内侧皮质不同复位等级对股骨转子间骨折髓内钉内固定术后临床疗效的影响

【摘要】 目的 探究内侧皮质不同复位等级对股骨转子间骨折 (FIF) 股骨近端髓内钉内固定术后临床疗效的影响。 方法 选取2016年6月至2019年10月正阳县人民医院收治的76 例FIF患者作为研究对象,并根据股骨近端髓内钉内固定术后即刻正位 X 线片显示的头颈骨块内侧皮质和股骨干内侧皮质的位置关系将患者分为正性支撑组(25例)、中性支撑组 (26例)和负性支撑组(25例),其中正性支撑组患者头颈骨块内侧皮质位于股骨干内侧皮质内上方,中性支撑组患者头颈骨块内侧皮质与股骨干内侧皮质影像学上完全对位,负性支撑组患者头颈骨块内侧皮质位于股骨干内侧皮质外上方。 对比观察 3 组患者术中出血量、手术时间、术后即刻尖顶距(TAD)、骨折愈合时间、股骨颈长度及颈干角变化情况以及临床疗效与并发症发生情况。结果 3 组患者术中出血量、手术时间及术后即刻 TAD 无明显差异 (F =0.021、0.015、0.255,P =0.980、0.985、0.880)。 正性支撑组患者骨折愈合时间明显短于负性支撑组 (q =5.373,P <0.001),而正性支撑组和中性支撑组、中性支撑组和负性支撑组间无明显差异 (q =3.145、2.280,P = 0.074、0.246)。术后即刻及术后3个月,正性支撑组患者股骨颈长度均明显长于中性支撑组和负性支撑组(术后即刻: q =6.172、13.920,P 均 <0.001;术后 3 个月: q =16.240、30.600,P 均 < 0.001),且中性支撑组患者股骨颈长度明显长于负性支撑组 (q = 7.887、14.660,P均<0.001);正性支撑组患者颈干角均明显大于中性支撑组和负性支撑组 (术后即刻: q = 3.562、7.839,P =0.037、P <0.001;术后 3 个月: q =12.360、24.860,P 均 <0.001),且中性支撑组患者颈干角明显大于负性支撑组 (q =4.353、12.740,P =0.008、P <0.001)。 术后 6 个月,正性支撑组患者中优 15 例、良 8 例、中 1 例?差 1 例,明显优于中性支撑组患者的优8例、良8例、中7例、差3例以及负性支撑组患者的优 6 例、良 7 例?中 6 例、差6例 (Z = - 2.520、- 3.150,P = 0.012、0.002),而中性支撑组与负性支撑组间无明显差异(Z = -0.917,P =0.359)。正性支撑组患者术后并发症发生率为 4.00%,中性支撑组患者术后并发症发生率为23.08%,负性支撑组患者术后并发症发生率为 28.00%,3 组患者并发症发生情况无明显差异 (χ2 =5.361,P =0.069)。 结论 FIF患者髓内钉内固定术后内侧皮质正性支撑复位稳定性更好,可明显缩短骨折愈合时间,改善股骨颈长度及颈干角,临床疗效较好,术中有意识的获得正性支撑复位非常必要。     

基于影像学特征对骨质疏松性椎体压缩骨折病人经皮椎体成形术后同椎体再发骨折的预测研究

目的 探讨基于影像学特征对骨质疏松性椎体压缩骨折（OVCF）病人经皮椎体成形术（PVP）后的列线图模型预测术椎椎体再发骨折的价值。 方法 回顾性纳入急性OVCF并行PVP后的病人93例。所有病人均行X线及MRI检查,根据椎体再发骨折诊断标准将病人分为再发骨折组（48例）和无再发骨折组（45例）。采用t检验和卡方检验比较2组间临床资料及影像特征的差异,对差异有统计学意义的指标进行多因素Logistic回归分析,获取再发骨折的独立危险因素,采用R软件建立列线图模型并绘制其校准曲线。采用受试者操作特征（ROC）曲线评估模型的预测效能,计算ROC曲线下面积（AUC）。应用校准曲线对列线图模型进行验证。 结果 再发骨折组的椎体高度恢复率、延伸至终板的骨折线、椎体内裂隙（IVC）、骨水泥周围积液及骨水泥-终板未接触（NPEC）与无再发骨折组的差异均有统计学意义（均P<0.05）;多因素Logistic回归分析显示延伸至终板的骨折线[优势比（OR）=3.232]、存在IVC（OR=27.117）和NPEC（OR=1.993）及较高的椎体高度恢复率（OR=2.943）为同椎体再发骨折的独立危险因素（均P<0.05）。存在延伸至终板的骨折线的椎体骨质前份前移距离[（3.12±2.62） mm]大于无延伸者[（1.67±2.18） mm]（P<0.05）。与不存在IVC病人相比,存在IVC病人的椎体高度恢复率（分别为7.19%±8.60%和12.63%±11.81%）和NPEC发生率[78.38%（58/74）和94.74%（18/19）]均更高（P<0.05）。列线图模型预测再发骨折的AUC为0.860,敏感度0.792,特异度0.844。校准曲线显示列线图预测概率与实际概率一致性尚可。 结论 基于影像学特征建立的列线图模型能够预测术椎椎体再发骨折。     

Who will benefit from antiresorptive treatment (bisphosphonates)?

Bisphosphonates are very effective treatments of postmenopausal osteoporosis. They suppress bone turnover, increase bone mineral density (BMD), and maintain or improve structural and material properties of bone, thereby decreasing the risk of fractures. All patients selected for treatment according to current international guidelines can benefit from bisphosphonate therapy independently of their prevalent rate of bone turnover. Long-term extensions (up to 10 years) of pivotal clinical trials with daily bisphosphonate administration showed sustained efficacy with no evidence of adverse effects on bone metabolism and skeletal fragility. Recent studies focus on the resolution of the effects of bisphosphonates on bone metabolism and fracture risk following cessation of long-term treatment. Such studies may help to formulate treatment recommendations according to the risk of the individual patient.     

肌少症和骨质疏松对类风湿关节炎患者脊柱骨质疏松性骨折的协同影响

目的探讨肌少症和骨质疏松(OP)对RA患者脊柱骨质疏松性骨折(OPF)发生的协同影响.方法选择389例住院的RA患者和同期156例年龄、性别相匹配的健康人,采用双能X线吸收测量(DEXA)法测定腰椎和髋部的骨密度(BMD),采用生物电阻抗法测定四肢骨骼肌质量,摄脊柱X线正侧位片并以半定量法进行脊柱骨折的判定.统计学方法:2组间计量资料比较采用t检验,组间率的比较采用x2检验,2项分类资料的多元回归分析采用Logistic回紧(backward LR法)分析.结果RA患者各测定部位BMD均低于对照组(P<0.01),RA组骨质疏松发生率(128/389,32.9%)高于对照组[(20/156,12.8%),χ^2=22.706,P<0.01];RA患者脊柱OPF发生率为21.6%(84/389),高于对照组中[(3.8%,6/156),χ^2=25.439,P<0.01].RA患者中肌少症的发生率为54.8%,高于对照组[(9.6%,15/156),χ^2=93.241,P<0.01];RA组肌少症合并骨质疏松的发生率(28.5%)高于对照组[(5.8%),χ^2=118.110,P<0.01 ].不同骨量(骨量正常、骨量减少、骨质疏松)分组间RA患者脊柱OPF发生率的差异有统计学意义(χ^2=43.373,P<0.01),且呈现出随着骨量逐渐降低,脊柱OPF发生率逐渐升高的趋势(χ^2=43.003,P<0.01).伴肌少症的RA患者脊柱OPF发生率(27.2%,58/213)高于无肌少症的RA患者[(14.8%,26/176),χ^2=8.833,P=0.003].根据骨质疏松和肌少症分组的3组间(1=无肌少症和骨质疏松;2=单纯肌少症或骨质疏松;3=肌少症合并骨质疏松)RA患者脊柱OPF发生率的差异有统计学意义(χ^2=33.832,P<0.01),且从第1组到第3组脊柱OPF的发生率有逐渐增高的趋势(χ^2=37.164,P<0.01).与未服用糖皮质激素(GC)组相比,服用GC组的RA患者具有更高的肌少症发生率(χ^2=7.136,P=0.008)、OP发生率(CI=10.900,P=0.004)和脊柱OPF发生率(χ^2=20.673,P<0.01).Logistic回归分析显示:高龄[OR(95%CI)=1.069(1.038,1.101),P<0.01]、服用GC[OR(95%CI)=3.169(1.679,5.984),P<0.01]、肌少症和骨质疏松[OR(95%CI)=2.113(1.430,3.124),P<0.01]的同时存在为RA患者发生脊柱OPF的危险因素.结论RA患者肌少症、骨质疏松和脊柱OPF的发生率均明显增高,且肌少症和骨质疏松对RA患者脊柱OPF的发生具有协同作用.     

The differential effects of bisphosphonates,SERMS (selective estrogen receptor modulators), and parathyroid hormone on bone remodeling in osteoporosis

Osteoporosis is a skeletal metabolic disease characterized by a compromised bone fragility, leading to an increased risk of developing spontaneous and traumatic fractures. Osteoporosis is considered a multifactorial disease and fractures are the results of several different risk factors both extra- and intraskeletal. Thus bone fragility can be the end point of several different causes: a) failure to reach an optimal peak bone mass during growth; b) excessive bone resorption resulting in decreased bone mass and microarchitectural deterioration; c) inadequate formation upon an increased resorption during the process of bone remodeling. The pharmacological therapeutical options, available to date, are directed on prevention of fractures. The aim of this paper is to describe the activities and the mechanisms of action, as known at present, of the most used therapies for osteoporosis and their clinical implications. Improvement of knowledge in this field will allow us to further improve therapeutical choices and pharmacological interventions.     

Food groups and bone health

Studies aimed at determining the relationship between key nutrients (especially calcium) and bone health have examined directly the effect of a specific nutrient (or, in some cases, various nutrients) commonly consumed in the human diet. Consideration of the foods man actually consumes rather than the nutrients contained within them is an alternative strategy that has been adopted in other disciplines examining the relationship between diet and disease. Two studies indicate that a high fruit and vegetable, intake is protective for the skeleton, whereas high candy consumption is associated with lower bone mass, irrespective of gender. These data also suggest that a high intake of fatty, sugary foods is detrimental to bone health around the time of menopause. Because milk and milk products provide greater than 50% of the total calcium in the Western diet as well as a number of other key nutrients including phosphorus, magnesium, and zinc, they have a fundamental role in bone health determination. Milk supplementation also improves the nutritional quality of postmenopausal women's diets to a greater extent than calcium. Data for alcohol consumption are also intriguing. Recently, a positive association was noted between tea drinking and bone mass in postmenopausal women and may point to the influence of flavonoids contained in tea on bone health.     

Osteoporosis in children and young adults

Osteoporosis is a major public health problem with serious long-term complications. In children, the definition of osteoporosis is not only based on densitometric criteria but also takes into account vertebral and long bone fragility fractures. Several factors, such as long-term high-dose steroids, chronic inflammation, malnutrition, immobility, lack of sex steroids, and medication can reduce bone density and increase the risk for fragility fractures when left untreated. Also, genetic conditions can predispose to primary bone fragility disorders, with osteogenesis imperfecta being the most common. Furthermore, since the growing skeleton is at an increased rate of bone remodeling, the ability to heal long bone fractures and reshape vertebral fractures differentiates children from adults. The scope of this chapter is to review the risk factors of osteoporosis and fragility fractures and describe the commonest causes of primary and secondary osteoporosis and their management in children and young adults.     

骨瓜提取物注射液对骨质疏松性椎体压缩骨折患者疼痛缓解及骨密度的影响

目的探析骨质疏松性椎体压缩骨折患者应用骨瓜提取物注射液对疼痛及骨密度的影响。方法对2017年1月~2018年12月在某院进行治疗的84例骨质疏松性椎体压缩骨折患者进行分组研究,采用抽签法分为对照组(n=42)与研究组(n=42)。对照组应用锝[99Tc]亚甲基二膦酸盐注射液治疗,在此基础上,研究组联合应用骨瓜提取物注射液治疗,对比两组临床疗效及疼痛程度、骨密度、骨钙素水平变化。结果研究组临床总有效率为95.24%,对照组为78.57%,差异有统计学意义(P<0.05)。研究组治疗2个月、6个月后疼痛评分均低于对照组,差异有统计学意义(P<0.05)。研究组治疗6个月后骨密度大于对照组,差异有统计学意义(P<0.05)。研究组治疗6个月后骨钙素水平低于对照组,差异有统计学意义(P<0.05)。结论骨质疏松性椎体压缩骨折患者应用骨瓜提取物注射液治疗,可进一步提高临床效果,缓解疼痛,增加骨密度。     

小儿伤科泡腾颗粒对闭合性骨折模型大鼠治疗效果研究

目的对比分析小儿伤科汤剂与小儿伤科泡腾颗粒对闭合性骨折模型大鼠的治疗效果。方法选取45只幼年雄性SD大鼠作为研究对象,利用骨折器建立大鼠胫骨闭合性骨折模型。根据随机数字表原则,将模型大鼠随机分为对照组、汤剂组和颗粒组,每组15只。所有大鼠手法复位固定后,对照组大鼠采用温开水灌胃作为对照,汤剂组大鼠采用小儿伤科汤剂灌胃治疗,颗粒组大鼠采用小儿伤科泡腾颗粒灌胃治疗。分别在治疗14 d、28 d、35 d时,每组处死5只大鼠,采集腹主动脉血检测血清钙、血清磷、血清碱性磷酸酶(ALP)指标,同时对患肢进行X摄片检查骨折愈合情况,以Lane-Sandhu X射线评分标准评价骨缺损修复情况。结果治疗14 d时,三组大鼠血清钙、血清磷、血清ALP指标比较差异均无统计学意义(P>0.05)。治疗35 d时,汤剂组和颗粒组大鼠血清钙指标低于对照组,差异有统计学意义(P<0.05)。但汤剂组和颗粒组大鼠比较差异无统计学意义(P>0.05)。治疗28 d、35 d时,汤剂组和颗粒组大鼠血清ALP高于对照组,差异有统计学意义(P<0.05)。但汤剂组和颗粒组大鼠比较差异无统计学意义(P>0.05)。治疗14 d时,三组大鼠Lane-Sandhu评分比较差异无统计学意义(P>0.05)。治疗28 d、35 d时,汤剂组和颗粒组大鼠Lane-Sandhu评分均高于对照组,差异有统计学意义(P<0.05)。但汤剂组和颗粒组大鼠Lane-Sandhu评分比较差异无统计学意义(P>0.05)。结论小儿伤科汤剂与小儿伤科泡腾颗粒治疗闭合性骨折模型大鼠效果相当。     

弹性髓内钉在儿童四肢骨折中的应用

目的研究弹性髓内钉对儿童四肢骨折患儿骨折愈合和并发症的影响。方法 40例儿童四肢骨折患儿,采用随机数字表法分为观察组与对照组,每组20例。观察组患儿采用弹性髓内钉固定,对照组患儿采用小切口复位。比较两组患儿骨折愈合和邻近关节活动情况、手术指标、骨折愈合时间及并发症发生情况。结果观察组患儿骨折愈合优良率为100.00%、邻近关节活动优良率为100.00%,均高于对照组的60.00%、70.00%,差异有统计学意义(χ^2=10.000、7.059, P=0.002、0.008<0.05)。观察组患儿手术时间、切口长度、住院时间和骨折愈合时间均短于对照组,出血量少于对照组,差异有统计学意义(P<0.05)。观察组患儿并发症发生率为10.00%,低于对照组的45.00%,差异具有统计学意义(P<0.05)。结论弹性髓内钉治疗儿童四肢骨折愈合和邻近关节活动效果显著,且其手术简便、手术时间短、患儿创伤小,治疗后并发症较少,值得临床应用。