双侧股骨干骨折多发于严重创伤，常合并头颅、胸腹部等其余部位损伤，其发生率约1%-7%，死亡率约6%-30%。

对股骨干骨折，髓内钉固定已成标注术式。但双侧股骨干骨折髓内钉的内固定治疗，双侧应同期固定或分期固定，仍存争议。同期固定可避免二次手术风险，但手术创伤大，对严重创伤患者存在“二次打击”，可能会导致不良结局并发症发生。

对此，一项多中心研究比较了双侧股骨干骨折，同期固定与分期固定在并发症方面的差异。文章发表于2021.09 JOT杂志。

Objective（目的）

评价髓内钉(IMN)治疗双侧股骨骨折患者在同期手术或2次分期手术中的并发症发生率。

[Objective: To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures.]

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Patients（病例）

10个一级创伤中心对自1998年至2018年间接受同期单次或两次分期手术治疗的双侧股骨骨折患者进行了多中心回顾性研究。共纳入246例双侧股骨骨折患者。

[Patients: A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. Two hundred forty-six patients with bilateral femur fractures.]

图1 病例挑选与治疗方法流程图。

图2 两组患者基线资料与损伤特征。

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Results（结果）

共纳入246例患者，其中188例为同期固定患者，58例为分期固定患者。两组的性别、年龄、损伤严重程度评分、简明损伤评分、二次损伤、格拉斯哥昏迷评分和开放性骨折比例相似。急性呼吸窘迫综合征(ARDS)在分期组发生率较高(13.8% vs 5.9%；p= 0.05)。当进一步调整年龄、性别、损伤严重程度评分、简明损伤评分、格拉斯哥昏迷评分和入院乳酸时，同期固定组发生ARDS的风险降低了78%。住院死亡率在同期固定组中较高(2.7%比0%)，尽管这并没有统计学意义(P = 0.22)。

[Results: A total of 246 patients were included, with 188 singlestage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22).]

图3 分期手术与同期手术的时间截点及间隔。

图4  两组并发症比较。

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Conclusion（结论）

这是迄今为止最大的多中心研究，评估了同期和分期髓内钉内固定治疗双侧股骨干骨折的结果。同期双侧股骨髓内钉固定可降低可耐受确定性手术的多发伤患者ARDS的发生率。然而，未来将需要一项标准化方案的前瞻性研究来辨别同期与分期固定是否对死亡率有影响，并确定危险因素。

[Conclusion: This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk.]