骨痂延长术治疗桡骨化脓性骨髓炎后继发桡侧球棒手畸形的临床报道

[目的]评价利用镶嵌式双臂外固定器行骨痂延长术治疗桡骨骨髓炎后继发桡侧球棒手畸形的临床效果。[方法]回顾性分析应用镶嵌式骨外固定器行骨痂延长术治疗桡骨化脓性骨髓炎后导致的Heikel’sⅢ型桡侧球棒手畸形的临床资料,男9例,女4例;骨缺损长度3～8 cm,平均5.8 cm;桡偏角度30°～70°,平均55°。术后观察前臂肘、腕关节功能及骨不连的愈合指数,进行统计学分析。[结果]13例患者均获得24～58个月随访,球棒畸形纠正,术后的桡偏角度0～10°,平均5.0°±3.1°,P<0.05有统计学意义;双侧前臂等长,肘腕关节屈曲、伸直功能恢复良好;前臂旋后功能改善至71.8°±13.5°,P<0.05提示结果有统计学差异,所有病例无神经、血管损伤。[结论]利用镶嵌式骨外固定器行骨痂延长术是治疗桡骨骨髓炎后继发桡侧球棒手畸形的一种疗效好,副作用小,操作简单的有效手术。     

Nonincisional osteotomy for gradual lengthening by callus distraction in the hand and foot

Gradual lengthening by distraction osteogenesis is widely used for brachydactyly. The most frequent postoperative complaint of the patients treated with this method is the appearance of the scar caused by the skin incision for the osteotomy, which is an integral technique of distraction osteogenesis. A nonincisional approach to osteotomy would reduce the dorsal scarring. Gradual lengthening by callus distraction with nonincisional osteotomy was performed in 14 digits. The mean gain in length was 14.3 mm (10-19 mm). Of 14 digits, 13 digits achieved the target length and sufficient bone consolidation and 1 digit showed early consolidation. There was no case in which complications occurred because of the drilling. Nonincisional osteotomy for callus distraction in the hand and foot reduced dorsal longitudinal scarring and achieved good cosmetic results as compared with an ordinary osteotomy involving skin incision.     

A technique of distraction osteosynthesis in the hand

Moderate digital lengthening may be accomplished with a step osteotomy that preserves attached sleeves of periosteum. A new external fixation apparatus, the Mini-H-Fixator, allows gradual distraction and solid bone fixation after surgery and facilitates this operation. The advantage of this procedure is that it results in rapid bone formation in the osteotomy gaps, obviating the need for bone grafting.     

延伸骨痂的骨化模式

在世界上曾经风迷一时的Ilizarov外固定方法因其较为安定的成绩,现在在骨科领域里已经成为规定的术式。然而在另一方面,人们对张压力效应和牵引性组织形成原理的理解程度,还有就其原理是否已被科学性地阐明都存有疑义。在此,根据多年来的动物实验结果以及文献的检索,就有关延伸骨痂的骨化模式的问题加以探讨。     

Principles of callus distraction

Callus distraction is based on the principle of regenerating bone by continuous distraction of proliferating callus tissue. It has become the standard treatment of significant leg shortening and large bone defects. Due to many problems and complications, exact preoperative planning, operative technique and careful postoperative follow-up are essential. External fixators can be used for all indications of callus distraction. However, due to pin tract infections, pain and loss of mobility caused by soft tissue transfixation, fixators are applied in patients with open growth plates, simultaneous lengthening with continuous deformity corrections, and increased risk of infection. Distraction over an intramedullary nail allows removal of the external fixator at the end of distraction before callus consolidation (monorail method). The intramedullary nail protects newly formed callus tissue and reduces the risk of axial deviation and refractures. Recently developed, fully intramedullary lengthening devices eliminate fixator-associated complications and accelerate return to normal daily activities. This review describes principles of callus distraction, potential complications and their management.     

Metatarsal lengthening by callus distraction for brachymetatarsia

Twelve metatarsal lengthening procedures by callus distraction were performed in seven patients with brachymetatarsia. The mean age at the time of the surgery was 12.0 years (range, 11.1-14.5 years). The mean duration of follow-up was 5.2 years (range, 1.2-13.5 years). The bones were lengthened at a rate of 0.7 mm/day by a mean of 20 mm (range, 15-30 mm), which was 45% of their original length (range, 37-61%). The mean healing index was 73 days/cm (range, 41-98 days/cm). Corrective shortening osteotomy was performed in one case in which the metatarsophalangeal joint was dislocated due to excessive lengthening. In 10 of the remaining 11 cases, joint stiffness, narrowing of the joint space and some degree of plantar subluxation of the metatarsophalangeal joint were observed during distraction, but these were gradually resolved without either elongation of the tendon or metatarsophalangeal joint fixation with Kirschner wire.     

Resection debridement of the lower leg with compensatory callus distraction

In fractures with severe soft tissue defects and exposed bone, so much bone is resected in the fracture zone that the soft tissue defect can be closed with shortening of the lower leg. Subsequent osteotomy of the compact layer and callus distraction (Ilizarov method) at another level restores the tibia to its former length. Ten patients were treated, with an average healing time of 39 days per centimeter of lengthening. In all cases healing was achieved. Five patients had complications but none had any permanent sequelae. The hypermetabolism of the cell organelles in all kinds of tissue during the distraction period has a good effect on the healing of wounds and osteomyelitis. The healing process is short, so that patients are only in hospital for a relatively short time.     

截骨外固定术矫正先天性跖骨短缩畸形

目的：探讨治疗先天性跖骨短缩畸形的有效、安全的手术方法。方法：对患侧跖骨进行截骨外固定器牵引,达到理想长度后进行髂骨植骨,克氏针固定出院,门诊拆除克氏针。结果：本组8个短缩足趾经以上跖骨截骨外固定延长后均收到满意效果,平均延长1．50cm（25％）,未出现不良手术并发症。随访6～12个月,效果满意,无1例短缩复发。结论：本文应用截骨外固定术矫正先天性跖骨短缩畸形,完全改善了患者的外观,相对于其他手术方法有显著的优点。     

Bone-lengthening for shortness of the fourth toe

Short fourth metatarsals were observed in 102 patients, often bilaterally. Forty-six of these patients were treated by variations on Jinnaka's bone-lengthening method--that is, interposing a spindle-shaped bone graft within the metatarsophalangeal joint. We examined twenty-six patients clinically and roentgenographically after a follow-up averaging 11.4 years. Satisfactory results were obtained in 74.4 per cent.     

Distalization of the patella during tibial callus distraction

Consecutive distalization of the patella is described in two patients undergoing segmental transportation after high tibial corticotomy. Revision surgery with loosening and proximal reattachment of a portion of the patellar ligament bridging the callus distraction zone could re-establish the correct patellar position. Despite excellent callus formation after tibial corticotomy just below the tibial tuberositas, this procedure should be performed more distally as the fibers of the patellar tendon spread laterally and distally. Received: 16 October 1996     

Soft tissue distraction in hand surgery: the “pentagonal frame” technique

Soft tissue distraction (STD) is an increasingly accepted operation in all fields of hand surgery from elbow contracture release to PIP joint release. Current techniques reported lack the ability to distract the joints of the fingers or the hand, maintain the length of released contractures, and hold them in a position while active and passive physiotherapy is possible. We describe a technique by which STD of the hand and fingers is done with no joint or tendon involvement overcoming the aforementioned drawbacks. Thirty-three patients with hand contractures were treated. In this method, a thin 1–1.5-mm Kirschner wire was passed horizontally at the proximal head of the distal phalanx and bent like a frame around the finger, forming a pentagonal shape for anchorage. The distal distraction was exerted at the distal phalanx. Various forms of external fixation were then used to distract a finger, several fingers, or the hand by placing tension on this frame; the distraction was either static (with a wire exerting pressure) or dynamic (using a rubber band to adjust the tension). After obtaining the desired result, the wire or rubber band was temporarily freed to commence active and passive physiotherapy. We maintained the frame for 3–6 weeks. All 33 patients were successfully treated. No major complications were encountered during the follow-up period (3–5 years). The pentagonal frame allows for effective distraction of soft tissues and joint ligaments and maintains the space needed for healing of fractures of the metacarpals and phalanges.     

Limb reconstruction with the callus distraction method after bone tumor resection

The callus distraction method was applied to nine patients who were referred to us because of a bone tumor. Their mean age was 17 years and 3 months (range 7-37 years). Three were female, and 6 were male. All of the tumors were localised on the femur, and the histological diagnosis was two chondrosarcomas, one Ewing's sarcoma, three osteosarcomas, one giant cell bone tumor, and the remainder benign fibrous histiocytoma. The mean length of the defect after resection of the tumor was 11.5 (range 8-20) cm. Preoperative and postoperative chemotherapy were applied to patients with osteosarcoma and Ewing's sarcoma. The patients were followed up for 22 (range 15-30) months on average. The mean period of use of the external fixator was 12.5 (range 8-18) months. One patient suffered a tumour recurrence and died after 20 months. Complications included one deep infection, one skin invagination, and one premature consolidation and bone bridge in the defect area. All of the complications were successfully treated. Functional evaluation gave excellent results in four patients, good in three, and fair in two. This method can be used without any need for massive autogenous bone graft in repairing defects of any length and diameter produced after excision of the lesion and thus can be considered as an alternative to other techniques.     

The influence of callus distraction on the growth plate

Objectives This study was designed to investigate the morphology, thickness and cellularity of the growth plate during callus distraction performed in the immediate vicinity of the growth plate. Methods Lengthening of the right tibia by 25% was carried out on 24 beagle dogs by callus distraction. Distraction was started at the fifth postoperative day with a distraction rate of 0.5 mm twice a day. A control group of six dogs underwent tibial osteotomy and external fixation without distraction. Half of the dogs of both groups were sacrificed at the end of the distraction phase of 25 days (Group A) and the remaining 15 dogs after an additional consolidation period of 25 days (Group B). The tibia and femur was removed from the distracted right leg and from the left control side of each animal and longitudinal sections were cut and stained with Pentachrome. The thickness and cellularity of the regeneration zone, the proliferation zone and the hypertrophic zone were determined for the proximal tibial and the distal femoral epiphysis. Results During the distraction phase the thickness of the proximal tibial growth plate and its cellularity were reduced on the distraction side. During the consolidation phase there was a slight recovery in the proximal tibial growth plate. Conclusions Callus distraction leads to a temporary reduction in growth of the affected physis.     

Callus distraction in the hand skeleton

From 1992 to 1996, 27 patients with traumatic amputations or malformations underwent lengthening of thumb and fingers. A total of 36 procedures were carried out. In several cases, deepening of the web space or bone transplantations proved to be necessary to improve general function or to compensate for missing bone structure. Complications included pin-track infections, necrosis of bone, non-union and scarring. Overall the results indicate that distraction of the thumb and fingers is a feasible operative technique leading to a promising improvement of function.     

Technique of nonvascularized toe phalangeal transfer and distraction lengthening in the treatment of multiple digit symbrachydactyly

A combination of nonvascularized multiple toe phalangeal transfers, web space deepening, and distraction lengthening may provide excellent function in the child born with the oligodactylous type of symbrachydactyly. These techniques may reconstruct multiple digits, maintaining a wide and stable grip span with good prehension to the thumb.We detail the techniques of each of these 3 stages in reconstruction and describe appropriate patient selection. Potential complications are discussed. However, with strict attention to technical details, these complications can be minimized.     

Complications of distraction lengthening in the hand

This study examined the features of 16 complications from 51 distraction lengthenings in the hands of 43 patients. From 1996 to 2006, 24 metacarpals and 27 phalanges were lengthened at a rate of 0.5 and 0.25 mm/day, respectively, using a callus distraction technique. The indications were congenital (33 cases in 27 patients) and traumatic (18 cases in 16 patients) deformities. The average percentage lengthening in the phalanges and metacarpals was 62% (16 mm) and 63% (34 mm), respectively. The distraction rates in the phalanges and metacarpals were 69 and 52 days/cm, respectively. The overall complication rate was 31%. Major complications requiring secondary procedures were non-union (one case), fracture (one case), premature union (one case), angulations (two cases) and dislodgment of pins (two cases). The minor complications encountered were delayed callus formation (four cases), joint stiffness (four cases) and soft tissue thinning (one case). Traumatic deformities had more complications than the congenital ones (nine of 18 cases and seven of 33 cases, respectively). The phalanges had a higher rate of complication than the metacarpals (11 of 27 cases and four of 24 cases, respectively). Most patients with complications except for two children with dislodgment were as satisfied with the final results as those without complications. Although callus distraction in the hand requires a long treatment period and has a relatively high rate of complication, it appears to be effective in achieving adequate bone length. A high level of patient compliance and prompt management of complications by an experienced surgeon are essential for achieving good results.     

Complications following metatarsal lengthening by callus distraction for brachymetatarsia.

We performed six metatarsal lengthenings in four patients for brachymetatarsia of the fourth toe by callus distraction from 1991 to 1995. Healing was achieved in all cases. The average amount of lengthening was 30% (range, 15-41%) of the original length. The average healing index was 82 days/cm (range, 66-113 days/cm). After the operation, range of movement of the metatarsophalangeal joint decreased in all cases (120 degrees before and 57 degrees after surgery). In two cases in which the lengthening exceeded 40% of the original length, stiffness of the joint (20 degrees and 0 degrees each) and joint deformity occurred. These two cases also had angulation of the metatarsal. Corrective osteotomy and release surgery was performed in one case. Angulation of the metatarsal was corrected, but the range of movement of the joint did not much recover after surgery. Another case was left untreated because the patient had no complaints. In metatarsal lengthening by callus distraction, the amount of lengthening should not exceed 40% of the original length.