El Attal R, Hansen M, Rosenberger R, Smekal V, Rommens P M, Blauth M
Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
Oper Orthop Traumatol. 2011 Dec;23(5):397-410. doi: 10.1007/s00064-011-0071-5.
Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare and to maintain joint mobility. Good bony healing in closed and open fractures.
Closed and open fractures of the tibia and complete lower leg fractures distal to the isthmus (AO 42), extraarticular fractures of the distal tibia (AO 43 A1/A2/A3), segmental fractures of the tibia with a fracture in the distal tibia, and certain intraarticular fractures of the distal tibia without impression of the joint line with the use of additional implants (AO 43 C1)
Patient in reduced general condition (e.g., bed ridden), flexion of the knee of less than 90°, patients with knee arthroplasty of the affected leg, infection in the area of the nail's insertion, infection of the tibial cavity, complex articular fractures of the proximal or distal tibia with joint depression.
Closed reduction of the fracture preferably on a fracture table or using a distractor or an external fixation frame. If necessary, use pointed reduction clamps or sterile drapery. In some cases, additional implants like percutaneous small fragment screws, poller screws or k-wires are helpful. Open reduction is rarely necessary and must be avoided. Opening of the proximal tibia in line with the medullary canal. Canulated insertion of the Expert(TM) tibia nail (ETN; Synthes GmbH, Oberdorf, Switzerland) with reaming of the medullary canal. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device.
Immediate mobilization of ankle and knee joint. Mobilization with 20 kg weight-bearing with crutches. X-ray control 6 weeks postoperatively and increased weight-bearing depending on the fracture status. In cases with simple fractures, good bony contact, or transverse fracture pattern, full weight-bearing at the end of week 6 is targeted.
Between July 2004 and May 2005, 180 patients were included in a multicenter study. The follow-up rate was 81% after 1 year. Of these, 91 fractures (50.6%) were located in the distal third of the tibia. In this segment, the rate of delayed union was 10.6%. Malalignment of > 5° was observed in 5.4%. A secondary malalignment after initial good reduction was detected in only 1.1% of all cases. The implant-specific risk for screw breakage was 3.2%. One patient sustained a deep infection. If additional fibula plating was performed an 8-fold higher risk for delayed bone healing was observed (95%CI: 2.9-21.2, p< 0.001). If the fracture of the fibula was at the same height as on the tibia, the risk for delayed healing was even 14-fold (95% CI: 3.4-62.5, p< 0.001). Biomechanically plating of the fibula does not increase stability in suprasyndesmal distal tibia-fibular fractures treated with an intramedullary nail. Using the ETN with its optimized locking options, fibula plating is not recommended, thus, avoiding soft tissue problems and potentially delayed bone healing.
恢复小腿的轴线、长度和旋转。实现骨合成的足够初始稳定性，以利于功能后续护理并保持关节活动度。实现闭合性和开放性骨折的良好骨愈合。
胫骨的闭合性和开放性骨折以及峡部远端的小腿完全骨折（AO 42）、胫骨远端的关节外骨折（AO 43 A1/A2/A3）、胫骨节段性骨折且胫骨远端有骨折，以及使用额外植入物的某些胫骨远端关节内骨折且关节线无凹陷（AO 43 C1）
全身状况较差的患者（如卧床不起）、膝关节屈曲小于90°、患侧腿进行过膝关节置换术的患者、髓内钉插入部位感染、胫骨髓腔感染、胫骨近端或远端伴有关节凹陷的复杂关节骨折。
骨折的闭合复位，最好在骨折手术台上进行，或使用牵引器或外固定架。必要时，使用点状复位钳或无菌布单。在某些情况下，额外的植入物如经皮小碎片螺钉、拨钉器螺钉或克氏针会有帮助。很少需要切开复位，必须避免。沿髓腔方向打开胫骨近端。使用带髓腔扩髓的Expert™胫骨钉（ETN；Synthes GmbH，瑞士奥伯多夫）进行空心插入。控制轴线、长度和旋转。使用射线可透过的钻头进行远端锁定，并使用瞄准装置进行近端锁定。
立即活动踝关节和膝关节。使用拐杖进行20公斤负重活动。术后6周进行X线检查，并根据骨折情况增加负重。对于简单骨折、骨接触良好或横行骨折模式的病例，目标是在第6周结束时完全负重。
在2004年7月至2005年5月期间，180名患者纳入了一项多中心研究。1年后的随访率为81%。其中，91处骨折（50.6%）位于胫骨远端三分之一处。在该节段，延迟愈合率为10.6%。观察到5.4%的病例存在>5°的对线不良。在所有病例中，仅1.1%的病例在初始良好复位后出现二次对线不良。植入物特定的螺钉断裂风险为3.2%。1名患者发生深部感染。如果进行了额外的腓骨钢板固定，观察到延迟骨愈合的风险高8倍（95%CI：2.9 - 21.2，p<0.001）。如果腓骨骨折与胫骨骨折在同一高度，延迟愈合的风险甚至高14倍（95%CI：3.4 - 62.5，p<0.001）。在使用髓内钉治疗的胫腓骨远端联合上方骨折中，对腓骨进行生物力学钢板固定不会增加稳定性。使用具有优化锁定选项的ETN，不建议进行腓骨钢板固定，从而避免软组织问题和潜在的延迟骨愈合。
