第一跖骨骨折的手术治疗

目的 探讨第一跖骨骨折的手术治疗方法.方法 2003年1月-2006年1月,手术治疗第一跖骨骨折17例,其中男15例,女2例;年龄11～65岁,平均40.5岁.第一跖骨基底部骨折4例,第一跖骨干骨折7例,第一跖骨头颈部骨折6例.其中4例为开放性骨折.采用的手术方法为切开复位钢板内固定、单纯螺钉固定,配以螺钉或克氏针同定较大的骨折块.结果 14例患者获得随访12～24个月,平均14个月.伤口Ⅰ期愈合,无感染.骨折愈合时间8～16周,平均10.5周.患者术后平均13周(9～18周)时可完全负重行走,无明显疼痛不适.采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)中前足评分标准,评分为78～i00分,平均86.3分.结论 第一跖骨骨折的解剖复位和确切内固定是维持足部正常形态、恢复足弓功能的关键.     

带线锚钉缝合固定腓骨肌腱治疗第五跖骨基底部撕脱性骨折

目的 回顾分析带线锚钉缝合固定腓骨肌腱治疗第五跖骨基底部撕脱性骨折的临床疗效.方法 5例第五跖骨基底部1区骨折患者(男3例,女2例),术前平均病程7 d.影像检查发现5例均为第五跖骨基底部1区骨折,骨折块较小、粉碎且明显移位.手术去除第五跖骨基底部粉碎骨折块,游离腓骨肌腱止点,用直径5 mm带线锚钉将腓骨肌腱止点编织缝合在第五跖骨基底部,石膏托将患侧足固定于外翻位.术后6周开始逐渐负重行走.结果 本组5例患者均获随访,随访时间在6个月以上;所有患足外观无畸形.前足主动外翻及外展功能恢复正常,与健侧对比力量无减弱.结论 带线锚钉缝合固定腓骨肌腱治疗第五跖骨基底部撕脱性骨折能较好解决小骨折块固定困难的问题,术后腓骨长短肌腱功能恢复好;手术具有操作简单、剥离范围小、无须二次手术等优点.     

胫骨中远1/3骨折应用交锁髓内钉治疗时腓骨骨折不予固定的临床观察

目的探讨胫骨中远1/3骨折应用交锁髓内钉治疗时同水平腓骨骨折不予固定的临床治疗。方法回顾性分析唐山市第二医院创伤骨科2014年5月-2017年7月胫腓骨中远1/3骨折患者34例,男性21例,女性13例;年龄19~63岁,平均40.5岁,均采用胫骨骨折交锁髓内钉固定,腓骨骨折不予固定。术后采用美国足与踝关节协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分评价踝关节情况。结果 34例患者术后均获得随访,随访时间12~24个月,平均13.6个月。患者均获得骨性愈合,骨折愈合时间为2~3个月,平均2.4个月。术后12个月随访无骨髓炎、骨折不愈合、畸形愈合、内固定断裂失效等病例。AOFAS踝与后足评分,评分84~96分,平均91.5分;其中优28例,良6例。结论胫骨中远1/3骨折应用交锁髓内钉治疗,腓骨骨折不予固定时患者胫腓骨骨折愈合率高,无胫骨骨折不愈合及畸形愈合发生。     

记忆合金弓齿钉内固定治疗第5跖骨基底部骨折

目的探讨记忆合金弓齿钉内固定治疗第5跖骨基底部骨折的临床疗效。方法本组25例,其中男18例,女7例,平均39岁。受伤原因:跌倒时扭伤19例,重物砸伤6例。22例为闭合性骨折,3例为开放性骨折,其中1例合并同侧距骨骨折。第5跖骨基底部Ⅰ区骨折14例,Ⅱ区骨折10例,Ⅲ区骨折1例。结果本组病例获8~28个月(平均18个月)随访。全部病例获得骨性愈合,平均愈合时间7.5周(6~10周)。未发生深部感染、骨不连、足部畸形等并发症。本组病例术后8个月~1年半左右再次手术将内固定顺利取出。按Mary-land足部评分系统评分,优20例,良5例,优良率100%。结论记忆合金弓齿钉治疗第5跖骨基底部骨折固定可靠,可使患者早期下床活动,获得满意的疗效,是一种较理想的内固定方式。     

后内侧入路切开复位内固定治疗后Pilon骨折的疗效分析

目的评估后内侧切口治疗后Pilon骨折的临床疗效。方法回顾分析2008年4月~2013年4月我院139例后踝骨折患者临床资料,根据入院时的影像学资料,其中29例诊断为后Pilon骨折,并采用后内侧切口行切开复位内固定治疗且资料完整。男性19例,女性10例;年龄21~74岁,平均46.3岁。损伤原因包括坠落伤12例,平地扭伤10例,道路交通伤7例;均伴外踝骨折及关节软骨面塌陷;所有患者足踝部肿胀、畸形及活动受限。受伤至手术时间1~11d,平均5.3d;术后定期随访切口及骨折愈合情况,并采用美国足踝外科学会(AOFAS)踝与后足功能评分系统评价术后疗效。结果 29例均获随访,随访时间15~47个月,平均24.6个月。所有患者切口均一期愈合;术后2d X线片显示,解剖复位(胫骨远端关节面无台阶,踝穴正常)26例,复位良好(胫骨远端关节面移位1mm,踝穴增宽1mm)3例,解剖复位率89.7%;29例骨折均愈合,愈合时间12~21周,平均15.2周。末次随访时AOFAS评分为81~100分,平均89.5分,其中优21例,良8例,优良率100%。结论后Pilon骨折采用后内切口可完全暴露整个后内侧骨折块,有利于骨折复位和固定,临床疗效满意,应作为治疗后Pilon骨折的首选入路。     

股骨逆行髓内钉治疗全膝关节置换术后Kim ⅠB型股骨髁上骨折

目的探讨逆行髓内钉固定治疗全膝关节置换术后股骨髁上骨折的手术方法及临床疗效。方法采用回顾性病例描述研究分析。2012年2月-2016年8月四川大学华西医院骨科、成都市第二人民医院骨科应用髓内钉逆行固定全膝关节置换术后KimⅠB型股骨髁上骨折40例,男性25例,女性15例;年龄37~76岁,平均60.5岁。记录术中出血量、手术时间、骨折愈合时间、并发症,随访Neer评分、VAS评分。结果手术时间40~70min,平均52.1min;术中出血量30~105mL,平均65.5mL;骨折全部愈合,愈合时间17~33周,平均20.8周。无内固定松动、断裂,骨髓炎不良情况。40例均完成随访,随访时间13~35个月,平均20.6个月;Neer评分平均85.2分。40例患者中非常满意10例,满意24例,不满意6例,总满意率为85.0%(34/40)。患者术后2周VAS评分平均32.1分,功能25.3分,运动18.3分,解剖重建8.8分;术后2年VAS评分平均77.1分。结论股骨逆行髓内钉治疗全膝关节置换术后KimⅠB型股骨髁上骨折疗效确切,创伤小,恢复快,值得临床推广。     

经三角肌入路微创钢板技术治疗肱骨大结节骨折

目的探讨分析经三角肌入路微创钢板技术(minimally invasive plate osteosynthesis,MIPO)治疗肱骨大结节骨折的手术方法及临床效果。方法回顾性分析笔者医院2010年6月~2014年6月收治的15例粉碎性移位型肱骨大结节骨折病例,其中男性9例,女性6例;年龄29~63岁,平均41.3岁。所有病例均采用经三角肌前中束间隙入路MIPO微创钢板内固定技术,通过分析手术时间、术中出血、住院时间、骨折愈合情况及术后患者功能恢复情况进行疗效评。结果本组平均手术时间52.5min(45~90min),平均术中出血量85.3mL(60~110mL),平均住院时间7.2d(5~12d),15例患者均骨性愈合。本组15例均得到随访,平均随访时间16.3个月(10~26个月);平均骨折愈合时间4.2个月(3~6个月),1例出现伤口浅表感染。末次随访,按照肩关节Neer功能评分,平均(88.7±4.5)分(78~94分)。功能评价:优9例,良4例,中2例,优良率86.7%。疼痛视觉模拟评分(VAS)为0~3分,平均0.8分。结论经三角肌入路MIPO技术治疗粉碎性移位型肱骨大结节骨折具有微创、并发症少、固定可靠、住院时间短等特点,临床疗效满意。     

微创Bunnell缝合法辅助小切口技术治疗急性闭合性跟腱断裂

目的分析微创Bunnell缝合法辅助小切口技术治疗急性闭合性跟腱断裂的临床疗效及应用价值。方法回顾性分析2016年1月—2018年1月首都医科大学良乡教学医院应用微创Bunnell缝合法辅助小切口技术治疗急性闭合性跟腱断裂20例,男性16例,女性4例;年龄22～40岁,平均32.6岁;术前美国足踝外科协会(AOFAS)踝与后足功能评分(44.6±3.6)分;Amer-Lindholm疗效评定标准评价均为差。术前超声检查均显示跟腱完全断裂。术中记录手术时间、出血量,术后密切随访,记录AOFAS评分及活动度。结果手术时间25～40min,平均30.5min;术中出血量20～40mL,平均26.5mL。术后切口均一期愈合,无感染及腓肠神经损伤。患者均获得随访,随访时间12～18个月,平均15.4个月。术后12个月,AOFAS踝与后足功能评分为(94.1±3.7)分,其中优19例,良1例,优良率100%; Amer-Lindholm疗效评定标准评价,优16例、良4例,优良率100%。结论微创Bunnell缝合法辅助小切口技术治疗急性闭合性跟腱断裂具有手术时间短、创伤小、操作简单及术后恢复良好的优点。     

关节镜辅助下空心钉内固定治疗伴后踝骨折的踝关节骨折

目的探讨关节镜辅助下空心钉内固定治疗后踝骨折的临床疗效。方法对2009年1月~2012年12月收治的16例伴有后踝骨折的踝关节骨折病例资料进行回顾性研究,其中男性11例,女性5例;年龄19~65岁,平均26岁。损伤按照Lauge-Hansen分类:旋后外旋型Ⅲ度损伤3例,旋后外旋型Ⅳ度损伤10例,旋前外旋型Ⅳ度损伤3例。骨折按照AO/OTA分型:43-B2型4例,43-B3型10例,43-C3型2例。所有患者先于仰卧位对外踝和(或)内踝进行固定,然后同时使用踝关节镜进行前踝关节镜检查,根据探查情况同时行游离碎骨块取出、韧带清理、微骨折等治疗。再行俯卧位手术,于踝关节镜下行后踝复位、空心钉固定及其它处理。术后通过临床检查、影像学评估、美国足踝外科学会(AOFAS)的踝-后足评分和视觉模拟评分(VAS)对临床结果进行评估。结果 16例术后获12~32个月(平均19个月)随访,骨折愈合时间为10~16周(平均12.8周)。末次随访时AOFAS踝-后足评分为83~100分(平均93.4分),VAS评分为0~3分(平均1.2分),无踝关节创伤性关节炎的表现。结论使用关节镜辅助空心钉内固定治疗合并后踝骨折的踝关节骨折临床疗效良好,且具有创伤小、疗效好、并发症少等优点。     

边对边H形缝合治疗外侧半月板后根部Forke & Petersen Ⅱ型损伤疗效分析

目的:探讨边对边H形缝合治疗外侧半月板后根部Forke&PetersenⅡ型损伤的手术方法及近期疗效。方法:我科自2010年6月至2013年6月对28例外侧半月板后根部Forke&PetersenⅡ型损伤患者采用关节镜下边对边H形全内缝合进行修补,同时处理其他损伤。以末次随访MRI检查及二次关节镜检评估其愈合情况,采用Lysholm评分评价其术后膝关节功能恢复情况。结果:26例患者获随访,随访时间15~36个月,平均24个月,所有患膝关节活动度正常,Lysholm评分由术前59±5.3分提高到94.4±2.8分(t=35.07,P=0.00),差异具有统计学意义;术后末次随访MRI提示外侧半月板根部断裂部位愈合,连续性完整;13例患者在术后6~10个月(平均8个月)进行了二次关节镜检,提示均完全愈合,未见明显损伤,半月板张力良好。结论:边对边H形全内缝合技术可用于治疗外侧半月板后根部Forke&Peters-enⅡ型损伤,具有创伤小、二次镜检愈合率高等优点,具有良好的近期疗效。     

Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis

BACKGROUND: Fractures of the proximal fifth metatarsal, other than those involving the tuberosity, have a tendency to delayed union or even nonunion. HYPOTHESIS: Tension-band wire technique is a good alternative in treating fractures of the fifth metatarsal located in the proximal junction of the metaphysis and the diaphysis. STUDY DESIGN: Case series; level of evidence, 4. METHODS: Between 1996 and 2001, a total of 27 cases of proximal metaphysial/diaphysial fractures of the fifth metatarsal were treated with tension-band wiring. All of the patients had undergone prior unsuccessful nonoperative or operative treatment. The mean delay from the diagnosis of the fracture to the final operative procedure was 19.5 weeks (range, 6-48 weeks). RESULTS: The mean length of follow-up was 35 months (range, 12-70 months). All patients were able to return to their prior levels of activity. The mean time for union as shown on radiographs was 12.8 weeks, and the return to full activity took 8 to 20 weeks (mean, 14.7 weeks). There were no delayed unions, nonunions, or refractures during the follow-up. CONCLUSION: The tension-band wire technique seems to give good results in the treatment of proximal metaphysial/diaphysial fractures of the fifth metatarsal in cases of primary unsuccessful nonoperative treatment or primary unsuccessful intramedullary screw fixation.     

Fractures of proximal portion of fifth metatarsal bone: anatomic and imaging evidence of a pathogenesis of avulsion of the plantar aponeurosis and the short peroneal muscle tendon

PURPOSE: To evaluate the normal anatomy of the structures supporting the proximal portion of the fifth metatarsal bone and investigate the pathogenesis of fractures in this region. MATERIALS AND METHODS: In two cadaveric feet, the region of the lateral component of the plantar aponeurosis (PAL), short peroneal muscle (SPM) tendon, and third peroneal muscle (TPM) tendon was dissected. These two foot specimens and four nondissected foot specimens were studied at magnetic resonance (MR) imaging. Two of the six specimens were studied at computed tomography (CT). Sectioning the nondissected foot specimens enabled anatomic correlation. In two additional specimens, simulation of the presumed mechanism of fifth metatarsal bone fracture was attempted. The radiographic, CT, and MR images obtained in 13 patients with fractures of the proximal portion of the fifth metatarsal bone were evaluated. RESULTS: Anatomic, CT, and MR imaging studies revealed broad insertion of the PAL into the plantar aspect of the proximal portion of the fifth metatarsal bone in all specimens. The SPM tendon was consistently attached more distally and to the lateral side of the tuberosity, blending with the PAL fibers. The TPM tendon was inconsistently identified inserting anteriorly to the SPM tendon. No fracture was created in the specimens subjected to attempted injury. Frequent attachment of the PAL and the SPM tendon to the avulsed fragment was confirmed in clinical cases. CONCLUSION: The pathogenesis of fractures of the proximal portion of the fifth metatarsal bone appears to be related to avulsion injury of PAL and SPM tendon fibers.     

Fractures of the base of the fifth metatarsal

In 1902 Sir Robert Jones described a fracture of the fifth metatarsal which he incurred while dancing. Since that time, fractures of the base of the fifth metatarsal have been called "Jones fractures". Fractures of the tuberosity at the base of the fifth metatarsal are common and usually respond readily to conservative treatment. Less frequently the fracture occurs more distally through the proximal metaphysis. Eleven patients with fractures of the proximal metaphysis were reviewed to determine if they represented a clinically distinct subgroup. Seven of the patients were men between 19 and 25 years of age who fractured the fifth metatarsal playing sports. The fractures were slow to heal and one required internal fixation with bone grafting. Fractures of the proximal metaphysis of the fifth metatarsal have a different mechanism of injury and a less favourable prognosis than do tuberosity fractures. When they occur in young athletes, more aggressive treatment is required.     

经踝后内侧入路结合无头加压空心钉内固定治疗距骨后突内侧结节骨折

目的评估经踝后内侧入路结合无头加压空心钉内固定治疗距骨后突内侧结节骨折的疗效。方法 2012年1月—2015年12月上海市黄浦区中心医院骨科共收治5例距骨后突内侧结节骨折患者,其中男性3例,女性2例;年龄27~62岁,平均46.2岁。单纯距骨后突内侧结节骨折1例,合并距下关节脱位者4例。所有患者入院后常规行X线摄片及三维CT检查以明确受伤情况,待软组织条件允许后,于伤后1周左右(第4~10天)行经踝后内侧入路切开复位螺钉内固定治疗。术后患者定期复查X线片,并采用美国足踝外科协会(AOFAS)踝与后足评分系统评估功能恢复情况。结果所有患者术后均获随访,平均随访12.3个月(8~14个月)。5例均无伤口感染、神经损伤等并发症发生。术后AOFAS踝与后足评分平均为84分(57~94分)。1例于术后1年继发创伤性关节炎。结论经踝后内侧入路结合无头加压空心钉治疗距骨后突内侧结节骨折安全可靠,术中可清晰暴露,复位固定良好,避免了内踝截骨。     

钢板与螺钉内固定治疗后踝骨折的临床疗效比较

目的比较钢板与螺钉内固定治疗后踝骨折的疗效。方法回顾性分析2015年3月-2017年3月甘肃省天水市四零七医院脊柱关节科治疗的66例后踝骨折患者。男性36例,女性30例;年龄21~63岁,平均39.6岁。根据手术方法不同分为钢板内固定33例(钢板组)和螺钉内固定33例(螺钉组),观察并比较两组患者手术时间、术后住院时间、术后完全负重时间、骨折愈合时间、踝关节活动度及美国足踝外科协会(AOFAS)踝与后足功能评分。结果患者获得随访:钢板组(24.7±11.3)个月,螺钉组(23.8±10.3)个月(t=0.338,P=0.736);手术时间:钢板组(77.8±13.9)min,螺钉组(67.8±14.6) min(t=2.850,P=0.006);术后住院时间:钢板组(6.6±1.7) d,螺钉组(6.4±1.8) d(t=0.464,P=0.644);术后完全负重时间:钢板组(9.2±2.1)周,螺钉组(10.8±2.2)周(t=3.022,P=0.004);骨折愈合时间:钢板组(11.6±2.7)周,螺钉组(12.5±2.9)周(t=1.304,P=0.197)。术后6个月随访时AOFAS评分:钢板组(89.5±6.5)分,螺钉组(82.3±6.4)分(t=5.731,P<0.001);末次随访时AOFAS评分:钢板组(91.4±6.3)分,螺钉组(91.3±6.7)分(t=0.0623,P=0.950);术后6个月随访时踝关节活动(背屈、跖屈、内翻、外翻)范围:钢板组(19.4±3.5)°、(38.6±5.7)°、(19.8±3.7)°、(24.7±4.4)°,螺钉组(17.2±4.6)°、(35.2±4.8)°、(17.2±3.2)°、(22.1±5.3)°;末次随访时踝关节活动(背屈、跖屈、内翻、外翻)范围:钢板组(20.3±4.3)°、(40.3±5.5)°、(21.2±3.5)°、(26.2±4.2)°,螺钉组(19.8±4.3)°、(41.3±5.5)°、(20.8±3.5)°、(26.8±4.2)°。两组术后6个月随访时踝关节活动度比较差异有统计学意义(P<0.05),而末次随访时,两组踝关节活动度比较,差异无统计学意义(P>0.05)。结论对于后踝骨折,采用钢板或螺钉内固定治疗均可获得满意临床疗效。采用钢板固定,患者可早期完全负重活动,早期(术后6个月)踝关节功能更优,而螺钉固定手术创伤较小。     

前后联合切口入路治疗累及后柱的复杂胫骨平台骨折疗效分析

目的探讨前后联合切口入路治疗累及后柱的复杂胫骨平台骨折的临床疗效。方法回顾性分析惠州市中心人民医院创伤骨科2012年1月~2014年1月收治的累及后柱的复杂胫骨平台骨折患者22例,其中男性14例,女性8例;年龄20~70岁,平均49.7岁。致伤原因:道路交通伤15例,坠落伤7例。平台前外侧骨折6例,前内侧骨折11例,前内、前外广泛骨折5例。受伤至手术时间3~14d,平均6.5d。22例均采取前内侧或前外侧联合后内侧倒"L"型切口入路+支撑钢板内固定术治疗,分析患者的临床资料、手术时间、术中出血量、住院时间、术中并发症(切口感染、内固定松动或断裂情况)、骨折愈合时间(以X线片下骨折线消失为准)以及术后12个月膝关节美国特种外科医院(HSS)评分。结果所有患者手术顺利,手术时间(173.4±40.3)min,术中出血量(187.5±53.1)mL,术后住院时间(16.3±4.6)d,骨折愈合时间(31.2±7.5)周。术中及术后无严重手术相关并发症。所有患者获得随访,平均随访时间(15.3±4.9)个月;术后12个月时膝关节HSS评分为(84.6±17.3),优良率为81.8%(18/22),两侧膝关节活动度差异无统计学意义(P0.05)。结论对于累及后柱的复杂胫骨平台骨折,前内侧或前外侧联合后内侧倒"L"型切口入路对组织损伤小,骨折端暴露充分,利于直视下复位内固定,对膝关节远期影响较小。     

小切口取部分腓骨短肌腱重建踝关节外侧副韧带

目的 介绍小切口取部分腓骨短肌腱解剖重建外侧副韧带治疗慢性踝关节外侧不稳的疗效.方法 11例慢性踝关节外侧不稳患者接受小切口取部分腓骨短肌腱解剖重建踝关节外侧副韧带的手术治疗,年龄16～42岁,平均27.6岁.术前病程4～32个月,平均10.3个月.术后定期行双侧踝关节对比稳定检查、应力位X线片及MRI检查,并按美国足踝外科协会(AOFAS)踝-后足功能评分表进行功能评分.结果 11例患者术后平均随访17.5个月(12～37个月).AOFAS踝-后足功能评分平均88.3分(72～96分),其中优6例(55%),良4例(36%),一般1例(9%).术后复查MRI证实重建韧带恢复良好.随访期间未发现踝关节不稳复发或其他并发症.结论 小切口取部分腓骨短肌腱解剖重建踝关节外侧副韧带是治疗慢性踝关节外侧不稳一种安全、有效的方法.     

Stress fractures in figure skaters

In 1987, during two great skating contests--the Universiade in the Tatra Mountains and the Gold Pirouette in Zagreb--a total of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, 9 had stress fractures. Four stress fractures occurred during preseason training (two fibular, one second metatarsal, and two fourth metatarsal stress fractures). Increased mileage was reported by three skaters and the fourth had done too much speed training on hills. Five stress fractures occurred during the season (one tibial and two tarsal navicular stress fractures and two stress fractures of the base of the fifth metatarsal). In all cases, the fracture occurred in the take-off leg. All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The time from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Of the nine injured skaters, eight were treated conservatively and one skater with Jones' fracture was treated surgically. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after treatment began. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility.