肱骨骨不连的原因分析及治疗

目的探讨肱骨骨不连的原因和不同固定、植骨方法治疗肱骨骨不连的临床疗效。方法对51例肱骨骨不连进行回顾性分析。固定方式：钢板内固定30例，交锁髓内钉内固定12例，单臂或组合式外固定架8例，异体骨板加螺钉内固定1例。植骨来源：自体髂骨植骨16例，重组合异种骨植骨(RBX)12例，自体髂骨联合RBX植骨17例，异体骨植骨2例，异体骨联合RBX植骨2例。结果51例患者中，2例失访。49例随访8个月～9年，平均4年7个月。总愈合率89．8％，钢板治疗组愈合率83．3％，外固定架治疗组愈合率100％，交锁髓内针治疗组愈合率100％。12例单独应用RBX植骨治疗肱骨骨不连全部愈合；自体髂骨联合RBX植骨15例愈合，愈合率88．2％；自体髂骨植骨14例愈合，愈合率87．5％。结论髓内针内固定或外固定架固定治疗肱骨骨不连较钢板优越，创伤小，固定确实，功能恢复满意；RBX植骨治疗骨不连，安全、无免疫排斥反应、生物相容性好，对促进骨愈合疗效可靠。     

有限切开附加锁定钢板治疗髓内钉术后非感染性骨不连

目的 分析长管状骨骨干骨折髓内钉术后非感染性骨不连的原因,探讨有限切开植骨附加锁定钢板固定治疗这类骨不连的疗效.方法 对16例长管状骨骨干骨折髓内钉手术后并发非感染性骨不连,采用有限切开附加锁定钢板内固定、断端植骨的方法治疗,并对其疗效进行观察.结果 经11～24个月(平均15个月)的随访,所有患者获得骨性愈合,愈合率100%.无髓内钉下沉、断钉及断板等并发症发生,关节功能良好.结论 有限切开附加钢板内固定结合植骨技术是一种治疗长管状骨骨干骨折髓内钉术后非感染性骨不连的有效方法.     

胫骨骨折术后骨不连30例原因与疗效分析

目的分析胫骨骨折术后骨不连发生的原因与治疗效果。方法自1989年1月～2003年12月共收治胫骨骨折术后骨不连30例，其中22例采用有限接触钢板内固定 自体髂骨植骨术，4例采用外固定支架固定，4例采用带锁髓内钉内固定 植骨固定。结果术后平均随访14个月(8月～3年)，未发生骨髓炎等并发症。经X线片检查，骨折均骨性愈合，其中6～12月愈合17例，12～18个月愈合11例，大于18个月愈合2例。结论骨折区段的血供、内固定材料、操作技术三大综合因素是造成骨不连的主要原因。自体髂骨植骨加可靠内固定是治疗的重要方法。     

内外固定加植骨治疗肱骨骨不连(附23例报告)

目的 :采用外固定支架加自体骨大块髂骨植骨内固定治疗多次手术失败的肱骨骨折骨不连。方法 :采用单边外固定支架固定折端加自体大块髂骨植骨并用克氏针或螺丝钉固定髂骨块及骨折端。结果 :所有病例 3～ 6个月愈合 ,治愈率 95 %。结论 :外固定支架加自体髂骨夹板式植骨加内固定治疗肱骨骨不连 ,操作简单 ,缩短骨不连治疗时间 ,治愈率高 ,是一种理想的植骨方式。     

自体髂骨骨板螺钉内固定加外固定架治疗肱骨干萎缩型骨不连

目的 探讨萎缩型肱骨干骨不连的手术治疗方法 .方法 应用自体髂骨植骨、髂骨骨板螺钉内固定加外固定架治疗18例萎缩型肱骨干骨不连.结果 18例骨折均愈合,患肢功能恢复良好,无桡神经损伤、针道感染等并发症.结论 自体髂骨骨板螺钉内固定加外固定支架治疗肱骨干萎缩型骨不连,临床疗效满意,是一种有效的治疗方法 .     

锁定加压钢板内固定结合自体髂骨植骨治疗肱骨干骨折术后无菌性骨不连

目的探讨锁定加压钢板(LCP)内固定结合自体髂骨植骨治疗肱骨干骨折术后无菌性骨不连的疗效。方法应用LCP内固定结合自体髂骨植骨治疗45例肱骨干骨折术后无菌性骨不连。结果本组获随访7～38个月,骨不连均获治愈。肩关节功能优良率91.1%,肘关节功能优良率100%。结论 LCP内固定结合自体髂骨植骨可以显著提高骨愈合率,是治疗肱骨干骨折术后无菌性骨不连的有效方法之一。     

胫骨骨折术后骨不连治疗方法的疗效比较

[目的]探讨带锁髓内钉固定后胫骨骨折骨不连治疗方法的选择和疗效。[方法]348例带锁髓内钉固定胫骨骨折中发生骨不连36例。采用冲击波治疗lO例；髓内钉动力化8例；髓内钉动力化加自体植骨6例；单纯自体植骨5例；改钢板固定加自体植骨3例；肥大型骨不连更换髓内钉4例。[结果]所有病例平均随访28个月。6个月内再手术者较6个月后再手术者愈合时间明显缩短（P〈0.05）。冲击波治疗10例中1例不愈合，经2次冲击波治疗后愈合。髓内钉动力化8例中2例不愈合，经冲击波治疗后愈合，其中2例发生骨缩短；髓内钉动力化加自体植骨6例均愈合；单纯自体植骨5例中2例8个月未愈合，更换髓内钉加自体植骨后愈合；改钢板固定加自体植骨3例均愈合；肥大型骨不连更换髓内钉4例均愈合。【结论】早期治疗带锁髓内钉固定后胫骨骨折骨不连效果肯定。髓内钉动力化可促进骨愈合，但有引起骨缩短的可能；更换髓内钉或钢板加自体植骨治疗骨不连效果满意；冲击波有促进骨不连愈合的作用。     

锁定钢板联合自体髂骨植骨治疗股骨干骨不连13例

目的观察13例股骨干骨不连患者采用自体髂骨块联合锁定钢板双固定治疗后的临床疗效。方法 13例股骨干骨不连患者均采取自体髂骨取骨,联合锁定钢板采用双固定骨折端方法进行治疗。结果 13例患者随访时间12~26个月,平均18个月。骨折均获骨性愈合,1例患者伤口延迟愈合,经换药后愈合,无一例发生切口皮肤坏死、深部感染、内固定松动或断裂,无成角畸形。根据HSS膝关节评分为88~97分,平均93分,Rasmussen膝关节功能评分法进行综合评分:优10例,良2例,可1例,差0例。结论符合文献报道:自体髂骨块联合锁定钢板双固定治疗股骨干骨不连临床疗效确切,是一种经济、有效的治疗方法。     

带锁髓内钉加自体髂骨植骨治疗胫骨骨不连3例

目的探讨胫骨骨折骨不连的治疗方法。方法3例胫骨骨不连病人,全部采用带锁髓内钉加自体髂骨植骨。结果3例病人经随访12~36个月,平均15个月,骨折均在4~10个月骨性愈合,功能恢复良好,无感染及断钉现象发生。结论本组病例采用带锁髓内钉治疗,固定坚强,自体髂骨植骨,植骨可补充骨的基质,自体松质骨成活率高,有促进骨折愈合的作用。     

自体髂骨结构性植骨联合锁定钢板内固定治疗四肢长骨难治性骨折不愈合

目的观察自体髂骨结构性植骨联合锁定钢板内固定治疗病程超过10年四肢长骨难治性骨折不愈合的临床疗效。方法回顾性分析自2010-07—2018-09采用自体髂骨结构性植骨联合锁定钢板内固定治疗病程长达10年以上的19例四肢长骨难治性骨折不愈合,骨折断端清创后采用锁定钢板内固定,断端侧方开槽并予以自体髂骨结构性植骨。结果 19例均获得随访,随访时间平均22.3(13～45)个月。1例出现持续性尺神经麻痹症状,1例出现桡神经麻痹症状。末次随访时18例获得骨性愈合,1例肱骨干骨折未愈合者拒绝进一步手术治疗。随访期间未出现切口感染、骨桥形成、内固定失败等并发症。末次随访时疼痛VAS评分为0～3(0.8±1.0)分,较术前明显降低。最终的功能评定结果:优9例,满意7例,不满意2例,失败1例。结论自体髂骨结构性植骨联合锁定钢板内固定可以有效治疗四肢长骨难治性折不愈合,可以提供足够的稳定性及合适的骨生长环境,操作方法容易掌握。处理骨折断端时需要彻底清除瘢痕组织及硬化骨,植骨时要确保自体髂骨与骨折两端良好接触,同时要特别严格保护周围血管神经。     

Salvage of humeral nonunions with onlay bone plate allograft augmentation

Eight women and one man were treated for 10 established diaphyseal humeral nonunions. Six patients sustained fractures in motor vehicle accidents and two patients sustained fractures in a fall. Two of the fractures were open. One patient with multiple myeloma originally was treated conservatively and received local radiation, followed by open reduction and internal plate fixation. The other patients previously were treated with fracture braces, intramedullary nails, dynamic compression plates, or a combination of these techniques. After removal of the surgical hardware and fibrous tissue at the nonunion site, stable fixation was accomplished using a cortical long bone plate allograft (femoral and tibial) or fibular shaft allograft and a dynamic compression plate. All humeral nonunions had united at an average of 2.9 months. Radiographic incorporation of the allograft cortical bone plate and fibular shaft into the host cortex occurred in all but one patient by 3 months. Graft to host junction healing was accomplished by incorporation of the cortical allograft plate into the host cortex, resulting in an increased diameter of the bone. Cortical allograft bone plates and fibular grafts provide structural and probably osteoinductive support to enhance healing of these nonunions.     

Fresh autogeneic, frozen allogeneic, and decalcified allogeneic bone grafts in dogs

In fully-grown mongrel dogs, diaphyseal ulnar defects 25 mm long were stabilised by screws and plates, and were temporarily filled with silicone rubber blocks. After eight weeks the block was replaced either by fresh autogeneic cancellous bone, allogeneic deep-frozen cancellous bone, allogeneic decalcified bone matrix, or bone matrix gelatin. After 24 weeks the implants were evaluated by radiography, histology, and measurements of new bone volume, using computer-assisted density registration on microradiographs. Only the autogeneic bone grafts led to healing in all instances. Bone regeneration in the other groups was not significantly better than in the sham group in which no graft was employed. Decalcified bone matrix proved ineffective.     

The results of primary total knee arthroplasty with bone stock restoration by autologous grafts from resected bony ends]

AIM OF THE STUDY: The aim of the study is the comparison of results of primary total knee arthroplasty with large bone stock deficiencies treated with autologous bone grafts from resected joint ends (both solid and morselized) with the group of patients in whom knee arthroplasty was made without the need of bone grafting. MATERIAL AND METHOD: 342 primary total knee replacements implanted till the end of 2004 at Orthopaedic and Traumatology Department in Lublin were examined. Bone stock defects were treated in 37 knees (35 patients). The necessity of reconstruction resulted from destruction of knee joint surfaces in advanced degenerative osteoarthritic processes or rheumatic disease. Autologous solid bone grafting was used in 22 knees, morselized in 13, meanwhile 2 different required both types of grafts. The medial tibial condyle bone stock defects were the most frequent--26 knees. Control group consists of 39 knees in 33 patients treated in the same period without the need for bone grafting and prostheses were implanted directly on resected surfaces. Preoperative and postoperative knee function was established with Hospital for Special Surgery Score (HSS). The X-rays were analyzed with the special regard for: correctness of implants placing, presence of radiolucence zones both around implants and grafts, and bone grafts healing. RESULTS: The analysis of subsequent X-rays showed bone grafts healing (both solid and morselized) in 21 knees. In 4 knees progressive bone grafts lysis was observed. The remaining knees showed the presence of grafts and lack of evidence of healing in surrounding host bone. No differences were observed in number of intra- and postoperative complications, radiographic knee replacements geometry and long-term clinical results in both groups of patients. CONCLUSIONS: 1) Results of total knee replacements with autologous bone grafting for bone stock reconstruction are comparable with the results of TKR without the need for bone grafting. 2) Natural harvesting of the graft material from resected joint ends and effectiveness of reconstruction increase the value of the method. 3) The durability of early good results need further examination.     

骨移植替代材料在加速骨折治疗中的应用

具有骨不连倾向的高能骨折,传统的治疗方法是先切开复位内固定,待骨不连发生后,再植骨治疗。这一方法的最大缺点是治疗周期长,二次手术增加了患者的痛苦,且并发症高,不利于早日康复。C harnley早在1961年就提出对此类骨折应早期植骨,以缩短骨愈合时间。近年来,自体骨因取骨量受限、供骨区并发症高,一些生长因子、生物陶瓷以及复合材料等骨移植替代材料,已成为替代自体骨加速骨愈合的早期植入材料。     

Vertical alveolar ridge augmentation using autogenous bone grafts and platelet-enriched fibrin glue with simultaneous implant placement.

OBJECTIVE: The aim of this study was to evaluate the combined use of autogenous bone and platelet-enriched fibrin glue as grafting material for vertical alveolar ridge augmentation with simultaneous implant placement in a canine alveolar ridge defect model. STUDY DESIGN: In 6 mongrel dogs, bilateral vertical alveolar ridge defects were created in the mandible. After 3 months of healing, 2 dental implants were placed in each defect of the mandible, creating 6-mm supra-alveolar peri-implant defects. The 2 implants per defect were subjected to surgical treatments involving either a combination of autogenous bone grafts and platelet-enriched fibrin glue, or a conventional flap procedure only (control). After a healing period of 6 months, the dogs were humanely killed for histological and histometric analyses. RESULTS: Implant placement alone produced limited vertical alveolar height (0.6 +/- 0.4 mm). However, alveolar augmentation including a combination of autogenous bone grafts and platelet-enriched fibrin glue with simultaneous implant placement resulted in alveolar ridge augmentation amounting to 4.2 +/- 1.0 mm, comprising 63% of the defect height. New bone-implant contact was 40.5% in the defects treated with combined autogenous bone grafts and platelet-enriched fibrin glue, and was 48.4% in the resident bone; this difference was not statistically significant. CONCLUSION: The present study demonstrates that vertical alveolar ridge augmentation using autogenous bone grafts and platelet-enriched fibrin glue with simultaneous implant placement might effectively increase vertical alveolar ridge height and allow for an acceptable level of osseointegration.     

Donor marrow-derived cells as immunogens and targets for the immune response to bone and skin allografts

The relative importance of donor marrow-derived cells in the immunogenicity of bone and skin allografts was compared. Radiation chimeras were created to have marrow-derived cells (MDCs) of a different genotype from their nonmarrow-derived cells (NMDCs). Such animals were used as donors of bone or skin for recipients chosen so that either the MDCs or the NMDCs of the graft would be incompatible. Immunogenicity was determined by measuring the recipient antibody response. The effect of the immune response on the bone graft (rejection) was determined by impaired bone healing. When MDCs alone were H-2 disparate with the recipient, bone grafts were immunogenic, and the bone graft healing was impaired. In contrast, skin grafts in the same combinations were immunogenic but were not rejected if the differences were only expressed on the MDCs of the graft. The role of NMDCs in all of these experiments was more difficult to interpret, but the results suggested that NMDCs are relatively unimportant for healing of bone grafts, although critical for rejection of skin grafts. We conclude that, unlike the situation with skin grafts, the major inducers and targets of the immune response to bone allografts are marrow derived.     

Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity.

OBJECTIVE: To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy.Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. RESULTS: Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. CONCLUSIONS: Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. SIGNIFICANCE: Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.     

Use of demineralized allogeneic bone implants for the correction of maxillocraniofacial deformities.

Two major problems in maxillocraniofacial surgery are the limited amount of fresh autogenous bone, the standard material for bone grafting, and the resorption of the grafted bone. Experimental studies with demineralized, devitalized bone matrix have shown induction of endochondral ossification. Fifty-five demineralized allogeneic implants have been used in 44 patients over the past two years for a variety of congenital (n = 37) and acquired (n = 7) defects. The allogeneic bone was obtained from cadavers, prepared as powders, chips or blocks, and was demineralized. After having been sterilized by irradiation, they were used to augment contour, fill defects, or construct bone within soft tissue. Of implanted sites that could be evaluated by physical examination, 31 of 31 were solid by three months. By radiographic examination three of 19 were healed by three months, and an additional 11 were positive by six months. Induced bone was seen in four of four biopsy specimens. Infection occurred in four of 44 patients (9%), comparable with conventional grafts. Implant resorption occurred in four instances. Allogeneic demineralized implants offer several advantages over conventional bone grafting, such as avoidance of a harvesting operation, ease of manipulation, and potentially unlimited material in banked form. In addition, healing by induced osteogenesis may bypass the resorption seen with healing of mineral-containing grafts.     

Pedicled vascularized bone grafts for disorders of the carpus: scaphoid nonunion and Kienbock's disease

The use of reverse-flow pedicled vascularized bone grafts from the dorsal distal radius makes it possible to transfer bone with a preserved circulation and viable osteoclasts and osteoblasts. The resultant primary bone healing without creeping substitution within the dead bone is an alternative to conventional bone grafting in aiding or accelerating healing, replacing deficient bone, and/or revascularizing ischemic bone. Recent advances in understanding the anatomy and physiology of vascularized pedicled bone grafts have increased their use in treating a variety of carpal maladies. A basic understanding of the vascular anatomy, as well as the surgical principles and experimental and clinical results of pedicled vascularized bone grafts from the dorsal distal radius, is critical to understanding the use of these grafts in the treatment of scaphoid nonunions and Kienbock's disease.     

Use of allogenous bone graft and osteosynthetic stabilization in treatment of massive post-sternotomy defects

Thoracic stabilization using transverse plate fixation represents a modern and safe method of sternal dehiscence treatment. However, it still remains difficult to apply in cases of massive loss of bone tissue of the chest wall. An unsatisfactory stability of thorax often results in severe respiratory insufficiency, and also affects healing of soft tissue closure while increasing the risk of development of chronic fistulas and other dehiscences. In the reported case, we opted for a unique treatment of massive post-sternotomy defect using an allogenous bone graft of calva. Transverse titanium plates were applied to achieve stabilization of bone grafts and chest wall.