Rommens P M, Küchle R, Hofmann A, Hessmann M H
Department of Orthopedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany.
Acta Chir Orthop Traumatol Cech. 2017;84(5):330-340.
Intramedullary nailing is a worldwide accepted technique for stabilization of fractures of long bones. Technique, instruments and implants primarily have been developed for the fixation of short (transverse and oblique) diaphyseal fractures. First generation nails were hollow and slotted, which gave them some elasticity. When the tip of the nail passed the fracture gap, picked up the opposite fracture fragment and was driven further down, the longitudinal axis of the bone was restored and the extremity realigned. Bone length was restored by closure of the fracture gap. The tight connection between the deformable hollow nail and the inner cortex at the isthmus realized a press-fit, which achieved a very stable bone-implant construct. The nail had the function of a weight-shearing implant. Interlocked nails represent the second-generation nails. They changed the spectrum of indications for nailing considerably. Not only short middle-third shaft fractures, but shaft fractures of all types (from transverse to comminuted) and all localizations can be stabilized with an interlocked nail. Due to interlocking, length and rotation are controlled. The nail bridges the area of instability, being a weight-bearing implant. Small diameter, solid nails formed the next generation of nail implants. They were conceived for the provisional treatment of fractures with an enhanced risk of postoperative infection such as open fractures or closed fractures with severe soft tissue damage. They were increasingly used for minimal invasive treatment of closed fractures without soft tissue damage as well, as reaming was not necessary and endosteal blood supply less damaged. Nevertheless, it became clear that they were connected with a higher incidence of implant failure and revision surgery. Another development was the creation of nails with multiple and angular stable interlocking options. Major advantage is that high stability is obtained in the fracture fragment, in which multiple interlocking is used. This property gives the possibility of nailing fractures close to a joint with a short fracture segment (24). Nevertheless, intramedullary nailing of metaphyseal fractures remains controversial. Major complications to be avoided are malalignment, delayed union, nonunion and implant failure due to suboptimal fracture reduction (23).
髓内钉固定术是一种被全球广泛接受的长骨骨折稳定技术。技术、器械和植入物主要是为固定短的（横行和斜行）骨干骨折而开发的。第一代髓内钉是空心且有槽的，这赋予了它们一定的弹性。当髓内钉尖端穿过骨折间隙，夹住对侧骨折碎片并进一步打入时，骨骼的纵轴得以恢复，肢体得以重新对线。骨折间隙的闭合恢复了骨长度。可变形空心钉与峡部内侧皮质之间的紧密连接实现了压配，从而形成了非常稳定的骨 - 植入物结构。髓内钉具有承重植入物的功能。带锁髓内钉代表第二代髓内钉。它们极大地改变了髓内钉固定术的适应证范围。不仅短的中1/3骨干骨折，而且所有类型（从横行到粉碎性）和所有部位的骨干骨折都可用带锁髓内钉进行稳定固定。由于有锁定装置，长度和旋转得以控制。髓内钉跨越不稳定区域，是一种承重植入物。小直径实心髓内钉构成了下一代髓内钉植入物。它们是为临时治疗术后感染风险增加的骨折而设计的，如开放性骨折或伴有严重软组织损伤的闭合性骨折。它们也越来越多地用于无软组织损伤的闭合性骨折的微创治疗，因为无需扩髓，对骨内膜血供的损伤较小。然而，很明显它们与植入物失败和翻修手术的发生率较高有关。另一项进展是创造了具有多种角度稳定锁定选项的髓内钉。主要优点是在使用多重锁定的骨折碎片中可获得高稳定性。这一特性使得用短骨折段（24）对靠近关节的骨折进行髓内钉固定成为可能。然而，干骺端骨折的髓内钉固定仍存在争议。需要避免的主要并发症是对线不良、延迟愈合、不愈合以及由于骨折复位欠佳导致的植入物失败（23）。
