两种Borden截骨术的生物力学模拟对比实验

目的　通过生物力学加载实验 ,比较改良Borden截骨术和Borden截骨术的纵向稳定性 ,截骨端面载荷的分布规律。方法　用四具成年男尸的左右股骨 ,左股骨按Borden术式制成截骨模型 ,右股骨按改良Borden术式要求制成截骨模型 ,在相同部位贴电阻片。在SWL -Ⅰ型生物力学万能试验机上施加纵向载荷 ,进行同步测量两种术式的纵向稳定性 ,截骨端面的载荷分布规律。结果　在相同载荷作用下 ,改良Borden截骨术的纵向位移小于Borden截骨术。改良Borden截骨术的截骨端面的应力分布均匀性优于Borden截骨术。结论　改良Borden截骨术比Borden截骨术有较好的稳定性 ,截骨端面的应力分布较均匀 ,为术后骨折愈合创造良好的力学环境 ,是一种较好的治疗严重髋内翻的术式     

Combination of femoral fracture treatment and corrective osteotomy in a child with osteogenesis imperfecta

The main feature of osteogenesis imperfecta is an excessive fragility and deformability of the bones owing to reduced mass and bone quality. This leads to angular deformity and frequent fractures. These fractures usually heal rapidly, and conservative treatment is the norm. In displaced and unstable fractures, elastic intramedullary nailing is a treatment option. We report a case of a 3-year-old child with osteogenesis imperfecta type I who suffered an undisplaced femoral shaft fracture in the presence of a preexisting 32° femoral antecurvation. This deformity greatly increases the risk of a refracture due to the pathological induction of stress risers. Therefore, fracture treatment by unreamed elastic intramedullary nailing was combined with simultaneous correction osteotomy, resulting in anatomic alignment and uncomplicated fracture healing. The single-stage surgical stabilization performed allowed rapid mobilization along with a decreased likelihood of refracture.     

Weil截骨术与Jacopy截骨术治疗应力性跖痛症的临床疗效对比观察

背景：跖痛症是指发生于跖骨头下方的前足疼痛,可由解剖结构异常、病理性或医源性因素诱发。其病变主要是因为前足集中的局部应力负荷反复作用造成。治疗可分为保守治疗与手术治疗,对大部分跖痛症而言,采用保守治疗即可取得较好的疗效,若保守治疗无效,则可采取手术治疗,其目的是恢复前足正常的应力分布。目的：探讨跖骨远端weil截骨术与Jacoby截骨术治疗应力性跖痛症的临床疗效,从而为临床上更加合理有效的治疗跖痛症提供方法和依据。方法：2010年5月至2012年9月,我院收治应力性跖痛症患者65例,其中42例（63足）患者资料完整,得到随访,男8例（13足）,女34例（50足）;年龄39～78岁,平均56-3岁。单侧11例,双侧31例;病变于第2跖骨头下24例,第3跖骨头下ll例,第2、3跖骨头下同时累及7例。合并跖趾关节脱位12例,跽外翻畸形16例,跖间神经瘤5例。所有病例随机分为A、B两组,A组19例（32足）,B组23例（31足）。A组采用跖骨远端Weil截骨术、B组采用Jacoby截骨术治疗,经过平均18个月的随访,对手术前后局部疼痛症状、患者足底应力变化、足部功能改善情况进行比较分析。结果：两种手术前后疼痛缓解均有显著性差异,以Weil截骨组疼痛缓解更明显,但两组间疼痛缓解无明显统计学差异。两组患者手术前后患趾跖骨头下应力峰值明显下降。Weil截骨组,手术前后立位时和足跟抬高时的病变跖骨头下应力分别下降35％和51％;Jacoby截骨组分别下降25％,n45％。根据美国足踝外科协会Maryland跖趾关节百分评分法对两组患者进行评定：优,A组24足（占75％）,B组22足（占71％）;良,A组6足（占18．8％）,B组5足（占16．1％）;可,A组2足（占6．2％）,B组4足（占12．9％）。A组优良率为93．8％,B组为87．1％。结论：对于应力性跖痛症患者,跖骨远端Weil截骨术与Jacoby截骨术治疗均可取得满意确切的效果。但weil截骨术手术操作技巧要求更高,Jacoby截骨术对初学者更易掌握。临床需要根据患者的实际情况及个体需求灵活选择。     

Supracondylar osteotomy of the paediatric femur using the locking compression plate: a refined surgical technique

Locking compression plates (LCP) have been developed for paediatric patients, and these provide safe bone fixation and allow for immediate weight-bearing. These plates are becoming increasingly popular and are proving to especially useful for the treatment of proximal and distal (supracondylar) femoral osteotomies. They are thought to provide better grip in osteoporotic bone. The technique has been described in the provider’s manual as well as recently by Joeris et al. (Int Orthop 2012: 36:2299–2306). The LCP system offers optimal stability after the final fixation, but temporary fixation using the originally described method is unstable, and we consider the medialisation instrument unsatisfactory as it has very small contact area with the lateral aspect of the femur and does not provide sound rotational control. For this reason we have developed a technique whereby temporary, stable fixation using fine K-wires can be attained for the proximal, diaphyseal fragment, following sound fixation with locking screws of the distal fragment. This procedure allows for full clinical (including rotation) and radiographic assessment intraoperatively, as well as fine adjustment in all three planes. This modification enables optimal correction before the final fixation and avoids unnecessary, large drill holes which may otherwise act as dangerous tress risers, endangering stability and weight-bearing. Here we describe a refined technique of the supracondylar femoral osteotomy using the paediatric LCP Condylar Plate.     

Triplanar trochanteric osteotomy: a modified anterior trochanteric slide osteotomy

Current methods of trochanteric sliding osteotomy typically preserve the lateral aspect of the greater trochanter, the vastus lateralis, the abductors, posterior capsule, and the external rotators. Our modification to this technique includes leaving an anterior vertical ridge of bone that resists the anterior-directed forces acting on the osteotomy. Furthermore, a chevron-shaped osteotomy provides some additional stabilization to the proximally directed pull of the abductors. We believe these modifications improve the intrinsic stability of the osteotomy, theoretically decreasing the rate of nonunion.     

The Bernese peri-acetabular osteotomy through a modified approach. A technical note

Introduction

A modification of the technique for performing the Bernese periacetabular osteotomy is described.

Materials and methods

A medial approach to the Ischium and a subtle re-orientation of the pubic osteotomy are detailed.

Conclusion

Surgical morbidity is likely decreased with a concurrent cosmetic advantage without compromise to surgical correction or patient safety.     

The value of trochanteric displacement in a varus producing intertrochanteric osteotomy

Surgical Principles In order to maintain or increase the abductor lever arm during a varus producing intertrochanteric osteotomy, distal displacement of the greater trochanter is often needed. Without displacing the trochanter, a significant weakness of the abductors would occur [4, 5]. With greater trochanter osteotomy, access to the hip joint is improved, permitting better visualization of the upper part of the femoral head and the roof of the acetabulum (ie, for a simultaneous shelf procedure). When a flexion component is added to the osteotomy, the trochanteric osteotomy increases the range of correction in the sagittal plane and reduces mechanical pressure on the anterosuperior surface of the femoral head [3]. The aim of an isolated greater trochanteric osteotomy is to advance distally and to lateralize the abductors. To achieve fixation, the preserved soft tissue layer, screws, or a tension wire cerclage are used [4–6, 10]. The indication of a trochanteric osteotomy combined with an intertrochanteric osteotomy has increased [1, 4, 10, 11]. The technique described in detail below is part of a varus osteotomy performed as previously described by M. E. Müller [7, 8, 10] and relies on the use of AO osteotomy plates [9]. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 211–218 (German Edition).     

Components of the Wilson Osteotomy That Are Effective on Hallux Valgus Repair

Wilson osteotomy of the first metatarsal is a technically simple and reliable operation for the correction of the hallux valgus (HV) deformity. The major anatomic components of the osteotomy are the osteotomy angle and the distance of the osteotomy to the first metatarsophalangeal (MTP) joint. Lateralization of the first metatarsal head is the rationale for correction of the deformity. The main disadvantage of the technique is the considerable shortening of the first metatarsal. The relation between the amount of HV correction, first metatarsal shortening, and the anatomic parameters of the osteotomy was evaluated. Radiographs of 46 feet of 32 patients were retrospectively evaluated after an average follow-up period of 31.4 months. From the preoperative, early postoperative, and last control radiographs, the amount of HV correction, first metatarsal shortening, the osteotomy angle, the distance of the osteotomy to the first MTP joint, and lateralization of the first metatarsal head were measured. The presented study indicated that the osteotomy angle and the lateral displacement of the metatarsal head have a significant correlation with the amount of HV correction. Distance of the osteotomy to the first MTP joint has no relevance with the repair of the deformity. A positive linear correlation was present between the osteotomy angle and the first metatarsal shortening. Because the amount of first metatarsal shortening has significant influence over the clinical result, the main aim in a Wilson osteotomy should be maximum lateral displacement of the metatarsal head with a minimum osteotomy angle.     

Modified valgus osteotomy of the femoral neck for late presenting femoral neck stress fractures in military recruits

Neglected or late presenting femoral neck stress fractures are often associated with varus deformity, with potential risks of nonunion and osteonecrosis. We proposed a surgical technique whereby a wedge osteotomy was performed at the basal part of the neck, on the tensile surface, keeping the inferomedial femoral neck as a hinge. The femoral shaft was abducted to close the osteotomy site and it was fixed with three cannulated cancellous screws. Three military recruits who presented with neglected femoral neck stress fracture with varus deformity were operated on with the proposed modified femoral neck valgus osteotomy. All the fractures united without any complications and the patients resumed their professional activity.     

超声骨刀在下颌角肥大矫正术中的应用

目的 探讨超声骨刀在下颌角肥大矫正术各部位骨质截除的临床应用方法、效果和价值.方法 下颌角肥大美容就医者30例,其中男5例,女25例,均采用鼻插管全身麻醉,口内切口,骨膜下分离充分显露下颌骨,注意妥善保护颏神经,根据不同类型下颌角肥大的术前设计,用超声骨刀分别或同时进行下颌角截骨、下颌缘截骨、下颌骨外板劈除等操作.结果 超声骨刀可以完全截断下颌角骨质,顺利完成下颌角整形截骨的各项操作,比传统的刀锯更加精确,截骨曲线流畅.所有受术者均未出现血管、神经意外损伤及骨折现象,术后随访1年,截骨线条美观,外形稳定,形态效果满意.结论 采用超声骨刀进行下颌角肥大矫正术,可较好地提高手术精确度和安全性,但较传统刀具,超声骨刀截骨时间略长,必须熟悉与刀具不同的操作方式和手感.     

Rotational biplanar Chevron osteotomy

IntroductionThe Chevron osteotomy is a reliable and popular osteotomy for treating hallux valgus worldwide. Many modifications have been described, but none of them address the rotational deformity of the first metatarsal. The objective of this study is to describe a variation of biplanar Chevron osteotomy which can address first metatarsal rotation when necessary.MethodsThe indications for the Rotational Biplanar Chevron Osteotomy (RBCO) are mild to moderate hallux valgus deformity associated with hallux pronation related to internal rotation of the first metatarsal bone. We describe a technique that uses a medial based wedge parallel to the plantar limb of the osteotomy in order to make the distal fragment free to correct rotation.ResultsThe more recent concern about hallux valgus surgery is the very interesting concept that this deformity really occurs in three different planes, and we may have mistreated the rotation component with our current techniques. Many authors have revisited many common techniques in order to adapt them to correct metatarsal pronation. To our best knowledge, this is the first paper to describe a modification of the Chevron osteotomy to address the rotation of the first metatarsal.ConclusionWe can conclude that the rotational biplanar Chevron osteotomy can be an useful tool in the treatment of mild hallux valgus associated with metatarsal pronation.     

Modified sliding trochanteric osteotomy in revision total hip arthroplasty

Traditional trochanteric sliding osteotomy preserves the lateral aspect of the greater trochanter, the abductors, and vastus lateralis in continuity. Our modification uses a lateral approach to the hip and osteotomy immediately anterior to the insertion of the posterior capsule and external rotators onto the greater trochanter. The osteotomy and attached abductors and vastus lateralis are translated anteriorly, leaving the posterior capsule and external rotators attached to the proximal femur. This surgical approach preserves the posterior soft-tissue stabilizing structures that resist posterior dislocation of the hip. In a retrospective review of 2 consecutive 2-year series of acetabular component revisions only between 1997 and 2001, 4 of 27 acetabular revisions using a traditional trochanteric slide subsequently dislocated; only 1 of 30 subsequent cases using a modified sliding trochanteric osteotomy dislocated. Modified sliding trochanteric osteotomy facilitated surgical exposure and produced a trend toward a lower dislocation rate that did not reach statistical significance with the small numbers of patients available.     

Benefit of Adding Fibular Osteotomy to Open-Wedge,Valgus, Distal Tibial Osteotomy for Correcting Varus Ankle Arthritis: An In Vitro Study

Early-stage varus ankle arthritis can usually be treated with a medial, open-wedge, valgus, distal tibial osteotomy; however, the value of adding a fibular osteotomy has been debated. We sought to determine the increase in the maximum medial osteotomy gap and correction angle provided by fibular osteotomy. In 3 sequential experiments on 12 fresh cadaveric legs, we first performed a medial open-wedge, valgus, distal tibial osteotomy alone. Second, we added a transverse fibular osteotomy. Finally, we added a blocked fibular osteotomy. In each experiment, we measured the maximum corrected osteotomy gap and the maximum correction angle. Correction was defined as the absence of lateral cortex diastasis and talocrural joint incongruity. The mean ± standard deviation maximum osteotomy gaps and correction angles were 8.40 ± 1.6 mm and 10.70° ± 3.3° for the tibial osteotomy alone, 15.70 ± 4.6 mm and 20.20° ± 5.6° for the tibial plus transverse fibular osteotomy, and 16.67 ± 3.7 mm and 20.56° ± 4.6° for the tibial plus transverse plus blocked fibular osteotomies, respectively. The corresponding median maximum correction angles were 10° (range 8° to 18°), 19.5° (range 14° to 30°), and 20° (range 14° to 28°). The osteotomy gap and correction angle in the distal tibial and transverse fibular osteotomy were significantly greater than those in the distal tibial osteotomy alone (p < .001 for both) but not in the distal tibial and blocked fibular osteotomy (p = .62 for the gap and p = .88 for the correction angle). Our data support the clinical use of adjunct transverse fibular osteotomies. The blocked fibular osteotomy provided no additional benefit.     

Both-bone forearm osteotomy for supination contracture: a cadaver model

PURPOSE: To quantify the magnitude of rotational correction possible when comparing a single forearm bone osteotomy and fixation with stepwise osteotomy and fixation of both bones in a cadaver model and to determine if the order in which the stepwise osteotomies are performed influences the amount of correction. METHODS: Ten fresh-frozen cadaveric forearms were fixed to a frame positioned in the field of view of a motion-capture system. An experimental supination contracture was induced in full supination. Cadaver forearms were assigned randomly to group I (ulna osteotomy, rotation, plating) or group II (radius osteotomy, rotation, plating). Cadavers in group I were used later in group III (ulna + radius) by completing a radial osteotomy, rotation, and fixation in the forearms with the plated ulna. Similarly the specimens assigned to group II were used later in group IV (radius + ulna) by completing an ulna osteotomy, rotation, and fixation in the forearms with the plated radiuses. Measurements of forearm pronation were made after single-bone (groups I, II) and stepwise both-bone (groups III, IV) rotational osteotomies. RESULTS: Stepwise rotational osteotomy and fixation of the ulna followed by the radius produced significantly more corrective pronation (101 degrees) than rotating the radius followed by the ulna (65 degrees). Rotating the radius gave only moderate correction (58 degrees) and minimal correction was produced by ulna osteotomy alone (15 degrees). CONCLUSIONS: Rotational osteotomy of both forearm bones can create approximately 100 degrees of correction when performed at the proximal ulna followed by the distal radius. If less rotation is needed then the distal radius osteotomy alone can provide approximately 60 degrees of correction.     

弧形截骨术和外板劈除术对下颌角形态变化的比较

目的探讨和比较下颌角弧形截骨成形术后和下颌角外板劈除术后对下颌角肥大患者下颌角的形态变化差异。方法对下颌角肥大行弧形截骨成形术的30例和行下颌角外板劈除术后的20例的头颅正、侧位片进行测量比较。结果下颌角弧形截骨成形术使下颌角间距变小,下颌角角度变钝,下颌升支长度变短,下颌角点向前上移位,下颌角区的下颌骨最大宽度变小,下颌骨升支及体部变窄;下颌角外板劈除法可以使下颌角间距变小,而下颌升支长度,下颌角区的下颌骨最大宽度,下颌骨升支及体部的宽度均无明显变化。结论下颌角弧形截骨成形术对面下部正面观和侧面观均有较大改善,下颌角外板劈除术主要对面下部正面观有较大改善,在进行下颌角肥大成形术时,应注意手术适应证的选择。     

Changes in load distribution in the knee after opening-wedge or closing-wedge high tibial osteotomy

The treatment of unicompartmental osteoarthritis of the knee by high tibial osteotomy has been carried out by closing-wedge osteotomy. The advantages for opening-wedge osteotomy are ease of procedure and improved correction with comparable short-term to midterm results. It is not known how the opening-wedge high tibial osteotomy procedure alters the load distribution between the medial and lateral compartments of the knee. The current biomechanical study investigated opening-wedge vs closing-wedge osteotomies in 5 pairs of cadaver knees. The results showed that at 5 degrees osteotomy, the closing-wedge provided superior results of load transfer from medial to lateral compartment than that seen with opening-wedge, but at 10 degrees osteotomy, there was no significant difference in load transfer in the knee compartments between the 2 surgery modes.     

Metatarsal and phalangeal double osteotomy of the first shaft in the treatment of hallux valgus

Numerous surgical techniques have been proposed for the surgical treatment of hallux valgus. Some of them only concern soft tissues; others combine a surgery on the soft tissues with a procedure on the bone structures. The technique we present combines a basimetatarsal valgization by subtractive external osteotomy with a wide metatarso-phalangeal freeing. The basimetatarsal osteotomy allows to correct the deformities in the three planes of space. The basi phalangeal osteotomy is not systematic but is proposed in case of severe hallux valgus, superior to 45° or in case of hallomegalia (gigantism of hallux).     

Tips,quips and pearls: Ultrasound-guided distal metatarsal minimal invasive osteotomy (US-DMMO)

Metatarsalgia is a frequent cause of forefoot pain. Surgical treatment is based on the performance of osteotomies at the level of the minor radii to restore a normal distribution of pressure within the forefoot and improve the biomechanics during gait. In recent years, percutaneous surgery of the foot, and specifically distal metatarsal minimal invasive osteotomy, have proven to be a valid technique, providing satisfactory clinical results, similar to open osteotomy with less soft tissue aggression, but it requires intraoperative fluoroscopy to be performed. This article will present a modification to guide the procedure by ultrasound providing a new option that eliminates radiation and provides greater portability and accessibility.     

Surgery of the deformities in ankylosing spondylitis: Our experience of lumbar osteotomies in 31 patients

Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery. for rare indications. The authors report 31 lumbar osteotomies. The goal is to correct the deformity through a posterior limited approach and to minimise the neurological risks. The modifications developed by the authors for monosegmental closing wedge osteotomies are explained. The posterior resection is rhomboid shaped with a bilateral lamina removal. An osteotomy is performed in a forwards direction on the lateral aspects of the vertebral body without bone resection. This osteoclasty allows progressive vertebral body compression. Pediclectomy is associated if the corresponding foramen at the osteotomy level becomes too narrow in the process of redressing the spine. The resection level is adjusted so that superior and inferior posterior arches come into contact with a good compression. The authors point out the risk of lateral translation. Before the osteotomy, the two adjacent vertebrae are implanted with 5-mm cylindrical pedicular screws, so that posterior fixation can be carried out at any time. Posterior monobloc fixation allows for very great compression of the osteoclasty. The authors compare the results of their experiences in opening and closing osteotomy. They progressively changed their technique for closing osteotomies, because of published vascular complications and mechanical risks (instability and pseudarthrosis in opening osteotomies). Closing osteotomy also minimises the risk of stenosis with radicular compression or traction if an important correction is performed. The level of the osteotomy varied in this series, which had a correction rate of up to 75°. The choice of level depends on secondary effects on pelvic position and projection of the centre of gravity. The preferred procedure remains a monosegmental correction because it is faster and easier, with minimum bleeding. Short monobloc posterior fixation is sufficient to maintain reduction and to obtain stability from posterior compression.     

Bilateral displaced femoral neck stress fractures treated with valgus subtrochanteric osteotomy: A case report and two-year follow-up

Bilateral femoral neck stress fractures are uncommon injuries that are successfully treated with surgical treatment; however, there is a high complication rate, as well as the challenging issue of the joint preserving procedure. This study reports the rare case of simultaneous valgus subtrochanteric osteotomy with a satisfactory outcome. A twenty-year-old male military recruit, with no history of previous hip pain or significant injury, presented with gradually progressive bilateral hip pain for three months after recruitment into military training. He was unable bear weight on both hips for one day prior to hospital without risk of sudden injury. A preoperative radiograph revealed displaced bilateral femoral neck fractures, and magnetic resonance imaging (MRI) demonstrated no evidence of avascular necrosis of the femoral heads. A bilateral valgus subtrochanteric osteotomy procedure was simultaneously and successfully performed on both hips. Six months after surgery, the patient was able to walk independently without any complications, and radiographic unions were presented. The two-year follow up radiographs showed no evidence of avascular necrosis of the femoral heads. The valgus subtrochanteric osteotomy procedure is an effective joint preserving procedure in femoral neck stress fractures, including the uncommon bilateral cases.