Vetter S Y, Keil C, von Recum J, Wendl K, Grützner P A, Franke J
MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Unfallchirurgische Klinik an der Ruprecht-Karls-Universität Heidelberg.
Z Orthop Unfall. 2014 Oct;152(5):498-503. doi: 10.1055/s-0034-1383011. Epub 2014 Oct 14.
Minimally invasive treatment of diaphyseal femur fractures (DFF) with closed reduction and intramedullary nailing is a well established procedure. However, a femoral malrotation after intramedullary nailing is considered to be a substantial problem. Studies have described femoral malrotation (FMR) in 17-35 % after this procedure. Computed tomography (CT) of both femora is accepted as an objective, reproducible measurement method to determine a postoperative femoral malrotation. An anatomic reposition of the centreline of the femur remains of high importance since a malrotation > 15° can lead to a significant limitation of the range of motion (ROM) and to clinical symptomatic constraints.
PATIENTS/MATERIAL AND METHODS: Between July 2007 and December 2011 patients with unilateral DFF were treated with closed reduction and intramedullary nailing. Exclusion criteria were defined as bilateral or prior treatment for femoral fractures, open epihyseal plate or pregnancy. In all cases a postoperative CT scan of the femora was conducted to analyse a femoral malrotation. The indication for a correction was posed in cases of a malrotation > 15°. The data were not randomised and evaluated retrospectively.
In total 94 patients with unilateral DFF were included. 21 female and 73 male with an average age of 33.15 ± 14.04 years (range 14-94). In the postoperative CT scan an average FMR of 11.58 ± 9.41° (range 0-44°) was determined. In 15 cases (15.95 %), 10 male (13.7 %) and 5 female (23.81 %) a FMR > 15° (average: 23.66 ± 5.74°) was noticed. A subsequent surgery with a correction in average of 17.53 ± 6.83° was performed. After the correction the malrotation averaged 6.07 ± 5.61°. The results support the existing data that the treatment of DFF with closed reduction and intramedullary nailing may lead to a significant femoral malrotation despite a precise intraoperative monitoring. The data demonstrate that nearly 15 % of all patients appear after closed reduction and intramedullary nailing with a femoral malrotation greater than 15°. A routinely utilised postoperative CT scan provides additional information to discover an occult malrotation.
In spite of diligent attendance to the femoral torsion intraoperatively in DFF a significant femoral malrotation may result after closed reduction and intramedullary nailing. To prevent a limitation of ROM and clinical constraints a routinely performed postoperative CT scan with a adequate surgical correction is recommended.
采用闭合复位髓内钉内固定术对股骨干骨折进行微创治疗是一种成熟的手术方法。然而，髓内钉固定术后股骨旋转不良被认为是一个严重问题。研究表明，该手术后股骨旋转不良（FMR）的发生率为17% - 35%。双侧股骨的计算机断层扫描（CT）被公认为是一种客观、可重复的测量方法，用于确定术后股骨旋转不良情况。由于旋转不良>15°会导致活动范围（ROM）显著受限并产生临床症状性限制，因此股骨中心线的解剖复位仍然至关重要。
患者/材料与方法：2007年7月至2011年12月期间，对单侧股骨干骨折患者采用闭合复位髓内钉内固定术进行治疗。排除标准定义为双侧股骨骨折或既往有股骨骨折治疗史、开放性骨骺板或妊娠。所有病例均进行术后股骨CT扫描以分析股骨旋转不良情况。对于旋转不良>15°的病例，进行矫正手术。数据未进行随机分组，而是进行回顾性评估。
共纳入94例单侧股骨干骨折患者。其中女性21例，男性73例，平均年龄33.15±14.04岁（范围14 - 94岁）。术后CT扫描显示，平均股骨旋转不良角度为11.58±9.41°（范围0 - 44°）。15例（15.95%）患者出现股骨旋转不良>15°，其中男性10例（13.7%），女性5例（23.81%）（平均：23.66±5.74°）。随后进行了平均矫正角度为17.53±6.83°的手术。矫正后，旋转不良平均角度为6.07±5.61°。结果支持现有数据，即尽管术中进行了精确监测，但采用闭合复位髓内钉内固定术治疗股骨干骨折仍可能导致明显的股骨旋转不良。数据表明，在所有接受闭合复位髓内钉内固定术的患者中，近15%出现股骨旋转不良大于15°的情况。常规使用的术后CT扫描可提供额外信息以发现隐匿性旋转不良。
尽管在股骨干骨折手术中认真关注了股骨扭转情况，但闭合复位髓内钉内固定术后仍可能出现明显的股骨旋转不良。为防止活动范围受限和临床症状，建议常规进行术后CT扫描并进行适当的手术矫正。
