Percutaneous reduction combined with bone graft in treatment of displaced intra-articular calcaneal fractures

Objective： To introduce the experience and key points of percutaneous reduction combined with bone graft to treat calcaneal fractures. Methods： Percutaneous reduction and internal fixation combined with bone graft was performed from April 2004 to April 2006 on 15 cases （16 sides） with intra-articular calcaneal fractures including 13 males （14 feet） and 2 females （2 feet） ,with average age of 36. 6 years （24-61 years）. All patients underwent radiography including lateral and axial views for calcaneus, oblique view for foot and three-dimensional CT imaging reconstruction. According to Sanders classification, there were 12 feet of type Ⅱ （3 type Ⅱa, 3 type Ⅱb and 8 type Ⅱc） and 2 feet of type Illac. The length of calcaneus was recovered through traction by Steinmann pin which passed through calcaneal tubercle perpendicularly and the posterior facet was elevated until reduction by a curve scissors through an 0.5 cm incision along the primary fracture line of lateral calcaneus. The calcaneus was fixed with different cannulated cancellous screws according to the type of fractures. Then bone graft was injected to fill the defect of calcaneus through lateral incision. Results： All patients were followed up for an average of 18.4 months （ranged, 12 to 34 months）. No complication such as wound infection, screw breakage and calcaneum varus was found postoperatively. The average time for bone healing was 10 weeks. The results were excellent in 12 cases, good in 4 cases according to the American Orthopaedic Foot and Ankle Society （AOFAS） hindfoot score. The rate of excellent and good clinical results was 100%. The mean AOFAS hindfoot score in tongue type group （86.5±4.4） was better than in joint depression type group （81.2±1.7, P〈0.05）. Radiography showed basic restoration of Bohler＇s angle, Gissane＇s angle and calcaneal shape. Conclusion： The combination of percutaneous reduction and injectable bone graft is suitable for surgical treatment of Sanders Ⅱ and Ⅲ type calcaneal fractures, with advantages of simple operation, fewer complications and good clinical results.     

Fracture morphology and biomechanical characteristics of Pauwels III femoral neck fractures in young adults

BackgroundPauwels classification, which categorizes types of femoral neck fractures, cannot fully reflect the three-dimensional characteristics of this injury. The purpose of our study was to determine the morphological characteristics of Pauwels III fractures through computed tomography image analysis and summarize the relevant biomechanical characteristics of different morphological fractures.MethodsWe retrospectively reviewed a total of 209 patients diagnosed with Pauwels type III femoral neck fractures. Fracture reduction was simulated based on mirror symmetry of the bilateral femur by Mimics. The fracture angle was measured and subtypes were defined. Biomechanical characteristics were compared by finite element analysis and validated using a biomechanical experiment, which was performed on a cadaveric sample.ResultsPauwels III femoral neck fractures can be divided into three subtypes: anterior, posterior, and classical. The proportion of three subtypes was 28.71%, 67.46%, and 3.82%, respectively. The anterior subtype showed the lowest axial stiffness but highest implant and bone stress. High stress distributions was concentrated on the screw-bone interface and screw-plate connections.ConclusionsBiomechanical differences across the three subtypes of Pauwels III femoral neck fractures could increase our understanding of the biomechanical characteristics that underlie the Pauwels type III femoral neck fractures (such as, three-dimensional morphology and the stress distribution of bone and implant) that have been associated with high failure rates.     

小蝶形钛钢板的研制及其在跟骨关节内骨折手术中的应用

目的 介绍小蝶形钛钢板的研制及其在跟骨关节内骨折手术中的应用，并探讨其适应证及优缺点。方法 2001年2月-2004年4月，采用小切口和小蝶形钢板对22例26侧跟骨关节内骨折进行切开复位内固定治疗，男16例19足，女6例7足；年龄23～61岁，平均36．8岁。单侧跟骨18例18足，双侧跟骨4例8足；左足11侧，右足15侧。损伤原因：高处坠落伤20例24足，交通伤2例2足。骨折分型按Sanders方法，Ⅱ型12足（Ha3足，Hb7足，Hc2足），Ⅲ型14足（Ⅲab5足，Ⅲac7足，Ⅲbc2足）。结果 17例21足获得随访，时间为12～34个月，平均19．2个月。按Maryland足评分方法（Maryland Foot Score）评价术后功能：Ⅱ型骨折9足，优7足，良2足；Ⅲ型12足，优6足，良5足，可1足。所有的足外形恢复正常，能够穿正常鞋，无跛行。X线检查示Boehler角、Gissane角、距骨倾斜、跟骨宽度及丘部高度基本恢复正常，无明显并发症。结论小蝶形钛钢板适用于Sanders Ⅱ和Ⅲ型跟骨骨折的手术治疗，具有操作简单、固定可靠、并发症少和临床疗效好等优点。     

距下关节镜辅助下闭合复位经皮螺钉内固定治疗跟骨关节内骨折

目的探讨距下关节镜辅助下闭合复位经皮螺钉内固定治疗跟骨关节内骨折的适应证及优、缺点。方法2003年2月至2004年12月,在距下关节镜辅助下采用闭合复位经皮螺钉内固定治疗单侧跟骨关节内骨折12例,男7例,女5例;年龄23～61岁,平均36.8岁;右侧8例,左侧4例;高处坠落伤11例,车祸伤1例。SandersⅡ型8例(ⅡA型1例,ⅡB型5例,ⅡC型2例),Ⅲ型4例(ⅢAB型2例,ⅢAC型1例,ⅢBC型1例)。结果12例中11例手术顺利,达到或接近解剖复位,1例SandersⅢAB型骨折由于中间的骨折块压缩过深而未能达到复位要求,改为小切口切开复位小蝶形钢板内固定治疗。术中关节镜检查证实关节面骨折间隙和台阶均<1mm。术前B"hler角为18.4°±5.8°,Gissane角为109.1°±10.2°,跟骨宽度为(35.9±2.2)mm;术后B"hler角为25.4°±3.5°,Gissane角为118.1°±6.4°,跟骨宽度为(32.3±1.1)mm。9例获得随访,随访时间10～25个月,平均17.4个月。按Maryland足评分系统评价术后功能,其评分为82～100分,平均92.5分,优6例,良3例。所有获得随访患者无一例发生骨折再移位等并发症,足外形良好,能够穿正常鞋,无明显跛行。结论距下关节镜辅助下闭合复位经皮螺钉内固定适用于SandersⅡ型和部分SandersⅢ型跟骨骨折的治疗,可获得良好的复位和可靠的固定,并明显降低软组织损伤等并发症的发生率,是一种有效、可行的微创治疗方法。     

髓内钉与钢板内固定治疗胫骨远端关节外骨折的比较研究

目的通过对已发表文献进行汇总分析,根据现有数据资料总结髓内钉与钢板内固定治疗胫骨远端关节外骨折预后的比较。方法通过系统检索1975年1月～2011年5月发表的关于钢板或髓内钉治疗胫骨远端关节外骨折的英文文献。2位作者全文阅读并决定是否符合纳入标准或排除标准,收集相关结果和数据,通过循证医学分析方法,加权汇总分析两种治疗方案的功能预后和并发症。结果有22篇文献纳入研究,包括880例手术患者。髓内钉组的平均手术时间长于钢板组,但差异无统计学意义。髓内钉组的平均愈合时间显著短于钢板组。髓内钉组的感染率低于钢板组,但差异无统计学意义。髓内钉组的畸形愈合率显著高于钢板组。髓内钉组骨折的延迟愈合率和不愈合率与钢板组无统计学差异。髓内钉组的二次处理率(13.6%)高于钢板组(8.9%),但差异无统计学意义。结论根据此项研究结果,髓内钉内固定治疗胫骨远端关节外骨折可以更快愈合,使患者更早进行功能锻炼,但畸形愈合的概率高于钢板组,因此,具体的术式选择还应该根据患者的具体情况和医生的习惯决定。     

内侧柱是否使用螺钉支撑对锁定钢板治疗肱骨近端骨折的疗效比较

目的 :比较内侧柱是否使用螺钉支撑对锁定钢板治疗肱骨近端骨折的疗效。方法 :自2012年1月至2013年7月,采用锁定钢板治疗46例肱骨近端骨折患者,男25例,女21例;年龄29~80岁,平均55.1岁。其中内侧柱使用螺钉支撑组(支撑组)25例,男13例,女12例;年龄38~80岁,平均(55.8±11.8)岁;骨折按Neer分型:2部分骨折8例,3部分骨折10例,4部分骨折7例。内侧柱未使用螺钉支撑组(未支撑组)21例,男12例,女9例;年龄29~79岁,平均(54.2±14.8)岁;Neer分型:2部分骨折6例,3部分骨折9例,4部分骨折6例。比较两组患者的手术时间、骨折愈合时间及并发症情况,并在末次随访时采用Neer肩关节功能评分进行疗效评价。结果:46例患者获得随访,时间12~41个月,平均15.6个月。支撑组手术时间(1.6±0.4)h,未支撑组(1.5±0.4)h;支撑组骨折愈合时间(3.0±0.6)个月,未支撑组(3.1±0.6)个月;两组患者手术时间、骨折愈合时间比较差异无统计学意义(P0.05)。Neer肩关节功能评分支撑组(89.7±4.9)优于未支撑组(83.1±7.1),差异有统计学意义(P0.05)。支撑组未出现明显并发症,未支撑组4例出现并发症。结论:内侧柱使用螺钉支撑对锁定钢板治疗肱骨近端骨折有固定牢靠、并发症少等优点,术后功能恢复更满意。     

尺骨鹰嘴截骨入路治疗肱骨远端冠状面骨折的疗效观察

目的:探讨尺骨鹰嘴截骨入路切开复位内固定治疗肱骨远端冠状面骨折的疗效。方法:回顾性分析2005年1月至2013年1月,采用尺骨鹰嘴截骨入路切开复位内固定治疗的34例肱骨远端冠状面骨折患者的临床资料。男15例,女19例;年龄17~84岁,平均(54.9±10.2)岁;左侧18例,右侧16例。按Bryan-Morrey分型联合McKee分型,Ⅰ型10例,Ⅱ型5例,Ⅲ型10例,Ⅳ型9例。采用Mayo肘关节功能评分对结果进行评价并行统计学分析。结果:随访15~96个月,平均(35.1±7.2)个月。肘关节平均屈(132.1±11.2)°,伸(4.6±1.9)°;Mayo评分73~94分,平均85.9±6.3,优13例,良15例,可6例。Bryan-MorreyⅠ、Ⅱ、Ⅲ和Ⅳ型患者Mayo肘关节功能评分平均为88.6±3.7、85.8±4.6、81.8±5.8和87.5±9.1,差异均无统计学意义。结论:尺骨鹰嘴截骨入路切开复位内固定治疗肱骨远端冠状面骨折的疗效满意,该截骨方法可以维持术后骨折复位,提高肘关节功能。     

Development of the Plymouth VTE Risk Score for patients treated with lower limb immobilisation in a cast or boot

There is approximately a 2% risk of clinically significant VTE following temporary lower limb immobilisation after injury with an ankle immobilising plaster cast or boot. There is evidence that thromboprophylaxis for lower limb immobilised patients reduces the risk of VTE by approximately 50% but there is no international consensus as to which patients should receive thromboprophylaxis. The Plymouth VTE Risk Score was developed to identify patients at particular risk of VTE, in order to offer chemical prophylaxis to reduce their VTE risk. The score showed high completion rates, reliability and consistency. Using the Plymouth VTE Risk Score Version 3 (2014), we found an incidence of clinical VTE of 0.36% with 37.6% of patients being advised to have thromboprophylaxis. This is a lower VTE incidence than in most other studies of this patient group, which is of the order of 2 to 3%. The optimal RAM to use in clinical practice is yet to be defined, further clinical research is needed to accurately stratify patient risk and to define optimal risk treatment levels. We suggest research should focus on comparative clinical studies of risk assessment models.     

第二掌背动脉双轴点岛状皮瓣的解剖及临床应用

目的为第2掌背动脉(seconddorsalmetacarpalartery,SDMA)双轴点岛状皮瓣的临床应用提供解剖学依据,并观察其效果。方法30例新鲜成人尸手标本经肱动脉灌注天然乳胶—红色球磨染料混合液,观察SDMA皮肤返支动脉的走行、分支、分布及其吻合支。临床采用SDMA双轴点岛状皮瓣修复拇指皮肤缺损18例,背侧11例,掌侧7例,其中背侧皮肤缺损伴拇长伸肌腱缺损3例,中指背侧近侧皮肤缺损2例。切取皮瓣2cm×3cm～3cm×5cm。结果尸手标本中,皮肤返支血管出现率100%。皮肤返支血管在SDMA与食指伸肌腱交叉连接远侧0.5±0.2cm处穿出,在距掌指关节近侧1.2±0.5cm处进入皮肤;可见1.7±0.7支细小皮肤返支血管分支,在背侧浅静脉深面向近侧纵向扇行分布行走,血管网间有很多吻合;皮肤返支血管外径0.3±0.1mm,长6.5±0.8cm。临床应用18例,术后皮瓣全部成活。16例获8～14个月随访,2例失访。随访期间皮瓣色泽好,外形满意。皮瓣内神经桥接指固有神经的3例和与指背神经吻合的9例,两点辨别觉分别为0.9、1.1mm;未吻接神经的4例两点辨别觉为13～15mm。结论皮肤返支动脉的走行、分支、分布恒定,皮肤返支血管可增加SDMA皮瓣血管蒂长度,为临床应用提供解剖学依据,克服了SDMA岛状皮瓣从指背取皮需植皮留下瘢痕的缺点。     

半髋关节置换治疗高龄不稳定股骨粗隆间骨折的疗效分析

目的探讨半髋关节置换治疗高龄不稳定股骨粗隆间骨折的疗效。方法对12例Evens-JensenⅣ型高龄股骨粗隆间骨折行骨水泥型半髋关节置换术,X线片观察骨折愈合及假体情况,Harris髋关节评分评价疗效。结果术后10例获平均为16个月(9~22个月)的随访,X线片显示骨折愈合好,无假体脱位、松动等并发症。Harris髋关节评分优4例,良4例,中1例,差1例。结论半髋关节置换术是治疗高龄股骨粗隆间不稳定骨折的有效方法之一,但应严格掌握适应证。