动态牵引支架结合有限内固定与克氏针内固定治疗近指间关节Pilon骨折的病例对照研究

目的:比较动态牵引支架结合有限内固定与克氏针交叉内固定治疗近指间关节Pilon骨折的临床疗效及安全性。方法:自2012年6月至2014年6月,采用动态牵引支架结合有限内固定与克氏针交叉内固定两种手术方案治疗闭合近指间关节Pilon骨折41例45指,全部获得随访。动态牵引支架结合有限内固定组(A组)21例22指,男12例,女9例;平均年龄(30.6±5.6)岁。克氏针交叉内固定组(B组)20例23指,男11例,女9例;平均年龄(30.1±5.3)岁。定期复查X线片,评定关节主动活动范围、骨折愈合时间、感染率及术后关节活动疼痛等指标。结果:根据中华医学会手外科学会上肢部分功能评定试用标准评定,A组功能评定优良19例,B组13例,A组优于B组(Z=2.558,P=0.011).骨折平均愈合时间 A组(7.9±2.1)周,B组(8.1±2.3)周,两组差异无统计学意义(t=-0.304,P=0.762).A组感染5指,B组1指,A组感染率高于B组(χ²=3.287,P<0.05).术后关节活动疼痛VAS评分A组0.18±0.50,B组0.65±0.88,A组关节疼痛低于B组(t=-2.207,P<0.05).结论:动态牵引支架结合有限内固定治疗近指间关节Pilon骨折方法可靠,能有效固定骨折,进行早期功能锻炼,恢复关节功能。     

外固定支架结合小夹板固定分阶段治疗老年桡骨远端骨折的临床疗效

目的 探讨急诊行外固定支架治疗的C型桡骨远端骨折病人术后早期去除外固定支架,改用小夹板外固定的临床疗效。方法 对2012年3月至2015年3月于湖北省中医院急诊行外固定支架固定治疗的90例C型桡骨远端骨折病人的临床资料进行回顾性分析,按术后外固定支架的固定时间分为小夹板组和对照组。小夹板组44例,男17例,女27例;年龄为62~85岁,平均70.5岁;急诊采用外固定支架固定,术后3~4周去除外固定支架而改用小夹板继续固定2~3周。对照组共46例,男16例,女30例;年龄为61~87岁,平均71.3岁;急诊采用外固定支架固定,术后6~7周去除外固定支架。比较两组病人术后6、12个月的Gartland-Werley评分及病人满意率。结果 随访12~36个月,平均23.6个月。术后6个月,小夹板组和对照组的Gartland-Werley评分分别为（3.67±2.68）分、（4.12±2.64）分,优良率分别为88.64%、86.96%;术后12个月,小夹板组和对照组的评分分别为（2.99±2.18）分、（3.44±2.76）分,优良率分别为95.45%、93.48%,两组的Gartland-Werley评分、优良率比较,差异均无统计学意义（P均＞0.05）。小夹板组和对照组术后7周的治疗满意率分别为90.91%（40/44）、65.22%（30/46）,差异有统计学意义（χ²=8.588,P=0.003）。结论 采用外固定支架结合小夹板外固定分阶段治疗C型桡骨远端骨折,临床疗效满意,提高了病人满意度,是一种可靠的治疗选择。     

超关节外固定支架结合有限内固定治疗高能量Pilon骨折

目的：讨论超关节外固定支架结合有限切开内固定治疗高能量Pilon骨折的临床疗效.方法：自2003年9月至2011年4月应用超关节外固定支架结合有限内固定治疗36例高能量损伤的Pilon骨折患者.男25例,女11例;年龄16～72岁,平均38岁.患者术前可以通过常规X线检查或行三维螺旋CT检查明确诊断.术后采用AOFAS评分标准对疗效进行评定.对于骨折断端是粉碎的、不平整的,可以用螺钉、克氏针或钢丝固定,无须剥离骨膜,可以使骨折断端和骨折块之间相互靠拢以增强稳定性,然后超关节外固定支架固定.结果：所有患者获随访,时间4～27个月,平均13个月.32例伤口Ⅰ期愈合.骨折愈合时间2～6个月,平均3个月.踝关节活动度和骨折愈合按AOFAS评分标准进行评定,总分88.2±3.6;优13例,良20例,可3例.12例发生针孔感染,5例出现针孔处疼痛,1例因过度负重导致固定针断裂,经处理均获得痊愈.无神经、血管损伤及骨髓炎等并发症.结论：超关节外固定支架结合有限切开内固定治疗高能量Pilon骨折固定确切、操作简单、符合生物力学固定原则,有利于骨折愈合.     

外固定支架结合有限内固定治疗胫骨Pilon骨折

目的 探讨外固定支架结合有限内固定治疗胫骨Pilon骨折的临床疗效。方法 对22例Pilon骨折患者采用微创手术治疗，利用外固定支架结合有限内固定固定骨折。结果 22例患者均获得随访，时间6-24个月，骨折全部愈合，无感染，踝关节功能良好。结论 外固定支架结合有限内固定治疗胫骨PilonⅠ，Ⅱ型骨折是一种有效的治疗方法，具有手术切口小，对骨折端血运破坏小，固定牢固等优点。     

外固定支架结合有限内固定治疗Pilon骨折

目的探讨外固定支架结合有限内固定治疗Pilon骨折的疗效。方法采用外固定支架结合有限内固定治疗24例Pilon骨折。结果 24例均获得随访,时间10~20个月。无骨不连、皮肤坏死发生。踝关节功能Mazur评分：优14例,良7例,可3例。结论外固定支架结合有限内固定可以获得术后骨折稳定,取得良好踝关节功能,是治疗Pilon骨折有效的手术方案。     

自制多功能组合式复位固定钳在股骨、胫骨骨干骨折的初步应用

目的 总结自制多功能组合式复位固定钳治疗股骨、胫骨骨干骨折的临床效果。方法 回顾性分析2019年1月至2020年5月我院收治的86例股骨干骨折、胫骨干骨折病人的临床资料,根据治疗方式不同分为观察组和对照组,每组各43例。观察组采用多功能组合式复位固定钳治疗,对照组采用传统持骨钳把持。比较两组病人切口长度、术中出血量、手术时间、骨折愈合时间、并发症发生等情况。结果 对照组切口大小、术中出血量、手术时间、愈合时间均高于观察组,差异均有统计学意义（P均＜0.05）;观察组优良率为97.67%,高于对照组的83.72%,差异无统计学意义（χ²=3.445,P=0.063）;对照组（16.28%）并发症发生率高于观察组（2.33%）,差异无统计学意义（χ²=3.445,P=0.063）。结论 自制多功能组合式复位固定钳在实际操作过程中使用灵活,有利于减少创伤,方便了手术操作,缩短了手术时间,有其临床应用价值。     

外固定支架结合有限内固定和植骨治疗Pilon骨折

目的探讨外固定支架结合有限内固定和植骨治疗Pilon骨折的疗效。方法36例Pilon骨折患者,7例开放性骨折者行急诊清创有限内固定加外固定架治疗;29例闭合性骨折者中26例肿胀消退后行切开复位有限内固定和植骨结合外固定架治疗,3例骨筋膜室综合征者二期行同样术式。结果36例均获随访,时间6～46个月。骨折临床愈合时间14～26周,患肢力线正常。4例伤口感染,4例皮肤坏死,6例踝关节功能障碍;无针道感染和松动,未见骨折不连或畸形愈合,无窦道形成及骨髓炎。临床疗效按美国足与踝关节协会（AOFAS）踝与后足功能评分：优19例（90～100分）,良11例（75～89分）,可5例（50～74分）,差1例（〈50分）。结论正确评估局部软组织条件,根据Pilon骨折的类型和软组织损伤程度选择合适的手术方式和手术时机,合理使用外固定支架结合有限内固定维持骨折复位和下肢力线,干骺端缺损区充分植骨,整复关节面,适当功能锻炼,晚负重,术后可达到良好的临床效果。     

动力型外固定架结合有限内固定治疗Pilon骨折

目的探讨Orthofix动力型外固定支架结合有限内固定在治疗高能量Pilon骨折中的价值。方法2002年4月至2004年3月对11例高能量Pilon骨折采用Orthofix公司第四代跨关节外固定结合克氏针或螺钉有限内固定治疗,远端外固定螺钉固定于跟骨和距骨颈,外固定活动轴和踝关节运动的轴心位置保持一致。术后3周开始踝关节功能锻炼,2~5个月后去除外固定。结果11例均得到随访,随访6~18个月(平均13个月),骨折全部达骨性愈合,无切口感染、内植物外露等并发症。踝关节症状与功能评分按Mazur标准进行,临床评分68~97分(平均82分),其中优6例,良4例,可1例。结论Orthofix跨关节动力型外固定支架结合有限内固定治疗高能量Pilon骨折能促进骨折愈合,有利于踝关节早期活动,最大程度恢复踝关节功能,是治疗高能量Pilon骨折的一种理想方法。     

外固定架结合有限内固定治疗高能量Pilon骨折

目的通过观察单边外固定支架结合有限内固定治疗高能量Pilon骨折的临床过程，探索Pilon骨折的治疗方法。方法自1998年1月至2006年5月治疗高能量Pilon骨折26例，随访8-24个月，平均12．3个月。结果该组治疗病人骨折获得了解剖复位及早期固定，骨折愈合良好，踝关节功能恢复良好，切口感染率低。结论单边外固定支架结合有限内固定是目前治疗高能量Pilon骨折的较佳方法。     

肩关节镜下辅助复位联合双排缝线桥技术治疗肱骨大结节骨折的临床疗效

目的 探讨肩关节镜下辅助复位联合双排缝线桥技术治疗肱骨大结节骨折的临床疗效。方法 选取2018年1月至2019年12月于江西中医药大学附属医院实施肩关节镜下辅助复位联合双排缝线桥技术治疗肱骨大结节骨折的25例病人作为观察组,另将同期收治的25例行切开复位钢板内固定术治疗肱骨大结节骨折的病人纳入对照组。比较两组病人围手术期相关指标、末次随访关节活动度、术后并发症发生情况及治疗满意度。结果 观察组的术中出血量、住院时间、手术切口长度均显著低于对照组,手术时间、前屈活动度、内旋活动度、外展活动度显著高于对照组,组间比较,差异均有统计学意义（P＜0.05）;两组间的骨折愈合时间、外旋活动度及后伸活动度比较,差异无统计学意义（P＞0.05）。观察组的术后并发症发生率（8%）较对照组（36%）显著降低,差异有统计学意义（χ²=1.264,P=0.024）。观察组的总满意度为96%（24/25）,显著高于对照组的80%（20/25）,差异有统计学意义（χ²=3.374,P=0.014）。结论 肩关节镜下辅助复位联合双排缝线桥技术治疗肱骨大结节骨折临床疗效确切,值得临床推广应用。     

Method of fracture fixation using external fixation devices

An improvement of the results of treatment can be reached, beside respecting the indication of external fixateurs, with correct tactics of the treatment. Because of the disadvantages of the fixateur externe, we strive to restrict their use, to the time by all means necessary, and if possible to use other methods of fixation. This is motivated especially by the effect on fracture healing and the hindering of the movements and activity of the patient.     

Biological fixation of subtrochanteric fractures by external fixation

Fifty-one subtrochanteric fractures have been stabilized by external fixation over the last 9 years. Union occurred in all types of fractures, usually within 6 months. Soft tissue interposition led to non-union in three patients. Refracture in one patient and significant limb-length discrepancy in two patients was seen. The technique is versatile, easily reproducible and ‘biological’. Protected weight-bearing is not necessary after removal.     

Prediction of fixation failure after sliding hip screw fixation

Cut-out of the lag screw is the commonest cause of fixation failure after sliding hip screw fixation of extracapsular hip fracture. A number of technical aspects of surgery have been used to asses the risk of cut-out. This study was to determine which of these indicators was the most reliable predictor of cut-out. The anterior-posterior and lateral post-operative radiographs of 23 cases of cut-out were compared with those of 77 cases of uneventful fracture healing. The tip-apex distance with correction for magnification was found to show the most significant difference between patients with cut-out against those without (P = 0.001), followed by the lag screw position on the lateral radiographs (P = 0.0095 and 0.014), reduction of the fracture on the anterior-posterior radiograph (P = 0.011 and 0.016) and the uncorrected tip-apex distance (P = 0.019). We recommend that for audit and research purposes the corrected tip-apex distance, fracture reduction and implant positioning methods should be used. For routine clinical practice, the uncorrected tip to apex distance, which is sum of the distance from the tip of the lag screw to the apex of the femoral head on anterior-posterior and lateral radiograph, and fracture reduction angle on the anterior-posterior radiograph are recommended.     

Trans-sacral fixation for failed posterior fixation of the pelvic ring

Introduction: In the treatment of certain pelvic ring pathologies (non-unions and failure of ilio-sacral screw fixation) trans-sacral fixation (i.e. fixation from iliac wing to the other traversing the body of S1) may be necessary. The purpose of our study was to describe our early experience and describe the surgical technique. Materials and methods: Seven cases of trans-sacral fixation were identified with a mean patient age of 49-years-old with four females and three males. The diagnosis at the time of trans-sacral fixation was failure of posterior ring fixation in four (three of which had vertical sacral fractures), mal-position of iliosacral (IS) screw in one, failure of fusion of sacroiliac (SI) joint in two. All these cases were augmented with a 4.5 mm reconstruction plate placed in tension posteriorly. Results: At average follow up of 39 months (range 24–75), all patients achieved union. There were no neurological or vascular complications. Two patients required reoperations prior to union. Our current use for this technique is with a 8.0 mm screw (16 mm thread). Conclusions: Initial experience with trans-sacral fixation has proven to be very effective technique to solve the most difficult problems in posterior pelvic ring fixation. We reserve its use to the following indications: nonunion/malunion of the pelvic ring, and sacral fractures.     

Biologic fixation

One of the major problems of implant surgery is the failure of the bone-cement interface. Because of such failures, observed with increasing frequency with the passage of time, biologic fixation of total joint implants by means of bone ingrowth has become the focus of considerable interest among orthopedic surgeons. Actual bone ingrowth has been demonstrated into porous metals, resulting in a strong interface between metal and bone. Many clinical trials of biologic fixation, including endoprostheses and total hip, shoulder, and knee prostheses, are being conducted. The brief experience of such fixation in humans supports the hypothesis that bone ingrowth will provide stable fixation for load-bearing prostheses. Many questions remain to be answered about biologic fixation and the burden that falls upon the clinical scientist to identify the proper niche for this process in the care of the musculoskeletal patient.