Predictors of Early Complications of Total Shoulder Arthroplasty

The authors hypothesized that age, body mass index (BMI), and medical comorbidities (graded with the Charleson Comorbidiy index [CCI]) could be used to predict early complications after TSA. The authors performed a retrospective review of primary TSAs with a minimum of 90-day follow-up. One hundred twenty-seven patients met the inclusion criteria. Complications occurred in 12 (9.4%) of patients. Major complications occurred in 1 patient (0.8%), medical in 8 (6.3%), and surgical in 4 (3.1%). CCI significantly correlated with complication rates and multivariate regression analysis demonstrated CCI to be the only significant determinant of overall complication rates (P = 0.005) and medical complication rates (P = 0.015). While BMI subgroup did not affect complication rates, transfusion rates, intra-operative blood loss, or operative time, our study may have been underpowered for this variable.     

腓骨长肌腱前半部作为自体移植材料的临床研究

 目的 探讨腓骨长肌腱前半部（anterior half of the peroneus longus tendon,AHPLT）作为自体肌腱移植材料重建膝关节韧带的可行性及疗效。方法 2007年7月至2008年1月采用AHPLT作为自体肌腱移植材料的膝关节韧带损伤患者100例,男33例,女67例;年龄16~62岁,平均32.3岁。关节镜下内侧髌股韧带重建49例、多条韧带重建19例、后十字韧带双束重建18例和前十字韧带双束重建14例。切取AHPLT作为全部（49例）或部分（51例）重建材料,采用单切口或双切口技术,重建韧带用螺钉挤压固定。术后评估膝关节Kujala评分、Lysholm评分、Marx评分、国际膝关节文献委员会（International Knee Documentation Committee,IKDC）膝关节主观评估表和客观等级评定、踝关节足踝功能障碍指数（Foot and Ankle Disability Index,FADI）及美国足踝外科学会（American Orthopedic Foot and Ankle Society,AOFAS）评分。结果 92例获得2年以上随访。术后2年,不同韧带重建组患者膝关节IKDC主观评分、Kujala评分、Lysholm评分及Marx评分均高于重建术前。多条韧带重建、后十字韧带双束重建和前十字韧带双束重建术后IKDC客观等级评定结果达到正常及接近正常者分别为17例、15例和12例,优良率分别为89.5%（17/19）、93.7%（15/16）和100%（12/12）。全部患者手术前后AOFAS评分分别为（97.4±2.0）分和（97.2±1.6）分,FADI评分分别为（96.8±2.2）分和（96.9±2.5）分,差异均无统计学意义。患者均未出现腓神经损伤、腓骨长肌腱断裂等并发症。结论 AHPLT作为自体肌腱移植材料重建膝关节韧带具有操作可行性,近期临床疗效好,切取肌腱后对踝关节功能影响小。     

内侧半月板退变性损伤的关节镜下分型

 目的 探讨内侧半月板退变性损伤的关节镜下分型及其临床意义。方法 2012年1至12月因内侧半月板退变性损伤接受关节镜手术者122例,不包括因重度滑膜炎需做滑膜切除者。男27例,女95例;年龄37~80岁,平均（61.8±8.9）岁。左膝63例,右膝59例。BMI平均（26.5±3.4） kg/m2,术前Lysholm评分（47.2±15.0）分。关节镜术中依据Outerbridge软骨损伤分级对软骨损伤进行评估,比较不同分型者（后角水平撕裂、后角根部损伤和复杂严重损伤）Ⅳ度软骨退变性损伤所累及的关节面数量及术前Lysholm评分。结果 后角水平撕裂33例,Ⅳ度软骨退变性损伤累及的关节面（1.24±1.48）个,术前Lysholm评分（52.5±14.4）分,其中疼痛评分（7.7±6.5）分;后角根部损伤16例,Ⅳ度软骨退变性损伤累及的关节面（1.13±1.26）个,术前Lysholm评分（37.5±8.4）分,其中疼痛评分（3.1±4.0）分;复杂严重损伤73例,Ⅳ度软骨退变性损伤累及的关节面平均（2.26±1.61）个,术前Lysholm评分平均（46.9±15.3）分,其中疼痛评分（6.8±5.4）分。后角根部损伤者术前Lysholm评分低于后角水平撕裂和复杂严重损伤者,差异有统计学意义;其中疼痛评分的差异也有统计学意义。后角根部损伤者Ⅳ度软骨退变性损伤累及的关节面数量与后角水平撕裂者的差异无统计学意义;均小于复杂严重损伤者,差异有统计学意义。结论 关节镜下内侧半月板退变性损伤可分为三种类型。后角根部损伤和后角水平撕裂的软骨退变性损伤相对较轻,是较早期的关节退变;其中后角根部损伤的临床症状和功能减退较为明显。复杂严重损伤的软骨退变性损伤相对较重,是较晚期的关节退变,但临床症状和功能减退却相对较轻。     

模拟高空跳伞着陆状态下踝关节动态角速度与垂直反作用力的测定

 目的 通过模拟高空跳伞着陆训练环境测定不同高度半蹲式跳伞着陆状态下的踝关节角速度、地面垂直反作用力,为预防跳伞着陆踝部损伤提供生物力学依据。方法 募集18名健康志愿者,包括空军地勤人员9名、职业跳伞人员9名。两组受试者身高、体重的差异无统计学意义。受试者分别从30 cm和60 cm高的跳台以半蹲式跳伞着陆并腿姿势跳落到测力台上。高速摄像机记录着陆过程,测定踝关节跖屈角位移及时间、地面垂直反作用力,计算角速度,分析踝关节动态角位移、角速度、垂直作用力与不同高度的相关性。结果 30 cm高度：地勤人员组与跳伞运动员组踝关节角位移分别为25.73°±8.13°、20.05°±12.27°,垂直反作用力分别为（3 372.4±748.6） N、（5 181.5±1 726.2） N,受力时间分别为（0.049±0.015） s、（0.012±0.004） s,缓冲时间分别为（1.397±0.746） s、（1.737±0.451） s,差异均有统计学意义。60 cm高度：地勤人员组与跳伞运动员组踝关节角速度分别为（25.45±15.01） °/s、（16.51±4.18） °/s,垂直反作用力分别为（4 616.0±1124.7） N、（7 119.5±2 307.4） N,受力时间分别为（0.048±0.013） s、（0.015±0.006） s,缓冲时间分别为（0.922±0.347） s、（1.617±0.547） s,差异均有统计学意义。结论 从不同的测试高度跳下,跳伞运动员组的地面垂直反作用力大于地勤人员组,但角速度及角位移小于地勤人员组。对比地勤人员组,跳伞运动员组的受力时间短而缓冲时间更长。     

自体与异体肌腱微创重建踝关节外侧韧带的临床对比研究

 目的 比较应用自体半腱肌腱与同种异体肌腱微创移植重建踝关节外侧韧带的临床疗效。方法 回顾性分析2006年9月至2011年6月采用微创手术治疗慢性踝关节外侧不稳患者资料。其中应用自体半腱肌腱重建踝关节外侧韧带（自体组）32例,男19例,女13例;年龄17～62岁,平均32.4岁。同期应用同种异体肌腱重建踝关节外侧韧带（异体组）36例,男22例,女14例;年龄15～67岁,平均34.2岁。两组患者均采用相同的手术方法重建距腓前韧带及跟腓韧带。结果 自体组手术时间[（85.5±11.5） min］长于异体组[（58.1±10.2）min］,发热天数异体组[（5.5±1.5）d］长于自体组[（2.5±1.2）d］。自体组23例随访（33.5±6.7）个月,异体组26例随访（28.5±6.7）个月。美国足踝外科协会（AOFAS）踝与后足评分,自体组术前（62.3±8.2）分,术后（95.1±7.5）分;异体组术前（60.2±8.4）分,术后（94.8±5.5）分。5例患者（自体组3例、异体组2例）在不平地面行走时,踝关节有残余不稳定。自体组1例患者平整地面行走踝关节有残余不稳定。自体组无一例膝部肌腱供区功能障碍。术后AOFAS评分自体组16例为优,5例为良,2例为差;异体组17例为优,5例为良,4例为差。应力位X线片示自体组距骨倾斜角平均由14.0°减少到3.8°,异体组平均由13.0°减少到3.6°;距骨前移距离自体组平均由12.3 mm减少到4.6 mm,异体组平均由11.5 mm减少到4.3 mm。结论 自体肌腱与同种异体肌腱移植重建踝关节外侧韧带的临床疗效无差异,但自体肌腱愈合时间较异体肌腱快,而异体肌腱具有损伤小,手术简便等优点。     

Reduction of Intermetatarsal Angle after First Metatarsophalangeal Joint Arthrodesis in Patients with Hallux Valgus

We present a radiographic review of 94 patients who underwent first metatarsophalangeal joint arthrodesis. The main focus of our review was to assess the change in the intermetatarsal angle (IMA). The change in the IMA was measured for the entire group and for 2 subgroups (IMA 11° to 15° and IMA >15°). The results of the angular measurements for the total data set were as follows: mean preoperative first IMA, 15.32° (range 11° to 24°), mean postoperative IMA, 9.88° (range 3° to 18°), and mean change in IMA of 5.44° (range −2° to 13°; p < .001). Group 1, with an IMA of 11° to 15°, included 52 patients, with a mean change in the IMA of 4.21° (range −2° to 9°; p < .001). Group 2, with an IMA greater than 15° (range 16° to 24°), included 42 patients, with a mean change in the IMA of 6.83° (range 2° to 13°; p < .001). The change in the preoperative to postoperative IMA in group 1 compared with that in group 2 was statistically significant (p < .001). The results of the present study have confirmed the observations of previous investigators that arthrodesis of the first metatarsophalangeal joint for hallux abducto valgus deformity results in a reduction of the IMA and that a proportionately larger reduction can be expected when the IMA is larger.     

Retrospective Analysis of the Rate and Interval to Union for Joint Arthrodesis of the Foot and Ankle

Arthrodesis is a common procedure indicated for surgical treatment of end-stage degenerative joint disease of the foot and ankle. Many published studies have reviewed the union rate, focusing on specific technique or fixation. However, studies reporting on the average period required to achieve fusion, irrespective of the type of fixation or surgical method used, have been lacking. We report on the union rate and interval to fusion in patients who had undergone primary arthrodesis of various joints of the foot and ankle. A retrospective review of the medical records of 135 patients was performed. The specific joints studied were ankle, and the subtalar, triple, first tarsometatarsal, first metatarsophalangeal, and hallux interphalangeal joints. Our results showed that the average interval for complete fusion was significantly less for the joints in the forefoot, with the subtalar joint, ankle, and triple arthrodesis requiring a longer period to achieve complete fusion. The nonunion rate was also greater when the fusion involved the joints of the rearfoot. Our results have refuted the idea that 6 weeks is the minimum period required to achieve fusion in the foot and ankle. The results of our study support the need for additional education of the patients and surgeons that the interval required for recovery after foot and ankle fusion depends on the location and surface area that has been fused.     

Observed Changes in Radiographic Measurements of the First Ray after Frontal Plane Rotation of the First Metatarsal in a Cadaveric Foot Model

We observed the changes in the angular measurements commonly used in the evaluation of the first metatarsal and first metatarsophalangeal joint in cadaveric specimens before and after frontal plane rotation of the first metatarsal. Measurements of the first and second intermetatarsal angle (IMA), hallux abductus angle, proximal articular set angle, and tibial sesamoid position (TSP) were taken after varying degrees of varus and valgus rotation of the first metatarsal. Standard dorsoplantar radiographs were taken at 0°, 10°, 20°, and 30° of valgus rotation of the first metatarsal and repeated at 10°, 20°, and 30° varus rotation of the first metatarsal. The data were analyzed using a mixed linear model to compare the change in each angle measurement over the range of valgus and varus rotation. The change in the TSP was significant in both valgus and varus rotations (p = .0004 and p = .028, respectively), an increase in valgus rotation causing an increase in the TSP and an increase in varus rotation causing a decrease in TSP. The change in the IMA was significant compared with valgus rotation (p = .028), showing that as the valgus rotation increased, the IMA also increased. However, compared with the varus rotation, the correlation was not significant (p = .18). The proximal articular set angle and hallux abductus angle measurements, compared with metatarsal rotation, showed positive trends but were not statistically significant. From our results and a review of the published data, we have hypothesized that frontal plane rotation of the first metatarsal is an integral component of hallux abducto valgus pathologic features, specifically in relation to the TSP and IMA.     

不稳定性齿突游离小骨的诊断及治疗：26例患者临床分析

目的通过临床病例分析探讨不稳定性齿突游离小骨的临床特点及后路融合手术的治疗效果。方法回顾性分析2005年5月-2012年5月本院采用手术治疗有临床症状的不稳定性齿突游离小骨患者26例。分析总结病史特点、临床表现、影像学表现及手术治疗效果。结果 26例患者中男16例,女10例。年龄36-66岁,平均43.3岁。15例既往有明确外伤史,21例患者有颈部症状,所有患者均有不同程度的神经损伤症状,术前神经功能日本骨科学会（Japanese Orthopaedic Association,JOA）评分8-15分,平均10.1分。所有患者影像学均有寰枢椎脱位表现,其中22例为可复性,有2例伴有上颈椎其他畸形。24例行后路寰枢椎融合术,2例行枕颈融合术,术中无椎动脉、脊髓损伤发生,术后平均随访26个月（12-36个月）,26例患者均达到骨性融合,无内固定松动、断裂等并发症。术后12个月,颈部症状及神经功能明显改善,JOA评分为12-17分,平均15.1分（P〈0.05）。结论不稳定性齿突游离小骨容易损伤脊髓,应尽早手术重建其稳定性,经后路融合手术安全有效。     

寰椎椎板钩联合枢椎椎弓根螺钉治疗寰枢椎失稳的临床疗效

目的探讨后路寰椎椎板钩联合枢椎椎弓根螺钉技术治疗寰枢椎失稳的临床疗效。方法 2009年12月-2012年12月,行后路寰椎椎板钩联合枢椎椎弓根螺钉固定技术的寰枢椎失稳患者,有效随访资料36例,其中男26例,女10例;年龄21-66岁,平均42.3岁;有脊髓损伤症状者28例,日本骨科学会（Japanese Orthopaedic Association,JOA）评分9.3±1.8;有颈枕区疼痛症状者30例,颈枕区视觉模拟量表（visual analog scale,VAS）评分3.9±1.1;36例患者颈椎障碍功能指数（neck disability index,NDI）术前27.6±8.3;有发作性眩晕症状者6例;寰枢椎脱位26例,术前均行颅骨牵引术并达到复位。结果所有患者均顺利完成手术。术中出血量为80-600 mL,平均295 mL;手术时间95-210 min,平均157 min。术后随访个6-42个月,平均21个月,35例术后6月获得融合,影像学检查可见连续骨小梁,植骨融合率97.2%。末次随访JOA评分改善至13.7±2.0,平均改善率58%;术后VAS评分1.8±0.9;NDI降低至12.9±6.4。JOA评分、VAS评分和NDI评分术前与术后对比差异均具有统计学意义（P〈0.05）。术中未出现椎动脉、脊髓神经损伤或脑脊液漏等并发症。随访期间未发现椎板钩脱位、松动,6例有发作性眩晕患者眩晕症状消失。结论寰椎椎板钩联合枢椎椎弓根螺钉技术手术操作简单、风险低,手术时间短,有良好临床的效果,可作为治疗寰枢椎失稳的一种选择。