多段截骨矫形加钛板与克氏针内固定治疗儿童脆骨病胫腓骨畸形

目的探讨多段截骨矫形钛板植骨加钛板与克氏针内固定治疗儿童脆骨病致胫腓骨畸形的临床疗效。方法笔者自2008-01—2014-09诊治脆骨病(OI)致胫腓骨骨折及骨畸形患儿11例,经术前三维重建胫腓骨,测量畸形角度、设计截骨位置及角度,采用多段截骨矫形钛板植骨加钛板与克氏针内固定治疗。结果 11例均获得平均19.6(6~36)个月随访,骨折平均愈合时间13.2(11~16)周。术后肢体长度较术前平均延长19(11~26)mm。切口均一期愈合,未发现明显排异反应,无血管及神经损伤、内固定松动断裂,术肢无感染、骨不连等并发症。其中2例后期出现其他部位骨折。术后患儿生活自理能力得到较大改善。结论多段截骨矫形钛板植骨+克氏针内固定治疗脆骨病致胫腓骨畸形,能明显矫正肢体畸形,有效降低再骨折及骨畸形愈合的发生率。     

可延长髓内钉微创治疗成骨不全术后股骨再发畸形或骨折

目的 探讨可延长髓内钉治疗成骨不全术后股骨再发畸形或骨折的疗效.方法 回顾性分析2009年6月至2012年6月采用可延长髓内钉治疗21例成骨不全术后股骨再发畸形或骨折患儿资料,男13例,女8例；年龄9岁6个月至15岁7个月,平均12岁3个月.所有患儿均已行股骨干截骨矫形不可延长髓内钉手术,此次手术距初次手术时间为2～4年,平均3年.所有患儿成长肢体于髓内钉远端部位再次出现畸形或骨折,其中9例为股骨干弯曲畸形,畸形成角度数为10°～30°,平均15°；12例为再发骨折.依据修订后的Sillence分型:Ⅲ型6例,Ⅳ型14例,Ⅴ型1例.21例患儿均在大转子及远端截骨处切开手术,切口长度为2～3 cm,采用可延长髓内钉再次固定骨折及矫正畸形.结果 21例患儿均获得随访,随访时间6～30个月,平均18个月.骨折愈合时间为7～12周,平均8.5周.待X线片示截骨愈合后患儿开始负重行走.所有患儿及其父母均对手术结果及畸形矫正效果表示满意,末次随访时患儿Barthel指数评分由术前平均72.85分(范围,50～90分)提高到术后平均91.42分(范围,80～100分).WeeFIM评分由术前平均55.42分(范围,40～70分)提高到术后平均79.00分(范围,70～86分).10例术前需拐杖辅助行走患儿,随访时可独立行走；6例术前因骨折而卧床患儿中,4例可独立行走,2例需拄拐活动.末次随访时,无一例出现感染、骨髓炎等并发症,无神经、血管损伤病例.结论 应用可延长髓内钉小切口手术,对肢体损伤小、出血少、骨折愈合时间短、患儿痛苦小,是治疗成骨不全术后股骨再发畸形或骨折的良好方法.     

下肢髓内钉术后非感染性骨不连的对策：内植骨结合阻挡钉技术

[目的]分析下肢骨干骨折髓内钉术后非感染性骨不连的原因，观察内植骨结合阻挡钉技术治疗这类骨不连的疗效。[方法]对12例下肢骨干骨折髓内钉治疗术后并发非感染性骨不连的患者（其中股骨5例，胫骨7例；肥大型8例，萎缩性4例），采用稳定骨断端（更换更粗髓内钉＋阻挡钉）、矫正骨畸形（阻挡钉＋复位器）以及增强骨愈合能力（内植骨技术）的办法，观察其疗效。[结果]术后随访1—2年（平均1．5年）。所有患者最终获得骨性愈合，愈合率100％，愈合时间4．7—13．5个月，平均7．8个月。所有患者主观疼痛症状消失，无明显并发症发生。[结论]内植骨结合阻挡钉技术是一种治疗下肢骨干骨折髓内钉术后非感染性骨不连的有效方法。     

股骨上段复杂骨折内固定方法选择

[目的]探讨股骨上段复杂骨折的最佳内固定方法。[方法]治疗52例(54肢)股骨上段复杂骨折,均采取开放复位内固定。应用交锁髓内钉治疗成人骨折32例(34肢)和130°角钢板治疗儿童骨折20例。闭合性骨折36肢,开放性骨折18肢。采用自体髂骨植骨5肢和同种异体骨植骨10肢。[结果]术后随访9~40个月,平均16个月。无伤口感染、骨不连、畸形愈合和股骨头坏死等并发症。成人和儿童平均骨临床愈合时间分别为6.8个月和6.5个月。远期疗效按马元璋标准评定,肢体关节功能恢复优良率94.4%。[结论]根据患者年龄选择合适的内固定方法和术中精确的复位对提高股骨上段复杂骨折的疗效十分重要。交锁髓内钉用于成人和130°角钢板用于儿童是较为理想的选择。     

钛弹力钉治疗儿童尺桡骨下1/3双骨折

[目的]探索儿童尺桡骨下1／3双骨折的微创治疗方法。[方法]采用经皮钛弹力钉下行插钉技术治疗尺桡骨下1／3骨折15例，年龄4～12岁，平均7．4岁，随访4个月～2a，平均随访12．4个月。[结果]1例插钉过程中钉头穿透骨皮质，1例术后出现钉尾皮肤激惹，所有病例术后活动功能优良。[结论]合理运用微创插钉技术，使用钛合金为材料的弹性髓内钉固定儿童尺桡骨下1／3骨折，可以取得满意的手术效果。     

不同骨延长器治疗肢体畸形并大段骨缺损

[目的]利用Ilizarov支架、Orthofix肢体重建系统（Orthofix LRS）及Hybrid固定系统（Hybrid Fixation System）与Orthofix LRS的组合，对不同的肢体畸形并大段骨缺损进行矫形及骨延长治疗，同时观察其疗效。[方法]自2000年8月-2004年3月分别用Ilizarov支架、Orthofix LRS及Hybrid支架与Orthofix LRS的组合进行骨痂牵开／骨段滑移治疗合并肢体畸形的大段骨缺损。畸形处采用线形／楔形截骨。畸形愈合并骨短缩者楔形截骨后进行骨痂牵开骨延长术，骨不连并畸形及短缩者接合点加压与截骨矫形骨段滑移延长同时进行。[结果]矫正股骨短缩畸形7cm1例，胫骨6例，内翻畸形2例，后成角畸形2例，混合畸形2例。平均延长5．3cm（4．5—7cm），平均延长时间3．5个月，平均延长后外固定时间7个月，无神经血管损伤，膝踝关节活动未受影响。[结论]Ilizarov支架、Orthofix LRS、Hybrid固定系统与Orthofix LRS的组合用于骨痂牵开／骨段滑移治疗合并肢体畸形的大段骨缺损均能达到矫形及骨延长的治疗目的。Orthofix LRS及Hybrid固定系统与Orthofix LRS的组合较Ilizarov支架操作简便，安全可靠，患者乐于接受。     

多段截骨矫形髓内固定治疗儿童成骨不全症

 目的 探讨对成骨不全症患儿施行多段截骨矫形髓内固定手术的安全性, 评价其治疗效 果及并发症。 方法2005 年8 月至2010 年8月, 共收治123 例儿童成骨不全症患儿。共160 侧肢体:股 骨119 侧, 胫骨41 侧。男85 例, 女38 例。患儿手术时平均年龄为8 岁3 个月(2 岁1 个月~15 岁7 个 月)。依据修订的Sillence 分型:III型45 例, IV型74 例, 吁型4 例。术前根据畸形程度, 通过术前X 线片 确定截骨点, 术中均行直视下截骨。选用直径及长度适宜的髓内钉, 股骨自大转子, 胫骨自足底插入。股 骨术后行石膏裤、胫骨术后行长腿石膏托固定;术后6 周去石膏, 开始在支具保护下逐渐站立及行走。 123 例患儿均周期性静脉给予帕米膦酸二钠治疗, 给药时间距手术至少间隔2 个月。 结果 123 例患儿 全部获得平均38 个月(13~64 个月)随访。截骨平均术后8 周愈合。患儿父母对手术结果及畸形矫正均 满意, 患儿生活自理能力、活动范围较术前明显改善。14 例患儿因出现Rush 钉偏移接受再次手术, 25 例患儿术后2 年因骨骼生长Rush 钉相对变短而需要更换内固定。 结论 多段截骨矫形髓内固定术是 治疗成骨不全症的有效手术方法, 可以显著矫正畸形、改善活动能力和避免再次骨折;但需要注意髓内 钉移位等并发症, 对生长期儿童需要定期更换内固定。     

儿童长骨骨巨细胞瘤诊断及外科治疗

[目的]研究儿童四肢长骨骨巨细胞瘤的发病，评价不同手术方式的效果。[方法]对1994年12月～2003年12月本院收治的骨巨细胞瘤患者进行统计分析，根据Enneking分级系统分级，Ⅰ-Ⅱ级采用肿瘤刮除，氯化锌烧灼残腔，双氧水浸泡和异体植骨的方法进行治疗，Ⅲ级采用瘤段切除大段异体骨移植重建，术后定期随访。[结果]在128例骨巨细胞瘤患者中，儿童患者8例发病率为6．3％。其中Ⅰ级2例，Ⅱ级5例，Ⅲ级1例，伴发病理性骨折2例。6例行肿瘤刮除植骨后骨修复完善，肢体无畸形，2例病理性骨折愈合良好；1例异体骨段移植骨愈合良好，无塌陷及骨折，但患肢短缩2．5cm，无移植排斥；1例腓骨上端病变行腓骨小头切除，无功能障碍。术后随访2—9a，平均5．4a，未见肿瘤局部复发和远处肺转移。[结论]骨巨细胞瘤可以发生在儿童四肢长骨，刮除、氯化锌烧灼、双氧水浸泡和异体植骨可以达到满意效果，而瘤段切除会对儿童肢体发育产生影响。     

克氏针辅助复位弹性钉治疗儿童严重移位尺桡骨骨折

[目的]探讨克氏针辅助复位弹性钉治疗儿童严重移位尺桡骨骨折的方法和疗效。[方法]回顾性分析2010年10月~2014年8月对21例收治的有完整随访资料的移位严重的儿童尺桡骨骨折,所有骨折均为闭合性,男15例,女6例,年龄3~14岁,平均7.6岁,采用克氏针辅助复位弹性髓内钉内固定治疗。[结果]经3个月~1年随访,所有病例骨折完全愈合,平均愈合时间为8周。患肢各关节功能及前臂旋转功能均恢复正常。[结论]弹性髓内钉符合儿童骨折治疗的生物力学特点,治疗儿童尺桡骨骨折具有创伤小、操作相对简单、骨折愈合快、并发症少的优点,利用克氏针辅助复位,有助于移位严重的尺桡骨骨折的闭合复位。     

髋臼发育不良骨盆截骨术内固定的改进

[目的]探讨髋臼发育不良骨盆截骨术中“T”形钢板内固定的应用。[方法]临床19例髋臼发育不良患者，骨盆截骨后应用解剖钢板固定。观察术后骨愈合、髋臼角改善和并发症情况。[结果]本组术后随诊1．5—2a。术后骨折线消失、骨愈合的时间为7周-4个月，平均2．2个月。未发生骨不连，髋臼矫形角度未发生丢失。[结论]骨盆截骨后钢板内固定稳定，可有效防止常规克氏针、石膏固定的并发症.     

Combination of femoral fracture treatment and corrective osteotomy in a child with osteogenesis imperfecta

The main feature of osteogenesis imperfecta is an excessive fragility and deformability of the bones owing to reduced mass and bone quality. This leads to angular deformity and frequent fractures. These fractures usually heal rapidly, and conservative treatment is the norm. In displaced and unstable fractures, elastic intramedullary nailing is a treatment option. We report a case of a 3-year-old child with osteogenesis imperfecta type I who suffered an undisplaced femoral shaft fracture in the presence of a preexisting 32° femoral antecurvation. This deformity greatly increases the risk of a refracture due to the pathological induction of stress risers. Therefore, fracture treatment by unreamed elastic intramedullary nailing was combined with simultaneous correction osteotomy, resulting in anatomic alignment and uncomplicated fracture healing. The single-stage surgical stabilization performed allowed rapid mobilization along with a decreased likelihood of refracture.     

Telescoping intramedullary stabilization of the lower extremities for severe osteogenesis imperfecta

Intramedullary extendable Bailey-Dubow nails were used for treatment of lower extremity deformities resulting from osteogenesis imperfecta. Sixteen patients had 56 nails placed in 48 long bones, including 18 revisions. All patients were braced postoperatively. The average duration of follow-up was 4.8 years. Nine patients who were nonambulatory preoperatively walked in braces postoperatively. Despite a high rate of complication, extendable nails provide correction of the angular deformities of osteogenesis imperfecta, decrease fracturing, and allow most previously nonambulatory children to walk.     

The role of expanding intramedullary rods in osteogenesis imperfecta

We report the results of using 83 expanding intramedullary rods in 24 children with osteogenesis imperfecta after a mean follow-up of five years three months. In all, 62% of the rods have expanded after one primary operation. Thirty-four additional operations were necessary; 11 for the correction of rotation or angulation deformities and 23 for revision of the rod or T-piece. All these revisions were successful. Complications were more frequent in children who required very small rods. Problems with Bailey-Dubow rods led to the development of the Sheffield rod system; 17 bones treated with these rods are included in the series. Before surgery only eight of the 24 children were able to walk but at review 20 children were walking, 15 without walking aids. Elongating intramedullary rods should be available to all children with osteogenesis imperfecta as they improve walking capability, reduce the number of fractures, prevent deformity and allow integration of the child into society.     

Limb lengthening and correction of deformity in the lower limbs of children with osteogenesis imperfecta

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.     

Deformity correction by external fixation and/or intramedullary nailing in hypophosphatemic rickets

Background?There are many modalities of treatment for complex lower extremity deformity in hypophosphatemic rickets. We evaluated the outcomes of deformity correction using an external fixation and/or intramedullary nailing in hypophosphatemic rickets

Patients and methods?55 segmental deformities (20 femora, 35 tibiae) from 20 patients were examined retrospectively. There were 9 children and 11 adults. Distraction osteogenesis was used in 28 segments and acute deformity correction in 27. External fixation was applied in 24 segments, intramedullary nailing in 6, and external fixation and intramedullary nailing in 25.

Results?There were 18 major and 13 minor complications in 26 of 28 segments with distraction osteogenesis, and 13 major and 10 minor complications in 19 of 27 segments with acute correction. Recurrent deformity or refracture occurred in 10 of 21 segments with distraction osteogenesis by external fixation only, 4 of 6 with acute correction by intramedullary nailing, and 1 of 25 with distraction osteogenesis or acute correction by external fixation and intramedullary nailing. Nail-related complications occurred in 3 of 6 with intramedullary nailing and 2 of 25 with external fixation and intramedullary nailing.

Interpretation?External fixation and intramedullary nailing can be recommended to prevent complications during or after deformity correction in hypophosphatemic rickets.     

Deformity correction by external fixation and/or intramedullary nailing in hypophosphatemic rickets

Background There are many modalities of treatment for complex lower extremity deformity in hypophosphatemic rickets. We evaluated the outcomes of deformity correction using an external fixation and/or intramedullary nailing in hypophosphatemic rickets

Patients and methods 55 segmental deformities (20 femora, 35 tibiae) from 20 patients were examined retrospectively. There were 9 children and 11 adults. Distraction osteogenesis was used in 28 segments and acute deformity correction in 27. External fixation was applied in 24 segments, intramedullary nailing in 6, and external fixation and intramedullary nailing in 25.

Results There were 18 major and 13 minor complications in 26 of 28 segments with distraction osteogenesis, and 13 major and 10 minor complications in 19 of 27 segments with acute correction. Recurrent deformity or refracture occurred in 10 of 21 segments with distraction osteogenesis by external fixation only, 4 of 6 with acute correction by intramedullary nailing, and 1 of 25 with distraction osteogenesis or acute correction by external fixation and intramedullary nailing. Nail-related complications occurred in 3 of 6 with intramedullary nailing and 2 of 25 with external fixation and intramedullary nailing.

Interpretation External fixation and intramedullary nailing can be recommended to prevent complications during or after deformity correction in hypophosphatemic rickets.     

Combined technique for the correction of lower-limb deformities resulting from metabolic bone disease

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture.     

Hyperplastic callus formation in osteogenesis imperfecta following intramedullary rodding

Hyperplastic callus formation has been reported in patients with osteogenesis imperfecta following fractures but not following intramedullary rodding. The present case is that of a child who developed massive hyperplastic callus following osteotomy and intramedullary rodding of all lower extremity bones. Noted complications of intramedullary rodding include refracture, delayed union, nonunion, and pin migration, and it is our belief that hyperplastic callus formation should be considered another potential complication.     

Displaced olecranon apophyseal fractures in children with osteogenesis imperfecta

Three boys with mild osteogenesis imperfecta (OI) who sustained eight apophyseal avulsion fractures of the olecranon were compared with four normal boys with a unilateral apophyseal fracture. The children with OI were younger (11 years 7 months) than the normal children (14 years 3 months). All fractures were treated with tension band wiring (TBW). The contralateral elbow fractured 1 to 12 months later in the children with OI. Refractures occurred in two elbows, 6 to 16 months after the initial fracture and after TBW removal. One refracture presented late as a nonunion and was treated with bone grafting and plate fixation. None of the normal children experienced refracture after TBW removal. Good functional results and range of movement were achieved. Surgical treatment is recommended for all displaced fractures of the olecranon apophysis. There is a high risk of bilateral injury and a risk of refracture following removal of TBW in children with OI.