附加锁定加压钢板与微创稳定系统联合自体骨植骨治疗逆行髓内钉术后股骨远端骨不连的对比分析

Comparison of efficacy between augmentative locking compression plating and less invasive stabilization system with autogenous bone grafting for distal femoral nonunion after failed retrograde intramedullary nailing

目的对比附加锁定加压钢板(LCP)与附加微创稳定系统(LISS)联合自体骨植骨术(ABG)治疗逆行髓内钉术后股骨远端骨不连的临床疗效。方法 44例逆行髓内钉术后股骨远端骨不连患者按附加内固定方式不同,分为附加LCP联合ABG组(附加LCP组,21例)和附加LISS联合ABG组(附加LISS组,23例)。记录并比较两组手术时间、骨愈合时间、骨愈合率、术后并发症发生率和内固定拔除术后1年患膝关节SF-36评分。结果所有病例平均随访19.8个月(12~36个月),附加LCP组和附加LISS组的骨愈合率分别为90.5%和100%(附加LISS组:OR=3.2,95%CI 0.7~1.3),附加LCP组中2例伴患膝关节僵硬患者(为AO33C1型和AO33C2型)分别于术后7、9个月发生骨再不连。两组患者的平均骨愈合时间[(9.7±1.8)个月vs.(5.1±0.6)个月]、骨再不连时间[(8.0±0.8)个月vs.0个月]和术后并发症发生率(9.5%vs.4.3%)差异均有统计学意义(均P<0.05),而在手术时间上[(109.3±20.2)min vs.(112.8±24.3)min]差异无统计学意义(P>0.05)。在内固定拔除术后1年随访时,两组患者在疼痛水平[72.8(66.7~77.8)分vs.84.4(78.9~94.0)分]和总体健康感知方面[62.0(57.0~67.0)分vs.67.0(62.0~72.0)分]的SF-36评分,差异有统计学意义(均P<0.05)。结论附加LCP联合ABG术适合治疗AO33A型的逆行髓内钉术后股骨远端骨不连患者;而对于AO33C型的骨不连患者的处理,采用附加LISS联合ABG术较附加LCP联合ABG术可能具有更大的优势。

Objective To compare the clinical efficacy between augmentative locking compression plate(LCP) and less invasive stabilization system(LISS) with autogenous bone grafting(ABG) in treating distal femoral nonunion subsequent to failed retrograde intramedullary nailing(RIN). Methods A retrospective study was performed for 44 patients with distal femoral nonunion subsequent to failed RIN, who were divided into the augmentative LCP group(n=21) with ABG and the augmentative LISS group(n=23) with ABG according to different internal fixation augmentation. Dates including operation time, time to union, union rate, time to renonunion, complication rate and SF-36 scores a year after hardware removal were recorded and compared between the two groups. Results The mean follow-up time for all patients was 19.8 months(12-36 months). Nineteen cases(90.5%) achieved the bone union in augmentative LCP group with ABG and 23 cases(100%) in augmentative LISS group with ABG [LISS group: odds ratio(OR)=3.2, 95% confidence interval(CI) 0.7-1.3]. Two patients with a stiff knee treated with augmentative LCP with ABG for distal femoral nonunion(type AO33C1 and AO33C2, respectively)obtained secondary nonunion at 7 and 9 months postoperatively. Time to union [(9.7±1.8) months vs.(5.1±0.6) months], time to renonunion [(8.0±0.8) months vs. 0 month], postoperative complication rate(9.5% vs. 4.3%)of two groups was different significantly(all P<0.05). However, no significant difference was found in the average operation time[(109.3±20.2) min vs.(112.8±24.3) min] of two groups(P>0.05). At the follow-up a year after hardware removal, health related quality of life(HRQOL) in the augmentive LISS group was significantly improved at the level of pain [72.8(66.7-77.8) scores vs. 84.4(78.9-94.0) scores]and general health perception [62.0(57.0-67.0) scores vs. 67.0(62.0-72.0) scores], as compared to the augmentive LCP group(all P<0.05). Conclusion We suggest augmentative LCP with ABG may be optimal for distal femoral nonunions after RIN of type AO33 A fractures, whereas augmentative LISS with ABG for that of type AO33 C fractures more.