髓外固定辅助双植骨治疗股骨转子下骨折髓内固定术后骨不连

Medullary external fixation assisted by double grafting for subtrochanteric femoral nonunions after intramedullary fixation

目的探讨髓外固定股骨近端接骨板(PFP)及锁定加压接骨板(LCP)辅助双植骨头钉孔道内松质骨、异体骨混合打压植骨及骨不连断端结构植骨治疗股骨转子下骨折髓内固定术后骨不连的手术技巧和临床疗效。方法回顾性分析2018年1月至2018年12月期间西安交通大学附属红会医院创伤骨科下肢病区收治且完整随访的21例股骨转子下骨折髓内固定术后骨不连患者资料。男15例,女6例;平均年龄为52.3岁(27~65岁)。骨不连类型:萎缩型18例,缺血型3例。患者骨不连手术与骨折初次手术的时间间隔平均为10.3个月(9~13个月),骨折手术均采用髓内固定(PFNA):闭合复位10例,切开复位11例(其中钢丝捆扎8例)。骨不连均采用髓外固定(PFP+LCP)辅助双植骨(头钉孔道内松质骨、异体骨混合打压植骨+骨不连断端结构植骨)治疗。术后12个月采用Harris评分评估髋关节功能。结果21例患者术后获平均11.4个月(10~12个月)随访。所有患者术后骨不连均获愈合,平均愈合时间为5.2个月(4~6个月)。1例患者术后出现皮下血肿,再次行清创术。术后12个月Harris髋关节评分平均为85.7分(84~92分)。结论PFP接骨板能够有效纠正内翻畸形并坚强固定,LCP接骨板+皮质骨结构植骨能够提供内侧力学支撑,松质骨+异体骨混合打压植骨能够有效增加头钉孔道内骨量,增加近端螺钉的把持力。该方法可以极大地提高骨折愈合率,减少并发症的发生,且能获得较好的髋关节功能。

Objective To evaluate the clinical efficacy and operative techniques of medullary external fixation with proximal femoral plate(PFP)and locking compression plate(LCP)assisted by double grafting(cancellous bone and allograft bone grafting in nail holes plus structural grafting at ununited fracture ends)for subtrochanteric femoral nonunions after intramedullary fixation.Methods Between January 2018 and December 2008,21 patients received secondary revision at Department of Orthopedics,Honghui Hospital for subtrochanteric femoral nonunion after intramedullary fixation.All of them obtained full follow-up.They were 15 men and 6 women,with an average age of 52.3 years(from 27 to 65 years).There were 18 cases of atrophic nonunion and 3 ones of ischemic nonunion.The intervals between primary operation and secondary revision averaged 10.3 months(from 9 to 13 months).All the fractures were treated by intramedullary fixation with closed reduction in 10 cases and open reduction in 11 cases(including 8 ones of wire binding).All the nonunions were managed with PFP and LCP assisted by double grafting(cancellous bone and allograft bone grafting in nail holes plus structural grafting at ununited fracture ends).Functional recovery of the hip was evaluated by Harris scoring 12 months after operation.Results The 21 patients obtained an average follow-up of 11.4 months(from 10 to12 months).All the nonunions got united after an average time of 5.2 months(from 4 to 6 months).Postoperative subcutaneous haematomas occurred in only one patient which was treated by a secondary debridement.The mean hip Harris scores were 85.7(from 84 to 92).Conclusions As PFP can effectively correct varus deformity and strengthen fixation,LCP plus structural grafting can provide medial mechanical support,and cancellous bone and allograft bone grafting can increase the bone mass in nail holes,our composite method can greatly increase the healing rate of subtrochanteric femoral nonunions after intramedullary fixation with better functional recovery of the hip joint.