Blachut P A, O'Brien P J, Meek R N, Broekhuyse H M
Department of Orthopaedics, Vancouver Hospital and Health Sciences Centre, University of British Columbia, Canada.
J Bone Joint Surg Am. 1997 May;79(5):640-6. doi: 10.2106/00004623-199705000-00002.
One hundred and fifty-two patients who had 154 closed fractures of the shaft of the tibia were prospectively randomized to management with interlocking intramedullary nailing either with or without reaming. Thirteen patients who had been randomized to treatment without reaming were switched to the group that had reaming because of technical reasons; these patients were excluded from the analysis of the results. An additional five patients were lost to follow-up. Thus, seventy-two patients (seventy-three fractures) who had been managed with nailing with reaming and sixty-three patients (sixty-three fractures) who had been managed with nailing without reaming were available for follow-up at an average of twelve months (range, three to thirty-three months) postoperatively. The two groups were similar with regard to demographics and the configurations of the fractures. The average total duration of the procedures performed without reaming was eleven minutes shorter than that of the procedures done with reaming (p = 0.0013). The duration of fluoroscopy was not significantly different between the two groups (p = 0.35, Mann-Whitney test). The average estimated blood loss was identical for the two groups. Seventy fractures (96 per cent) that were treated with nailing with reaming and fifty-six (89 per cent) that were treated with nailing without reaming united without the need for an additional operation (p = 0.19). Because of the small sample size, the study has insufficient power (34.7 per cent) to detect this difference if it is real. There was only one deep infection, which developed after nailing without reaming. The nail fractured after one procedure with reaming. A screw fractured after two procedures with reaming and after ten without reaming (p = 0.012); multiple screws fractured after three procedures in the latter group. Malunion occurred after three nailing procedures with reaming and after two without reaming. Four malunions were of very proximal fractures and one was of a very distal fracture. Seventeen screws and twenty-four nails were removed after nailing with reaming, and twenty screws and nineteen nails were removed after nailing without reaming; neither of these prevalences was significantly different between the two groups (p = 0.27 and 0.89; chi-square test). We concluded that there are no major advantages to nailing without reaming as compared with nailing with reaming for the treatment of closed fractures of the shaft of the tibia. There was a higher prevalence of delayed union and breakage of screws after nailing without reaming.
152例胫骨干闭合性骨折患者被前瞻性随机分为扩髓或不扩髓的交锁髓内钉治疗组。13例随机分到不扩髓治疗组的患者因技术原因改为扩髓组；这些患者被排除在结果分析之外。另外5例患者失访。因此，72例（73处骨折）接受扩髓髓内钉治疗的患者和63例（63处骨折）接受不扩髓髓内钉治疗的患者在术后平均12个月（范围3至33个月）时可供随访。两组在人口统计学和骨折类型方面相似。不扩髓手术的平均总时长比扩髓手术短11分钟（p = 0.0013）。两组之间透视时间无显著差异（p = 0.35，曼-惠特尼检验）。两组的平均估计失血量相同。70处（96%）接受扩髓髓内钉治疗的骨折和56处（89%）接受不扩髓髓内钉治疗的骨折无需二次手术即愈合（p = 0.19）。由于样本量小，如果这种差异真实存在，该研究检测此差异的效能不足（34.7%）。仅1例深部感染发生在不扩髓髓内钉治疗后。1例扩髓手术后髓内钉断裂。2例扩髓手术和10例不扩髓手术后出现螺钉断裂（p = 0.012）；后一组3例手术后出现多枚螺钉断裂。3例扩髓髓内钉手术和2例不扩髓髓内钉手术后出现畸形愈合。4例畸形愈合为极近端骨折，1例为极远端骨折。扩髓髓内钉治疗后取出17枚螺钉和24根髓内钉，不扩髓髓内钉治疗后取出20枚螺钉和19根髓内钉；两组的这些发生率均无显著差异（p = 0.27和0.89；卡方检验）。我们得出结论，对于胫骨干闭合性骨折的治疗，与扩髓髓内钉治疗相比，不扩髓髓内钉治疗没有主要优势。不扩髓髓内钉治疗后延迟愈合和螺钉断裂的发生率更高。
