带瞄准装置的交锁髓内针在下肢骨折中的应用(附76例报告)

目的 总结使用带锁髓内针治疗股骨、胫骨骨折的临床经验。方法 回顾性分析从1998年6月～2001年1月所做带锁髓内针治疗股骨和胫骨骨折的病人76例，其中股骨30例，胫骨46例，均为闭合性骨折。术中股骨均采用开放复位，胫骨闭合复位26例，开放复位20例，未使用C型臂X光机透视：术后病人即刻行邻近关节功能活动锻炼。结果 30例胶骨干骨折3个月内临床骨愈合；46例胫骨骨折6个月临床愈合。胫骨、股骨病人中有30例远端锁钉未能锁上，无断钉断针及感染发生全部病人术后关节功能恢复达正常的90％～100％。结论 操作简单，不需电视X光机透视，易于推广。内固定稳定可靠，抗疲劳度好，能早期行功能锻炼，最大限度的恢复肢体功能。     

倒置股骨远端微创内固定系统治疗股骨近段骨不连

目的 报告倒置股骨远端微创内同定系统(LISS)治疗股骨近段骨不连的效果及其评价. 方法2003年4月至2007年2月采用对侧股骨远端LISS倒置固定治疗股骨近段骨折术后骨不连17例,其中肥大型8例,萎缩型6例,骨缺损型3例.所有患者均进行植骨,其中局部滑行加骨痂植骨6例,自体髂骨植骨9例,吻合血管的游离腓骨移植2例. 结果术后所有患者获得5～32个月(平均13.8个月)随访,所有骨折均顺利愈合,无切口感染,接骨板螺钉松动、断裂发生;完全负重时间16.5周(11～28周).采用Sanders创伤后髋关节评分标准评估髋关节功能:优10例,良5例,差2例,优良率88.2%.结论 倒置股骨远端LISS固定辅以自体骨植骨能明显促进骨折愈合,是治疗股骨近段骨不连的有效方法.     

带旋髂深血管的游离髂骨瓣移植修复胫骨骨不连

目的：探讨应用带旋髂深血管的游离髂骨瓣移植修复胫骨骨不连的临床疗效。方法2003-2013年对30例胫骨骨不连患者,治疗组15例应用带旋髂深动静脉的髂骨瓣或髂骨皮瓣移植修复,对照组15例采用单纯髂骨移植。结果长期随访发现,治疗组的髂骨瓣均成活,胫骨骨不连骨性愈合时间最早6个月;对照组移植骨再生时间最早9个月,骨髓腔再通时间最早1年。结论采用显微外科技术吻合带旋髂深血管的游离髂骨瓣修复胫骨骨不连,对比单纯髂骨移植,愈合时间明显缩短,疗效可靠。     

Clinical and radiological midterm results from using the Fixion expandable intramedullary nail in transverse and short oblique fractures of femur and tibia

Background  A locked nail is the principal method used to eliminate rotatory components in femoral and tibial fractures. Nevertheless, weight bearing is not directed onto the fracture site, slowing down the healing process; another possibility is to use a large-diameter nail and ream the canal to obtain as much adherence as possible and increase the grip, but this can cause a number of complications. The expandable nail is a new option that in theory should remove some problems with previous techniques. Materials and methods  This was a retrospective nonrandomized study encompassing 21 femoral fractures and 27 tibial fractures in 45 patients. They were classified according to the AO classification. Clinical and radiological checks were done at one, three, and six months and at one year from the surgery in order to check for signs of clinical and radiological healing. A good alignment was considered to be the presence of a deformity of less than 5° in the sagittal and lateral planes and the absence of rotatory clinically evident problems. This protocol was adhered to up to six months after surgery by all of the patients, while only 62.2% performed the last control. The mean follow-up was 15 months. A second group of 48 consecutive fractures (24 femural and 24 tibial) treated with locked nail was created to compare surgical times. Results  Appropriate alignment was observed in all cases; the healing process appeared slower: radiological healing occurred in most cases at six months. The following complications were reported: a case of intraoperative fracture widening with no effect on the treatment; a case of a lesion of the tip of the nail with pneumatic system rupture that necessitated nail substitution; two cases of retarded consolidation at six months, with both tibial fractures treated successfully by intralesion platelet gel; a case of incarcerated nail on 17 removals, resolved by shearing. We had no cases of clinically evident compartment syndrome or pulmonary embolism. Conclusions  The expandable Fixion nail presents significant advantages in the treatment of transverse and short oblique fractures of femur and tibia because it is easy to use, involves minimal X-ray exposure and can control rotations. Nevertheless, it high cost limits its use. We consider it as an alternative to locked nail.     

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing.During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21-75 years). The patients had previously undergone an average of 4.8 operations (range 3-6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2-12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction-compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13-42 months). Results were evaluated using Paley's functional and radiological scoring system.Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89-412 days) and mean lengthening index was 32 days/cm (range 27-39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases.The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.     

Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft

INTRODUCTION: Intramedullary nailing has long been used successfully in the treatment of aseptic nonunions of the femur and tibia. However, recently the efficacy of reamed intramedullary nailing in the treatment of nonunions of the femur has been questioned by some publications reporting unfavourable results. The purpose of this study is to evaluate the treatment results of femoral and tibial diaphyseal nonunions with intramedullary nailing. PATIENTS AND METHODS: We retrospectively reviewed thirty-two patients with femoral or tibial diaphyseal nonunions who were treated with reamed intramedullary nailing between May 2002 and April 2006. Fixation status at the time of treatment were nail in twenty-eight patients (12 femurs, 16 tibiae), plate in three cases (2 femurs, 1 tibia), no implant in one femur. We used a dynamically locked, reamed intramedullary nailing. Only in bone defects greater than 50% of the cortical diameter and more than 2 cm in length was open bone grafting performed. RESULTS: Solid union was achieved in 93% (fourteen of fifteen) of femoral nonunions and 94% (sixteen of seventeen) of tibial nonunions. CONCLUSIONS: Our protocol with a dynamically locked, reamed nailing with the use of an oval hole and no open bone grafting for a defect less than 50% of the diameter and immediate weight bearing was successful in the treatment of femoral and tibial diaphyseal nonunions.     

Intramedullary nailing of the femur with an inflatable self-locking nail: comparison with locked nailing

We report a comparative study between an inflatable expandable nail and a traditional locked intramedullary implant in closed fractures of the femoral shaft. We matched each of 43 patients who had undergone intramedullary fixation with an inflatable expandable nail with a patient of the same sex, age (within 2 years), and fracture who had undergone statically locked intramedullary fixation with traditional nails. The mean duration of surgery was significantly shorter in the patients who were treated with the inflatable expandable nail. There were no differences in average blood loss, transfusion requirements, or hospitalization. Five of the patients who underwent traditional nailing required dynamization to achieve union. The inflatable expandable nail allows effective management of diaphyseal fractures of the femur. Interlocking is not necessary, operative times are reduced, and exposure to ionizing radiation is minimized. At present, however, the inflatable expandable nail used in the this investigation is markedly more expensive than traditional devices.     

带蒂骨痂植骨交锁髓内钉内固定治疗胫骨硬化型骨不连

[目的]观察交锁髓内钉内固定、带蒂骨痂和自体髂骨植骨术治疗胫骨硬化型骨不连的临床疗效.[方法]本组胫骨硬化型骨不连12例,男8例,女4例;年龄26～64岁,平均45岁,全部采用开放置入交锁髓内钉内固定、带蒂骨痂和自体髂骨植骨术治疗.[结果]经12～72个月,平均48个月的随访,所有病例均于4～6个月内获得骨性愈合.[结论]交锁髓内钉内固定、带蒂骨痂和自体髂骨植骨术治疗胫骨硬化型骨不连具有：（1）合理的生物力学设计;（2）抗骨折旋转及短缩功能;（3）对局部血运破坏小;（4）带蒂骨痂植骨的＂架桥＂作用和自体髂骨植骨的成骨作用促进骨愈合,值得推荐使用.     

Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia

Background:

Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail.

Materials and Methods:

Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at least one year.

Results:

The average operative time was 90 min (range, 55-125 min) for femoral fractures and 53 min (range, 25-115 min) for tibial fractures. Radiation exposure was minimum, average being 84 seconds (range, 54-132) for femoral fractures and 54 seconds (range, 36-78) for tibial fractures. All fractures healed, but few had complications, such as infection (one case with tibial fracture) bent femoral nail with malunion (n = 1), and delayed union (n = 3; 2 cases in femur and 1 case in tibia). Mean time of union was 5.1 months (range, 4-10½ months) for femoral fractures and 4.8 months (range, 3-9 months) for tibial fractures.

Conclusion:

We found the nail very easy to use with effective fixation in AO type A and B fractures in our setting. Less surgical time is required with minimum complications. The main advantage of the expandable nail is that if affords. satisfactory axial, rotatory, and bending stability with decreased radiation exposure to operating staff and the patient.     

A biodegradable scaffold for the treatment of a diaphyseal bone defect of the tibia

The aim of this study was to compare angiogenesis and osteogenesis occurring within 8.0 mm diaphyseal defects created in canine tibiae treated using autograft or a biodegradable bone scaffold. All tibiae were reamed to 7.0 mm and fixed with a 6.5‐mm statically locked intramedullary nail. Each of the 18 canines as allotted to one of three treatment groups: (1) left empty (N = 5), (2) treated with iliac crest autograft (N = 6), or (3) treated with a PLGA/calcium phosphate biodegradable scaffold (N = 7). Fluorescent markers were given at successive time periods: calcein green at 6 weeks, xylenol orange at 9 weeks, and tetracycline at 11 and 14 weeks. Animals were sacrificed at 15 weeks and their legs were perfused with a radio opaque compound. Samples were analyzed using Micro CT, bright‐field microscopy and fluorescent microscopy. Scaffold samples were found to have significantly greater bone formation (p = 0.015) and blood vessel formation (p < 0.001) at their osteotomy sites than autograft samples. Bone formation rate in the periosteum was significantly greater in the autograft samples than the scaffold samples for all time periods. Bone formation at the osteotomy site was found to be significantly greater when associated with greater blood vessel formation (p = 0.026). The PLGA/calcium phosphate biodegradable scaffold we have employed supports angiogenesis within a segmental tibial defect that has adequate soft tissue coverage. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 28:474–480, 2010     

交锁髓内钉治疗股骨和胫腓骨骨折

目的探讨交锁髓内钉治疗股骨和胫腓骨骨折的疗效：方法对47例（51肢）股骨和胫腓骨骨折采用交锁髓内钉固定,分析临床疗效。结果随访7～36个月,骨折全部愈合,功能恢复良好,效果满意。结论交锁髓内钉治疗股骨和胫腓骨骨折具有适应证广、创伤小、固定牢靠等优点,可作为股骨和胫骨干骨折的首选治疗方法。应严格掌握适应证及手术时机,熟练掌握操作技术。     

外固定架辅助髓内钉技术治疗股骨畸形和股骨干骨折不愈合

目的 探讨外固定架辅助髓内钉(fixator assist nailing,FAN)技术治疗股骨畸形、股骨干骨折不愈合伴畸形和畸形愈合的疗效.方法 回顾性分析在2008年1月至2011年12月采用FAN技术治疗8例股骨干骨折不愈合伴畸形、3例维生素D抵抗性佝偻病性股骨畸形、2例股骨干骨折畸形愈合.男11例,女2例;年龄16～50岁,平均33岁.10例采用一期手术,3例采用二期手术.12例采用单边外固定架,1例采用环形外固定架.8例采用顺行髓内钉,5例采用逆行髓内钉.2例患者采用自体髂骨植骨,1例骨痂剪碎后植骨.结果 12例患者获得完整随访,随访时间12～48个月,平均21个月.7例股骨干骨折不愈合的患者骨折在术后3～6个月愈合,平均3.8个月.5例股骨畸形行截骨术的患者截骨端在术后3～5个月(平均3.5个月)愈合.根据Paley评分标准,9例为优,2例为良,1例为可.术前下肢不等长(48.2±23.0) mm,术后为(27.3±24.6) mm,肢体长度增加4.6～41.0 mm(平均23.3 mm).术前机械轴偏向(27.5±24.4) mm,术后(6.3±8.3) mm.未发生感染和神经、血管损伤.结论 FAN技术结合了外固定架安全、微创、便于调节,可准确矫正畸形优点和髓内钉固定患者依从性高特点,可有效地治疗代谢性骨病引起的股骨畸形、股骨干骨折不愈合伴畸形和畸形愈合.     

削骨痂植骨治疗胫骨骨搬运后期对合端骨不连的经验

目的探讨削骨痂植骨治疗胫骨骨搬运后期骨不连的疗效和经验。方法回顾性分析2012年1月至2016年6月应用骨搬运技术治疗的胫骨骨缺损患者,选取在骨搬运后期对合端未能顺利愈合的患者22例,行切开手术,清除骨端软组织卡压、清理硬化骨,削取对合端或延长段骨痂回植于胫骨对合端,使对合端最终骨性愈合。结果 22例患者术后获5~18个月(平均8个月)随访,其中18例削痂植骨术后顺利愈合,2例术后发生伤口感染,经清抗感染治疗,最终愈合;1例患者植骨吸收,经历再次植骨后愈合;1例患者途中外固定松动,导致骨折,更改为内固定+植骨,最终愈合;其余21例根据Paley等骨不连愈合评分标准评定结果:优18例,良1例,中1例,差1例,优良率为86.36%。结论胫骨骨搬运后期胫骨骨不连通过非手术方法不能愈合的患者,可尝试削取骨痂植骨的方治疗使对合端愈合。     

股骨、胫骨骨折交锁髓内钉固定后骨不连的诊治

目的探讨股骨、胫骨骨折应用交锁髓内钉固定后骨不连的诊断及应用微创内固定系统(LISS)或锁定加压钢板(LCP)治疗其骨不连的临床疗效。方法2003年2月～2004年12月,对7例股骨和胫骨骨折患者髓内钉固定后应用X线或CT扫描观察骨不连情况,并应用LISS或LCP固定 植骨治疗,病程10～49个月,平均23.3个月。结果7例患者获4～16个月(平均9.1个月)随访;骨折均在术后4～6个月牢固连接,平均愈合时间4.7个月,无植入物松动等并发症发生。结论对骨折端较长时间存在骨折线、且骨折局部伴有疼痛症状者要果断进行手术干预,消除骨折端的微动和消灭骨缺损。LISS或LCP因其先进的锁定设计,可有效治疗股骨和胫骨骨不连。     

皮质外骨桥技术结合骨皮质切削技术治疗股骨骨不连29例疗效分析

[目的]探讨运用皮质外骨桥技术结合骨皮质切削技术治疗骨不连的临床效果.[方法]对2004～2010年本科收治的29例股骨骨不连患者进行回顾性对照研究.其中运用皮质外骨桥技术结合骨皮质切削技术治疗的患者16例作为实验组,其余13例运用传统自体骨植骨内固定方法治疗作为对照组.实验组中11例运用皮质外骨桥技术,5例运用皮质外骨桥技术结合骨皮质切削技术治疗.随访期限为13个月～2年,所有患者均在术后第1d及术后每月行X线检查至骨折临床愈合,收集2组资料,比较骨折影像学愈合时间以及下地完全负重时间,运用SPSS17.0统计软件包对2组数据进行统计检验.[结果]2组患者骨不连均在5～9个月达到临床愈合,疗效良好.实验组与对照组相比,骨折影像学愈合时间以及下地完全负重时间明显缩短,有显著统计学差异.[结论]运用皮质外骨桥技术结合骨皮质切削技术治疗股骨骨不连与传统手术方法相比,骨折影像学愈合时间以及完全负重时间明显缩短,具有良好的临床效果,有一定的临床推广价值.     

锁定钢板联合自体髂骨植骨治疗股骨干骨不连13例

目的观察13例股骨干骨不连患者采用自体髂骨块联合锁定钢板双固定治疗后的临床疗效。方法 13例股骨干骨不连患者均采取自体髂骨取骨,联合锁定钢板采用双固定骨折端方法进行治疗。结果 13例患者随访时间12~26个月,平均18个月。骨折均获骨性愈合,1例患者伤口延迟愈合,经换药后愈合,无一例发生切口皮肤坏死、深部感染、内固定松动或断裂,无成角畸形。根据HSS膝关节评分为88~97分,平均93分,Rasmussen膝关节功能评分法进行综合评分:优10例,良2例,可1例,差0例。结论符合文献报道:自体髂骨块联合锁定钢板双固定治疗股骨干骨不连临床疗效确切,是一种经济、有效的治疗方法。     

骨干人工假体在股骨近端恶性肿瘤切除后骨缺损重建中的初步应用

 目的 探讨采用骨干人工假体对股骨近端骨干恶性肿瘤切除后结构性骨缺损进行重建的可行性。方法 2011年6月至2014年7月对7例股骨近端恶性骨肿瘤患者采用骨干人工假体置换,男3例,女4例;年龄28~76岁,平均61.8岁。原发恶性骨肿瘤4例,转移癌3例。术前常规行X线、CT及MR检查,通过MRI测量瘤段骨长度及软组织侵犯范围,再根据截骨长度选择骨干人工假体配件。取股骨近端外侧直切口,逐层切开皮肤、皮下组织,按肿瘤切除原则充分显露术前MRI测量的瘤段骨及软组织肿瘤并截骨,扩髓后安装骨干人工假体,依次缝合各层组织。术后切除组织送病理学检查。结果 手术时间45~120 min,平均90 min;术中出血量200~800 ml,平均400 ml。随访6~24个月,平均14个月。1例骨肉瘤患者术后1年因出现肺转移而死亡,3例原发恶性骨肿瘤患者术后未出现术区复发及远处转移。1例乳腺转移癌患者术前多发转移,术后行综合治疗,带瘤生存;2例乳腺转移癌患者随访期间未出现原位复发或转移。7例患者术后患肢髋关节功能均无受限。结论 使用骨干人工假体对股骨近端骨干恶性肿瘤切除后结构性骨缺损进行重建,保留了邻近的髋关节及肌腱附着点,操作简单,住院时间较短,可早期负重,是一种理想的治疗股骨近端骨肿瘤的保肢手术方法。