Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
Orthop Traumatol Surg Res. 2010 Oct;96(6):674-82. doi: 10.1016/j.otsr.2010.07.003. Epub 2010 Aug 24.
Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing.
The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures.
From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score.
We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points.
The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table.
Level IV; cohort type prospective study.
髓内钉固定是治疗胫骨骨干骨折的经典方法。稳定胫骨远端四分之一的骨折被认为是精细的。我们报告了一项连续的多中心前瞻性研究，研究对象为采用顺行髓内钉治疗的远端胫骨-腓骨骨折。
工作假说为确定单独使用髓内钉治疗小腿骨折时遇到的问题。
2007 年 5 月至 2008 年 11 月，51 例患者（19 名女性，32 名男性；平均年龄 46.2 岁[范围，17-93 岁]）的 51 处骨折采用髓内钉治疗。骨折根据 Association pour l'Ostéosynthèse（AO）分类进行分类，其中大多数为 A1 型（29/51）。13 处骨折存在关节下延伸，5 例采用螺钉固定。所有病例均采用标准或矫形外科手术台进行髓内钉固定，扩髓。髓内钉固定为静态和远端锁定（50/51）。通过临床和影像学检查（包括双侧下肢的前后位和侧位图像以及 Olerud 评分）对患者进行评估。
我们报告了 1 例死亡和 8 例失访，1 年后有 42 例可供回顾。平均 15.7 周时，骨愈合率为 97.6%。术后即刻，观察到 14 处轴向偏差大于 5°，主要为外展，只有 1 处大于 10°。只有腓骨固定缺失是初始轴向偏差以及随时间推移骨折不稳定的唯一可识别的危险因素。观察到 2 例感染，6 个月时有 4 例继发性移位，其中 1 例可归因于感染导致的远端锁定改变。进行了 4 次动力化。未发现其他危险因素。12 个月时的平均 Olerud 功能评分是 83.5 分。
临床结果与文献报道相似。从影像学角度来看，骨愈合的时间和率是相同的。然而，畸形愈合的发生率明显更高。文献中报道的畸形愈合的危险因素包括干骺端扩大、骨折粉碎、骨折部位过于远端、患者年龄较小、患者在标准手术台上安装以及技术错误。腓骨固定缺失是本研究中唯一具有统计学意义的点，这也是文献中争论的焦点。下肢远端骨折的髓内钉固定可获得良好的临床结果。然而，就畸形愈合率而言，该技术必须精确和严格。我们建议系统地进行腓骨固定，并使用矫形外科手术台。
IV 级；队列型前瞻性研究。
