外固定架结合髓内钉延长术治疗股骨缺损和不等长

Femoral lengthening or transport in combination with an intramedullary nail

目的探讨联合应用髓内钉及外固定架治疗股骨缺损和不等长的方法和疗效。方法2001年1月～2003年12月联合应用髓内钉及外固定架治疗2例股骨缺损分别为8 cm和11 cm的患者、3例股骨短缩为4～7 cm的患者。手术于股骨内顺行置入带锁髓内钉(或保留原有髓内钉),带锁髓内钉仅锁定一端,安装外固定架。4例于股骨近段截骨,1例于股骨远段截骨。5例患者中2例使用Ilizarov重建外固定架,3例使用Orthofix重建外固定架。术后平均延迟16．2 d(13～24 d)后开始牵开延长,1mm/d,共分4次完成。对于股骨短缩患者,当股骨达到预期延长长度后再次手术将髓内钉远端锁定,然后去除外固定架,开始早期功能锻炼。对于骨缺损患者,当股骨达到预期延长长度后仍须等待新生骨痂密度有所增加后将髓内钉远端锁定并去除外固定架。结果5例患者获平均36．4个月(22～47个月)随访,平均延长长度为7．2 cm (4～10 cm),外固定架放置时间平均为5个月(3～8个月),外固定架指数平均为0．75个月/cm(0．57～1．00个月/cm)。所有患者股骨延长段未出现轴向偏移或再骨折,坚实化良好。最后随访时,5例患者膝关节活动度平均为107°(80°～135°)。结论联合应用髓内钉及外固定架肢体延长术能够明显缩短外固定架置放时间,避免肢体畸形,有利于膝关节早期功能恢复,在治疗大段骨缺损及肢体不等长中具有一定优势。手术时间长、术中出血多、治疗费用高和手术切口瘢痕增加是其缺点。

Objective To review the results of limb lengthening over an intramedullary nail in management of femoral defect and length discrepancy. Methods Femoral lengthening over an antegrade intramedullary nail was applied to treat length discrepancy of 4 to 7 em for three cases, and femoral defects of 8 and 11 em respectively for two eases from January 2001 to December 2003. The nail and an external fixator （Ilizarov external fixator for bone defect and Orthofix limb-reconstruction system for discrepancy） were applied concomitantly at the time of femoral osteotomy. After a mean fixation time of 16. 2 days （13 to 24 days）, gradual distraction began at a rate of 0. 25 millimeter four times a day. When the managed femur reached the expected length, the nail was locked and the fixator was removed in patients with length discrepancy. The procedure was not finished in patients with bone defects until bony consolidation was partially seen. Results All the patients were followed up for a mean time of 36.4 months （range, 22 to 47 months）. The mean gain in length was 7.2 em （range, 4 to 10 em） with good consolidation, the mean duration of external fixation was 5 months （range, 3 to 8 months）, and the mean external fixation index was 0. 75 month per centimeter （range, 0. 57 to 1.00 month per centimeter） . Neither axial deviation nor re-fracture occurred. At the last follow-up, the mean range of movement of knee was 107° （80° to 135°） . Conclusions In management of defect and length discrepancy of limbs, lengthening over an intramedullary nail has the advantages of short duration of external fixation, good protection against refraeture, and earlier rehabilitation of knee joint, as well as disadvantages of long operation time, massive intraoperative bleeding, high cost and much postonerative searring.