重建外固定支架治疗股骨转子下骨折内固定术后感染性骨不连的疗效分析

Treatment of infected nonunion after internal fixation of subtrochanteric fracture with a reconstruction stent of external fixation

目的:探讨应用重建外固定支架治疗股骨转子下骨折内固定术后感染性骨不连的疗效。方法:回顾性分析2017年1月至2022年10月期间太原长城骨伤手外科医院收治并获完整随访的5例男性股骨转子下骨折内固定术后感染性骨不连患者资料。年龄(30.0±13.5)岁;骨折按Seinsheimer类型:ⅢA型1例,ⅢB型1例,Ⅳ型2例,Ⅴ型1例;原内固定方式:髓内系统固定4例,钢板固定1例;Cierny-Mader分型均为Ⅳ型(弥散型)。采用一期彻底清创后,先于股骨外侧分别在骨折两端各置入2~3枚羟基磷灰石(HA)涂层螺钉,行单边重建外固定支架固定;然后4例近端加装组配1/3环于矢状位再辅以1~2枚HA涂层螺钉构成混合式外固定支架固定骨折,1例于股骨前侧矢状位分别在骨折两端各置入2枚HA涂层螺钉,2个单边重建外固定支架固定。抗生素骨水泥填充骨缺损,骨缺损长度为(3.8±1.8)cm。清创术后6~8周感染无复发,行抗生素骨水泥取出,3例患者行自体髂骨植骨术,2例患者行截骨运输术。记录患者的感染控制情况、骨愈合时间、外固定支架拆除时间、并发症、Sanders髋关节创伤后评分及Paley等的骨性评分等。结果:5例患者术后获(23.4±8.1)个月随访。3例经1次清创、2例经2次清创后骨折端感染获得控制。1例因近端钉道感染松动,2次更换HA涂层螺钉,对合端行自体髂骨植骨术;其余4例无并发症发生。所有患者的延长段和骨折端均达骨性愈合。患者骨重建术后影像学愈合时间为(10.2±3.4)个月,外固定支架佩戴时间为(18.0±4.5)个月。均无感染复发或遗留感染。末次随访时根据Sanders髋关节创伤后评分标准评定疗效:优4例,良1例;根据Paley等的骨性评分标准评定疗效均为优。结论:应用重建外固定支架结合抗生素骨水泥技术一期控制感染,二期行骨重建术能成功治疗股骨转子下骨折内固定术后感染性骨不连,且保留髋关节功能,是一种可行的治疗方法。

Objective To evaluate the treatment of infected nonunion after internal fixation of subtrochanteric fracture with a reconstruction stent of external fixation.Methods A retrospective study was conducted to analyze the data of 5 male patients with infected nonunion after internal fixation of subtrochanteric fracture who had been treated and completely followed up at The Great Wall Orthopaedics and Hand Surgery Hospital from January 2017 to October 2022.The patients were(30.0±13.5)years old.Seinsheimer fracture types:ⅢA(1 case),ⅢB(1 case),Ⅳ(2 cases),andⅤ(1 case);original internal fixation:intramedullary system(4 cases)and plate fixation(1 case);the Cierny-Mader anatomical classification:typeⅣ(diffuse type)for all.After complete debridement at stage one,2 or 3 hydroxyapatite(HA)coated screws were placed at both fracture ends from the lateral side of the femur for unilateral reconstruction external fixation.Next,a hybrid external fixation scaffold was added with a 1/3 ring at the sagittal position and 1 or 2 HA screws in 4 cases while unilateral reconstruction external fixation was constructed at both sides by inserting 2 HA screws into both fracture ends from the anterior femur at the sagittal position in 1 case.Antibiotic bone cement was used to fill bone defects of(3.8±1.8)cm.At 6 to 8 weeks after debridement when infection did not recur,antibiotic bone cement was removed before autogenous iliac bone grafting was performed in 3 patients and osteotomy bone transport in 2 patients.Infection control,bone union time,time for removal of external fixation stent,complications,Sanders hip function score and Paley bone outcome score were recorded.Results The 5 patients were followed up for(23.4±8.1)months after surgery.Infection at the fracture ends was controlled after 1 time of debridement in 3 patients and after 2 times of debridement in 2 patients.The loosening HA screws were replaced twice due to infection at the proximal nail tract,and autologous bone grafting was performed at the opposite fracture ends in 1 case;no complications occurred in the other 4 cases.Bony union was achieved at the extended segment and fracture ends in all patients.The time for imaging union after bone reconstruction was(10.2±3.4)months.The time for wearing a stent of external fixation was(18.0±4.5)months.There was no recurrent infection or lingering infection.According to the Sanders hip function score at the last follow-up,4 cases were excellent and 1 case was good;according to the Paley bone outcome score,the curative effect was excellent in all.Conclusion Application of a reconstruction stent of external fixation combined with antibiotic bone cement can control infection at the first stage and conduct bone reconstruction at the second stage to successfully treat the infected nonunion and preserve the hip function after internal fixation of subtrochanteric fracture.