距骨骨折后缺血坏死的相关因素分析

目的 :探讨距骨骨折类型和手术方式与骨折后坏死的关系。方法 :自2009年3月至2013年11月收治78例距骨骨折患者,43例随访2~5年,其中男27例,女16例;年龄17~65岁,平均38.6岁。39例距骨颈损伤,4例距骨体损伤。根据损伤情况采取前内侧、前外侧及联合入路手术等方法治疗,受伤后6~48 h进行治疗。分析患者前期骨折类型以及手术方式与后期骨坏死发生概率之间的关系。结果:78例中43例获随访,19例发生距骨坏死,包括距骨颈Ⅰ型骨折2例,距骨颈Ⅱ型骨折5例,距骨颈Ⅲ型骨折5例,距骨颈Ⅳ型骨折5例,距骨体骨折2例(均为合并距骨颈骨折的患者)。共29例采取手术治疗,采用不同手术方式治疗的患者发生距骨坏死的差异无统计学意义。结论:距骨颈骨折较距骨体骨折更易发生缺血坏死,在距骨颈骨折分型中,Ⅲ、Ⅳ型发生缺血坏死可能性大。     

距骨颈骨折的手术治疗

目的探讨距骨颈骨折的特点、分型手术方法及并发症防治。方法1996年7月～2001年11月，共治疗距骨颈骨折患者47例．男32例．女15例；年龄18～49岁，平均31．6岁；坠落伤13例，车祸伤28例．其它损伤6例；合并踝部骨折12例；开放性骨折脱位4例。根据Hawkins分型方法，Ⅰ型骨折6例，Ⅱ型骨折26例．Ⅲ型骨折15例。Ⅰ型骨折为无移位、稳定性骨折，采取非负重石膏管型固定；Ⅱ、Ⅲ型骨折行急诊手术，解剖复位．松质骨拉力螺钉内固定，其中Ⅲ型骨折同时行距下关节一期融合．非负重短腿石膏管型固定8～48周，至X线片示骨折愈合后，再逐渐负重。结果生部病例均获得随访，隧访时间2～5年．平均3.6年。根据患者的主诉、后跟及踝关节的外形、功能及X线征象来分析临床疗效，优17例(362％)，良22例(46．8％)．可5例(10．6％)，差3例(6．4％)；优良率为83．0％。术后发生距骨体坏死8例，Ⅱ型骨折3例；Ⅲ型骨折5例，其中术后3例因距骨体坏死、塌陷或疼痛性关节炎而行踝关节融合术。单纯踝关节炎4例；距骨下关节炎61例，其中3例台并踝美节炎；踝关节内侧皮肤坏死、缺损1例。结论距骨颈骨折并发症多而后果严重，宜早期诊断并进行有效解剖复位和固定，以预防距骨体缺血性骨坏死、创伤性关节炎、骨折愈台不良等并发症，     

距骨损伤与距骨坏死及其治疗

目的 探讨距骨损伤对距骨缺血坏死的影响及其治疗方法。方法 本文通过25例距骨重度骨折脱位、3例距骨全脱位和17例距骨周围脱位的治疗,并分别经平均7年和2年5个月的随访观察,来分析三种不同类型的损伤对距骨缺血坏死的影响。结果 距骨重度骨折脱位和全脱位缺血坏死率和创伤性关节炎发生率100％,距骨周围脱位则无缺血坏死发生。作者比较重度距骨骨折脱位和全脱位采用切开复位内固定、距骨切除和关系融合术三种治疗方法的结果,仅融合术最为满意。结论 作者建议在距骨有发生缺血坏死高危损伤的病例,融合术应是首选的方法。     

手术内固定加血管束植入治疗距骨骨折脱位

目的探讨手术治疗距骨骨折脱位，防止距骨后期坏死的方法。方法对28例距骨骨折脱位进行回顾性研究，随访治疗效果。早期手术，运用克氏针及可吸收螺丝钉固定距骨，跗外侧血管束植入距骨。结果本组28例，随访6个月～9年，平均26个月，优良率为96．4％，效果满意。结论早期手术加血管束植入治疗距骨骨折脱位，操作方法简单实用，临床疗效确切，可在临床推广应用。     

距骨缺血性坏死

距骨缺血性坏死是外科治疗上一个棘手的问题,一方面原因是其深藏的解剖位置,另一方面原因是其脆弱的血供。距骨坏死主要分为三类：第一,特发性的缺血坏死,由非创伤和医疗方面的因素所引起,其发生率低,约占距骨坏死的l0％;第二,使用药物引起的坏死,常常由于使用激素治疗其他疾病造成,而且合理用量的激素使用也可造成距骨的坏死,这类坏死约占15％.     

距骨骨折的治疗原则及进展

距骨骨折在足踝部损伤中发病率较低,但治疗难度较大,并发症多,预后较差。其治疗分为保守治疗和手术治疗,整体治疗方案有多种方法。目前主流手术治疗策略是采用坚强有效的固定方式,恢复距骨解剖形态,尽力保留血运,减少畸形,达到早期愈合。本文通过对距骨骨折的治疗难点及发展现状等进行文献回顾,总结了治疗原则,并归纳了最新进展,以期对...     

距骨骨折23例治疗的临床体会

距骨骨折临床并不多见，但随着交通及建筑业的发展，距骨骨折有逐渐增多的趋势。本院自１９９１年６月至２００１年４月共收治距骨骨折、脱位２３例，其中１７例给予手术治疗。现将治疗结果分析报告如下。临床资料１．一般资料：本组共２３例，男１６例，女７例；年龄１８～４６岁，平均３１岁。开放性骨折８例，闭合骨折１５例。致伤原因：车祸伤１１例，高处坠落伤６例，摔伤４例，扭伤２例。其中手法复位石膏固定６例，５例手法复位失败后给予手术，余１２例均行急诊手术。２．骨折分类：距骨体骨折３例；距骨体骨折伴内、外踝骨折５例；…     

距骨骨折后缺血性坏死诊断进展

构成踝关节重要部分的距骨发生缺血性坏死(AVN),直接影响踝关节功能.距骨骨折后AVN发生率与距骨自身血供、损伤机制、骨折类型密切相关.X线片检查在距骨AVN诊断中起着基础筛选作用,MRI检查及组织学检查有助于及早发现距骨AVN,CT检查对于评估距骨AVN手术治疗有着重要意义.     

距骨骨折后缺血性坏死诊断进展

构成踝关节重要部分的距骨发生缺血性坏死(AVN),直接影响踝关节功能。距骨骨折后AVN发生率与距骨自身血供、损伤机制、骨折类型密切相关。X线片检查在距骨AVN诊断中起着基础筛选作用,MRI检查及组织学检查有助于及早发现距骨AVN,CT检查对于评估距骨AVN手术治疗有着重要意义。     

距骨缺血性坏死的手术治疗研究进展

目的 对距骨缺血性坏死手术治疗研究进展进行综述。方法 广泛查阅近年来国内外距骨缺血性坏死相关文献,从发病机制、手术治疗方式及预后等方面进行总结。结果 距骨缺血性坏死早期临床症状不明显,患者就诊时大多已进展至Ficat-ArletⅢ～Ⅳ期,需要手术治疗。目前,该病手术治疗方法主要包括髓芯减压、带血管蒂骨瓣移植、关节置换术及关节融合术等。早期距骨缺血性坏死可保守治疗,如治疗失败可以考虑髓芯减压。关节融合术应作为终末期骨关节炎和塌陷患者的补救手术,存在严重骨丢失时需行胫距跟融合术和植骨。带血管蒂骨瓣移植效果良好,对各期距骨缺血性坏死均有一定治疗效果,但合适骨瓣供区仍需进一步研究。结论 距骨缺血性坏死手术方法以及不同分期治疗体系均有待完善。     

Modified Blair Tibiotalar Arthrodesis for Post-traumatic Avascular Necrosis of the Talus: A Case Report

Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis.     

Arthroscopic Management of Avascular Necrosis

In light of observed difficulty with current imaging modalities in the accurate staging of AVN, the authors favor arthroscopic evaluation as an adjunct to traditional imaging modalities. Arthroscopic or direct visualization is required for accurate evaluation and staging, especially in stage IV disease that has proven to have widely variable assessments using the Marcus,¹³ Ficat,³ and Steinberg¹⁴ classification systems.Early and accurate diagnosis is essential to the long-term survival of the joint while minimizing the potential morbidity to the patient. The revision rate of total joint arthroplasty after AVN of the hip has been shown to be higher than that of the normal population.^{40, 41 and 42} It is important to make every attempt to preserve the native femoral head and cartilage. Successful operative treatment of AVN requires that the patient be appropriately staged. Marcus,¹³ Ficat,³ and Steinberg¹⁴ each proposed radiologic classification systems using methods available at the time to optimize patient selection for operative intervention. None of those classification systems use the powerful diagnostic potential of arthroscopy and direct visualization of the femoral head.More accurate staging with arthroscopy may enable more successful application of salvage techniques such as free vascularized fibular grafting (FVFG)²⁰ in mid- to late-stage disease. Current radiographic techniques such as plain radiographs and MRI have shown a reduced ability to accurately assess the condition of the weight-bearing cartilage surface or degree of its collapse. Recent studies by Urbaniak and colleagues,^{23 and 43} showed increased long-term survivability in patients without evidence of collapse at the time of attempted salvage by FVFG. In early reports²⁰ of 103 patients receiving FVFG for AVN of the femoral head, there was a significant difference in the survivability of FVFG in stage IV versus stage V hips. The stage V hips showed a higher survival at 68% versus 57% for stage IV hips. This was attributed to patient bias and a younger patient population. Accurate staging with arthroscopy may have permitted more accurate classification of these patients. Undetected chondral collapse and delamination of the femoral head present at time of grafting in the radiographic stage IV hips could certainly account for variation in results within this group. This reinforces the need for accurate knowledge of the presence and degree of cartilage collapse to appropriately select these patients for the FVFG or one of the other salvage procedures.Hip arthroscopy offers a direct, minimally invasive technique to accurately classify patients with later-stage disease that may or may not benefit from FVFG,²⁰ core decompression with or without grafting,²¹ autologous bone marrow transplantation,²² nonvascularized bone grafting,²⁴ or other resurfacing procedures.⁴⁴ MRI is probably the most useful screening tool for early detection and evaluation of AVN. It is useful in determining the size, quality, and location of the infarct, which may have prognostic value.^{14, 45 and 46} However, several studies have shown the inability of MRI to accurately evaluate the articular cartilage of the femoral head and acetabulum.^{17 and 18} Improvements in MRI and future diagnostic technologies may make arthroscopic evaluation of the articular cartilage unnecessary. Presently, hip arthroscopy using the techniques described earlier can give the surgeon the most accurate assessment tool for proper staging, selection of appropriate patients for advanced salvage procedures, and assist in the management of this difficult condition.     

Fracture of the Body of the Talus

Fifty-one patients with fracture of the body of the talus were seen at follow-up examination an average of 23 months after treatment. Osteonecrosis had developed in 8 out of 17 patients with displaced shearing or crush fractures of the trochlea. Malunion as well as subluxation predisposed to osteoarthrosis in the subtalar and talocrural joints. Thus, osteoarthrosis was present in 9 out of 21 patients without malunion, in 8 out of 16 patients with malunion, and in 11 out of 14 with malunion as well as subluxation. Judging from the nature of the complaints, the difficulties in rehabilitation, and the disability assessment, the prognosis was fairly grave, also after the small, usually non-displaced fractures of the posterior and lateral tubercles. Out of 20 patients with fractures of this type only 6 obtained almost complete relief from their symptoms, only 8 could go back to their previous work on a full-time basis, and 11 were assessed to be 10 per cent or more disabled. Fractures in the posterior and lateral tubercles must therefore be interpreted as links in more extensive injuries involving the subtalar joint and possibly the talocrural joint with associated injuries to articular cartilage, joint capsules, and ligaments.     

距骨严重骨折——脱位的手术治疗(附24例报告)

作者对24例距骨严重骨折脱位行手术治疗,按Gillgust分类法,24例中Ⅲ°19例,Ⅱ°5例骨折伴踝部复合伤。19例切开复位内固定,2例距下关节融合,3例胫距和距踉两关节融合术。随诊3—25年,疗效优良率为79.2％。认为尽早复位和适当的内固定是治疗的关键。     

距骨骨折脱位的手术治疗

目的探讨距骨骨折脱位的特点、类型、手术方法及影响疗效的相关因素。方法本组距骨骨折脱位30例,均为男性;年龄18~46岁,平均33.6岁。骨折根据Hawkins分型,Ⅰ型4例,Ⅱ型20例,Ⅲ型6例。Ⅰ型距骨骨折采用闭合松质骨拉力螺钉内固定。Ⅱ、Ⅲ型骨折均行急诊手术,采用前外侧或前内侧切口暴露,骨折解剖复位后,以2枚松质骨拉力螺钉交叉内固定;其中Ⅲ型骨折并取自体髂骨块跨骨折线嵌入植骨。术后踝关节中立位短腿石膏管形外固定8~12周,复查X线示骨折线模糊后拆除石膏行不负重下踝关节活动,骨折线消失后可完全负重行日常活动。结果 30例均获得随访,随访时间1.5~6年,平均3年。根据美国足踝协会后足评分系统评定,优10例(33.3%),良13例(43.3%),可5例(16.7%),差2例(6.7%),优良率为76.6%。结论距骨骨折脱位虽然并发症多并且后果严重,但是通过急诊手术、骨折解剖复位、尽量保护血运、有效内固定、自体髂骨块跨骨折线嵌入植骨、术后力争早期踝关节功能锻炼,可降低病残率。     

头状骨移位替代治疗晚期月骨无菌性坏死

目的 寻找一种临床治疗晚期月骨无菌性坏死方便有效的方法。方法 作于1985年始，在对50侧新鲜成人上肢标本及100侧长春出土腕骨标本解剖观测的基础上，设计了以骨间前动脉背侧支为血管筋膜蒂的头状骨移位术，用于替代坏死碎裂的月骨，以治疗晚期月骨无菌性坏死。结果 临床应用22例，术后随访1～13年，全部病例均消除了腕痛，腕关节功能和手的握力有了明显改善，均恢复了原有工作。结论 本手术方法既切除了病灶又保持了腕骨的稳定和腕关节功能，对治疗晚期月骨无菌性坏死是一种疗效好、副作用小、功能满意的方法。     

早期股骨头缺血性坏死的手术治疗

股骨头缺血性坏死的早期诊断和治疗对本病的预后意义极大。自 1 992年 6月～ 1 996年 9月 ,我们对 2 7例Ficat 0～Ⅲ期的34个髋关节行经颈开窗髓芯减压自体骨移植手术治疗 ,平均随访 37月 ,以全国首届骨坏死会议百分法评定手术效果。疗效总体优良率70 .1 % ,Ⅱ期以前优良率 85 .3 % ,治疗效果良好。本手术优点为能够有效降低骨内压 ,改善髓内微循坏 ;死骨清除直接彻底 ,松质骨植入利于骨的重建和预防关节软骨塌陷 ;CPM机应用利于关节软骨的修复 ,股骨头结构重建和关节功能恢复。本手术适用于股骨头缺血性坏死的早期病人 ,尤其是Ficat 0～Ⅱa期。