Biber R, Bail H J
Universitätsklinik für Unfall- und Orthopädische Chirurgie, Paracelsus Medizinische Privatuniversität , Breslauer Str. 201, 90471, Nürnberg, Deutschland,
Oper Orthop Traumatol. 2014 Oct;26(5):438-54. doi: 10.1007/s00064-014-0303-6. Epub 2014 Sep 13.
Intramedullary stabilization of periprosthetic distal femoral fractures by interlocking nailing. Closed reduction by retrograde nail can be combined with the use of transmedullary support screws (TMS principle of Stedtfeld).
Supracondylar fractures above stable knee arthroplasty (Rorabeck types I and II), femoral shaft fractures ipsilateral of stable hip and/or knee arthroplasty, contraindications for antegrade nailing
Closed box design of femoral implant, intercondylar distance of the femoral component smaller than nail diameter, more than 40° flexion deficit of the knee, inability to place two bicortical distal interlocking screws. Relative contraindication: insufficient overlap with proximal implants
Supine position and knee flexion of approximately 45°. Fluoroscopy should be possible between the knee and hip. Longitudinal skin incision into the pre-existing scar over the patellar tendon which is then split. The nail entry point is located in the intercondylar groove at the deepest point of Blumensaat's line, often predetermined by the femoral arthroplasty component. Reaming is rarely necessary. Transmedullary support screws may correct axial malalignment during nail insertion. Static interlocking in a direction from lateral to medial by the aiming device. Insertion of locking cap.
Retrograde nailing normally allows full weight bearing. Range of motion does not need to be restricted.
Out of 101 fractures treated between 2000 and 2013 with a Targon RF nail (Aesculap, Tuttlingen, Germany) 10 were periprosthetic, all were classified as Rorabeck type II and of these 6 fractures were metaphyseal and 4 were diaphyseal. In four cases proximal implants were present. The mean operative time for periprosthetic fracture fixation did not significantly differ from that for normal retrograde femoral nailing. There were no postoperative infections, fixation failures or delayed unions. There was one revision for secondary correction of maltorsion.
通过交锁髓内钉对人工关节周围股骨远端骨折进行髓内固定。逆行髓内钉闭合复位可结合使用经髓内支撑螺钉（施泰德费尔德的经髓内支撑螺钉原则）。
稳定膝关节置换术上方的髁上骨折（罗雷贝克I型和II型）、稳定髋关节和/或膝关节置换术同侧的股骨干骨折、顺行髓内钉的禁忌证
股骨假体的封闭盒设计、股骨部件的髁间距离小于髓内钉直径、膝关节屈曲畸形超过40°、无法置入两枚双皮质远端交锁螺钉。相对禁忌证：与近端假体的重叠不足
仰卧位，膝关节屈曲约45°。应能在膝关节和髋关节之间进行透视。沿髌腱上方原有的瘢痕做纵向皮肤切口，然后将髌腱劈开。髓内钉进针点位于布鲁门萨特线最深点的髁间沟内，通常由股骨置换部件预先确定。很少需要扩髓。经髓内支撑螺钉可在插入髓内钉时纠正轴向畸形。通过瞄准装置从外侧向内侧进行静态交锁。插入锁定帽。
逆行髓内钉固定通常允许完全负重。无需限制活动范围。
2000年至2013年间，使用Targon RF髓内钉（德国图特林根的蛇牌公司）治疗的101例骨折中，有10例为人工关节周围骨折，均分类为罗雷贝克II型，其中6例骨折为干骺端骨折，4例为骨干骨折。4例存在近端假体。人工关节周围骨折固定的平均手术时间与正常逆行股骨髓内钉固定的平均手术时间无显著差异。无术后感染、固定失败或延迟愈合。有1例因继发畸形矫正而进行翻修。
