体外冲击波治疗骨折延迟愈合和骨不连研究进展

骨折后延迟愈合及骨不连的发生率高达5%~10%,目前手术是治疗骨不连的“黄金标准”,主要包括清理骨折断端、再通髓腔、自体骨移植及更换固定方式,但骨不连的手术治疗存在创伤大、感染以及二次手术取出内固定的问题。近年来,体外冲击波疗法（ESWT）因其无创、高效、低廉等优势在骨肌疾病的治疗中得到广泛应用,尤其在治疗骨折延迟愈合和骨不连方面取得良好疗效,本文就体外冲击波疗法在治疗骨折骨不连的进展做一综述,期望能够对临床工作有所帮助。     

体外冲击波治疗骨折延迟愈合和骨不连研究进展

骨折后延迟愈合及骨不连的发生率高达5%~10%,目前手术是治疗骨不连的“黄金标准”,主要包括清理骨折断端、再通髓腔、自体骨移植及更换固定方式,但骨不连的手术治疗存在创伤大、感染以及二次手术取出内固定的问题。近年来,体外冲击波疗法（ESWT）因其无创、高效、低廉等优势在骨肌疾病的治疗中得到广泛应用,尤其在治疗骨折延迟愈合和骨不连方面取得良好疗效,本文就体外冲击波疗法在治疗骨折骨不连的进展做一综述,期望能够对临床工作有所帮助。     

不同能量级别体外冲击波与骨不连愈合的关系

[目的]根据不同能量级别体外冲击波对兔桡骨骨不连的影响，获得治疗骨不连的最佳冲击波能量。[方法]选用雌性新西兰大白兔32只，随机分为A、B2组，以每只动物双前肢桡骨为实验对象，又分为A1、A2、B1、B2四组，A1、B1组为右前肢，A2、B2组为左前肢，制成桡骨骨不连模型。分别用0．3、0．4、0．5、0．6mj／mm^2 4种能量级别的冲击波对A1、A2、B1、B2 4组分别进行治疗，于治疗前后观察和比较各组的治疗情况、x线片和组织学变化，并作统计学分析。[结果]各组治疗前后骨折间隙的变化在统计学上均有非常显著性差异（P〈0．01），而治疗后第8、12周各组间比较，A：、B，组骨折间隙的愈合情况明显优于A1、B2组，差异有显著或非常显著性意义（P〈0．05～P〈0．01）。[结论]0．4～0．5mj／mm^2是治疗骨不连的最佳冲击波能量级别，能量过低或过高均可影响骨不连愈合或造成组织损伤。     

体外冲击波治疗骨不愈合的护理

目的:探讨体外冲击波治疗骨不愈合的护理.方法:收集2005年7月-2007年7月,我院应用ESW治疗骨不愈的资料.结果:30例患者都取得了较好的疗效.     

体外冲击波原理与成骨

体外冲击波(extracorporeal shock wave,ESW)是声波的一种,具有声波的性质,是压力急剧变化的产物,能在极短的时间内产生很高的压力幅度.1988年,Haupt首次用ESW治疗骨不愈合患者获得成功.美国FDA在2000年2月对低能超声波(LIPU,体外冲击波的一种)在治疗骨折不愈合中的应用给予批准.下面从ESW的基本原理及其在骨创伤修复中对成骨的作用及机制作一综述.     

体外冲击波治疗骨不连

骨折后骨延迟愈合和不愈合的发生率为5％-10％。传统的手术固定和骨移植为较为有效的治疗方法,治愈率可达90％左右;然而手术治疗亦产生了严重的并发症,深部感染、感觉缺失等主要并发症的发生率为8．6％;浅表感染、供骨区疼痛等次要并发症的发生率为20．6％,而且部分患者仍需再次手术治疗。为此许多学者探索有效的微创技术治疗骨不连。骨的声     

体外冲击波疗法在骨科领域的应用

近十余年体外冲击波疗法（extracorporeal shock wave therapy，ESWT）在治疗一些骨科疾病方面发挥着日益重要的作用。因其对骨不连、骨折延迟愈合、肩周炎、网球肘、跟痛症等疾病疗效显著，且具有非侵入性、方法简单、安全有效、费用相对低廉等优点，赢得了越来越多的关注和认同。     

体外冲击波与外科手术治疗骨不连的对比分析

[目的]探讨2种不同治疗方法的优缺点和适应证选择[方法]冲击波组25例。手术组28例,带锁髓内钉加自体骨植骨13例;钢板加自体骨植骨10例;外固定支架加自体骨植骨5例。[结果]两组患者均获12～18个月随访,冲击波组不愈合2例,1例经再次作冲击波治疗后愈合,另1例则改为手术治疗后愈合。手术组不愈合2例,1例再次手术后愈合,另1例加用体外冲击波治疗后愈合。两组一期治愈率分别为92%和92.86%,无显著性差异(P0.05)。[结论]在疗效相近的情况下,体外冲击波治疗骨不连具有无创、费用低、无需住院等优点。但2种方法要获得满意的疗效,必须严格掌握适应证。     

体外冲击波治疗四肢骨折内固定术后骨不连

[目的]探讨体外冲击波治疗四肢骨折内固定术后骨不连的机制和疗效.[方法]本组18例.均有切开复位+内固定或外同定支架固定手术史.固定方法:带锁髓内钉5例;钢板7例;记忆合金环抱器3例;外同定支架3例.骨折部位:尺骨2例,肱骨3例,股骨5例,胫骨8例.均采用冲击波治疗2～3次.[结果]所有患者均获随访,两次冲击波治疗后18例中13例获得愈合.治疗3个月无明显骨痂生长5例,再行第3次冲击波治疗后2例获得愈合.最终成功15例,治愈率为83.3%.[结论]冲击波治疗骨不连具有创伤小、并发症少、费用低、无需住院、疗效确切等优点,临床治疗四肢骨折内固定术后骨不连疗效满意.     

体外高能震波治疗骨不连和骨延迟愈合的初步结果

目的观察Ossatron高能体外震波仪治疗骨不连和骨延迟愈合的效果。方法2004年10月～2005年10月采用体外震波治疗18例四肢骨折术后骨不连和4例骨延迟愈合患者,C型臂X线机透视定位,根据不同骨折部位选择合适的震波能量、频率和冲击次数。内固定不稳定者震波治疗后以石膏或支具固定6～8周。术后6、12周及以后每个月随访复查X线片,直至骨折愈合。结果所有患者获3～12个月(平均6．7个月)随访。10例患者震波后出现局部瘀斑或肿胀,术后1～3 d缓解；无其它并发症发生。22例患者中,13例(59．1%)获骨性愈合,骨折愈合时间平均为4．3个月(6周～6个月)。18例内固定稳定的患者中12例骨折获愈合,其愈合率为66．7%。9例患者(40．9%)骨折未愈合。结论震波治疗对骨折断端稳定的骨不连和延迟愈合具有一定疗效,其突出特点是安全、无创。     

Dormia支架在ESWL中的选择性应用

目的 探讨防止体外冲击波碎石（ＥＳＷＬ）治疗巨大肾结石后发生石街的方法。方法 采用ＥＳＷＬ结合预置Ｄｏｒｍｉａ支架的方法治疗巨大肾结石１５例,结果 全部患者术后均未发生嵌顿性石街,大部分结石粉末可通过拔除支架一同带出或沿支架自行排出,结论：Ｄｏｒｍｉａ支架作为巨大肾结石ＥＳＷＬ的辅助治疗工有有效地防止术后石街形成,促进碎石排出,但应注意掌握其适用范围和留置时限。     

影响体外冲击波碎石术疗效的因素分析

目的　探讨影响体外冲击波碎石术(ESWL)疗效的因素。　方法　回顾ESWL治疗尿路结石患者234例的临床资料。分析患者性别、年龄、病程、结石大小、位置、X线形态及合并肾积水情况等因素与治疗成功率的关系。ESWL术后3个月接受KUB、IVU和B超检查,剩余结石<2mm为碎石成功, >2mm为治疗不成功。　结果　234例碎石成功率78. 6% (184 /234)。男性组和女性组治疗成功率分别为80. 3% (122 /152)和75. 6% (62 /82),P>0. 05。治疗不成功组与成功组病程分别为(1262. 6±1742. 1)d、(722. 9±1364. 6)d,P>0. 05;结石直径分别为(1. 1±0. 6)cm、(1. 0±0. 4)cm,P>0. 05;年龄分别为(58. 8±13. 6)岁、(42. 8±12. 2)岁,P<0. 05。肾盂结石(22. 7%, 10 /44)与肾盏结石(40. 0%, 8 /20),肾盂结石与输尿管结石( 18. 8%, 32 /170 ),输尿管上段结石( 15. 8%, 18 /114)与下段结石(25. 0%, 14 /56)间不成功率比较,差异无统计学意义(P>0. 05)。均匀高密度结石(20. 0%, 6 /30)与杂色结石(21. 6%, 44 /204)不成功率两组比较差异无统计学意义(P>0. 05)。结石直径0. 3~1. 0cm者(1. 9%, 2 /108), 1. 0 ~2. 0cm者(29. 8%, 28 /94), >2. 0cm者(62. 5%, 20 /32)不成功率3组两两比较P<0. 05。结石大小与治疗剂量呈正相关(r=0.28,P=0. 006)。     

体外冲击波碎石应用抗生素的必要性研究

目的 探讨体外冲击波碎石（ESWL）治疗中应用抗生素的必要性。方法 将63例结石病人按结石部位与复杂程度分为三组：单纯肾结石组、输尿管结石组、复杂性尿路结石组，然后在ESWL治疗前和治疗后1周的血、尿标本，分别作细菌培养，并以显色法作为内毒素浓度的测定。结果 三组病人ESWL治疗前后血液内毒素浓度差异均无显著性（P〉0．05）；单纯肾结石组、输尿管结石组病人ESWL治疗前后尿液内毒素浓度差异均无显著性（P〉0．05），复杂性尿路结石组病人ESWL治疗后尿液内毒素浓度显著高于治疗前（P〈0．05）。结论 ESWL造成泌尿系结石病人全身感染的可能性小，但引起复杂性、多发性结石病人尿路感染的可能性较大，这些病人ESWL治疗应用抗生素是必要的；感染性结石预防性使用抗生素也是必要的。     

Histopathologic effects of extracorporeal shock wave lithotripsy on rabbit kidney

Summary Despite the widespread clinical use of the lithotriptor, the margin of safety for the kidney during shock wave application is substantially unknown. Although a series of pilot studies have been performed in laboratory animals, long-term follow-up is mandatory to establish the effect of extracorporeal shock wave lithotripsy (ESWL) and subsequent dose-dependent changes on the kidneys. An experimental study was performed in 45 rabbits; to define and compare the early and late complications of ESWL in the kidneys. The rabbits were divided into three groups of 15 animals each that received 1000, 1500 or 3000 shock waves respectively at 15–20 kV. The rabbits in each group were killed and necropsy performed within 24 h for the first 5 animals, 1 week for the second 5 animals and 2 months post-ESWL for the last 5 animals. Dose-dependent moderate damage (subcapsular hemorrhage, interstitial hemorrhage, capsular tension and perirenal hemorrhage) were noted in all kidneys at 24 h after treatment. Evidence of permanent changes (some fibrosis, tubular and glomerular damage, chronic inflammatory alterations) was noted in long-term follow up. Complete necrosis of the treated kidney was not encountered in this study.     

ESWL对男性体内精子的影响

目的 探讨体外冲击波碎石（ＥＳＷＬ）对男性生殖细胞的影响。方法 对３５例生育能力的输尿管下段结石男性患者进行ＥＳＷＬ治疗,并对术前,术后即刻,术后１周及１个月的体内精液进行观察。结果 术后精子密度和活动率均下降,其中以术后即刻和１周较明显,有显著性差异（Ｐ〈０．０１）,术后１个月恢复正常,结论 ＥＳＷＬ对男性体内精子的影响为一过性可复性损害。     

坦索罗辛在输尿管下段结石ESWL后辅助排石中的作用

目的:探讨α1肾上腺素能受体阻滞剂坦索罗辛在输尿管下段结石ESWL后辅助排石中的效果.方法:64例输尿管下段结石患者随机分成两组,组Ⅰ为对照组,ESWL后应用消炎痛25 mg,3次/d,排石颗粒5 g,3次/d,未应用输尿管平滑肌松弛剂;组Ⅱ为实验组,ESWL后在对照组治疗方案基础上予以口服坦索罗辛0.4mg,1次/d.每例患者观察时间不超过2周.结果:在观察时间内两组排石率分别为42.3%和78.9%.两组比较差异有统计学意义(P＜0.01).观察时间内两组再次发生肾绞痛而需要镇痛药治疗的患者分别为15.4%和7.9%,两组比较差异有统计学意义(P＜0.01).组Ⅱ除1例发生头晕外,无其他不良反应发生.结论:坦索罗辛能提高输尿管下段结石ESWL后的排石率,减少再发生肾绞痛的机率.且安全有效.可作为输尿管下段结石ES-WL后的辅助排石方法.     

Effect of extracorporeal shock waves on callus formation during bone lengthening

The effects of extracorporeal shock waves (ESWs) on callus formation during bone lengthening were studied in 25 female Japanese white rabbits. Bone lengthening of 9.8mm was obtained over 2 weeks using the Orthofix M-100 bone fixator. ESWs were applied 3 weeks after surgery. Pins were removed 7 weeks after surgery, and specimens were prepared after the animals were killed at 9 and 24 weeks. The shock wave setting used was 0.42mJ/mm² with a pulse interval of 2Hz; 3000 shots each were applied to the central and peripheral areas. The specimens were evaluated using radiography, bone mineral density (BMD) measured by dual energy absorptiometry (DXA), and a three-point bending test to evaluate mechanical strength. Histological examination was performed on the lengthened portion. Radiographs and histological observations revealed no apparent fractures in nonlengthening tibias at the shock wave energy densities used. Radiographic observations revealed no apparent differences between the control group and the ESW group. BMD measurements by DXA revealed significantly increased bone mass in the ESW group 9 weeks after surgery. At 24 weeks after surgery the mean BMD had decreased to 25% and 15% of the values at 9 weeks in the control and ESW groups, respectively. The three-point bending test revealed no significant differences between the groups. Histological observations revealed significant capillary formation and osteoblasts and chondrocytes in the bone marrow as well as bridging of newly formed trabeculae 2 weeks after the bone was lengthened. At 4 weeks after treatment, observations included parts of the lengthened portion with no cortex or immature bone. At 9 weeks after surgery, cortex formation and a normal medullary cavity were clearly observed in the control group, whereas observations in the treated group included areas of the lengthened portion with no cortex and formation of immature trabecular structures and increased cancellous bone in the center of the lengthened portion. At 24 weeks after surgery, more prominent cortex formation and fatty marrow were observed in the ESW group than in the control group.     

Use of double-J stents prior to extracorporeal shock wave lithotripsy is not beneficial: results of a prospective randomized study

Objectives Since introduction of extracorporeal shockwave lithotripsy (ESWL) in treating patients with urinary tract stones in our clinic for the first time in our city Aden 5 years ago, we stented all patients with kidney stone >1 cm routinely before the procedure. Our aim of this study is to compare symptoms and complications of patients with and without stenting. Patients and methods In 2003, 120 patients with renal stone(s) amenable to ESWL management were prospectively treated in two groups: stented (60 patients) and unstented (60 patients). All patients were admitted for 48 h after ESWL and then followed for 3 months after discharge by the same treating group of doctors. Patients were followed-up radiographically to assess stone-free rate after 1 and 3 months. Results There was no statistical difference in flank or abdominal pain, nausea, vomiting, transient hematuria, temperature or use of analgesics on the first and second day after ESWL in the stented or unstented group. Fifty-one patients (85%) of stented group complained of side effects attributable to stent including urinary frequency and urgency, bladder pain and hematuria with urination, which in all patients but 3 of them were treated as out patient and one of the unstented group, who were readmitted because of mild to severe pain, fever, and chills. In all stented patients, we removed the stents after 2 weeks; except in readmitted patients where it was removed earlier. Plain X-ray film was done for all patients after one and 3 months. Eight patients with stents (6.7%) had >5 mm residual fragments. In these patients second ESWL session was necessary. Three months stone-free rate was 88% in stented and 91% in unstented group, respectively. Conclusion The use of double-J stents prior to ESWL treatment is not beneficial.     

Efficacy of extracorporeal shock wave lithotripsy for ureteric stones in children

Objectives: Management of ureteral stones in children represents a challenging problem. In this study, we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (ESWL) in 192 children with ureteric stones. Methods: Between 1990 and 2003, 192 children (≤ 14 years old) with ureteric calculi were treated with the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, NJ). There were 39 stones in the proximal ureter, 19 in the mid-ureter and 134 in the distal ureter. Results: Mean patient age was 7.3±4.1 years (6 months–14 years). There were 122 boys (64.2%) and 70 girls (35.8%). All procedures were performed on an outpatient basis with intravenous sedation in 73 cases (38.1%), general anesthesia in 68 cases (35.7%) and no anesthesia in 51 cases (26.2%). A maximum of 3500 shocks and 18 kV per session were used. A 94% success rate was achieved in proximal (n: 39) and mid-ureteral stones (n: 19). Stone free rates for distal ureteral calculi were 90.6% for stones less than 1 cm in diameter (n: 94) and 91.7% for stones between 1 and 2 cm (n: 26). Overall re-treatment and efficacy quotient rates for proximal ureteral stones were 45.1% and 68.9%, 62.5% and 61.5% for mid-ureteral calculi, and 49.6% and 60.0% for distal ureteral stones. Conclusion: Our results indicate that ESWL with highly satisfactory stone free rates ranging between 90 and 100% and negligible complications can be considered as a first line treatment for ureteric stones in the pediatric age group.