关节镜下改良后踝入路切除治疗成人疼痛性跟距骨桥

目的探讨采用关节镜下改良后踝入路切除治疗成人疼痛性跟距骨桥的疗效。方法 2015年1月-2017年12月,采用后踝高位外侧观察入路结合低位内侧操作入路切除治疗9例成人疼痛性跟距骨桥。男6例,女3例;年龄19~30岁,平均24岁。2例无明确局部外伤,7例有足踝部扭伤病史。病程6~30个月,中位病程12个月。跟距骨桥Rozansky分型:Ⅰ型5例(5足),Ⅱ型2例(2足),Ⅲ型2例(2足)。患者既往无肢体功能障碍后遗症、无肢体关节手术史。术后随访复查踝关节正侧位X线片、踝关节CT。比较手术前后疼痛视觉模拟评分(VAS)及美国矫形足踝协会(AOFAS)踝-后足评分。结果患者手术时间60~90 min,平均76 min。术后患者均获随访,随访时间12~24个月,平均18个月。术后切口均Ⅰ期愈合,无感染、皮肤坏死、下肢深静脉血栓形成、血管神经及肌腱损伤、骨桥复发等并发症发生。术后踝关节功能恢复良好,疼痛明显缓解;患者于术后3~5个月,平均3.9个月重返工作岗位。末次随访时VAS评分为(0.7±0.5)分,与术前(4.2±0.5)分比较差异有统计学意义(t=20.239,P=0.000);AOFAS踝-后足评分为(94±4)分,与术前(62±2)分比较差异有统计学意义(t=–27.424,P=0.000),末次随访时获优7例,良2例。结论后踝高位外侧观察入路结合低位内侧操作入路显露跟距骨桥更直观,操作空间更大,操作过程更灵活,术中根据特定解剖标志程序化切除跟距骨桥,操作具有可行性。     

经胫骨入路与经辅助内侧入路制备股骨隧道类等长重建前交叉韧带的疗效比较北大核心CSCD

目的比较经胫骨入路与经辅助内侧入路制备股骨隧道类等长重建前交叉韧带(ACL)的位点和疗效。方法回顾性分析2018年1月至2019年12月期间解放军第九〇四医院骨科收治的47例ACL断裂患者资料。根据不同手术入路分为两组:A组21例,男15例,女6例;年龄为(29.5±4.8)岁;采用经胫骨入路可调袢钢板固定重建ACL。B组26例,男18例,女8例;年龄为(31.2±9.6)岁;采用经辅助内侧入路可调袢钢板固定重建ACL。比较两组患者的股骨隧道位置、末次随访时膝关节Lysholm评分及国际膝关节文献委员会评分(IKDC)、膝关节前后及旋转稳定性等。结果两组患者术前一般资料的比较差异均无统计学意义(P>0.05),具有可比性。47例患者术后获18~27个月(平均22.3个月)随访。四格表法定位股骨隧道内口中心位点:A组和B组患者的X轴位点分别为25.6%±2.5%、26.7%±1.8%,差异无统计学意义(P>0.05),Y轴位点分别为19.8%±2.0%、30.6%±1.5%,差异有统计学意义(P<0.05)。末次随访时A组和B组患者膝关节Lyholm评分分别为(90.9±3.4)、(92.4±3.9)分,IKDC评分分别为(89.9±3.5)、(90.2±3.8)分,差异均无统计学意义(P>0.05)。末次随访时两组患者之间前抽屉试验、Lachman试验及轴移试验结果比较差异均无统计学意义(P>0.05)。结论经胫骨入路和经辅助内侧入路制备股骨隧道类等长重建ACL,前者位点较后者更接近髁顶位置,二者术后近期均能获得满意疗效。     

An applied research on precise sustentacular screw placement based on anatomical division of the anterior lateral wall of calcaneus and the sustentaculum tali北大核心CSCD

Objective To evaluate our novel path based on anatomical division of the anterior lateral wall of calcaneus and the sustentaculum tali for precise sustentacular screw placement in the surgical treatment of calcaneal fractures of Sanders types Ⅱ and Ⅲ. Methods The anterior lateral wall of the calcaneus was divided into the anterior-superior zone S1, the anterior-inferior zone S2, the posterior-superior zone S3 and the posterior-inferior zone S4 for demarcation of the screw insertion points by our method of Four Zones, and into the front, middle and rear sections by our method of Three Sections for demarcation of the screw target points. The specimens were scanned by CT and modeled by Mimics. On the 3D virtual model of the calcaneus, one screw was placed from each zone of the anterior lateral wall of the calcaneus to the sustentaculum tali body. The screw placement target for S1 and S2 was the medial intersection point P1 of the front and middle sections of the sustentaculum tali, and that for S3 and S4 was the medial intersection point P2 of the middle and rear sections of the sustentaculum tali. It was observed whether the screws were placed in the bone channel. A total of 72 patients were included who had been admitted to Department of Orthopaedics, Suqian Hospital Affiliated to Xuzhou Medical University for calcaneal fractures of Sanders types Ⅱ and Ⅲ from January 2017 to January 2021. They were divided into an anatomical division group and a 3D printing group according to their screw placement method for the sustentaculum tali. In the anatomical division group of 32 patients subjected to screw placement based on our anatomical division, there were 25 males and 7 females, aged from 24 to 60 years; in the 3D printing group of 40 patients subjected to screw placement assisted by 3D printing, there were 31 males and 9 females, aged from 25 to 58 years. The disparities between the parameters of sustentacular screw placement and the actual values were compared in the anatomical division group, and the total number of screws, screws on average, distribution of screws, and accuracy of screw placement were compared between the 2 groups. Results All the screws which were virtually placed in the specimens of the calcaneus from S1 and S2 to P1 and from S3 and S4 to P2 passed through the bony channel, with no perforation into the tarsal sinus. There was no significant difference in the general date between the anatomical division group and the 3D printing group, showing they were comparable (P > 0.05). In the anatomical division group, a total of 52 screws were placed to the sustentaculum tali with an average of (1.63 ± 0.48) screws per patient, and 2 screws were placed in 20 patients, yielding an accuracy rate of screw placement of 92.3% (48/52). There were no statistically significant differences between the parameters and the actual values of screw placement in the anatomical division group (P > 0.05). In the 3D printing group, a total of 63 screws were placed to the sustentaculum tali with an average of (1.58 ± 0.49) screws per patient, and 2 screws were placed in 23 patients, yielding an accuracy rate of screw placement of 93.7% (59/63). There were no significant differences in the above comparisons between the anatomical division group and the 3D printing group (P > 0.05). Conclusion In the surgical treatment of calcaneal fractures of Sanders types Ⅱ and Ⅲ, the sustentacular screw placement based on our anatomical division of the anterior lateral wall of the calcaneus and the sustentaculum tali can lead to similar clinical accuracy as 3D printing-assisted screw placement does. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

The effect of in-out-in axis pedicle screws on the vertebral artery in the posterior occipitocervical surgery北大核心CSCD

Objective To observe the effect of insertion of in-out-in axis pedicle screws on the vertebral artery in the posterior occipitocervical surgery for atlantoaxial subluxation or instability. Methods The data of 52 patients with atlantoaxial dislocation or instability were analyzed who had been treated by internal fixation with in-out-in pedicle screws in the posterior occipitocervical surgery from January 2015 to February 2021 at Department of Spine and Spinal Cord Surgery, Henan Provincial People's Hospital. There were 30 males and 22 females, aged from 17 to 65 years (mean, 41.2 years). There were 26 cases of unilateral vertebral artery high-riding, 3 cases of bilateral high-riding, 19 cases of unilateral narrow pedicle due to C2 and C3 fusion, and 4 cases of bilateral narrow pedicles. X-ray, CTA and MRI were performed before and 3 days after surgery. The patients' clinical symptoms were recorded. CTA was used to measure the diameter of the vertebral artery at the transverse foramina of C2 and C3 and to observe the effect of in-out-in screws on the morphology of the vertebral artery. X-ray and CT examinations were performed at 6 months after surgery to observe the bone fusion. Results The surgery went on uneventfully in all the patients. In the 9 cases undergoing anterior and posterior surgery, the operation time averaged 271.2 min (from 213 to 352 min) and the bleeding volume 471.5 mL (from 230 to 830 mL). In the 43 cases undergoing posterior surgery, the operation time averaged 171.6 min (from 131 to 226 min) and the bleeding volume 395.9 mL (from 170 to 660 mL). There was no such complication as spinal or vascular injury. The CTA reexamination 3 days after surgery showed that the diameter of the vertebral artery was (2.92±0.55) mm and (3.04±0.54) mm, respectively at the cervical 2 and 3 transverse foramina, showing no significant change compared with the preoperative values [(2.91±0.68) mm and (3.11±0.50) mm] (P>0.05) and that the vertebral artery was displaced externally and inferiorly in 21 cases. Follow-ups for all patients ranged from 7 to 24 months (mean, 11 months). At 6 months after surgery, bone fusion was observed by imaging and no breakage or displacement of the internal fixation was observed. Conclusion The in-out-in pedicle screws in the posterior occipitocervical surgery may have little impact on the vertebral artery, leading to reliable clinical outcomes. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

Comparison of hook thin plate compression technique with conventional screw-plate fixation for tibial tubercle avulsion fractures in adolescents北大核心CSCD

Objective To compare the outcomes between hook thin plate compression technique and conventional screw-plate fixation in the treatment of adolescent tibial tubercle avulsion fractures. Methods A retrospective analysis was performed of the 43 adolescent patients with tibial tubercle avulsion fracture who had been treated at Department of Orthopedics and Traumatology, Beijing Jishuitan Hospital from January 2018 to October 2020. There were 42 males and one female, aged from 13 to 17 years. According to their treatment methods, they were divided into an observation group (9 cases) treated with hook thin plate compression technique and a control group (34 cases) treated with fixation with cannulated screws alone or in addition with a 1/3 tube plate. The maximum range of knee flexion, Böstman score, and cases returning to school at one month after operation, as well as fracture union time, Böstman score and cases with complications at the last follow-up were compared between the 2 groups. Results There were no significant differences in the preoperative general data between the 2 groups, showing comparability (P>0.05). By the postoperative one month, the maximum range of knee flexion [90.0° (85.0°, 102.5°)], Böstman score [21.0 (18.5, 21.0)] and cases returning to school (7) in the observation group were significantly better than those in the control group [22.5° (15.0°, 30.0°), 11.0 (10.0, 13.0), and 0] (P<0.001). The last follow-up revealed no significant differences between the 2 groups in frature union time [(2.7±0.5) months versus (2.8±0.5) months], Böstman score [30.0 (30.0, 30.0) versus 30.0 (30.0, 30.0), 30.0)] or cases with complications (1 versus 2) (P>0.05). Conclusion In the treatment of adolescent tibial tubercle avulsion fractures, compared with conventional fixation with cannulated screws alone or in addition with a 1/3 tube plate, hook thin plate compression technique may lead to better outcomes, because it allows early rehabilitation to shorten the postoperative immobilization time and promote early functional recovery. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

Comparison of Jefferson-fracture reduction plate and micro titanium plate in the transoral single-segment fixation of unstable atlas fractures北大核心CSCD

Objective To compare Jefferson-fracture reduction plate (JeRP) and micro titanium plate in the transoral single-segment fixation of unstable atlas fractures. Methods From January 2008 to December 2020, 45 patients with unstable atlas fracture were treated by single-segment fixation through an oral approach with a JeRP or a micro titanium plate at Department of Orthopedic Surgery, General Hospital of Southern Theatre Command. They were 24 males and 21 females, aged from 15 to 67 years. By the Gehweiler classification, 11 atlas fractures were type Ⅰ and 34 type Ⅲ; by the American Spinal Injury Association (ASIA) classification, the spinal cord injury was grade D in 7 cases and grade E in 38 cases; by the Dickman classification, the atlas transverse ligament injury was type Ⅰ in 4 cases and type Ⅱ in 11 cases. Of the patients, 26 were treated by transoral single-segment fixation with a JeRP and 19 by transoral single-segment fixation with a micro titanium plate. The 2 groups were compared in terms of baseline data, operation time, blood loss, hospital stay, visual analog scale (VAS) for neck pain and atlas lateral mass displacement (LMD) before operation and at the last follow-up, and intraoperative and postoperative complications. Results The 2 groups were comparable because there was no significant difference between them in the preoperative general data (P>0.05). All patients were followed up for 12 to 55 months (mean, 21.8 months). Wound dehiscence or infection was observed in none of the patients after operation. About 12 months after operation, all fractures achieved bony union, neck pain basically disappeared, and neck movement had no obvious limitation. The hospital stay was (13.9±2.2) d for the JeRP group and (14.2±2.9) d for the micro titanium plate group, showing no significant difference between the 2 groups (P>0.05). The operation time was (203.5±173.4) min and the blood loss (167.3±138.6) mL in the JeRP group, significantly more than those in the micro titanium plate group [(121.5±50.5) min and (98.4±57.2) mL] (P<0.05). In the JeRP group, the preoperative LMD was (6.7±1.7) mm and the preoperative VAS score (6.8±1.0) points, significantly higher than the last follow-up values [(0.7±0.6) mm and (0.7±0.6) points] (P<0.05). In the micro titanium plate group, the preoperative LMD was (6.6±1.5) mm and the preoperative VAS score (6.7±0.9) points, significantly higher than the last follow-up values [(0.9±0.6) mm and (0.8±0.7) points] (P<0.05). However, there was no significant difference in the preoperative or the last follow-up comparison between the 2 groups (P>0.05). Implant loosening was observed in one patient in the JeRP group while foreign body sensation in the throat was reported in one patient after operation in the micro titanium plate group. Conclusions Both JeRP and micro titanium plate in the transoral single-segment fixation can lead to effective treatment of unstable atlas fractures. Compared with JeRP, the micro titanium plate can effectively shorten operation time and reduce blood loss due to its smaller size and lower incision. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

3D printing-assisted percutaneous balloon dilatation plasty for treatment of osteoporotic calcaneal fractures of Sanders type Ⅱ or Ⅲ in the elderly patients北大核心CSCD

Objective To compare the clinical efficacy between 3D printing-assisted percutaneous balloon dilatation calcaneal plasty (3D-PCP) and conventional open reduction and internal fixation (ORIF) via the extended lateral L-shaped approach in the treatment of osteoporotic calcaneal fractures of Sanders type Ⅱ or Ⅲ in the elderly patients. Methods Retrospectively analyzed were the data of 36 elderly patients with osteoporotic calcaneal fracture of Sanders type Ⅱ or Ⅲ who had been surgically treated at Department of Orthopaedics, Yixing People's Hospital from June 2012 to June 2018. According to their treatment methods, the patients were divided into a 3D-PCP group [16 cases, 9 males and 7 females with an age of (73.0 ± 3.4) years] and an ORIF group [20 cases, 8 females and 12 females with an age of (71.4 ± 2.6) years]. The 2 groups were compared in terms of hospital stay, operation time, intraoperative fluoroscopy frequency, suture removal time, weight bearing time, fracture healing time, visual analogue scale (VAS) for the surgical site 2 days and one year after surgery, American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score, calcaneal imaging parameters (Böhler angle, Gissane angle, and length, width and height of the calcaneus axis) at 2 days and one year after surgery, and postoperative complications. Results There was no significant difference in the preoperative general data between the 2 groups, showing comparability (P > 0.05). All patients were followed up for 14 to 18 months (mean, 15.6 months). Compared with the ORIF group, the 3D-PCP group had significantly shorter hospital stay, significantly shorter operation time, significantly earlier suture removal, significantly earlier weight-bearing, significantly lower VAS scores at 2 days after surgery, significantly higher AOFAS ankle-hindfoot scores at one month after surgery, but significantly more times of intraoperative fluoroscopy (all P < 0.05). In all patients, the VAS scores at 2 days after surgery were significantly lower than those before surgery, and those at one year after surgery significantly lower than those at 2 days after surgery (P < 0.05). In all patients, the AOFAS ankle-hindfoot scores at one month after surgery were significantly higher than those before surgery (P < 0.001). In the ORIF group, the AOFAS ankle-hindfoot scores at one year after surgery were significantly higher than those at one month after surgery (P < 0.05), but in the 3D-PCP group there was no such a significant difference between one year and one month after surgery (P > 0.05). There was no significant difference in VAS score, AOFAS score, fracture healing time or postoperative imaging parameters between the 2 groups at one year after surgery (P > 0.05). There was no significant difference either in the incidence of complications between the 2 groups (P > 0.05). Conclusion In the treatment of osteoporotic calcaneal fractures of Sanders type Ⅱ or Ⅲ in the elderly patients, compared with conventional ORIF, 3D-PCP shows advantages of shorter operation time, minimal invasion, quicker incision healing, shorter hospital stay, earlier weight-bearing exercise, and better functional recovery but a disadvantage of increased times of intraoperative fluoroscopy. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.