Yoon Yong-Cheol, Jang Myung Jin, Jeun Jigang, Song Hyung Keun
Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, 21 Namdong-daero, 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea.
Department of Orthopaedic Surgery, Gachon University College of Medicine, 21 Namdong-daero, 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea.
Arch Orthop Trauma Surg. 2025 Aug 8;145(1):401. doi: 10.1007/s00402-025-06020-6.
INTRODUCTION: Intramedullary nailing (IMN) is the treatment of choice for femoral shaft fractures with wedge-shaped fragments. However, the management of wedged fragments remains controversial. This study investigated whether wedged fragments affect bone union rates in patients treated with IMN. The primary hypothesis was that wedged fragments would not significantly affect bone union when proper IMN principles were followed. MATERIALS AND METHODS: Between March 2014 and June 2023, 162 patients were diagnosed with femoral shaft fractures (AO/OTA 32-B type) accompanied by wedge fractures. The surgeries involved the use of a reconstruction antegrade nail with a greater trochanteric entry point. Closed reduction was performed, and recon-type screws were used for proximal fixation of the femoral neck and head and at least two screws distally. The wedged fragments were not manipulated further. We analyzed the characteristics of the wedged fragments, including size, displacement, angle, and reversal morphology, and assessed the main fracture gap size in relation to bone union outcomes. RESULTS: The study included 95 of the 162 patients, of whom 82 (86.3%) achieved bone union and 13 (13.7%) experienced nonunion. Demographic and preoperative variables showed no significant differences between the union and nonunion groups. Postoperative radiographic analysis of the wedged fragments revealed no significant differences in fragment size, angle, displacement, or presence of reversed fragments. However, the main fracture gap size significantly differed, averaging 5.2 mm in the union group and 15.6 mm in the nonunion group(p = 0.01). Complications included superficial infections in four patients and malrotation in three, which were managed conservatively. CONCLUSIONS: Wedge fragments in femoral shaft fractures do not significantly affect bone union with IMN. Instead, the size of the main fracture gap is critical for healing. Surgery should focus on stable fixation and minimization of the main fracture gap rather than manipulating the wedged fragments.
引言：髓内钉固定术（IMN）是治疗伴有楔形骨折块的股骨干骨折的首选方法。然而，楔形骨折块的处理仍存在争议。本研究调查了楔形骨折块是否会影响接受IMN治疗患者的骨愈合率。主要假设是，在遵循正确的IMN原则时，楔形骨折块不会显著影响骨愈合。 材料与方法：2014年3月至2023年6月期间，162例患者被诊断为伴有楔形骨折的股骨干骨折（AO/OTA 32-B型）。手术采用经大转子入路的重建顺行髓内钉。进行闭合复位，并使用重建型螺钉对股骨颈和股骨头进行近端固定，远端至少使用两枚螺钉。楔形骨折块未作进一步处理。我们分析了楔形骨折块的特征，包括大小、移位、角度和反向形态，并评估了与骨愈合结果相关的主要骨折间隙大小。 结果：该研究纳入了162例患者中的95例，其中82例（86.3%）实现了骨愈合，13例（13.7%）发生了骨不连。人口统计学和术前变量在愈合组和骨不连组之间无显著差异。对楔形骨折块的术后影像学分析显示，骨折块大小、角度、移位或反向骨折块的存在均无显著差异。然而，主要骨折间隙大小存在显著差异，愈合组平均为5.2毫米，骨不连组平均为15.6毫米（p = 0.01）。并发症包括4例患者发生浅表感染，3例患者发生旋转不良，均采用保守治疗。 结论：股骨干骨折中的楔形骨折块对IMN治疗后的骨愈合无显著影响。相反，主要骨折间隙的大小对愈合至关重要。手术应侧重于稳定固定并尽量减小主要骨折间隙，而非处理楔形骨折块。
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