关节镜下外固定架牵引复位治疗胫骨平台骨折

目的探讨在关节镜监视下结合外固定架牵引复位治疗胫骨平台骨折的临床疗效。方法2003年2月至2005年1月共治疗26例胫骨平台骨折患者,Schatzker分型为:Ⅰ型4例,Ⅱ型5例,Ⅲ型4例,Ⅳ型6例,Ⅴ型5例,Ⅵ型2例。术前摄X线片和CT扫描,术中在关节镜监视下对膝关节行外固定架牵引复位,通过螺钉或钢板进行内固定。根据Rasmussen评分对术后疗效进行评定。结果所有患者均获得随访,随访时间7～21个月,平均16个月。术后在1．5～4个月骨性愈合,未出现切口愈合不良、感染和筋膜间隔综合征等并发症,在随访期间未发生创伤性关节炎和膝关节内翻、外翻畸形。根据Rasmussen评分,11例为优,13例为良,2例可,本组平均为(27±2)分。结论采用关节镜监视下结合外固定架牵引复位技术治疗SchatzkeⅠ～Ⅵ型胫骨平台骨折,具有创伤小、骨折愈合快等优势,可增大关节腔内的操作间隙,提高骨折复位的准确性,有利于膝关节功能恢复。     

Outcome of open comminuted tibial plateau fractures treated using an external fixator

Background The purpose of this study was to evaluate the outcome of open severe comminuted tibial plateau fractures treated with minimal internal fixation and circular external fixation frames. Methods Fifteen open comminuted tibial plateau fractures were involved in this retrospective study. In eight knees, the fracture was reduced through an extended open traumatic wound. In seven patients, another limited incision over the major fracture line or area of comminution was performed to assist in reducing the articular reduction. Simultaneous bone grafting, soft tissue reconstruction, and stabilization of the fracture using a circular external fixator were carried out. Results The patients were followed for an average of 32 months (range 24–54 months). The average time to union of the fractures and frame removal was 22.8 weeks (range 16–44 weeks). The quality of the reduction of the joint surface was rated as anatomical in four patients, good in five patients, fair in three patients, and poor in three patients. Four patients experienced loss of articular reduction. The Knee Society Clinical Rating scores indicated that three knees were excellent, seven were good, one was fair, and four were poor. Complications included one case of septic arthritis, one of osteomyelitis, one of malunion, and four with loss of reduction. Conclusions This technique provided acceptable results for open severe comminuted fractures of the tibial plateau without comminuted posterior wall fractures. The most significant disadvantage of the technique is insufficient anatomical reduction and loss of reduction in comminuted posterior wall fractures in the coronal plane. This technique should be combined with a minimally invasive internal fixation method to prevent loss of reduction in open severe comminuted and irreducible tibial plateau fractures.     

镶嵌式外固定支架治疗胫骨干骨不连与骨缺损

目的 探讨应用镶嵌式外固定支架治疗胫骨干骨不连与骨缺损的临床疗效.方法 自2006年3月至2010年10月收治40例胫骨干骨折术后骨不连及骨缺损患者,男30例,女10例;年龄19～45岁,平均28.4岁;左侧26例,右侧14例.骨不连按Weber-Czech分类:非感染性骨不连30例,感染性骨不连10例;合并骨缺损或肢体短缩18例,骨缺损或肢体短缩2～10 cm,平均6.1 cm.均采用镶嵌式外固定支架固定治疗.骨不连断端未植骨处理.同期行皮瓣修复者4例,行负压封闭引流二期皮瓣或植皮修复者5例.结果 36例患者术后获10～48个月(平均15个月)随访,4例失访.所有患者骨不连均获愈合,愈合时间为6～12个月,平均7.8个月.短缩2～3 cm者3例,短缩2 cm以下者4例.4例患者骨折愈合后骨折端在冠状面或矢状面上有成角,成角5°～10°,平均8°.相邻膝、踝关节功能恢复良好.结论 镶嵌式外固定支架治疗胫骨干骨不连及骨缺损方法简单、有效,可早期功能锻炼,感染患者可获一期愈合.     

腓肠肌肌皮瓣结合外固定架治疗胫骨骨折术后骨及固定物外露

我院自 1998年至今 ,采用腓肠肌肌皮瓣结合外固定架治疗胫骨骨折术后局部软组织缺损、骨及固定物外露 38例 ,取得了满意的疗效。1　材料与方法1.1　病例资料　本组 38例 ,男 31例 ,女 7例 ,年龄 18～ 5 5岁。均为外伤致胫腓骨开放骨折。左侧 16例 ,右侧 2 2例。38例均在外院急诊行清创胫骨骨折内固定手术。其中 2 9例行钢板固定 ,其余为钢丝捆绑或螺钉固定。术后因局部软组织损伤严重 ,缺血坏死 ,致胫骨及内固定物外露 ,外露时间最短 2周 ,最长近 2个月。其中皮肤缺损面积最大 17 0cm× 7 0cm ,最小 5 0cm× 5 0cm ,骨、内固定物外露位于…     

The treatment of open tibial fractures and of tibial non-union with a novel external fixator

We report the results of external fixation in 29 patients treated for tibial fractures and tibial non-union using a novel multi axial external fixator (MAXX) followed prospectively until bony union. The results of treatment were classified according to the Association for the Study and Application of the Method of Ilizarov (ASAMI). Overall, 13 patients had excellent bone results; 13 had good bone results; two had fair bone results, and 1 patient had poor bone results. Regarding functional results, 21 patients had excellent results; 6 obtained good results; none had fair results, and two had poor results. Acute patients did better functionally than chronic patients. This fixator is safe and versatile, although the indications for its use are very specific.     

具有闭合整复功能的胫腓骨骨折外固定架研制与应用

目的研制新型具备闭合整复胫腓骨骨折功能的外固定架。方法外固定架采用硬塑材料,主要构成为内部装有多组齿轮和蜗杆系统的复位环,侧方移位调整架,前后移位调整架及四根带螺纹的连接杆组成全环型骨折整复固定系统。通过手柄驱动齿轮,带动复位环、调整架及水平穿过骨端的复位针对移位的骨折端实施三维六个自由度的整复,多组位置可调的半环型固定臂锁卡于连接杆相应位置与交叉穿过骨端的骨针连接完成整复后的固定。结果临床应用该装置完成胫腓骨骨折闭合整复固定32例,基本达到解剖复位,愈合良好。结论所研制的胫腓骨骨折闭合整复外固定架具备很好的整复及固定功能,为胫腓骨骨折闭合复位治疗提供了很好的方法。     

人工骨在治疗胫骨平台骨折中的应用

目的 :探讨人工骨植入治疗胫骨平台骨折的临床效果。方法 :回顾分析 2 0 0 0年1月～ 2 0 0 2年 12月收治的胫骨平台骨折 43例 ,对其中随访资料完整的行人工骨移植治疗者2 9例进行分析 ,全部病例术前均行X线正侧位拍片、CT平扫 ,根据骨折情况制定手术方案 ,术中用“T”型或解剖型钢板固定。结果 :随访时间 6个月～ 3年 6个月 ,平均 2 7.3个月 (SD =10 .0个月 ) ,按Merchant评分标准优良率 86.2 %。结论 :应用人工骨植入治疗胫骨平台骨折疗效满意 ,且手术时间短 ,并发症少。     

动力外固定支架治疗胫骨骨折的并发症分析与对策(附11例报告)

目的:探讨动力外固定支架治疗胫骨骨折并发症的处理及预防措施。方法:对动力外固定支架治疗胫骨骨折出现并发症患者11例进行回顾性分析。其中男9例,女2例,年龄17～48岁,平均27.2岁,使用动力外固定支架固定时问为1.5～13个月,平均5.4个月。其中出现感染8例;骨延迟愈合5例,骨不愈合1例,外支架断裂3例,畸形愈合2例。入院后不同的并发症予以相应处理。结果:固定过程中严格的生物力学操作可以避免固定系统因应力干扰出现螺钉松动、断裂和主体断裂;早期钉孔感染一般比较局限,通过适当的处理能够避免加重扩大;适当的动力化可以避免骨延迟愈合或骨不连。结论:外固定支架是一种具备“生物学固定”理念的骨折固定器具,如果在胫骨骨折的固定过程中由于对外支架设计理念的理解不足,会导致感染、延迟愈合或不愈合等多种并发症,可以通过术中及术后的适当处理加以避免。     

Distal tibial reconstruction with use of a circular external fixator and an intramedullary nail. The combined technique

BACKGROUND: Distal tibial reconstruction with use of an external fixator when there is bone loss, limb-length discrepancy, and/or ankle instability is associated with many problems. The technique of limb-lengthening, ankle arthrodesis, and segmental transfer over an intramedullary nail has been introduced to overcome these problems. The present study investigates this combined technique. METHODS: Between 2002 and 2005, six patients, who ranged from seventeen to seventy years old, underwent distal tibial reconstruction and ankle arthrodesis with use of a circular external fixator and an intramedullary nail to treat a distal tibial defect following resection for chronic osteomyelitis or tumor or to treat a limb-length discrepancy combined with ankle instability. Functional and radiographic results were evaluated, with use of the criteria described by Paley et al., at an average follow-up of thirty-four months. RESULTS: The mean size of the bone defects in three patients was 5.3 cm (2, 7, and 7 cm), and the mean amount of the limb-shortening in four patients was 5.25 cm (range, 4 to 6 cm). The mean external fixation time was 3.5 months, and the mean external fixator index was 0.57 mo/cm. There was no recurrence of infection in the two patients with osteomyelitis. All six patients had excellent bone results, and the functional results were excellent for two patients and good for four patients. There were four complications, three of which were categorized, according to Paley, as a problem (a difficulty that occurs during lengthening and is resolved without operative intervention) and one that was categorized as an obstacle (a difficulty that occurs during lengthening and needs operative treatment). CONCLUSIONS: The combined technique is an improvement over the classic external fixation techniques of distal tibial reconstruction with ankle arthrodesis. It reduces the duration of external fixation, thus increasing patient acceptance, and it is associated with a low complication rate facilitating more rapid rehabilitation.     

外固定架结合骨段滑移治疗胫骨骨折

目的探讨利用外固定架结合骨段滑移治疗胫骨骨折的方法。方法应用外固定架结合骨段滑移的方法治疗11例胫骨骨折合并骨缺损和软组织缺损的患者。胫骨缺损长度4～12 cm;软组织缺损面积4 cm×5cm～8 cm×16 cm。使用单边重建外固定架,经过扩创、清除死骨、骨膜下截骨、骨段滑移、骨接触端植骨等步骤完成骨段滑移。结果 11例均获随访,时间18～48个月。胫骨骨折均获得愈合。骨段滑移5～12(8±1.9)cm。4例出现钉道浅表感染。2例膝关节屈伸活动度较健侧减少15°,1例踝关节屈伸减少10°,但是不影响生活。2例进行了浅表创面游离植皮。无经历第二次深部扩创、无进行皮瓣转移。结论外固定架结合骨段滑移是治疗胫骨骨折、骨缺损的有效办法,具有创伤小、疗效确切的优点。     

Treatment of infected tibial fractures and pseudarthrosis using an external fixator

The clinical course and the results of our treatment of 18 patients with External Fixator after infection or pseudarthrosis are demonstrated. On an average of 6.1 months the patients wore the external fixator, the time of consolidation of the fracture was 17.2 months from the accident. At the date of examination - 16 months to 10 years after removal the external fixator all fractures and pseudarthroses were united. Two patients still had a fistula three years after removal of the external fixator. Three patients had slight pain in the area of the former fracture or the complication-wound; disturbance of sensibility in the area of the scar and the meshgrafts were found at 11 patients. The mobility of the knee joint was nearly free in all patients, the mobility of the ankle joint was impaired in most of them.     

Biomechanical comparison of conventional open reduction and internal fixation versus calcium phosphate cement fixation of a central depressed tibial plateau fracture

OBJECTIVE: To evaluate the effect of calcium phosphate bone cement on stability and strength of the fracture repair in a central depressed tibial plateau fracture cadaveric model. DESIGN: Paired human cadaveric tibial specimens. SETTING: Biomechanics laboratory. PATIENTS: Uniform pure depression fractures of lateral tibial plateau were created in twenty human cadaveric tibial specimens. INTERVENTION: The first part of the study used thirteen pairs of tibiae in two groups: a control group receiving the conventional treatment of morselized bone graft and two cancellous screws and an experimental group receiving calcium phosphate bone cement only. The second part of the study used seven pairs of tibiae in two experimental groups: one receiving calcium phosphate bone cement with a more extensive void preparation and the other group receiving calcium phosphate bone cement with a more extensive void preparation and two screws. MAIN OUTCOME MEASUREMENTS: Each tibia was loaded on a Material Testing Systems machine from twenty newtons to 250 newtons for 10,000 cycles to simulate immediate postoperative load transmission to the tibial plateau. Specimens were then loaded to failure to determine the ultimate strength of the reconstruction. Displacement of the articular fragment and stiffness at each cycle were measured during dynamic loading. Peak load, deformation at peak load, and resistance to depression were measured during the load to failure. RESULTS: The treatment of depressed tibia plateau fractures with a calcium phosphate cement provides equivalent or better stability than conventional open reduction and internal fixation in pure depression tibial plateau fractures. If the fracture void is prepared by eliminating the cancellous bone under the subchondral plate, the results are further improved. CONCLUSIONS: This study suggests that the non-weight-bearing postoperative period may be significantly reduced without clinically significant articular collapse.     

解剖型钢板内固定结合CPM治疗胫骨平台骨折56例

我们自 1996年采用解剖型钢板治疗 5 6例胫骨平台骨折 ,术后结合CPM进行功能锻炼 ,疗效满意 ,现报告如下。1　临床资料　　本组 5 6例 ,男 4 2例 ,女 14例 ;年龄 17～ 82岁 ,平均 39岁。致伤原因 :交通伤 4 1例 ,高处坠落伤 9例 ,摔倒后致伤 4例 ,棍棒击伤 2例 ;均为新鲜骨折。所有病例术前均常规行患膝关节正侧位X线片及CT扫描检查。按AO分类法[1] :B1型 4例 ,B2 型 13例 ,B3型 11例 ,C1型 10例 ,C2 型 12例 ,C3型 6例。合并部血管神经损伤 7例 ,合并小腿骨筋膜室综合征 5例 ,合并膝关节韧带及半月板损伤 2 0例。 16例尚合并有其它…     

Indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures

The aim of the present study is to assess the results of indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures. The study included 28 patients with high-energy tibial plateau fractures (Schatzker type V and VI). The ages ranged from 22 to 58 years with an average of 35 years. The trauma was a road traffic accident in 16 cases and a fall from a height in 12 cases. Concomitant soft tissue injuries were present in 18 cases such as skin wounds in 6 cases, excessive swelling with skin blisters in 9 cases, and compartment syndrome in 3 cases. After clinical and radiological evaluation all the patients were treated by indirect reduction using a traction table and a hybrid external fixator. The average time to healing was 3.2 months. At the final follow-up the range of knee movement ranged from 0 degrees-140 degrees with an average of 110 degrees. The results were satisfactory in 23 cases and unsatisfactory in 5 cases according to the Rasmussen knee functional score. Complications included pin tract infection in 12 cases, an extension lag in 2 cases, varus deformity of about 15 degrees in one case, deep infection in one case and early osteoarthritic changes in 2 cases. Hybrid external fixation is a good method for treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.     

Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail

BACKGROUND: Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. METHODS: Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. RESULTS: The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. CONCLUSIONS: This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.     

轴向动力型外固定器在胫骨Pilon骨折治疗中的应用

目的回顾分析运用轴向动力型外固定器和改良穿针技术治疗严重胫骨Pilon骨折的效果。方法研究分析2000年7月至2003年2月间14例严重Pilon骨折(Rtiedi-Allgtiwer Ⅱ型和Ⅲ型)患者,年龄20-52岁(平均38岁),采用有限内固定结合轴向动力型外固定器治疗,远端外固定针置入技术经过改良,2枚外固定针分别置入距骨和跟骨,使外固定器远端夹具旋转轴线与胫距关节旋转轴线重合。结果随访5—36个月(平均18个月),骨折愈合时间12-24周(平均14周)。最后一次随访时,ASS评分优5例,良6例,可3例。无切口裂开、皮缘坏死、表浅及深部感染、骨髓炎,无骨折移位及关节面塌陷;仅有1例近端外固定针道感染,经清创及口服抗生素治疗好转。结论经过改良的轴向动力型外固定器技术结合有限内固定是治疗严重胫骨Pilon骨折的有效方法。     

胫腓骨远端骨折应用环形外固定架治疗分析

目的：探讨应用环形外固定架治疗胫腓骨远端骨折的临床疗效。方法将我院骨科在2012年6月～2013年6月收治的104例胫腓骨远端骨折患者作为研究对象,随机分为观察组和对照组,每组各52例,观察组采用环形外固定架治疗,对照组采用单臂外固定技术进行治疗,观察两组治疗效果。结果经治疗,观察组治疗优良率为94.3%,对照组治疗优良率为80.3%,两组比较差异具有统计学意义（P＜0.05）。结论对胫骨远端骨折患者,采用环形外固定架进行治疗,可有效降低软组织损伤、促进骨折复位闭合、减少感染风险,也可免除因取出内固定物所带来的痛苦,是一种安全、有效的治疗方法。     

锁定加压钢板结合植骨术治疗胫骨平台骨折

目的探讨锁定加压钢板结合植骨术治疗胫骨平台骨折的临床效果。方法应用锁定加压钢板固定结合植骨术治疗32例胫骨平台闭合骨折患者。结果手术时间62~135(98.5±3.5)min。术后1周内行X线检查,30例患者获得解剖或接近解剖复位(占93.8%),2例患者功能复位(占6.2%)。患者均获得随访,时间5~16(8.2±1.5)个月。骨折均骨性愈合。膝关节功能评价根据HSS评分标准:优23例,良5例,可3例,差1例,优良率87.5%。结论应用锁定加压钢板固定结合植骨术治疗胫骨平台骨折术后并发症少,膝关节功能恢复良好,治疗效果满意。     

Treatment of tibial defect and bone nonunion with limb shortening with external fixator and reconstituted bone xenograft

Objective: To explore the effect of external fixator and reconstituted bone xenograft (RBX) in the treatment of tibial bone defect, tibial bone nonunion and congenital pseudarthrosis of the tibia with limb shortening. Methods : Twenty patients ( 13 males and 7 females)with tibial bone defect, tibial bone nonunion or congenital pseudarthrosis of the tibia with limb shortening were treated with external fixation, Two kinds of external fixators were used: a half ring sulcated external fixator used in 13 patients and a combined external fixator in 7 patients.Foot-drop was corrected at the same time with external fixation in 4 patients. The shortened length of the tibia was in the range of 2-9 cm, with an average of 4.8 cm. For bone grafting, RBX was used in 12 patients, autogenous ilium was used in 3 patients and autogenous fibula was implanted as a bone plug into the medullary canal in 1 case,and no bone graft was used in 4 patients. Results: All the 20 patients were followed-up for 8 months to 7 years, averaging 51 months. Satisfactory function of the affected extremities was obtained. All the shortened extremities were lengthened to the expected length. For all the lengthening area and the fracture sites,bone union was obtained at the last. The average healing time of 12 patients treated with RBX was 4.8 months. Conclusions: Both the half ring sulcated external fixator and the combined external fixator have the advantages of small trauma, simple operation, elastic fixation without stress shielding and non-limitation from local soft tissue conditions, and there is satisfactory functional recovery of affected extremities in the treatment of tibial bone defects, tibial bone nonunion and congenital pseudarthrosis of the tibia combined with limb shortening.RBX has good biocompatibility and does not cause immunological rejections. It can also be safely used in treatment of bone nonunion and has reliable effect to promote bone healing.