Krettek C, Schandelmaier P, Rudolf J, Tscherne H
Unfallchirurgische Klinik, Medizinische Hochschule Hannover.
Unfallchirurg. 1994 Nov;97(11):575-99.
Nailing technique has changed in recent years in some important aspects which are not limited to the omitted reaming procedure. These changes concern patient positioning, reduction technique, the use of temporary stabilizers such as the 'Pinless', and determination of implant length and diameter. Approach and exposure techniques have been modified to new, less invasive procedures, in order to fulfill technical, functional and aesthetic requirements. Techniques and tricks have been developed for avoidance of fragment diastasis and axial and torsional malalignment. Finally, simple algorithms are described for the management of large bone defects, bilateral tibia shaft or ipsilateral femoral shaft fractures, number and location of locking bolts, the 'when and how' of patient mobilization and load bearing, and primary and secondary dynamization. These algorithms, techniques and procedures were developed in a series of 152 tibia shafts, which were stabilized with the AO unreamed tibia nail (UTN) in a prospective study between March 1989 and June 1994. Of these, 75 cases with a mean follow-up of 19.4 +/- 6.3 (range 11-37) months after trauma were reviewed. Fractures were classified according to Müller (1990): 14 type A, 37 type B and 24 type C. Closed soft tissue damage was categorized according to our classification: C0/1, n = 5; C2, n = 12; C3, n = 9 (Tscherne 1982). Among 49 open fractures 8 were OI, 18 OII, 10 OIIIA and 13 OIIIB (Gustilo 1976). The main minor intraoperative complication was drill bit breakage (n = 10), most frequently at the proximal locking holes. The main postoperative complication was breakage of locking bolts (n = 16), mainly between weeks 6 and 20. Minor secondary reinterventions were, in most cases, secondary dynamization under local anaesthesia. Major reintervention were: soft tissue reconstructions (n = 5), isolated cancellous bone graft (n = 6), and change of treatment (n = 12). There were nine changes to a reamed nail, two changes, in very proximal fractures, to plate osteosyntheses. There were three deep infections. Mean time to union was 23.9 weeks (range 10-48 weeks, n = 73); in two cases non-union was observed. The overall result was judged with the Karlström-Olerud score, which was applicable in 66 of 75 cases; excellent, n = 2; good, n = 22; satisfactory, n = 24; fair, n = 9; poor, n = 9. In the remaining nine cases no scoring was attempted because of severe injuries around the knee or ankle.
近年来，髓内钉技术在一些重要方面发生了变化，这些变化不仅限于省略扩髓步骤。这些变化涉及患者体位、复位技术、使用如“无针”等临时固定器以及确定植入物的长度和直径。手术入路和显露技术已被改进为新的、侵入性较小的方法，以满足技术、功能和美学要求。已开发出避免骨折块分离以及轴向和扭转畸形的技术和技巧。最后，描述了用于处理大骨缺损、双侧胫骨干或同侧股骨干骨折、锁定螺栓的数量和位置、患者活动和负重的“时机与方式”以及一期和二期动力化的简单算法。这些算法、技术和操作是在1989年3月至1994年6月期间对152例胫骨干进行前瞻性研究中开发的，这些胫骨干采用AO非扩髓胫骨髓内钉（UTN）进行固定。其中，对75例创伤后平均随访19.4±6.3（范围11 - 37）个月的病例进行了回顾。骨折根据Müller（1990年）分类：14例A型，37例B型和24例C型。闭合性软组织损伤根据我们的分类进行：C0/1，n = 5；C2，n = 12；C3，n = 9（Tscherne 1982年）。在49例开放性骨折中，8例为OI型，18例为OII型，10例为OIIIA型，13例为OIIIB型（Gustilo 1976年）。主要的术中 minor 并发症是钻头折断（n = 10），最常见于近端锁定孔处。主要的术后并发症是锁定螺栓折断（n = 16），主要发生在术后6至20周之间。在大多数情况下，minor 二次干预是在局部麻醉下进行二期动力化。主要的再次干预包括：软组织重建（n = 5）、单纯松质骨移植（n = 6）以及治疗方法改变（n = 12）。有9例改为扩髓髓内钉，2例在非常近端的骨折中改为钢板内固定。有3例深部感染。平均愈合时间为23.9周（范围10 - 48周，n = 73）；观察到2例骨不连。总体结果采用Karlström - Olerud评分进行评估，该评分适用于75例中的66例；优，n = 2；良，n = 22；满意，n = 24；尚可，n = 9；差，n = 9。在其余9例中，由于膝关节或踝关节周围严重损伤未进行评分。
