经皮自体骨髓移植在骨缺损瘢痕组织内成骨作用的实验研究与临床应用

目的观察经皮自体骨髓移植在骨缺损瘢痕组织内的成骨作用,探索治疗骨不连的新途径。方法选健康家兔１８只,建立双侧桡骨中段骨及骨膜缺损１ｃｍ模型,６周后,实验侧（右）骨缺损区经皮注射自体红骨髓２ｍｌ,对照侧（左）骨缺损区经皮注射自身外周血２ｍｌ。在不同时间内进行Ｘ线片、组织学检查及新生组织钙、磷含量测定。临床应用经皮自体骨髓移植治疗骨不连１５例,其中腕舟骨不连７例,肱骨不连３例,股骨不连２例,胫骨不连３例。骨不连时间为７～４８个月,平均１３个月。结果实验侧骨缺损区在骨髓注射后不同时间的Ｘ线片、组织学检查均显示新骨形成逐渐增多,钙、磷含量均高于对照侧。对照侧无成骨现象。临床应用的１５例中,１３例在５～９个月骨折愈合,２例未愈合。结论经皮自体骨髓移植在骨缺损瘢痕组织内有成骨作用,在临床上可作为治疗骨不连的方法,尤其适用于骨不连部位软组织条件差、不具备开放植骨的病例。     

带蒂骨膜瓣植入联合PRP治疗腕舟骨骨不连伴骨坏死

目的分析应用自体骨与去白细胞富血小板血浆混合注入病灶联合带蒂骨膜瓣植入治疗腕舟骨骨不连伴骨坏死的临床疗效。方法2017年6月至2019年1月间我科应用自体骨与去白细胞富血小板血浆混合注入病灶联合带蒂骨膜瓣植入治疗腕舟骨骨不连伴骨坏死10例,男8例,女2例;年龄26~46岁,平均(32.7±3.7)岁;左侧3例,右侧7例;腰部骨不连7例,远极骨不连2例,近极骨不连1例;从腕部外伤至手术治疗时间3~14个月,平均(5.1±0.9)个月。术后对患者疗效进行随访观察,并采用Jiranek腕舟骨骨折疗效评价标准进行评定。结果所有患者均获随访,随访时间11~24个月,平均(12.9±1.4)个月。所有患者切口均甲级愈合,术后2周如期拆线。骨折愈合时间12~22周,平均(13.1±1.2)周,患者临床症状完全或部分缓解。Jiranek评分为80~95分,平均(89.2±4.1)分。结论应用自体骨与去白细胞富血小板血浆混合注入病灶联合带蒂骨膜瓣植入治疗腕舟骨骨不连伴骨坏死临床效果满意,值得肯定并进一步推广。     

Herbert螺丝钉治疗腕舟骨骨折骨不连（附13例报告）

Ｈｅｒｂｅｒｔ螺丝钉治疗腕舟骨骨折骨不连（附１３例报告）黄迅悟常青孔祥星刘蜀彬荆海赵大庆１９９２年１２月～１９９４年９月我院用Ｈｅｒｂｅｒｔ螺丝钉治疗腕舟骨骨不连１３例，１２例愈合，占９２．３％。１材料与方法均为男性，年龄１８～２５岁，平均２２岁，...     

应用Herbert螺钉内固定治疗腕舟骨骨折

目的介绍用Herbert螺钉内固定治疗不稳定型腕舟骨骨折及腕舟骨骨折骨不连的疗效.方法 1992年12月至1996年12月,用Herbert螺钉内固定治疗不稳定型腕舟骨骨折20例,腕舟骨骨折骨不连14例.结果不稳定型腕舟骨骨折失访5例,15例术后平均随访12.8个月,骨折全部愈合;腕关节活动范围在106°～128°之间.腕舟骨骨折骨不连14例术后平均随访18.3个月,骨折愈合率为85.7%.结论 Herbert螺钉治疗腕舟骨骨折具有对骨折端的加压作用、固定稳固、可经关节面置入、无需取出等优点.     

带筋膜血管蒂的桡骨骨膜瓣及自体红骨髓移植治疗陈旧性腕舟骨骨折

目的探讨应用带筋膜血管蒂的桡骨骨膜瓣及自体红骨髓移植治疗腕舟骨陈旧性骨折骨不连的治疗方法。方法1998年5月～2004年12月对19例腕舟骨陈旧性骨折骨不连患者采用切开复位带桡动脉茎突返支骨膜骨瓣及自体红骨髓移植治疗，随访其疗效。结果术后19例均获随访。时间3～36个月，平均15个月；骨折愈合率为100％，愈合时间为3～4个月，腕关节功能完全恢复正常。结论用带筋膜血管蒂的桡骨骨膜瓣并自体红骨髓移植治疗陈旧性腕舟骨骨折，操作简单、成骨作用强，并有加速骨折愈合的作用。     

自体骨棒结合松质骨、骨髓移植治疗腕舟骨骨不愈合

目的观察自体皮质骨棒结合松质骨、骨髓移植治疗陈旧性腕舟骨骨不连的临床疗效。方法随机选择13例陈旧性腕舟骨骨折骨不连的患者,骚刮骨折两端．建立新的骨折面,取胫骨近端前内侧皮质骨制作骨棒,舟骨复位后固定其骨折端,取其松质骨移植骨折端,结合或不结合克氏针内固定,胫骨近端内抽取自体红骨髓2ml快速加压注入骨折端,使其混合于松质骨内。结果术后随访6～25个月,平均11个月。术后CR片显示所有病例腕舟骨骨折均在4～5个月获得骨性愈合。功能锻炼后,腕关节活动度达健侧腕关节活动标准,所有病例无疼痛,均恢复了原工作。结论该方法具有促进骨折愈合和固定的双重作用。结合自体松质骨及骨髓移植提高了骨折愈合率。保留了原腕舟骨的解剖结构和生物力学特性．操作简单、经济,是一种有效的治疗方法。     

以桡动脉返支为蒂的桡骨骨膜骨瓣移位治疗舟骨骨不连

目的　介绍带蒂桡骨骨膜骨瓣治疗腕舟骨骨不连的术式。方法　自 1986年 3月以来 ,选择 2 6例腕舟骨陈旧性骨折骨不连 ,设计并应用带蒂桡骨骨膜骨瓣移位植入 ,骨瓣为 1.0 cm× 0 .4cm× 0 .5 cm,术后观察其疗效。结果　 2 6例腕舟骨骨折骨不连患者切口均 期愈合 ,骨不连在术后 2～ 3个月内获得骨性愈合 ,腕关节功能基本恢复正常。结论　该术式是治疗腕舟骨骨折骨不连的一种有效方法     

双克氏针固定结合桡动脉腕掌支蒂骨瓣治疗腕舟骨骨不连

目的探讨桡动脉腕掌支蒂桡骨瓣植入腕舟骨骨不连处双克氏针固定的方法及临床疗效。方法以桡动脉腕掌侧支为蒂挖取桡骨形成的带蒂骨瓣,植入已清理形成骨槽腕舟骨骨折骨不连处,用0.8 mm双克氏针贯穿固定骨瓣及骨折,治疗腕舟骨骨不连36例。结果术后随访9~37个月,平均17个月。骨折均愈合。Coony评分总体疗效:优25例,良9例,可2例,优良率为94.44%。结论桡动脉腕掌侧支蒂桡骨瓣是治疗腕舟骨骨不连的理想方法 ,双克氏针固定更容易、更微创、疗效更好。     

带血管蒂桡骨远端骨膜瓣植入治疗腕舟骨骨不连

腕舟骨骨折是腕骨中最常见的骨折之一，其延迟愈合和骨不连的发生率较高。１９９４年５月以来，我科采用带桡动脉升支的桡骨远端骨膜瓣植入术治疗腕舟骨骨不连９例，效果满意。一、资料与方法１．一般资料：本组共９例，男８例，女１例，年龄２０～３０岁，平均２４岁。伤...     

股骨重建髓内钉内固定与经皮注射自体红骨髓治疗股骨粗隆下骨不连

目的：采用股骨重建髓内钉内固定与经皮注射 自体红骨髓治疗股骨粗隆下骨不连。材料与方法：共９例,平均年龄５２岁,以往平均手术次数２次,骨折后时间平均２年６个月。方法：用股骨重建髓内钉静力型固定骨折端。取自体髂骨植骨。术后７ｄ,１４ｄ,抽取自体红骨髓,注射于骨折端。结果：所有病例在５－１０个月愈合。结论：上述方法可提供坚强地内固定,又可补充成骨基质和成骨前质细胞,是治疗股骨股骨粗隆下骨不连的较好方法。     

Retrograde Herbert screw fixation for treatment of proximal pole scaphoid nonunions

Most nonunions of the carpal scaphoid bone can be treated with a high rate of success by use of conventional bone grafting techniques. However, fractures with a small proximal pole fragment may be difficult to treat by use of these techniques. Nine patients with nonunion and three patients with unstable proximal pole fractures were treated with retrograde dorsal Herbert screw fixation and adjunctive bone grafting. Follow-up averaged 25 months. Of the 12 patients, the fracture healed in 11 and one fracture remained ununited. This technique has been successful in our practice and should be considered in the treatment of small proximal pole nonunions and displaced proximal pole fractures.     

Treatment of scaphoid fractures and nonunions

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.     

Fractures and nonunions of the carpal scaphoid in children

Fractures of the carpal scaphoid in children show some quite remarkable differences with respect to fractures of the carpal scaphoid in adults. A review of the literature shows that fractures in children are more often located in the distal third, are more often incomplete and are usually not displaced. Our experience with 23 fresh fractures of the carpal scaphoid in children confirms these findings of the literature. Nonunion of the carpal scaphoid is exceedingly rare in children. When reviewing the literature we could find only 29 published cases of nonunion of the carpal scaphoid in children. In most articles describing carpal scaphoid nonunion in children, bone grafting is recommended as the treatment of choice. We report two children with a nonunion of the carpal scaphoid treated successfully by cast immobilization. Therefore, we propose that a child with a nonunion of the carpal scaphoid bone that has never been immobilized previously should be treated by cast immobilization. Surgery should be considered only if there is no indication of healing after 3 months of immobilization.     

Percutaneous autologous bone marrow transplantation for nonunion of the femur.

Percutaneous bone marrow injections were performed on 7 nonunions of the femur. There were 6 hypervascular nonunions and one avascular nonunion. Two nonunions presented with active infections. One other patient had a history of infection which had subsided. One nonunion received the injection twice. After the site of nonunion was curetted and the bone surface was scored, 150 ml of bone marrow aspirated from the iliac bone was injected. Complete union occurred in 4 patients within 9 months; all of them were uninfected hypervascular nonunions following intramedullary nail fixation. One nonunion with a bone defect united partially leaving a 1 x 1 cm defect. The two infected femoral nonunions failed to unite. The results show that percutaneous autologous bone marrow injection for femoral nonunions can be considered for uninfected hypervascular nonunions following intramedullary nail fixation. In these cases stimulation of healing processes of fracture leading to consolidation can be expected from bone marrow injection. However, femoral nonunion with an active infection and loss of fixation is considered to be a contraindication for this technique.     

经皮交叉克氏针固定、自体骨髓移植治疗Herbert Ⅰ型腕舟骨骨折的临床研究

目的观察经皮交叉克氏针固定、自体骨髓移植治疗HerbertⅠ型腕舟骨骨折的临床效果。方法随机选择36例新鲜无错位（HerbertⅠ型）腕舟骨骨折患者，采用经皮交叉克氏针固定，抽取自体红骨髓5ml，快速、加压注入舟状骨骨折部位，术后6周开始，每周拍摄计算机X线片（CR-X）1次，至骨折愈合，并记录骨折愈合及恢复工作时间。结果术后随访6周～4年，36例全部愈合，骨折愈合时间为7～12周，平均8．3周。35例腕关节活动度达到健侧腕关节活动标准，活动后无疼痛，均恢复了正常工作。1例腕关节伸屈活动术后较术前有明显改善，但仍未达健侧腕关节活动范围，且活动时疼痛。结论经皮交叉克氏针固定、自体骨髓移植治疗HerbertⅠ型腕舟骨骨折，较传统治疗方法，具有损伤小、操作简单、安全，最大限度地避免了医源性损伤，缩短了骨折愈合时间，提高了治愈率，是一种有效的治疗方法。     

Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid

PURPOSE: With their intrinsic vascularity vascularized bone grafts provide an alternative solution to the challenging problem of scaphoid nonunions. The union rate (after imaging evaluation including magnetic resonance imaging [MRI]) and functional outcome of using vascularized bone grafts pedicled on the palmar carpal epiphyseal artery for waist nonunions of the scaphoid are reported in this prospective case series. METHODS: The technique was applied to 9 waist nonunions resulting from fractures. The mean time elapsed from the initial injury to the procedure was 22 months and the mean follow-up time was 24 months. The graft was pedicled on the artery running at the distal edge of the pronator quadratus and was inserted in the nonunion as an intercalary graft. Six patients had postoperative MRIs to evaluate fracture healing and graft incorporation. RESULTS: Union was accomplished in all cases between 6 and 12 weeks. Postoperative MRI showed the viability of the graft (contrast-enhanced images) and confirmed union and graft incorporation. Complete absence of pain was noted in all patients. The Mayo modified wrist score increased from 63 to 92 after surgery and according to this score results were excellent in 5 patients and good in 4. CONCLUSIONS: Vascularized bone grafts from the anterior radius lead to rapid union and consolidation in cases of waist nonunion. Postoperative MRI confirms viability of the graft, union, and graft incorporation. The approach is limited to the distal radius and wrist and lacks donor site morbidity. The interposition of the graft from the palmar side allows correction of the humpback deformity and patients regain carpal height, grip strength, and painless motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Treatment of scaphoid nonunion by radical curettage, trapezoidal iliac crest bone graft, and internal fixation with a Herbert screw

Ten adult male patients with scaphoid nonunions were treated by radical curettage, trapezoidal iliac crest bone grafting, and internal fixation with a Herbert screw. The mean patient age was 24.7 years, and the mean duration of the nonunion before surgery was 37.3 months. Mean follow-up time was 30.4 months. Nine of the ten nonunions healed, although one patient required a second bone-grafting procedure. The mean postoperative grip strength was 45.0 kg, and the mean postoperative pinch strength was 11.5 kg. The mean postoperative range of motion was volar flexion, 76.1 degrees; dorsiflexion, 74.2 degrees; radial deviation, 22.1 degrees; and ulnar deviation, 40.1 degrees. The scapholunate angle decreased from a mean of 72.8 degrees preoperatively to 60.6 degrees postoperatively (p less than 0.025). The mean carpal index was 0.57 postoperatively. Mean scaphoid length increased postoperatively and was within 0.2 mm of the opposite (normal) scaphoid in every patient except the single patient with a persistent nonunion (p less than 0.025). All patients returned to work (eight as laborers), and nine of ten wrists were subjectively rated as good or excellent. The results of the series suggests that treatment of displaced scaphoid nonunion by radical curettage, trapezoidal iliac crest bone grafting, and internal fixation with a Herbert screw is an effective method of treatment that reconstitutes scaphoid anatomy and promotes excellent wrist function.     

Treatment of Delayed/Nonunion of Scaphoid Waist with Synthes Cannulated Scaphoid Screw and Bone Graft

Fracture of the scaphoid bone is the most common fracture of the carpus, and frequently, diagnosis is delayed. The unique anatomy and blood supply of the scaphoid itself predisposes to delayed union or nonunion. The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid nonunions. Our aim was to conduct a retrospective study looking at the union rate, time to union, and complications and correlating the outcome of treatment against the delay between injury and surgery and location of the fracture within the bone. This study is a review of a cohort of 30 patients treated with a cannulated Synthes scaphoid screw and corticocancellous bone grafting for scaphoid waist delayed union and nonunion at our center. We achieved 86% overall union rate. The patients with delayed union achieved a 100% union rate. Three out of four patients with persistent nonunion after surgery reported no pain and improved function. The failure rate was 75% in patients who had sustained their fracture more than 5 years previously. Our study demonstrates that delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years can be successfully treated by fracture compression and bone grafting. No support of any kind was received from anybody.