两种骨骺刺激术影响长骨局部生长的实验研究

目的 比较截骨和骨膜切除两种常用骨骺刺激术对兔胫骨局部骨生长的影响。方法 将４０只兔分为胫骨上端骨骺远端２ｍｍ处截骨和上端骨骺线上下１ｍｍ以内骨膜切除两组，经大体骨标本测量。Ｘ线摄片，四环素荧光标记，组织学及电镜观察，进行比较研究，结果 骨膜切除术对骨骺生长的刺激作用大于截骨术。结论 骨膜切除术可作为治疗儿童膝关节畸形的良好方法。     

手术治疗脊髓灰质炎后遗症膝反屈畸形

目的 探讨脊髓灰质炎后遗症膝反屈畸形的手术治疗效果。方法 采用股骨下端和胫骨上端前侧骨骺刺激、股骨髁上前倾截骨、胫骨平台下植骨抬高术或上端截骨垫高术等5种手术方法治疗37例39个膝关节。结果 术后35例37个膝获随访,随访时间9个月～6年,平均4年5个月。29例达到矫正效果,4例畸形复发行二次手术。结论 膝反屈的成因复杂,只有根据临床类型选择正确的手术方法,才能达到矫正目的。     

胫股联合截骨矫正重型膝反屈36例

胫股联合截骨矫正重型膝反屈３６例翁树秋，肖正龙，杨小山，徐开明，徐景卫指导邬华彬我院自１９８９年～１９９４年采用胫股二处联合截骨矫正重型膝反屈畸形３６例，经临床观察，效果满意，现报告如下。１临床资料本组３６例，其中男１５例、女２１例；年龄１６～３２岁...     

麻痹性膝反屈畸形手术方式的比较和评价：附295例报告

自１９７７年以来，运用８种手术方式治疗２９５例婴儿瘫麻痹性膝反屈畸形。男性１４６例，女性１４９例；年龄６～３６岁，平均１９．５５岁；膝反屈度数１５～７０°，平均３４．６３°。所有病人均得随访。认为疗效肯定的有胫骨平台抬高术；胫骨平台抬高和股骨髁下翻联合手术；腰肌代绳肌术及幼儿胫骨骨骺线附近前部骨膜切除术。相对可供选择的术式有胫骨上端截骨术，胫骨结节下抬高术及Ｈｅｙｍａｎ氏术，而胫骨平台骨阻挡术为不可取的术式。术前研究膝部软组织骨结构情况和能供肌转移之髓以上肌肉肌力情况，以及手术操作仔细、准确对疗效有直接关系。     

胫骨平台垫高术治疗膝反屈的临床体会

胫骨平台垫高术治疗膝反屈的临床体会张雪松，冯守诚自１９８９～１９９２年，我们用胫骨平台垫高术治疗膝反屈畸形１６例共１８膝，随访１～３年，疗效满意，报告如下：１．临床资料１．１一般资料本组１６例中男７例，女９例，年龄８～２４岁，平均１６岁，膝反屈３０～...     

股骨髁上反屈截骨术所致膝关节载荷传导紊乱的探讨（附358例远期随诊报告）

股骨髁上反屈角截骨术（以下简称反屈角截骨术）自１９７８年问世以来，确实给数以千计的脊髓灰质炎后遗症患者带来了福音，但临床实践及远期随诊观察表明，该手术也确给众多的手术后患者带来了远期严重的，甚至是难以挽回的（诸如骨性关节炎等）并发症。作者通过对术后１１～１５年３５８例３７６个膝的远期随诊观察及反屈角截骨术对膝关节影响的生物力学分析，确认反屈角截骨术导致膝关节载荷传导紊乱是产生该手术远期并发症的原因。为此，对该手术提出了有益商榷意见。１、截骨前应使膝关节屈曲角度减至１０°左右；２、对于股骨下段前弓弧度增大，绳肌肌力又在４级以上的患者，只做伸直截骨，二期行肌替代术；３、对于连枷膝患者，如若做该手术则应行连枷膝改造术     

胫骨高位截骨合并骨膜移植治疗膝关节骨性关节炎

膝关节骨性关节炎十分常见，治疗较为困难。为了提高膝关节骨性关节炎的治疗效果，于１９８８年７月～１９９２年１０月，采用胫骨高位外翻截骨植骨矫正膝关节骨性关节炎膝内翻畸形的同时，用自体骨膜移植治疗髌骨软骨软化症。手术治疗３２例（５１个膝）。经平均５．１年随访，优良率为９０．２％，明显优于各式单纯胫骨高位截骨术。认为，该手术是治疗膝关节骨性关节炎膝内翻畸形伴髌骨软骨软化症的有效方法之一     

胫骨高位截骨术治疗膝关节骨性关节炎

自１９９０年５月－１９９５年１２月，应用膝关节外固定加压融合器行高位径骨截骨术治疗伴有膝内翻畸形的骨性关节炎１０例１０膝，并随访６个月－５年半，平均３年９个月。术后结果，股胫角由术前平均１８４．７°矫正到平均１７０．３°。评分由术前平均４７分，增加到平均８５分。手术采用胫骨楔形截骨，双期氏针加压外固定。术中同时行胫骨远端前移１ｃｍ，以改善髌股关节的负重关系。     

再论股骨髁上反屈截骨术

本文报告12例儿麻后遗股四头肌瘫痪,由于膝关节屈曲平均65°(40～80°)而行股骨髁上反屈截骨术,结果6例无效;6例有骨关节炎征象。因此,本文着重讨论当膝有明显屈曲畸形时行反屈曲截骨术,可提前产生骨关节炎及其机理。提出如膝屈曲>30°,应先行松解再作反屈曲截骨术。     

股骨粗隆下不全截骨及钻孔治疗Perthes病

Ｐｅｒｔｈｅｓ病，又称儿童股骨头无菌性坏死、儿童股骨头缺血坏死、股骨头骨软骨病等。１９８６年以来，我们采用股骨粗隆下不全截骨及股骨头骺钻孔术治疗本病１８例，获较满意疗效。临床资料　本组１８例，均为男性，年龄３～１４岁，发病至就诊时间最短的半月，最长的３年。临床表现主要是患侧髋或膝疼痛，跛行，髋关节外展受限；Ｘ线表现为股骨头骺骨化中心较小，股骨头向外侧移位，股骨颈变短粗和有囊性缺损区，骨骺变扁，密度呈不均匀性增高或节裂等。按邸建德等［１］提出的分期方法，本组Ⅱ～Ⅲ期者１７例，Ⅳ期１例。治疗方法　取…     

Effects of two epiphyseal—stimulating procedures on local growth of long bones in rabbits

Objective:To study the effects of two epiphyseal stimulating procedures on local growth of long bone in rabbits.Methods:Osteotomy was performed in the metakphysis near the proximal tibial epiphyseal plate and hemicircumferential periosteal excision was made on the proximal tibial epiphysis.Tibia roentgenography,tetracycline labelling,histological method and electron microscopy were used.Results:The local stimulating effect following the hemicircumferential periosteal excision was more remarkable than the osteotomy.Conclusions:Periosteal excision is a better treatment for children‘s knee deformity.     

骨膜骨肉瘤与高度恶性表面骨肉瘤

目的报告表面骨肉瘤的两种少见亚型,即骨膜骨肉瘤和高度恶性表面骨肉瘤的诊治经验。方法回顾 5例骨膜骨肉瘤和 4例高度恶性表面骨肉瘤患者的影像学和病理学特点,并对临床治疗结果进行分析。 5例骨膜骨肉瘤患者,男 1例,女 4例;年龄 28～ 42岁,平均 35岁;肿瘤位于胫骨上段者 4例,股骨下段者 1例。 4例高度恶性表面骨肉瘤患者,男 3例,女 1例;年龄 17～ 23岁,平均 19.25岁; 4例患者肿瘤均位于股骨下段。结果 5例骨膜骨肉瘤均予以广泛切除,除 1例因局部复发行截肢术,现无瘤生存 1年 3个月外,余 4例已无瘤生存 3～ 9年,平均 5年 9个月。 4例高度恶性表面骨肉瘤患者,虽经积极综合治疗,但仅 1例无瘤生存 7年; 1例术后 2年 5个月复发而截肢,现无瘤生存 1年 9个月; 1例于术后 2年 4个月死于肺转移;另 1例在确诊后 3个月死亡。结论骨膜骨肉瘤和高度恶性表面骨肉瘤各具鲜明的影像学和病理学特点,骨膜骨肉瘤恶性程度较低,应采用以局部广泛切除为主的手术治疗,预后相对较好;而高度恶性表面骨肉瘤的生物学行为则与经典的髓内骨肉瘤相似,预后较差,必须采用手术与化疗相结合的综合治疗方法。     

Oncological and functional outcome of periosteal osteosarcoma

Background:

Periosteal osteosarcoma is an uncommon variant of osteosarcoma which constitutes less than 2% of all osteosarcomas. Whereas adequate surgical excision remains the cornerstone of treatment, the role of chemotherapy in this tumor is still unclear. Existing literature contains very few single center studies on the outcomes for periosteal osteosarcomas and any additional information will help in better understanding of these uncommon lesions. This study aims to evaluate the oncologic and functional outcomes of treatment of periosteal osteosarcoma treated at our institute.

Materials and Methods:

A retrospective analysis of 18 cases of periosteal osteosarcoma treated between January 2001 and December 2010 was carried out. There were 12 males and 6 females. The mean age at presentation was 16.3 years (range 5-26 years). Tibia and femur were the most common sites (n = 8). 16 of 18 patients received chemotherapy, 16 had limb sparing resection, one had an amputation and one had rotationplasty. Of the 16 patients with limb salvage, conventional wide excision was done in 11 cases. In 5 cases tumor was excised with hemicortical excision. Of the 11 cases treated with wide excisions, 4 patients underwent an osteoarticular resection and in 7 patients a joint preserving segmental intercalary resection was done.

Results:

All patients were available for followup. Surgical margins were free in all patients. A good response to chemotherapy was seen in 4/11 cases and poor in 6/11 cases. In one case the histological response was not discernible due to predominant chondromyxoid nature of the tumor. The median followup was 61 months (range: 18-130 months). There were two local recurrences (11%) at 9 and 18 months postsurgery. Pulmonary metastasis subsequently occurred in 4 cases (22%). Fourteen patients are currently alive and continuously disease free. Disease free survival at 5 years was 77.8% and overall survival (OVS) was 83.3%. Patients without marrow involvement had a better OVS at 5 years when compared with patients with marrow involvement (90% vs. 75%) (P = 0.23).

Conclusion:

Surgical excision remains the mainstay of treatment. Intramedullary involvement may suggest aggressive disease biology. The role of chemotherapy is still debatable and multicenter studies are needed to provide guidelines.     

Shortening of the first metatarsal as a complication of metatarsal osteotomies

There have been few reports of shortening of the first ray of the foot because of damage to the physis of the first metatarsal during the performance of metatarsal osteotomy for residual metatarsus adductus. In a retrospective study of twenty-seven feet in twenty patients who underwent this procedure, eight feet in seven patients were noted to have some degree of residual shortening of the first ray. This is an incidence of 30 per cent. The follow-up period after osteotomy ranged from two years to seven years and four months (average, four years). We could find no clear correlation between the occurrence of shortening and the patient's age at osteotomy, sex, or race, or the etiology of the adduction for which the osteotomy had been done. A clear correlation was found, however, with the surgical technique that had been employed. In two of the eight feet with a short first ray, the osteotomy had been done within the physis of the first metatarsal. In the other feet the procedure had employed an osteotomy site close to the physis or extensive periosteal dissection, or both. The results in our patients implicate subperiosteal dissection of the first metatarsal as an important, previously unreported cause of damage to the physis and of the resultant shortening. We recommend radiographic determination of the relationship of the osteotomy site to the physis before dissection is performed.     

Dome-shaped proximal tibial osteotomy using percutaneous drilling for osteoarthritis of the knee

We have improved a surgical technique for proximal tibial osteotomy that involves percutaneous drillings. We performed the modified dome-shaped proximal tibial osteotomy on 44 knees in 42 patients (8 men and 34 women) with an average age of 66 years (range 50-78 years) for osteoarthritis of the knee. The mean follow-up period was 39 months (range 24-63 months). The varus angle was 4 degrees +/- 3.6 degrees (mean +/- SD) preoperatively, and the valgus angle was 12 degrees +/- 3.3 degrees postoperatively. Pain relief was obtained in all cases postoperatively. Transient pin tract infection occurred in one case, but it resolved completely following local irrigation. Intercondylar fracture of the upper fragment with no displacement was noted in two patients. They were treated with AO cancellous screw fixation, and improvement of pain was obtained in both cases. Osteotomy drill guide instruments are useful for accurately performing dome-shaped osteotomy. Our proximal tibial dome osteotomy with an external fixator allowed early motion and accurately maintained the angle of correction.     

Periosteal chondroma and periosteal chondrosarcoma

A clinicopathologic study of 46 patients with periosteal chondroma and 14 patients with periosteal chondrosarcoma revealed that periosteal chondroma tended to affect younger patients and that the lesion was usually smaller. Radiographically, the typical periosteal chondroma was a small, well-marginated tumor on the outer surface of a long bone. Erosion of the cortical surface and marginal buttresses were usually present. Periosteal chondrosarcoma had a more aggressive appearance and was seen as a large mass located superficially on the cortex; the margins of the mass were more irregular than those of chondroma. Histologically, periosteal chondroma frequently showed hypercellularity, plump nuclei, and binucleation. Thus, the differentiation of chondroma from chondrosarcoma is difficult and is based mainly on evidence of invasion. The prognosis in periosteal chondroma is good: only one patient had a local recurrence, none of the tumors underwent malignant change, and excision seems to be curative. However, the prognosis in periosteal chondrosarcoma is not as good: two patients died of metastasis to the lungs after local excision and two patients had recurrences after local resection. Periosteal chondrosarcoma should be treated more aggressively than periosteal chondroma.     

Eccrine Porocarcinoma Treated with Mohs Micrographic Surgery: A Report of Five Cases

BACKGROUND: Eccrine porocarcinoma is a rare, locally aggressive, potentially fatal neoplasm. While wide local excision has traditionally been the treatment of choice, recurrences following excision are common. OBJECTIVE: The purpose of this study was to review the traditional treatments of eccrine porocarcinoma as well as to introduce Mohs micrographic surgery as an alternative to wide local excision. METHODS: We reviewed all cases of eccrine porocarcinoma seen at Emory University between 1985 and 1999. All cases were treated definitively with Mohs micrographic surgery. The clinical characteristics and outcome of each case are summarized. RESULTS: Five patients with eccrine porocarcinoma were treated with Mohs micrographic surgery. There have been no recurrences to date, with an average follow-up of 2.1 years (ranging from 5 months to 4 years). CONCLUSION: Follow-up of five patients supports the view that Mohs micrographic surgery may be an effective treatment for eccrine porocarcinoma.     

Chronically unreduced traumatic anterior dislocation of the hip: a report of four cases.

Four cases of unreduced (2-11 months postinjury) anterior hip dislocation are reported. One public dislocation 2 months postinjury was treated by open reduction with a fair result. A unique case of iliac dislocation 11 months postinjury, overlooked due to an associated femoral shaft fracture, was treated by valgus/derotation osteotomy. Two obturator dislocations 7.5 and 9.5 months postinjury were treated by a subcapital osteotomy and displacement of the femoral neck into the acetabulum (modified excision arthroplasty). Both of these patients had fairly stable, painless, and mobile hips at 2.1 and 2.8 years follow-up. By our method, subsequent total hip arthroplasty remains a viable option, in contrast to the previously described method of trochanteric osteotomy, whereby the proximal femoral anatomy is distorted.     

带血管蒂骨膜瓣移位修复肱骨骨折及骨不连

目的 探讨带血管蒂的肱骨远端骨膜瓣移位修复肱骨难愈性骨折及骨不连。方法 1995年以来应用该骨膜瓣修复肱骨难愈性骨折及骨不连23例,其中粉碎性、多段骨折等难愈合性骨折12例,骨不连11例,合并桡神经损伤7例。手术方式为开放复位,内或外固定及应用带血管蒂骨膜瓣移位覆盖骨断端。结果 术后经6－24个月随访,除2例骨不连患者对关节活动不满意外,其余病例均获得良好的效果,骨膜瓣成骨好。难愈性骨折愈合时间为2－3个月,骨不连愈合时间为3－5个月,桡神经功能均恢复。结论 桡侧副血管蒂肱骨远端骨膜瓣对肱骨骨折及骨不连具有很好的修复作用。