无植骨Ilizarov外固定技术治疗股骨萎缩性骨不连

Ilizarov external fixation without bone graft for atrophic femoral shaft nonunion

目的探讨无植骨Ilizarov外固定技术治疗股骨萎缩性骨不连的临床疗效。方法回顾分析2010年10月-2017年1月收治的12例股骨萎缩性骨不连患者临床资料,男8例,女4例;年龄24~61岁,平均41.7岁。7例骨不连位于股骨中上段,5例位于股骨远端或髁上。病程1~9年,平均3.7年。既往手术1~9次,平均2.8次。手术取出原固定物,清理骨不连骨折端,安装Ilizarov环形外固定器,骨缺损长度<4 cm者术中直接加压固定;患侧肢体较健侧短缩>2.5 cm者术中行股骨近端闭合截骨加装骨延长组件,备术后肢体延长;所有患者未植骨。记录患者外固定器佩戴时间、骨不连临床愈合时间、并发症发生情况;采用Paley等的骨不连评价标准评价疗效。结果术后患者均获随访,随访时间24~50个月,平均30个月。12例骨不连均达临床愈合,愈合时间6.0~23.5个月,平均11.5个月。外固定器佩戴时间为7~25个月,平均13.5个月。末次随访时采用Paley等的骨不连评价标准,优6例、良4例、可2例,优良率83.3%。4例股骨成角畸形>7°,伸膝功能无明显影响,未再行截骨手术等特殊处理。2例术后患侧肢体短缩>2.5 cm,通过穿补高鞋替代;4例跨膝关节固定患者术后膝关节活动度丢失10~30°;10例发生针道感染,其中4例感染并固定针松动者给予拔针后更换位置重新固定,余6例感染但固定针未松动者通过局部换药、针道护理及口服抗炎药物感染控制。无深部感染和血管神经损伤等并发症发生。结论 Ilizarov外固定技术治疗股骨萎缩性骨不连骨愈合率较高,相对微创、无需植骨,初步临床效果确切,对于多次手术失败的患者同样有效。治疗时需要重视术后外固定器护理及康复训练。

Objective To explore the effectiveness of Ilizarov external fixation without bone graft in the treatment of atrophic femoral shaft nonunion. Methods The clinical data of 12 patients with atrophic femoral shaft nonunion admitted between October 2010 and January 2017 were retrospectively analyzed. There were 8 males and 4 females, aged from 24 to 61 years, with an average age of 41.7 years. The nonunion sites located in the middle and upper femur in 7 cases and in the distal femur or supracondylar in 5 cases. The disease duration ranged from 1 to9 years, with an average of 3.7 years. Previous operations ranged from 1 to 9 times, with an average of 2.8 times. The original fixator was removed, the fracture end of nonunion was debrided, and Ilizarov external fixator was installed. In patients with the length of bone defect less than 4 cm, direct compression fixation was performed during operation;in patients with limb shortening more than 2.5 cm, proximal femoral osteotomy and bone lengthening components were required to prepare limb lengthening after operation;all patients did not receive bone graft. The wearing time of external fixator, clinical bone healing time of nonunion fracture end, and complications were recorded. The effectiveness was evaluated by Paley’s nonunion evaluation criteria. Results All patients were followed up 24-50 months,with an average of 30 months. Bony union was achieved in all 12 cases with a healing time of 6.0-23.5 months(mean, 11.5 months). The wearing time of external fixator ranged from 7 to 25 months, with an average of 13.5 months. At last followup, according to Paley’s nonunion evaluation criteria, the results were excellent in 6 cases, good in 4 cases, and fair in 2 cases,with an excellent and good rate of 83.3%. Sagittal angulation deformity of femur more than 7° occurred in 4 cases,with no significant effect on knee extension function, and no special treatment such as osteotomy was performed. Two patients had shorter limbs(>2.5 cm) after operation and were replaced by high shoes;4 patients with trans-knee fixation lost knee joint mobility of 10-30° after operation;10 cases of needle tract infection occurred, of which 4 cases with infection and loosening of fixed needle were replaced and re-fixed after needle extraction, the remaining 6 cases of infection without loosening of fixed needle were controlled by local dressing change, needle nursing, and oral cephalosporin anti-inflammatory drugs. No complications such as deep infection and vascular nerve injury occurred.Conclusion Ilizarov external fixation has a high healing rate for atrophic femoral shaft nonunion, which is relatively minimally invasive and can avoid bone grafting. Its preliminary effectiveness is exact, and it is also effective for patients who have experienced multiple failed operations. It is necessary to pay attention to the nursing and rehabilitation training after external fixation.