【摘要】 目的 探讨髓内钉联合锁定钢板髓内髓外组合式固定结合自体髂骨植骨治疗股骨干无菌性骨不连的疗效。方法 回顾性分析2018年11月至2024年4月采用钉板组合式固定结合自体髂骨植骨治疗24例股骨干无菌性骨不连患者的临床资料。其中,闭合性骨折22例,开放性骨折2例。股骨近端骨折7例,股骨中段骨折9例,股骨远端骨折7例,股骨颈合并同侧股骨中段骨折1例。根据AO/ASIF分型:A型9例, B型8例, C型7例。股骨干萎缩型骨不连20例,肥大型骨不连4例。入院时内固定类型:髓内钉16例,锁定钢板7例,外支架1例。病程平均(17.1±10.1)月。1例曾行骨不连手术。采用保留原髓内钉附加锁定钢板固定15例,改用髓内钉联合锁定钢板固定9例,所有患者均行自体髂骨植骨。观察手术时间、术中失血量、骨不连愈合时间、术后并发症及膝关节活动度,术前及末次随访采用视觉模拟评分法(VAS)进行疼痛评分,末次随访依据Wu评分标准评价疗效。结果 本组24例患者均顺利完成手术,手术时间平均(169.8±34.9) min,术中出血量平均(736.3±168.7)mL。平均随访(24.8±10.3)月。均获骨愈合,愈合时间4～11个月,平均(7.1±1.7)月。无伤口感染、内固定松动断裂、下肢深静脉血栓形成、骨髓炎等并发症。末次随访VAS评分由术前(4.7±1.1)分降至(0.9±1.2)分,膝关节活动度由术前106.1°±24.9°改善至124.6°±15.6°,均有统计学差异(P<0.001或P<0.01)。所有患者髋关节活动正常,膝关节活动受限(活动度<100°)3例。末次随访评价疗效:优19例,良5例,优良率100%。结论 髓内钉联合锁定钢板髓内髓外组合式固定结合自体髂骨植骨治疗股骨干无菌性骨不连,愈合率高,并发症少,疗效满意。更多还原

【Abstract】 Objective To investigate the clinical outcomes of nail-plate combined fixation(intramedullary nail and extramedullary locking plate) with autologous iliac bone grafting for aseptic nonunion of the femoral shaft. Methods A retrospective analysis was conducted on 24 patients with aseptic femoral shaft nonunion who were treated with combined intramedullary nail and locking plate fixation augmented with autologous iliac bone grafting between November 2018 and April 2024. Among them, there were 22 cases of closed fracture and 2 cases of open fracture. The fracture sites included the proximal femur in 7 cases, the mid shaft in 9 cases,the distal femur in 7 cases, and 1 case of femoral neck fracture combined with ipsilateral mid shaft femoral fracture. Based on the AO/ASIF classification, there were 9 cases of type A, 8 cases of type B, and 7 cases of type C. There were 20 cases of atrophic nonunion and 4 cases of hypertrophic nonunion. The prior fixation methods included intramedullary nails in 16 cases, locking plates in 7 cases, and external fixators in 1 case.The mean time from initial fracture to surgery for nonunion was(17. 1±10. 1) months. One patient had a history of previous surgery for nonunion. In terms of surgical procedures, the existing intramedullary nail was retained and augmented with a locking plate in 15 cases, while the remaining 9 cases were treated with exchange nailing combined with a locking plate; autologous iliac bone grafting was performed in all patients. The operation time,intraoperative blood loss, time to union, postoperative complications, and knee range of motion(ROM) were recorded. Pain was assessed using the Visual Analogue Scale(VAS) both preoperatively and at the last follow-up.Clinical outcomes at the last follow-up were evaluated according to the Wu scoring criteria. Results The surgical interventions were successfully completed in all 24 patients. The mean operation time was(169. 8±34. 9) minutes, and the mean intraoperative blood loss was(736. 3±168. 7) mL. All patients were followed up for a mean of(24. 8±10. 3) months. Bone union was achieved in all cases within 4 to 11 months with a mean time to union of(7. 1±1. 7) months. No complications such as surgical site infection, implant failure(loosening or breakage), deep vein thrombosis, or osteomyelitis occurred. At the last follow-up, the mean VAS score significantly improved from 4. 7±1. 1 preoperatively to 0. 9±1. 2(P<0. 001). The mean knee ROM also significantly improved from 106. 1° ±24. 9° preoperatively to 124. 6° ±15. 6°(P<0. 01). Hip joint motion was normal in all patients, while 3 patients had limited knee ROM(<100°). According to the Wu criteria at the last follow-up, the outcomes were excellent in 19 cases and good in 5 cases, yielding an excellent and good rate of 100%. Conclusion The nail-plate combined fixation(intramedullary nail and extramedullary locking plate) with autologous iliac bone grafting is an effective treatment for aseptic femoral shaft nonunion,associated with a high union rate, a low rate of complications, and satisfactory clinical outcomes.更多还原