脊柱侧凸Lenke分型和PUMC分型系统可信度和可重复性的对比分析研究

目的 对特发性脊柱侧凸的Lenke分型系统和中国协和医科大学北京协和医院（PUMC）分型系统进行对比研究,比较其不同观察者问的可信度和同一观察者内的可重复性。方法5名脊柱外科医师对62例手术治疗的青少年特发性脊柱侧凸的术前X线片独自进行测量,使用Lenke分型和PUMC分型系统分别进行评估和分型。3周后,再由这位医师重复同样的程序分型。每位医师测量过的X线片均不能遗留任何标记。收集结果,分别作不同观察者问可信度和同一观察者内可重复性的分析,计算,κ值,检验一致性,将两种分型系统进行对比研究。结果Lenke分型系统的总体可信度和可重复性分别平均为69．8％（κ=0．675）和74．2％（κ=0．690）。其中弯曲类型的可信度和可重复性分别平均为86．5％（κ=0．808）和87．4％（κ=0．826）;腰椎修正的可信度和可重复性分别平均为95．2％（κ=0．919）和94．5％（κ=0．908）;胸椎矢状面修正的可信度和可重复性分别平均为85．2％（κ=0．734）和89．0％（κ=0．805）。PUMC分型系统的可信度和可重复性分别平均为91．O％（κ=0．896）和90．2％（κ=0．892）。结论Lenke分型系统的可信度和可重复性好。PUMC分型系统的可信度和可重复性更好。Lenke和PUMC分型系统均比较全面,但PUMC分型系统相对简单,包含的类型较少,临床医师进行分型时所产生的分歧少,对手术有指导意义。     

脊柱结核GATA、SMU分型的可信度及可重复性对比分析

目的对比脊柱结核GATA、SMU分型的可信度及可重复性,探讨SMU分型的临床应用价值。方法随机选取佛山市中医
院于2004年1月~2011年12月期间收治的100例脊柱结核患者资料,男54例,女46例;年龄16~68岁,平均45岁。每例均有完
整的X线、MRI及CT资料。由5名经验丰富的医师分别进行脊柱结核两种分型,对分型类别的一致性进行分析,计算Kappa值
检验可信度,3 个月后再次分型,对分型的可重复性进行分析,计算Kappa 值检验可重复性。结果GATA分型可信度平均为
（59.9±4.84）%,Kappa值0.412±0.058,可重复性平均为（75.6±5.27）%,Kappa值0.624±0.078;SMU分型的可信度平均为（81.6±
6.06）%,Kappa值0.753±0.068,可重复性平均为（89.8±2.28）%,Kappa值0.862±0.037。结论脊柱结核SMU分型具有较优的可
信度及可重复性,对规范临床治疗具有较好的指导意义,但仍需进一步临床验证及完善。
     

骨盆骨折3种分型的可信度和可重复性比较

目的 对骨盆骨折Tile、Young-Burgess和AO分型的可信度和可重复性进行分析.方法 选取符合纳入标准的临床和影像学资料完善的骨盆骨折患者100例,由创伤骨科医师按3种分型方法进行分型,8周后打乱顺序再次分型,应用Kappa值和分型一致性进行可信度和可重复性分析.结果 Tile分型前后两个阶段可信度Kappa值分别为0.743和0.745,可重复性Kappa值为0.771;Young-Burgess分型前后两个阶段可信度Kappa值分别为0.587和0.590,可重复性Kappa值为0.691;AO分型前后两个阶段可信度Kappa值分别为0.402和0.406,可重复性Kappa值为0.498.结论 Tile分型较Young-Burgess、AO分型的可信度和可重复性好,易于掌握和应用.     

新医正骨法纠正椎体旋转位移治疗31例青少年特发性脊柱侧凸的疗效观察

目的:评价新医正骨疗法治疗青少年特发性脊柱侧凸的疗效.方法:2001/2006收治保守治疗青少年特发性脊柱侧凸62例,Cobb角≥10°,平均年龄14.3±3.4(10～18)岁,King分型均为I型,治疗组31例,对照组31例,治疗组用新医正骨疗法配合矫形鞋及等其他综合治疗,对照组采用牵引、理疗、按摩等治疗.结果:总有效率治疗组93%,对照组71%,二者存在显著性差异(P＜0.01).结论:新医正骨疗法纠正椎体旋转位移在治疗青少年特发性脊柱侧凸有显著疗效,且损伤少,安全性好,患者易于接受.     

后路TSRH治疗King Ⅳ型青少年特发性脊柱侧凸的术中配合

目的 :探讨后路TSRH治疗KingⅣ型青少年特发性脊柱侧凸术中配合的相关问题。方法 :采用后路TSRH治疗 6例KingⅣ型特发性脊柱侧凸 ,冠状面Cobb氏角平均 6 7.6°(5 2°～ 80°) ,所有病例均采用后路TSRH钩、钉、棒进行矫形、内固定、融合。结果 :手术时间平均 15 0min ,术中出血平均 30 0ml,Cobb氏角平均矫正 5 5 .5° ,矫正率为 82 .1% ,矫形丢失率为 1.7%。结论 :采用TSRH治疗KingⅣ型侧凸效果良好 ,术中配合好能缩短手术时间、减少术中出血及脊髓损伤的可能性     

新AOSpine胸腰椎损伤分类的可信度与可重复性分析

目的：评估新AOSpine胸腰椎损伤分类的可信度与可重复性。方法对45例胸腰椎损伤患者进行回顾性分析。由4名脊柱外科医生对患者医的影像学资料（腰椎正侧位X线片及CT扫描）根据新AOSpine胸腰椎损伤分类方法进行分型。1个月后重新打乱顺序由该4名医生再次进行分型,收集分型结果,分别作可信度和可重复性分析,计算Kappa值检验其一致性。结果4名观察者均采用新AOSpine胸腰椎损伤分类方法进行分型,结果的一致性为68.9%（60.0%～75.6%）,可信度kappa值为0.644（0.543～0.720）,属基本可信。同1名观察者先后两次分型结果的可重复性为76.7%（73.3%～80.0%）,kappa值为0.732（0.691～0.771）,属基本可信。结论新AOSpine胸腰椎损伤分类方法具有较高的可信度与可重复性,然而其临床意义还亟需大样本长期随访研究。     

腰骶移行椎Castellvi和陈崇文等分型可信度与可重复性比较及意义

目的比较腰骶移行椎Castellvi分型和陈崇文等分型系统的可信度和可重复性,探讨陈崇文等分型的临床价值。方法选取住院及门诊治疗资料较完整患者80例,其中男47例,女33例。年龄16～55岁,平均36．7岁。每例均有完整的腰椎x线正侧位片、移行椎三维cT重建及腰骶MRI片。由4名有分型经验的脊柱外科医师分别进行Castellvi分型和陈崇文等分型,2周后再次进行分型,收集结果后对分型可信度和可重复性进行分析。计算Kappa检验的一致性。结果Castellvi分型和陈崇文等分型可信度分别为84．83％（Kappa=0．789）、87．67％（Kappa=0．892）,可重复性分别为90．75％（Kappa=0．895）、93％（Kappa=0．914）。结论陈崇文等分型直观、简洁、易记,对治疗有指导意义。     

基于Lenke分型的青少年特发性脊柱侧凸融合手术治疗进展

青少年特发性脊柱侧凸(AIS)是一类病因不明的复杂三维脊柱畸形, 严重影响患者的身心健康及生活质量而需手术矫形。合适的融合矫形策略不仅能获得良好的矫正效果, 降低术后并发症发生率, 还能保留更多活动节段, 维持患者脊柱的活动功能。然而, 如何制定AIS的融合手术策略一直以来是国内外学者争论的焦点。脊柱侧凸分型系统的建立对于AIS的融合手术策略制定具有非常重要的临床意义, 而Lenke分型系统目前已成为国际上通用的AIS标准分型。近些年, 大量学者在Lenke分型系统的框架下不断地完善和丰富了AIS的融合手术策略。因此, 本文就基于Lenke分型系统的AIS融合手术治疗进展做一综述。     

青少年特发性脊柱侧凸术前分型对手术指导的重要性

<正>青少年特发性脊柱侧凸类型比较繁杂,制定手术策略也是多方面、多层次和多系统的工程,其术前分型对手术指导有极其重要意义。现大多数学者认为,对Cobb角50°、骨骼发育未成熟者,Cobb角≥40°、非手术治疗无效(半年内侧凸进展超过5°)、胸椎后凸过小或过大、胸腰段后凸或腰椎后凸畸形及伴有明显外观畸形者应考虑手术治疗。然而,特发性脊柱侧凸临床表现多种多样,每个类型的侧凸又有不同的特点,其手术方法也不尽相同。因此,重视分型,正确制定手术方案,对保证手术疗效、避免并发症有重要意义。1983年,King等回顾分析了405例特发性胸椎侧凸患者的资料,根据其侧凸的部位、顶椎、侧凸程度、柔软度和代偿弯曲等将特发性脊柱侧凸分型。其分型是冠状面分型,是     

后路脊柱截骨矫形治疗重度僵硬后凸型脊柱侧凸

目的:评价应用后路脊柱截骨矫形治疗重度僵硬后凸型脊柱侧凸的效果 .方法:回顾性分析北京大学第一医院骨科自2005年3月至2006年9月应用后路脊柱截骨矫形治疗重度脊柱僵硬后凸型侧凸11例(平均年龄11.2岁),其中神经纤维瘤病3例,先天性脊柱侧弯5例,脊髓灰质炎1例,特发性脊柱侧凸2例.11例患者的Bending像脊柱活动度均小于25%.平均随访时间1.3年(0.5～2年).结果:术中1节段后柱楔形截骨3例,2节段后柱楔形截骨2例,3节段后柱楔形截骨2例,经椎弓根截骨2例,椎体切除+后柱切除2例.术前后凸畸形平均108°(87°～135°),侧凸畸形平均97°(65°～135°),术后后凸畸形平均矫正至49°(改善率55%),侧凸平均矫正至37°(改善率66%).术后身高平均增加4.7 cm.11例矫形手术无神经系统并发症发生. 结论:应用后路脊柱截骨矫形治疗重度僵硬后凸型脊柱侧凸是一种较为有效的手术方法.     

Reliability of a Novel Cobb Protractor for Measuring the Cobb Angle of Radiograph in Scoliosis

Objective To introduce a novel Cobb protractor and assess its reliability and rapidity for measuring Cobb angle in scoliosis patients. Methods The novel Cobb protractor had two endplate markers. A measurement was performed just to align the two markers to each endplate of the curve. The Cobb angle on the posteroanterior radiographs of 24 patients clinically diagnosed with adolescent idiopathic scoliosis was measured by three orthopedic surgeons with both standard Cobb method and the new technique, and the time of measurement was recorded. Intraclass correlation coefficients(ICCs) were calculated to assess the reliability of the new method. Results The time for a measurement with the new tool was approximately 10 seconds less than the time that used to finish a measurement with the standard method(P<0.05). The overall mean Cobb angle for the major curve of the 24 patients was 47.8°. The mean overall intraobserver and interobserver ICC was 0.971 and 0.971 for the Cobb method group, while the overall intraobserver ICC and the interobserver was 0.985 and 0.979 for the new tool group. Conclusions The novel Cobb protractor could perform quick measurement and measure almost all forms of radiographs. The Cobb protractor might be an ideal instrument to measure the Cobb angle.     

POSTERIOR SELECTIVE THORACIC FUSION IN ADOLESCENT IDIOPATHIC SCOLIOSIS

Objective To define the criteria of posterior selective thoracic fusion in patients with adolescent idiopathic scoliosis.Methods By reviewing the medical records and roentgenograms of 17 patients with adolescent idiopathic scoliosis who underwent posterior selective thoracic fusion, the curve type, Cobb angle, apical vertebral rotation and translation, trunk shift, and thoracolumbar kyphosis were measured and analyzed.Results There were 17 King type Ⅱ patients (PUMC type: Ⅱb1 13, Ⅱc3 4). The coronal Cobb angle of thoracic curve before and after operation were 56.9°and 21.6° respectively, the mean correction rate was 60.1%. The coronal Cobb angle of lumbar curve before and after operation were 34.8° and 12.1° respectively, and the mean spontaneous correction rate was 64.8%.At final follow-up, the coronal Cobb angle of thoracic and lumbar curve were 23.5° and 15.2° respectively, there were no significant changes in the coronal Cobb angle, apical vertebral translation and rotation compared with that after operation.One patient had 12° of thoracolumbar kyphosis after operation, no progression was noted at final follow-up. There was no trunk decompensation or deterioration of the lumbar curve. In this group, 3.9 levels were saved compared with fusing both the thoracic and lumbar curves.Conclusion Posterior selective thoracic fusion can be safely and effectively performed in King type Ⅱ patients with a moderate and flexible lumbar curve, which can save more mobile segments and at the same time can maintain a good coronal and sagittal balance.     

Are distal radius fracture classifications reproducible? Intra and interobserver agreement

CONTEXT AND OBJECTIVE: Various classification systems have been proposed for fractures of the distal radius, but the reliability of these classifications is seldom addressed. For a fracture classification to be useful, it must provide prognostic significance, interobserver reliability and intraobserver reproducibility. The aim here was to evaluate the intraobserver and interobserver agreement of distal radius fracture classifications. DESIGN AND SETTING: This was a validation study on interobserver and intraobserver reliability. It was developed in the Department of Orthopedics and Traumatology, Universidade Federal de S?o Paulo - Escola Paulista de Medicina. METHOD: X-rays from 98 cases of displaced distal radius fracture were evaluated by five observers: one third-year orthopedic resident (R3), one sixth-year undergraduate medical student (UG6), one radiologist physician (XRP), one orthopedic trauma specialist (OT) and one orthopedic hand surgery specialist (OHS). The radiographs were classified on three different occasions (times T1, T2 and T3) using the Universal (Cooney), Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF), Frykman and Fernández classifications. The kappa coefficient (kappa) was applied to assess the degree of agreement. RESULTS: Among the three occasions, the highest mean intraobserver k was observed in the Universal classification (0.61), followed by Fernández (0.59), Frykman (0.55) and AO/ASIF (0.49). The interobserver agreement was unsatisfactory in all classifications. The Fernández classification showed the best agreement (0.44) and the worst was the Frykman classification (0.26). CONCLUSION: The low agreement levels observed in this study suggest that there is still no classification method with high reproducibility.     

基于棘突体表投射空间三维位置的脊柱形态测量仪在脊柱侧凸形态测量中的初步应用

目的 探讨基于棘突体表投射空间三维位置的脊柱形态测量仪在不同脊柱侧凸形态测量中的应用。方法 纳入32例青少年特发性脊柱侧凸（AIS）患者,应用本课题组前期开发的通过空间姿态传感器感知棘突位置变化的脊柱形态测量仪,测量患者背部体表投射位置的棘突连线成角（SPA）。采用线性回归模型构建SPA与全脊柱正侧位X线片所测量Cobb角的数量关系。根据Lenke分型进行亚组分析,进一步在不同侧凸形态中探究SPA与Cobb角的数量关系。结果 32例AIS患者中,男11例、女21例,年龄为（13.94±0.84）岁;Lenke 1型20例,Lenke 5型12例;8例患者主弯累及T5～T11,4例累及T5～T12,1例累及T6～T11,7例累及T6～T12,4例累及T11～L3,8例累及T12～L4。线性回归分析发现,在AIS患者中,Cobb角与SPA呈线性关系,两者之间数量关系为：Cobb角=1.128×SPA+3.724。进一步亚组分析发现,在Lenke 1型AIS患者中,Cobb角和SPA同样存在线性关系,两者之间数量关系为：Cobb角=1.128×SPA+3.303。结论 基于棘突体表投射空间三维位置的脊柱形态测量仪能够初步应用于脊柱胸段侧凸的形态测量,棘突在体表的空间投射位置是脊柱形态测量的有效解剖参考标志。     

昆明小鼠状态焦虑动物模型明暗箱实验的重测信度及参数相关性

目的 探讨明暗箱穿梭试验(LDB)作为小鼠状态焦虑动物模型评价方法的重测信度及其参数相关性.方法 成年雄性昆明小鼠放入明暗穿梭箱,摄像系统记录5 min的行为变化,试验间隔1周进行2次;通过组内相关系数(ICC)、Kappa一致系数(Kappa)和Pearson相关系数(Pearson)进行统计分析,实验参数如下:首次进入暗箱潜伏期、明区停留时间百分率、明区水平运动百分率、总水平运动得分、明区垂直运动百分率、总垂直运动得分、总得分、穿梭次数及粪便粒数.结果 ①ICC结果表明,仅总垂直运动得分(ICC=0.5207,P＜0.01)显示LDB重测信度尚可接受,穿梭次数参数亦可考虑(ICC=0.4731,P＜0.05),而其他参数均显示LDB重测信度较差.②Kappa结果表明,所有参数均显示LDB重测信度较差,其中总垂直运动得分参数尚可考虑(Kappa=0.4286,P＜0.01).③Pearson结果表明,穿梭次数与明区停留时间百分率(Pearson=-0.4030,P＜0.05;Pearson=-0.1490,P＞0.05)、明区水平运动百分率(Pearson=-0.4331,P＞0.05;Pearson=-0.1893,P＞0.05)、明区垂直运动百分率(Pearson=-0.4485,P＜0.05;Pearson=0.02845,P＞0.05)初测重测几乎均呈弱负相关,与总水平运动得分(Pearson=0.8603,P＜0.01;Pearson=0.6341,P＜0.01)、总垂直运动得分(Pearson=0.4271,P＞0.05;Pearson=0.7245,P＜0.001)初测重测呈较好正相关.结论 总垂直运动得分可以作为昆明小鼠LDB的一个稳定参数,具有较好的重测信度;穿梭次数与明区停留时间百分率、明区水平运动百分率、明区垂直运动百分率初测重测呈弱负相关,与总水平运动得分、总垂直运动得分初测重测呈较好正相关.

Abstract：

Objective To explore the test-retest reliability and correlations of the light-dark box (LDB).Methods The behavior of mice in LDB was recorded twice, for five minutes,with a one-week inter-trial interval.Following parameters were evaluated:latency time for the first entry into the dark area (Latence); percentage of time exploring in the light area ( Ltime％ ); percentage of squares crossing in the light area ( Lcross％ ); total number of squares crossing ( Cross ); percentage of rears in the light area ( Lrear％ ); total number of rears (Rear); total score (Total); transitions between two areas (Transition); and number of fecal boli (Fbi). Subsequently,the intraclass correlation coefficient (ICC), the Kappa agreement coefficient (Kappa) and the Pearson correlation coefficient (Pearson) were calculated for these parameters. Results ①ICC for Lrear％ ( ICC =0.5207, P＜0.01 ) showed a fair reliability. ②Kappa for all parameters indicated a poor reliability. ③Pearson displayed weak negative correlations between Transition and Ltime％ ( Pearson = - 0.4030, P ＜ 0.05; Pearson =- 0. 1490, P＞ 0. 05 ), Lcross％ ( Pearson = - 0. 4331, P ＞ 0. 05; Pearson = - 0.1893, P ＞ 0.05 ), Lrear％ ( Pearson = - 0. 4485, P ＜ 0. 05; Pearson = 0. 02845, P ＞ 0. 05 ), however, fair positive correlations between Transition and Cross (Pearson =0. 8603, P＜0.01; Pearson =0.6341, P＜0. 01 ) ,Rear(Pearson =0.4271, P＞0. 05;Pearson = 0. 7245, P ＜ 0. 001 ). Conclusion Rear is found to be stable over time, and indicated a fair reliability.There is a weak negative correlation between Transition and Ltime％, Lcross％, Lrear％, but fair positive correlations between Transition and Cross, Rear.     

Lenke 2型特发性脊柱侧凸三维矫形手术的有限元模拟

目的 利用建立的Lenke 2型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)三维有限元模型,分别仿真模拟前路、后路手术矫形操作,探讨其最佳手术方案。方法 建立Lenke 2型AIS的有限元模型,分别模拟前路和后路共5种不同的矫形方案,比较不同手术方案的矫形效果和双肩平衡参数的变化。结果 5种不同矫形方案有限元模拟术后的上胸弯冠状面Cobb角和矫形率分别为:21.5(44.8%)、26.5(32.1%)、28.1(27.9%)、34.1(12.5%)、32(17.9%),各矫形方案的主胸弯矫正率无明显差别。胸椎矢状面生理后凸得以维持。5种矫形方案术后各双肩平衡影像学参数较术前有所升高,除方案A(上端固定椎为T2)外,其余各方案的喙突高度差均＞9 mm,锁骨角均＞2.5°,锁骨倾斜角差均＞4.5°。结论 对于左肩高的含结构性上胸弯Lenke 2型AIS,上端固定椎选择T2且完全融合上胸弯,可取得上胸弯、主胸弯良好的三维矫形和双肩平衡。部分融合上胸弯(上端固定椎为T3、T4),上胸弯的矫正率稍差,术后容易出现轻度到中度双肩失平衡。前路或后路选择性胸主弯融合,难以恢复上胸弯的正常脊柱序列,术后会导致轻度到中度双肩失平衡。     

特发性重度僵硬性脊柱侧凸的手术治疗

目的探讨特发性重度僵硬性脊柱侧凸的手术治疗效果。方法回顾性分析1999年6月至2003年6月手术治疗的特发性重度僵硬性脊柱侧凸。男9例,女15例,平均年龄17岁(12~20岁)。术前站立位主侧凸冠状面Cobb角平均98°(80°~117°),仰卧位反向弯曲相上柔韧性平均20·8%(5%~29·5%)。合并有矢状面畸形者15例。全部病例以北京协和医院分型原则进行手术融合。19例行前后路联合矫形术,5例行一期单纯后路矫形术。结果全部病例获随访,随访时间平均18个月(12~30个月)。术后主侧凸冠状面角58°(32°~100°),主侧凸矫正率平均为41·0%(10·9%~61·0%)。术后1例脱钩而行翻修术。1例钢丝断裂而无神经症状,给予严密观察。最后一次随访主侧凸冠状面角平均63°(31°~104°),矫正平均丢失5°(0°~10°)。无假关节形成及失代偿发生。结论与椎体截骨术相比,前路松解加后路矫形内固定术及单纯后路矫形内固定术具有危险性小、出血少、感染率低等优点,对特发性重度僵硬性脊柱侧凸来说,是一种安全有效的治疗方法。适当矫形及恢复冠状面和矢状面平衡是手术治疗的关键。