扩髓胫骨髓内钉治疗胫骨多段骨折的手术技巧及疗效观察
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摘要
背景:使用胫骨髓内钉治疗胫骨多段骨折时,如何判断力线、旋转、成角相对困难。目的:探讨扩髓胫骨髓内钉治疗胫骨多段骨折的临床疗效。方法:2014年1月至2017年1月治疗22例胫骨多段骨折患者,男17例,女5例;年龄23～63岁,平均38.6岁。10例闭合性损伤,12例开放性骨折(GustiloⅠ型1例,Ⅱ型4例,ⅢA型7例)。骨折按AO/OTA分型均为C2型。开放性骨折患者入院后先予以清创、外固定架固定,伤口稳定后更换髓内钉。闭合骨折患者入院后予以跟骨牵引,直至手术更换髓内钉。结果:所有患者术后随访10～24个月,平均13.7个月。末次随访按照JohnerWruh胫骨干骨折疗效评估标准:优14例,良7例,可1例,优良率95.5%。结论:胫骨扩髓髓内钉在治疗胫骨多段骨折时具有手术创伤小、固定牢靠、对软组织损伤少等优点;但对于干骺端部位的骨折段复位时需要额外的操作或特殊入路胫骨髓内钉,减少该部位的成角畸形;扩髓时需要保护中间骨段,防止轴向旋转破坏血运,导致骨缺血愈合困难。
Background: When intramedullary nailing is used to treat tibial multi-segmental fracture, it is relatively difficult to judge the force alignment, rotation and angulation. Objective: To explore surgical technique and clinical efficacy of reamed intramedullary nailing for multi-segmental fractures of the tibia. Methods: Totally 22 patients with tibial multi-segmental fracture treated by reamed intramedullary nailing between January 2014 and January 2017 were enrolled in this study. There were17 males and 5 females with an average age of 38.6 years(range, 23-63 years). There were 10 closed injuries and 12 open injuries(Gustilo classification: type Ⅰ, 1 case; type Ⅱ,4 cases, type Ⅲ A, 7 cases). All the fractures were classified to AO/OTA Type C2. Intramedullary nails were used after debridement and external fixation in open fractures of the tiabia. Closed fractures were treated with calcaneal traction until the operation was replaced by intramedullary nailing. Results: All the patients were followed up for an average of 13.7 months(range, 10-24 months). According Johner-Wruh evaluation of tibial shaft fractures, the outcome was excellent in 14 cases, good in 7 cases, and fair in 1 case at the final follow-up. Conclusions: Reamed intramedullary nailing has the advantages of less trauma, stable fixation, less injury for soft tissues in treatment of multi-segmental fractures of the tibia. But for some metaphyseal fractures, it requires additional operation or special approach of intramedullary nailing; during reaming, it is essential to protect the middle segment and prevent it from axial rotation which can destroy blood supply and result in difficulty in bone healing.
Background: When intramedullary nailing is used to treat tibial multi-segmental fracture, it is relatively difficult to judge the force alignment, rotation and angulation. Objective: To explore surgical technique and clinical efficacy of reamed intramedullary nailing for multi-segmental fractures of the tibia. Methods: Totally 22 patients with tibial multi-segmental fracture treated by reamed intramedullary nailing between January 2014 and January 2017 were enrolled in this study. There were17 males and 5 females with an average age of 38.6 years(range, 23-63 years). There were 10 closed injuries and 12 open injuries(Gustilo classification: type Ⅰ, 1 case; type Ⅱ,4 cases, type Ⅲ A, 7 cases). All the fractures were classified to AO/OTA Type C2. Intramedullary nails were used after debridement and external fixation in open fractures of the tiabia. Closed fractures were treated with calcaneal traction until the operation was replaced by intramedullary nailing. Results: All the patients were followed up for an average of 13.7 months(range, 10-24 months). According Johner-Wruh evaluation of tibial shaft fractures, the outcome was excellent in 14 cases, good in 7 cases, and fair in 1 case at the final follow-up. Conclusions: Reamed intramedullary nailing has the advantages of less trauma, stable fixation, less injury for soft tissues in treatment of multi-segmental fractures of the tibia. But for some metaphyseal fractures, it requires additional operation or special approach of intramedullary nailing; during reaming, it is essential to protect the middle segment and prevent it from axial rotation which can destroy blood supply and result in difficulty in bone healing.
引文
[1] Richard RD, Kubiak E, Horwitz DS. Techniques for the surgical treatment of distal tibia fractures. Orthop Clin North Am,2014,45(3):295-312.
[2] Zhang J, Ebraheim NA, Li M, et al. External fixation using a locking plate:a reliable way in treating distal tibial fractures.J Orthop Trauma, 2015, 29(11):e454-e458.
[3] Piatkowski, Piekarczyk P, Kwiatkowski K, et al. Comparison of different locking plate fixation methods in distal tibia fractures. Int Orthop, 2015,39(11):2245-2251.
[4]马腾,王谦,路遥,等.闭合复位髓内钉固定胫骨骨折术中远端是否存在内外翻的判断.中华创伤骨科杂志,2016,18(7):553-557.
[5] Johner R, Wruhs 0. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res, 1983,(178):7-25.
[6] Zhou Y, Wang Y, Liu L, et al. Locking compression plate as an external fixator in the treatment of closed distal tibial fractures. Int Orthop, 2015,39(11):2227-2237.
[7] Avilucea FR, Sathiyakumar V, Greenberg SE, et al. Open distal tibial shaft fractures:a retrospective comparison of medial plate versus nail fixation. Eur J Trauma Emerg Surg,2016, 42(1):101-106.
[8] Bombaci H, Güneri B, G(o|¨)rgec M, et al. A comparison between locked intramedullary nailing and plate-screw fixation in the treatment of tibial diaphysis fractures. Acta Orthop Traumatol Turc, 2004, 38(2):104-109.
[9] Cross JD, Stinner DJ, Burns TC, et al. Return to duty after typeⅢopen tibia fracture. J OrthopTrauma, 2012, 26(1):43-47.
[10] Shrestha D, Acharya BM, Shrestha PM. Minimally invasive plate osteosynthesis with locking compression plate for distaldiametaphyseal tibia fracture. Kathmandu Univ Med J(KUMJ), 2011,9(34):62-68.
[11] Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res,1996,(328):185-189.
[12] Shahulhameed A, Craig S. Roberts, Ojike NI. Technique for precise placement of poller screws with intramedullary nailing of metaphyseal fractures of the femur and the tibia. Injury, 2011, 42(2):136-139.
[13]朱越,罗从风,周蔚,等.髓内钉治疗胫骨多段骨折.中华创伤骨科杂志,2006,8(1):93-94.
[14] Ziran BH, Darowish M, Klatt BA, et al. Intramedullary nailing in open tibia fractures:a comparison of two techniques.Int Orthop, 2008,28(4):235-238.
[15] Keating JF, O'Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fracture of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am, 1997,79(3):334-341.
[16] Schemitsch EH, Kowalski MJ, Swiontkowski MF, et al. Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia. J Orthop Res,2009, 13(3):382-389.
[17]白祥,禹宝庆,顾龙殿,等.应用微创经皮接骨板内固定技术与带锁髓内钉治疗开放性C2型胫骨骨折的临床疗效比较.中国骨与关节外科,2014,7(5):363-366.
[18] Liporace FA, Stadler CM, Yoon RS. Problems, tricks, and pearls in intramedullary nailing of proximal third tibial fractures. J Orthop Trauma, 2013, 27(1):56-62.
[2] Zhang J, Ebraheim NA, Li M, et al. External fixation using a locking plate:a reliable way in treating distal tibial fractures.J Orthop Trauma, 2015, 29(11):e454-e458.
[3] Piatkowski, Piekarczyk P, Kwiatkowski K, et al. Comparison of different locking plate fixation methods in distal tibia fractures. Int Orthop, 2015,39(11):2245-2251.
[4]马腾,王谦,路遥,等.闭合复位髓内钉固定胫骨骨折术中远端是否存在内外翻的判断.中华创伤骨科杂志,2016,18(7):553-557.
[5] Johner R, Wruhs 0. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res, 1983,(178):7-25.
[6] Zhou Y, Wang Y, Liu L, et al. Locking compression plate as an external fixator in the treatment of closed distal tibial fractures. Int Orthop, 2015,39(11):2227-2237.
[7] Avilucea FR, Sathiyakumar V, Greenberg SE, et al. Open distal tibial shaft fractures:a retrospective comparison of medial plate versus nail fixation. Eur J Trauma Emerg Surg,2016, 42(1):101-106.
[8] Bombaci H, Güneri B, G(o|¨)rgec M, et al. A comparison between locked intramedullary nailing and plate-screw fixation in the treatment of tibial diaphysis fractures. Acta Orthop Traumatol Turc, 2004, 38(2):104-109.
[9] Cross JD, Stinner DJ, Burns TC, et al. Return to duty after typeⅢopen tibia fracture. J OrthopTrauma, 2012, 26(1):43-47.
[10] Shrestha D, Acharya BM, Shrestha PM. Minimally invasive plate osteosynthesis with locking compression plate for distaldiametaphyseal tibia fracture. Kathmandu Univ Med J(KUMJ), 2011,9(34):62-68.
[11] Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res,1996,(328):185-189.
[12] Shahulhameed A, Craig S. Roberts, Ojike NI. Technique for precise placement of poller screws with intramedullary nailing of metaphyseal fractures of the femur and the tibia. Injury, 2011, 42(2):136-139.
[13]朱越,罗从风,周蔚,等.髓内钉治疗胫骨多段骨折.中华创伤骨科杂志,2006,8(1):93-94.
[14] Ziran BH, Darowish M, Klatt BA, et al. Intramedullary nailing in open tibia fractures:a comparison of two techniques.Int Orthop, 2008,28(4):235-238.
[15] Keating JF, O'Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fracture of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am, 1997,79(3):334-341.
[16] Schemitsch EH, Kowalski MJ, Swiontkowski MF, et al. Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia. J Orthop Res,2009, 13(3):382-389.
[17]白祥,禹宝庆,顾龙殿,等.应用微创经皮接骨板内固定技术与带锁髓内钉治疗开放性C2型胫骨骨折的临床疗效比较.中国骨与关节外科,2014,7(5):363-366.
[18] Liporace FA, Stadler CM, Yoon RS. Problems, tricks, and pearls in intramedullary nailing of proximal third tibial fractures. J Orthop Trauma, 2013, 27(1):56-62.