矮身材和侏儒症的双下肢内外结合延长术(二)(附638例报告)

（上期连载文章刊登于2005年第13卷第17期1285页） 3.4适应证问题 通过双下肢延长已成为成年人增加身高唯一有效的方法,已成为极少数有增高要求的成年人的一种追求和最终选择,既是对传统医疗服务模式的一种挑战,也是骨科医生新的使命.现代健康标准是“身心快乐,感觉良好,语言清晰,交往和谐,从个体角度有能力达到其人生目标.”[36]而远非是“临床上查不出阳性体征就是没有病,没有疾病就是健康”的传统的生物医学观点。     

带锁髓内钉治疗胫骨骨折(附76例报告)

目的 总结带锁髓内钉治疗胫骨骨折的经验。方法 采用带锁髓内钉内固定的不同类型的胫骨骨折76例。其中闭合骨折55例，开放骨折21例。76例平均随访时间17．9个月(4～31个月)。疗效评定采用Johner-wruh评分标准。结果 在55例闭合骨折中，优49例，良5例，中1例；21例开放骨折，优17例，良3例。差1例。术后均无继发性骨筋膜室综合征，无神经损伤、钉体断裂和感染。结论 带锁髓内钉适用于治疗胫骨骨折，非扩髓带锁髓内钉适于开放骨折和多发伤；早期手术并不影响预后。且可减少并发症。     

不扩髓带锁髓内钉治疗胫骨骨折(附43例报告)

目的　报告 1995年 5月～ 1998年 12月应用不扩髓带锁髓内钉治疗胫骨骨折 43例。方法　采用不扩髓带锁髓内钉治疗胫骨骨折 ,闭合复位 38例 ,切开复位 5例。结果　随访半年以上 30例 ,骨折全部愈合。结论　胫骨不扩髓带锁髓内钉应用后取得了满意的疗效 ,是治疗胫骨骨折的较好方法 ,易于在各级医院开展。     

交锁髓内钉治疗股骨干粉碎骨折的远期疗效(附1 38例报告)

目的对应用交锁髓内钉治疗股骨干粉碎骨折的临床经验进行总结。方法施行鱼口交锁髓内钉治疗股骨干粉碎骨折138例,其中Ⅲ型、Ⅳ型98例,开放23例。结果随访平均18.4个月,优良率97.8％。迟发感染1例,断、弯髓内钉各1例,断弯螺丝钉6例,均骨性愈合。结论除个别特殊情况外,交锁髓内钉是股骨干粉碎骨折的最佳治疗     

不扩髓带锁髓内钉治疗胫骨骨折(附25例报告)

带锁髓内钉治疗胫骨骨折逐渐开展起来，但术中多行扩髓，对手术辅助设备要求较高。不宜在基层医院推广。为探讨不扩髓带锁髓内钉内固定的可行性及临床价值，我院自1999年11月至2002年5月应用不扩髓带锁髓内钉治疗胫骨骨折25例，本文就治疗中的一些问题讨论。     

有限切开功能复位在下肢长管状骨骨折带锁髓内钉固定术中的应用(附213例报告)

[目的]总结带锁髓内钉治疗下肢长管状骨骨折的临床经验。[方法]带锁髓内钉治疗下肢长管状骨骨折213例，其中68例采用小切口或有限切口复位，严重粉碎性骨折达到功能复位。术后行包括CPM在内的有序功能锻炼。[结果]获得随访205例，时间8-29个月，平均13个月。Ⅰ期愈合189例，延迟愈合16例，经动力化或植骨后，全部骨性愈合，优良率为95．1％。[结论]带锁髓内钉是治疗下肢长管状骨骨折的理想方法，术中骨折复位与保护骨折块血供并重的观念是正确的。     

小切口开放复位带锁髓内钉治疗下肢骨干骨折

目的 探讨应用小切口开放复位带锁髓内钉治疗下肢骨干骨折的临床疗效。方法回顾分析自2002年1月至2007年6月,应用带远端瞄准器的顺行带锁髓内钉治疗下肢骨干骨折103例。结果骨折大部分愈合,平均愈合时间为5．2个月。骨不连2例,并发症发生率为11％。结论小切口开放复位带锁髓内钉是治疗下肢骨干骨折的一种较好的方法,具有损伤小,骨折愈合率高、功能恢复好的优点,尤其适合在基层医院推广应用。     

A comparative study of the therapeutic effect between long and short intramedullary nails in the treatment of intertrochanteric femur fractures in the elderly

Purpose: To compare the clinical effects of long vs. short intramedullary nails in the treatment of intertrochanteric fractures in old patients more than 65 years old. Methods: A retrospective analysis of 178 cases of intertrochanteric fractures of the femur (AO type A1 and A2) in the elderly was conducted from January 2008 to December 2013. There were 85 males (47.8%) and 93 females (52.2%) with the age of 65e89 (70.2±10.8) years. The patients were treated by closed reduction and long or short intramedullary nail (Gamma 3) fixation. The length of short nail was 180 mm and that for long nail was 320e360 mm. The general data of patients, operation time, intraoperative blood loss, length of hospital stay, preoperative hemoglobin level, blood transfusion rate, postoperative periprosthetic fractures, infections, complications, etc were carefully recorded. Results: There were 76 cases (42.7%) in the long intramedullary nail group and 102 cases (57.3%) in the short nail group. All the cases were followed up for 12-48 (21.3±6.8) months, during which there were 21 deaths (11.8%), mean (13.8±6.9) months after operation. The intraoperative blood loss was (90.7±50.6) ml in short nail group, greatly less than that in long nail group (127.8±85.9) ml (p=0.004). The short nail group also had a significantly shorter operation time (43.5 min±12.3 min vs. 58.5 min±20.3 min, p=0.002) and lower rate of postoperative transfusion (42.3% vs. 56.7%, p=0.041). But the length of hospital stay showed no big differences. After operation, in each group there was 1 case of periprosthetic fracture with a total incidence of 1.1%, 1.3% in long nail group and 0.9% in short nail group. At the end of the follow-up, all patients achieved bony union. The average healing time of the long nail group was (6.5±3.1) months, and the short nail group was (6.8±3.7) months, revealing no significant differences (p=0.09). Postoperative complications showed no great differences either. Conclusion: Both the intramedullary long and short nail fixation has a good clinical effect in treating intertrochanteric femur fractures in the elderly. They showed no significant difference in terms of therapeutic effect, hospital stay and postoperative complications. The incidence of periprosthetic fractures treated by either length of nails was low. But short intramedullary nailing can obviously decrease the intraoperative blood loss, operation time and postoperative blood transfusion.     

掌指骨延长的研究进展

目的总结掌指骨延长的研究进展,探讨存在的问题及进一步研究方向。方法查阅近年国内外关于掌指骨延长的文献,并进行总结分析。结果目前有多种方法治疗手指短缩畸形,掌指骨延长法相对占优势。它包括一次性骨延长、骨痂延长、缓慢牵伸延长3种,每种方法均有优势和局限。但在截骨部位、延长长度及速度以及术后并发症等方面尚存争议。结论相对于一次性骨延长和骨痂延长术,缓慢牵伸延长术创伤小、并发症少,但远期疗效尚不明确,还需要长期临床随访观察。     

股骨闭合复位器辅助复位股骨交锁髓内钉固定治疗股骨干骨折的临床疗效分析

目的 探讨股骨闭合复位器辅助复位股骨交锁髓内钉固定治疗股骨干骨折的临床疗效。方法 回顾性分析手术治疗股骨干骨折的100例病人,其中股骨闭合复位器辅助复位股骨交锁髓内钉固定50例（复位器辅助组）,单纯牵引架牵引复位股骨髓内钉固定50例（牵引架辅助组）,比较两组的手术时间、出血量、导针反复进针次数、骨折愈合时间、需要骨折断端切开辅助复位例数及术后并发症发生率。结果 随访时间为12~18个月。复位器辅助组：骨折均愈合,愈合时间为4~8个月,无感染、内外翻、短缩畸形发生,术后Harris髋关节评分及美国特种外科医院（Hospital for Special Surgery, HSS）膝关节评分优良率均达92.0%。牵引架辅助组：发生骨不连1例,余病人骨折均愈合,愈合时间为4~9个月,无感染发生,无内外翻、短缩畸形发生,Harris及HSS评定标准优良率均达88.0%。两组手术时间、出血量、导针反复进针次数、骨折断端切开辅助复位例数比较,差异均有统计学意义（t=10.699,P＜0.001;t=22.517,P＜0.001;t=3.010,P=0.003;χ²=6.383,P=0.012）。骨折愈合时间、并发症发生率、髋膝关节功能优良率比较,差异均无统计学意义（t=0.646,P=0.520;χ²=1.010,P=0.315;χ²=0.444,P=0.505）。结论 股骨闭合复位器辅助复位股骨交锁髓内钉固定治疗股骨干骨折,操作简便、创伤小、效果可靠。     

211例下肢长骨骨折带锁髓内钉固定的临床评价

目的 对211例下肢长骨骨折带锁髓内钉内固定治疗的临床结果进行评价。方法 用不扩髓带锁髓内钉为主要固定方法，对211例股骨、胫骨骨折进行手术复位内固定治疗，术后进行包括CPM在内的有序功能锻炼。结果 获得随访189例，时间4～26个月，平均9个月。全组病例获得骨性愈合，无骨不连发生，骨折延迟愈合7例，膝关节功能受限4例。按Johner-wruch标准：优158例，良22例，中9例，优良率95．2％。结论 带锁髓内钉是治疗下肢长骨骨折较好的方法，其适应证较以往有进一步的拓展，术中骨折复位与保存骨折块血供并重的理念是正确的。     

Radiographic predictors of symptomatic locking screw removal after treatment of tibial fractures with intramedullary nails

IntroductionThe purpose of this study was to determine the radiographic parameters associated with symptomatic locking screw removal after intramedullary tibial nail insertion. Our hypothesis was that locking screws located closer to joints and those extending longer than the width of the bone result in more symptomatic implant removal.MethodsWe conducted a retrospective cohort study at our Level I trauma center. Seventy-five patients underwent surgical removal of symptomatic locking screws from 2007 to 2014 and were compared with a control group of 122 patients from the same time period who did not undergo symptomatic locking screw removal. Our main outcome measures were radiographic and demographic factors associated with implant removal.ResultsMultivariable regression indicated that a proximal locking screw that started anterolateral and was directed posteromedial was the strongest radiographic predictor of symptomatic removal (odds ratio [OR], 2.83; p = 0.03). An Injury Severity Score <11 (OR, 3.10; p < 0.001) and a body mass index <25 kg/m² (OR, 2.15; p = 0.02) were also associated with locking screw removal. The final prediction model discriminated patients requiring symptomatic locking screw removal with moderate accuracy (area under the receiver operating characteristic curve = 0.73).ConclusionsThe strongest radiographic predictor for symptomatic locking screw removal after tibial nail insertion was the direction of the most proximal locking screw. In contrast to previous research on retrograde femoral nails, tibial locking screws that were closer to the joints were not associated with an increased likelihood of symptomatic screw removal. Clinicians can use these data to help counsel patients regarding the likelihood of symptomatic screws and perhaps to help guide screw placement in cases with multiple options.     

股骨髓内钉芯钻瞄准系统与体外瞄准架系统的远端锁定效果比较

目的比较股骨髓内钉芯钻瞄准系统与体外瞄准架系统在治疗股骨干骨折远端锁定过程中的应用效果。方法选取我院2015年8月至2017年8月连续收治的98例拟行髓内钉固定术治疗闭合股骨干骨折的病人,按随机数字表法分为研究组和对照组,每组49例。研究组病人采用芯钻瞄准系统进行股骨髓内钉远端锁钉操作,对照组病人应用体外瞄准架系统进行远端锁钉操作。比较分析两组病人的术中远端锁钉首次锁定成功率、远端锁定透视次数、远端锁定完成时间和术中出血量。结果研究组与对照组远端锁钉首次锁定成功率分别为93.9%和49.0%,研究组成功率明显高于对照组,差异有统计学意义(P<0.05)。研究组远端锁定透视次数、远端锁定完成时间、术中出血量[(3.2±0.5)次、(7.3±1.1)min、(220.7±10.5)ml]均少于对照组[(12.2±2.4)次、(15.2±3.6)min、(350.3±33.7)ml],差异均有统计学意义(P均<0.05)。结论采用芯钻瞄准系统进行远端锁钉的置入可以有效提高远端锁钉的锁定成功率、减少手术创伤及降低医患术中放射线暴露量。     

肾病综合征儿童矮身材的机制与治疗

原发性肾病综合征(PNS)是儿童常见肾脏病。糖皮质激素及其他免疫抑制剂的广泛应用使肾病综合征的治愈率及生存率得到了显著的提高。但肾病综合征自身复杂的病理生理机制及糖皮质激素等免疫抑制剂的长期使用导致了肾病综合征患儿生长发育迟缓问题越显突出,而儿童时期生长发育对成年后的身高具有重要影响。对于PNS儿童矮身材的防治目前尚无系统的成熟的方案,应用重组人生长激素治疗矮身材儿童是目前的主要手段,但其安全性及有效性仍需要进一步的研究给予证实。     

闭合复位交锁髓内钉治疗胫骨干骨折

目的探讨闭合复位交锁髓内钉治疗胫骨干骨折的临床应用和疗效。方法对21例胫骨干新鲜闭合性骨折患者行闭合复位交锁髓内钉静力性固定。结果经6~29个月随访,21例骨折全部愈合。结论闭合复位交锁髓内钉是治疗胫骨干骨折的理想方法。     

Comparison of Intramedullary Nail Versus Conventional Ilizarov Method for Lower Limb Lengthening: A Systematic Review and Meta‐Analysis

The objective of this systematic review and meta‐analysis was to compare the lengthening and then nailing (LATN) technique to the conventional Ilizarov method for limb lengthening. A systemic search of potential relevant literature was performed in databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, and the ISI Web of Knowledge, from their inception to 22 May 2015 using medical subject heading (MeSH) terms “Ilizarov,” “bone lengthening,” or “intramedullary nail.” A total of 89 titles and abstracts were preliminarily reviewed, of which 4 studies eventually satisfied the eligibility criteria, consisting of one randomized controlled trial (RCT), two clinical controlled trials and one retrospective cohort study. A total of 354 limbs were included in the study, among which 183 were lengthened over an intramedullary nail, and 171 limbs were lengthened conventionally. The mean difference (MD) was ?50.21 for the external fixation index between the two groups (95% CI, ?51.83 to ?48.59; P < 0.00001) with high heterogeneity (I² = 99%); no significant difference in length was gained (MD = ?0.30, 95% CI = ?0.72 to 0.12; P = 0.16) with high heterogeneity (I² = 80%); and there was high significant difference for the consolidation index (MD = ?19.97; 95% CI, ?21.59 to ?18.35; P < 0.00001) with high heterogeneity (I² = 100%). The overall rate of complications was relatively low, and differed significantly between the two groups. Through this meta‐analysis, we find that LATN is superior to the conventional method in regards to the external fixation index and the consolidation index, which means that LATN is an effective technique that can decrease the time needed in external fixation.