不同筋膜血管蒂骨瓣植入治疗舟状骨陈旧性骨折

目的介绍利用不同筋膜血管蒂桡骨茎突骨瓣植入治疗陈旧性腕舟状骨骨折的疗效。方法2002年9月-2010年5月,采用以桡动脉返支为蒂的骨瓣,或以骨间背动脉桡侧终末支的筋膜蒂骨瓣植入结合内固定治疗腕舟状骨陈旧性骨折41例。结果38例经6～27个月（平均19．3个月）的随访,X线片显示腕舟骨骨折均在术后4～6个月获得骨性愈合,愈合率达100％。腕关节活动度为4例腕掌屈60°背伸50°34例腕掌屈达70°-80°．背伸45°-55°。腕关节活动时无疼痛。腕关节功能按Krimmer评分表测定：总体疗效为优29例,良9例。结论采用带不同血管蒂桡骨茎突骨瓣植入治疗舟状骨陈旧性骨折疗效确切。     

桡动脉腕掌支蒂桡骨瓣移植治疗腕月骨骨坏死

目的探讨应用桡动脉腕掌支蒂桡骨瓣移植治疗腕月骨骨坏死的手术方法。方法根据桡骨远端血液供应的解剖学基础,设计带桡动脉腕掌支蒂桡骨瓣,移植治疗腕月骨早期骨坏死6例。结果术后随访11个月～3年5个月,5例腕痛完全消失,1例腕关节用力活动后,出现酸痛不适。腕关节活动度明显改善,腕关节背伸平均45°,屈曲平均37°,患手握力比术前明显增加,达正常侧的85．6%。X线照片显示月骨密度恢复正常。结论桡动脉腕掌支蒂桡骨瓣移植治疗腕月骨骨坏死具有血管解剖恒定、血供可靠、手术操作简单,是治疗腕月骨早期骨坏死的一种有效手术方法。     

自体骨膜联合带蒂骨瓣移植替代月骨

目的 探讨治疗晚期月骨无菌性坏死、月骨陈旧性脱位的新术式。方法 对2例晚期月骨无菌性坏死及1例陈旧性月骨脱位行月骨摘除后,自体骨膜联合带血管筋膜蒂骨瓣移植替代月骨术。结果 随访8～36月,2例腕痛消失,1例腕痛缓解,保持了腕高、腕骨间的稳定和腕关节功能。X线照片示替代月骨骨瓣的位置及密度基本正常。结论 应用自体骨膜联合带蒂骨瓣移植作为月骨的替代物,对晚期月骨无菌性坏死及陈旧性脱位的治疗,操作简便、创伤小、临床效果好。     

头状骨移位治疗月骨无菌性坏死

目的 介绍以骨间前动脉背侧支为蒂的头状骨移位治疗晚期月骨无菌性坏死。方法 对18例Lichtman分Ⅲ、Ⅳ期月骨无菌性坏死患者采用坏死月骨摘除，以骨间前动脉背侧支为蒂的头状骨移位替代坏死月骨。结果 术后随访1～5年，平均32个月，移位头状骨有可靠血运，16例腕痛消失，2例仍有轻度腕痛，优良率100％。结论 应用该法替代月骨支撑腕关节，符合腕关节功能解剖，是治疗Ⅲ、Ⅳ期月骨无菌性坏死的有效方法。     

头状骨移位治疗月骨无菌性坏死

目的　介绍以骨间前动脉背侧支为蒂的头状骨移位治疗晚期月骨无菌性坏死。方法　对 18例Lichtman分Ⅲ、Ⅳ期月骨无菌性坏死患者采用坏死月骨摘除 ,以骨间前动脉背侧支为蒂的头状骨移位替代坏死月骨。结果　术后随访 1～ 5年 ,平均 32个月 ,移位头状骨有可靠血运 ,16例腕痛消失 ,2例仍有轻度腕痛 ,优良率 10 0 %。结论　应用该法替代月骨支撑腕关节 ,符合腕关节功能解剖 ,是治疗Ⅲ、Ⅳ期月骨无菌性坏死的有效方法     

带血管蒂骨瓣移植治疗腕舟骨骨不连

目的：总结带血管蒂骨瓣移植治疗腕舟骨骨不连的疗效。方法：以带桡动脉茎突返支桡骨瓣移植治疗3例,桡骨远端背外侧带血管蒂的骨瓣移植4例,带第2掌背动脉掌骨基底骨瓣移植1例。通过平均10个月的随访,观察骨折愈合和腕关节功能改善情况。结果：骨折全部愈合。腕关节功能评价：优6例,良1例,可1例。结论：该手术疗效较好,操作简单,副损伤小,是治疗腕舟骨骨不连的有效方法之一。     

头状骨带蒂移位与血管蒂骨瓣植入治疗月骨无菌坏死

目的 报道带骨间前动脉背侧支血管蒂的头状骨移位术与以桡动脉茎突返支为蒂的桡骨瓣植入术联合应用治疗月骨晚期缺血性坏死的结果。方法 对46例患者行坏死月骨摘除头状骨带蒂移位后以血管蒂骨瓣植入填塞头状骨空隙。结果 术后随访16～48个月，平均21．5个月，43例腕痛完全消失，3例明显缓解，握力平均达健侧的80％，腕关节活动范围达健侧的75％。结论 两种术式的联合应用对Ⅲ、Ⅳ期月骨缺血性坏死疗效显著。     

桡动脉腕掌支骨膜瓣治疗陈旧性舟状骨骨折

目的探讨应用桡动脉腕掌支骨膜瓣治疗陈旧性舟状骨骨折的临床疗效。方法根据桡动脉腕掌支解剖学基础,于桡骨远端掌侧切取桡动脉腕掌血管穿支骨膜瓣,同时采用自体松质骨植骨、克氏针内固定治疗10例陈旧性舟状骨骨折患者。术后定期行腕关节X线、三维CT检查,观察舟状骨骨折愈合情况。结果患者均获得随访,时间6~23个月。术后4~7个月舟状骨骨折全部愈合。末次随访时根据Krimmer标准评价疗效:优5例,良3例,可2例。结论桡动脉腕掌支骨膜瓣血供丰富,血管蒂长,旋转弧度大,是治疗陈旧性舟状骨骨折不愈合较好的方法。     

带血管蒂骨膜瓣移位修复舟骨骨折的解剖与临床

目的通过解剖学观测,为腕背支骨膜瓣的临床应用提供依据.方法50侧成成人尸体上肢标本,观测骨间前动脉腕背支的走行、分支、分布及吻合情况,设计腕背支及其分支为蒂骨膜瓣移位术.结果(1)腕背支距桡骨茎突上(6.0±1.0)cm处,贴骨间膜背份下行分为内、外侧终支,分别与尺、桡动脉的腕背支相吻合.腕背支近端两侧分出尺、桡侧骨皮支,二者降支循尺、桡骨背份走行,并分出骨膜支分布;(2)临床应用15例,术后3～5个月骨折愈合,腕关节功能恢复.结论以骨间前动脉腕背支为蒂的骨膜瓣可用于舟、月骨损伤修复.     

头状骨带蒂移位与血管蒂骨瓣植入治疗月骨无菌坏死

目的：报道带骨间前动脉背侧支血管蒂的头状骨移位术与以桡动脉茎突返支为蒂的桡骨瓣植入术联合应用治疗月骨晚期缺血性坏死的结果。方法：对４６例患者行坏死月骨摘除,头状骨带蒂移位后以血管蒂骨瓣植入填塞头状骨空隙。结果：术后随访１６～４８个月,平均２１．５个月,４５例腕痛完全消失,１例明显缓解,握力平均达健侧的８０％,腕关节活动范围达健侧的７５％。结论：２种术式的联合应用对Ⅲ、Ⅳ期月骨缺血性坏死疗效显著。     

以掌背动脉为蒂尺骨远段背侧骨瓣移位术的应用解剖

目的 为以掌背动脉为蒂的尺骨远段背侧骨瓣移位修复第３、４、５掌骨头缺损提供解剖学依据。方法 在３０侧成人上肢标本上解剖,观察腕背动脉网的构成及分支。结果 腕背动脉网由桡动脉及尺动脉腕背支及与骨间后动脉终末支,骨间前动脉腕背支吻合形成,由该网发生第２、３、４掌背支,第２、３、４掌背动脉由掌背支与掌深弓所发深支吻合而成。结论 以第３、４掌背动脉为蒂的尺骨远端背侧半片骨瓣,可修复第３、４、５掌骨头缺损。     

Volar versus dorsal plating in the management of intra-articular distal radius fractures

PURPOSE: To compare the complications and functional and radiographic outcomes of volar and dorsal plating of intra-articular distal radius fractures. METHODS: This retrospective review included 34 patients found by searching a database of 350 patients treated for distal radius fractures. Inclusion criteria were (1) at least 1 year of follow-up data and (2) open reduction and internal fixation of a multifragmentary fragment intra-articular distal radius fracture with either a nonlocking volar or dorsal plate. Twenty patients were treated with a dorsal plate and 14 patients were treated with a volar nonlocking plate. Objective and subjective outcome parameters were compared between the 2 groups. Objective evaluations included wrist range of motion, grip strength, and preoperative and postoperative radiographic parameters (radial inclination, palmar tilt, ulnar variance, fracture pattern). Subjective evaluations were performed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score and the Gartland and Werley score. RESULTS: Volar plating resulted in a significantly better Gartland-Werley score compared with dorsal plating. There were no significant differences in the DASH score.Volar collapse was documented in 5 of the 20 patients in the dorsal plating group, which resulted in a mild loss of pronation compared with the volar plating group. No collapse occurred in the volar plating group. In addition the difference in the percentage of wrist range of motion compared with the contralateral wrist was not significant. Dorsal plating was associated with a ruptured extensor indicis tendon in 1 patient; secondary surgical procedures were required in 4 patients (tenolyses and radial styloidectomy). Volar plating was associated with median nerve neuropathy in 2 patients and intersection syndrome in one. CONCLUSIONS: Although both groups of patients had similar DASH scores the functional outcome in terms of Gartland and Werley scores was better in the volar plating group. In addition there was a higher rate of volar collapse and late complications in the dorsal plating group compared with the volar plating group. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Pedicled vascularized bone grafts for disorders of the carpus: scaphoid nonunion and Kienbock's disease

The use of reverse-flow pedicled vascularized bone grafts from the dorsal distal radius makes it possible to transfer bone with a preserved circulation and viable osteoclasts and osteoblasts. The resultant primary bone healing without creeping substitution within the dead bone is an alternative to conventional bone grafting in aiding or accelerating healing, replacing deficient bone, and/or revascularizing ischemic bone. Recent advances in understanding the anatomy and physiology of vascularized pedicled bone grafts have increased their use in treating a variety of carpal maladies. A basic understanding of the vascular anatomy, as well as the surgical principles and experimental and clinical results of pedicled vascularized bone grafts from the dorsal distal radius, is critical to understanding the use of these grafts in the treatment of scaphoid nonunions and Kienbock's disease.     

以第一、二伸肌腱鞘支持带上动脉为血管蒂的桡骨瓣治疗舟骨骨不连

目的 探讨以第一、二伸肌腱鞘支持带上动脉(1,2 ICSRA)为血管蒂的桡骨瓣带蒂逆行转移治疗舟骨骨不连的手术指征、技术和疗效.方法 2007年2月至2010年10月,我科对15例舟骨骨不连患者,应用以1,2 ICSRA为血管蒂的桡骨瓣远端蒂转移植骨内固定进行治疗.其中腰部骨不连9例,近端骨不连6例.9例伴有近端骨折块缺血性坏死;3例伴有舟状骨弓背畸形及嵌入体背伸不稳(DISI);2例伴有桡骨茎突关节炎表现.所有病例均采用腕桡侧纵形切口,13例予以交叉克氏针内固定,2例行单枚Herbert螺钉附加1枚克氏针固定.12例将带血管蒂植骨块从舟骨背侧嵌插植入,3例将植骨块楔形修整后自舟骨掌侧植入.术后随访骨折愈合时间、腕痛、腕关节活动度及握力等情况.结果 术后随访时间为6～ 21个月,平均13个月,2例失访.所有随访病例X线片显示舟骨均获得骨性愈合,平均愈合时间为14.2周.所有患者腕痛消失,腕关节屈曲(59.92±4.82)°,背伸(49.73±4.58)°.根据改良的Mayo腕关节功能评分标准评定:优9例,良2例,可2例;优良率为84.6％.结论 以1,2 ICSRA为血管蒂的桡骨瓣逆行转移植骨手术,能促进舟骨骨不连的愈合,特别对有近端骨块缺血性坏死的患者疗效显著.     

应用桡动脉茎突返支为蒂的桡骨骨瓣或骨膜瓣移植治疗腕舟骨骨折不连接

目的观察以桡动脉返支为蒂的桡骨骨瓣或骨膜瓣移植对腕舟骨骨折不连接的治疗作用.方法20例腕舟骨骨折骨不连,应用桡动脉返支为蒂的桡骨骨瓣移植加桡骨茎突切除治疗12例,应用桡动脉返支为蒂的桡骨骨膜瓣移植加桡骨茎突切除治疗8例.测量手术前后腕关节屈伸和尺桡偏活动度、握力,应用腕舟评分对患者的自觉功能恢复情况进行评定.结果20例腕舟骨骨折骨不连均愈合,愈合时间平均为7±0.2周(6～12周).腕舟骨评分结果为:优16例,良3例,可1例.结论以桡动脉返支为蒂的桡骨骨瓣或骨膜瓣移植加桡骨茎突切除是治疗腕舟骨骨折骨不连的有效方法.     

以桡动脉返支为蒂的桡骨骨膜骨瓣移位治疗舟骨骨不连

目的　介绍带蒂桡骨骨膜骨瓣治疗腕舟骨骨不连的术式。方法　自 1986年 3月以来 ,选择 2 6例腕舟骨陈旧性骨折骨不连 ,设计并应用带蒂桡骨骨膜骨瓣移位植入 ,骨瓣为 1.0 cm× 0 .4cm× 0 .5 cm,术后观察其疗效。结果　 2 6例腕舟骨骨折骨不连患者切口均 期愈合 ,骨不连在术后 2～ 3个月内获得骨性愈合 ,腕关节功能基本恢复正常。结论　该术式是治疗腕舟骨骨折骨不连的一种有效方法     

Revascularization procedures for Kienböck disease

The goals of treatment in Kienb?ck disease include preservation of wrist function, maintaining normal wrist kinematics, and revascularization of the necrotic lunate when and if possible. A variety of pedicled vascularized bone graft options exist and include but are not limited to pedicled grafts from the volar radius, dorsal radius, metacarpal heads or bases, and pisiform. Of the various treatment options, pedicled vascularized bone grafts from the dorsal distal radius based on the fourth and fifth extensor compartment arteries has been successful in the revascularization of the necrotic lunate at our institution. Vascularized bone grafting is an attractive alternative to conventional bone grafting by improving the local biological environment and thereby promoting revascularization. Recent advances in the anatomy and physiology of vascularized pedicled bone grafts have increased our ability to apply them to the treatment of Kienb?ck disease. The purpose of this article is to describe the various types of pedicled vascularized bone graft available, to detail the vascular anatomy of the dorsal distal radius, and to describe the surgical technique of our preferred vascularized bone graft (the fourth+fifth extensor compartment artery graft). In addition, the indications, contraindications, and outcomes are described.     

桡动脉返支骨瓣移植治疗手舟骨AO-B型陈旧性骨折

目的:探讨应用桡动脉茎突返支骨瓣治疗手舟骨AO-B型陈旧性骨折的临床疗效。方法:2007年10月到2011年10月采用桡动脉返支骨瓣移植术治疗41例陈旧性手舟骨骨折患者,男26例,女15例;年龄16～43岁,平均(27.3±4.5)岁;手术前病程6～22个月,平均11个月。均属于AO分型的B型,即手舟骨腰部陈旧性骨折。术前及术后6个月复查时对所有患者腕部功能依据Cooney腕关节评分系统评分,同时在随访过程中注意观察患者骨愈合情况。结果:36例患者获完整随访,随访时间4～15个月,平均(8.3±2.4)个月。所用患者手术切口愈合良好,无感染等并发症发生。随访过程中影像学证实骨折均完全愈合,患者Cooney腕关节评分由术前53.61±13.97提高到术后的81.81±8.71(P<0.01).末次随访时疗效优13例,良8例,中15例。结论:桡动脉返支骨瓣移植术是一有效治疗陈旧性手舟骨骨折的方法,其治疗方法科学、疗效确切,具有较高的临床应用价值。     

Vascularized bone grafting from the dorsal distal radius for Kienböck's disease: technique, indications and review of the literature

The goals of surgical procedures in Kienb?ck's disease are to preserve wrist function, revascularize the necrotic lunate and maintain normal wrist kinematics when possible. Of the various treatment options, pedicled vascularized bone grafts from the dorsal distal radius permit the transfer of vascularized osseous tissue to the necrotic lunate in order to revascularize it. Vascularized bone grafting is an attractive alternative to conventional bone grafting by improving the local biological environment and thereby promoting revascularization. Recent advances in the anatomy and physiology of vascularized pedicled bone grafts have increased our ability to apply them to the treatment of Kienb?ck's disease. The purpose of this article is to describe the detailed vascular anatomy of the dorsal distal radius, the surgical technique, indications as well as contraindications of our preferred method of pedicled vascularized bone grafts of Kienb?ck's disease.