青少年脊柱侧凸的后路CDH Legacy矫形内固定技术与疗效

[目的]探讨脊柱侧凸后路CDH Legacy在脊柱侧凸后路矫形中的应用及其矫形效果。[方法]2003年7～8月，共有9例患者接受后路CDH Legacy矫形内固定加植骨融合手术，其中女7例，男2例；年龄11～18岁，平均13．5岁。病因学分类：青少年特发性脊柱侧凸（AIS）7例，先天性脊柱侧凸（CS）1例，神经纤维瘤病伴脊柱侧凸（NFI）1例。术前Cobb＇s角48^o～68^o，平均54^o。7例AIS和1例CS患者直接行一期后路CDH Legacy矫形内固定术，另1例NFI因Risser为0，先行一期前路骨骺阻滞再行二期后路CDH Legacy矫形固定。[结果]本组无死亡、感染，无神经系统并发症。未发生术中骨折及脊膜胸膜损伤。1例并发肠系膜上动脉综合征，给予禁食等保守治疗后症状缓解。手术时间210～300min，平均260min；出血量300～1000ml，平均700ml。术后Cobb’s角平均20^o，矫正率63％。本组随访20～30个月，平均23个月，随访1年时均获得骨性融合，无额状面或矢状面失偿，纠正丢失4^o，纠正丢失率7．4％。[结论]CDH Legacy在矫形效果与以往第3代内固定系统无明显差异，有操作简便、内固定牢固和选择多样性的特点。     

闭合复位空心螺钉内固定治疗股骨颈骨折的疗效

目的 探讨闭合复位空心螺钉内固定治疗股骨颈骨折的临床疗效。方法 在C型臂X线透视下牵引床牵引复位，经皮穿入2～3枚导针，顺导针拧入空心螺钉治疗股骨颈骨折110例，术后随访2～6年。平均3年8个月。结果 除1例手术后第6天因突发心肌梗死死亡，2例骨折不愈合外，其余107例均获得愈合，骨折愈合率为98．2％。远期出现股骨头缺血坏死及塌陷29例，坏死发生率为26．36％。结论闭合复位空心螺钉内固定治疗股骨颈骨折，其方法简单，固定牢固，治疗效果好。     

老年不稳定性股骨转子骨折髓内固定的治疗策略

目的探讨应用股骨近端髓内钉（proximal femoral nail，PFN）治疗老年不稳定性股骨转子骨折的手术方法及术后功能锻炼策略。方法采用PFN治疗老年不稳定性股骨转子骨折77例79侧，男29例29侧，女48例50侧。年龄60—95岁，平均73．6岁。根据AO／ASIF骨折分型：A2型56例58侧，A3型21例21侧。术后早期功能锻炼。对骨折复位情况、内固定效果、髋关节功能、术中及术后并发症等进行统计。结果术中复位效果优良率100％，手术操作优良率81％～84．5％。术后3～6个月时骨折均愈合。随访1～2年，髋关节功能恢复良好，无复位丢失、内固定失败等。结论PFN能提供可靠的内固定，用于老年不稳定性股骨转子骨折的治疗临床效果良好。     

胫骨髁间隆起撕脱骨折的手术治疗

自１９７５～１９９５年，作者采用切开复位，钢丝内固定治疗了胫骨髁间隆起撕脱骨折以及合并胫侧副韧带等损伤３１例，其中单纯胫骨髁间隆起撕脱骨折２４例；合并胫侧副韧带或内外侧半月板损伤者７例。术中骨折均达到解剖复位。术后骨折愈合良好，检查抽屉试验转阴率为８９％。膝关节功能恢复满意，优良率为８９．６％，而同期非手术治疗者优良率仅为７９．２％。作者认为：膝关节稳定性和功能的恢复，与骨折块良好复位及周围软组织损伤的修复有关。单纯保守治疗，骨折块移位愈合，交叉韧带处于松弛状态，可引起膝关节不稳定和继发性损害。采用手术治疗则能满足骨折复位和膝关节功能恢复的需要。因此，对该类型骨折宜早期手术治疗为好。     

桡骨远端关节内粉碎性骨折内外联合固定的手术疗效

[目的]探讨桡骨远端关节内粉碎性骨折的有效治疗方法.[方法]21例C3型桡骨远端骨折病例,应用开放复位外固定架联合钢板或克氏针内固定手术方法,根据放射线检查,Gartland & Werley 和改良Green & O′Brein 评分系统,对手术前、手术后以及术后远期腕关节功能进行评价,并对手术解剖复位情况和功能恢复进行统计学分析.[结果]经随访6～36个月(平均19个月),术后远期伤侧腕关节活动范围为健侧78%,手握力为健侧82%,桡关节面存在台阶及骨折分离间隙平均2 mm,桡骨远端长度恢复平均11 mm.根据Gartland & Werley 和改良Green & O′Brein 评分系统,远期功能分别为优5例和3例,良12例和9例,一般4例和2例,差0例和2例.术后关节面的解剖复位与功能预后明显相关.[结论]开放复位外固定架联合钢板或克氏针内固定是保证复位满意,稳定复位效果,取得术后远期满意功能恢复的有效治疗方法.     

带关节的超关节外固定架结合有限内固定治疗Pilon骨折

目的应用带关节的超关节外固定架结合有限内固定治疗Pilon骨折，并评估其疗效。方法2002年2月～2004年6月采用单边带关节的超踝关节T型外固定架结合有限内固定治疗19例（21侧）Pilon骨折患者。支架远端螺钉固定于距骨或跟骨，近端螺钉固定于胫骨骨折近端，使踝关节可以距下关节为中心在一定范围内活动。依据伤口软组织情况在术后2～3周松动外固定支架关节开始踝关节功能锻炼。结果19例患者全部获得随访10～18个月，平均13个月。临床效果满意，无切口、伤口及钉道感染，无神经、血管损伤，无骨不连等并发症。踝关节骨折复位情况（Burwell＆charnley踝关节骨折复位评分法）为C1型5例全部达解剖复位；C2型达解剖复位7例，一般2例，C3型达解剖复位4例，一般1例，复位差2例。踝关节症状和功能评分（Baird＆Jackson评分法）为72～98分，平均92分；优4侧，良12侧，可3侧，差2侧，优良率为84．2％。结论带关节的超关节外固定支架结合有限内固定治疗Pilon骨折可避免伤口并发症和骨不连的发生，能更好地恢复关节面的解剖关系，有利于踝关节早期活动，避免关节僵硬，是治疗Pilon骨折的理想方法之一。     

桡骨远端骨折手术与非手术治疗的疗效比较

目的比较手术与非手术治疗桡骨远端骨折的疗效。方法选取自2010—01—2013—06收治的桡骨远端骨折264例268侧,采取手法复位石膏外固定桡骨远端骨折168例171侧,切开复位内固定手术治疗桡骨远端骨折患者96例97侧（含因手法复位再移位者8例8侧）。结果264例获得随访12～36个月（平均26个月）。腕关节功能评价根据Cooney标准进行评定：手法复位石膏外固定组优良率为84．8％,切开复位内固定手术治疗组优良率为95．9％。结论对于不稳定桡骨远端骨折的治疗,切开复位内固定手术治疗优于手法复位石膏外固定,但由于手法复位石膏外固定方法简单、费用低廉、患者痛苦较小,故仍可作为稳定或相对稳定性桡骨远端骨折的首选治疗方法。     

第一掌骨基底关节内骨折内固定后40例远期随访结果

目的观察40例第一掌骨基底关节内骨折切开复位内固定术后的远期疗效。方法对1978-1998年间，在我科治疗的40例闭合性第一掌骨基底关节内骨折的患者进行远期随访观察。随访项目包括：手术当时骨折复位状况、术后拇指腕掌关节主观症状、运动受限及X线片情况。结果术后40例获得5～26年随访（7例为信访），其中14例（占35．0％）有主观症状，但大多较轻微。来院随访的33例中，17例（占51．5％）有拇指运动受限，15例（占37．5％）握、捏力下降，22例（占67．0％）X线片上有第一腕掌关节炎表现。创伤性关节炎的发生与骨折复位质量有关，差异有统计学意义（P〈0．01），且关节炎发生率随时间进展有增加的趋势。主观症状、拇指运动受限的程度与骨折复位质量无关，差异无统计学意义。结论治疗第一掌骨基底关节内骨折，无论采用切开或闭合复位的方法，均应尽力达到关节面的解剖复位。     

跨腕关节外固定器治疗不稳定性桡骨远端骨折

目的 回顾分析闭合复位、单侧外固定器跨腕关节固定治疗不稳定性桡骨远端骨折的效果。方法 2000年6月～2005年3月，利用外固定器跨腕关节固定治疗45例50侧不稳定性桡骨远端骨折，年龄15～78岁（平均44．8岁）。骨折按AO分型：A3型5例5侧，B3型4例4侧，C1型3例3侧，C2型9例9侧，C3型24例29侧。手法或外固定器协助复位，外固定器静力性固定，骨折愈合后拆除外固定器。随访8～48个月（平均20个月）。结果 骨折愈合时间6～8周，平均7．6周。4例4侧出现针道表浅感染，经口服抗生素及局部换药后好转。最后一次随访时，影像学评估（Stewan改良的Sarmiento评分）：优39例42侧，良6例8侧。腕关节功能按Garland与Werley功能评分标准：优34例37侧，良8例9侧，可3例4侧，优良率为92％。结论 闭合复位、单侧外固定器跨腕关节静力性固定桡骨远端骨折，通过选择合适的外固定针置入部位，可以避免桡神经损伤及第二掌骨医源性骨折，减少针道感染及松动等并发症的发生，并有利于术后早期行手部功能锻炼；无需辅助性植骨促进骨折愈合，是不稳定性桡骨远端骨折的有效治疗方法。     

45例肘管综合征术后远期随访报告

目的：探讨肘管综合征远期疗效和影响疗效的有关因素。方法：对４５例４８侧肘管综合征术后进行了远期随访。随访时间２１个月～１４年，平均５年２个月。结果：优良３６侧，占７５％（３６／４８）；差４侧，占８．３％（４／４８）。术前病程长短、手内肌萎缩程度和爪形手畸形的存在与否，对远期疗效有明显影响。而年龄、尺侧腕屈肌肌力、术中神经卡压程度和术后早期疗效等，对远期疗效的影响无统计学意义。结论：对肘管综合征应早期诊断和治疗，其远期疗效较好。     

Long-term functional evaluation of diaphragmatic motility after repair of congenital diaphragmatic hernia

Background/Purpose

A few studies have taken into account the diaphragmatic function in patients successfully treated for congenital diaphragmatic hernia (CDH). Monodimensional sonography has been reported to be useful in assessing the diaphragmatic motility. Aim of the present study was to investigate, in a long-term follow-up, the diaphragmatic function after CDH repair.

Methods

Ten patients, with a mean age of 16 (5-26) years, were enrolled. All had had a left diaphragmatic hernia repaired, but no one received a patch. Ten subjects of matched age were used as controls. The diaphragmatic excursions appear, at M-mode sonography, as a sinusoid; the amplitude of the curve on the vertical axis measured the movement in centimeters. Chest x-ray and spirometry were also performed in CDH patients.

Results

A reduced diaphragmatic motility on the left (treated) side was recorded. The amplitude of the contraction was significantly reduced when compared with the contralateral side (1.19 ± 0.2 vs 2.33 ± 0.9 cm; P = .017) and was also significantly reduced in comparison with the motion of the left side of controls (1.19 ± 0.2 vs 1.83 ± 0.4 cm; P = .01). There was no difference in the amplitude of contraction between the left and right sides of control patients and between the right side of CDH patients and the controls. Spirometry was normal in all patients but one, who had a slight reduction of ventilation on the left side.

Conclusion

M-mode sonography appears as a very useful tool in quantitative evaluation of diaphragmatic movements and should be extensively used during follow-up of patients after CDH repair. Motility of the repaired diaphragmatic is reduced, even after a long period, but this does not affect the respiratory function in patients who survived CDH repair.     

全髋关节置换术治疗先天性髋关节发育不良

目的: 探讨全髋关节置换治疗成人先天性髋关节发育不良的手术方法和疗效。方法: 对 25例 28髋成人先天性髋关节发育不良继发骨性关节炎患者行全髋关节置换术。结果:刀口均Ⅰ期愈合。经 13个月~6年, 平均 27个月随访, Harris评分 87分 (术前 46分 ), 优 5髋、良 19髋、中 4髋,优良率为 85. 7%。结论: 全髋关节置换术是治疗成人先天性髋关节发育不良继发骨性关节炎的有效方法。     

Clinical outcome following anterior cervical discectomy and fusion with and without anterior cervical plating for the treatment of cervical disc herniation—a 25-year follow-up study

Extreme long-term clinical outcome studies following anterior cervical discectomy and fusion (ACDF) with an autologous iliac crest with and without Caspar plating (ACDF + CP) for the treatment of radiculopathy caused by cervical disc herniation (CDH) are extremely rare. Hospital records of patients who underwent ACDF or ACDF + CP for the treatment of CDH at least 17 years ago were reviewed. Information about diagnosis, surgery, pre- and postoperative clinical process, and repeated procedure was analyzed. At final follow-up, patients were reviewed with a standardized questionnaire including the current neurological status, Neck Disability Index (NDI), Odom’s criteria, a modified EQ-5D, and limitations in quality of life. One hundred twenty-two patients with a mean follow-up of 25 years were evaluated. ACDF was performed in 80 and ACDF + CP in 42 patients, respectively. At final follow-up, 81.1% of patients were free of radicular pain and had no repeated procedure. According to Odom’s criteria, 86.1% of good to excellent functional recovery was noted. The mean NDI and EQ-5D was 14% and 5 points, respectively. There was no significant difference in the assessed clinical outcome parameters between patients treated with ACDF and ACDF + CP. The rate for repeated procedure due to degenerative cervical disorders was 10.7 and 7.4% due to symptomatic adjacent segment disease with 25 years. ACDF and ACDF + CP achieved a high rate radicular pain relief (89.3%) and clinical success (86.1%) for the treatment of CDH within a 25 years follow-up. No statistical difference concerning clinical outcome and rate of repeated procedure was detected.     

先天性髋脱位闭合复位后股骨头缺血性坏死的长期随访

目的：对１９８５年１月～１９８９年１２月采用闭合复位、蛙式支架治疗的患儿作了平均１０年的长期随访，评价了股骨头缺血性坏死（以下简称头坏死）发生率和各种影响因素，探讨头坏死与Ｘ线结果、临床功能之间的关系，提出预防头坏死的方法和措施。方法：本组６４例共７９髋，复位时的平均年龄为２１个月，１８髋术前行皮牵引，５１髋术前行内收肌切断。闭合复位均在全麻下施行，成功后穿戴蛙式支架６个月，然后改为贝氏架３个月，共穿戴９个月。结果：平均随访时间为１０年４个月，随访时平均年龄１１．７岁。７９髋中３６髋出现头坏死（４６％）。不同性别、不同脱位侧别、复位前是否行皮牵引和内收肌切断的头坏死发生率的差异均无显著性意义（Ｐ＞０．０５），头坏死发生率与脱位程度及复位后制动体位关系密切。闭合复位前，股骨头骨骺未出现，发生头坏死率明显升高（Ｐ＜０．０５），多为股骨头全部受累。复位时年龄小于１８个月者，其头坏死发生率明显低于１８个月之后复位者（Ｐ＜０．０５）。随访时临床功能优良率为８３％，而Ｘ线片的优良率则是６０％。结论：临床功能障碍的出现是一个缓慢、渐进的过程，相当时间内并不产生髋关节疼痛和跛行。对远期疗效的估计应以Ｘ线变化为主要依据。     

A population-based study of congenital diaphragmatic hernia: impact of associated anomalies and preoperative blood gases on survival.

BACKGROUND/PURPOSE: Although neonatal care has improved over the past 20 years, mortality rate with congenital diaphragmatic hernia (CDH) remains 50% to 60%, possibly reflecting differences in management or selection biases. The authors determined the incidence, outcome, effect of coexisting anomalies, and prognostic indicators for neonates with CDH in a single inborn population older than 13 years. METHODS: Forty-three neonates with CDH, those symptomatic within the first 6 hours of life, were identified using a validated neonatal database and diagnosis coding data from medical records among 180,643 live inborn neonates delivered at Parkland Memorial Hospital between 1983 and 1995. Charts were reviewed for prenatal history, demographic variables, presence of coexisting malformations, preoperative arterial blood gases, surgical findings, and outcome. Survival to hospital discharge was the primary outcome variable. RESULTS: The incidence of CDH was 1 in 4,200 live births; overall survival rate was 51%. Thirty-two (74%) neonates underwent surgical repair, often at less than 8 hours of life; postoperative mortality rate was 31%. Eighteen (42%) had coexisting major anomalies or chromosomal abnormalities. Eighty percent of neonates with isolated CDH survived, whereas 89% with CDH and associated defects died. Nonsurvivors had lower birth weights and Apgar scores, were more acidotic, and had more severe respiratory compromise. When best preoperative pH was > or = 7.25 or PaCO2 < or = 50 mm Hg, 80% of neonates survived. CONCLUSION: In this inborn population-based review of neonatal CDH between 1983 and 1995, the best predictors of survival were the presence or absence of other anomalies and the best preoperative PaCO2 and pH.     

Durability of giant hiatus hernia repair in 455 patients over 20 years

Introduction

The surgical management of symptomatic giant hiatus hernia (GHH) aims to improve quality of life (QoL) and reduce the risk of life threatening complications. Previous reports are predominantly those with small sample sizes and short follow-up periods. The present study sought to assess a large cohort of patients for recurrence and QoL over a longer time period.

Methods

This was a follow-up study of a prospectively collected database of 455 consecutive patients. Primary repair of GHH was evaluated by endoscopy/barium meal for recurrence and a standardised symptom questionnaire for QoL. Recurrence was assessed for size, elapsed time, oesophagitis and symptoms.

Results

Objective and subjective review was achieved in 91.9% and 68.6% of patients. The median age was 69 years (range: 15–93 years) and 64% were female. Laparoscopic repair was completed in 95% (mesh in 6% and Collis gastroplasty in 7%). The 30-day mortality rate was 0.9%. The proportion of patients alive at five and ten years were 90% and 75% respectively. Postoperative QoL scores improved from a mean of 95 to 111 (p<0.01) and were stable over time (112 at 10 years).The overall recurrence rate was 35.6% (149/418) at 42 months; this was 11.5% (48/418) for hernias >2cm and 24.2% (101/418) for <2cm. The rate of new recurrence at 0–1 years was 13.7% (>2cm = 3.4%, <2cm = 10.3%), at 1–5 years it was 30.8% (>2cm = 9.5%, <2cm = 21.3%), at 5–10 years it was 40.1% (>2cm = 13.8%, <2cm = 26.3%) and at over 10 years it was 50.0% (>2cm = 25.0%, <2cm = 25.0%). Recurrence was associated with oesophagitis but not decreased QoL. Revision surgery was required in 4.8% of cases (14.8% with recurrence). There were no interval major GHH complications.

Conclusions

Surgery has provided sustained QoL improvements irrespective of recurrence. Recurrence occurred progressively over ten years and may predispose to oesophagitis.     

Late Presentation of Bochdalek-Type Congenital Diaphragmatic Hernia in Children: A 23-Year Experience at a Single Center

Purpose The purpose of this article is to report on our 23-year experience of treating children with late-presenting congenital diaphragmatic hernia (CDH), focusing on diagnostic difficulties, associated anomalies, and morbidity. Method We reviewed 19 children in whom Bochdalek-type CDH was diagnosed after the neonatal period, between 1983 and 2005. Results There were 14 boys and 5 girls, with a mean age of 18.3 months (range, 5 weeks–14 years). Ten (52.6%) of the patients presented with respiratory symptoms and five (26.3%) with gastrointestinal symptoms. The diagnosis of CDH was based on the findings of chest X-rays, gastrointestinal tract contrast radiographs, and computerized tomography findings. The CDH was on the left side in 16 patients and on the right side in three patients. A hernia sac was present in seven (36.8%) patients. The only postoperative complications were intestinal obstruction caused by adhesions, incisional hernia, and eventration of the diaphragm in one patient each. None of the patients died within this study period. Conclusion The possibility of a delayed presentation of CDH should be considered in the differential diagnosis of recurrent non-specific respiratory or gastrointestinal tract symptoms in a child. A plain roentgenogram with a swallowed nasogastric tube might assist in the diagnosis. Early surgical correction of the diaphragmatic defect is crucial for preventing life-threatening complications.     

Effectiveness on oral pain of 808-nm diode laser used prior to composite restoration for symptomatic non-carious cervical lesions unresponsive to desensitizing agents

This study compares sensitivity reduction after dental restoration with and without prior diode laser (DL) irradiation for cervical dentine hypersensitivity (CDH) from non-carious cervical lesions (NCCLs) unresponsive to desensitizing agents. Eighty-eight teeth of 28 subjects (21 females; age 23–64 years), with CDH from NCCL were included in this study. NCCLs of each oral quadrant were randomized in two groups (study group (SG)) to estimate the sensitivity reduction after dental restoration (SG-1) compared with the DL irradiation used prior to restoration placement (SG-2). The subjects were asked to rate the sensitivity experienced during air stimulation using a visual analog scale before (baseline), immediately after, and at 6 and 12 months from restoration. The outcomes showed a significant reduction of discomfort compared to baseline for NCCLs of SG-2 with the decrease of 78.5, 78.9, and 78.1 % immediately and at 6 and 12 months after restoration, respectively; in comparison with the decrease of 70.1, 67, and 65.3 % for NCCLs of SG-1 immediately and at 6 and 12 months after restoration, respectively; and compared to baseline. The DL irradiation prior to dental restoration can further improve the painful symptomatology of CDH from NCCL unresponsive to desensitizing agents.     

Congenital dislocation of the hip in Western Australia. A comparison of neonatally and postneonatally diagnosed cases

Speculation that neonatally diagnosed congenital dislocation of the hip (CDH) may have a different etiology from cases diagnosed in the postneonatal period has not been examined in Australia because insufficient data have been available. A population-based study of CDH in children up to the age of two years who were born in Western Australia (WA) in 1981, 1982, or 1983 is the subject of this report. Study material comprised cases of CDH from the WA Congenital Malformations Register and denominator data (all births in WA for 1981-1983) from the Health Department of WA. From this material, rates of CDH were calculated for each of the study variables of interest. The rate of CDH was low for babies born to aboriginal mothers, and it is postulated that this may have a cultural basis, possibly in infant carrying postures. Overall, the prevalence of CDH for 1981-1983 was 6.4 cases per 1000 births, with 4.2/1000 diagnosed in the neonatal period and 2.2/1000 in the postneonatal period. Epidemiologic differences were noted between infants diagnosed in the neonatal period and those diagnosed postneonatally; rates of neonatally diagnosed CDH were higher in first births, breech presentation, and postmature infants than were rates of postneonatally diagnosed cases. Bilateral dislocation was more common (45.3%) in neonatally diagnosed cases than in postneonatally diagnosed cases (23.3%). These findings tended to support the idea that the time of diagnosis may define two distinct entities in CDH.     

What is the best prosthetic material for patch repair of congenital diaphragmatic hernia? Comparison and meta-analysis of porcine small intestinal submucosa and polytetrafluoroethylene

BackgroundProsthetic patches are widely used for congenital diaphragmatic hernia (CDH) repair. We compared the complication rate of absorbable (Surgisis [SIS]; Cook Biotech, Inc, West Lafayette, IN) and nonabsorbable (polytetrafluoroethylene [PTFE]) materials for this purpose.MethodsThis is a retrospective review of all neonates with CDH undergoing patch closure at our institution over 10 years. Meta-analysis was also performed combining our data with the published literature examining the effect of patch type on recurrence and small bowel obstruction (SBO).ResultsPrimary patch (13 SIS, 9 PTFE) repair was performed in 22 (26%) of 84 patients with CDH. Groups were comparable in terms of demographics, hospital stay, ventilator days, need for high frequency oscillation, age at surgery, and length of follow-up. Likewise, recurrence rate (SIS, 4 [31%]; PTFE, 3 [33%]; P, nonsignificant [NS]), incidence of postoperative SBO (SIS, 1 [7%] vs PTFE, 2 [22%]; P, NS), and mortality (SIS, 2 [15%] and PTFE, 2 [22%]; P, NS) were similar. Meta-analysis failed to find a significant difference between SIS and PTFE both for recurrence rate (odds ratio, 1.21 [0.51-2.84]; P, NS) and SBO (odds ratio, 1.47 [0.44-4.96]; P, NS).ConclusionsThere was no difference in the incidence of CDH recurrence, SBO, or mortality post-CDH patch repair using either SIS or PTFE in our series. Meta-analysis failed to show any difference in recurrence and SBO rates between the 2 materials.