Ilizarov 技术矫治马蹄足畸形中胫距关节前脱位的治疗及预防

 目的 总结 Ilizarov 技术矫治马蹄足畸形中发生胫距关节前脱位的概率、治疗及预防方法。方法 回顾性分析 2011 年 10 月至 2012 年 4 月,应用 Ilizarov 技术矫治 38 例马蹄足畸形患者资料,其中 5 例于术后 14～28 d 发生胫距关节前脱位,男 4 例,女 1 例;年龄 19～30 岁,平均 23.8 岁;均为马蹄内翻足畸形患者。5 例患者初次手术采用 Ilizarov 技术矫治马蹄足畸形,同时行经皮跟腱延长术、经皮跖腱膜切断术、胫后肌松解、胫前肌移位,其中 4 例同期行距骨周围截骨术,1 例同期行第一跖骨基底截骨术,1 例同期行胫骨近端去旋转截骨术;发生胫距关节前脱位后,1 例经手法复位,4 例使用 Ilizarov 复位装置后继续按原计划牵伸调整外固定架矫形,直至满意。结果 5 例马蹄内翻足畸形患者在行 Ilizarov 技术矫形过程中发生胫距关节前脱位的概率为 13.2%（5/38）。5 例患者均获得随访,随访时间 6～12 个月,平均 10 个月,马蹄足畸形均完全矫正。末次随访时应用国际马蹄足畸形研究学组评分为 3～10 分,平均 4.8 分;其中优 2 例,良 3 例,优良率为 100%。无一例发生钉道感染、神经血管损伤、血栓等并发症。结论 胫距关节脱位是 Ilizarov 技术矫治马蹄足畸形中较常见的并发症,发生率约为 13%。发生胫距关节前脱位后,及时安装距骨复位装置可获得良好效果。围手术期管理应注意外固定铰链关节与踝关节瞬时旋转中心的匹配。     

应用单侧纵轴动力外固定器矫正下肢畸形

作者于１９８９年１０月～１９９４年１２月，采用截骨矫形加单侧纵轴动力外固定器固定的方法，治疗不同类型的下肢畸形６０例７８个部位。结果显示：７７处截骨均为一期愈合，１处延迟愈合；针孔感染率为０．６％。平均随访时间２．５年，全部病例肢体畸形矫正满意，关节功能恢复好。作者认为，应用本固定器创伤小、操作简单、固定牢固。由于具有弹性固定作用，可促进骨痂生长、加速骨愈合，对关节功能影响小，并发症少，最突出的优点是可将肢体畸形矫正至理想角度。     

Kriterien zur Behandlung von Oberschenkelschaftfrakturen im Kindesalter

Overgrowth and rotational deformity of the injured leg are sequelae of femoral shaft fractures in children. It is still questioned whether the posttraumatic rotational deformity is corrected spontaneously and whether this leads to arthrosis. An individual follow up of 25 children out of 94 with a malrotation after conservatively treated femoral shaft fracture-two to three times up to 4 years after the accident-showed a spontaneous correction of malrotation in 15 (60%). No prearthrotic sign could be found by physical and roentgenographical examination. In accordance with recent publications these results demonstrate again that in children up to the age of ten operative treatment of isolated femoral shaft fracture is not indicated, as posttraumatic malrotation is corrected at least to almost physiological values and no extensive study exist so far, which give evidence that malrotation after femoral fracture in children leads to arthrosis.     

"Prognostic" analysis of late results of trochanteric femoral osteotomy following post-traumatic malalignment

Post-traumatic axial malalignment of the lower limbs causes osteoarthrosis of the adjacent joints. Whether or not correction osteotomy is indicated depends upon the degree and the location of the deformity. Malalignment of the proximal femur should be corrected if the axis of the leg does not pass through the knee joint. If the axis is outside the central half of the tibial head, the indication for correction osteotomy is a relative one: varus deformities are more difficult to compensate and it is more urgent that these be corrected. Of 103 patients who underwent osteotomies of the proximal femur during the period 1973-1981, there were 73 in whom it was possible to follow up an average of 7 years after the realignment procedure. In nearly two-thirds of these patients the clinical symptoms noted before surgery had improved. In 10 cases of pseudarthrosis of the femoral neck, necrosis of the femoral head could not be avoided in spite of the surgical correction; nonetheless, the prognosis is better if the correction is done within the first 3 months after the trauma.     

应用Isola三维矫形系统治疗脊柱侧凸

目的：应用Isola系统矫正脊柱侧凸冠状面、矢状面和轴状面的畸形，评价其治疗效果。方法：回顾性分析2001年3月至2003年6月应用Isola系统治疗脊柱侧凸22例，特发性侧凸18例，先天性侧凸4例。男13例，女9例，年龄12。18岁，平均14．5岁，术前冠状面Cobb角450～83°，平均62°，矢状面Cobb角-12°-54°，平均34°，椎体旋转按Nash-Moe分型Ⅰ度6例、Ⅱ度13例，Ⅲ度3例。结果：术后冠状位矫正为20°～31°，矫正率为62％～85％，平均为69％，矢状位矫正为21°-32°，平均26°。椎体旋转矫正1度。随访9个月～3年，平均2．4年。植骨融合良好，矫正角度丢失率〈4．4％。结论：应用Isola内固定系统矫正脊柱侧凸，利用悬臂技术产生的平移力可获得冠状面良好的矫正率，同时可获得矢状面的矫正，并保持躯干平衡，应用椎弓根钉效果更佳。     

Surgical procedure for flexion contracture and recurvatum in total knee arthroplasty

A specific protocol for dealing with flexion contracture and recurvatum in total knee arthroplasty surgery was evaluated. In cases of flexion contracture, this protocol included choosing the larger femoral size when the femur was between sizes to make the flexion space smaller and to allow overresection of the tibial surface to correct the flexion contracture. In all cases, bone resection was done first, osteophytes were resected next, and ligaments were balanced after the trials were in place. Extra bone was resected from the distal femur to correct residual flexion contracture only if ligament balancing failed to correct the deformity. In cases of recurvatum, the smaller femoral size was chosen to enlarge the flexion space, allowing underresection of the tibia to stabilize the knee in extension. The cutting guides were positioned so that 3 to 5 mm less than the distal thickness of the femoral component was removed to stabilize the knee in extension. To evaluate this protocol, a computerized database was used to review records of 530 patients (552 knees) who had flexion contracture (542 knees) or recurvatum (10 knees) before surgery. Ligament release and correction of varus or valgus contracture corrected flexion contracture to less than 3 degrees in 515 knees (95%). Sixteen knees (3%) had release of the posterior capsule to correct residual flexion contracture, and 11 knees (2%) required overresection of the distal femoral surface to achieve correction of flexion contracture. By 1 year the flexion contracture was 2 degrees +/- 1 degree. In the knees with preoperative recurvatum, none had residual recurvatum at the conclusion of surgery, and none had recurrent deformity. None of the knees required a hinge or a stabilized component with a highly conforming central post.     

后路全脊椎切除折顶椎管三维同心闭合矫形治疗重度脊柱角状后凸畸形

目的:评价后路全脊椎切除折顶矫形治疗重度脊柱角状后凸畸形的安全性和临床初步效果.方法:2004年6月至2008年5月,收治重度脊柱角状后凸畸形患者11例.男4例,女8例,年龄16-42岁,平均27.9岁:其中先天性椎体形成不良6例,胸腰椎结核3例,陈旧性脊柱骨折2例,神经纤维瘤病1例.术前矢状面角状后凸Cobb角82°～150°,平均107.0°;10例合并侧凸畸形,冠状面侧凸Cobb角11°～128°,平均52.7°;6例先天性椎体发育不良中有1例合并神经损害,3例结核中有1例合并神经损害,根据Frankel分级均为D级.均采用顶椎全脊椎切除折顶椎管三维同心闭合矫形术治疗,随访观察治疗效果.结果:手术时间为7.9～14.7h.平均11.1h.术中出血2400～5100ml,平均3866ml.脊髓短缩1.6～2.7cm,平均2.1cm.融合同定节段为8～14节椎体,平均12.5节.矢状面Cobb角由术前平均107.0°矫正至26.1°矫正率75.6%.冠状面Cobb角由术前平均52.7°矫正至12.3°,矫正率76.7%.躯干矢状偏移距离平均矫正率76.4%.术前2例神经损害者,术后Frankl分级恢复到E级,随访9～61个月,平均25.9个月.所有患者获得良好的骨质愈合,无脊髓损伤,也无矫正度的丢失.结论:全脊椎切除折顶复位术矫正重度脊柱角状后凸畸形疗效满意,椎管三维同心闭合技术保证了截骨面椎管在矢状面、冠状面及水平面的安全闭合.     

Prophylactic surgical correction of Crawford's type II anterolateral bowing of the tibia using Ilizarov's method

The treatment of anterolateral bowing with an intact tibia is directed toward prevention of the fracture and subsequent pseudoarthrosis. Patients with anterolateral bowing of the tibia are usually treated with an ankle-foot orthosis until the deformity is improved. There is no documentation that an orthosis can prevent the fracture or correct the deformity, and if the deformity is not corrected, it will result in different mechanical problems. In this study, 6 legs in 6 patients with anterolateral bowing of the tibia with a narrow sclerotic medullary canal (Crawford type II) were treated using Ilizarov's method. The average age was 6.8 years. All patients underwent correction of the anterolateral bowing by excision of the affected part. If the gap was less than 4 cm, acute shortening followed by bone lengthening was done. If the gap was more than 4 cm, bone transport was preferred. The mean duration of follow-up was 3.2 years. The anterolateral bowing was corrected in all patients. Complications such as pin track infection, premature consolidation and delayed union at the docking site were encountered. We believe that Ilizarov's method offers a more efficient solution for this type of deformity than prophylactic orthotic treatment or prophylactic bypass bone graft.     

Taylor空间支架矫正创伤后膝内、外翻畸形

  目的 探讨Taylor空间支架（Taylor Spatial Frame, TSF）矫正创伤后膝内、外翻畸形的临床疗效和精确度。方法 回顾性分析2006年6月至2010年12月,采用TSF矫正26例创伤后膝内、外翻畸形患者的病例,男19例,女7例;年龄19～62岁,平均39岁;创伤后膝内翻畸形20例,膝外翻畸形6例。21例行胫骨高位截骨,3例行股骨髁上截骨,2例同时行股骨髁上和胫骨高位截骨。安装TSF、测量支架的安装参数后截骨。术后7～10 d,根据电子处方,每天3次调节TSF支架上的可伸缩螺杆的长度,调节范围为0～3 mm。结果 经过7～35 d调节,20例畸形得到一次性完全矫正,患肢的胫骨、股骨力线恢复,肢体的成角、旋转和短缩畸形均得到矫正。6例尚残存轻微成角和短缩畸形,经第二次4～10 d的支架调整,畸形矫正。截骨处新骨生成和矿化良好,术后2.5～6.0个月去除外固定架。术后随访12～60个月,畸形无复发。术后11例发生针道感染,经应用敏感抗生素治疗,感染控制。1例去除外固定架后1.5个月发生股骨远端截骨处再骨折,经保守治疗骨折愈合。无一例患者发生血管神经损伤和继发性马蹄足畸形。结论 TSF矫正创伤后膝内、外翻畸形疗效确切,精确度高。     

Osteotomy of the tibia for correction of complex deformity.

Twenty complex tibial deformities due to anterior poliomyelitis in 18 patients were corrected by a modified O'Donoghue osteotomy. This technique allowed correction of the deformity in three planes. This was achieved by widening the rectangular window distally to correct both rotation and valgus and by trimming the anterior edges of the step cuts to correct flexion deformity. An above-knee cast was applied for eight to 13 weeks and the patients followed up for a mean of 3.2 years. One of the 18 patients developed delayed union because of fracture of the medial limb of the step cut. The results showed excellent correction of the three-plane deformity and there was no recurrence. This method of osteotomy is a safe and simple procedure which does not require internal fixation and allows correction of torsional and angular deformity.     

Nonunions and malunions after pelvic fractures: why they occur and what can be done?

MATERIALS AND METHODS: Between 1987 and 2005, 55 patients were treated operatively to correct 44 malunions and 11 nonunion of the pelvic ring. These pathologies were the consequence of a nonoperative initial treatment for 38 cases, or of an inappropriate indication, such as the use of an external fixator as the definitive treatment of an unstable pelvic fracture in 15 and symphysis cerclage wiring in 2. Three patients had undergone ORIF of the lumbar spine performed by neurosurgeons, but the pelvic fractures below were ignored. On the basis of damaging mechanisms and of the main instability plane, initial lesions were classified as follows: 32 shearing lesions, 11 rotatory by antero-posterior compression, 7 by lateral compression, 5 mixed. In 23 cases the site of the posterior lesion was the sacrum, 4 of which were H fractures type; 13 were sacroiliac joint dislocations, or rotatory instability of the joint (in 2 cases the lesion was bilateral), 8 were sacroiliac dislocation fractures (crescent fractures); 7 were fractures of the iliac wing. Four patients only had pubic symphysis diastasis. Indications for surgery were pain associated with deformity or instability. Surgery was performed through a multistage procedure. Mean surgery time was 6h (range: 2-10h), with a mean blood loss of 700ml (range: 200-5000ml). Follow-up ranged from a minimum of 16 months to a maximum of 14 years (mean: 5.85 years). RESULTS: At the last follow-up, all patients but one had consolidated and were considered stable. All patients had improved walking ability. Six patients still report pain. Even if most of the deformity were corrected with a significant decrease of pre-operative symptoms achieved, deformity correction was considered satisfactory but not anatomic, in 12 patients (21%). Complications occurred in 24% of patients but most were temporary. CONCLUSIONS: The most frequent cause of pelvic malunion or nonunion was inadequate treatment. To reduce the number and the percentage of disabilities, it is necessary that specialised centres provide patients with early treatment that is adequate and definitive.     

Limb lengthening and correction of deformity in the lower limbs of children with osteogenesis imperfecta

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.     

微创截骨外固定器固定治疗膝内翻畸形

[目的]探讨微创截骨矫形外固定器固定治疗膝内翻的效果。[方法]采用股骨髁上微创截骨矫形,外固定器固定治疗患者27例32膝。[结果]所有病例均一期骨性愈合,畸形矫正满意,畸形矫正度数为15°~33,°平均21°。身高增加1.6~3.1 cm,关节立线及膝关节功能均良好。[结论]微创截骨矫形单侧外固定器固定治疗成人膝内翻畸形具有创伤小、可控制性好、骨愈合快、并发症少等优点。     

婴儿单侧完全性唇裂鼻畸形同期整复术后发育的近期观察

目的 探讨婴儿单侧完全性唇裂鼻畸形同期整复术方法,并初步观察其对鼻部发育的影响.方法 对27例单侧完全性唇裂鼻畸形患儿在婴儿期行唇裂鼻畸形同期整复术,术后随访6～8年,采用人体测量学方法定量分析患者术后照片,对所定的各标志点进行测量、分析和评价.结果 27例患儿中,10例鼻外形远期效果为优,良14例,差3例.结论 在了解鼻部血供解剖的基础上,应用适宜的手术方法进行婴儿单侧完全性唇裂鼻畸形同期整复,对鼻部发育无明显影响,可以减轻或消除学龄前患儿的唇裂伴发鼻畸形.     

大龄先天性髋脱位股骨与骨盆截骨的疗效观察

目的：探讨股骨截骨与髋臼成形在纠正先天性髋脱位畸形中的作用。方法：以股骨短缩及旋转截骨为主的一期综合手术矫正先天性髋脱位的全部畸形。结果：术后三年随访评分；手术矫正的30髋中，优23髋、良3髋，优良率86.7%，可2髋，差2髋。结论：关节间的压力和髋臼的包容差是引起并发症的关键所在。以股骨短缩及旋转截骨为主的综合手术是大龄先天性髋脱位纠正畸形的理想手术。     

陈旧性鼻眶骨骨折综合征的同期治疗

目的：为减轻患者痛苦，尽可能减少手术切口及手术次数，同期治疗陈旧性鼻眶骨骨折引起的鼻眼相关综合征。方法：利用解剖部位毗邻的特点。经同一进路，同时修复陈旧性鼻眶骨骨折引起的内紫韧带断裂，内紫角移位、变形，鼻泪管阻塞、溢泪，鼻梁塌陷、歪斜等一系列鼻眼综合畸形患者18例。其中男11例，女7例，年龄为5－38岁。结果：经6个月至4年的随访，除2例幼年患者仍有溢泪，另1例内紫角行第2次复位外，均获得满意效果。结论：在保证医疗质量的前提下，有关专业的医师联手协作对相关部位进行同期治疗，毕其功于一役，值得在有条件的医疗机构推广。     

Treatment of distal femoral nonunions by external fixation with simultaneous length and alignment correction

The use of external fixation for management of distal femoral nonunions may minimise some of the problems frequently encountered in these patients. Fifteen patients treated by external fixation for distal femoral nonunions between 1987 and 1997 were reviewed. There were nine males and six females. The average age was 35.4 years (17-53) with an average follow up of 4.6 years (2-8). Nine followed an open fracture, five a closed fracture and one a femoral osteotomy. Five of the cases were infected nonunions. In all cases an internal fixation device was used as the initial method of treatment. All patients had the nonunion site stabilised with an external fixator. In 12 cases the knee joint was crossed with the fixator to further stabilise the fracture site. All patients had some degree of leg length discrepancy or malalignment that required correction. Fourteen cases united. The other patient united following intramedullary nailing. The average time to union was 10.4 months (4-24). The average range of movement was 80 degrees after treatment. Up to 9 cm of lengthening was achieved using the external fixation system (mean 5.0 cm). The mean angular correction was 15 degrees. One patient had persistent pain despite union at the time of the last follow up. The advantages of preservation of soft tissue, immobilisation of the fracture site by crossing the knee joint and the facility for proximal lengthening make external fixation a definite option in the management of distal femoral nonunions.     

The effect of extraarticular varus and valgus deformity on total knee arthroplasty

Because of trauma, metabolic bone disease, congenital deformity, or prior osteotomy, an extraarticular deformity may be present in patients requiring total knee arthroplasty. If the extraarticular deformity is not corrected extraarticularly, it must be corrected by compensatory distal femoral or proximal tibial wedge resection to produce overall limb alignment. Because such a wedge resection between the proximal and distal attachments of the collateral ligaments will produce asymmetrical ligament length, complex instabilities may result. This article, through overlay templates and trigonometric analysis, evaluates all the issues confronting the surgeon deciding whether to pursue intraarticular or extraarticular correction. The conclusions are as follows: (1) the closer a deformity is to the knee, the greater its importance, (2) femoral deformities are more difficult to correct intraarticularly than tibial deformities because femoral compensatory wedge resection produces instability only in extension, and (3) intraarticular correction of varus deformities produces lateral instability that is usually better tolerated than medial instability, and some extraarticular deformities are best treated by extraarticular correct, independent, or total knee arthroplasty.