股骨干骨折骨不连保留髓内钉复合植骨侧方钢板固定△

Lateral plate and bone graft with intramedullary nail retention for nonunion of femoral shaft fracture

摘要:

[目的]介绍侧方钢板联合自体髂骨及骨形态发生蛋白-2（bone morphogenetic protein-2, BMP-2）复合植骨治疗股骨干骨折髓内钉术后骨不连的手术技术及临床结果。[方法]患者麻醉后取仰卧位，于同侧髂部截取合适面积髂骨块备用。以术前透视定位骨折部位为中心，取患侧大腿外侧纵行切口，暴露骨折端，清理骨折端并去除断端死骨及硬化骨直至骨面新鲜出血，选取合适长度重建钢板或锁定钢板置于股骨断端外侧，依次钻孔、测深、拧入螺钉固定，根据骨折断端处理后缺损情况将所取髂骨修剪为合适大小骨块，与 BMP-2 混合后充分填塞于骨折断端，放置引流管，逐层缝合伤口并加压包扎。[结果]所有患者均顺利完成手术，手术时间平均（102.7±13.2）min。术中出血量平均（257.6±70.3）mL。随访时间平均（15.8±3.8）个月， 术后 9 个月膝关节活动度（120.5±5.9）°，末次随访 HSS 膝关节功能评分（87.9±2.4）分，膝关节功能优 12 例、良 1 例，优良率为 100%。末次随访时骨折均愈合良好。[结论]侧方钢板联合自体髂骨及 BMP-2 植骨治疗股骨干骨折髓内钉术后骨不连疗效满意，愈合率高，术后患肢功能恢复良好。

Abstract:

[Objective] Introduce the surgical technique and clinical results of lateral plate combined with iliac bone autograft and BMP-2 with intramedullary nail retention for nonunion of the femoral shaft fractures secondary to intramedullary nail fixation. [Methods] After anesthesia, the patient was put in supine position, iliac bone autografts were harvest ipsilaterally. Based on preoperative images, a longitudinal incision centered on the fracture site was made on lateral side of the affected thigh to expose the nonunion. The fracture ends were debrided with previous intramedullary nail retension, involving removing dead bone and hardened bone until fresh bleeding on the bone surface. A reconstructive plate or locking plate in suitable length was placed on the outer side of the femoral fracture ends, with drilling, depth measure, and screw fixation conducted in sequence. According to the defect situation after debridement, the iliac bone autograft was trimmed into a suitable size, mixed with BMP-2, and fully filled in gap between the fracture ends. As the drainage tube was placed, the wound was closed in layers and bandaged in proper pressure. [Results] All patients successfully completed the surgery and were followed up from 12 to 24 months with a mean of (15.8±3.8) months. At the last follow-up, all patients had the fractures nonunion healed well, with a healing time of (7.5±1.7) months in a mean, ranged from 5 to 10 months. The knee extension-flexion range of motion (ROM) was (120.5±5.9)° 9 months postoperatively, while the HSS score for knee function at the last follow-up were of (87.9±2.4) in a mean. The clinical outcome was marked as excellent in 12 cases and good in one case, with excellent and good rate of 100% at the latest follow-up. [Conclusion] The lateral plate combined with autologous iliac bone and BMP-2 grafting with nail retention for nonunion of femoral shaft fractures secondary to intramedullary nail fixation achieves satisfactory clinical outcome, with advantages of high healing rate and good recovery of limb function.