微创与切开复位接骨板内固定治疗膝关节内骨折的比较

[目的]比较研究微创接骨板内固定和切开复位接骨板内固定对膝关节内骨折的治疗效果,探讨生物学内固定在膝关节内骨折中的使用价值.[方法]总结近年来根据生物学固定原则,以微创接骨板固定术(MIPO)治疗的膝关节内骨折共21例.以创伤类型及年龄等因素进行配对,选择切开复位内固定(ORIF)治疗的病例资料比较手术及术后恢复情况.采用HSS评分评价结果.[结果]MIPO组随访10～16个月(平均14.2个月),有2例进行骨移植术,平均手术时间60.0 min,术中失血量45.0 ml,平均骨折愈合时间10.0周,3例有5°以上膝内、外翻畸形,HSS功能评分平均86.67分;ORIF组经过12～48个月(平均21.2个月)随访,有18例进行骨移植术,平均手术时间79.52 min,平均术中失血量117.1 ml,平均骨折愈合时间12.24周,2例发生5°以上膝关节内、外翻畸形,HSS功能评分平均82.14分.两组均获得骨愈合,没有感染和内固定断裂等并发症发生.比较发现两组患者在手术时间、术中失血量、骨折愈合时间和功能恢复方面差异有统计学意义.[结论]对于合适的膝关节内骨折病例以微创接骨板内固定治疗可以降低植骨需求和术中失血,在手术过程和术后恢复方面有明显优势.     

Surgical treatment of complex tibial plateau fractures by closed reduction and external fixation. A review of 32 consecutive cases operated

Abstract Complex tibial plateau fractures are a challenge in trauma surgery. In these fractures it is necessary to anatomically reduce the articular part of the fracture and to obtain stable fixation. The aim of this study is to review the results of a surgical technique consisting of fluoroscopic closed reduction and combined percutaneous internal and external fixation. Thirty-two complex tibial plateau fractures in 32 patients were included. Twenty-one fractures were closed, 4 were open Gustilo grade I, 3 were Gustilo grade II and 4 were Gustilo grade III. The mean age was 37.8 years (range 21–64 years). Surgery was performed with patients in transcalcaneal traction and the knee flexed at 30° was used. Through a 1-cm incision centred over the tibial metaphysis of the tibia, a 3.2-mm hole was drilled in the antero-medial tibial aspect. The tibial plateau fracture fragments were elevated using either 1 or 2 curved Kirschner wires under fluoroscopy to control the reduction. Then the fragments were fixed with 2 cannulated AO screws inserted through small incisions into the medial aspect of the tibial plateau. Knee rehabilitation started postoperatively. Weight bearing started after 8–12 weeks depending upon the radiographic appearance. All external fixators were removed in outpatient facilities. All patients were clinically and radiographically evaluated at a mean follow-up of 48 months (range 38–57 months). Clinical results were evaluated according to the Knee Society clinical score. Average healing time was 24 weeks (range 18–29 weeks). In 1 patient a non-union occurred. This patient was treated with open reduction and plate fixation. In 2 patients a varus knee deformity occurred and a surgical correction was performed. There were no surgical complications. Mean knee range of motion was 105° (range 75–125°) and mean Knee Society clinical score was 89. Twenty-five results were scored as excellent, 4 good, 2 fair and 1 poor. Using this technique there is limited soft tissue damage and virtually no periosteum damage to the fracture fragments. However anatomical reconstruction of the joint can be obtained. Furthermore knee rehabilitation can be started immediately after surgery. We think that these factors were responsible for the optimal clinical long-term results.     

腓肠神经内侧头肌支切断术瘦小腿

目的探讨一种以腓肠神经内侧头肌支切断来改善小腿外形的新方法。方法在腘窝处切开,暴露腓肠神经内侧头肌支,并切断,使局部肌肉失神经萎缩,而缩小小腿的容积。结果本组4例,术后小腿周径平均缩小3.6±0.8cm,小腿外形满意。结论本方法为一简单、安全而有效的技术,能达到缩小小腿部的目的。     

切开复位取髂骨植骨治疗跟骨压缩性骨折不用内固定与用内固定手术比较

目的探讨切开复位取髂骨植骨治疗压缩性跟骨骨折用否内固定治疗的方法与疗效。方法回顾分析1999年9月~2005年2月52例波及中后关节面的跟骨压缩性骨折病例,第1组采用切开复位,将压缩骨折复位,主要是将跟骨、跟距关节面复位,取片状髂骨填塞骨缺损空腔植骨,不用内、外固定。第2组采用切开复位,将压缩骨折复位,主要是将跟骨、跟距关节面复位,取片状髂骨填塞骨缺损空腔植骨,用内固定。两组病例进行比较。结果所有病例均获随访,时间为6~12个月。术后按足部评分标准(JOA)进行功能评估,总体优良率为92.8%。结论对跟骨压缩性骨折采取切开复位取髂骨植骨术不用内固定治疗,局部切口小,创伤轻,无创缘坏死,较容易获得骨折的解剖复位,无须第二次手术取内固定,愈合后功能好,疗效满意。     

Long-term results of open reduction for residual subluxation in congenital dislocation of the hip: A new open reduction method involving 360° circumferential capsulotomy

We report satisfactory results with a new operative treatment, conducted via an extensive anterolateral approach, involving 360 degree circumferential capsulotomy, for residual subluxation in congenital dislocation of the hip (CDH). Long-term radiographic results of this procedure (group A) were compared retrospectively with the results of partial capsulotomy (group B), which preserved the posteroinferior joint capsule. The mean center edge angle in group A (22.5°) was greater than that in group B (16.0°). Satisfactory results were achieved in 11 of 15 hips (73%) (Severin class I or II) in group A, and in 5 of 12 hips (42%) in group B. These results suggest that whole circumferential capsulotomy can remove obstacles to complete reduction, and that acetabular development can be expected in hips reduced by the procedure, without the performance of innominate osteotomy. We believe that our technique is a useful alternative for the treatment of residual subluxation in CDH.     

Congenital defects of lower limbs and associated malformations: A population based study

As part of a detailed study of limb defects and associated patterns of congenital malformations, cases with lower limb deficiencies were analysed separately. We identified a total of 130 cases with deficiencies of the lower limbs without defects of the upper limbs. This gives an incidence of 1.07/10,000 livebirths, or 1/9,337 for this group of limb defects. Most common were femur deficiencies and deficiencies of the foot. A preponderance of males was found in the group of transverse defects of the leg (fibula/tibia deficiencies) and central axis deficiencies, while females had significantly more often longitudinal tibia defects and preaxial ray defects. © 1993 Wiley-Liss, Inc.     

闭合复位治疗婴幼儿发育性髋脱位的疗效观察

Objectives To retrospectively review the results of closed reduction for developmental dysplasia of the hip (DDH), and analyze the causative for the dissatisfactory results of radiolagieal. Methods From 1997 to 2005 the results of closed reduction for DDH in 60 children (77 hips) over 4.5 years period were retrospectively reviewed. Radiological final results of the patients were evaluated with Severin classification. The causative factors made from medical records and radiographs were used to make statistical analysis. Results Seventy-three percent of the patients (56/77) had satisfactory results according to Severin classification. Twenty-one hips classed as SeverinⅢ-Ⅴ. Seventeen of the 21 hips had a reconstructive procedure. Avaseular necrosis was observed in 29 hips (38%). The most important parameters affecting the result were age at reduction (P ＜ 0. 05) and avascular necrosis (P ＜ 0.05).Conclusions In order to achieve better clinical and radioiogical results, the infants suffering from the DDH should be treated in the early stage. The postoperative avascular necrosis usually leads to poor prohnosis.     

(iii) Minimal invasive techniques in the management of tibial plateau fractures

Intra-articular fractures of the proximal tibia present a wide spectrum of injury patterns with associated soft tissue injury. The last two decades have seen the techniques of management evolve from extensive open reduction and rigid internal fixation to arthroscopy-assisted minimal invasive surgery (MIS) and biologically benign internal fixation. The ultimate aim is to prevent the occurrence of late degenerative arthritis. This could be achieved in selected patients using minimal invasive surgery, which offers the advantages of better visualisation and management of intra-articular soft tissue injuries, confirmation of fracture reduction viewed from the joint surface, faster rehabilitation and fewer wound complications.     

Non-invasive assessment of changes in left ventricular diastolic time intervals after acute blood volume reduction in haemodialysis

The effects of acute blood volume reduction induced by haemodialysison diastolic time intervals were studied in 19 patients by echo-and phonocardiography. Haemodialysis significantly decreasedleft ventricular diameters. The isovolumic relaxation time wasprolonged and negatively correlated with left ventricular enddiastolic dimensions. To study the effect of load reductionon left ventricular filling time, cardiac cycles with the sameR–R interval, before and after haemodialysis, were compared.At any given R–R interval dialysis resulted in a significantprolongation of the filling time. This study shows that diastolictime intervals are dependent on left ventricular loading conditions,and this effect should be considered when these time intervalsare evaluated in the clinical setting.     

Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools?: Empirical evidence from An integrated school- and community-based demonstration intervention addressing drug use among adolescents

The objective of this demonstration project was to determine if school-based harm minimization drug education was potentially acceptable and effective for junior and senior high school students in Nova Scotia. We conducted a four-year quasi-experimental intervention using mixed quantitative and qualitative methodologies. The intervention was a co-operative participatory research project with various activities determined by the participants. The project involved a partnership of four schools, two school boards, two regional addiction services, the provincial department of health, and a university. The outcomes evaluation was based on a sample of 1117 and 849 students in the intervention schools, compared with 3755 and 4247 students in the rest of the province, in 1998 and 2002, respectively. The evaluation of acceptability was based on an analysis of 491 documents generated from 1998 to 2002. The outcomes of effectiveness were specific risks and harmful consequences associated with substance use. We found that harm minimization was an acceptable approach to drug education targeting the senior high school population, and there was also some evidence of effectiveness in that age group in that the prevalence of several risks and negative consequences of substance use decreased significantly in the intervention schools relative to the rest of the province. In junior high school, harm minimization was found to not be an acceptable approach to drug education. This demonstration project provides evidence that school-based harm minimization may be acceptable and effective in senior high schools but may not be acceptable in junior high schools.