以第一、二伸肌腱鞘支持带上动脉为血管蒂的桡骨瓣治疗舟骨骨不连

目的 探讨以第一、二伸肌腱鞘支持带上动脉(1,2 ICSRA)为血管蒂的桡骨瓣带蒂逆行转移治疗舟骨骨不连的手术指征、技术和疗效.方法 2007年2月至2010年10月,我科对15例舟骨骨不连患者,应用以1,2 ICSRA为血管蒂的桡骨瓣远端蒂转移植骨内固定进行治疗.其中腰部骨不连9例,近端骨不连6例.9例伴有近端骨折块缺血性坏死;3例伴有舟状骨弓背畸形及嵌入体背伸不稳(DISI);2例伴有桡骨茎突关节炎表现.所有病例均采用腕桡侧纵形切口,13例予以交叉克氏针内固定,2例行单枚Herbert螺钉附加1枚克氏针固定.12例将带血管蒂植骨块从舟骨背侧嵌插植入,3例将植骨块楔形修整后自舟骨掌侧植入.术后随访骨折愈合时间、腕痛、腕关节活动度及握力等情况.结果 术后随访时间为6～ 21个月,平均13个月,2例失访.所有随访病例X线片显示舟骨均获得骨性愈合,平均愈合时间为14.2周.所有患者腕痛消失,腕关节屈曲(59.92±4.82)°,背伸(49.73±4.58)°.根据改良的Mayo腕关节功能评分标准评定:优9例,良2例,可2例;优良率为84.6％.结论 以1,2 ICSRA为血管蒂的桡骨瓣逆行转移植骨手术,能促进舟骨骨不连的愈合,特别对有近端骨块缺血性坏死的患者疗效显著.     

带血管蒂桡骨茎突骨瓣移植及可吸收钉治疗腕舟骨骨折不愈合17例

目的探讨带血管蒂桡骨茎突骨瓣移植及可吸收钉治疗腕舟骨骨折不愈合的方法及疗效。方法采用带血管蒂桡骨茎突骨瓣植入及可吸收钉内固定治疗17例腕舟骨骨折不愈合患者,术后石膏固定拇指掌指关节固定于对掌位4～6周,早期康复训练。结果17例患者均达到骨性愈合,背伸45°～50°,掌屈55°～60°,手部握力平均提高2级。随访6～18个月,优14例,良2例,可1例,优良率94.1%。结论带血管蒂桡骨茎突骨瓣移植及可吸收钉治疗陈旧性舟骨骨折操作简便,创伤小,疗效好,易推广,为治疗腕舟骨陈旧性骨折的较好方法。     

带血管筋膜蒂桡骨茎突骨瓣加Herbert螺钉内固定治疗陈旧性腕舟骨骨折

目的探讨带血管筋膜蒂桡骨茎突骨瓣加Herbert螺钉内固定治疗陈旧性腕舟骨骨折的临床疗效。方法将40例陈旧性腕舟骨骨折患者按治疗方法不同分为自体骨移植加Herbert螺钉内固定组(A组,20例)和带血管筋膜蒂桡骨茎突骨瓣加Herbert螺钉内固定组(B组,20例),比较两组手术时间、骨折愈合时间、术后6个月腕关节功能Krimmer评分。结果患者均获得随访,时间6个月~2年。手术时间:A组为(52.3±9.4)min,短于B组的(88.5±9.5)min,差异有统计学意义(P0.05)。骨折愈合时间:A组为(17.3±2.2)周,长于B组的(12.4±2.3)周,差异有统计学意义(P0.05)。术后6个月腕关节功能Krimmer评分:A组为(83.5±7.4)分,低于B组的(96.8±7.5)分,差异有统计学意义(P0.05)。结论带血管筋膜蒂桡骨茎突骨瓣加Herbert螺钉内固定术操作简便、创伤小、疗效满意,是治疗陈旧性腕舟骨骨折的有效方法。     

手术治疗舟骨骨折49例结果及体会

目的报道手术治疗49例舟骨骨折的结果及体会。方法经皮或切开复位Acutrak钉/空心钉/可吸收钉/U形钉内固定舟骨骨折,陈旧性骨折及骨坏死者加做带血管蒂桡骨茎突骨瓣移植,记录术后骨折愈合时间、握力、腕关节活动度、疼痛、恢复工作时间及腕关节功能评分。结果对本组患者进行随访1～8.5年,平均3.6年;骨折愈合时间为7～12周,平均10.8周。腕关节平均评分85.2分;功能优28例,良21例,差0例。所有患者均恢复原来的工作或改为较轻的工作。结论经皮或切开复位螺钉固定、带血管蒂桡骨茎突骨瓣移植是治疗舟骨骨折的一种好方法;骨折类型不同,手术方法也需有所变化。Acutrak钉固定效果好于空心钉或可吸收钉。短期随访,未见有桡骨茎突切除的并发症。桡腕关节桡侧切口有利于显露骨折端及骨瓣制备,值得推荐。带血管蒂桡骨茎突骨瓣移植可缩短骨折愈合时间。     

带筋膜血管蒂桡骨骨膜骨瓣移植治疗陈旧性舟骨骨折

目的探讨带筋膜桡动脉茎突返支蒂桡骨骨膜骨瓣移植治疗陈旧性腕舟状骨骨折的临床疗效。方法切开复位，采取桡骨茎突切除加用带筋膜血管蒂骨膜骨瓣移植治疗陈旧性腕舟骨骨折15例，术后进行5～16个月随访。结果临床用骨瓣治疗舟骨骨折15例，骨瓣血供丰富，术后10～12周愈合，腕关节功能恢复正常。结论带筋膜血管蒂桡骨骨膜骨瓣是移植治疗陈旧性腕舟骨骨折及骨不连的一种可靠的方法。     

陈旧性腕舟骨骨折的治疗分析

目的 通过对腕舟骨骨不连三种治疗方法的临床观察与分析，探讨治疗腕舟骨骨不连接的有效手术方法。方法 从1988年－2001年，采用桡骨茎突切除加植骨术治疗腕舟骨骨折骨不连11例，桡骨茎突切除植骨加游离骨膜移植术5例，带血管筋膜蒂的第二掌骨骨瓣移位术6例。结果 术后22例获得随访，随访时间4个月－12年，骨性愈合率100％，愈合时间为3－4个月，腕关节功能完全恢复，无腕关节不稳、创伤性关节炎等并发症发生。结论 三种手术方法有各自的适应证：桡骨茎突切除加植骨适用于无坏死的陈旧舟骨骨折；桡骨茎突切除植骨加游离骨膜移植适用于舟骨断端植骨后有间隙，软骨缺损的舟骨骨折；带血管筋膜蒂的第二掌骨骨瓣适用于舟骨近端无菌坏死的舟骨骨折。     

桡骨茎突切除加植骨及克氏针内固定术治疗陈旧性腕舟骨骨折不愈合

目的探讨桡骨茎突切除加植骨及克氏针内固定术治疗陈旧性腕舟骨骨折不愈合的疗效。方法采用桡骨茎突切除加植骨及克氏针内固定术治疗23例陈旧性腕舟骨骨折患者。结果 23例均获随访,时间1~4年。患者均骨性愈合。腕关节功能根据Krimm er评分进行评估：优21例,良2例。结论桡骨茎突切除加植骨及克氏针内固定术治疗陈旧性腕舟骨骨折不愈合操作简便,创伤小,疗效满意,是一种较好的方法。     

骨条植骨固定加桡骨茎突切除治疗腕舟骨骨不连

目的:报道应用骨条植骨固定加桡骨茎突切除术治疗腕舟骨骨不连的临床应用效果。方法:用桡骨近端骨条植骨固定腕舟骨骨折并切除桡骨茎突治疗腕舟骨骨不连23例。结果:23例全部获得随访,随访时间1～2年,骨性愈合率100％,愈合时间2～3个月,腕关节功能恢复正常。结论:该手术方法操作简便,损伤小,疗效好,是治疗腕舟骨骨不连的有效方法。     

应用桡动脉茎突返支为蒂的桡骨骨瓣或骨膜瓣移植治疗腕舟骨骨折不连接

目的观察以桡动脉返支为蒂的桡骨骨瓣或骨膜瓣移植对腕舟骨骨折不连接的治疗作用.方法20例腕舟骨骨折骨不连,应用桡动脉返支为蒂的桡骨骨瓣移植加桡骨茎突切除治疗12例,应用桡动脉返支为蒂的桡骨骨膜瓣移植加桡骨茎突切除治疗8例.测量手术前后腕关节屈伸和尺桡偏活动度、握力,应用腕舟评分对患者的自觉功能恢复情况进行评定.结果20例腕舟骨骨折骨不连均愈合,愈合时间平均为7±0.2周(6～12周).腕舟骨评分结果为:优16例,良3例,可1例.结论以桡动脉返支为蒂的桡骨骨瓣或骨膜瓣移植加桡骨茎突切除是治疗腕舟骨骨折骨不连的有效方法.     

应用带血运桡骨茎突骨瓣治疗腕舟骨骨折和骨缺损

目的探讨以桡动脉返支为蒂桡骨茎突骨瓣治疗腕舟骨骨折和骨缺损的治疗效果。方法对19例第2、3型腕舟骨骨折患者行桡动脉返支为蒂的桡骨茎突骨瓣移植,克氏针交叉加压固定治疗舟骨嵌入骨折13例;同时应用带血运的桡骨瓣重建因磨损、吸收所致的舟状骨缺损6例。结果19例腕舟骨骨折和骨缺损患者,X线示骨折全部骨性愈合,舟状骨形态恢复正常。采用改良Gartland—Werley腕关节功能评分标准进行评估：优16例,良2例,中1例。结论桡动脉返支为蒂桡骨茎突骨瓣移植治疗腕舟骨骨折和骨缺损效果肯定。     

Treatment of scaphoid nonunion with 1,2 intercompartmental supraretinacular artery vascularized graft and compression screw fixation

PurposeAim of the present study was to evaluate the clinical, functional, and radiological outcomes of 1,2-intercompartmental supraretinacular artery (1.2-ICSRA) vascularized graft technique together with compression screw fixation for the management of scaphoid nonunions.MethodsA retrospective study was designed to evaluate the medical records of the 21 patients treated with 1,2-ICSRA vascularized graft for established scaphoid nonunion of the waist or proximal pole between 2015 and 2018. Seventeen patients who met the criteria were included in the study. The retrospectively analysed demographic parameters included age, gender, injured hand (dominant/non-dominant), aetiology of the injury, delay between injury and operation, initial treatments following the fracture, tobacco use, and background diseases that may affect healing (diabetes, vasculopathy etc.). Radiological and clinical examinations were routinely performed 2 weeks, 6 weeks, 3 months and 6 months after surgery and during the final follow-up. Postoperative clinical and functional outcomes at the latest follow-up were evaluated by measuring active wrist range of motion, grip strength, Turkish version of Quick Disabilities of the Arm, Shoulder and Hand Questionnare (Quick DASH) and Mayo Wrist scores and comparing them with preoperative values.ResultsAll 17 patients were male with an average age of 26.82 ± 4.08 years (range 20–35 years). The fracture site was located in the scaphoid waist and proximal pole in 5 (29.4%) and 12 (70.6%) patients, respectively. Avascular necrosis was observed in 13 patients (2 at the waist, 11 at the proximal pole). The mean follow-up duration was 18.88 ± 11.98 months (range 6–44 months). No graft extrusion occurred, and no other complication was observed in any of the patients. Amongst the 17 patients, 15 (88.2%) achieved union. The total wrist motions of patients were better postoperatively than preoperatively. However, only improvement in wrist extension was found to be statistically significant. Quick DASH and Mayo Wrist scores of the patients and grip strength were significantly improved postoperatively.ConclusionThe 1,2-ICSRA vascularized graft technique together with compression screw fixation offers an easy and reliable option for the treatment of scaphoid nonunions with a high union rate and good functional and clinical outcomes.Level of Evidence : IV Therapautic     

桡骨远端背侧带血管蒂骨瓣转位联合外固定支架治疗陈旧性舟骨骨折

目的 评价桡骨远端背侧带血管蒂骨瓣转位联合腕关节外固定支架治疗陈旧性舟骨骨折的中远期疗效.方法 回顾性分析1995年2月至2006年11月行桡骨远端背侧带血管蒂骨瓣转位联合腕关节外固定支架治疗的13例陈旧性舟骨骨折患者,其中男12例,女1例;平均年龄为29.7岁(21～42岁);9例伴近侧极缺血坏死.受伤至手术时间平均为22.2个月(8～46个月).血管蒂为1,2区间间伸肌支持带上血管.固定方式包括螺钉或克氏针内固定及外固定支架固定.评价方式包括Mayo腕关节临床功能评分以及影像学评价.结果 13例患者术后获平均82.9个月(62～116个月)随访,骨折均获愈合,平均愈合时间为11.2周(8～15周).Mayo功能评价:优3例,良8例,可2例.末次随访时,舟骨角、舟月角、Mayo评分、关节活动度、握力均较术前有显著提高.结论 以1,2区间间伸肌支持带上血管为蒂的桡骨远端背侧骨瓣转位联合腕关节外固定支架治疗陈旧性舟骨骨折,手术过程相对简单,疗效满意.使用外固定支架是能够早期进行功能锻炼进而改善腕关节功能的重要因素.     

A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis

PURPOSE: To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole nonunions. METHODS: Thirteen patients with symptomatic nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the nonunion site after scaphoid fixation with a Herbert screw. RESULTS: After a mean follow-up period of 19 months 10 of the 13 nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent nonunions occurred. CONCLUSIONS: Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

腕关节镜下植骨经皮内固定治疗舟骨骨折不愈合

目的探讨腕关节镜辅助微创植骨内固定治疗舟骨骨折不愈合手术方法和疗效。 方法2015年10月至2018年10月,采用腕关节镜辅助微创方法治疗外固定未愈合的不稳定型舟骨骨折9例,9例患者均为舟骨骨折不愈合,无合并舟月分离及舟骨近极塌陷。所有患者根据术前影像学检查评估舟骨骨折移位情况,骨折端硬化和骨质吸收缺损情况。术中从腕中关节入路刨除硬化骨后复位植骨内固定。收集患者术前及术后Mayo评分和疼痛视觉模拟评分(VAS评分),两组间数据比较采用配对t检验。 结果9例患者均获得随访,随访时间平均(11±4)个月。所有患者末次随访之时均获得骨性愈合,Mayo腕关节评分(89.4±5.8)分,与术前(52.2±6.7)分相比(t＝19.8,P<0.001),优8例,良1例。VAS评分由术前(5.2±0.7)分降至(1.6±0.7)分(t＝15.6,P<0.001)。 结论腕关节镜辅助微创治疗不稳定型舟骨骨折不愈合是一种有效的治疗选择,采用腕关节镜技术去除硬化骨,取髂骨碎屑植骨内固定能取得较为理想的临床效果。     

1，2伸肌室间支持带上动脉为蒂骨瓣移植治疗舟骨骨折不愈合

目的探讨1,2伸肌室间支持带上动脉（1,2 intracompartmental supraretinacular artery 1,2 ICSRA）的解剖特点及治疗舟骨骨折不愈合的临床疗效。方法2008年7月-2010年9月共收治确诊的舟骨骨折不愈合患者11例,均采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbert螺钉内固定进行治疗,观察患者的骨折愈合情况及并发症,并以DASH评分对腕关节功能进行评价。结果所有患者均获6～33个月随访,平均17个月。11例患者均获骨性愈合,骨折愈合时间为9～14周。平均12周。术后6个月DASH评分平均为6．5分,腕关节功能接近正常。结论慎重的选择适应证,熟悉相关解剖知识,仔细的手术操作,采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbeft螺钉内固定治疗舟骨骨折不愈合可取得满意的临床疗效。     

第一、二伸肌室间支持带上动脉为血管蒂的楔形骨瓣转移治疗舟骨骨不连

目的 探讨以第1,2伸肌室间支持带上动脉(1,2 ICSRA)为血管蒂的楔形骨瓣转移治疗舟骨骨不连伴背侧镶嵌不稳定(DISI)的技术和疗效.方法 对12例舟骨骨不连伴背侧镶嵌不稳定的患者,设计并应用1,2 ICSRA为血管蒂的楔形骨瓣进行治疗,采用腕背侧单一切口同时完成畸形矫正和骨瓣转移.术后随访骨折愈合时间、腕痛状况,比较手术前后腕关节活动度、握力、腕骨排列情况.结果 术后随访时间为6～24个月,平均12个月.X线片显示舟骨骨折均获得骨性愈合,愈合率为100%,平均愈合时间为11.3周.11例患者腕痛消失;1例腕痛持续,经行桡骨茎突切除后好转.12例术后头月骨间角、舟月骨间角、腕高指数恢复正常;腕关节屈伸、桡尺偏活动度接近术前的2倍,握力为术前的3.5倍.结论 1,2 ICSRA为血管蒂的楔形骨瓣转移能促进舟骨愈合,矫正骨折成角,有利于腕部生理力学的重建,是治疗舟骨骨不连伴DISI的有效方法.     

Dorsal capsular-based vascularized distal radius graft for proximal pole scaphoid nonunion with avascular necrosis

BackgroundScaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft.MethodsBetween 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation.ResultsUnion rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up.ConclusionsThe dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.     

Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid

PURPOSE: With their intrinsic vascularity vascularized bone grafts provide an alternative solution to the challenging problem of scaphoid nonunions. The union rate (after imaging evaluation including magnetic resonance imaging [MRI]) and functional outcome of using vascularized bone grafts pedicled on the palmar carpal epiphyseal artery for waist nonunions of the scaphoid are reported in this prospective case series. METHODS: The technique was applied to 9 waist nonunions resulting from fractures. The mean time elapsed from the initial injury to the procedure was 22 months and the mean follow-up time was 24 months. The graft was pedicled on the artery running at the distal edge of the pronator quadratus and was inserted in the nonunion as an intercalary graft. Six patients had postoperative MRIs to evaluate fracture healing and graft incorporation. RESULTS: Union was accomplished in all cases between 6 and 12 weeks. Postoperative MRI showed the viability of the graft (contrast-enhanced images) and confirmed union and graft incorporation. Complete absence of pain was noted in all patients. The Mayo modified wrist score increased from 63 to 92 after surgery and according to this score results were excellent in 5 patients and good in 4. CONCLUSIONS: Vascularized bone grafts from the anterior radius lead to rapid union and consolidation in cases of waist nonunion. Postoperative MRI confirms viability of the graft, union, and graft incorporation. The approach is limited to the distal radius and wrist and lacks donor site morbidity. The interposition of the graft from the palmar side allows correction of the humpback deformity and patients regain carpal height, grip strength, and painless motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.