Lim Hae-Seong, Kim Chong-Kwan, Park Youn-Soo, Moon Young-Wan, Lim Seung-Jae, Kim Sang-Min
1Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea 2Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea 3Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea.
J Bone Joint Surg Am. 2016 Dec 7;98(23):1978-1987. doi: 10.2106/JBJS.15.01422.
The purpose of this study was to analyze factors that affect healing time after operative treatment of complete femoral fractures associated with long-term use of bisphosphonates. In particular, we sought to determine surgically controllable factors related to fracture-healing time.
Ninety-nine consecutive patients (109 fractures) who had been surgically treated for a complete atypical femoral fracture were enrolled. All patients had a documented history of bisphosphonate therapy at the time of presentation, with an average duration of 7.4 ± 3.5 years (range, 3 to 20 years). Baseline demographic data, characteristics of the fracture and surgery, and radiographic findings including femoral neck-shaft angle, coronal and sagittal bowing of the femur, and thickness of the femoral cortex were examined. Univariate and multivariate logistic regression analyses were performed to identify predictive factors associated with delayed union or nonunion.
Of the 109 fractures, 76 (69.7%) showed osseous union within 6 months after the index surgery and were assigned to the successful healing group. The remaining 33 fractures (30.3%), which showed delayed union or nonunion, were assigned to the problematic healing group. There were differences in body mass index (BMI), bisphosphonate therapy duration, and the rate of prodromal symptoms between the 2 groups. Supra-isthmic fracture location, femoral bowing of ≥10° in the coronal plane, and a lateral/medial cortical thickness ratio of ≥1.4 were predictive of problematic healing but were uncontrollable factors. Iatrogenic cortical breakage around the fracture site as well as a ratio of ≥0.2 between the remaining gap and the cortical thickness on the anterior and lateral sides of the fracture site were controllable predictive factors associated with problematic healing.
Intramedullary nailing without cortical breakage around the fracture site and decreasing the anterior and lateral fracture gaps (avoidance of distraction) as much as possible are recommended to reduce healing time in complete femoral fractures associated with long-term use of bisphosphonates.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
本研究的目的是分析影响长期使用双膦酸盐类药物治疗后股骨完全骨折手术治疗愈合时间的因素。特别是，我们试图确定与骨折愈合时间相关的手术可控因素。
纳入99例连续接受手术治疗的非典型股骨完全骨折患者（109处骨折）。所有患者在就诊时均有双膦酸盐治疗记录，平均治疗时间为7.4±3.5年（范围3至20年）。检查了基线人口统计学数据、骨折和手术特征以及影像学检查结果，包括股骨颈干角、股骨的冠状面和矢状面弯曲度以及股骨皮质厚度。进行单因素和多因素逻辑回归分析以确定与延迟愈合或不愈合相关的预测因素。
109处骨折中，76处（69.7%）在初次手术后6个月内实现骨愈合，被归入愈合成功组。其余33处骨折（30.3%）表现为延迟愈合或不愈合，被归入愈合问题组。两组在体重指数（BMI）、双膦酸盐治疗持续时间和前驱症状发生率方面存在差异。峡部以上骨折部位、冠状面股骨弯曲度≥10°以及外侧/内侧皮质厚度比≥1.4是愈合问题的预测因素，但为不可控因素。骨折部位周围的医源性皮质破损以及骨折部位前侧和外侧剩余间隙与皮质厚度之比≥0.2是与愈合问题相关的可控预测因素。
对于长期使用双膦酸盐类药物相关的股骨完全骨折，建议采用骨折部位周围无皮质破损的髓内钉固定，并尽可能减小骨折部位前侧和外侧间隙（避免分离），以缩短愈合时间。
治疗性IV级。有关证据水平的完整描述，请参阅作者指南。
