Rapp M, Kraus R, Illing P, Sommerfeldt D W, Kaiser M M
Klinik für Kinderchirurgie, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland.
Klinik für Kinder- und Jugendmedizin, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
Unfallchirurg. 2018 Jan;121(1):47-57. doi: 10.1007/s00113-017-0313-6.
Operative treatment of diaphyseal fractures of the femur in older children and adolescents remains controversial due to multiple surgical options and higher complication rates in single-center studies compared to younger children. This retrospective multicenter study aimed to register early and late complications in day-by-day treatment.
Sixteen hospitals with particular expertise in pediatric orthopedic trauma participated in this study. Patients with diaphyseal femur fractures, a body weight ≥50 kg (aged 10-16 years) and treated between 2008 and 2012 were included. Age, weight, fracture type, and choice of operative treatment were correlated to complication rate and type. Patients with pathologic fractures and/or metabolic bone disorders were excluded.
Fifty-three children (15 females and 38 males; mean age: 14.2 y [SD 1.4 y]; mean body weight: 60.5 kg [max. 95 kg]) with 54 fractures were included. Elastic stable intramedullary nailing (ESIN) was the treatment of choice in 31 of 42 fractures with open growth plates. In the subgroup with two nails, 7 of 12 patients experienced revision surgery due to instability or shortening. Three patients with ESIN and end caps had no complications. In the subgroup with three inserted nails (11 patients), one patient was converted to external fixation. Nine patients received primary or secondary plate osteosyntheses. Within this group, two patients had deep infections; one implant failure, and one peri-implant fracture were recorded. Adolescent lateral femoral nailing (ALFN), when used as the primary treatment option in two patients, was free of complications. When used as a secondary treatment option in three patients, one patient had a pseudarthrosis and one an infection. Both were treated in further operative procedures. In a group of eight patients with closed physes, regular intramedullary nailing as primary or secondary treatment of choice resulted in one locking screw change. As late complications, leg length discrepancy (LLD) over 15 mm (n = 2) and loss of range of motion (ROM) (n = 4; two knee and three hip) were noted in patients receiving multiple revisions or serious postoperative complication.
Children older than 10 years of age with a body weight ≥50 kg and open physes are prone to complications regardless of treatment choice. A smaller revision rate occurred in patients treated with ESIN and end caps or a third nail compared to the other treatment options. When physes are closed, rigid intramedullary nailing is the treatment of choice.
与年幼儿童相比，大龄儿童和青少年股骨干骨折的手术治疗仍存在争议，因为手术选择多样且单中心研究中的并发症发生率更高。这项回顾性多中心研究旨在记录日常治疗中的早期和晚期并发症。
16家在小儿骨科创伤方面具有特殊专业知识的医院参与了本研究。纳入2008年至2012年间治疗的体重≥50 kg（年龄10 - 16岁）的股骨干骨折患者。年龄、体重、骨折类型和手术治疗选择与并发症发生率和类型相关。排除病理性骨折和/或代谢性骨病患者。
纳入53例儿童（15例女性和38例男性；平均年龄：14.2岁[标准差1.4岁]；平均体重：60.5 kg[最大95 kg]），共54处骨折。在42处生长板开放的骨折中，31处选择弹性稳定髓内钉固定（ESIN）。在使用两枚髓内钉的亚组中，12例患者中有7例因不稳定或短缩而接受翻修手术。3例使用ESIN并加用端帽的患者无并发症。在使用三枚髓内钉的亚组（11例患者）中，1例患者转为外固定。9例患者接受了一期或二期钢板内固定。在该组中，记录到2例深部感染、1例植入物失败和1例植入物周围骨折。青少年股骨干外侧髓内钉固定（ALFN）在2例患者中作为主要治疗选择时无并发症。在3例患者中作为次要治疗选择时，1例发生假关节，1例发生感染。两者均接受了进一步的手术治疗。在一组8例生长板闭合的患者中，常规髓内钉作为一期或二期首选治疗导致1例锁定螺钉更换。作为晚期并发症，在接受多次翻修或严重术后并发症的患者中，发现腿长差异（LLD）超过15 mm（n = 2）和活动范围（ROM）丧失（n = 4；2例膝关节和3例髋关节）。
体重≥50 kg且生长板开放的10岁以上儿童无论治疗选择如何都容易发生并发症。与其他治疗选择相比，使用ESIN并加用端帽或第三枚髓内钉治疗的患者翻修率较低。当生长板闭合时，坚强髓内钉固定是首选治疗方法。
