Ilizarov骨搬移技术轴向偏移的临床观察

目的 :探讨Iliazrov骨搬移技术治疗骨不连出现轴向偏移的角度、发生率、原因及对策。方法 :自2007年1月至2012年12月,对10例骨不连患者行Ilizarov骨搬移技术治疗,其中男8例,女2例;年龄18~49岁,平均(30.3±10.6)岁。骨缺损部位:胫骨上段2例,胫骨中段2例,胫骨下段5例,股骨上段1例。根据Paley骨缺损分型:B1型6例,B3型4例。观察术后患者发生轴向偏移角度、发生率,并采用Paley评价标准对其骨性结果进行评价。结果 :10例患者术后均获得随访,时间19~32个月,平均(22.0±5.6)个月。3例患者对合端自然愈合,其余7例经植骨相应处理后愈合。佩戴外固定架时间16~28个月,末次随访时发生冠状位成角3例,成角度数5°~11°,平均(8.7±3.2)°;矢状位成角4例,成角6°~9°,平均(8.5±2.1)°。发生轴向偏移共4例。末次随访时Paley评价标准,骨性结果:优7例,良3例;功能结果:优6例,良4例。结论:轴向偏移在Ilizarov骨搬移术后较常见,造成骨愈合延迟及患肢力线不良,术中术后应采取相应措施避免或减少其发生以提高骨愈合率。     

Ilizarov技术联合皮瓣即时扩张技术Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形

目的:探讨采用Ilizarov技术联合皮瓣即时扩张技术Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形的临床疗效及安全性。方法:自2010年1月至2015年1月,采用Ilizarov外固定技术联合挛缩侧皮肤术中即时扩张技术Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形患者30例,男21例,女9例;年龄25~60岁,平均(40.2±5.5)岁。定期复查X线片,去除Ilizarov外固定后采用美国特种外科医院(HSS)评分标准评定膝关节功能,并采用疼痛视觉模拟评分(VAS)评价其疼痛缓解程度。结果:术后所有患者获随访,时间6~35个月,平均22个月。其中29例患者切口均Ⅰ期愈合,1例患者出现切口感染并发骨髓炎,2例患者并发固定钉松动,扩张皮瓣区均无坏死,无神经血管牵拉损伤症状。术后4~7个月去除外固定架,平均(5.2±1.1)个月。矫正成角角度10°~35°,平均(25.5±3.5)°。术后根据HSS评分标准,总分92.5±6.6,其中优25例,良4例,中1例;VAS评分1.2±1.5。结论:采用Ilizarov技术联合皮瓣即时扩张技术能够Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形,带架时间短,无皮肤坏死及神经症状,能够早期负重锻炼并改善患肢功能。     

Fracture healing following high energy tibial trauma: Ilizarov versus Taylor Spatial Frame

Introduction

The optimal treatment of high energy tibial fractures remains controversial and a challenging orthopaedic problem. The role of external fixators for all these tibial fractures has been shown to be crucial.

Methods

A five-year consecutive series was reviewed retrospectively, identifying two treatment groups: Ilizarov and Taylor Spatial Frame (TSF; Smith & Nephew, Memphis, TN, US). Fracture healing time was the primary outcome measure.

Results

A total of 112 patients (85 Ilizarov, 37 TSF) were identified for the review with a mean age of 45 years. This was higher in women (57 years) than in men (41 years). There was no significant difference between frame types (p=0.83). The median healing time was 163 days in both groups. There was no significant difference in healing time between smokers and non-smokers (180 vs 165 days respectively, p=0.07), open or closed fractures (p=0.13) or age and healing time (Spearman''s r=0.12, p=0.18). There was no incidence of non-union or re-fracture following frame removal in either group.

Conclusions

Despite the assumption of the rigid construct of the TSF, the median time to union was similar to that of the Ilizarov frame and the TSF therefore can play a significant role in complex tibial fractures.     

Foot and Ankle Function after Tibial Overlengthening

Lengthening the tibia more than 25% of its original length can be indicated for proximal femoral deficiency, poliomyelitis, or femoral infected nonunion. Such lengthening of the tibia can adversely affect the ankle or foot shape and function. The present study aimed to assess the effect of tibial lengthening of more than 25% of its original length on the foot and ankle shape and function compared with the preoperative condition. This was a retrospective study of 13 children with severe proximal focal femoral deficiency, Aitken classification type D, who had undergone limb lengthening from June 2000 to June 2008 using Ilizarov external fixators. The techniques used in tibial lengthening included lengthening without intramedullary rodding and lengthening over a nail. The foot assessment was done preoperatively, at fixator removal, and then annually for 3 years, documenting the range of motion and deformity of the ankle and subtalar joints and big toe and the navicular height, calcaneal pitch angle, and talo-first metatarsal angle. At fixator removal, all cases showed equinocavovarus deformity, with decreased ankle, subtalar, and big toe motion. The mean American Orthopedic Foot and Ankle Society score was significantly reduced. During follow-up, the range of motion, foot deformity, and American Orthopedic Foot and Ankle Society score improved, reaching nearly to the preoperative condition by 2 years of follow-up. The results of our study have shown that tibial overlengthening has an adverse effect on foot and ankle function. This effect was reversible in the patients included in the present study. Lengthening of more than 25% can be safely done after careful discussion with the patients and their families about the probable effects of lengthening on foot and ankle function.     

跟骨骨折外固定技术的发展

20世纪以来,足踝外科领域对于跟骨骨折的处理逐渐成熟,但是内固定技术一直存在内植物占位以及切口皮肤感染等问题。外固定技术为上述问题提供了解决方案,使用外固定处理开放性跟骨骨折以及软组织条件差的闭合性跟骨骨折具有诸多优势。临床上应用外固定技术对跟骨骨折的治疗早已开展,然而外固定治疗跟骨骨折的相关文献却很少。本文就跟骨骨折应用外固定技术治疗的历史及方法作一综述,理清其优劣,便于临床医师选择及制定手术方案、治疗策略。     

Bicondylar tibial plateau fractures treated with fine-wire circular external fixation

Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.     

一期游离组织瓣移植二期Ilizarov技术手术治疗小腿大面积软组织缺损并大段胫骨缺损

目的探讨一期游离组织瓣移植二期Ilizarov技术手术治疗小腿大面积软组织缺损并大段胫骨缺损的疗效。方法笔者自2008-10—2014-10应用一期游离组织瓣移植二期Ilizarov技术手术治疗小腿大面积软组织缺损并大段胫骨缺损28例,感染性骨缺损23例,非感染性骨缺损5例。结果 28例均获随访1.5~3.0年,平均2.1年。创面游离组织瓣及皮片均成活,愈合时间3~10周,平均6周。其中创面一期愈合10例,游离组织瓣术后游离植皮12例,游离组织瓣术后换药治疗创面愈合6例。本组5例骨折对合端对位良好,直接愈合;其余23例由于新生骨轴向偏移、骨折端软组织嵌入使断端对位欠佳,行外固定架调整、取自体髂骨移植术,术后对合端均愈合。去除外固定架时间10~26个月,平均18个月,骨愈合指数1.4~1.8个月,平均1.6个月。伤肢均恢复无辅助下行走功能,15例步态正常,7例因腓总神经损失或伸肌群缺损而跛行,6例因踝关节活动受限而跛行。结论一期游离组织瓣移植二期Ilizarov技术手术治疗小腿大面积软组织缺损并大段胫骨缺损安全性高,供区损伤小,肢体功能恢复好。     

Ilizarov Treatment of Congenital Pseudarthrosis of the Tibia: A Multi-Targeted Approach Using the Ilizarov Technique

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopaedics. The treatment goals are osteosynthesis, stabilization of the ankle mortise by fibular stabilization, and lower limb-length equalization. Each of these goals is difficult to accomplish but regardless of the surgical options, the basic biological considerations are the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation, and the correction of any angular deformity. The Ilizarov method is certainly valuable for the treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. Leg-length discrepancy can be managed by proximal tibial lengthening using distraction osteogenesis combined with or without contralateral epiphysiodesis. However, treatment of CPT is fraught with complications due to the complex nature of the disease, and failure is common. Residual challenges, such as refracture, growth disturbance, and poor foot and ankle function with stiffness, are frequent and perplexing. Refracture is the most common and serious complication after primary healing and might result in the re-establishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. This review describes a multi-targeted approach for tackling these challenges, which utilizes the Ilizarov technique in atrophic-type CPT.     

The fixed flexed and subluxed knee in the haemophilic child: what should be done?

Summary. Knee haemarthroses are very common in the haemophiliac and often, despite infusion of the missing coagulation factor, synovitis develops. The warm swollen joint is maintained in the most comfortable position for the haemophiliac: flexion. Ambulation is achieved by planterflexion of the ankle joint and toewalking. As the chronic synovitis persists, the range of movement of the knee is affected, with loss of full extension. Development of radiological degenerative signs develop. The quadriceps muscle usually weaken due to disuse, but the hamstrings are active in maintaining the flexion of the joint. As the process continues, the tibia subluxes posteriorly on the condyles of the femur. The posterior capsule of the knee joint soon contracts, permanently limiting knee extension. A case is described on whom an Ilizarov device was used to gradually return the limb to a function position. This will allow the patient to complete his growth prior to a definitive orthopaedic procedure.     

Treatment of intertrochanteric fractures in geriatric patients with a modified external fixator

Forty-two geriatric patients who had an intertrochanteric fracture were treated with a semicircular modification of the Ilizarov frame designed by Cattaneo and Catagni between January 1997 and September 2001. Twenty-five of the patients were female, 17 male. The average age of the patients was 77.5 years (range, 63-99). No intraoperative complication occurred. Deep pin-track infection was found in four patients and varus deformity was observed in two patients and shortening of less than 2 cm in 10 patients. Fixator removal was achieved in a mean time of 12 weeks (range, 10-18). No implant failure, refracture or stiffness of knee and hip joint movements was recorded. We concluded that the treatment of intertrochanteric fractures of the elderly patients with our modification provides significant advantages such as minimal operative and anaesthetic risks, no blood loss, early weight-bearing, short hospitalisation time and rapid union time.