Osteosynthesis of ununited femoral neck fracture by internal fixation combined with iliac crest bone chips and muscle pedicle bone grafting.
Osteosynthesis of ununited femoral neck fracture by internal fixation combined with iliac crest bone chips and muscle pedicle bone grafting.
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DOI：
10.4103/0019-5413.185591
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发表时间：
2016-07
影响因子：
1
通讯作者：
Baksi DP
中科院分区：
文献类型：
--
作者：
Baksi DD;Pal AK;Baksi DP
股骨颈骨折不愈合在发展中国家很常见，主要是由于延迟出现或初次内固定失败。此类骨折通常表现为股骨颈部分或全部吸收，8 - 30%的病例出现股骨头坏死，转子向上移位，给接骨术带来问题，尤其是在年轻人中。描述了几种治疗此类疾病的技术，如截骨术或非血管皮质骨或松质骨移植术，在骨折愈合方面提供了不同程度的成功，但由于股骨头缺血性坏死（AVN）的发生率不同，长期结果不令人满意。此外，股骨头AVN存在时，游离腓骨移植或松质骨移植均不能令人满意。带血管旋髂深动脉在髂嵴植骨、带血管游离腓骨移植、带肌蒂骨膜移植的基础上行带血管旋髂深动脉植骨术，成功率高。接骨术是年轻人股骨颈骨折不愈合的首选治疗方法。在1977年6月至2009年6月期间接受手术的293例患者中，有42例失访。排除7例臀中肌肌蒂骨移植术（MPBG）。因此，在244例患者中，208例（85.3%）未治疗的骨不连和36例（14.7%）初次内固定失败后的骨不连可用于研究。未治疗骨不连患者从受伤到手术时间平均为6.5个月，内固定失败患者平均为11.2个月。患者年龄16~55岁。股骨颈部分吸收70例，次全吸收174例。135例（54.3%）患者的组织学检查和48例（19.7%）患者的影像学检查发现股骨头缺血性坏死（AVN）证据。采用切开复位、空心髋螺钉内固定、髂骨碎骨、股方肌MPBG等方法治疗。平均随访时间为12.5年（范围3 - 35）。骨折愈合202例（82.8%），延迟愈合18例（7.3%），骨不连24例（9.8%）。骨折愈合后16 - 22周允许完全负重。最长随访时的平均Harris髋关节评分为85.5。在并发症中，20例（8.2%）发生浅表伤口感染，7例（2.9%）发生深部感染，39例（16%）发生髋内翻。骨折愈合后，术前股骨头密度大多消失，20例（8%）出现新鲜股骨头密度，9例（45%）出现节段性塌陷。股骨颈骨折不愈合的特点是股骨颈吸收、后方皮质缺损、骨折面变平、覆盖、纤维组织介入、伴或不伴股骨头缺血性坏死。上述方法纠正了上述病理，并提供了满意的结果，在长期随访中，骨折愈合率为90.1%。
Ununited femoral neck fracture is seen commonly in developing countries due to delayed presentation or failure of primary internal fixation. Such fractures, commonly present with partial or total absorption of femoral neck, osteonecrosis of femoral head in 8–30% cases with upward migration of trochanter posing problem for osteosynthesis, especially in younger individuals. Several techniques for treatment of such conditions are described like osteotomies or nonvascularied cortical or cancellous bone grafting provided varying degrees of success in terms of fracture union but unsatisfactory long term results occurred due to varying incidence of avascular necrosis (AVN) of femoral head. Moreover, in presence of AVN of femoral head neither free fibular graft nor cancellous bone graft is satisfactory. The vascularied bone grafting by deep circumflex iliac artery based on iliac crest bone grafting, free vascularied fibular grafting and muscle pedicle periosteal grafting showed high incidence of success rate. Osteosynthesis is the preferred treatment of choice in ununited femoral neck fracture in younger individuals. Of the 293 patients operated during the period from June 1977 to June 2009, 42 were lost to followup. Seven patients with gluteus medius muscle pedicle bone grafting (MPBG) were excluded. Thus, out of 244 patients, 208 (85.3%) untreated nonunion and 36 (14.7%) following failure of primary internal fixation were available for studies. Time interval between the date of injury and operation in untreated nonunion cases was mean 6.5 months and in failed internal fixation cases was mean 11.2 months. Ages of the patients varied from 16 to 55 years. Seventy patients had partial and 174 had subtotal absorption of the femoral neck. Evidence of avascular necrosis (AVN) femoral head was found histologically in 135 (54.3%) and radiologically in 48 (19.7%) patients. The patients were operated by open reduction of fracture, cannulated hip screw fixation, iliac crest bone chips and quadratus femoris MPBG. The mean followup is 12.5 years (range 3-35). The union of fractures occurred in 202 (82.8%), delayed union in 18 (7.3%), and established nonunion in 24 (9.8%) patients. Full weight bearing was permitted at 16–22 weeks after union of fractures. Mean Harris hip score at the longest followup was 85.5. Among the complications, superficial wound infection occurred in 20 (8.2%), deep infection in seven (2.9%), and coxa vara in 39 (16%) patients. Preoperative radiodensity of femoral head disappeared mostly after the union of fracture whereas fresh radiodensity of femoral head appeared in 20 (8%) patients; nine (45%) of them developed segmental collapse. Ununited femoral neck fractureis characterized by absorption of femoral neck, posterior cortical defect, smoothening and overriding of fracture surfaces with intervening fibrous tissues associated with or without AVN of femoral head. The above method of osteosynthesis rectified the above pathology and provided satisfactory results with union of fractures in 90.1% patients at long term followup.