不同移植体修复晚期颅骨缺损56例的疗效分析

目的　评估不同移植体修复晚期颅骨缺损的疗效。方法　自1991年以来,应用不同移植体修复晚期颅骨缺损56例,其中应用MEDPOR6例、自体肋骨30例、颅骨外板8例、羟基磷灰石8例、固体硅橡胶4例。结果　经6～12个月临床随访,治疗效果明显,成功率达91.1%,除1例假体外露及1例癫痫发作外,其余无严重并发症发生。结论　颅骨缺损的修复,MEDPOR及自体颅骨及肋骨是安全可靠的,羟基磷灰石及硅橡胶须严格掌握适应证,尽量少用。     

不同移植体修复晚期颅骨缺损56例的疗效分析

目的　评估不同移植体修复晚期颅骨缺损的疗效。方法　自 1991年以来 ,应用不同移植体修复晚期颅骨缺损 5 6例 ,其中应用MEDPOR 6例、自体肋骨 30例、颅骨外板 8例、羟基磷灰石 8例、固体硅橡胶 4例。结果　经6～ 12个月临床随访 ,治疗效果明显 ,成功率达 91.1% ,除 1例假体外露及 1例癫痫发作外 ,其余无严重并发症发生。结论　颅骨缺损的修复 ,MEDPOR及自体颅骨及肋骨是安全可靠的 ,羟基磷灰石及硅橡胶须严格掌握适应证 ,尽量少用。     

The effect of split thickness skin grafts on bone growth

Summary The forces of contraction of split thickness skin grafts applied directly to the periosteal surface of membrane bone of the rabbit snout and cranium causes an inhibition of bone growth. This inhibition was measured at the centre of the grafted area.     

膜状成骨与软骨成骨贴附移植后的组织学观察及骨计量学分析

目的深入探讨骨贴附移植后的变化及不同胚胎来源骨质(膜状成骨和软骨成骨)移植后的差异。方法应用新西兰兔、恒河猴采用荧光素双标记法,在不脱钙骨切片上,选用类骨质宽度、骨质矿化沉积率、荧光标记率等骨动力学指标对骨移植后的再生和改建进行计算机图像分析和定量测量。结果骨体积存留率:膜状成骨为(78.4±3.5)%,软骨成骨为(56±5.1)%;骨矿化沉积率:膜状成骨为(3.60±0.8)μm/d,软骨成骨为(0.92±0.33)μm/d;类骨质宽度;膜状成骨为(14.56±2.69)μm,软骨成骨为(7.38±2.20)μm;荧光标记率:膜状成骨为(91.22±2.69)%,软骨成骨为(51.28±4.11)%。结论膜状成骨移植后较软骨成骨可保持更多的骨质体积,有更为明显的成骨再生能力且可诱导宿主骨成骨的能力不同,膜状成骨优于软骨成骨。     

Thoracolumbar fracture reduction by percutaneous in situ contouring

Purpose

Percutaneous in situ contouring is based on bilateral bending of rods on the spine, thus increasing lordosis at the fracture. It was analyzed if this technique would provide a better reduction than prone positioning and how sagittal alignment would behave.

Methods

Twenty-nine patients were operated using in situ contouring and selective anterior fusion for non-neurologic A2, A3 or B2 fractures. Clinical results were assessed prospectively using visual analog scale (VAS) and Oswestry Disability Index (ODI). The radiographic deformity correction was measured by sagittal index and regional kyphosis. Sagittal balance was assessed using kyphosis, lordosis, T9 tilt, pelvic incidence, pelvic tilt and sacral slope. Posterior wall fragment reduction was evaluated by computed tomography.

Results

After 2 years, VAS and ODI were comparable to the status prior to the accident. The sagittal index was 19.7° preoperatively, 5.3° after prone positioning and −1.1° after in situ contouring (p < 0.001). The loss of correction was 2.4°, mainly during the first 3 months. Similar observations were made for regional kyphosis. The sagittal spino-pelvic alignment was stable postoperatively. A preoperative canal obstruction ≥50 % was observed in 16 patients, and the fragments migrated anteriorly in all patients.

Conclusions

Percutaneous instrumentation and anterior fusion provides good clinical results. In situ contouring increases lordosis obtained by prone positioning. Anterior column lengthening and ligamentotaxis reduce posterior wall fragments, which decompress the canal without laminectomy. The fusion of anterior defects prevents the loss of correction and provides a stable sagittal profile. The instrumentation may be removed without damaging the paravertebral muscles and loss of correction.     

自体颅骨移植在眶底重建中的应用

目的 评价自体颅骨移植在治疗面部外伤致眶底缺损中的作用。方法 对34例面部创伤眶底爆裂骨折（以下简称眶底骨折）有骨质缺损者,采用冠状切口取自休遭受,结膜切口加外眦切开入路进行骨移植修复缺损。结果 所有病例术后创口愈合良好,无感染。供骨区无并发症发生。1例术后3个月内有轻微下睑外翻,通过自行按摩半年后已不明显,8例术前有眶下区麻木者,术后1-6个月全部恢复,4例有复视者术后消失,通过半年至5年（平衡11个月）的随诊,移植骨成活良好,供受骨区切口瘢痕不明显,均取得了满意的临床疗效。结论 自体颅骨移植并发症少,对眶底的重建有许多优点。是眶底重建的理想移植材料。     

Osteoclastic resorption of equine cranial and postcranial bone in vitro

To address possible differences in the resorbability of cranial and postcranial bone, slices of equine frontal bone and leg (first phalanx or third metacarpus) were seeded with embryonic chick bone cells and cultured for 20–24 h. After removing the cells and drying the specimens, the areas and volumes of more than 800 resorption pits in each set were measured using a video–rate reflection confocal microscope system. Relative mineralization densities were determined by quantitative electron backscattering analysis. The mean mineralization density was greater in the leg bone, but the mean depths for resorption pits in frontal bone were smaller (median volume/area ratios, experiment 1 and experiment 2: 1.98 μm frontal and 3.79 μm leg versus 2.70 μm and 4.20 μm, respectively; P < 0.0001, Mann–Whitney), even though the areas were greater in the frontal (medians, 286 μm² and 324 μm², versus 242 μm² and 201 μm²; P < 0.0001). This study has shown a difference between cranial and postcranial equine bone in the shape and size of resorption pits formed in vitro. Overall, it has shown that cranial bone may be resorbed at least as readily as postcranial bone. This result is counter to the clinical impression that cranial bone has a greater staying power than postcranial bone when used as a grafting material. Received: June 7, 1999 / Accepted: Oct. 18, 1999     

Thoracolumbar fractures surgically treated by “in situ contouring”

This is a retrospective study on a series of 70 patients with thoracolumbar fractures (TL), surgically treated by the in situ bending technique (ISB). Its purpose is to show the performances and limits of the ISB technique for the early correction of post-traumatic spine deformities as well as to estimate the overall outcome in this series and to discuss the indications for anterior grafting. Although the management of limbs fractures is a cleared issue today, spine fractures management is still a matter of debate. Surgical treatment progresses fast, while indications, the fixation techniques, fracture reduction options, and associated grafting are still blurry. Seventy patients with TL fractures, mean age 40.3 years (20–80) were treated by posterior fusion with a standard construct and deformity reduction by means of the ISB technique. Mean follow-up was 30.7 months (12–78). Pre- and post-operative deformity was evaluated and the relative deformity as defined by Farcy’s sagittal index (SIF) was analyzed. Thirty-eight patients underwent anterior interbody grafting. The pre-operative SIF decreased from 16.98 to 1.62° (15.36° decrease). Eighty percent of patients were normo- or hyper-corrected. The loss of correction during the follow-up occurred within the disc (SIF: −2.24°, vertebral kyphosis 0.94°, p<0.001), and was lower in patients who underwent secondary anterior grafting (−5.21° vs.–1.18°, p=0.002). Clinical outcome is good (Oswestry=29.75) and seems to be better in cases of double approach (20.71 vs. 37.,4, p=0.001). Sepsis occurred in ten cases, and two patients experienced construct dismounting. One patient had a retroperitoneal hematoma that required embolization. Seventy-one percent of operated patients went back to their previous work after surgery. Spine fractures deserve an efficient treatment. The ISB technique improves post traumatic kyphosis. This results is maintained at long term if the posterior fusion is associated with anterior grafting in cases where the correction within the disc exceeds 50% of the total correction.     

Scaphoid reconstruction with vascularized bone grafts from the distal radius

The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.     

Aneurysmal bone cysts in the cranial vault and base of skull

Three cases of aneurysmal bone cyst of the skull are reported. The localization in the base of the skull (two cases) is extremely rare and simulates a space-occupying intracerebral lesion. The clinical and microscopic findings, and their significance for the differential diagnosis from malignant brain tumors, are described.     

异体颅骨、骨形态发生蛋白及骨膜修复颅骨巨大缺损

以异体颅骨和骨形态发生蛋白为材料,应用部分带蒂骨膜瓣和头皮瓣成功修复4例巨大颅骨缺损。缺损范围最小为9cm×7cm,最大13cm×11.5cm。经术后1～2年随访,外观均好,且移植异体骨逐渐被吸收,新生骨已形成。     

异体颅骨、骨形态发生蛋白及骨膜修复颅骨巨大缺损

以异体颅骨和骨形态发生蛋白为材料，应用部分带蒂骨膜瓣和头皮瓣成功修复４例巨大颅骨缺损。缺损范围最小为９ｃｍ×７ｃｍ，最大１３ｃｍ×１１．５ｃｍ。经术后１～２年随访，外观均好，且移植异体骨逐渐被吸收，新生骨已形成。     

The use of free, mainly cancellous bone grafts for reconstruction of phalanges and metacarpal bones following tumour resection

Neoplasms of the hand frequently require amputation which is associated with significant disability and disfigurement. Although reconstruction using autologous cortical bone grafts has been performed in such cases, bone resorption is a common problem and allogeneic bone may be required to fill large defects. Reconstruction using cancellous bone is an alternative technique that we have developed to overcome the limitations of cortical grafts. Here, we present five cases of bone tumours of the hand which have undergone reconstruction using a cancellous bone grafting technique.     

骨形态发生蛋白-2/胶原/掺锶羟基磷灰石材料修复颅骨缺损

目的 制备骨形态发生蛋白-2( BMP-2)/胶原/掺锶羟基磷灰石材料并探讨其修复大鼠颅骨缺损的可行性和有效性.方法 扫描电镜观察Ⅰ型胶原制备单纯胶原、胶原/羟基磷灰石、胶原/掺锶羟基磷灰石、BMP-2/胶原/掺锶羟基磷灰石4组骨修复材料表面结构.用BMP-2/胶原/掺锶羟基磷灰石材料浸提液进行细胞毒性试验和体外溶血试验评价其生物相容性.在大鼠头颅制备颅骨极限骨缺损模型,分别植入4种骨修复材料.术后12周CT扫描观察骨缺损修复影像学.苏木素-伊红(HE)和Masson染色观察骨缺损组织学变化,并在骨缺损及其周围新生骨部位行骨桥蛋白( OPN)和β-连环蛋白(β-catenin)免疫组织化学染色.结果 在扫描电镜下观察发现单纯的胶原材料为交织样物质结构,胶原/羟基磷灰石材料为交织晶体板状结构胶原/掺锶羟基磷灰石和BMP-2/胶原/掺锶羟基磷灰石材料晶体结构为单晶体交织状.BMP-2/胶原/掺锶羟基磷灰石材料浸提液对细胞相对增殖率(RGR)无显著影响(P＞0.05),材料的细胞毒性为1级.骨缺损CT扫描平均CT值分别为(98.5±10.2)、(208.4±19.5)、(418.4±27.1)、(476.8±30.5)hu,BMP-2/胶原/掺锶羟基磷灰石材料缺损部位CT值最高.HE和Masson染色见BMP-2/胶原/掺锶羟基磷灰石组骨质愈合完全,原骨缺损处多为红色成熟骨.胶原/掺锶羟基磷灰石组植入区内蓝色的新生骨较多.胶原/羟基磷灰石材料组,植入区在植入材料边缘新生骨形成,界限仍然清晰.单纯胶原组骨质未愈合,骨缺损处为淡蓝色条索状结构,中间未见骨形成.对比其他3组,BMP-2/胶原/掺锶羟基磷灰石组存在大量棕色的OPN和β-catenin染色阳性新生骨组织,差异有统计学意义(P＜0.05).结论 BMP-2/胶原/掺锶羟基磷灰石材料促进骨修复能力强于单纯胶原、胶原/羟基磷灰石、胶原/掺锶羟基磷灰石材料.     

In situ versus reversed saphenous vein for femoropopliteal bypass: a prospective randomized study of 100 cases

With the purpose of comparing results using the greater saphenous vein in situ or as a reversed conduit, 100 femoropopliteal bypasses, performed in 91 patients between October 1980 and January 1985, were randomized into two statistically comparable groups of 50 procedures of each type. Seventy-five percent of patients had cutaneous signs of ischemia and 20% had isolated rest pain. Average follow-up was 32 months for the in situ group and 33.4 months in the reversed bypass group. The quality of the vein was statistically better in the in situ group (p<0.01). There were six cases of early thrombosis in the in situ group compared to four in the reversed bypass group. In the in situ group, half of the thromboses could be attributed to inadequate valviar destruction. Seven delayed thromboses were noted in the in situ group whereas there were two in the reversed saphenous vein bypass group. The actuarial rates of bypass patency at three years in the reversed and in situ groups were 88.2 and 70.8%, respectively (x2=2.62; NS). Analysis of results suggests that: 1) the reversed saphenous vein bypass provides excellent results if vein harvest and preparation are as atraumatic as possible; 2) expertise in rendering the valves incompetent markedly increases patency in thein situ technique; 3) during the first 12 months, Doppler follow-up of measured distal pressures is necessary in order to detect pathologic changes of the bypass and adjacent arterial tree.     

血管内皮细胞原位获取的研究

目的建立稳定、成熟的内皮细胞原位获取法。方法应用原位获取法从恒河猴及成人的73条表浅或腹腔血管中获取内皮细胞。A、B两组分别用0.1％Ⅱ型胶原酶消化25分钟、15分钟。结果A组内皮细胞获取率明显高于B组。两组中大隐静脉、劲外静脉、上肢浅静脉、胃网膜右静脉、髂总动脉的内皮细胞获取率明显高于既往的机械获取法、灌注酶解消化法、外翻酶解消化法（P＜0.01）.结论原位获取法的内皮细胞获取率明显高于既往的内皮细胞获取方法,其理想的消化时间25分钟。     

骨髓基质成骨细胞-松质骨基质复合人工骨修复颅骨缺损的实验研究

目的 观察松质骨基质－骨髓基质成骨细胞复合工人骨在骨缺损区的成骨作用，探索该组织工程化人工骨修复颅骨缺损的可行性。方法 成年新西兰兔骨髓细胞体外培养、诱导后，接种于藻酸盐－松质骨基质中，形成松质骨基质－藻酸盐－骨髓基质成骨细胞复合人工骨，修复自体颅骨缺损。分别植入松质骨基质和骨髓基质成骨细胞作为对照。植入4周和8周后行X线摄片和组织学检查，观察骨形成情况。结果 复合人工成骨量优于单纯植入松质骨基持或骨髓基质成骨细胞组，并明显优于空白对照。结论 松质骨基质－骨髓基质成骨细胞复合人工骨髓修复颅骨缺损效果良好，可以作为临床大型骨缺损修复的途径之一。     

Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid

PURPOSE: With their intrinsic vascularity vascularized bone grafts provide an alternative solution to the challenging problem of scaphoid nonunions. The union rate (after imaging evaluation including magnetic resonance imaging [MRI]) and functional outcome of using vascularized bone grafts pedicled on the palmar carpal epiphyseal artery for waist nonunions of the scaphoid are reported in this prospective case series. METHODS: The technique was applied to 9 waist nonunions resulting from fractures. The mean time elapsed from the initial injury to the procedure was 22 months and the mean follow-up time was 24 months. The graft was pedicled on the artery running at the distal edge of the pronator quadratus and was inserted in the nonunion as an intercalary graft. Six patients had postoperative MRIs to evaluate fracture healing and graft incorporation. RESULTS: Union was accomplished in all cases between 6 and 12 weeks. Postoperative MRI showed the viability of the graft (contrast-enhanced images) and confirmed union and graft incorporation. Complete absence of pain was noted in all patients. The Mayo modified wrist score increased from 63 to 92 after surgery and according to this score results were excellent in 5 patients and good in 4. CONCLUSIONS: Vascularized bone grafts from the anterior radius lead to rapid union and consolidation in cases of waist nonunion. Postoperative MRI confirms viability of the graft, union, and graft incorporation. The approach is limited to the distal radius and wrist and lacks donor site morbidity. The interposition of the graft from the palmar side allows correction of the humpback deformity and patients regain carpal height, grip strength, and painless motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Use of frozen cranial vault bone allografts in the repair of extensive cranial bone defects

Summary In cranioplasty complexity is proportional to the size of the defect, particularly if greater than 50 cm². If the patient's own bone flap is not available, allogenic frozen bone graft can be used instead.Between June 1990 and June 1995 twenty cranioplasties with allogenic frozen bone grafts were performed. Age of patients ranged between 23 and 63 years (average 38.4 years). Male/female ratio was 2 1.7. Size of craniectomy ranged between 65 and 150 cm² (average 83.3 cm²). Follow-up ranged between 10 and 58 months (average 41 months).Donors were tested to rule out transmissible diseases, infections, sepsis and/or cancer. Bone grafts were removed under aseptic conditions, microbiological cultures were taken, wrapped in a gauze soaked with Gentamicin sulphate and Bacitracin, sealed in three sterilised vinyl plastic bags, and stored in a deep freezer for a minimum of 30 days (range 36–93 days, average 67 days), at a temperature of –80 °C.Grafts were placed in the defect after a step was carved on its borders to facilitate the contact between host and graft. Vancomycin 1 g. IV/12 hours and Ceftriaxone 1 g. IV/12 hours were administered for five days.Grafts were covered by means of scalp flaps. Only one required a musculocutaneous free flap. None was exposed, extruded or had to be removed.Plain skull X-ray studies showed progressive remodelling of the grafts. Partial resorption was observed in two (2/20, 10%) and loss of thickness in another 3/20 (15%), but with no changes in the contour.Biopsies were taken in 3/20 (15%) cases at a second surgical procedure. Areas of osteoclastic resorptive activity mixed with others of osteoblastic bone apposition, showed replacement with new bone.We conclude that cranial vault frozen allografts are a good alternative to autologous bone when the latter is absent or not present in sufficient amount.