轴向载荷力学测试在胫腓骨骨折术后外固定器拆除中的临床应用

目的探讨外固定器轴向载荷力学测试用于指导临床骨折术后拆除外固定器时间判断的安全性及有效性。方法 2014年1月-2015年8月,收治27例因外伤致胫、腓骨骨折患者。男21例,女6例;年龄19~63岁,平均45岁。闭合骨折7例,开放骨折20例。X线片复查示:螺旋型不稳定骨折4例,粉碎型不稳定骨折23例。一期行外固定器固定。其中3例外固定术后出现感染致骨不连,1例发生骨折不愈合伴骨缺损;行二期胫骨截骨延长术。外固定后待正侧位X线片复查明确骨折处均有连续性高密度骨痂形成后,行外固定器轴向载荷力学测试。当外固定器轴向载荷分担比10%时,拆除外固定器。结果经外固定治疗21~85周(平均44周)后,行外固定器轴向载荷力学测试。测试结果显示,26例外固定器轴向载荷分担比10%,拆除外固定器;拆除外固定器后随访6周,患者下肢完全负重,恢复正常生活,无再骨折发生。1例术后85周外固定器轴向载荷分担比为14%,X线片检查显示骨折成角畸形未完全愈合,拆除外固定器后发生再骨折,改行髓内固定术。结论外固定器轴向载荷力学测试可以客观反映并定量评价骨折愈合情况,可用于指导外固定器拆除时间的确定。     

骨外固定动力化治疗开放性胫腓骨骨折北大核心CSCD

目的探讨骨外固定动力化对开放性胫腓骨骨折愈合的影响。方法回顾分析2016年2月—2017年2月采用骨外固定治疗的胫腓骨开放性骨折患者临床资料,根据术后处理方法不同分为弹性动力化组(A组)和恒弹性固定组(B组),每组13例。两组患者性别、年龄、骨折分型等一般资料比较差异均无统计学意义(P>0.05),具有可比性。B组患者术后按传统方法,根据骨折愈合时间、X线片等影像学检查及临床医师经验评价骨折愈合程度,骨折达到临床愈合时拆除外固定架;A组术后12周开始根据X线片检查骨痂生长情况,对患者进行轴向力学载荷比测试,轴向力学载荷比为5%~10%时进行动力化处理。比较两组患者外固定架使用时间、骨折愈合时间及并发症发生率。结果两组患者均获随访,随访时间4~13个月,平均5.7个月。治疗期间两组均未发生外固定架松动、断裂及骨折移位、再骨折等并发症。A组外固定架使用时间为(24.77±1.42)周,骨折愈合时间为(23.04±1.30)周,与B组的(34.38±1.71)周和(32.46±1.66)周比较均显著减少(t=16.10,P=0.00;t=15.58,P=0.00)。A组术后发生针道感染2例、肌力减退1例,并发症发生率为23.1%;B组发生针道感染3例、肌力减退1例及骨折延迟愈合1例,并发症发生率为38.5%;两组并发症发生率比较差异无统计学意义(P=1.000)。结论骨外固定动力化能够加速骨折愈合,且安全性较高。     

骨外固定动力化治疗开放性胫腓骨骨折

目的探讨骨外固定动力化对开放性胫腓骨骨折愈合的影响。方法回顾分析2016年2月—2017年2月采用骨外固定治疗的胫腓骨开放性骨折患者临床资料,根据术后处理方法不同分为弹性动力化组(A组)和恒弹性固定组(B组),每组13例。两组患者性别、年龄、骨折分型等一般资料比较差异均无统计学意义(P0.05),具有可比性。B组患者术后按传统方法,根据骨折愈合时间、X线片等影像学检查及临床医师经验评价骨折愈合程度,骨折达到临床愈合时拆除外固定架;A组术后12周开始根据X线片检查骨痂生长情况,对患者进行轴向力学载荷比测试,轴向力学载荷比为5%~10%时进行动力化处理。比较两组患者外固定架使用时间、骨折愈合时间及并发症发生率。结果两组患者均获随访,随访时间4~13个月,平均5.7个月。治疗期间两组均未发生外固定架松动、断裂及骨折移位、再骨折等并发症。A组外固定架使用时间为(24.77±1.42)周,骨折愈合时间为(23.04±1.30)周,与B组的(34.38±1.71)周和(32.46±1.66)周比较均显著减少(t=16.10,P=0.00;t=15.58,P=0.00)。A组术后发生针道感染2例、肌力减退1例,并发症发生率为23.1%;B组发生针道感染3例、肌力减退1例及骨折延迟愈合1例,并发症发生率为38.5%;两组并发症发生率比较差异无统计学意义(P=1.000)。结论骨外固定动力化能够加速骨折愈合,且安全性较高。     

半环槽式骨外固定器治疗胫腓骨开放性骨折

目的：探讨半环槽式骨外固定器治疗胫腓骨开放性骨折的临床疗效。方法：2005年3月至2011年3月,经闭合手法复位或辅助克氏针撬拨复位半环槽式外固定器治疗94例胫腓骨开放性骨折患者,男63例,女31例;年龄17～65岁,平均39岁。横形骨折5例,斜形与螺旋形骨折19例,粉碎性骨折70例。骨折按Gustilo分类：ⅢA型49例,ⅢB型45例。术后观察伤口感染发生率、骨折愈合时间,并采用Johner-Wruhs评定标准对其功能进行评价。结果：所有患者获随访,时间14～63个月,平均29个月。骨折愈合时间16～39周,平均21.4周,无骨折不愈合、骨髓炎及小腿骨筋膜室综合征等并发症发生。94例中伤口I期愈合者81例,深部伤口感染者2例。功能评价采用Johner-Wruhs评定标准,优52例,良37例,中5例。结论：闭合复位或辅助克氏针撬拨复位及外固定器固定可降低胫腓骨开放性骨折感染率。对于胫腓骨开放性粉碎骨折半环槽式骨外固定器固定3～6周时根据骨折端愈合情况去除中间固定骨折块的克氏针,使支架动力化,可促进骨折愈合。     

单边外固定器治疗胫腓骨骨折228例临床分析

目的总结应用单边外固定器治疗胫腓骨骨折临床效果及经验。方法 228例胫腓骨骨折患者,采用局部有限侵入手术,在直视下协助复位,做单边外固定或合并有限内固定。结果本组解剖复位112例（49.1%）,功能复位116例（50.9%）。201例获随访,平均时间13（10～16）个月。骨折愈合时间平均11（7～32）周。7～16周227例拆除支架,无肌肉萎缩、骨质疏松、骨不连等并发症发生。术后钉道感染6例,经换药、抗生素治疗后愈合。螺钉松动4例,均更换比原螺钉直径大1.0～1.5 mm的螺钉后痊愈。结论单边外固定器治疗胫腓骨骨折有效避免了伤口感染、骨不连、内固定断裂等并发症,且骨折愈合时间明显缩短,是治疗胫腓骨骨折的较好方法。     

小切口有限内固定加外固定器治疗胫腓骨骨折

目的 :介绍小切口有限内固定加外固定器治疗复杂胫腓骨骨折的方法并对治疗结果进行评估。方法 :2 55例中 89例复杂胫腓骨骨折 ,采用小切口有限内固定 (螺钉、钢丝、克氏针或丝线 )后加外固定器固定。术后早期酌情纵向加压 ,外固定器动力化锻炼。结果 :术后随访 1 2～ 84个月 ,平均愈合时间 4～ 5个月 ,再移位数 5例 (5 .88% )。结论 :小切口有限内固定结合外固定器治疗复杂胫腓骨骨折可以避免伤口并发症 ,缩短骨折愈合时间 ,减少骨折延迟愈合、骨不连的出现 ,是治疗胫腓骨骨折的有效方法。     

轴向动力型外固定器在胫骨Pilon骨折治疗中的应用

目的回顾分析运用轴向动力型外固定器和改良穿针技术治疗严重胫骨Pilon骨折的效果。方法研究分析2000年7月至2003年2月间14例严重Pilon骨折(Rtiedi-Allgtiwer Ⅱ型和Ⅲ型)患者,年龄20-52岁(平均38岁),采用有限内固定结合轴向动力型外固定器治疗,远端外固定针置入技术经过改良,2枚外固定针分别置入距骨和跟骨,使外固定器远端夹具旋转轴线与胫距关节旋转轴线重合。结果随访5—36个月(平均18个月),骨折愈合时间12-24周(平均14周)。最后一次随访时,ASS评分优5例,良6例,可3例。无切口裂开、皮缘坏死、表浅及深部感染、骨髓炎,无骨折移位及关节面塌陷;仅有1例近端外固定针道感染,经清创及口服抗生素治疗好转。结论经过改良的轴向动力型外固定器技术结合有限内固定是治疗严重胫骨Pilon骨折的有效方法。     

胫骨新型动力型Hoffmann外固定器的研制与应用

目的探讨自行研制的胫骨新型动力型Hoffmann外固定器(NDHEF)生物力学性能和临床应用效果。方法将15根成人尸体胫骨标本,随机分为3组,制成胫骨中段短斜形骨折模型,分别采用NDHEF、改良型Hoffmann外固定器(IHEF)和多功能外固定器(MEF)固定,进行轴向压缩、弯曲和扭转载荷以及应力遮挡的生物力学测试。自1995～2004年128例胫腓骨开放性骨折分别采用NDHEF和IHEF治疗,随访并评估其临床疗效。结果生物力学实验结果表明在轴向压缩、弯曲和扭转刚度方面,NDHEF与IHEF相似,但均明显强于MEF,差异有显著性意义(P＜0．05)；应力遮挡方面,NDHEF明显小于IHEF和MEF,差异有显著性意义(P＜0．05)。临床应用NDHEF治疗开放性胫腓骨骨折患者40例,并与应用IHEF治疗的88例开放性胫腓骨骨折患者进行比较,经12～36个月(平均16．8个月)随访,骨折完全愈合时间：NDHEF平均22．3周,IHEF平均26．8周,两组问差异有显著性意义(P＜0．05)；延迟愈合和畸形愈合率：NDHEF均为7．5%,IHEF分别为15．9%和4．5%,两组比较差异均无显著性意义(P＞0．05)。结论新型动力型Hoffmann外固定器具有较大的生物力学优越性,临床应用可减少应力遮挡、促进骨折愈合,是一种较好的治疗胫骨骨折的外固定器；固定后再移位倾向可以通过辅助措施加以克服。     

髓内钉与髓外内固定治疗不稳定型股骨转子下骨折的疗效比较

目的 比较髓内钉与髓外内固定治疗不稳定型股骨转子下骨折的疗效. 方法 回顾性分析2005年1月至2011年8月期间收治且获得随访的65例不稳定型(Russell-Taylor分型B型)股骨转子下骨折患者资料,男40例,女25例;年龄为32～ 87岁,平均53.4岁.根据内固定方式不同分为两组:髓内钉组34例,髓外内固定组31例(其中锁定加压钢板内固定治疗21例,动力髋螺钉内固定治疗10例).记录并比较两组患者的手术时间、术中出血量、骨折复位质量、住院时间、骨折愈合时间及术后12个月髋关节Harris评分. 结果 65例患者术后获12 ～ 18个月(平均15.6个月)随访.髓内钉组患者的手术时间[(67.9±19.0) min]较髓外内固定组[(79.8±22.4) min]短,术中出血量[(112.6±63.4) mL]较髓外内固定组[(178.5±97.5)mL]少,骨折愈合时间[(21.0±6.5)周]较髓外内固定组[(28.0±8.7)周]短,术后12个月髋关节Harris评分[(83.4±8.1)分]较髓外内固定组[(79.2±7.4)分]高,差异均有统计学意义(P＜0.05).但两组患者的骨折复位质量、住院时间比较差异均无统计学意义(P＞0.05).2例患者出现骨不连,均为采用锁定加压钢板固定者,改为髓内钉固定后骨折获愈合;2例患者出现畸形愈合,其中髓外内固定组1例,髓内钉组1例. 结论 髓内钉较髓外内固定治疗不稳定型股骨转子下骨折更有优势.     

自制多功能骨外固定器在近关节骨折的应用

目的探讨近关节端多功能骨外固定器治疗长管骨近关节端骨折或关节内骨折的临床效果。方法采用近关节端多功能骨外固定器治疗股骨髁上骨折18例,股骨髁骨折6例,胫骨平台骨折6例,胫骨上段骨折8例,胫腓骨下段骨折6例。结果平均随访时间16.2个月,42例临床愈合,2例延迟愈合,平均愈合时间10周。关节功能正常38例,占88%。结论近关节端多功能骨外固定器可满足近关节端骨折复位和固定的需要,特别适用于开放性、粉碎性骨折,固定牢稳,便于早期功能锻炼。     

Shear movement at the fracture site delays healing in a diaphyseal fracture model.

This study tested the hypothesis that interfragmentary axial movement of transverse diaphyseal osteotomies would result in improved fracture healing compared to interfragmentary shear movement. Ten skeletally mature merino sheep underwent a middiaphyseal osteotomy of the right tibia, stabilized by external fixation with an interfragmentary gap of 3 mm. A custom made external fixator allowed either pure axial (n=5) or pure shear movement (n=5) of 1.5 mm amplitude during locomotion by the animals. The movement of the osteotomy gap was monitored weekly in two sheep by an extensometer temporarily attached to the fixator. After 8 weeks the sheep were killed, and healing of the osteotomies was evaluated by radiography, biomechanical testing, and undecalcified histology. Shear movement considerably delayed the healing of diaphyseal osteotomies. Bridging of the osteotomy fragments occurred in all osteotomies in the axial group (100%), while in the shear group only three osteotomies (60%) were partially bridged. Peripheral callus formation in the shear group was reduced by 36% compared to the axial group (p<0.05). In the axial group bone formation was considerably larger at the peripheral callus and in between the osteotomy gaps but not in the intramedullary area. The larger peripheral callus and excess in bone tissue at the level of the gap resulted in a more than three times larger mechanical rigidity for the axial than for the shear group (p<0.05). In summary, fixation that allows excessive shear movement significantly delayed the healing of diaphyseal osteotomies compared to healing under axial movement of the same magnitude.     

Temporary distraction and compression of a diaphyseal osteotomy accelerates bone healing

Mechanical strain during callus distraction is known to stimulate osteogenesis. It is unclear whether this stimulus could be used to enhance the healing of a normal fracture without lengthening the bone. This study tested the hypothesis that a slow temporary distraction and compression of a diaphyseal osteotomy accelerates fracture healing. Fourteen sheep underwent a middiaphyseal osteotomy of the right tibia, stabilized by external fixation. An external fixator allowed either a temporary axial distraction (TD group; n = 6) or a constant fixation (C group; n = 8). Distraction began 7 days postoperatively at a rate of 0.5 mm twice per day for 2 days with subsequent shortening of 1.0 mm twice on the third day. The procedure was repeated four times. Fluorochrome labeling was performed postoperatively. After 8 weeks the sheep were sacrificed and healing was evaluated using densitometric, biomechanical, and histological methods. Bending stiffness of the tibiae after 8 weeks was 58% higher in the TD group than in the C group. The volume of the periosteal callus was significantly (p = 0.05) higher in the TD group (3.9 cm³) than in the C group (2.7 cm³). There was 20% more bone in the fracture gap of the TD group than the C group. There was a significantly higher bone formation rate in the TD group than in the C group. This study demonstrated the feasibility of fracture healing stimulation by the temporary application of distraction and compression. © 2008 Orthopaedic Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:772–777, 2008     

Treatment of tibial defect and bone nonunion with limb shortening with external fixator and reconstituted bone xenograft

Objective: To explore the effect of external fixator and reconstituted bone xenograft (RBX) in the treatment of tibial bone defect, tibial bone nonunion and congenital pseudarthrosis of the tibia with limb shortening. Methods : Twenty patients ( 13 males and 7 females)with tibial bone defect, tibial bone nonunion or congenital pseudarthrosis of the tibia with limb shortening were treated with external fixation, Two kinds of external fixators were used: a half ring sulcated external fixator used in 13 patients and a combined external fixator in 7 patients.Foot-drop was corrected at the same time with external fixation in 4 patients. The shortened length of the tibia was in the range of 2-9 cm, with an average of 4.8 cm. For bone grafting, RBX was used in 12 patients, autogenous ilium was used in 3 patients and autogenous fibula was implanted as a bone plug into the medullary canal in 1 case,and no bone graft was used in 4 patients. Results: All the 20 patients were followed-up for 8 months to 7 years, averaging 51 months. Satisfactory function of the affected extremities was obtained. All the shortened extremities were lengthened to the expected length. For all the lengthening area and the fracture sites,bone union was obtained at the last. The average healing time of 12 patients treated with RBX was 4.8 months. Conclusions: Both the half ring sulcated external fixator and the combined external fixator have the advantages of small trauma, simple operation, elastic fixation without stress shielding and non-limitation from local soft tissue conditions, and there is satisfactory functional recovery of affected extremities in the treatment of tibial bone defects, tibial bone nonunion and congenital pseudarthrosis of the tibia combined with limb shortening.RBX has good biocompatibility and does not cause immunological rejections. It can also be safely used in treatment of bone nonunion and has reliable effect to promote bone healing.     

Carbon external fixator--CARBOELASTOFIX in treatment of tibia diaphysis fractures]

The authors presents the results of healing status of tibia diaphysis fractures treated with carbon-plate fixator on a group of 12 patients (9 men and 3 women with age between 27 and 89 years). Long-term mechanical investigations and studies at animals, performed at our Department have shown advantages of bone fixation performed with a new device for osteosynthesis, called by authors CARBOELASTOFIX. General principle of the method is the use of external fixation device, made of carbon-epoxide resin composite plates with variable flexibility, enabling hastened fracture healing. The research allowed also to work out the guidelines of indications for surgery, surgical technique and method of modifying flexibility of fixation consistently with fracture healing course. The mean time of observation (from the operation to the healing) was 23 weeks, having 10 good and 2 bad results.     

外固定支架在严重多发伤并胫腓骨开放性骨折中应用的病例对照研究

目的：探讨早期外固定架固定开放性胫腓骨骨折对严重多发伤患者治疗和预后的影响。方法：采用回顾性对比分析，73例严重多发伤（ISS〉16分）患者按胫腓骨骨折手术方法不同分2组。治疗组42例，男31例，女11例；平均年龄40．2岁；均急诊行清创、骨折复位外固定支架固定术。对照组31例，男22例，女9例；平均年龄42．6岁；均急诊行清创、跟骨牵引术或石膏外固定术。比较两组患者急性呼吸窘迫综合征（ARDS）、多器官功能障碍综合征（MODS）发生情况及病死率、小腿创面感染率、创面及骨折愈合时间。结果：两组的并发症（ARDS）发生率差异有统计学意义，行外固定架治疗组低于对照组（P〈0．05），治疗组感染率明显低（P〈0．05），创面愈合时间明显短。结论：外固定架治疗严重多发伤并胫腓骨开放性骨折，明显减少并发症发生率，降低创面感染率。     

全程使用与分阶段使用外固定架和石膏外固定治疗胫腓骨开放性骨折疗效比较

目的　探讨分阶段使用单侧多功能外固定架 (UMEFA )和石膏外固定治疗胫腓骨开放性骨折的疗效。方法　 89例胫腓骨开放性骨折经清创、骨折复位后均予以UMEFA外固定。然后 ,将其分 2组。A组 5 3例为全程骨外固定组 ,其中 8例因并发症较严重 ,中途拆除外固定架 ,其余 45例外固定维持至骨折愈合。B组 36例为临时骨外固定组 ,伤口愈合、肿胀消退、骨折纤维连接时拆除外固定架 ,改用长腿管状石膏外固定。结果　B组并发症的发生率为 8% ,显著低于A组40 % ( P <0 .0 1)。B组患者骨折愈合的平均时间为 2 13.6d ,显著低于A组 2 68.4d( P <0 .0 5 )。B组患者骨折愈合的优良率为 83% ,显著高于A组 60 % (P <0 .0 5 )。结论　分阶段使用外固定架和石膏外固定治疗胫腓骨开放性骨折 ,具有治疗效果好、骨折愈合快、并发症少等优点。     

胫腓骨下段开放性粉碎骨折的治疗(附20例临床报告)

目的探讨胫腓骨下段开放性粉碎骨折的综合治疗。方法20例胫腓骨下段开放性粉碎骨折采用半环槽式外固定器固定、皮瓣转移、腓骨内移、骨折端加压并同期行上干骺端骨延长等综合治疗方法。结果伤口均一期愈合，所有皮瓣均成活，骨折临床愈合平均时间19周，7例因严重骨缺损经骨折端加压并同期行上干骺端骨延长后肢体均恢复正常长度。无1例针眼感染和血管、神经损伤。临床优良率为90％(18／20)。结论a)半环槽外固定器能克服胫腓骨下段开放性粉碎骨折的治疗困难，具有立体均衡固定。刚性可调，避免肢体受压。便于再次创面处理以及同期行骨折端加压和肢体延长等优点。b)半环槽式外固定器结合皮瓣转移、腓骨内移以及骨折端加压并同期行上干骺端骨延长等综合治疗方法是胫腓骨下段开放性粉碎骨折可选择的较好治疗措施之一。     

Unilateral external fixation until healing with the dynamic axial fixator for severe open tibial fractures

One hundred one cases of open tibia fractures were treated until healing with a unilateral external fixation device that permits fracture site compression with weight bearing. There were 38 type II and 63 type III (24 IIIA, 33 IIIB, six IIIC) open fractures. A standard protocol was followed including irrigation and debridement and, when necessary, flap coverage (19 cases) and bone grafting (31 cases). Fixators were applied at the first debridement and removed when the fracture was healed. All patients were permitted early partial weight bearing and progressed to full weight bearing with fixator dynamization. Ninety-six cases healed in the fixator (12-50 weeks; average, 24.6). Three of the five failures were associated with screw complications. Five patients required screw changes and 29 required oral antibiotic therapy for screw complications. Ninety-five percent of healed cases had angulation of less than 10 degrees (in any plane). There were only six fracture site infections during the course of treatment. Dynamic axial fixation may be applied at the first debridement and be used until healing in severe open tibia fractures. Change of the fixator to another treatment method is not required.     

Internal stabilization after external fixation of fractures of the shaft of the tibia: sense or nonsense?

A series of 95 patients with fresh fractures of the shaft of the tibia, treated primarily with a Vidal-Adrey transfixation frame, was studied retrospectively. Only 20 fractures (21.0 per cent) attained clinical and radiological consolidation within 4 months after injury. Pseudarthrosis was seen in 12 patients (12.9 per cent). The external fixator was attached for an average time of 25.0 weeks. Pin loosening was seen in seven patients (7.3 per cent), minor pin track infection in nine (9.4 per cent) and major pin track infection in three (3.1 per cent). In 31 patients (32.6 per cent) a second operative procedure was necessary to accelerate fracture healing. In 17 patients an autologous bone graft was carried out with the external fixator in place. Internal stabilization was performed after removal of the external fixator frame in 14 cases, at an average time of 9.4 months after injury. In difficult fractures we feel that change from external to internal fixation should be performed earlier; it makes early removal of the fixator pins possible and prevents the problems associated with prolonged use of fixator frames. The internal fixation, eventually combined with a transplantation of cancellous autografts, creates a mechanical and biological stimulus for bone consolidation. Functional recovery may also be improved because of a shorter healing time.     

单边可延长外固定支架治疗GustiloⅢB/C型胫骨开放性骨折伴骨缺损

【摘要】〓目的〓探讨应用单边可延长外固定支架治疗GustiloⅢB、C型开放性胫骨骨折并骨缺损的临床疗效。方法 2011年6月至2014年6月,应用单边可延长外固定支架治疗GustiloⅢB/C型开放性胫骨骨折并骨缺损21例。主要方法:一期清创清除游离碎骨及严重污染的骨组织,修整骨折端整齐后短缩患肢对合、修复血管神经肌腱,安装单边可延长外固定支架,并在胫骨近端截骨;术后2周开始骨搬运延长,逐渐延长恢复短缩部分胫骨,恢复肢体长度,骨折愈合后拆除外固定支架。结果〓本组21例随访时间10个月~3年,平均18个月。17例均通过一期短缩肢体修复创面,3例通过局部旋转皮瓣修复创面,1例局部皮瓣部分坏死后通过植皮修复创面。所有骨折端及截骨端最终全部愈合,骨折愈合时间为5~13个月,平均时间8个月。结论〓应用单边可延长外固定支架治疗GustiloⅢB/C型开放性胫骨骨折伴骨缺损,通过急诊短缩患肢消灭创面,同时胫骨干骺端截骨延长的治疗方案,最终肢体长度恢复、骨折愈合。