Intramedullary nail retention and augmentation plating for the treatment of nonisthmal femoral shaft nonunions

doi:10.3969/j.issn.2095-4344.2013.39.012

Abstract

Abstract:

BACKGROUND: Exchange nailing has been reported to be a very good method for metaphyseal nonunion after femoral shaft fracture treated with intramedullary nail. However, the effect of intramedullary nail exchanging is not ideal for the treatment of nonisthmal femoral shaft nonunions.
OBJECTIVE: To compare the clinical and imaging outcomes between intramedullary nail exchanging and intramedullary nail retention plus augmentation plating for the treatment of nonisthmal femoral shaft nonunions.
METHODS: The clinical data of 39 patients with nonisthmal nonunions of femoral shaft fractures after failure of intramedullary nail were retrospectively analyzed, and 21 patients were treated with intramedullary nail exchanging and 18 patients were treated with intramedullary nail retention plus augmentation plating. Clinical therapeutic effect was evaluated by Tohner-Wrnch standard.
RESULTS AND CONCLUSION: All cases were followed-up for more than 15 months. In the intramedullary nail exchanging group, postoperative internal fixator loosening occurred in three cases who obtained bony union by intramedullary nail retention plus augmentation plating combined with autogenous iliac bone graft. The fixation time, blood loss, volume for suspended red blood cells transfusion, hospitalization costs and re-operation rate in the intramedullary nail retention plus augmentation plating group were lower than that in the intramedullary nail exchanging group (P < 0.05). All the patients in two groups obtained bony union, and the clinical and radiographic healing time in the intramedullary nail exchanging group were longer than those in the intramedullary nail retention plus augmentation plating group (P < 0.05); according to Tohner-Wrnch standard at final follow-up, excellent in
10 cases, good in six cases and poor in five cases in the intramedullary nail exchanging group, and the excellent and good rate was 76%; in the intramedullary nail retention plus augmentation plating group, there were 11 cases of excellent and seven cases of good, and the excellent and good rate was 100%; there was significant difference between two groups (P < 0.05). Due to relatively simpler manipulation, shorter fixation time, less intraoperative blood loss, slighter trauma, less hospitalization cost, lower re-operation rate and more satisfactory therapeutic effect, intramedullary nail retention plus augmentation plating combined with autogenous iliac bone graft has been a better method for the treatment of nonisthmal nonunions of femoral shaft fractures after failure of intramedullary nailing when compared with intramedullary nail exchanging.

Key words: prostheses and implants, femoral fractures, fractures, ununited, bone nails, internal fixators

CLC Number:

R318

Ru Jiang-ying, Cang Hai-bin, Hu Yu-hua, Hu Chuan-liang. Intramedullary nail retention and augmentation plating for the treatment of nonisthmal femoral shaft nonunions[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(39): 6932-6939.

Figures/Tables 5

2.3 两组内固定后骨折愈合及膝关节活动情况更换髓内钉组：X射线片结果显示，治疗后6-10个月，16例患者达到完全骨性愈合，骨折线消失，平均愈合时间7.9个月；治疗后1年随访时，5例未按期完成骨愈合，骨性愈合率为76.2%，其中3例予再次行保留髓内钉、附加钢板并联合自体髂骨植骨治疗，2例单纯行植骨，最终均完成骨性愈合。再次内固定后临床骨愈合时间平均7.3个月(5-10个月)。内固定中于骨不连部位切取组织行细菌培养，结果显示无异常。末次随访时，21例患者中膝关节活动度屈曲平均112°(105°-130°)，伸直为-5°(-15°-0°)。保留髓内钉附加钢板组：X射线片结果显示，治疗后6个月，3例达到完全骨性愈合，骨折线消失；15例骨折端有明显骨痂形成，骨折线模糊。治疗后6-9个月12例X射线片显示达到骨性愈合，平均愈合时间7.5个月；另3例治疗后10-11个月X射线片显示达到骨性愈合，平均10.3个月。骨性愈合率为100%；末次随访时，18例患者中膝关节活动度恢复良好，屈曲平均为122°(105°- 140°)，伸直为0°。 2.4 两组内固定后疗效与结果比较两组随访时间、内固定后引流血量、膝关节活动范围及住院时间比较差异均无显著性意义(P > 0.05)；而两组内固定时间、内固定中出血量、内固定中输悬浮红细胞、住院费用、再手术率比较差异有显著性意义(P < 0.05)。两组患者最终均获得骨性愈合, 更换髓内钉组的临床及影像学愈合时间均显著长于保留髓内钉附加侧板组(P < 0.05)。末次随访时，根据Tohner-Wrnch标准评定疗效[7]：更换髓内钉组：优10例，良6例，差5例，优良率76.2%；保留髓内钉附加侧板组：优11例，良7例，优良率100%，两组之间比较差异有显著性意义(P < 0.05)。见表2，3。"

References

[1]Pihlajamäki HK, Salminen ST, B?stman OM.The treatment of nonunions following intramedullary nailing of femoral shaft fractures.J Orthop Trauma. 2002;16(6):394-402.
[2]Oh JK, Bae JH, Oh CW, et al.Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft. Injury. 2008;39(8):952-959.
[3]Brinker MR,O'Connor DP.Exchange Nailing of Ununited Fractures. J Bone Joint Surg Am.2007,89:177-188 .
[4]张建政,刘智,孙天胜,等.附加钢板治疗髓内钉固定后股骨萎缩性骨不连[J].中华创伤杂志,2011,27(5):451-455.
[5]Park J, Kim SG, Yoon HK, et al.The treatment of nonisthmal femoral shaft nonunions with im nail exchange versus augmentation plating. J Orthop Trauma. 2010 Feb;24(2):89-94.
[6]赵刚,张伯松,孙林,等.带锁髓内钉治疗股骨干骨折术后旋转不稳定所致不愈合的诊断和治疗[J].中华外科杂志,2009,47(16): 1232-1235.
[7]李宝文,王东昕,李学良,等.股骨干骨折术后不愈合25例临床分析[J].中国修复重建外科杂志,2008,22(6):763-764.
[8]刘振东.扩髓换钉治疗股骨干无菌性骨不连[J].中华创伤骨科杂志, 2005,7(5):470-472
[9]李衡,张奉琪,任栋,等.股骨干骨折带锁髓内钉固定后不愈合的治疗[J].中华骨科杂志,2005,24(8):476-480.
[10]Lin CJ, Chiang CC,Wu PK,et al. Effectiveness of plate augmentation for femoral shaft nonunion after nailing. J Chin Med Assoc.2012;75(8):396-401.
[11]Said GZ, Said HG, el-Sharkawi MM.Failed intramedullary nailing of femur: open reduction and plate augmentation with the nail in situ. Int Orthop. 2011;35(7):1089-1092.
[12]Lambiris E,Panagopoulos A,Zouboulis P,et al.Current concepts：aseptic nonunion of femoral shaft diaphysis.Eur J Trauma Emerg Surg,2007;33(2):120-134.
[13]Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop. 2005;29(5):287-290.
[14]Johner R, Raccaud O, Dournow J. Standard radiological study of the knee. Rev Med Suisse Romande. 1994;114(4): 335-341.
[15]Court-Brown CM,Keating JF,Ch istie J,et al. Exchange intramedullary nailing. Its use in aseptic tibial nonunion. J Bone Joint Surg Br.1995;77:407-411.
[16]Bhandari M,Schemitsch EH. Bone formation following intramedullary femoral reaming is decreased by indomethacin and antibodies to insulin-like growth factors. J Orthop Trauma. 2002;16:717-722 .
[17]Banaszkiewicz PA, Sabboubeh A, McLeod I, et al. Femoral exchange nailing for aseptic non-union: not the end to all problems.Injury.2003;34(5):349-356.
[18]Weresh MJ,Hakanson R,Stover MD,et al.Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma.2000;14:335-338.
[19]Ueng SW, Chao EK, Lee SS, et al. Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing. J Trauma. 1997;43(4):640-644.
[20]Park K, Kim K, Choi YS. Comparison of mechanical rigidity between plate augmentation leaving the nail in situ and interlocking nail using cadaveric fracture model of the femur. Int Orthop.2011;35(4):581-585.
[21]Lynch JR, Taitsman LA, Barei DP,et al.Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg.2008; 16(2):88-97.
[22]茹江英,仓海滨,胡传亮,等.附加侧板联合植骨治疗股骨干骨折髓内钉固定后骨不连[J].中国组织工程研究,2013,17(4):604-611.
[23]李福春,谷贵山,金成浩,等.更换髓内钉治疗股骨干骨折髓内钉内固定术后骨不连：12例资料回顾性分析[J].中国组织工程研究与临床康复,2007,11(47):9584-9586.
[24]Shroeder JE, Mosheiff R, Khoury A, et al. The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions. J Orthop Trauma. 2009;23(9):653-657.
[25]李冀,赵伟超,关鹏飞,等.长骨医源性骨不连的临床流行病学调查[J].中国骨与关节损伤杂志,2012,27(1):34-36.
[26]刘璠,祁俊.骨折不愈合与延迟愈合的成因与治疗[J].中华创伤骨科杂志,2005,7(5):405-408.
[27]王秋根,高堪达,高伟,等.下肢髓内钉术后非感染性骨不连的对策:内植骨结合阻挡钉技术[J].中国矫形外科杂志,2009,16(14): 1045-1047.
[28]Nadkarni B, Srivastav S, Mittal V, et al. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience. J Trauma.2008;65(2):482-486.
[29]刘智,李连华,孙天胜,等.附加钢板与交锁髓内钉治疗下肢长骨干骨折后肥大性骨
[30]张建政,孙天胜,刘智,等.更换髓内钉与保留髓内钉附加钢板治疗髓内钉固定后股骨肥大性骨不连[J].中华骨科杂志,2011,31(9): 949-954.