可延长髓内钉微创治疗成骨不全术后股骨再发畸形或骨折

Use of minimally invasive operation therapy with extended intramedullary nail on children with femoral fracture and deformity due to osteogenesis imperfecta

目的探讨可延长髓内钉治疗成骨不全术后股骨再发畸形或骨折的疗效。方法回顾性分析2009年6月至2012年6月采用可延长髓内钉治疗21例成骨不全术后股骨再发畸形或骨折患儿资料，男13例，女8例；年龄9岁6个月至15岁7个月，平均12岁3个月。所有患儿均已行股骨干截骨矫形不可延长髓内钉手术，此次手术距初次手术时间为2～4年，平均3年。所有患儿成长肢体于髓内钉远端部位再次出现畸形或骨折，其中9例为股骨干弯曲畸形，畸形成角度数为10°-30°，平均15°；12例为再发骨折。依据修订后的Sillence分型：Ⅲ型6例，Ⅳ型14例，V型1例。21例患儿均在大转子及远端截骨处切开手术，切口长度为2-3em，采用可延长髓内钉再次固定骨折及矫正畸形。结果21例患儿均获得随访，随访时间6-30个月，平均18个月。骨折愈合时间为7-12周，平均8．5周。待x线片示截骨愈合后患儿开始负重行走。所有患儿及其父母均对手术结果及畸形矫正效果表示满意，末次随访时患儿Baahel指数评分由术前平均72．85分（范围，50-90分）提高到术后平均91．42分（范围，80-100分）。Wee FIM评分由术前平均55．42分（范围，40-70分）提高到术后平均79．00分（范围，70-86分）。10例术前需拐杖辅助行走患儿，随访时可独立行走；6例术前因骨折而卧床患儿中，4例可独立行走，2例需拄拐活动。末次随访时，无一例出现感染、骨髓炎等并发症，无神经、血管损伤病例。结论应用可延长髓内钉小切口手术，对肢体损伤小、出血少、骨折愈合时间短、患儿痛苦小，是治疗成骨不全术后股骨再发畸形或骨折的良好方法。

Objective To evaluate the therapeutic effect of extendable intramedullary nail on children with femoral deformity due to osteogenesis imperfecta. Methods From June 2009 to June 2012, 21 patients with femoral deformity due to os- teogenesis imperfecta were treated with extendable intramedullary nail. There were 13 males and 8 females, aged from 9 years and 6 months to 15 years and 7 months （average, 12 years and 3 months）. All children had been performed osteotomy on the shaft of femur and implanted with non-extendable nail before 2-4 years （average, 3 years）. All children had suffered refracture and deformity, including 9 children with femoral bending deformity and 12 with refracture. The deformity angle ranged from 10° to 30°, with an average of 15°. According to revised Sillence classifications, there were 6 cases with type III and 14 with type IV and 1 case with type V. Twenty-one patients were operated with extendable nail for fixing fracture and correcting d~：fbrmity and incisions were 2-3 cm long and located on the great trochanter and distal osteotomy point. Results All of 21 children were fol- lowed up for 6-30 months （average, 18 months）. The bone healing time was 7-12 weeks （average, 8.5 weeks）. Patients started to walk after X-ray showing bone union. Parents of 21 children were satisfied with surgical operation effect and deformity correction. The Barthel index score improved from 72.85 （range, 50-90 points） preoperatively to 91.42 （range, 80-100 points） postoperative- ly at the latest follow-up of patients. WeeFIM index score increased from preoperative average of 55.42 points （range, 40-70 points） to postoperative average 79.00 points （range, 70-86 points）. Ten of all children with stick aid preoperative could walk in- dependently after small incision repairing, and 6 of all children in sickbed preoperative, 4 of 6 children could walk independent- ly, 2 of 6 children could walk with stick aid. Conclusion Small incision repair with extended intramedullary nail operation ther- apy is advantaged. It gets less bloody, less damages, less pain, less healing time and walking after removing plaster.