Guo绳肌远端延长治疗膝关节痉挛性屈曲畸形：附132例随访分析

作者对１９８９．７￣１９９４．７采用Ｇｕｏ绳肌远端延长术治疗的１３２例膝关节痉挛性屈曲畸形患者，进行了随访分析，畸形复发率１８％。复发与随访时间呈正相关。统计学处理表明：年龄的大小、痉挛的轻重可影响复发率；术前行走能力，膝屈曲度数及延长方式与复发率无关。     

枕骨大孔扩大术治疗上颈椎与颅底先天性畸形伴寰枢关节脱位的远期疗效

随访了１９８２～１９８９年间因上颈椎与颅底先天性畸形伴寰枢关节脱位而施行枕骨大孔扩大术治疗患者１２例，平均随访７．４年。结果发现１２例患者术后短期内神经症状均有不同程度缓解，而随访时有１１例神经症状复发或加重，占９１．７％。随访结果分析表明：枕骨大孔扩大术仍是一种治疗上颈椎与颅底先天性畸形伴寰枢椎脱位的有效方法，但应强调在枕骨大孔扩大减压后必须重建枕颈部的稳定性。     

小腿外伤后足趾屈曲畸形发生与疗效的相关因素分析

目的 统计不同小腿外伤致足趾屈曲畸形的发生率,探讨不同手术方式和手术时机对疗效的影响,及外伤后肌肉MRI表现与畸形发生的关系. 方法 1990年1月至2006年12月,采集小腿外伤病例1922例,502例患者于外伤后7～10 d行MRI检查.并发足趾屈曲畸形39例,男28例,女11例;年龄20～48岁,平均30.8岁.分别于畸形发生后3个月、3～6个月和6～18个月采用肌腱粘连松解及松解+肌腱延长两种方式矫正畸形.采用美国足与踝关节协会足趾关节功能评分法对矫正效果进行评定. 结果 39例全部得到随访,随访时间6～72个月(平均22个月),其中优18例,良15例,可4例,差2例,优良率84.62%.17例单纯行肌腱粘连松解术,复发2例;22例行松解+肌腱延长术,复发4例.畸形于6个月内矫正27例,复发5例,复发率18.52%;6个月以上矫正12例,复发1例,复发率8.33%.结论 本组小腿外伤后足趾屈曲畸形的发生率为2.03%,不同结构损伤,其发生率不同,以腓骨骨折最高,为3.38%.手术以单纯行肌腱粘连松解复发率为低.手术时机对预后有显著性影响,矫正手术宜在畸形发生后6个月以上进行.外伤后小腿<足母>长屈肌、趾长屈肌MRI信号的异常变化对足趾屈曲畸形发生的判断有一定的临床意义.     

腓骨骨折术后并发(足母)趾屈曲畸形的治疗

目的 探讨腓骨骨折切开复位内固定术后并发拇趾屈曲畸形的病因、临床表现、解剖学特征、诊断及治疗方法。方法 1996年10月至2004年3月，腓骨骨折术后并发拇趾屈曲畸形患者33例，男19例，女14例；年龄22-49岁，平均33．2岁。其中合并踝关节骨折24例，根据Lauge—Hansen分型：旋前-外旋型18例，旋后-外旋型4例，旋前-外翻型2例；胫腓骨远端1／3螺旋形骨折9例。腓骨骨折均行切开复位钢板螺钉内固定术。患者均于术后1-5个月，平均3个月出现拇趾屈曲畸形。其中单纯拇趾屈曲畸形19例，伴二、三趾屈曲畸形8例，伴二至五趾屈曲畸形6例。采用单纯肌腱粘连松解术、单纯拇长屈肌腱延长或合并趾长屈肌腱延长术矫正畸形。结果19例单纯拇趾屈曲畸形患者，7例行单纯拇长屈肌腱粘连松解术，12例行拇长屈肌腱延长术。14例合并其余足趾屈曲畸形患者，6例行单纯拇长屈肌腱延长术，8例行拇长屈肌腱合并趾长屈肌腱延长术。术后随访2-10个月，平均6个月，所有患者足趾畸形完全矫正，疼痛缓解，步态及穿鞋改善，无畸形复发。结论 腓骨骨折术后并发拇趾屈曲畸形，拇长屈肌腱与骨折处粘连是重要因素。在Henry结部位，拇长屈肌腱与趾长屈肌腱之间存在腱性连接的解剖变异，对于足部矫形手术具有特殊的临床意义。     

膝关节屈曲畸形的手术治疗(附391例分析)

目的：探讨选择合理的手术方式来矫正小儿麻痹后遗症膝关节的屈曲畸形。方法：本组报告391例，根据膝关节屈曲畸形的程度，采用6种不同手术方式。结果：术后随访99个月，优良率达95%。结论：根据膝关节屈曲畸形的程度，来选择合理的手术方式，是确保手术成功的前提。     

屈曲挛缩畸形的膝关节置换术

目的：探讨屈曲挛缩畸形的膝关节行关节置换的方法及疗效。方法：收集膝关节屈曲挛缩畸形病例56例,63膝,行膝关节置换。分别记录术前术后膝关节畸形程度,HSS评分,活动范围。并进行比较。结果：所有病例获得随访,屈曲挛缩畸形均得到改善,膝关节HSS评分由术前20．7分提高到术后平均73．6分。膝关节活动范围由术前平均32．6°（0°～55°）提高到术后平均92．7°（80°～125°）。结论：晚期骨性关节病所致的屈曲挛缩畸形的膝关节行膝关节置换术,着重注意软组织松解,力线调整。疗效满意。     

屈曲挛缩畸形膝关节置换的软组织平衡

目的：探讨屈曲挛缩畸形的膝关节行关节置换的方法,重点关注术中膝关节周围软组织平衡的方法。技巧及术后疗效。方法：自2010年6月～2012年6月共收治晚期膝关节疾病合并屈曲挛缩畸形患者156例,213膝,采取人工膝关节置换进行治疗,分别记录术前术后膝关节畸形程度,HSS评分,活动范围。并进行比较。本组病例平均年龄60．2岁（44～81岁）,女92例136膝,男64例77膝。膝骨性关节炎85例,类风湿性关节炎58例,创伤性关节炎13例。膝关节活动范围平均52．6°（33．5°～94．1°）。本组病例轻度屈曲畸形：83例117膝,中度屈曲畸形：58例76膝,重度屈曲畸形：15例20膝。平均屈曲畸形程度：45．8°。每例患者均进行术前及术后1年HSS评分进行疗效评价。结果：所有病例获得随访,屈曲挛缩畸形均得到改善,膝关节HSS评分由术前20．7分提高到术后平均73．6分。膝关节活动范围术前平均52．6°提高到术后平均92．7°。结论：晚期膝关节病所致的屈曲挛缩畸形的膝关节行膝关节置换术,除了在术中注意准确截骨外,应着重注意软组织松解,调整力线。     

膝关节屈曲畸形的全膝关节置换术

目的探讨全膝关节置换术对矫正膝关节屈曲畸形的患者所采用的方法和临床经验。方法本组52例中，男9例，女43例，年龄43～79岁，平均66岁。原发病变：骨性关节炎40例，类风湿性关节炎12例。术前膝关节屈曲畸形程度：10°～20°有39例，20°-40°有9例，40°～60°有3例，600～900有1例；同时合并膝外翻畸形6例，膝内翻畸形26例。49例行常规后稳定型膝关节置换术，3例行铰链式全膝关节置换术。结果术后测量，46例屈曲畸形患者得以完全矫正，4例残留〈5°的屈曲，1例残留5°～10°的屈曲，1例残留10°～15°的屈曲。随访时间6个月～12年，平均7．8年。KSS膝关节评分由术前平均31分提高至79分，功能评分由术前平均29分提高至82分。结论全膝关节置换术时，彻底松解膝关节周围软组织、适当增加股骨远端和胫骨平台的切骨，是矫正屈曲畸形的有效方法，其中松解后关节囊、重建后隐窝是关键。     

人工全膝关节置换术治疗单侧膝内翻合并屈曲挛缩畸形效果观察

目的探讨人工全膝关节置换术治疗单侧膝内翻合并屈曲挛缩畸形的效果。方法对28例单侧膝内翻合并屈曲挛缩畸形患者应用人工全膝关节置换术治疗,术后随访12个月,比较治疗前后膝关节股胫角、屈曲挛缩度、膝关节屈伸活动度和HSS评分及疗效。结果患者均顺利完成手术。随访12个月,患者膝关节股胫角,屈曲挛缩度,膝关节屈伸活动度与治疗前比较,差异有统计学意义(P0.05);依据膝关节HSS评分治疗优良率92.86%(26/28),未出现下肢不等长、跛行和严重感染等。结论人工全膝关节置换术治疗单侧膝关节内翻合并屈曲挛缩畸形,可明显改善膝关节功能,效果确切。术中软组织松解是矫正膝关节内翻屈曲挛缩畸形的关键。     

臀中小肌前置治疗脑瘫髋内收内旋畸形

臀中小肌前置治疗脑瘫髋内收内旋畸形乌鲁木齐第２３医院（８３０００６）刘刚，张东印报道了运用臀中小肌止点前移与内收肌松解、闭孔神经切断的联合手术方法治疗脑瘫髋屈曲内旋畸形１２例２４髋，均为截瘫型，平均年龄１５岁。平均随访１６个月，矫正髋屈曲内旋最大２５...     

Muscle strength and knee range of motion after femoral lengthening

Background and purpose — Femoral lengthening may result in decrease in knee range of motion (ROM) and quadriceps and hamstring muscle weakness. We evaluated preoperative and postoperative knee ROM, hamstring muscle strength, and quadriceps muscle strength in a diverse group of patients undergoing femoral lengthening. We hypothesized that lengthening would not result in a significant change in knee ROM or muscle strength.

Patients and methods — This prospective study of 48 patients (mean age 27 (9–60) years) compared ROM and muscle strength before and after femoral lengthening. Patient age, amount of lengthening, percent lengthening, level of osteotomy, fixation time, and method of lengthening were also evaluated regarding knee ROM and strength. The average length of follow-up was 2.9 (2.0–4.7) years.

Results — Mean amount of lengthening was 5.2 (2.4–11.0) cm. The difference between preoperative and final knee flexion ROM was 2° for the overall group. Congenital shortening cases lost an average of 5% or 6° of terminal knee flexion, developmental cases lost an average of 3% or 4°, and posttraumatic cases regained all motion. The difference in quadriceps strength at 45° preoperatively and after lengthening was not statistically or clinically significant (2.7?Nm; p = 0.06). Age, amount of lengthening, percent lengthening, osteotomy level, fixation time, and lengthening method had no statistically significant influence on knee ROM or quadriceps strength at final follow-up.

Interpretation — Most variables had no effect on ROM or strength, and higher age did not appear to be a limiting factor for femoral lengthening. Patients with congenital causes were most affected in terms of knee flexion.     

Effect on knee flexion of a modification to the surgical technique of pin placement during femoral lengthening

Loss of knee movement is a common problem in femoral lengthening. Two groups of 10 children were compared: one group lengthened by the Ilizarov technique using a standard method and one group in whom the technique was modified to incorporate a different method for determining the pin placement. Loss of knee flexion was compared between the two groups. A significant difference in the total loss of flexion ( <0.002), and in the amount of knee flexion, at the end of lengthening ( <0.001) and at 6 months after frame removal ( <0.004) was observed. This simple modification to surgical technique appears to decrease the knee flexion lost in children undergoing femoral lengthening by the Ilizarov method.     

Effects of surgical lengthening of the hamstrings without a concomitant distal rectus femoris transfer in ambulant patients with cerebral palsy

Eighteen ambulant patients (32 legs) who had undergone fractional lengthening of the medial and lateral hamstrings without rectus femoris transfer underwent pre- and postoperative gait analysis. A significant increase in the amount of knee extension and a decrease in the amount of peak knee flexion in swing were observed. This decrease in knee flexion signified a change towards more normal speed-related values. Dorsiflexion at initial contact decreased significantly for patients who did not undergo a gastrocnemius lengthening (n = 24). Absolute cadence was significantly lower after surgery, but the change in dimensionless cadence was not significantly different. This difference in the outcome between dimensionless and absolute stride parameters can be attributed to the increase in body height after surgery. The clinical significance of these findings is that it is important to recognize that postoperative effects of surgery on gait in children may, in part, be explained by changes in height and not surgery alone.     

Plating after lengthening (PAL): technical notes and preliminary clinical experiences

Introduction Shortening the period of time for the external fixator after limb lengthening decreases the complication rate and increases the patient satisfaction. Material and method We describe the plating after lengthening (PAL) as a new technique on five patients with limb length discrepancy (1 femoral, 4 tibial) who had lengthening procedure with Ilizarov technique. The mean amount of lengthening was 50 mm. The mean lengthening period was 100 days (5–135 days). When the lengthening period ended, the locking compression plate was applied percutaneously by using the technique of minimal invasive plate osteosynthesis, and the Ilizarov external fixator was removed. Results The fixator-free period was achieved at the beginning of the consolidation phase, except in two patients, which were delayed for plating because of pin-tract infection. No complication was encountered except in one patient who had limited flexion of knee joint. There was no need for blood transfusion. Discussion The PAL, which shortened the period of time for the external fixator, was an easy and safe method for the fixation of the bone after limb lengthening.     

Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial

BACKGROUND: Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with and without an Achilles tendon lengthening. Our primary hypothesis was that the Achilles tendon lengthening would lead to a lower rate of ulcer recurrence. Methods: Sixty-four subjects were randomized into two treatment groups, immobilization in a total-contact cast alone or combined with percutaneous Achilles tendon lengthening, with measurements made before and after treatment, at the seven-month follow-up examination, and at the final follow-up evaluation (a mean [and standard deviation] of 2.1 +/- 0.7 years after initial healing). There were thirty-three subjects in the total-contact cast group and thirty-one subjects in the Achilles tendon lengthening group. There were no significant differences in age, body-mass index, or duration of diabetes between the groups. Outcome measures were time to healing of the ulcer, ulcer recurrence rate, range of dorsiflexion of the ankle, peak torque (strength) of the plantar flexor muscles, and peak plantar pressures on the forefoot. RESULTS: Twenty-nine (88%) of thirty-three ulcers in the total-contact cast group and all thirty ulcers (100%) in the Achilles tendon lengthening group healed after a mean duration (and standard deviation) of 41 +/- 28 days and 58 +/- 47 days, respectively (p > 0.05). (One patient in the Achilles tendon lengthening group died before treatment was completed.) In the first seven months of follow-up, sixteen (59%) of the twenty-seven patients in the total-contact cast group who were available for follow-up and four (15%) of the twenty-seven patients in the Achilles tendon lengthening group who were available for follow-up had an ulcer recurrence (p = 0.001). At the time of the two-year follow-up, twenty-one (81%) of the twenty-six patients in the total-contact cast group and ten (38%) of the twenty-six patients in the Achilles tendon lengthening group had ulcer recurrence (p = 0.002). Compared with the group treated with the total-contact cast, the group treated with Achilles tendon lengthening had increased dorsiflexion and it remained increased at seven months (p < 0.001). Plantar flexor peak torque also decreased after Achilles tendon lengthening (p < 0.004), but it returned to baseline after seven months. Peak plantar pressures on the forefoot during barefoot walking were reduced (p < 0.0002) following Achilles tendon lengthening yet returned to baseline values within seven months after treatment. CONCLUSIONS: All ulcers healed in the Achilles tendon lengthening group, and the risk for ulcer recurrence was 75% less at seven months and 52% less at two years than that in the total-contact cast group. Achilles tendon lengthening should be considered an effective strategy to reduce recurrence of neuropathic ulceration of the plantar aspect of the forefoot in patients with diabetes mellitus and limited ankle dorsiflexion (相似文献   

Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up

Background

Overactivity or contractures of the hamstring muscles in ambulatory children with cerebral palsy (CP) can lead to either a jump gait (knee flexion associated with ankle plantar flexion) or a crouch gait (knee flexion associated with ankle dorsiflexion). Hamstring lengthening is performed to decrease stance knee flexion. However, this procedure carries the potential risk of weakening hip extension power as well as recurrence over time; therefore, surgeons have adopted a modified procedure wherein the semitendinosus and gracilis are transferred above the knee joint, along with lengthening of the semimembranosus and biceps femoris.

Purpose

The purpose of our study is to evaluate the differences between hamstring lengthening alone (HSL group) and hamstring lengthening plus transfer (HST group) in the treatment of flexed knee gait in ambulatory children with CP. We hypothesized that recurrence of increased knee flexion in the stance phase will be less in the HST group at long-term follow-up, and hip extensor power will be better preserved.

Methods

Fifty children with CP who underwent hamstring surgery for flexed knee gait were retrospectively reviewed. All subjects underwent a pre-operative gait study, a follow-up post-operative gait study, and a long-term gait study. The subjects were divided into two groups; HSL group (18 subjects) or HST group (32 subjects). The mean age at surgery was 9.9 ± 3.3 years. The mean follow-up time was 4.4 ± 0.9 (2.7–6.3) years.

Results

On physical examination, both groups showed improvement in straight leg raise, knee extension, popliteal angle, and maximum knee extension in stance at the first post-op study, and maintained this improvement at the long-term follow-up, with the exception of straight leg raise, which slightly worsened in both groups at the final follow-up. Both groups improved maximum knee extension in stance at the initial follow-up, and maintained this at the long-term follow-up. Only the HST group showed significant (p < 0.05) improvement in the peak hip extension power in stance at the first post-op study, and this increased further at the final follow-up. In the HSL group, there was an initial slight decrease in the hip extension power, which subsequently increased to pre-operative values at the long-term study. Only the HST group showed increase of the average anterior pelvic tilt at the long-term follow-up study, although this was small in magnitude. There were two subjects who developed knee recurvatum at the post-op study, and both were in the HST group.

Conclusions

There is no clear benefit in regards to recurrence when comparing HST to HSL in the long term. In both HSL and HST, there was reduction of stance phase knee flexion in the long term, with no clear advantage in either group. Longer follow-up is needed for additional recurrence information. There was greater improvement of hip extension power in the HST group, which may justify the additional operative time of the transfer.

Significance

This study helps pediatric orthopedic surgeons choose between two different techniques to treat flexed knee gait in patients with CP by showing the long-term outcome of both procedures.     

Surgical treatment of upper extremities of cases arthrogryposis multiplex congenita]

Between 1990-1999 at the Polish-American Pediatric Institute 36 children with arthrogryposis were treated. In 10 cases 21 corrective surgical procedures of the upper extremities were performed. Corrective procedures of the upper extremities were performed. Corrective procedures aimed at contractures of the hand, wrist and forearm, consisting of capsulotomies, lengthening of the finger flexor tendons and transposition of wrist flexor on to the wrist extensors were performed 8 times. Correction of extension contracture of elbow joint, consisting of posterior capsulotomy and lengthening of the triceps tendon was performed 9 times. In 4 cases transposition of the pectoralis major onto the biceps tendon according to Clark or Zancolli in Carrol's modification was performed. The average age of the children was 4.7 years (age ranging from 1.5 to 9 years), the follow-up period was 4.25 years (ranging from 0.5 to 10 years). Palmer contracture of the wrist was an average 80 degrees (70-90 degrees) before surgery. Passive flexion in the elbow joint was on average 15 degrees (0-35 degrees). Active flexion of the elbow was absent in all cases. After corrective procedures in the wrist, in 5 cases physiological positioning of the was achieved. After lengthening of the triceps tendon passive flexion of elbow was 80-90 degrees, in one extremity 70 degrees. After the Clark or Zancolli procedures active flexion of the elbow was 80 degrees in one case, 70 degrees in another and 50 degrees six months post-op. The author's own experiences indicate that and multi-stage interdisciplinary approach in necessary from the beginning in these cases.     

Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy

Purpose

The purpose of this study was to evaluate the results of distal femur extension osteotomy and medial hamstring lengthening in the treatment of fixed knee flexion deformity in patients with spastic diparetic cerebral palsy.

Methods

A retrospective study was done in a group of 12 diparetic cerebral palsy patients. A distal femur extension osteotomy was performed as part of multilevel surgery on lower limbs. The fixed knee flexion deformity was measured during physical examination, whereas hip and knee flexion in the stance phase and anterior pelvic tilt were both analyzed at kinematics. The pre- and post-surgery results were compared and analyzed statistically. A medical record review was done in order to identify the complications. The mean follow-up was 28 months.

Results

A significant reduction of fixed knee flexion deformity at physical examination and knee flexion in the stance phase at kinematics was observed, but with no decrease in hip flexion. As a non-desired effect, there was an increase in anterior pelvic tilt after surgical procedures. With regard to complications, a single patient had skin breakdown at a calcaneous area on one side and the recurrence of deformity was seen in 27% of cases.

Conclusions

In this study, in which fixed knee flexion deformity did not exceed 40° before surgery, the distal femur extension osteotomy was effective in increasing knee extension in the stance phase. However, an increase in anterior pelvic tilt, deformity recurrence and necessity for walking aids are possible complications of this procedure.     

Functional outcome following quadriceps tendon lengthening in congenital dislocation of the knee, with special reference to extensor weakness

This study reports the incidence and proposes a probable cause of flexion deformity and extensor weakness following lengthening of quadriceps tendon for the congenital dislocation of the knee and also proposes a modification of the functional grading given in the literature to this effect. Seventeen knees in ten patients were treated with a follow-up from 3 to 8 years. Fifteen knees were grade III and were operated with quadriceps lengthening and anterior capsulotomy. Two knees were Grade II and were initially closed reduced, but operated later due to recurrence. The results were graded on a modification of functional grading system given in the literature [1]. There were excellent results in four, good in five and fair in eight knees. There was an extensor weakness in ten knees (average 12.2°) and flexion deformity (15°) in one. Eight patients could squat and all started walking independently by 10–20 months of age, except one. V-lengthening of the quadriceps tendon produced a satisfactory improvement in the knee function. The theoretical role of the gastrocnemius and hamstring muscles in abetting flexion deformity and extensor weakness is suggested.