股骨干髓内钉术后骨不连的个性化治疗

Individualized treatment of aseptic femoral nonunion after intramedullary nailing

目的探讨通过判断骨不连形态及髓内钉稳定性进行分型，采用个性化固定方案治疗股骨干髓内钉术后无菌性骨不连的临床疗效。方法回顾性分析2012年1月至2016年1月西安交通大学附属红会医院创伤骨科收治的108例股骨干髓内钉术后无菌性骨不连患者资料，男89例，女19例；年龄23～65岁，平均45．5岁。具体分型方法及相应治疗方案如下：Ⅰ型（15例），断端有骨痂生成（局部无骨缺损）＋髓内钉稳定，保留髓内钉并附加钢板；Ⅱ型（43例），断端有骨痂生成（局部无骨缺损）＋髓内钉不稳定，更换更大型号的髓内钉／更换更大型号的髓内钉＋阻挡钉；Ⅲ型（23例），断端无骨痂生成（局部有骨缺损）＋髓内钉稳定，保留髓内钉、植骨并附加钢板；Ⅳ型（27例），断端无骨痂生成（局部有骨缺损）＋髓内钉不稳定，植骨并更换双钢板垂直固定。随访期间观察骨不连愈合、并发症发生情况及骨骼和功能评分优良率。结果所有患者术后获12～14个月（平均12．5个月）随访，骨不连均愈合，未发现有感染、再骨折等并发症发生，平均愈合时间为5．5个月（4～8个月），骨骼及功能评分优良率100％。结论根据骨不连形态及髓内钉稳定性进行分型，能够提示正确的个性化固定方案，极大地提高股骨干髓内钉术后无菌性骨不连的治愈率。

Objective To evaluate individualized treatment of aseptic femoral nonunion after interlocking intramedullary nailing based on the morphology of each nonunion and nailing stability in each specific patient. Methods This study reviewed 108 patients who had been treated and followed up for more than one year for aseptic femoral nonunion following interlocking intramedullary nailing between February 2012 and February 2016. They were 89 men and 19 women, aged from 23 to 65 years （average, 45.5 years）. The classification and corresponding treatments were as follows： Type Ⅰ （15 cases）, characterized by callus （ ＋ ）/ bone defect （-） and nailing stability （ ＋ ）, were treated by augmentation plating; Type Ⅱ （43 cases）, characterized by callus （ ＋ ）/bone defect （-） and nailing stability （-）, were treated by exchange for larger nailing/larger nailing with poller screws; Type Ⅲ （23 cases）, characterized by callus （-）/bone defect （ ＋ ） and stability of nailing （ ＋ ）, were treated by augmentation plating with bone grafting; Type IV （27 cases）, characterized by callus （-）/bone defect （ ＋ ） and stability of nailing（-）, were treated by double plating and bone grafting. The healing of bone nonunion, complications and assessments for bone and function were fol-lowed up. Results All these patients received follow-up for 12 to 14 months （average, 12.5 months）. All the nonunions were healed with no postoperative complications. Bone healing was achieved after 4 to 8 months （average, 5.5 months）. The good to excellent rates for bone and function were 100%. Conclusion To achieve better surgical outcomes, the treatment of aseptic femoral nonunion after interlocking intramedullary nailing should be individualized according to the morphology of each nonunion and nailing stability in each spe-cific patient.