Millar Michael J, Wilkinson Andrew, Navarre Pierre, Steiner Joel, Vohora Ashray, Hardidge Andrew, Edwards Elton
Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia.
Department of Orthopaedic Surgery, The Austin Hospital, Melbourne, Victoria, Australia.
J Orthop Trauma. 2018 May;32(5):245-250. doi: 10.1097/BOT.0000000000001110.
To evaluate patient-independent risk factors for aseptic femoral hypertrophic nonunion requiring exchange nailing, with particular reference to the fit of the nail at the isthmus within the canal.
Retrospective case control study.
Level 1 trauma center.
Between 2008 and 2012, 211 patients without any patient-dependent risk factors for nonunion were treated with a locked reamed intramedullary nail for a femoral shaft fracture. Twenty-three cases went on to hypertrophic nonunion requiring exchange nailing (treatment group) and 188 cases went on to union (control group). Patient-independent risk factors for exchange nailing were documented.
Patient-independent risk factors for exchange nailing were poor fracture reduction [Odds ratio (OR): 11.5, 95% confidence interval (CI), 4.0-33.4, P < 0.001], open fracture (OR: 7.6, 95% CI, 3.0-19.6, P = 0.004), Winquist classification of 4 (OR: 4.4, 95% CI, 1.9-6.7, P = 0.016), and poor nail fit (OR: 10.3, 95% CI, 5.1-28.4, P < 0.001). Multivariate analysis revealed nail fit as an independent predictor of femoral nonunion requiring exchange nailing (OR: 11.4, 95% CI, 6.9-15.2, P < 0.001). Moreover, we found a direct relationship between increasingly poor nail fit and increased risk of exchange nailing, with the criterion occurring at a nail fit ratio <70%.
When proceeding to femoral fracture reamed intramedullary nailing, we recommend a minimum nail fit of 70% at the isthmus and ideally 90% or more, to avoid surgical reintervention.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
评估无菌性股骨肥大性骨不连需要更换髓内钉的患者独立危险因素，特别关注髓内钉在髓腔峡部的适配情况。
回顾性病例对照研究。
一级创伤中心。
2008年至2012年期间，211例无任何骨不连相关患者独立危险因素的股骨干骨折患者接受了带锁髓内钉治疗。23例发展为肥大性骨不连需要更换髓内钉（治疗组），188例实现骨愈合（对照组）。记录了需要更换髓内钉的患者独立危险因素。
需要更换髓内钉的患者独立危险因素包括骨折复位不佳[比值比（OR）：11.5，95%置信区间（CI），4.0 - 33.4，P < 0.001]、开放性骨折（OR：7.6，95% CI，3.0 - 19.6，P = 0.004）、Winquist 4级分类（OR：4.4，95% CI，1.9 - 6.7，P = 0.016）以及髓内钉适配不佳（OR：10.3，95% CI，5.1 - 28.4，P < 0.001）。多因素分析显示，髓内钉适配情况是需要更换髓内钉的股骨骨不连的独立预测因素（OR：11.4，95% CI，6.9 - 15.2，P < 0.001）。此外，我们发现髓内钉适配情况越差，更换髓内钉的风险越高，当髓内钉适配率 < 70%时会出现该标准情况。
在进行股骨干骨折扩髓髓内钉固定时，我们建议髓腔峡部的髓内钉最小适配率为70%，理想情况为90%或更高，以避免再次手术干预。
预后III级。有关证据水平的完整描述，请参阅作者指南。
