髓内腓骨移植结合Ilizarov技术治疗胫骨感染性骨不连及骨缺损（附7例报告）

目的探讨髓内腓骨移植结合Ilizarov技术治疗胫骨感染性骨不连及骨缺损的效果。方法选择胫骨感染性骨不连及骨缺损7例,骨感染情况根据Ciemy—Mader分型,Ⅲ型局限型5例,Ⅳ型弥漫型2例;患者均有窦道形成,2例存在皮肤缺损及骨外露。7例均采用髓内腓骨移植结合Ilizarov外固定骨延长治疗。结果患者均获得随访,随访时间平均20．8个月。7例最终全部愈合,延长段或搬移段长度平均5．7cm,骨折端愈合时间平均19．6周。采用ASAMI标准评价治疗效果,骨愈合优良率100％,功能恢复优良率85．7％。结论髓内腓骨移植结合Ilizarov技术是治疗胫骨感染性骨不连及骨缺损的有效方法。     

四肢长骨骨不连所致骨缺损的外科治疗

目的探讨四肢长骨骨不连所致骨缺损的各种治疗方法的优缺点和适应征及最佳治疗方案。方法回顾分析16年来收治长骨缺损性骨不连79例的临床资料。采用髓内、髓外植骨、加压钢板治疗41例；交锁髓内钉固定方法治疗25例，其中股骨4l例，胫骨19例；肱骨6例；采用Hizarov技术治疗13例，其中股骨2例。胫骨l1例，结果全部骨不连均顺利愈合．骨缺损均得到修复。植骨内固定方法骨愈合时间4-24个月，平均6个月，患肢早期负重及关节活动恢复较快。结论应将局部软组织情况作为选择治疗方案的重要依据；植骨内固定方法要求植骨充分、内固定牢靠，强调植骨方式对骨结构重建有重要意义；对有骨与软组织损、骨外露的感染性骨不连的治疗，应采用Hizarov技术。     

不同材质异体骨移植治疗创伤性骨缺损临床分析

采用同种异体骨移植治疗创伤性骨缺损38例.所有患者随访10个月以上,37例骨性愈合,其中大段异体骨复合自体骨移植15例骨折愈合,感染性骨缺损感染复发1例,骨折不愈合;局限性骨缺损松质骨颗粒复合自体骨髓移植22例骨折全部愈合.认为同种异体骨为一种良好骨植入材料,长段异体骨复合自体骨后可用于创伤造成的大段骨缺损,异体松质骨颗粒复合自体红骨髓移植可用于修复陈旧性骨折和局限性骨缺损.     

VSD及组织瓣技术治疗合并感染的胫骨骨缺损

目的探讨合并感染的开放性胫骨骨折骨缺损的治疗方法。方法对11例合并感染的开放性胫骨骨折骨缺损患者彻底清创,外固定架固定,创面负压封闭引流（VSD）。创面新鲜后植骨,再次VSD 5-7 d后组织瓣转移修复创面。结果11例移植的组织瓣全部成活,8例术后创面渗液经换药愈合,1例植骨转移组织瓣术后仍有窦道,无感染急性发作,伤口换药未愈合。2例术后3个月伤口再感染,局部扩创后伤口愈合;6-12个月骨折愈合。结论彻底清创后,VSD＋早期植骨是治疗合并感染的开放性胫骨骨折骨缺损的有效方法之一。     

锁定加压钢板内固定联合自体髂骨植骨术治疗胫骨远端骨不连疗效观察

目的观察锁定加压钢板（LCP）内固定联合自体髂骨植骨术治疗胫骨远端骨不连的临床疗效。方法用LCP内固定联合自体髂骨植骨术治疗胫骨远端骨不连15例。结果本组患者骨不连均愈合,无感染及内固定松动、断裂发生。结论 LCP内固定联合自体髂骨植骨术治疗胫骨远段骨不连疗效满意。     

抗生素骨水泥链珠在创伤性骨髓炎治疗中的应用

目的 探讨抗生素骨水泥链珠（以下简称抗生素链珠）对创伤性骨髓炎的治疗效果.方法 42例创伤性骨髓炎患者,其中胫骨、肱骨中段骨干感染24例,胫骨干骺端骨感染18例.骨缺损3cm×4cm～8cm×5cm,软组织缺损6 cm×4 cm ～ 10 cm×4 cm.42例患者均行创面彻底清创,去除坏死及感染的骨组织及软组织,截除骨折端坏死骨质,反复冲洗创面后予抗生素链珠充填,创面行负压封闭引流（VSD）.24例骨干感染者待创面炎症反应消除后取出抗生素链珠,行植骨术;18例干骺端感染者待创面脓性分泌物较少后再次清创（取出临时抗生素链珠）,永久植入抗生素链珠.术后随访6～36个月,观察创面愈合时间、X线表现、感染复发情况等.结果 本组病例创面愈合时间21 ～39 d、平均29 d.随访6～36个月,X线片示所有骨痂生长良好,植骨部分已融合,未再发现死骨及空洞.结论 抗生素链珠充填联合VSD是治疗创伤性骨髓炎的较好方法.     

关节镜下复位植骨术治疗胫骨平台塌陷骨折疗效观察

目的观察关节镜下复位植骨术治疗胫骨平台塌陷骨折的疗效。方法 Schazker分型Ⅱ、Ⅲ型胫骨平台塌陷骨折患者20例,均在关节镜下采用复位植骨术治疗。结果手术均获成功。术后随访6个月~3 a,骨折全部愈合,Lysholm膝关节功能评分（87.5±3.3）分。结论导向复位植骨术治疗胫骨平台塌陷骨折疗效满意。     

老年膝内翻关节置换治疗胫骨内侧骨缺损的临床效果

目的探讨老年膝内翻畸形人工膝关节置换术(TKA)中胫骨内侧骨缺损的修复方法和治疗效果。方法回顾性分析该院关节外科2007年5月至2013年6月收治的资料较完整的48例(53膝)老年膝内翻畸形并胫骨内侧骨缺损患者,术中采用加大胫骨截骨量(胫骨截骨组)、骨水泥充填螺钉加强(水泥充填组)、自体骨移植(骨移植组)修复胫骨内侧骨缺损。对手术情况、术后影像学、术后并发症及膝关节评测量表(KSS)评分等进行分析,以评定临床疗效。结果 53膝均获完整随访,随访6~24个月,平均15个月,有3膝出现植骨不愈合,1膝骨水泥断裂、松动,4膝假体下沉,2膝出现膝关节不稳,1膝出现深静脉血栓。胫骨截骨组KSS评分由术前(38.17±5.26)分提高至末次随访时的(85.71±4.47)分,优良率达87.5%;水泥充填组KSS评分由术前(36.56±4.15)分提高至末次随访时的(90.14±5.01)分,优良率达92.7%;骨移植组KSS评分由术前(37.27±4.92)分提高至末次随访时的(92.86±3.47)分,优良率达93.4%。水泥充填组、骨移植组修复老年患者膝内翻胫骨内侧骨缺损效果良好,术后并发症少。结论采用骨水泥充填螺钉加强或自体骨移植修复老年膝内翻人工关节置换术中胫骨侧骨缺损,疗效满意。     

自体骨髓干细胞移植治疗骨不连及骨缺损

对140例肱骨、胫骨骨折后骨不连及骨缺损患者随机应用自体髂骨移植治疗(A组)及自体骨髓干细胞移植治疗(B组),并行简单有效内、外固定术。结果:A组术后1个月无骨痂形成,3个月无连续骨痂形成;B组术后1个月有骨痂形成,并行功能锻炼,3个月有连续骨痂形成,患处无压痛;平均愈合时间A组为(7.0±2.0)个月,B组为(5.0±1.5)个月(P<0.05);优良率A组为75.71%,B组为82.85%(P<0.05);治疗期间无明显不良反应。认为自体骨髓干细胞移植较传统植骨治疗骨不连及骨缺损有明显优势,具有广阔的应用前景。     

扩创Ⅰ期植骨治疗感染性开放骨折,骨缺损和骨折不愈合

扩创Ⅰ期植骨治疗感染性开放骨折、骨缺损和骨折不愈合枣庄矿务局滕南医院（２７７６０６）冯迎春，丁德湘，孔令胜１９９２～１９９５年，我院采用大剂量敏感抗生素、扩创、Ⅰ期植骨治疗１１例，疗效满意。１资料与方法本组男９例，女２例，年龄２１～５４岁。前臂骨折２...     

Arthroscopic-assisted bone grafting and percutaneous K-wires fixation for the treatment of scaphoid nonunion in the skeletally immature patient: Three cases report

Rationale:The treatment methods of pediatric scaphoid nonunion are still controversial. To our knowledge, arthroscopic-assisted treatments for pediatric scaphoid nonunion has not been reported in the English-language literature. Therefore, the purpose of this study is to report the use of arthroscopic-assisted bone grafting for scaphoid nonunion fracture in 3 patients and present a literature review.Patients concerns:Two 15-year-old patients developed carpal joint injuries over a year, prior to their hospital presentation, since they had not received adequate treatment. The third patient, 12 years of age, was diagnosed with scaphoid fracture after a traffic accident and underwent conservative treatment but presented to the hospital due to issues related with bone union.Diagnosis:All 3 patients were diagnosed with scaphoid nonunion at our hospital, using plain wrist radiographs and computed tomography.Interventions:All the patients underwent arthroscopic debridement; 2 patients received autogenous iliac cancellous bone graft, while the other patient received a bone substitute graft. The internal fixation of the scaphoid was performed with K-wires.Outcomes:Bone unions were achieved in all patients, and the final follow-up resulted in successful outcomes.Lessons:Arthroscopic-assisted bone grafting and percutaneous K-wire fixation can be considered as a good method for the treatment of pediatric scaphoid nonunion fractures. Therefore, it is a primary treatment option for symptomatic scaphoid nonunion fracture and displaced fractures.     

Difference in subchondral cancellous bone between postmenopausal women with hip osteoarthritis and osteoporotic fracture: Implication for fatigue microdamage,bone microarchitecture,and biomechanical properties

Objective

Osteoarthritis (OA) and osteoporosis (OP) of the hip rarely occur in the same patient. The purpose of this study was to determine whether this difference might be attributable to the different quantity and quality of subchondral cancellous bone in the two conditions.

Methods

Subchondral cancellous bone from the femoral head was obtained at the time of hip arthroplasty from 60 postmenopausal women, 30 with OA and 30 with OP. In each group, 10 specimens were subjected to compressive fatigue loading and 20 were left nonloaded. Specimens were examined by compressive mechanical testing, micro–computed tomography scanning, fluorescence microscopy, and nanoindentation techniques.

Results

Both the ultimate stress and the elastic modulus of cancellous bone from OA patients were significantly higher than those of cancellous bone from OP patients (P < 0.05). Compared to cancellous bone from OP patients, the bone volume fraction and trabecular thickness were significantly increased, but bone matrix mineralization was significantly decreased, in cancellous bone from OA patients (P < 0.05 for each comparison). The microcrack density was significantly higher in OP cancellous bone than in OA cancellous bone (P < 0.001), irrespective of fatigue loading. In addition, fatigue loading resulted in a significant increase in microcrack density in both OA and OP cancellous bone (P < 0.001). There was no significant difference in nanoindentation elastic modulus and hardness between cancellous bone from OA and OP patients, as well as between bones with and without fatigue loading.

Conclusion

The difference in mechanical properties between OA and OP cancellous bone is attributed to different bone mass and bone structure. OP cancellous bone is susceptible to fatigue damage due to insufficient structure. However, increased bone volume and plate‐like structure provide OA cancellous bone a superior capacity to resist fatigue damage.

     

Scaffold-free Three-dimensional Graft From Autologous Adipose-derived Stem Cells for Large Bone Defect Reconstruction: Clinical Proof of Concept

Long bone nonunion in the context of congenital pseudarthrosis or carcinologic resection (with intercalary bone allograft implantation) is one of the most challenging pathologies in pediatric orthopedics. Autologous cancellous bone remains the gold standard in this context of long bone nonunion reconstruction, but with several clinical limitations. We then assessed the feasibility and safety of human autologous scaffold-free osteogenic 3-dimensional (3D) graft (derived from autologous adipose-derived stem cells [ASCs]) to cure a bone nonunion in extreme clinical and pathophysiological conditions.Human ASCs (obtained from subcutaneous adipose tissue of 6 patients and expanded up to passage 4) were incubated in osteogenic media and supplemented with demineralized bone matrix to obtain the scaffold-free 3D osteogenic structure as confirmed in vitro by histomorphometry for osteogenesis and mineralization. The 3D “bone-like” structure was finally transplanted for 3 patients with bone tumor and 3 patients with bone pseudarthrosis (2 congenital, 1 acquired) to assess the clinical feasibility, safety, and efficacy. Although minor clones with structural aberrations (aneuploidies, such as tri or tetraploidies or clonal trisomy 7 in 6%–20% of cells) were detected in the undifferentiated ASCs at passage 4, the osteogenic differentiation significantly reduced these clonal anomalies. The final osteogenic product was stable, did not rupture with forceps manipulation, did not induce donor site morbidity, and was easily implanted directly into the bone defect. No acute (<3 mo) side effects, such as impaired wound healing, pain, inflammatory reaction, and infection, or long-term side effects, such as tumor development, were associated with the graft up to 4 years after transplantation.We report for the first time that autologous ASC can be fully differentiated into a 3D osteogenic-like implant without any scaffold. We demonstrated that this engineered tissue can safely promote osteogenesis in extreme conditions of bone nonunions with minor donor site morbidity and no oncological side effects.     

Relationship between NMR transverse relaxation, trabecular bone architecture, and strength.

Structure, biomechanical competence, and incremental NMR line broadening (R'2) of water in the intertrabecular spaces of cancellous bone were examined on 22 cylindrical specimens from the lumbar vertebral bodies of 16 human subjects 24-86 years old (mean, 60 years old). A strong association (r = 0.91; P < 0.0001) was found between Young's modulus of elasticity and R'2 for a wide range of values corresponding to cancellous bone of very different morphologic composition. NMR line broadening is caused by the inhomogeneity of the magnetic field induced as a consequence of the coexistence of two adjacent phases of different diamagnetic susceptibility--i.e., mineralized bone and water in the marrow spaces. Structural analyses performed by means of NMR microscopy and digital image processing indicated that the variation in R'2 is closely related to the trabecular microstructure. Mean trabecular plate density measured along the direction of the magnetic field was found to play a major role in predicting R'2 (r = 0.74; P < 0.0001). This behavior was confirmed when the plate density was varied in individual specimens, which was achieved by rotating the specimen, making use of the bone's structural anisotropy. It is concluded that the NMR transverse relaxation rate in human cancellous bone of the spine is significantly determined by trabecular structural parameters relevant to biomechanical strength. The results further underscore the important role played by the transverse trabeculae in contributing to cancellous bone strength. The work has implications on possible in vivo use of quantitative magnetic resonance for the assessment of fracture risk in osteoporotic patients.     

Aluminum metabolism and bone histology after kidney transplantation: a one-year follow-up study.

Parathyroid activity, bone aluminum (Al) metabolism, bone histology, and clinical bone disease were studied in 55 successfully grafted kidney recipients at transplantation (Tx) and after 1 yr of immunosuppression with a low dose corticosteroid and a high dose cyclosporin-A regimen. Symptoms of Al-related bone disease disappeared after Tx. Serum Al and stainable bone Al decreased. The rate of Al removal from the bone surfaces was independent of graft function (creatinine range, 62-415 mumol/L) and bone turnover. Osteoblast activity and bone formation rate increased, while mineralization lag time normalized. Indices of bone resorption remained elevated, indicating persisting hyperparathyroidism. Eighteen percent of the recipients had posttransplant hypercalcemia, most likely caused by incomplete involution of hyperplastic parathyroid glands, while 53% had normocalcemic hyperparathyroidism related to impaired graft function. Cortical thickness decreased, while cancellous bone volume remained stable after Tx; both indices correlated significantly at follow-up with their respective values at Tx. None of 46 radiologically examined recipients had aseptic bone necrosis 1 yr after Tx.     

Lack of Metabolic Bone Disease in Patients with Fracture of the Femoral Neck*

Abstract: To examine the widely held belief that osteoporosis and osfeomalacia are pathogenetic factors in femoral neck fracture, we compared such patients with vertebral fracture patients and controls. Cortical bone was measured in hand X-rays and cancellous bone in iliac crest biopsies, which were also used to assess osteoid, tetracycline and resorbing surface. The vertebral fracture patients were found to have a reduction of 53% and 41% in cancellous and cortical bone respectively compared to the controls, while in the much older femoral fracture patients the reductions were 19% and 16%. Three femoral fracture patients had mild osteomalacia from identifiable causes; a further one had fluorosis of bone and one had metastatic carcinoma; with the exception of these the osteoid covered surface of bone was less than in vertebral fracture patients and controls. We conclude that pathologic osteoporosis and osleomaiacia are not major factors in the pathogenesis of femoral neck fractures, though the normal age related reduction in bone mass may contribute. There may be another age related factor weakening the femoral neck. It was also noted that when assessed by a sensitive histochemical technique for osteoclast identification, bone resorption was not increased in either of the fracture groups.     

Bone metabolism alterations after kidney transplantation

Early after renal transplantation (RT) a rapid decrease in bone mineral density at the lumbar spine, femoral neck, and femoral shaft has been documented. In addition, an appreciable proportion of patients still remain losing bone late after RT. As a consequence, RT patients are at a high risk of bone fractures as compared to general population. Most fractures involve appendicular skeleton, particularly the feet and ankles, and the diabetic patient is at increased risk of fractures. Thus, early institution of preventive measures and treatment of established osteoporosis are central. The major cause of post-transplantation bone loss is corticosteroid treatment, and this should be used at the lower dose compatible with graft survival. Preexisting hyperparathyroidism also affects the early cancellous bone loss at the spine, and post-transplantation bone loss reflects variable individual susceptibility, resembling the polygenic determination of bone mineral density in general. Clinical trials have demonstrated that bisphosphonates or vitamin D plus calcium supplementation, prevent post-transplantation bone loss during the first 6-12 months. However, their role in preventing bone fractures has not been proven. Finally, recommendations for management, prevention and treatment, are summarized.     

带旋髂深血管蒂髂骨瓣移植治疗青壮年股骨颈骨折的疗效观察

目的探讨切开复位空心钉内固定联合带旋髂深血管蒂髂骨瓣移植术治疗不稳定青壮年股骨颈骨折的手术方法及疗效。方法对21例GardenⅢ及Ⅳ型青壮年股骨颈骨折采用切开复位空心钉内固定联合带旋髂深血管蒂髂骨瓣移植术治疗。结果 21例全部获随访,时间2年3个月～6年,20例术后均获骨折愈合,髋关节功能恢复良好,定期复查X线片未发现股骨头坏死征象。1例晚期出现股骨头缺血坏死,行人工髋关节置换。结论切开复位空心钉内固定联合带旋髂深血管蒂髂骨瓣移植术固定可靠,可提供股骨颈骨折后股骨头血运,促进骨折愈合,减少股骨头缺血坏死和骨不连的发生,是治疗青壮年股骨颈骨折的有效方法。     

Application of calcium phosphate bone paste to fracture treatment

Calcium phosphate bone paste (Biopex) is a viscous and injectable bioactive ceramic. The final maximum compressive strength is 80-90 Mpa, which is much higher than that of cancellous bone and slightly lower than that of cortical bone. Filling cancellous bone defects with this material could stabilize metaphyseal fractures in patients with osteoporosis and prevent subsequent reduction loss. Applications of this material to various fracture treatments have been reported and it was demonstrated that this material is useful if some complications are carefully avoided. Further studies are needed to determine the most suitable method for individual fractures to maximize the benefit and minimize the adverse effects.     

Histomorphometric analysis of bone biopsies from the iliac crest of adults with cystic fibrosis

This study reports the results of quantitative analysis of iliac bone histology in adults with cystic fibrosis (CF) and low bone mineral density (BMD). Twenty patients with CF had bone biopsies taken after double tetracycline labeling. Histomorphometric measurements were made by image analysis, and data were compared with those of healthy control subjects. Cancellous bone area was lower in the patients with CF (p = 0.003), and there was a trend towards a decrease in cancellous bone connectivity. Bone formation rate at tissue level was significantly lower in patients with CF (p = 0.0002). Wall width, representing the amount of bone formed within individual remodeling units, was decreased (p < 0.0001), as was mineralizing perimeter and mineral apposition rate. Analysis of resorption cavities revealed lower cavity area, reconstructed surface lengths, and cavity depths (p < 0.003) in patients with CF, whereas eroded surface area was higher (p = 0.0004). Our results demonstrate low cancellous bone volume in adult patients with CF with low BMD, the main cause of which appears to be low bone formation at tissue and cellular level. Osteomalacia was diagnosed in one patient. This condition should be excluded as a cause of low bone mineral density in patients with CF and vitamin D insufficiency corrected.