Sanders Ⅲ、Ⅳ型跟骨关节内骨折内固定术中植骨与不植骨的疗效比较

目的比较Sanders Ⅲ、Ⅳ型跟骨关节内骨折行切开复位内固定治疗术中植骨与不植骨的临床疗效。方法笔者自2010-01—2014-12采用切开复位内固定治疗97例Sanders Ⅲ、Ⅳ型跟骨关节内骨折,植骨组62例,不植骨组35例。比较植骨组与不植骨组的放射学结果、术后一般情况、并发症、足部功能评分等。结果本组97例获平均1.8(1~3)年随访。术后开始负重时间植骨组(12.1±1.5)周,不植骨组(13.8±1.3)周,植骨组术后开始负重时间早于非植骨组,差异有统计学意义(P0.05)。2组在术后2年随访时植骨组跟骨Bohler角丢失情况优于非植骨组,差异有统计学意义(P0.001)。2组术后住院天数、复位质量、并发症、骨折愈合情况、足部功能评分等方面比较,差异均无统计学意义(P0.05)。结论对于SandersⅢ、Ⅳ型跟骨关节内骨折,植骨治疗可早期负重行走,并可减少术后远期Bohler角丢失。     

Complications when using threaded K-wire fixation for displaced intra-articular calcaneal fractures

A retrospective chart review was performed on patients treated at a level one trauma centre for displaced intra-articular calcaneal fractures by a single trauma surgeon between January 1998 and July 2007. Patients were treated with open reduction and internal fixation utilising the extended lateral incision and a new type of fixation not described before. Threaded 1.575 mm (0.062 in.) Kirschner wires (K-wires) were used for fixation post-operatively along with standard plates, screws and bone substitute.There were 278 fractures in 246 patients that were treated with ORIF for displaced intra-articular calcaneal fractures during this 9-year period. Standard calcaneal lateral approach and hardware was supplemented with percutaneous threaded K-wires. An average of 5.0 fully threaded 1.575 mm K-wires were inserted per calcaneal fracture. Five (1.8%) patients had a K-wire infection; 0.6% of all K-wires became infected and 3.1% of K-wires broke.Lateral calcaneal apical wound issues are minimised and patients experience an overall low complication rate. The fixation also ensures non-weightbearing compliance.     

Displaced intra-articular calcaneal fracture treated surgically with limited posterior incision

The incidence of calcaneal fracture has been slowly increasing; however, the ideal treatment for displaced intra-articular fracture is not available yet, even though the fracture brings frequent complication and disability. Between April 1991 and March 1998, we treated 103 displaced intra-articular calcaneal fractures of 92 patients surgically with limited posterior incision, modified Gallie approach. There were thirty-seven tongue-type fractures, fifteen tongue-type fractures with moderate comminution, nineteen joint-depression fractures, twenty-nine joint-depression fractures with moderate comminution, and three extensively comminuted fractures. The fracture fragments were fixed mainly with partly threaded small cancellous screws or Steinmann pins without any bone graft. Ankle and subtalar motion was permitted immediately if fixation were stable enough. Otherwise, a short period of cast immobilization was utilized. With a mean follow-up of 28 months (range, 12 to 66 months), eighty six percent of feet had no pain or only occasional pain not requiring medication. Using American Orthopedic Foot and Ankle Society hindfoot score system for assessment, ninety percent of feet rated as good to excellent. We used "Circle draw test" for evaluation of subtalar motion during follow-up visitation and found eight-seven percent of feet showed good to excellent correlation with the functional recovery. We recommend a limited posterior incision for reduction and internal fixation of displaced intra-articular calcaneal fractures. For displaced intra-articular fractures with three or four large fragments without further comminution and without a displaced fracture of the calcaneal cuboid joint, this method is particularly useful. We also recommend a Circle draw test for evaluation of subtalar joint motion as well as an indicator of functional recovery after displaced calcaneal fractures.     

跟骨钛钢板内固定治疗移位跟骨关节内骨折的临床疗效

目的探讨跟骨钛钢板内固定在治疗移位跟骨关节内骨折临床疗效。方法自2006年1月。2009年4月．对28例30足移位跟骨关节内骨折采用跟骨外侧扩大“L”形切口,切开复位跟骨钛钢板内固定。根据骨缺损情况,必要时配合自体髂骨植骨。术后不需要石膏外固定。结果所有患者均获得6月～46月随访（平均为18．5月）。骨折全部愈合,平均愈合时间14．5周（12周～18周）。患者手术前Bohler＇s角平均为9．7。,术后半年为34．5°;Gissane’s角平均为103．2°。术后半年平均为132．50。按Maryland足部评分标准：优22足,良4足,可4足,优良率86．7％。结论跟骨解剖型钛钢板固定可靠,是治疗移位跟骨关节内骨折的理想方法。     

Hybrid grafting of post-traumatic bone defects using β-tricalcium phosphate and demineralized bone matrix

Objectives

Management of post-traumatic bone defects continues to be a substantial clinical challenge in orthopaedic trauma. This retrospective study evaluates the results of primary hybrid grafting of residual bone defects or voids, in displaced and comminuted long-bone fractures treated by plate fixation, using β-tricalcium phosphate and demineralized bone matrix.

Materials and Methods

Fifty-four patients having 62 fractures were included. Their mean age was 40.7 ± 10.7 years; femoral and tibial fractures were the commonest (70.9 %) in this study. Eight fractures (12.9 %) were open injuries; 13 fractures had critical-sized defects that averaged 3.4 ± 0.9 cm. Cortical bone defects occurred in 51 cases, and cancellous bone voids in eleven. Eleven patients (20 %) were polytraumatized. Tobramycin powder was added to the graft in all open fractures. The functional outcome was evaluated according to a modified Karlström and Olerud criteria.

Results

All fractures (100 %) had solid union without any implant failure. There was a significant delayed union (P < 0.001) in all critical-sized defects. The mean healing time showed a highly significant difference (P < 0.001) between closed and open fractures. The functional outcome was excellent in 28 fractures, good in 21 fractures, fair in nine fractures and poor in four fractures.

Conclusions

We believe that the ideal bone graft substitute for all situations does not exist; however, this hybrid grafting is a very good alternative to autogenous grafts especially in polytraumatized patients and when massive bone grafting is needed to reconstruct more than one bone in absence of segmental defects.     

Use of a biphasic cement bone substitute in the management of metaphyseal fractures

ObjectivesIn recent years, the increase in utilisation of bone substitutes in the reconstruction of bone defects has been fuelled by donor site complications associated with autologous bone harvesting. However the ability of bone substitute to stimulate bone union while maintaining fracture reduction has been a topic of debate. Cerament Bone Void Filler (CBVF) is a novel biphasic and injectable ceramic bone substitute that has high compressive strength and the ability to promote cancellous bone healing.Materials and MethodThis is a retrospective study to evaluate the surgical outcome of utilising CBVF in the treatment of depressed metaphyseal bone fractures over a two year period. The patients were followed up for at least six months after surgery and clinical parameters such as wound site complications were collated. Radiographic imaging was evaluated to determine loss of fracture reduction and rate of cement resorption.ResultsThirteen patients with depressed metaphyseal fractures were enrolled, which included: (i) one proximal humerus fracture; (ii) three tibial plateau fractures; and (iii) nine calcaneal fractures. None of the patients showed significant collapse in fracture reduction after six months of follow up. Cement resorption was noted in one patient as early as three weeks after surgery. There were no cases of cement leak or wound site complications.ConclusionCerament Bone Void Filler (CBVF) is a promising bone graft substitute in the management of depressed metaphyseal bone fractures, with the ability to maintain fracture reduction despite cement resorption.     

The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multicenter trial

In a prospective, nonrandomized, multicenter study, 109 patients with bone defects were treated with a surgical grade calcium sulfate preparation as a bone graft substitute. The calcium sulfate pellets were used in place of morselized cancellous bone graft for the treatment of patients with bone defects who usually would require grafting secondary to trauma, periprosthetic bone loss, tumor, or fusion. The calcium sulfate was used alone or mixed with other materials such as bone marrow aspirate, demineralized bone matrix, or autograft. The defects that were treated were contained and were not necessary for the stability of the bony structure. Radiographic and clinical data were collected at predetermined intervals for 12 months. At 6 months postoperatively, radiographic results for all patients showed that 99% of the calcium sulfate had been resorbed and 88% of the defect was filled with trabeculated bone. There were 13 complications; however, only four (3.6%) were attributable to the product. The results of a subgroup of 46 patients with benign bone lesions treated in the same manner are identical to the results of the overall study population. Surgical grade calcium sulfate pellets are considered a convenient, safe, and readily available bone graft substitute that yield consistent successful results.     

Early prophylactic bone grafting of high-energy tibial fractures

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.     

锁定钢板治疗跟骨关节内粉碎骨折的疗效分析

目的评价跟骨锁定钢板治疗跟骨关节内粉碎骨折的疗效。方法 2007年5月至2009年7月,应用跟骨锁定钢板治疗跟骨关节内粉碎骨折32例,男25例,女7例;年龄24～61岁,平均38.5岁。骨折按照Sanders分型,型5例,型19例,型8例。术后随访包括临床检查、X线片及采用Maryland足部评分标准进行足踝功能评分。结果 32例均获随访,时间10～28个月,平均17.2个月。骨折愈合时间9～19周,平均15.4周。无延迟愈合及不愈合,骨折端无移位,内固定无松动、断裂等现象。根据Maryland足部评分标准,优18例,良9例,一般3例,优良率为84.4%。结论跟骨锁定钢板是治疗跟骨关节内粉碎性骨折的有效方法,有利于患肢功能的早日恢复。     

Free vascularized fibula for the treatment of traumatic bone defects and nonunion of the forearm bones

Eighteen infected nonunions and segmental defects of both the radius and ulna which had failed to resolve with conventional treatment were treated with a free vascularized fibular graft to restore radial, but not ulnar, continuity. In three patients there was destruction of the wrist joint and in two destruction of the elbow. The time from injury to referral ranged from 4 weeks to 3 months. The ipsilateral fibula was used as an osseous or osseocutaneous free flap to reconstruct the radius. All fractures united with good soft-tissue healing and resolution of infection. One patient required additional cancellous bone grafting. The mean period required for radiographic bone union was 4 months. Reconstruction of only the radius provided a stable forearm with a reasonable range of forearm rotation.     

跟骨丘部植骨重建距下关节融合治疗跟骨关节内陈旧骨折

目的探讨跟骨丘部自体骨植骨重建距下关节融合术治疗陈旧性跟骨关节内骨折的手术方法及适应证. 方法 2000年7月～2003年10月,对11例跟骨陈旧性骨折患者行自体髂骨植骨丘部重建距下关节融合的方法进行治疗.其中男9例,女2例,年龄21～48岁;均为单侧足.跟骨外侧改良L形切口,全部取髂骨植骨重建跟骨丘部高度,髂骨块平均为3.0 cm×2.5 cm×1.8 cm,跟骨外膨的外侧壁均切除. 结果 11例获随访3～18个月,平均11.5个月.重建丘部骨10～12周愈合,术后8周部分负重,平均13.2周完全负重行走.根据张铁良跟骨关节内骨折评分标准:优4例,良5例,可2例.X线片示Bhler角、跟骨宽度以及跟骨丘部高度基本恢复正常. 结论自体髂骨植骨、跟骨丘部高度重建及距下关节融合术是治疗陈旧性跟骨骨折的一种有效方法,可矫正跟骨畸形,并恢复外形及功能.     

切开复位内固定治疗移位的跟骨关节内骨折

目的探讨切开复位可塑跟骨钢板内固定治疗移位的跟骨关节内骨折的疗效。方法对76例（82足）复杂跟骨关节内骨折行切开复位可塑跟骨钢板内固定治疗,其中39足予自体髂骨植骨。结果76例均获随访,时间12-35（22.3±3.7）个月。B hler角术前9.3°±3.2°,术后恢复到26.7°±6.8°;Gissane角术前101.6°±13.3°,术后恢复到120.1°±14.2°。根据Maryland足部评分系统：优39足,良31足,可8足,差4足。结论切开复位可塑跟骨钢板内固定治疗复杂的跟骨关节内骨折,固定牢固,能早期功能锻炼,可减少并发症。     

新型硫酸钙和脱钙骨基质混合物的临床应用

目的 评价新型硫酸钙和脱钙骨基质混合物作为骨移植替代物的临床应用效果. 方法 2005年2月至2008年2月采用新型人工骨移植治疗51例患者,按照植入物不同分为两组:人工骨与自体骨混合组21例,即植人硫酸钙和脱钙骨基质混合物加自体骨;单纯人工骨组30例,只植入硫酸钙和脱钙骨基质混合物.术后定期复查,观察人工骨吸收和新骨生长情况. 结果 51例切口一期愈合,无局部红肿、渗出.3例患者失访,48例随访6～36个月,平均16个月.单纯人工骨组术后4周可见人工骨部分吸收,颗粒形态模糊,术后8～12周(平均9.6周)完伞吸收,可见新生骨质,术后8～16周(平均11周)骨性愈合.人工骨与自体骨混和组术后8～12周(平均11.5周)人工骨颗粒完全吸收,骨折不愈合患者术后14～24周(平均19周)获骨性愈合,其余患者术后9～20周(平均13周)获骨性愈合. 结论 新型人工骨能够发挥增加移植物容量、促进骨生成的作用,无局部不良反应,是一种安全有效的骨移植替代物.     

带血管蒂的桡骨瓣植入治疗陈旧性腕舟骨骨折

目的 探讨治疗陈旧性舟状骨骨折的手术方法。方法 对36例陈旧性舟状骨骨折，采用带血管蒂桡骨瓣加植骨术治疗。结果 36例骨折全部骨性愈合。骨折愈合时间，术后8周24例，10周8例，12周2例，15周2例。35例腕关节功能恢复达健侧标准，活动时无疼痛。1例较术前有改善，活动时疼痛。结论 该术式手术操作简单，舟状骨骨折端植入的带血管蒂骨瓣形成“骨桥”，与植入的松质骨及舟状骨建立血供，可缩短骨折愈合时间及提高骨折愈合率，是治疗陈旧性舟状骨骨折的一种有效的手术方法。     

Interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures

The metaphyseal defects in 40 patients with displaced tibial plateau fractures necessitating surgical repair were filled with either cancellous autograft or interporous hydroxyapatite. Roentgenographic and clinical assessments at follow-up periods averaging 15.4 months (autograft) and 34.5 months (hydroxyapatite) demonstrated no significant differences in the two groups. Interporous hydroxyapatite is a safe, effective alternative to autogenous cancellous bone for the filling of metaphyseal defects associated with tibial plateau fractures.     

Open reduction and internal fixation of intra-articular calcaneal fractures in children

Calcaneal fractures are rare injuries in children and adolescents, and fractures with displaced intra-articular fracture patterns are even more rare. The purpose of this study was to report 9 intra-articular calcaneal fractures in 8 children (mean age, 12.6 years; range,10-15 years) treated with open reduction and internal fixation (ORIF) and to examine cases reported in the literature to better define the classification characteristics and operational outcomes of this uncommon fracture. Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. Clinical and radiographic examinations were performed at postoperative follow-up, and functional outcome was assessed with the modified American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Mean follow-up was 47 months (range, 21-72 months). Mean time to union was 9.2 weeks (range, 8-12 weeks). Mean modified AOFAS score was 65.2 points (range, 53-68 points). One foot experienced a minor complication.After a systematic review of the literature, 4 studies with a total of 35 patients (37 fractures) were included. All fractures were caused by high-energy injuries. Based on the Essex-Lopresti classification, 40.5% (15/37) were tongue-type fractures and 59.5% (22/37) were joint depression-type fractures. Based on the Sanders classification, 62.2% (23/37) of fractures were 2 parts, 32.4% (12/37) were 3 parts, and 5.4% (2/37) showed comminution. No significant difference was found in classification information between children and adults. The authors concluded that the characteristics of intra-articular calcaneal fractures in children are similar to those in adults, and operative treatment of these fractures yields good results with few complications.     

Response of a calcium sulfate bone graft substitute in a confined cancellous defect

Calcium sulfate, plaster of Paris, has a long clinical history for use as a bone graft substitute in various skeletal sites. The current authors examined the in vivo response of calcium sulfate pellets alone or in combination with autogenous bone graft in a bilateral critical-size distal femoral cancellous defect in an adult sheep model. New thick bone formation was seen in defects filled with calcium sulfate pellets alone. Increased immunostaining for bone morphogenetic protein-2, bone morphogenetic protein-7, transforming growth factor-beta, and platelet derived growth factor was seen in defects filled with calcium sulfate pellets alone and in combination with autograft. The local acidity during calcium sulfate resorption is proposed as a possible in vivo mechanism for this type of material.     

Bone Defects After Surgery for Displaced Intraarticular Calcaneal Fractures Spontaneously Improve Without Bone Grafting

BackgroundMost intraarticular displaced calcaneal fractures are accompanied by bone defects after surgical treatment, but the concern about negative effects of bone defects has not been resolved yet owing to the few studies on this issue. Therefore, studies on volumetric changes in bone defects over time and the correlation between postoperative outcomes and residual bone defects will be helpful to address the controversy on the necessity of bone grafting in bone defects of calcaneal fractures.Questions/purposes(1) Do bone defects change in size in the first year after surgical treatment of displaced intraarticular calcaneal fractures? (2) Does the size of residual bone defects correlate with postoperative radiographic or clinical outcomes?MethodsBetween 2015 and 2019, 99 patients with displaced intraarticular calcaneal fractures visited the investigators’ institution, of whom 95 received surgical treatment. Of the patients treated with surgery, 25% (24 of 95) did not undergo open reduction and internal fixation via an extensile lateral approach, and 19% (18 of 95) had multiple fractures, bilateral fractures, open fractures, or a history of previous surgery on the calcaneus; all of these patients were excluded. During the study period, CT was routinely performed for calcaneal fractures immediately after and 12 months after the surgery, but 6% (6 of 95) of the patients had insufficient CT data due to loss to follow-up before 12 months or other reasons, leaving 47 patients for evaluation in this retrospective study. Fractures were fixed with plate and screws, and bone grafting was not performed in all patients. To answer our first question, which was on the changes in bone defects over time, volumetric measurements of the bone defect were performed using CT via the ITK-SNAP software. The percentage of volumetric change was calculated as a fraction of the volumetric change over 12 months from the initial volume. The percentage of the residual bone defect was calculated as a fraction of the volume of the residual bone defect relative to the volume of the entire calcaneus. To answer our second question, which was on the correlation between residual bone defects and postoperative outcomes, we assessed the Böhler angle, Gissane angle, calcaneal height, Olerud-Molander Ankle Score (OMAS), and VAS score for pain and compared these parameters with the size of the residual bone defect using the Pearson correlation coefficient. The OMAS and VAS scores for pain were evaluated and recorded during patient visits, and we obtained the scores through a chart review. All volumetric measurements and radiographic evaluations were performed by two orthopaedic surgeons, and the intraobserver and interobserver reliability were assessed using the intraclass correlation coefficient.ResultsThe mean volume of the bone defect measured using CT was 4 ± 3 cm³ immediately after surgery and 1 ± 1 cm³ 12 months after surgery. During the first 12 months after surgery, the mean volume of the bone defect was reduced by 77% (95% confidence interval 73% to 80%). The mean residual bone defect in the entire calcaneus was 2% (95% CI 1% to 2%), and none of the postoperative outcomes were correlated with the residual bone defect.ConclusionAs bone defects substantially resolve without treatment, surgeons do not need to use bone graft for the surgical treatment of displaced intraarticular calcaneal fractures. Future studies that include patients who underwent bone grafting for the treatment of calcaneal fractures are needed to confirm our findings and to further investigate whether bone grafting has additional benefits for the recovery of bone defects.Level of EvidenceLevel III, therapeutic study.     

Bone grafting of cryosurgically treated bone defects: experiments in goats

It is hypothesized that cryosurgically treated bone defects are inappropriate host sites for cancellous bone grafting. The influence of autologous cancellous bone grafting on the healing of cryosurgically treated gap defects of long bones was investigated. A unilateral in vivo experiment was done to study bone strength and graft incorporation in the goat. The lining of a cylindrical defect of the femoral diaphysis was treated with a closed liquid nitrogen cryoprobe in 62 goats. Thirty-one animals received an impacted, morselized, cancellous bone graft harvested from the sternum. The other 31 animals served as controls. At 0, 4, 7, 10, 13, 16, and 26 weeks animals were euthanized and the femurs were evaluated for torsional strength, computed tomography, and histologic assessment. Specimens with a bone graft showed no significant increase in torsional strength with time compared to the controls. In all goats euthanized at 10 weeks or later, the graft was resorbed. The amount of bone apposition at the site of the cryosurgical lesion and the time at which the defect was bridged were similar in both groups. Autologous cancellous bone grafting does not accelerate healing of cryosurgically treated, stable, diaphyseal defects in the goat.     

Short-Term Outcomes of Open Reduction and Internal Fixation for Sanders Type III Calcaneal Fractures With and Without Bone Grafts

Calcaneal fractures, often caused by a fall from a height, are the most common injuries encountered by orthopedic surgeons. Currently, open anatomic reduction and internal fixation (ORIF) is considered a valuable treatment of displaced intraarticular fractures of the calcaneus; however, the need for bone grafting in the treatment is still controversial. Therefore, in the present study, we investigated the outcomes of 2 methods (with and without bone grafting) used for the surgical treatment of Sanders type III calcaneal fractures. From January 2013 to September 2015, 57 cases (55 patients) with displaced Sanders type III calcaneal fractures (53 unilateral and 2 bilateral) were enrolled. The patients were divided into 2 groups: group I was treated by ORIF with bone grafting (n = 28) and group II was treated by ORIF without bone grafting (n = 29). The radiologic evaluation included Böhler's angle, Gissane's angle, and the height and width of the calcaneum. In addition, the American Orthopaedic Foot and Ankle Society questionnaires and visual analog scale were completed by the patients. During the follow-up period, no differences were found in the outcome measures (Böhler's angle, p = .447; Gissane's angle, p = .599; calcaneal height, p = .065; calcaneal width p = .077; and American Orthopaedic Foot and Ankle Society questionnaires, p = .282) with or without bone grafting. The only difference between the 2 groups was the occurrence of postoperative pain (p = .024 and p = ≤ .05), which was greater in the patients who had undergone bone grafting. We have provided evidence that bone grafting with internal fixation in the treatment of intraarticular calcaneal fractures failed to improve the restoration of Böhler's angle or Gissane's angle. No statistically significant difference was found in the short-term outcomes between the 2 methods used for the surgical treatment of Sanders type III calcaneal fractures.