Yoon Richard S, Gage Mark J, Galos David K, Donegan Derek J, Liporace Frank A
Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center-RWJBarnabas Health, Jersey City, NJ, United States.
Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States.
Injury. 2017 Jun;48(6):1165-1169. doi: 10.1016/j.injury.2017.03.017. Epub 2017 Mar 18.
Intramedullary nailing (IMN) has become the standard of care for the treatment of most femoral shaft fractures. Different IMN options include trochanteric and piriformis entry as well as retrograde nails, which may result in varying degrees of femoral rotation. The objective of this study was to analyze postoperative femoral version between three types of nails and to delineate any significant differences in femoral version (DFV) and revision rates.
MATERIALS & METHODS: Over a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (AO/OTA 32A-C). Of these patients, 316 met inclusion criteria and obtained postoperative computed tomography (CT) scanograms to calculate femoral version and were thus included in the study. In this study, our main outcome measure was the difference in femoral version (DFV) between the uninjured limb and the injured limb. The effect of the following variables on DFV and revision rates were determined via univariate, multivariate, and ordinal regression analyses: gender, age, BMI, ethnicity, mechanism of injury, operative side, open fracture, and table type/position. Statistical significance was set at p<0.05.
A total of 316 patients were included. Piriformis entry nails made up the majority (n=141), followed by retrograde (n=108), then trochanteric entry nails (n=67). Univariate regression analysis revealed that a lower BMI was significantly associated with a lower DFV (p=0.006). Controlling for possible covariables, multivariate analysis yielded a significantly lower DFV for trochanteric entry nails than piriformis or retrograde nails (7.9±6.10 vs. 9.5±7.4 vs. 9.4±7.8°, p<0.05). Using revision as an endpoint, trochanteric entry nails also had a significantly lower revision rate, even when controlling for all other variables (p<0.05).
Comparative, objective comparisons between DFV between different nails based on entry point revealed that trochanteric nails had a significantly lower DFV and a lower revision rate, even after regression analysis. However, this is not to state that the other nail types exhibited abnormal DFV. Translation to the clinical impact of a few degrees of DFV is also unknown. Future studies to more in-depth study the intricacies of femoral version may lead to improved technology in addition to potentially improved clinical outcomes.
髓内钉固定术（IMN）已成为治疗大多数股骨干骨折的标准治疗方法。不同的髓内钉选择包括经转子和梨状肌入路以及逆行髓内钉，这可能导致不同程度的股骨旋转。本研究的目的是分析三种类型髓内钉术后的股骨扭转角度，并确定股骨扭转角度（DFV）和翻修率的任何显著差异。
在10年期间，417例患者接受了股骨干骨折（AO/OTA 32A-C）的髓内钉固定术。其中，316例符合纳入标准，并获得术后计算机断层扫描（CT）扫描图像以计算股骨扭转角度，因此被纳入本研究。在本研究中，我们的主要结局指标是健侧肢体与患侧肢体之间的股骨扭转角度差异（DFV）。通过单因素、多因素和有序回归分析确定以下变量对DFV和翻修率的影响：性别、年龄、体重指数、种族、损伤机制、手术侧、开放性骨折以及手术台类型/位置。设定统计学显著性为p<0.05。
共纳入316例患者。梨状肌入路髓内钉占大多数（n=141），其次是逆行髓内钉（n=108），然后是经转子入路髓内钉（n=67）。单因素回归分析显示，较低的体重指数与较低的DFV显著相关（p=0.006）。在控制可能的协变量后，多因素分析显示经转子入路髓内钉的DFV显著低于梨状肌入路或逆行髓内钉（7.9±6.10° vs. 9.5±7.4° vs. 9.4±7.8°，p<0.05）。以翻修为终点，即使在控制所有其他变量后，经转子入路髓内钉的翻修率也显著较低（p<0.05）。
基于入钉点对不同髓内钉之间的DFV进行的比较性客观比较显示，即使经过回归分析，经转子髓内钉的DFV显著更低且翻修率更低。然而，这并不是说其他类型的髓内钉表现出异常的DFV。DFV几度的临床影响也尚不清楚。未来更深入研究股骨扭转角度复杂性的研究可能会带来技术改进以及潜在的临床结局改善。
