Uliana Christiano Saliba, Bidolegui Fernando, Kojima Kodi, Giordano Vincenzo
Departamento de Ortopedia e Traumatologia, Hospital do Trabalhador, Curitiba, Brazil.
Hospital Sirio Libanes, Buenos Aires, Argentina.
Eur J Trauma Emerg Surg. 2021 Dec;47(6):1895-1901. doi: 10.1007/s00068-020-01333-0. Epub 2020 Feb 27.
In recent years, plate augmentation over a retained intramedullary (IM) nail has been shown to be an effective option for managing femur fracture nonunions because it improves the biomechanical environment of the fracture site without causing additional biological damage. In the current study, we present outcome data from 22 consecutive patients treated with plate augmentation for femoral shaft nonunion leaving the nail in situ.
Between 2015 and 2018, 22 consecutive patients with femoral shaft aseptic nonunion after IM nailing were treated with plate augmentation over a retained nail at four different institutions. Nonunion was categorized based on its anatomical location and was classified according to the Weber and Cech classification. Cortical defects greater than 1.0 cm, the type of nailing procedure, and the number of previous interventions were recorded. Patients were assessed clinically and radiographically to measure the healing of nonunion sites. The time to fracture union and complications were recorded. Descriptive statistics were used when applicable.
One site location was supra-isthmic, 12 were isthmic, and 9 were infra-isthmic. There were 10 cases of vascular nonunion and 12 cases of avascular nonunion. A cortical defect greater than 1.0 cm was observed in three patients. Antegrade nailing was performed in 11 patients, and retrograde nailing was performed in 11 patients. Reaming was performed in 12 patients. In eight patients, the fracture was openly reduced during the IM nailing index procedure. The average number of previous interventions before augmentation plating was 1.6 (1-4). Bone union was achieved in 19 patients after augmentation plating with an average follow-up of 23.5 months (12-51 months). Excellent and good clinical results were observed in all patients. There was no plate or screw breakage, and no patient developed infection.
Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing, with a high union rate and few complications. We believe the technique should gradually replace exchange nailing as the standard of care for the majority of femoral shaft nonunions that occur after IM nailing.
近年来，保留髓内钉的同时加用钢板已被证明是治疗股骨干骨折不愈合的有效方法，因为它可改善骨折部位的生物力学环境，且不会造成额外的生物学损伤。在本研究中，我们展示了22例因股骨干不愈合接受钢板增强治疗且髓内钉原位保留患者的治疗结果数据。
2015年至2018年期间，在四个不同机构，对22例髓内钉固定术后发生股骨干无菌性不愈合的患者，在保留髓内钉的同时进行钢板增强治疗。根据解剖位置对不愈合进行分类，并按照Weber和Cech分类法进行分型。记录大于1.0 cm的皮质骨缺损、髓内钉置入方式及既往干预次数。对患者进行临床和影像学评估，以测量不愈合部位的愈合情况。记录骨折愈合时间及并发症。适用时采用描述性统计方法。
1个部位位于峡部上方，12个部位位于峡部，9个部位位于峡部下方。血管性骨不连10例，无血管性骨不连12例。3例患者观察到皮质骨缺损大于1.0 cm。11例行顺行髓内钉置入，11例行逆行髓内钉置入。12例患者进行了扩髓。8例患者在髓内钉置入指数手术中进行了切开复位。钢板增强治疗前既往干预的平均次数为1.6次（1 - 4次）。19例患者在钢板增强治疗后实现了骨愈合，平均随访23.5个月（12 - 51个月）。所有患者均观察到优良的临床效果。未发生钢板或螺钉断裂，也没有患者发生感染。
髓内钉原位保留并加用钢板是治疗髓内钉固定术后股骨干不愈合的极佳选择，愈合率高且并发症少。我们认为该技术应逐渐取代更换髓内钉，成为大多数髓内钉固定术后股骨干不愈合的标准治疗方法。
