第三骨块对股骨干骨折髓内钉固定后骨愈合效果的影响

Effect of the third fragment on the healing of femoral shaft fractures after intramedullary nailing fixation

背景:文献报道,伴第三骨块的股骨干骨折髓内钉固定后不愈合发生率高于无第三骨块的股骨干骨折,认为第三骨块的位移或形态与骨不愈合有关。目的:探讨第三骨块对股骨干骨折髓内钉固定后骨愈合效果的影响。方法:选择2009年1月至2018年4月无锡市第二中医医院和无锡市人民医院收治的伴第三骨块股骨干骨折患者52例,其中男32例,女20例,年龄16-69岁,均接受髓内钉固定治疗。术后拍摄X射线片测量第三骨块的长度及远端、近端位移,根据第三骨块的长度分为:A组(1.0-3.9 cm),B组(4.0-7.9 cm)和C组(≥8 cm);根据第三骨块远端(D)或近端(P)移位分为:D1组、P1组(0-9 mm),D2、P2组(10-19 mm),D3、P3组(≥20 mm)。术后随访12个月判定骨折愈合情况,如12个月仍未愈合判定为不愈合。采用Logistic回归分析第三骨块形态对骨折愈合的影响。研究获无锡市第二中医医院和无锡市人民医院伦理委员会批准。结果与结论:①术后随访12个月,52例患者中41例骨折愈合,愈合率为79%;②A、B、C组间的第三骨块远端位移比较差异无显著性意义(P>0.05)、近端位移比较差异无显著性意义(P>0.05),3组间的骨折愈合率与骨折愈合时间比较差异无显著性意义(P>0.05);③第三骨块远端(或近端)位移越大,骨折愈合率越低、愈合时间越长,总体上3组间的骨折愈合率和愈合时间比较差异有显著性意义(P<0.05),移位<1 cm组与其他两组比较差异有显著性意义(P<0.05);④Logistic回归分析显示,第三骨块长度对骨折愈合无影响(P>0.05),第三骨块远端与近端位移对骨折愈合有影响(P<0.05);⑤第三骨块移位影响骨愈合效果,对于移位超过1 cm的第三骨块宜采用切开或闭合方式对第三骨块实施复位或固定。

BACKGROUND:It was reported that the incidence of nonunion for femoral shaft fractures with third fragment after intramedullary nailing fixation was higher than that without third fragment.Therefore,the displacement or morphology of the third fragment was related to bone nonunion.OBJECTIVE:To investigate the effect of third fragment on the healing of femoral shaft fractures after intramedullary nailing fixation.METHODS:Fifty-two cases of femoral shaft fractures with third fragment treated with intramedullary nailing fixation in Wuxi No.2 Chinese Medicine Hospital and Wuxi People's Hospital from January 2009 to April 2018 were retrospectively analyzed.There were 32 males and 20 females,the age ranged from 16 to 69 years old.X-ray films were taken to measure the length,distal and proximal displacement of the third fragment.According to the length of the third segment,the patients were divided into three groups:Group A(1.0-3.9 cm),Group B(4.0-7.9 cm)and Group C(≥8 cm).According to the displacement of the proximal(P)and distal(D)of the third fragment,the patients were divided into three groups:Group D 1,Group P 1(0-9 mm),Group D 2,Group P 2(10-19 mm),Group D 3,and Group P 3(≥20 mm).After 12 months of follow-up,the fracture healing was determined.If the fracture did not heal for 12 months,it was determined as nonunion.The influence of the third fragment morphology on difficult healing was analyzed by Logistic regression.The study was approved by the Ethics Committee of Wuxi No.2 Chinese Medicine Hospital and Wuxi People’s Hospital.RESULTS AND CONCLUSION:(1)After 12 months of follow-up,41 of 52 patients healed,the healing rate was 79%.(2)There was no significant difference in the distal displacement of the third fragment among groups A,B and C(P>0.05),and the difference in the proximal displacement was not significant(P>0.05).There was no significant difference in nonunion rate and healing time among the three groups(P>0.05).(3)According to the displacement of the proximal and distal of the third fragment,the greater the distal or proximal displacement,the lower the fracture healing rate and the longer the healing time;there were significant differences in healing rate and healing time among the three groups(P<0.05).The differences between the group with displacement<1 cm and other groups were significant(P<0.05).(4)Logistic regression analysis showed that the length of the third fragment had no significant effect on fracture healing(P>0.05);however,the distal and proximal third fragment displacement had significant influence on fracture healing(P<0.05).(5)The displacement of the third fragment has influence on the bone healing.Open or close reduction or fixation of the third fragment should be performed when the displacement is more than 1 cm.