骨延长术后骨痂愈合过程的B超监测

本文总结了143例（282次）骨延长术后骨痂愈合过程的三个阶段的B超显像及X线结果对照分析，结果表明：超声对原始骨痂形成期能清晰显示，较X线结果早2～9天，骨痂改造塑形期B超显像与X线结果一致，对血肿机化期骨痂的显示清晰，而X线难以显示。研究结果表明：B超观察骨延长术后骨痂愈合过程是切实可行的，弥补了X线检查的某些不足，为临床提供了一种有价值的检查方法并开辟了超声诊断技术的一个新领域。     

超声联合X线对Ilizarov骨搬移术后搬移区的监测价值研究

【摘要】目的：为行Ilizarov骨搬移术的患者术后找到一种长期且有效的影像学监测手段，提高骨延长成功率。方法：对19例接受Ilizarov骨搬移术的患者分别在第1周、第3-4周、第6-8周、第14-16周及第24周行高频超声检查、X线检查和临床评估，在超声声像图及X线平片上观察新生骨痂形态、密度，对新生骨痂量做半定量分析、测量搬移距离并做对比。结果：超声与X线对新生骨痂的半定量评分随时间变化趋势不同，认为在第1周、第3-4周、第6-8周、第24周超声与X线显示骨痂填充量的差异具有统计学意义（P＜0.05），在第14-16周超声与X线显示骨痂填充量的差异不具有统计学意义（P＞ 0.05）。在第1周、第3-4周、第6-8周、第14-16周，超声与X线对搬移区距离的测量值差异不明显，第24周，二者对搬移区长度的测量值产生明显差异。结论：与X线相比，高频超声在未矿化的更早期可以观测到新生骨痂，但在矿化后期提示作用有限，可以把超声联合X线作为Ilizarov骨搬移术后一种长期的常规监测手段。     

超声显像对兔下颌骨体部骨折愈合过程的监测

背景：目前临床上评估骨折愈合进程主要依赖于X射线片上桥接骨痂的形成和体积。但由于X射线对人体有辐射伤害，无创性的超声监测骨折愈合过程成为学者们研究的热点。目的：运用超声成像动态观察兔下颌骨骨折的愈合过程，并与X射线摄片比较。设计、时间及地点：随机分组设计、动物对照观察，实验于2006—12／2007-12在深圳宝安松岗人民医院实验室完成。材料：清洁级新西兰大耳白兔30只，兔龄7～12个月，由中山大学动物实验中心提供。方法：随机抽取6只用于正常下颌骨的超声及X射线观察，另外24只制成下颌骨骨折模型，分别于术后1d，1，2，4，6，8周对实验兔进行X射线平片、超声成像检查，依据X射线平片和超声图像对愈合情况进行评分。评分结果进行Spearman等级相关分析。主要观察指标：X射线平片、超声成像检查观察骨折愈合的情况。结果：30只兔均进入结果分析。X射线平片显示下颌骨骨折间隙内组织呈进行性钙化，随着时间延长，骨折间隙逐渐变窄，骨痂从无到有，骨折线从模糊到消失。超声图像显示骨折愈合中期，骨折间隙可见向外隆起的声束，并可穿过间隙。在骨折愈合后期，骨折间隙中向外隆起的声束消失，其后为声影，表明骨痂密度增高，骨痂钙化良好。各期的X射线检查与超声检查结果基本相符合，Spearman等级相关系数为0．966，P〈0．001。结论：超声检查和X射线平片检查一样，可以通过骨折间隙的变化及骨痂形成的范围来判断骨折愈合的情况。     

高频超声在骨搬移截骨端骨痂形成过程中的监测

目的 观察高频超声在骨搬移截骨端骨痂形成不同时期骨痂生长变化、周围软组织变化、骨痂内及周围组织血流信号,以及对搬移过程中并发症的监测,探讨高频超声对于骨痂监测的价值及局限性。 方法： 收集2018年7月至2019年6月接受骨搬移治疗的患者10例,分别在术后1周内、开始牵拉1-2周、6-8周、14-16周行超声检查,根据二维半定量评分及Alder血流评级进行记录,观察骨痂及其血流的变化。 结果:骨痂在不同时期的形态可表现为孤立点状、点条状状融合型、长线状三种,在中期牵拉,骨痂周围血流达到峰值,以及在搬移早期骨痂区无回声区的发生。 结论：高频超声在骨搬移早期对骨痂生长及并发症的监测具有重要的价值。     

双能X线骨密度仪检查及数字化X线摄影术用于骨搬移术后

目的 观察骨搬移术后应用双能X线骨密度仪（DEXA）检查及数字化X线摄影术（DR）的价值。方法 对19例因胫骨外伤致感染性骨不连及大面积骨缺损接受胫骨搬移术患者分别于术后2、4、6及8周、停止搬移即刻、停止搬移后4、8周、去外固定架前4周及去外固定架即刻行DEXA和DR检查,观察不同时间点胫骨搬移区新生骨痂（BMD_新生骨痂）和截骨上下端原骨质骨密度（BMD_{截骨上下端}）及二者比率,分析DR图像中胫骨新生骨痂的形态及填充量。结果 胫骨搬移术术后各时间点BMD_新生骨痂、BMD_{截骨上下端}及BMD比率总体差异均有统计学意义（P均<0.05）。BMD_新生骨痂及BMD比率在术后2周分别为（0.07±0.01） g/cm²及（5.56±1.24）%,且均随术后时间延长而升高（P均<0.05）;BMD_{截骨上下端}在术后2周为（1.21±0.07） g/cm²,随时间延长而降低,去外固定架前4周降至最低（P均<0.05）、去外固定架即刻有所升高但与前者差异无统计学意义（P>0.05）。DR显示,术后4周胫骨搬移始区见新生骨痂影,随时间延长而呈多形态变化;术后2周胫骨搬移区未见新生骨痂填充,至停止搬移即刻新生骨痂填充量达25%,停止搬移4、8周达50%、75%,去外固定架前4周基本达100%。结论 DEXA能动态监测骨搬移术后搬移区新生骨痂及截骨端原骨质BMD;DR可显示新生骨痂形态变化;骨搬移术后联合应用二者有助于评估预后。     

彩色多普勒超声观察骨折骨痂血运的

目的探讨彩色多普勒超声观察骨折骨痂血运的临床价值.方法用彩色多普勒超声对15例骨折患者在内固定术后第1周、第2周、第3周、第4周、第9周及第15周内依次观察患者骨折骨痂形成的声像特征及其血运情况,并与X线摄片进行对比分析.结果骨痂形成良好的患者,二维超声示患者术后一个月内骨折处骨痂形成饱满,彩色多普勒血流显像示骨痂内部及周围有丰富的血流信号,血流指数RI＜0.6.而骨折骨痂形成不良者,超声示骨折间骨痂细小,彩色多普勒超声示骨痂内部及周边缺乏血流信号,RI＞0.7.结论彩色多普勒超声可以作为一种早期诊断骨折骨痂愈合情况的方法,具有较高的临床价值.     

兔胫骨骨延长模型在低强度脉冲超声刺激条件下的骨再生与成熟

背景:实验证实,低强度脉冲超声有促进骨折愈合的作用.但低强度脉冲超声对骨折愈合早期骨质再生成熟的影响及其相关的作用机制仍不十分清楚.目的;创新性提出低强度脉冲超声能够在兔胫骨骨延长动物模型牵拉成骨早期骨再生成熟中发挥正效效应的理论假设,并期望以超声干预与不干预进行对照比较予以验证. 方法:36只成年健康新西兰兔随机数字表法分为超声治疗组和对照组,每组18只.所有动物均行胫骨中段截骨,以Orthofix M103型迷你外固定架延长器固定,术后7 d以0.5 mm/12 h延长10 d,总延长长度为10 mm,超声治疗组在延长完成后以低强度脉冲超声骨折治疗仪治疗,20 min/d,1次/d,对照组不给予低强度脉冲超声治疗.治疗4,8,12周后,X射线评定胫骨骨折断端愈合程度,采用Image J图像分析软件分析计算骨痂生成率;延长区新骨作苏木精-伊红染色、Masson三色染色、VG染色后光镜下组织学分析,并在显微镜下测新骨占总骨痂的面积.结果与结论:36只兔均进入结果分析.治疗4周后对照组仅见外骨痂连接形成骨桥,骨痂区密度低,还可见部分骨痂缺如:超声治疗组骨早期再生成熟优于对照组,表现在两断端骨痂影密度增高,数量增多,骨痂影由两端向中央生长,被密度高的骨痂取代,外骨痂已开始被吸收,骨痂充满延长区,密度增高增粗,骨折处皮质骨密度接近正常皮质骨,骨痂生成率明显提高(P＜0.05),与8,12周无差异.组织学分析显示,超声治疗组治疗4,8,12周时新骨形成早于对照组,治疗4周新骨占总骨痂面积的百分比大于对照组,治疗8,12周后两组新骨占总骨痂面积的百分比无差别.提示低强度脉冲超声可促进新骨形成,增加骨痂面积,在兔胫骨骨延长动物模型牵拉成骨后的骨再生成熟中有促进作用.     

肢体延长术的护理

肢体延长术,是克服两侧肢体不等长的一种手术。传统上大腿短缩用股骨延长;小腿短缩用胫骨延长。近年来又采用骨盆截骨延长、骨骺牵拉延长等。不论采用何种办法,术后护理的关健在于防止并发症。常见有神经牵拉后麻痹,甚至瘫痪,足下垂;血管受牵拉后肢体远端循环障碍;其次是针孔感染、骨迟愈合或不愈合、肢体畸形或再骨折等。目前肢体延长术在我国众多医院已开展。1982年以来。江西省宜丰县人民医院骨科共施行胫、股骨逐步延长、股骨一次延长、骨盆截骨延长、骨骺延长术共59例,延长长度最高达9厘米;第三军医大学西南医院骨科施行骨骺牵伸下肢延长术70例,最高     

兔骨不连模型成骨过程的影像与组织学对照分析

目的 通过影像与组织学对比观察,探讨兔骨不连模型成骨过程中不同时期的成骨特点.方法 选取纯种新西兰大白兔10只,在其双前肢桡侧沿桡骨中段截骨;对左侧行夹板外固定,定为愈合侧;对右侧不做固定,每天在麻醉下使骨断端被动活动避免其愈合,定为骨不连侧.在术后第1、2、4、6、8周分别进行X线检查及组织学对比观察.结果 X线示术后2周骨不连侧与愈合侧肢体骨痂的成量和断端的连接状况开始出现较明显的差异.组织学观察示术后1周骨不连侧与愈合侧肢体组织学开始出现差异,主要表现在血管重建、骨细胞形成及纤维组织增生方面.结论 对骨折后骨断端组织血供及成骨活性的判定是早期诊断骨不连的主要依据,准确判定有助于临床干预时相的选择.     

牵引成骨与小鼠早期骨折愈合

背景：牵引成骨技术治疗四肢骨缺损和发育不良等有一定的优势,但是有关骨延长区新骨的成骨方式,目前尚存在争议。目的：观察小鼠胫骨骨折愈合过程中与成骨方式有关的骨基质蛋白组织学与基因水平的表达,论证在外界牵张力的作用下骨折愈合方式。设计、时间及地点：组织学和蛋白基因检测,于2007-08/12在中南大学第三附属医院中心实验室完成。材料：8周龄雄性CD-1小鼠36只,体质量25～30g,由中南大学湘雅医学院实验动物中心提供。方法：接受左胫骨中上段骨干横行截骨,安置特制延长外固定架,胫骨牵引过程包括5d静止期,12d牵引期和70d固塑期,牵引期的牵引速率为0.1mm/次,共0.2mm/d。术后于5,9,13,17,24,31d采集左胫骨标本,分别作组织学检查和骨基质蛋白mRNA检测。主要观察指标：①小鼠胫骨牵引成骨模型骨折端组织学变化。②小鼠胫骨牵引成骨骨痂内各种基质蛋白mRNA在不同时间点的表达。结果：组织学检查显示：静止期其修复过程基本与骨折愈合相似;牵引期,被牵引骨痂显示3个典型的生物力学功能区：纤维间区,初始骨基质前沿和微骨柱形成区;固塑早期,牵引骨痂骨性愈合。mRNA检测显示：Ihh在牵引后的第4天可检测到表达,静止期及牵引后期无明显表达。Ⅱ型胶原从截骨后第5天即可检测,直到固塑期1周,但其mRNA表达逐渐减弱,到固塑期第2周即停止表达。X型胶原的表达在牵引期第4天达到高峰,然后逐步下降。骨钙素在截骨第5天尚不能被检测,其mRNA的表达在牵引后期和固塑期早期达高峰。结论：胫骨牵引静止期软骨内成骨和膜内成骨同时存在,但在机械牵张力作用下转为以膜内成骨为主的成骨过程。     

Low-intensity pulsed ultrasound initiates bone healing in rat nonunion fracture model.

Low-intensity pulsed ultrasound exposure has been shown clinically to shorten the fracture repair process and to induce healing of nonunions in humans, but its mechanism of action remains unclear. In this study we investigated the effect and mechanism of low-intensity pulsed ultrasound on nonunion fracture healing in rat tibias. A consistently reproducible nonunion was produced in rat tibias by muscle interposition without osteotomy. This model was produced by creating a closed tibial fracture with only the distal end of the tibialis anterior muscle interposed into the fracture site. One limb was noninvasively exposed to low-intensity pulsed ultrasound (a 200-millisecond burst of sine waves of 1.5 MHz, repeating at 1.0 kHz) for 20 minutes daily. The incident intensity was approximately 30 mW/cm2. Rats were killed at intervals between 2 and 6 weeks. The events were assessed by radiographs, microfocus X-ray computed tomograms, and histologic examination. After 6 weeks of exposure, 7 of 14 nonunion fractures showed healing on radiologic assessment. The results of three-dimensional microfocus X-ray computed tomographic reconstruction and histologic examination also supported this finding. On the other hand, all control tibias remained in a state of nonunion during the same period. These results indicate that low-intensity pulsed ultrasound promotes healing in the rat nonunion fracture model.     

全髋关节置换治疗伴有下肢短缩的陈旧性股骨颈骨折

背景:由于多数伴有下肢短缩的陈旧性股骨颈骨折患者经历过长期牵引或失败的内固定手术,髋部已严重骨质疏松,髋关节周围软组织及关节囊挛缩或股骨头缺血坏死,下肢短缩,临床治疗很困难。目的:探讨全髋关节置换治疗伴有下肢短缩的陈旧性股骨颈骨折的临床疗效。方法:对35例伴有下肢短缩的陈旧性股骨颈骨折患者施行全髋关节置换。置换前股骨髁上骨牵引、双下肢和骨盆正位片X射线测量,置换中股骨颈截骨水平及软组织松解程度,调整假体头颈长度等对下肢短缩进行纠正。结果与结论:置换后6例置换前短缩3.0～4.0cm,置换后仍然1例短缩在1.0cm,其余5例及29例短缩在2cm以内者置换后双下肢等长。置换后1年Harris评分较置换前明显提高(P<0.05)。说明全髋关节置换后功能恢复快而稳定,优良率高,近期随访效果良好,是治疗伴有下肢短缩的陈旧性股骨颈骨折有效方法。     

胎儿并腿畸形下肢骨骼异常三维超声骨骼成像技术、MRI与3D-HCT诊断研究

目的：探讨胎儿三维超声骨骼成像技术、胎儿磁共振成像（MRI）及引产后三维螺旋CT（3-HCT）在并腿畸形胎儿下肢骨骼异常诊断中的临床应用价值。方法应用胎儿超声骨骼成像技术与磁共振成像对7例并腿畸形胎儿进行分型诊断,并与引产后胎儿三维螺旋CT及病理检查结果对照,分析三维超声骨骼成像技术、MRI、三维螺旋CT在并腿畸形胎儿下肢骨骼异常产前与产后诊断中的应用结果。结果与终止妊娠后三维螺旋CT及病理检查结果对照,产前三维超声骨骼成像均正确显示7例并腿畸形胎儿（6例单胎,1例联体双胎）下肢股骨异常、胫腓骨异常及单足6例,无足1例。其中绒毛和（或）脐血染色体检查（5例）与生后病理检查提示男性3例,女性4例。根据Stocker并腿畸形分型标准,产前与引产胎儿标本影像学检查诊断并腿畸形Ⅲ型1例;Ⅳ型2例;Ⅴ型3例;Ⅵ型1例。7例胎儿MRI正确显示股骨异常4例、胫腓骨异常1例,足异常均未显示。结论产前三维超声骨骼成像技术与产后三维螺旋CT骨骼成像技术均为胎儿骨骼异常影像诊断新技术,可清晰显示胎儿骨骼声像,对下肢畸形胎儿正确诊断有重要临床应用价值。     

超声引导下闭合复位微创固定治疗肢体骨折的研究进展

C臂或常规X线辅助下闭合复位微创固定治疗肢体骨折,因其创伤小、愈合快而得到广泛重视并日趋成熟,但其放射性损伤不容忽视。随着超声技术的不断进步,其临床应用不仅限于骨折的诊断,而在辅助骨折闭合复位固定方面发挥重要作用。本文主要对目前国内外关于超声引导下闭合复位微创固定治疗肢体骨折的研究进展进行综述。     

Prenatal diagnosis of type 1 fibular hemimelia

Fibular hemimelia (FH) is a congenital longitudinal limb deficiency characterized by complete or partial absence of the fibula. Typically, it has been diagnosed at birth, when the neonate is seen to have lower limb shortening and a foot with missing toes. Although it is the most frequent lower limb deficiency anomaly, there are few published reports of prenatally diagnosed cases. Most of these published cases have involved the complete absence of the fibula, which is relatively easy to diagnose with antenatal ultrasound. In our opinion, our case is the first case of unilateral partial absence of the fibula detected using prenatal ultrasound imaging. Herein, we report a FH case associated with foot equinovalgus, and absence of the fourth and fifth foot rays diagnosed at 24 weeks’ gestation. The anomaly was confirmed after birth by X-ray, and conservative orthopedic management was chosen. Our case shows that partial limb defects can also be detected by prenatal ultrasound imaging.     

三维超声诊断胎儿肢体畸形

目的 探讨产前超声检查对胎儿肢体异常的诊断价值。方法 收集在我院接受孕期超声检查,并筛出胎儿肢体畸形56胎,对异常部位行三维超声检查并存储图像。结果 产前超声诊断56胎肢体畸形,其中5胎失访,余51胎经引产或生产后证实共有72处畸形,其中产前超声检出64处、漏诊8处。51胎（64处）肢体异常发生的部位为：手指部分缺失4处、尺或桡骨缺失6处、裂手（足）1处、下肢羊膜和脐带缠绕致缩环1处、短肢畸形6处、左下肢完全缺如1处、下肢胫、腓骨发育不全2处,足内翻36处,双手姿势异常6处,多指（趾）1处。产前超声准确率为88.89%（64/72）,漏诊率11.11%（8/72）。结论 三维超声的表面成像和骨骼成像模式可明显提高胎儿肢体异常的诊断率。     

Double osteotomy in the surgical treatment of Perthes' disease: Dega's transiliac osteotomy and subtrochanteric osteotomy

Background. The combination of Dega transililiac and femoral subtrochanteric is used in our department in the treatment of Legg-Calvé-Perthes' disease. Subtrochanteric osteotomy, initially performed as varus-derotation osteotomy, is now mainly extension osteotomy with shortening. Femoral shortening is crucial for joint decompression and makes room for pelvic redirection after pelvic osteotomy. Material and methods. 34 children (36 hips) were analyzed retrospectively. All children were operated using subtrochanteric osteotomy with shortening and Dega's transiliac osteotomy of the pelvis. There were several variants of subtrochanteric osteotomy: extension osteotomy only, varus-extension, extension-varus-derotation, extension-derotation, and varus-derotation. In one case only varus osteotomy was performed. Before surgery 18 hips were Catterall group IV, 14 group III and 4 group II; in the Herring classification, 24 hips were group B, 11 group C, and 1 group A. All patients were evaluated clinically and radiologically at follow-up using the Stulberg classification. The mean follow-up was 8 years. Results. In the Stulberg classification 4 hips were scored after surgery as group I, 23 as group II, 4 as group III, 4 as group IV and only 1 hip as group V. In 6 patients limping was observed, 2 patients had a positive Trendelenburg sign, and 11 a positive Duchenne sign. The mean shortening of the lower limb was 0.25 cm. Six patients complained of pain after physical activity. Conclusion. Subtrochanteric shortening osteotomy of the femur combined with Dega transiliac osteotomy is a safe and valuable procedure for surgical treatment of Perthes' disease.     

Ultrasonic mensuration of fetal limb bones in the second and third trimesters

Growth of fetal limb bones has been examined in a prospective cross-sectional study in 530 patients between 13 and 42 weeks of gestation by ultrasound. The length of the femur, tibia, humerus, and radius were measured in all cases, and fibula and ulna in 393 cases. For each week of gestation mean lengths (+/- 2 standard deviations) were calculated. All limb bones showed linear growth from 13 weeks to 25 weeks of gestation, after which the growth curve appeared nonlinear. A strong linear relationship (r greater than 0.98) between the BPD and bone length was found for each bone. In five aborted fetuses, prenatal sonographic measurements of the ossified diaphyses were compared with the postnatal radiologic measurement (30 limb bones). A good agreement was found (difference between ultrasound and X-ray measurements 0.7 +/- 0.5 [SD] mm or 3.0 +/- 2.4 [SD]%), indicating that ultrasound images the ossified diaphysis.     

Variability of the anteversion angle in children with Perthes' disease treated with varus-derotation subtrochanteric osteotomy

Background. Despite extensive research, it is still unknown whether a 40% increase in the anteversion angle value is a primary or a secondary change in Perthes' disease. The aim of the study was to evaluate the variability of the anteversion angle in children with unilateral Perthes disease treated operatively with varus and derotation osteotomy. Material and methods. 53 patients between 5 and 10 years were included in this study. The stage and type of necrosis were classified using radiological examination according to the Reiberg and Cattarall classification. The value of anteversion was determined using clinical and ultrasound examination in addition to directly during surgery. After the operation, the anteversion angle was 11 degrees . During a 6-year follow-up period, ultrasound examination was performed every 12 months. Angle values obtained through direct measurements were compared with the norms published by Lanz and Wachsmuth, and ultrasound measurements were compared with the norms for the age groups. Results. 47 patients were found to be in stage III of the disease and 6 were in stage II. During the period up to 36 months after surgery, the value of the anteversion angle gradually reached the same value as in a limb considered as "healthy". During the following 36 months these values remained unchanged. Conclusions. An increased value of the anteversion angle in children with Perthes' disease is observed in a limb considered as "healthy". An increased value of the anteversion angle in children with Perthes' disease is a secondary deformation caused by the arrest of the physiological decrease of its value during development.