摘要
骨折不愈合指骨折在预期时间内未能愈合,且无新的干预下不可能愈合的情况.骨折不愈合可根据有无感染和骨折部位的生物活性进行分类.无菌性骨折不愈合主要分为萎缩性、营养不良性、肥大性骨折不愈合以及假性关节和骨缺损,不同类型的骨折不愈合采用不同的治疗策略.治疗骨折不愈合的关键在于准确诊断、控制感染、矫正畸形,并根据患者的具体情况选择合适的治疗方法.软组织管理在骨折不愈合的治疗中也起着重要作用,有时需要进行软组织修复以提供良好的愈合环境.骨折不愈合的治疗方法分为非手术和手术治疗.非手术治疗的优势在于避免可能的手术并发症,可分为直接干预和间接干预.间接干预方式包括:戒烟、优化营养、纠正内分泌和代谢紊乱、消除或减少某些药物;直接干预措施包括:负重、外固定、电磁刺激、超声波刺激、冲击波治疗、甲状旁腺激素.在手术干预之前应先尝试保守治疗,保守治疗无效或需行积极干预时再考虑行手术治疗.手术治疗方案包括更换髓内钉、髓内钉动力化、钢板固定、环形外固定架、关节置换等,需根据软组织的完整性、骨质缺损程度和合并疾病进行选择.自体骨移植是治疗骨折不愈合的金标准,另外同种异体骨移植和其他骨移植替代品也是治疗不愈合的选择.最理想的治疗方法需同时考虑外科医生的经验和技能、治疗方法的相对风险和益处以及患者的耐受性.
Abstract
Nonunion of a fracture denotes the scenario wherein the fracture fails to achieve healing within the anticipated timeframe and is improbable to mend without further interventions.This ailment can be classified based on the presence of infec-tion and the biological activity at the fracture site,with a specific emphasis in this discourse on the management of aseptic non-union.The spectrum of nonunion encompasses atrophic,dystrophic,hypertrophic,pseudarthrosis,and bone defect variants,each necessitating distinctive treatment strategies.Successful management of nonunion hinges upon meticulous diagnosis,efficient in-fection control,and rectification of any associated deformities,all personalized to the unique circumstances of the individual pa-tient.Soft tissue management plays a pivotal role,often necessitating reparative measures to foster an optimal healing environment.The therapeutic approach to nonunion fractures delineates into non-surgical and surgical modalities,offering advantages in circum-venting potential surgical complications.Non-surgical interventions are further subdivided into direct and indirect methods.Indi-rect interventions encompass lifestyle modifications such as smoking cessation,nutritional optimization,correction of endocrine and metabolic irregularities,and medication adjustments.Direct interventions,conversely,encompass weight-bearing,external fix-ation,electromagnetic stimulation,ultrasound stimulation,shockwave therapy,and parathyroid hormone administration.Prudent clinical practice dictates the trial of conservative treatments before resorting to surgical interventions,with the latter reserved for instances of treatment resistance or necessitated by aggressive measures.Surgical options encompass a diverse array of tech-niques,contingent upon soft tissue integrity,degree of bone defect,and comorbiditics,including intramedullary nail replacement,dynamic intramedullary nails,plate fixation,circular external fixation frames,and joint replacements.Autogenous bone grafting stands as the gold standard for treating nonunion fractures,while allograft bone grafting and other bone graft substitutes present vi-able options for addressing nonhealing fractures.The optimal therapeutic approach mandates a comprehensive assessment of the surgeon's expertise,the comparative risks and benefits of interventions,and the patient's individual tolerance.
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