO 43 A1/A2/A3). Segmental fractures of the tibia. Certain intraarticular fractures of the tibia with use of additional implants (AO 41 C1/C2; AO 43 C1/C2). Stabilization during and after segmental bone transport or callus distraction of the tibia.
Patients in poor general condition (e.g., bedridden). Flexion of the knee of less than 90 degrees . Infection in the nail's insertion area. Infection of the tibial cavity. Complex articular fractures of the proximal or distal tibia with joint depression.
Closed reduction of the fracture. If necessary, use of reduction clamps through additional stab incisions or open surgical procedures. In some cases, additional osteosynthesis procedures are necessary (e.g., screws). Positioning of the patient may be performed on a radiolucent table or a traction table. Opening of the proximal tibia in line with the medullary canal. Cannulated or noncannulated insertion of the Expert Tibia Nail((R)) with or without reaming of the medullary canal depending on the fracture type and soft-tissue condition. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device.
Immediate mobilization of ankle joint and knee joint. Depending on the type of fracture, mobilization with 20 kg partial weight bearing or pain-dependent full weight bearing with crutches. X-ray control 6 weeks postoperatively and increased weight bearing depending on the fracture status.
In a prospective, international multicentric study, 181 patients with 186 fractures were included between July 2004 and May 2005. 57 of these fractures (30.7%) initially were graded open, 15 of them grade I, 32 grade II, and ten grade III. Most of the fractures (36%) were shaft fractures. After 1 year, 146 patients (81%) could be evaluated clinically and radiologically. The overall pseudarthrosis rate was 12.2% (18.2% for open and 9.7% for closed fractures). The risk for secondary operations or revisions (including dynamization of the nail) was 18.8%. Without consideration of dynamization procedures, revisions were necessary in only 5.4% of all patients. The risk for varus, valgus or antecurvation malalignment of more than 5 degrees in any plane on radiologic long leg views was 4.3% for shaft fractures, 1.5% for distal fractures, and 13.6% for proximal fractures. The implant-specific risk for bolt breakage was 3.2%.
恢复小腿的轴线、长度和旋转。实现骨折固定的足够初始稳定性以利于功能康复。尽早进行功能康复以维持关节活动度。实现闭合性和开放性骨折的良好骨愈合。
所有胫骨闭合性和开放性骨折以及小腿完全骨折（AO 42）。胫骨近端和远端某些关节外骨折（AO 41 A2/A3；AO 43 A1/A2/A3）。胫骨节段性骨折。胫骨某些关节内骨折需使用额外植入物（AO 41 C1/C2；AO 43 C1/C2）。胫骨节段性骨搬运或骨痂牵张过程中和之后的稳定。
一般状况较差的患者（如卧床不起者）。膝关节屈曲小于90度。髓内钉插入区域感染。胫骨髓腔感染。胫骨近端或远端复杂关节内骨折伴有关节凹陷。
骨折闭合复位。必要时，通过额外的小切口或开放手术操作使用复位夹。在某些情况下，需要额外的骨折固定手术（如螺钉）。患者体位可在射线可穿透手术台或牵引台上进行。沿髓腔方向打开胫骨近端。根据骨折类型和软组织状况，带锁或不带锁插入Expert Tibia Nail((R))髓内钉，髓腔可扩髓或不扩髓。控制轴线、长度和旋转。使用射线可穿透钻头进行远端交锁，使用瞄准装置进行近端交锁。
立即活动踝关节和膝关节。根据骨折类型，可进行20 kg部分负重活动或根据疼痛情况使用拐杖完全负重活动。术后6周进行X线检查，并根据骨折情况增加负重。
在一项前瞻性国际多中心研究中，2004年7月至2005年5月纳入了181例患者的186处骨折。其中57处骨折（30.7%）最初为开放性骨折，15处为I级，32处为II级，10处为III级。大多数骨折（36%）为骨干骨折。1年后，146例患者（81%）可进行临床和影像学评估。总体骨不连发生率为12.2%（开放性骨折为18.2%，闭合性骨折为9.7%）。二次手术或翻修（包括髓内钉动力化）的风险为18.8%。不考虑动力化操作，仅5.4%的所有患者需要翻修。在放射学长腿片上，任何平面内成角畸形（内翻、外翻或前弯）超过5度的风险，骨干骨折为4.3%，远端骨折为1.5%，近端骨折为13.6%。特定植入物的螺钉断裂风险为3.2%。
