Yoon Yong-Cheol, Oh Chang-Wug, Oh Jong-Keon, Kim Joon-Woo, Park Kyeong-Hyeon, Song Hyung Keun
Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Namdong-gu, Incheon, Republic of Korea.
Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu, Republic of Korea.
J Bone Joint Surg Am. 2022 Dec 7;104(23):2059-2067. doi: 10.2106/JBJS.22.00363. Epub 2022 Oct 10.
Increased anterolateral bowing of the femur is associated with atypical femoral fractures among older patients (including both those receiving and those not receiving treatment with bisphosphonates) as well as a greater likelihood of occurring in the diaphyseal versus the subtrochanteric region. Prophylactic intramedullary (IM) nailing is recommended for the treatment of incomplete atypical femoral fractures, which are radiographically evident. However, this bowing deformity is considered to be a major obstacle to IM nailing as it may be associated with postoperative complications. Corrective osteotomy combined with IM nailing straightens the exaggerated curvature of the femur. We hypothesized that this technique may lead to the safe and rapid healing of incomplete diaphyseal atypical femoral fractures, thereby reducing lateral tensile stress.
From October 2015 through March 2020, 17 female patients (20 femora) with a mean age of 76.1 years (range, 68 to 86 years) underwent a surgical procedure for the treatment of an incomplete diaphyseal atypical femoral fracture associated with anterolateral bowing. The surgical technique consisted of minimally invasive osteotomy and reconstruction with use of IM nailing, with or without an augmentation plate. Preoperative and postoperative radiographic findings (lateral and anterior bowing angles, anterolateral bowing grade, and lateral distal femoral angle [LDFA]) were compared. Primary union, time to union, and complications were evaluated as the outcomes.
Primary bone union was achieved in 19 of the 20 femora at a mean of 24.9 weeks (range, 20 to 40 weeks). There were 2 instances of delayed union, which healed at 36 and 40 weeks. The lateral bowing angle, anterior bowing angle, and LDFA significantly improved postoperatively (from 12.0° to 3.3°, from 17.3° to 11.5°, and from 93.5° to 88.8°, respectively) (p < 0.001). There was 1 instance of nonunion, which healed after plate augmentation without a bone graft.
Given the pathophysiology of elevated lateral tensile stress, corrective osteotomy and IM nailing may be an acceptable solution for the treatment of incomplete diaphyseal atypical femoral fractures associated with increased anterolateral bowing.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
股骨前外侧弓形增加与老年患者的非典型股骨骨折相关（包括接受和未接受双膦酸盐治疗的患者），并且在骨干与转子下区域相比更有可能发生。对于影像学上明显的不完全性非典型股骨骨折，建议采用预防性髓内（IM）钉固定治疗。然而，这种弓形畸形被认为是IM钉固定的主要障碍，因为它可能与术后并发症相关。矫正截骨术联合IM钉固定可矫正股骨的过度弯曲。我们假设这种技术可能导致不完全性骨干非典型股骨骨折安全快速愈合，从而降低外侧拉伸应力。
从2015年10月至2020年3月，17例平均年龄76.1岁（范围68至86岁）的女性患者（20个股骨）接受了手术治疗与前外侧弓形相关的不完全性骨干非典型股骨骨折。手术技术包括微创截骨术和使用IM钉固定进行重建，有或没有增强钢板。比较术前和术后的影像学表现（外侧和前侧弓形角度、前外侧弓形分级和股骨远端外侧角[LDFA]）。将一期愈合、愈合时间和并发症作为结果进行评估。
20个股骨中有19个在平均24.9周（范围20至40周）时实现了一期骨愈合。有2例延迟愈合，分别在36周和40周时愈合。外侧弓形角度、前侧弓形角度和LDFA术后显著改善（分别从12.0°降至3.3°，从17.3°降至11.5°，从93.5°降至88.8°）（p<0.001）。有1例骨不连，在未植骨的情况下通过钢板增强后愈合。
鉴于外侧拉伸应力升高的病理生理学，矫正截骨术和IM钉固定可能是治疗与前外侧弓形增加相关的不完全性骨干非典型股骨骨折的可接受解决方案。
治疗性III级。有关证据水平的完整描述，请参阅作者指南。
