胫骨平台垫高术治疗膝反屈的临床体会

胫骨平台垫高术治疗膝反屈的临床体会张雪松，冯守诚自１９８９～１９９２年，我们用胫骨平台垫高术治疗膝反屈畸形１６例共１８膝，随访１～３年，疗效满意，报告如下：１．临床资料１．１一般资料本组１６例中男７例，女９例，年龄８～２４岁，平均１６岁，膝反屈３０～...     

手术治疗脊髓灰质炎后遗症膝反屈畸形

目的 探讨脊髓灰质炎后遗症膝反屈畸形的手术治疗效果。方法 采用股骨下端和胫骨上端前侧骨骺刺激、股骨髁上前倾截骨、胫骨平台下植骨抬高术或上端截骨垫高术等5种手术方法治疗37例39个膝关节。结果 术后35例37个膝获随访,随访时间9个月～6年,平均4年5个月。29例达到矫正效果,4例畸形复发行二次手术。结论 膝反屈的成因复杂,只有根据临床类型选择正确的手术方法,才能达到矫正目的。     

钢板支撑抬高胫骨平台治疗膝反屈

对儿麻后遗症中30例严重膝反屈畸形之成年患者采用“了”形钢板支撑抬高胫骨平台矫正术,其中男19例,女11例,年龄16～26岁(平均22岁)。双侧畸形7例,单侧23例,反屈角度25～50°。30例都在单侧施行     

关于膝反屈术式的选择与比较

我院1983～1988年收治小儿麻痹后遗膝反屈72例,采用了三种不同术式治疗,现将66例随访结果分析如下: 临床资料:本组男21例,女45例,年龄最大26岁,最小5岁。侧别:左侧31例,右侧35例,其中双侧8例,共做74次手术。术前滕反屈10～20°20例,21～30°32例,31～40°10例,41～50°4例手术方法:(一)膝后软组织手术(A组):包括膝后关节囊紧缩、支持韧带松解,腘绳肌止点上移共10例。(二)胫骨平台下植骨(B组)45例。(三)髌骨阻挡术(C组)11例。     

全膝关节置换术中胫骨近端倾斜型骨缺损的重建

目的 通过对全膝关节置换术中腔骨近端倾斜型骨缺损的重建，介绍应用自体胫骨进行胫骨平台重建的方法和体会。方法 1992年11月～2000年9月．对22例(29膝)有胫骨近端倾斜型骨缺损的膝关节行全膝关节置换及自体胫骨移植术，男5例(5膝)，女17例(24膝)；年龄43～78岁，平均61．2岁。手术前诊断：骨关节炎13例(14膝)，其中膝内翻12例(13膝)，膝外翻1例(1膝)；类风湿关节炎7例(12膝)；滑膜软骨瘤病1例(1膝)；大骨节病1例(2膝)。术中将胫骨平台倾斜型骨缺损修整成台阶状水平型骨缺损。将截下的胫骨平台骨块修整后使其厚度和形状与缺损处匹配，并将带有皮质骨的部分尽量放置在台阶状缺损的外缘，以承受平台的压力。术中植骨厚度为8～15mm，平均10mm在置入假体以及在骨水泥固化之前，应在植骨块侧方加压。所有膝关节假体均采用抗生素骨水泥固定。结果 术后随访1～9年，平均4．2年，除1例因迟发性感染和植骨吸收再次出现膝内翻畸形和假体松动而行Ⅰ B-Ⅱ楔形假体翻修外．其它病例未发现自体移植骨的不愈合、移位、骨折、骨吸收和胫骨假体松动，HSS膝关节评分由术前10～26分提高到术后76～94分。结论 在胫骨近端倾斜型骨缺损的全膝关节置换术中，采用自体胫骨移植可恢复胫骨平台的完整性．防止平台塌陷．并为假体提供良好的初始稳定性，提高手术的成功率。     

胫骨平台垫高术治疗膝反屈的疗效及力学探讨

膝反屈是小儿麻痹后遗症较严重的畸形,多发生於股四头肌瘫痪及腘绳肌瘫痪。本文报告用胫骨平台垫高治疗膝反屈畸形25例共26膝,有效率100%,其中优良率占80.77%。对膝反屈畸形的生物力学病理改变进行了探讨。同时对手术适应证选择,术式选择及手术有关问题提出讨论。     

膝反屈畸形手术治疗64例报告

作者于1976～1986年,收治64例小儿麻痹后遗症膝反屈畸形,根据不同情况,采用多种手术治疗。其中58例得到随访,优良率达84.5％。软组织手术效果不能持久,骨性手术以胫骨平台垫高术效果可靠,值得采用。如果股骨髁面已变平,尚需做股骨下端前倾截骨术。膑骨阻挡术仅用于骨质无明显畸形的膝反屈病例。     

胫骨高位截骨术治疗膝内侧骨性关节炎的体会

目的探讨胫骨高位截骨术治疗膝内侧骨性关节炎的疗效及手术体会。方法回顾性分析自2016-06—2018-05采用胫骨高位截骨术治疗的26例膝内侧骨性关节炎,比较手术前后股胫角、胫骨近端内侧角、胫骨平台后倾角、疼痛VAS评分、膝关节功能HSS评分。结果 26例均获得随访,随访时间平均32(24～46)个月。术后1周股胫角为170°～177°(173.21±2.52)°,较术前减小;胫骨近端内侧角为87°～92°(89.61±1.27)°,较术前增加;胫骨平台后倾角为8°～18°(13.32±4.64)°,较术前增加,差异有统计学意义(P0.05)。末次随访时疼痛VAS评分为0～3(1.90±0.57)分,较术前降低;膝关节功能HSS评分为83～96(89.51±6.83)分,较术前增加,差异有统计学意义(P0.05)。1例于术后4个月出现术区感染,取出内固定物,清创、抗感染治疗6周后痊愈。1例出现胫神经损伤,表现为足底麻木,但踝关节与跖趾关节跖屈肌力正常,3年后复查时麻木感仍存在。结论胫骨高位截骨术治疗膝内侧骨性关节炎可取得满意的近期疗效,术后膝关节疼痛及功能均获得明显改善,但是术后胫骨平台后倾角有增大的趋势,术中应注意操作技巧。     

胫骨高位截骨术治疗内翻型膝关节骨关节炎远期疗效观察

为评价应用高位胫骨截骨术治疗内翻型膝关节骨关节炎的远期疗效，对２４例（２９膝）进行平均１０６年的随访。结果显示，８２６％疗效优良或满意。疗效与年龄有关，理想的股胫外侧角度（简称ＦＴＡ）１６８°～１７２°。５０岁以下，ＦＴＡ为１６５°～１７５°者多能获得满意以上结果。术式选用胫骨结节上楔形截骨抑或倒Ｖ截骨，应根据有无髌股关节炎而定。只要选择恰当，疗效与术式无关。本文结论是治疗６０岁以下内翻型膝关节骨关节炎应首选高位胫骨截骨术     

骨骺刺激术促进长骨局部生长实验研究和临床应用

采用截骨和骨膜切除术两种常用骨骺刺激方法对兔胫骨局部骨生长的刺激研究进行观察。结果表明骨膜切除术对骨骺生长的刺激作用大于截骨术。１９９２年后应用于临床，对３例血源性膝内翻、２３例脊髓灰质炎后遗膝反屈、１例脑性瘫膝反屈、１例佝偻病Ｘ形腿及３例截骨矫正膝反屈后并发膝外翻，应用骨膜切除术矫形。经６个月～４年２个月，平均３年１个月，随访获得满意疗效     

Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus

Twelve patients, ranging in age from thirty-four to seventy-two years (average, fifty-three years), were evaluated an average of five years (range, two to eight years) after open reduction and internal fixation of a two-part displaced fracture of the greater tuberosity of the proximal part of the humerus. The indication for operative reduction was one centimeter or more of displacement of the fracture as seen on the diagnostic radiographs. The anterosuperior deltoid-splitting approach, combined with rotation of the humerus, allowed adequate exposure of the retracted tuberosity. Internal fixation of the greater tuberosity with heavy, non-absorbable sutures and careful repair of the rotator cuff permitted early passive motion. All fractures healed without postoperative displacement. Six patients had an excellent result and six had a good result; active elevation averaged 170 degrees. There was one partial, transient palsy of the axillary nerve.     

Anterior decompression and arthrodesis of the cervical spine: long-term motor improvement. Part I--Improvement in incomplete traumatic quadriparesis.

Between 1973 and 1983, fifty-eight patients who had an incomplete spinal-cord injury secondary to a fracture or dislocation of the cervical spine were managed by anterior cervical decompression and arthrodesis with iliac bone grafts. In all patients, myelography showed that displaced fragments of bone or disc were compressing the anterior aspect of the spinal cord. Anterior decompression was performed in an attempt to improve function in the upper and lower extremities. The average interval from the injury to the decompression was thirteen months (range, one month to nine years). Two patients died of cardiopulmonary disease within two months after the operation, and one patient died eighteen months after the operation. The remaining fifty-five patients were followed for an average of six years (range, two to seventeen years). Twenty-nine patients became functional ambulators after the operation. An additional six patients who could walk before the operation had improvement in the ability to walk. Noteworthy improvement in motor-root function in the upper extremities was seen in thirty-nine patients. Only nine patients had no signs of improvement of motor function. Improvement was less in the patients in whom operative decompression had been done more than twelve months after the injury. The patients who had an extension injury to a spondylotic spine were older, and fewer of them had improvement. No patient lost neurological function as a result of the operation. Anterior decompression and arthrodesis, even when performed late after the injury, can improve neurological function in both the upper and lower extremities in many patients who have incomplete quadriplegia due to a fracture or dislocation of the cervical spine.     

Repair of unstable cuffs with a deltoid flap

We have found that upper arthrolysis for major ruptures of the cuff affecting the supraspinatus and infraspinatus muscles yielded only 40% of excellent and good clinical results at three years, with 1/4 of cases of exenteration of the humeral head on radiographs after 10 years, so that, as early as 1984, we had the idea of using a "tailor-made" active muscle flap taken from the anterior fibers of the middle deltoid muscle (Fick's fibers n degrees III) and sutured to the edges of the trophic perforation after exeresis reaching to the healthy tissue. In our opinion, this procedure is logical as we use a synergic transplant of the ruptured muscles of the cuff, preserving its nerves and blood vessels. This forms a living interposition material between the acromion and the greater tuberosity of the humerus, forming a real "three-bellies" muscle resisting the ascent of the humeral head. In fact, it reconstructs a contained cuff, which plays an important role to lower the humeral head. After a minimum of one year and an average of nineteen months for fifty shoulders, all of these have an esthetically satisfactory appearance, forty-seven are painless or painful only episodically; thirty-two have an active elevation exceeding 120 degrees; twenty-one have a symmetrical muscular strength for elevation and fifteen for outward rotation with 90 degrees abduction. Thirty-nine patients (78%) show satisfactory clinical results. Seventeen humeral heads are realigned. Electromyograms performed after six months showed that the flap contracted synchronously with the supra- and infraspinatus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstruction of the distal radius for primary bone tumors using a non-vascularized fibular graft (report of 4 cases)

We report four cases of primary bone tumour of the distal radius. Follow-up averaged ten years with a range of four to 13. Each case underwent excision of the tumour followed by reconstruction with a non-vascularised fibular graft. The aim of our study was to investigate the carcinologic, functional and radiological results at an average of ten years after the initial surgery. There were three high grade osteosarcomas and one giant cell tumour of bone. The mean postoperative wrist flexion was 45 degrees, extension was 20 degrees, pronation 30 degrees and supination 50 degrees. Radial tilt was a mean 10 degrees and ulnar tilt 15 degrees. All the patients had satisfactory function so as to be able to perform activities of daily living and to work. Grip strength was normal in three cases and reduced in one. Bone graft healing occurred at a mean of six months with a range of from four to nine months. Resection followed by a non-vascularised fibular graft is an effective way to managing these patients.     

Chronic sepsis following intramedullary nailing of femoral fractures

We reviewed 12 patients with chronic drainage after intramedullary nailing of a femoral shaft fracture. The fractures tended to be the result of high-speed trauma and were frequently comminuted. Six were open fractures and six were closed injuries. All but one had been managed initially with the open nailing technique, exposing the fracture site. In six cases we left the nail in place until bone union occurred, an average of 33 months after injury, removing the hardware thereafter. The remaining six patients, each with bone sequestra at the fracture site, underwent nail removal, debridement of nonviable bone, and external fixation followed by bone grafting; this group took 37 months to heal. There was one persistent nonunion in each group. Drainage did not cease in either group until the nail and all sequestra had been removed. There was an average of 4.3 cm of shortening, but no angulation greater than 10 degrees. Six patients were left with less than 45 degrees of knee flexion and only five had 100 degrees or more of knee flexion.     

Use of allograft bone for posterior spinal fusion in idiopathic scoliosis

Eighty-seven adolescents with idiopathic scoliosis (77 female and 10 male patients) who underwent posterior spinal fusion with instrumentation using only allograft bone for graft material were evaluated retrospectively. The average age at surgery was 14 years 3 months. Each patient had a minimum 2-year followup, with an average of 3 years 5 months followup. The average preoperative curve was 59 degrees thoracic (range, 31 degrees-90 degrees) and 52 degrees lumbar (range, 21 degrees-65 degrees). At followup, the thoracic curve measured an average of 35 degrees and the lumbar curve measured an average of 34 degrees. The average loss of correction from the immediate postoperative period until last followup was 6.5 degrees or 11% in the thoracic curve and 10 degrees or 19% in the lumbar curve. There were seven reoperations; one of these reoperations involved repair of a pseudarthrosis. There was one clinical infection. The typical patient had a 2-ounce allograft at an average cost of $800. The patients' average loss of correction, complication rate, and reoperation rate compare favorably with results reported in other series using autograft bone. The authors of this study showed the ability of allograft bone to produce reliable results with a satisfactory outcome. The potential advantages of using allograft must be weighed against the potential disadvantages before recommending its routine use.     

The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears

BACKGROUND: The impact of a recurrent defect on the outcome after rotator cuff repair has been controversial. The purpose of this study was to evaluate the functional and anatomic results after arthroscopic repair of large and massive rotator cuff tears with use of ultrasound as an imaging modality to determine the postoperative integrity of the repair. METHODS: Eighteen patients who had complete arthroscopic repair of a tear measuring >2 cm in the transverse dimension were evaluated at a minimum of twelve months after surgery and again at two years after surgery. The evaluation consisted of a standardized history and physical examination as well as calculation of the preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons. The strength of both shoulders was quantitated postoperatively with use of a portable dynamometer. Ultrasound studies were performed with use of an established and validated protocol at a minimum of twelve months after surgery. RESULTS: Recurrent tears were seen in seventeen of the eighteen patients. Despite the absence of healing at twelve months after surgery, thirteen patients had an American Shoulder and Elbow Surgeons score of >/=90 points. Sixteen patients had an improvement in the functional outcome score, which increased from an average of 48.3 to 84.6 points. Sixteen patients had a decrease in pain, and twelve had no pain. Although eight patients had preoperative forward elevation to <95 degrees, all eighteen regained motion above shoulder level and had an average of 152 degrees of elevation. At the second evaluation, a minimum of twenty-four months after surgery, the average score, according to the system of the American Shoulder and Elbow Surgeons, had decreased to 79.9 points; only nine patients had a score of >/=90 points, and six patients had a score of /=80.     

Surgical treatment of upper extremities of cases arthrogryposis multiplex congenita]

Between 1990-1999 at the Polish-American Pediatric Institute 36 children with arthrogryposis were treated. In 10 cases 21 corrective surgical procedures of the upper extremities were performed. Corrective procedures of the upper extremities were performed. Corrective procedures aimed at contractures of the hand, wrist and forearm, consisting of capsulotomies, lengthening of the finger flexor tendons and transposition of wrist flexor on to the wrist extensors were performed 8 times. Correction of extension contracture of elbow joint, consisting of posterior capsulotomy and lengthening of the triceps tendon was performed 9 times. In 4 cases transposition of the pectoralis major onto the biceps tendon according to Clark or Zancolli in Carrol's modification was performed. The average age of the children was 4.7 years (age ranging from 1.5 to 9 years), the follow-up period was 4.25 years (ranging from 0.5 to 10 years). Palmer contracture of the wrist was an average 80 degrees (70-90 degrees) before surgery. Passive flexion in the elbow joint was on average 15 degrees (0-35 degrees). Active flexion of the elbow was absent in all cases. After corrective procedures in the wrist, in 5 cases physiological positioning of the was achieved. After lengthening of the triceps tendon passive flexion of elbow was 80-90 degrees, in one extremity 70 degrees. After the Clark or Zancolli procedures active flexion of the elbow was 80 degrees in one case, 70 degrees in another and 50 degrees six months post-op. The author's own experiences indicate that and multi-stage interdisciplinary approach in necessary from the beginning in these cases.     

Total elbow arthroplasty with use of a nonconstrained humeral component inserted without cement in patients who have rheumatoid arthritis.

BACKGROUND: Most total elbow prostheses that are currently in use require cement for fixation of each component. We developed a new (type-5) prosthesis that does not need cement for fixation. METHODS: The humeral component is made of cobalt-chromium alloy, and its stem is porous-coated with a plasma spray of titanium alloy. There are two options for the ulnar component: an all-polyethylene type and a metal-backed type with a porous-coated stem. Forty-three elbows in thirty-seven patients who had rheumatoid arthritis were treated with total elbow replacement arthroplasty with use of the type-5 prosthesis. The humeral component was implanted without cement in all elbows, whereas the ulnar component was implanted without cement in eleven elbows and was fixed with cement in the remaining thirty-two. The elbows were followed for an average of three years and ten months (range, two years and six months to five years and six months). RESULTS: The clinical results were assessed according to a modification of the Mayo Clinic Performance Index. At the time of the latest follow-up, the overall result was excellent for six elbows, good for thirty-one, and fair for six. All elbows had been rated as poor before the operation. There was almost complete relief of pain in twenty-nine elbows and mild or occasional pain in the remaining fourteen. Flexion increased markedly, from an average of 104 degrees preoperatively to an average of 133 degrees postoperatively; this difference was highly significant (p < 0.001, Student t test). In contrast, extension (flexion contracture) worsened slightly, from an average of 38 degrees preoperatively to an average of 42 degrees postoperatively; this difference was significant (p < 0.05). There was one postoperative dislocation of the elbow, and ectopic bone formed in another, with recurrence of ankylosis. Both elbows had a reoperation, and a good result eventually was obtained. There were no instances of postoperative infection or neuropathy of the ulnar nerve. Radiographically, there were no radiolucent lines at the bone-metal interface of any of the humeral or ulnar stems that had been implanted without cement, suggesting solid fixation by osseointegration. CONCLUSIONS: The results of total elbow arthroplasty with use of this prosthesis appear promising. There was a high rate of relief of pain as well as of restoration of adequate function in patients in whom the elbow was severely affected by rheumatoid arthritis.     

Treatment of established and anticipated nonunion of the tibia in childhood

Nonunion in long bone fractures is rare in the skeletally immature patient. The authors report the outcome of a series of patients treated for tibial bone loss and nonunion at average follow-up of 66 months. Nine children aged 18 months to 17 years were treated. Three patients had established nonunion ranging from 7 months to 6 years, three had bone loss (1-6 cm), and three had fractures in which nonunion was anticipated (one Gustilo IIIb and two Tscherne III). Treatment involved wound excision for open fractures, debridement of devascularized bone, and stabilization with monolateral fixators (two patients) and circular fixators (seven patients). Five patients had unifocal treatment and four had multifocal treatment (three bone transports). Treatment time ranged from 3 to 12 months and was not related to the complexity of treatment. Functional outcome was measured using the Short Musculoskeletal Functional Assessment, a validated outcome assessment tool. At the latest follow-up (average 66 months), the mean knee flexion was 134 degrees and mean ankle range was 12 degrees dorsiflexion, 31 degrees plantar flexion. Physeal arrest was present in three children (limb length discrepancy 2-4 cm), but with no deformity. Functional outcome revealed a "Dysfunction Index" of 0% to 19% (average 7%) and a "Bother Index" of 0% to 16% (average 6%). Good function can be obtained following treatment of these severe injuries.