舟状骨稳定性骨不连手术治疗体会

<正>舟状骨稳定性骨不连(又称Herbert DI型)其特点是具有坚强的纤维连接阻止畸形的发生,由于舟状骨在损伤早期长度和形状保持良好,临床上漏诊及误诊率高。自2007年1月至2008年12月共诊治舟状骨稳定性骨不连4例,通过手术治疗,取得良好的效果,现做回顾性总结报告如下。     

载距突骨块的CT解剖特征及临床意义

目的利用CT确定跟骨载距突骨块的解剖参数, 并观察其临床意义。方法回顾性分析2019年1月至2020年9月同济大学附属同济医院骨科收集的96例(100足)正常跟骨CT影像学资料。男45例(48足), 女51例(52足);年龄(42.1±13.6)岁;左足56足, 右足44足。利用Mimics 22.0重建三维模型, 在各平扫层面逐层阅读跟骨, 以跟骨中央三角内侧第一条连续骨小梁为界, 分割出载距突骨块的模型, 测量其长、宽、高。利用3-Matic 22.0将载距突骨块外侧的轮廓投影到跟骨外侧壁并描画出轮廓线, 通过叠加投影线图, 获得100足投影线图汇总。在跟骨外侧壁投影线图汇总区域内选取7个进钉点, 测量各点到跟骨内侧面的距离。比较不同足别、不同性别的载距突骨块长、宽、高以及7个进钉点到跟骨内侧面的距离。结果载距突骨块长、宽、高分别为(45.19±4.60)、(38.57±4.59)、(40.76±5.48)mm, 不同足别载距突骨块长、宽、高及不同性别载距突骨块高比较差异均无统计学意义(P>0.05), 女性载距突骨块长、宽均显著小于男性, 差异均有统计学意义(P<0....     

不同黏度骨水泥椎体成形术对胸腰椎压缩骨折疗效分析

目的 探讨不同黏度骨水泥经皮椎体成形术(percutaneous vertebroplasty, PVP)对胸腰椎压缩骨折患者视觉模拟疼痛量表评分(visual analog scale, VAS)、骨水泥渗漏率的影响。方法 选取105例胸腰椎压缩骨折患者作为研究对象，选取时间为2018年5月～2020年6月，按照随机数字表法分为观察组(予以高黏度骨水泥，n=53)与对照组(予以低黏度骨水泥，n=52)。结果 观察组透视时间、总医疗费、骨水泥用量均低于对照组(P<0.05)。术前，两组伤椎前缘高度、后凸Cobb角、VAS评分比较，差异无统计学意义(P>0.05);术后，观察组的伤椎前缘高度高于对照组，而后凸Cobb角低于对照组(P<0.05),两组VAS评分差异无统计学意义(P>0.05)。观察组的骨水泥总渗漏率低于对照组(P<0.05)。结论 高黏度骨水泥与低黏度骨水泥用于PVP的疗效相当，均能有效减轻疼痛；高黏度骨水泥渗漏率较低。     

体位复位结合高黏骨水泥椎体成形术治疗椎体压缩性骨折疗效观察

目的 探讨体位复位结合高黏骨水泥在椎体成形术中治疗椎体压缩性骨折的临床疗效。方法 回顾性分析2012年3月～2015年10月接受治疗的单椎体压缩骨折患者159例,其中经皮椎体成形术(percutaneous vertebroplasty,PVP)治疗的56例患者纳入PVP组,经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗的51例患者纳入PKP组,经体位复位结合高黏骨水泥椎体成形术治疗的52例患者纳入高黏骨水泥组,通过术前术后视觉模拟疼痛评分（VAS）、椎体后凸Cobb角的改变以及术后椎体高度恢复率、骨水泥渗漏率,比较3组临床疗效。结果 3组术后VAS评分较各组术前评分均有显著性改善（P<0.05）。椎体高度恢复率PVP组为36%,PKP组75%（χ2=30.792,P=0.021）,高黏骨水泥组79%（χ2=37.831,P=0.016）,PKP组及高黏骨水泥组较PVP组差异具有统计学意义（P<0.05）。椎体后凸Cobb角PVP组手术前后分别为23.6±1.3、23.0±2.7（t=1.498, P=0.182）,PKP组及高黏骨水泥组术前分别为25.7±1.7、26.2±2.3,术后分别为12.8±2.1（t=34.096, P=0.001）、13.3±1.6（t=33.201, P=0.001）。经X线证实PVP组发生骨水泥渗漏8例（14.3%）,PKP组发生渗漏3例（5.9%）,高黏骨水泥组渗漏3例（5.8%）,PKP组及高黏骨水泥组骨水泥渗漏率与PVP组比较具有显著性差异（t=3.886、3.996, P=0.012、0.008）。结论 体位复位结合高黏骨水泥椎体成形术治疗椎体压缩性骨折,可以取得与PKP相同的临床疗效,因其不需使用昂贵的球囊,因而有着良好的临床推广应用前景。     

体位复位结合高黏骨水泥椎体成形术治疗骨质疏松性椎体压缩骨折的疗效观察

目的 探讨体位复位结合高黏骨水泥椎体成形术治疗骨质疏松性椎体压缩骨折(osteopo-rotic vertebral compression fractures,OVCF)的临床疗效.方法 回顾性分析2012年3月至2015年10月于我院接受治疗的单椎体OVCF病人159例,其中经皮椎体成形术(percutaneous vertebroplasty,PVP)治疗的56例病人纳入PVP组,采用经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗的51例病人纳入PKP组,经体位复位结合高黏骨水泥椎体成形术治疗的52例病人纳入高黏骨水泥组,比较三组病人的疼痛视觉模拟量表(visual analogue scale,VAS)评分、椎体后凸Cobb角以及术后椎体高度恢复率、骨水泥渗漏率等指标.结果 PVP组、PKP组、高黏骨水泥组病人的骨水泥渗漏率分别为14.3%、5.9%、5.8%,PVP组显著高于其他两组(χ2=30.792,P=0.021;χ2=37.831,P=0.016);三组病人术后的椎体高度恢复率分别为(36.0±2.9)%、(75.0±3.3)%、(79.0±3.6)%,PVP组显著低于其他两组(t=3.886,P=0.012;t=3.996,P=0.008);PKP组和高黏骨水泥组术后的Cobb角均较术前显著改善(t=34.096,P=0.001;t=33.201,P=0.001),但PVP组术后未见明显改善;三组病人术后的VAS评分均较术前评分显著改善(P<0.05).结论 体位复位结合高黏骨水泥椎体成形术治疗OVCF,可以取得与PKP相近的临床疗效,因其不需使用昂贵的球囊,因而有着良好的临床推广应用前景.     

经皮撬拨复位螺钉内固定治疗跟骨关节内骨折

目的 探讨经皮撬拨复位微创螺钉内固定治疗跟骨骨折的疗效和技术要点.方法 2006年3月至2010年4月作者采用经皮撬拨复位微创空心拉力螺钉结合松质骨螺钉,部分患者联合注射高黏度液体人工替代骨或颗粒骨填充治疗21 例24侧跟骨骨折,男17 例,女4 例;年龄21～67 岁,平均年龄38.3 岁.其中18 例为单侧,3 例...     

两种骨水泥治疗老年骨质疏松性椎体压缩骨折的比较

目的比较应用高黏度骨水泥的经皮椎体成形术(percutaneous vertebroplasty,PVP)与应用普通(低黏度)骨水泥的经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)在治疗老年骨质疏松性椎体压缩骨折的临床效果及并发症。方法 2014年6月至2015年6月青岛大学医学院附属烟台毓璜顶医院脊柱骨科收治的老年骨质疏松性椎体压缩骨折患者,采用完全随机化方法将实验对象按入院先后顺序分为高黏度组和低黏度组,分别行PVP手术及PKP手术。各组均于术前及术后3 d、1个月、6个月摄腰椎正侧位片。观察并比较两组患者的手术时间、骨水泥注入量、骨水泥渗漏数、骨水泥渗漏率,计算并比较各观察时间点的视觉模拟评分(visual analogue scale,VAS)和功能障碍指数(oswestry disability index,ODI)评分。结果高黏度组手术时间为18.3~30.6 min,平均为(25.3±3.8)min;低黏度组手术时间为27.9~44.3 min,平均为(36.8±4.2)min,两组手术时间对比差异有统计学意义(P0.05)。高黏度组骨水泥注入量3.8~5.5 m L,平均(4.2±0.3)m L;低黏度组骨水泥注入量3.7~5.9 m L,平均(4.3±0.5)m L,两组手术骨水泥注入量比较差异无统计学意义(P0.05)。高黏度组发生骨水泥渗漏2例,均为椎旁软组织内渗漏,渗漏率7.14%;低黏度组发生骨水泥渗漏3例,1例为椎旁软组织内渗漏,2例为椎间盘内渗漏,渗漏率为10.71%,两组手术骨水泥的渗漏率比较差异有统计学意义(P0.05)。两组患者术前及术后各观察时间点的VAS评分及ODI指数评分比较差异无统计学意义(P0.05)。结论应用高黏度骨水泥的PVP与应用低黏度骨水泥的PKP在治疗老年骨质疏松性椎体压缩骨折方面具有相似的临床治疗效果,但应用高黏度骨水泥的PVP能显著缩短手术时间。在骨水泥的渗漏方面,高黏度骨水泥能显著降低骨水泥的渗漏率,具有更好的临床安全性。     

经皮椎体成形术治疗老年骨质疏松性胸腰椎压缩性骨折术中骨水泥渗漏的相关因素

目的分析经皮椎体成形术(PVP)治疗老年骨质疏松性椎体压缩性骨折(OVCF)术中骨水泥渗漏的相关危险因素。方法收集2015年1月—2017年12月采用PVP治疗的297例老年OVCF患者资料。采用logistic回归法分析年龄、性别、骨折部位、椎体压缩程度、椎体终板/后壁完整性、骨折节段数、骨水泥注射量与骨水泥渗漏(椎间盘、软组织、血管内、椎管内及混合渗漏)的关系。结果术中共166例发生骨水泥渗漏,渗漏率55.9%。二元logistic回归分析示骨水泥剂量高是骨水泥渗漏的唯一危险因素。多元logistic回归分析示椎体压缩程度高和骨折节段数多是椎间盘渗漏的危险因素;骨水泥注射量大和椎体压缩程度高是软组织渗漏的危险因素;女性和年龄较低是血管内渗漏的危险因素;骨水泥注射量大和椎体终板/后壁破裂是椎管内渗漏的危险因素。结论不同的危险因素导致PVP术中不同的渗漏类型。明确不同危险因素与各渗漏类型间的相互关系有利于防止骨水泥渗漏的发生。     

维持性血液透析及腹膜透析患者骨密度的评估

目的了解我院MHD及PD患者BMD状况,探讨BMD与临床资料、骨代谢指标及生化指标的相关性及危险因素分析。方法选择我院住院及门诊随访的MHD及PD患者,透析龄均超过3个月,收集患者临床资料及血尿标本。采用超声骨密度仪检测患者BMD状况,对骨量异常患者的BMD及患者一般临床及实验室资料进行相关性分析,并进一步分析透析患者骨量异常的危险因素。采用SPSS19.0软件包进行数据统计及分析。结果 MHD组及PD组骨量异常发生率分别为57.98%,48.54%,有显著统计学差异;随着透析龄的延长,透析患者BMD下降,透析龄3年以上的PD患者比MHD患者的TScore值相对较高,两组间也存在统计学差异。高龄、高透析龄、高BMI、高血磷及高ALP血症是透析患者发生骨量异常的危险因素。结论 MHD患者比PD患者更易发生骨量异常,且随着透析龄的延长,透析患者骨量异常发生率增高,高龄、高透析龄、高BMI、高血磷及高ALP血症是透析患者发生骨量异常的危险因素。     

锁定钢板结合内侧柱植骨支撑治疗中老年肱骨近端骨折

目的 探讨采用锁定钢板固定的同时取髂骨植骨支撑内侧柱的方法,治疗中老年肱骨近端骨折的临床效果。方法 回顾性分析2011年01月至2014年6月采用锁定钢板固定的同时取髂骨植骨支撑内侧柱治疗肱骨近端骨折26例。与既往未行植骨支撑相比较,比较内容包括骨折愈合时间、1年后肩关节Constant评分、肱骨头内翻角度、严重并发症发生率等。结果 植骨支撑组骨折愈合时间比未植骨支撑组平均缩短5.0周;1年后植骨支撑组肩关节Constant评分比未植骨支撑组高5.8分;植骨支撑组肱骨头内翻角度比未植骨支撑组减少4.5°;植骨支撑组未发生严重并发症,未植骨支撑组发生1例螺钉穿出肱骨头关节面,并出现肱骨头坏死。差异均有统计学意义。结论 治疗中老年肱骨近端骨折,特别是骨质疏松内侧柱粉碎性骨折者,应该取髂骨植骨行内侧柱支撑。     

Spinal fusions: bone and bone substitutes

Vertebral arthrodesis is one of the most commonly performed, yet incompletely understood, procedures in spinal surgery. Despite major progress in internal fixation techniques, the high rate of non-unions indicates that physiologic, biologic and molecular events that are crucial to this process are not well known. This article will analyze the general biology of bone regeneration, and particularly discuss the properties and use of various bone graft materials and graft substitutes. Received: 9 August 2000/Accepted: 11 August 2000     

跖骨感染骨外露的显微外科治疗

[目的]回顾总结跖骨骨感染骨外露的显微外科治疗方法。[方法]自1995年～2005年采用显微外科技术治疗214例跖骨骨外露骨感染患者。[结果]全部病例获得随访1～10年，平均随访3年，14例游离植皮术后皮肤成活良好，199例术后皮瓣全部成活，1例腓肠神经营养血管皮瓣移位修复术出现远端部分皮肤坏死，后经换药处理后，伤口自然愈合。皮瓣移植术后质地良好，无溃疡复发。患足均可负重走路。[结论]应用显微外科技术治疗跖骨骨感染骨外露可获得较好的疗效。     

Assessment of bone density and bone loss

Osteoporosis International - Dual-energy X-ray absorptiometry has become the standard for the evaluation of osteoporosis. It is useful both for identifying those people who are going to be at risk...     

Trabecular bone remodeling and bone balance in hyperthyroidism

In vivo tetracycline double-labeled iliac crest bone biopsies from 15 hyperthyroid patients were used for the reconstruction of curves describing the variation of resorption depth and formation thickness with time. The curves emerging were compared to curves reconstructed from 13 age- and sex-matched normal individuals (mean age 44 years). The median function period for resorptive cells in hyperthyroid patients (16 days) was about one-third the resorptive period in normals (51 days). No significant difference between the osteoclast-, mononuclear-, or preosteoblast-like cell resorption depths could be demonstrated between the two groups. Consequently, the median resorption rate in hyperthyroid patients (3.8 μm/day) was more than 3 times higher than the value in the control group (1.1 μm/day). Median Sigma_f, was shorter in the hyperthyroid group (109 days) than in the control group (151 days, P < 0.05), as was the median initial mineralization lag time (5 and 16 days, respectively, P < 0.01). No significant difference between the measured mean completed wall thickness (mcwT) values in the hyperthyroid groups and the control group could be demonstrated (58.1 and 60.5 μm respectively). Median initial mineralization rate in the hyperthyroid group (1.2 μm³/μm² per day) was not significantly higher than the value calculated in the control group (0.9 μm³/ μm² per day), but median initial matrix appositional rate in hyperthyroids (4.8 μm³/μm² per day) was 3 times higher than the value calculated for normals (1.6 μm³/μm² per day) (P < 0.01). Direct measurements of mean completed wall thickness in the hyperthyroid group gave results (58.1 μm) that were not in accordance with the mean completed wall thickness calculated from the growth curve (52.1 μm, P < 0.02). In normals no such discrepancy could be demonstrated. Using the mcwT value estimated from the growth curve, the bone formation period was calculated to 90 days for hyperthyroid patients. This maximal estimate for mcwT was also significantly lower than the mean resorption depth measured in the hyperthyroid group (61.7 μm, P < 0.05), which means that a net negative balance per remodeling cycle existed in the hyperthyroid group. Bone balance was preserved in the control group.     

骨胶原与骨质疏松骨密度及骨生物力学的相关性研究

目的探讨骨胶原含量在绝经后骨质疏松症的发生、发展及在骨质疏松性骨折中的作用。方法取7个月龄未交配雌性SD大鼠60只，随机分为四组，A组：对照组（sham组）；B组：切除卵巢组；C组：切除卵巢＋雌激素治疗组；D组：切除卵巢＋降钙素治疗组。除A组外，其他三组通过切除双侧卵巢法12周后制成骨质疏松模型，24周后分别行k的力学特性、右侧股骨三点弯曲试验、羟脯氨酸含量、k骨密度（BMD）测定，Masson三色染色法显示骨胶原形态。结果A、C、D组与B组在k羟脯氨酸含量、BMD、k压缩力学参数值、右侧股骨生物力学参数值、骨胶原染色含量及形态方面差异均有统计学意义（P〈0．05），而A、C、D组之间差异无统计学意义（P〉0．05）。统计学分析显示羟脯氨酸含量与BMD及骨生物力学参数值呈直线相关性。结论骨质疏松的发生与骨胶原含量下降有关。骨胶原含量的下降与BMD降低及骨生物力学改变呈相关性。应用雌激素和降钙素治疗去势后骨质疏松大鼠，不仅可以提高其BMD含量和骨生物力学性能，而且还可以提高骨胶原的含量。     

Repair of long bone defects with demineralized bone matrix and autogenous bone composite

Background:

Repair of diaphyseal bone defects is a challenging problem for orthopedic surgeons. In large bone defects the quantity of harvested autogenous bone may not be sufficient to fill the gap and then the use of synthetic or allogenic grafts along with autogenous bone becomes mandatory to achieve compact filling. Finding the optimal graft mixture for treatment of large diaphyseal defects is an important goal in contemporary orthopedics and this was the main focus of this study. The aim of this study is to investigate the efficacy of demineralized bone matrix (DBM) and autogenous cancellous bone (ACB) graft composite in a rabbit bilateral ulna segmental defect model.

Materials and Methods:

Twenty-seven adult female rabbits were divided into five groups. A two-centimeter piece of long bone on the midshaft of the ulna was osteotomized and removed from the rabbits’ forearms. In group 1 (n=7) the defects were treated with ACB, in group 2 (n=7) with DBM, and in group 3 (n=7) with ACB and DBM in the ratio of 1:1. Groups 4 and 5, with three rabbits in each group, were the negative and positive controls, respectively. Twelve weeks after implantation the rabbits were sacrificed and union was evaluated with radiograph (Faxitron), dual-energy x-ray absorptiometry (DEXA), and histological methods (decalcified sectioning).

Results:

Union rates and the volume of new bone in the different groups were as follows: group 1 - 92.8% union and 78.6% new bone; group 2 - 72.2% union and 63.6% new bone; and group 3 - 100% union and 100% new bone. DEXA results (bone mineral density [BMD]) were as follows: group 1 - 0.164 g/cm², group 2 - 0.138 g/cm², and group 3 - 0.194 g/cm².

Conclusions:

DBM serves as a graft extender or enhancer for autogenous graft and decreases the need of autogenous bone graft in the treatment of bone defects. In this study, the DBM and ACB composite facilitated the healing process. The union rate was better with the combination than with the use of any one of these grafts alone.