重建钢板内固定治疗成人锁骨粉碎性骨折

目的:评价锁骨粉碎性骨折采用重建钢板内固定治疗的效果,以探讨锁骨粉碎性骨折更满意的治疗方法.方法:骨折类型采用Edward分型法,62例锁骨粉碎性骨折全部采用切开复位重建钢板内固定.62例患者中,57例获得随访(91.9%)平均随访时间为6个月～2.5年.结果:根据JOA肩关节评分系统评价术后功能,本组中优48例,良6例,一般2例,差1例,优良率94.8%.结论:粉碎性锁骨骨折即是肩关节内骨折,应考虑切开复位重建钢板内固定治疗,尽量恢复肩关节内的平整和锁骨的外形与力线,以避免日后的并发症发生.     

Ilizarov technique in management of nonunited fracture of both bones of the forearm

Nonunited fracture of the forearm, although not a common problem, is associated with marked disability. Nonunion can due to infection secondary to open fracture or can be a complication of surgical open reduction and internal fixation. Nonunion can also result from improper management or technique that is not suitable for the type of injury. This study reviews 11 patients with nonunited fractures of the shafts of the radius and ulna. Average duration of nonunion was 18 months. Nine patients presented with active infection or a history of infection in the form of open discharging wound with or without exposed bone, while two had no history of infection. Patients were managed by surgical debridment, removal of dead bone and hard wear, if any, and application of Ilizarov external fixation frame followed by acute shortening by compressing the fracture site. Three weeks later, gradual lengthening started to regain the normal length. Eradication of infection and sound union was achieved in all cases, with good hand, wrist, and elbow function on final follow-up. Limitation in pronation and supination ranges of movement were found in all cases. This could be due to multiple surgeries, long duration of management, the external fixation wires that crossed the distal and proximal radio-ulnar joints, or loss of the normal radial and ulnar bowing during lengthening. Ilizarov technique and external fixation represent an option in the management of resistant nonunion of diaphysial fractures in the forearm. Received: 5 July 2002, Accepted: 16 July 2002     

钩钢板治疗Neer II型锁骨骨折术后锁骨中段骨折的危险因素分析

目的分析钩钢板治疗Neer II型锁骨骨折术后锁骨中段骨折的潜在危险因素。 方法在2009年3月至2019年7月期间,有294例患者使用了钩钢板治疗锁骨远端骨折并符合入选标准,其中279例术后未发生锁骨中段骨折的患者（对照组）、15例发生了术后锁骨中段骨折的患者（并发症组）。本研究收集了患者的数据,包括性别、年龄、骨折患侧、体重指数、吸烟情况、最内侧螺钉的种类、是否由住院医师作为术者进行手术、术中钩钢板是否进行了塑型、钢板的孔数、钩的深度、并发症的发生时间和发生时有无第二次创伤。本研究采用卡方检验对所有潜在的危险因素在对照组和并发症组间进行了比较。最后对具有统计学差异的变量进行了Logistic回归分析。 结果高龄患者在使用钩钢板治疗锁骨远端骨折后,更容易出现锁骨中段骨折（OR= 3.478; 95% CI : 1.719~15.407; P= 0.003）。 结论患者高龄可以显著增加钩钢板固定后锁骨中段骨折的发生率。     

卧式复位与铸模结合“8”字绷带固定治疗锁骨骨折

近几年来,锁骨骨折的手术率越为越高,并不断有文献指出锁骨骨折手法整复"8"字绷带固定等传统疗法复位困难、冶疗时间工、效果差,主张积极采取手术治疗[1].     

Nonunion after primary treatment of tibia fractures with external fixation

The authors retrospectively reviewed 207 fractures of tibial diaphysis, treated primarily with external fixation without bone grafting. Forty-two fractures (20.3%) resulted in nonunion and required reoperation. Parameters analyzed for their significance for nonunion included, soft tissue damage, energy of injury, method of fracture reduction, type of external fixation frame, supplemental interfragmentary screw fixation, dynamization at the fracture site, and postoperative infection. Nonunion rate was found to be significantly higher in type II and III open fractures, high-energy fractures, fractures treated by external fixation using a bilateral frame, and fractures treated with supplemental interfragmentary screw fixation. Multivariate analysis showed that type II and III open fracture, high-energy injury, and supplemental interfragmentary screw fixation were the main risk factors for nonunion.     

Limited open reduction and Ilizarov external fixation in the treatment of distal tibial fractures

The authors reviewed 31 distal tibial fractures (16 involving the tibial plafond) treated with Ilizarov external fixation. The study population was composed of 19 males and 12 females, with an average age of 54. The fractures were classified according to the AO classification: A1 (3), A2 (6), A3 (6), C1 (2), C2 (8), C3 (6). There were six open injuries. In 14 pilon cases, open reduction of the intra-articular fragments and bone grafting via a limited incision was performed. Clinical follow-up averaged 28 months (range 18-42). All but one fracture united with an average healing time of 13.9 weeks. Nearly all patients with AO type A fracture had excellent or good functional scores. The 14 cases of AO C2 and C3 group had five (38%) good results, five (38%) fair results and three (24%) poor results. This method yielded results comparable with previous studies using open reduction and internal fixation. Twenty-nine percent of the patients had pin track infection, which remained the most important complication of this method.     

几种内固定治疗锁骨骨折疗效比较

目的比较多种内固定治疗锁骨骨折的疗效。方法分析自2001年6月至2005年6月不同方法治疗的锁骨骨折58例,其中克氏针9例,重建钢板25例,形状记忆合金按骨板11例,锁骨钩钢板13例。结果所有骨折均骨性愈合,肩关节功能恢复正常,但2例克氏针,2例重建钢板骨折延迟愈合,5例形状记忆合金钢板取出较困难。结论锁骨钩钢板治疗锁骨远端骨折有明显优势,中段粉碎性骨折采用重建钢板有明显优势。     

A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: Open reduction and internal fixation versus external Ilizarov fixation

Intra-articular fractures of the tibial plafond are complex injuries which continue to challenge orthopaedic surgeons in achieving anatomic reduction, while allowing early weight bearing and return to activity. Although a wide range of treatment options has been described for fixation of pilon fractures, the unique characteristic of each injury makes it difficult to advocate a general method of choice. We have attempted to compare a subset of AO/OTA type C pilon fractures treated either by a staged procedure of external fixation and conversion to open reduction and internal fixation (ORIF) versus definitive external Ilizarov fixation. Between 1998 and 2004, 42 patients admitted to our level 1 trauma centre underwent either procedure and were followed prospectively. Twenty-eight patients were treated with ORIF and 14 were treated by Ilizarov ring fixator. The outcome measures included time to union, as well as the rates of union, nonunion, malunion and infection. Although the ORIF group had a longer time to heal, the rates of nonunion, malunion and infection were lower compared to the Ilizarov group. However, these differences between the groups were not statistically significant. Thus, based on these results, no clinical recommendation can be made as to which procedure is better and safer for the patient. Future prospective randomised trials are required to determine with more scientific accuracy the optimal treatment strategy for these challenging injuries.     

螺纹弹性髓内钉闭合复位内固定治疗锁骨骨折

目的 设计一种螺纹弹性髓内钉(threaded elastic intramedullary nail,TEIN),观察其在闭合复位下固定锁骨骨折的疗效.方法 用钛合金(Tc4)或不锈钢(317L)材料加工TEIN,直径1.5、2.0和2.5 mm三种,长250 mm.TEIN近端为正圆锥体尖,相邻有15-150 mm长,且高出于钉体0.5 mm的自攻螺纹;远端为正三角形刃.2004年1月至2008年1月,采用闭合复位内固定55例(56根)锁骨骨折患者.男44例.女11例;年龄9-72岁,中位年龄31.0岁.内1/3横行骨折4根,中1/3骨折41根(横行骨折11根,斜行骨折17根,粉碎性骨折13根),外1/3骨折11根(按Craig分型:Ⅱ型7根.V型4根).结果 手术时间15-60 min,平均35.6 min.术后6-24周取出TEIN,平均取钉时间为8.8周.随访时间1-4年,平均3.4年.骨折恢复解剖学形态者33例(58.9%);恢复解剖学长度,对位较好17例(30.4%);4例中1/3粉碎性骨折,2例外1/3 Craig V型骨折骨折片未复位;总复位优良率为89.3%.中1/3骨折于肩锁关节内侧断钉1例;皮下形成滑囊24例(42.9%);局部皮肤形成压疮Ⅰ期14例,Ⅱ期5例(33.9%).外1/3骨折者术后1年时,肩关节Constant总评分为87.1(79.0-100.0)分.结论 TEIN可以闭合复位固定治疗锁骨骨折,具有微创、美观、促进骨折愈合和减少并发症等优点.     

Ilizarov外固定架在胫骨截骨延长治疗中的应用

目的：探讨Ilizarov外固定架在胫骨截骨延长治疗中的应用。方法：1990年1月～2002年12月对66例应用Ilizarov外固定架进行胫骨截骨延长的患者手术疗效进行分析。结果：延长长度最长9．3cm，最短5．7cm，平均7．3cm；延长时间24～128d，平均62d；拆架时间2．5～10个月，平均6．0个月；愈合指数27～56d／cm，平均34d／cm。无严重并发症发生，其中1例术后出现腓总神经损伤症状；4例出现不同程度的针道感染；6例出现膝关节屈曲受限；4例出现跟腱挛缩致足呈马蹄畸形。给予对症处理后好转。结论：应用Ilizarov外固定架技术对于胫骨截骨延长是一种有效的方法。     

髓内钉或克氏针与钢板固定治疗锁骨骨折的Meta分析

目的:系统评价髓内钉或克氏针与钢板固定比较治疗锁骨骨折的疗效和并发症。方法:计算机检索Pubmed、Embase、Cochrane数据库、中国期刊全文数据库(CNKI)、维普期刊数据库医药卫生辑(VIP)及万方数据库数据库。纳入比较髓内固定与髓外固定治疗锁骨骨折的前瞻性或随机随照研究。采用RevMan 5软件进行Meta分析,比较术后肩关节功能评分、手术疗效、手术指标及术后并发症率。结果:共纳入10篇随机对照研究、3篇半随机对照研究,合计976例纳入系统评价。5篇文献比较了克氏针与钢板的疗效,8篇文献比较了髓内钉与钢板的疗效。克氏针与钢板术后疗效优良率比值比(RR)3.79[95%可信区间,1.93,7.46],6篇文献报告了髓内钉与钢板术后Constant评分,总体均数差为-1.39[-3.43,0.65].5篇文献报告了髓内钉与钢板术后的大并发症率,RR为9.34[2.70,32.32].5篇文献比较了髓内钉与钢板的再手术率,RR为5.04 [1.52,16.77].结论:现有研究证据表明髓内钉治疗锁骨骨折的术后并发症率及再手术率明显低于钢板;克氏针固定的术后疗效明显低于钢板固定。现有数据的总样本量有一定程度的局限性,期待未来大样本高质量随机对照试验进一步证明结果。     

锁骨骨折的治疗现状

锁骨骨折的治疗争议只是近几年的事。回顾国内外文献可以发现，强调锁骨骨折手术治疗的趋势有所上升。而多少年来传统的保守治疗受到前所未有的挑战。随着现代内固定技术的发展，相信这种挑战会成为进一步上升的趋势。哪种类型的锁骨骨折需要手术？哪种类型无须手术？采用何种手术方式和内植物等等是本篇要重点讨论的问题。     

The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect

ObjectiveTo examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external fixator.Materials and methodsThe SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov).ResultsThe patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4).ConclusionsAlthough both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients’ mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients’ mental, the impact of the Orthofix LRS was less severe.     

The treatment of high tibial osteotomy non-union with the Ilizarov external fixator

To evaluate the results of the Ilizarov external fixator in the treatment of non-union post–high tibial osteotomy (HTO). Five non-unions, in four patients, following HTO were treated by Ilizarov fixation. Clinical outcome was assessed pre- and post-operatively by the Knee Society Clinical Rating System (KSCRS). Radiological analysis assessed bone healing pre- and post-operatively and measured proximal tibial alignment. All cases healed with a mean time of 25 ± 3 weeks (Mean ± SD) (range, 24–30 weeks) in the fixator. The clinical and radiological outcome improved in all cases. Four knees were initially in excessive varus and underwent correction of alignment, as measured by medial proximal tibial angle (MPTA), from 75.5° ± 8.4° (mean ± SD) to 90.2° ±  2.7° (normal range, 85°–90°). One patient was in excessive valgus and had a correction of MPTA from 100° to 87°. The KSCRS knee score improved from 35.6 ± 10.8 to 86.6 ± 13.9 (mean ± SD) (normal score = 100) and the functional score from 37.8 ± 11.8 to 85.4 ± 10.5 (mean ± SD) (normal score = 100). The Ilizarov technique is a minimally invasive method that produces excellent clinical, radiological and functional outcomes.     

Long-term functional outcome assessment of plate fixation and autogenous bone grafting for clavicular non-union

INTRODUCTION: The aim of our study was to assess the long-term functional and radiological outcome of clavicular non-union in patients treated with open reduction and bone grafting. A total of 24 non-unions treated between 1994 and 2001 were analysed using chart and radiological review and assessed with the American Academy of Orthopaedic Surgeons (AAOS) DASH questionnaire. RESULTS: There were 13 males and 10 females with a mean age of 37.95 (range 21-65) years. One patient had bilateral injuries. The average time from injury to operation was 10.3 (range 4-29) months and the average follow-up post-operatively was 42.1 (range 6-75) months. All patients were treated using a dynamic compression or reconstruction plate with autogenous bone grafting. Twenty-two of the 24 non-unions eventually healed. DASH assessment indicated a higher level of disability in the treated group than found in the normal population. This only proved significant in the sub-population of patients with associated co-morbidities. CONCLUSION: We conclude that the long-term outcome results of this procedure indicate it to be a well-tolerated and successful operation in treating the disability and pain associated with clavicular non-union. Most patients return to a daily level of function close to the general population. Patients with associated co-morbidities should have these treated pre-operatively for best results.     

A new approach for plate fixation of midshaft clavicular fractures

The majority of midshaft clavicle fractures unite uneventfully. Although the indications for operative intervention are limited and reported complication rates high, there are circumstances in which surgery is required. We describe a new, infraclavicular surgical approach to the clavicle used in a series of 89 patients over 9 years. Average time to union was 13.5 weeks. There was one case of deep infection and one of non-union, both of which resolved with further treatment. These results compare very favourably with previously published series and we submit that this operative approach allows safe management of an otherwise potentially hazardous procedure.     

重建钛板内固定治疗锁骨中段骨折

目的 探讨重建钛板内固定治疗锁骨中段骨折的疗效。方法 对37例锁骨中段骨折均采用切开复位重建钛板内固定，并随访分析其疗效。结果 所有骨折均临床愈合，功能良好。结论 重建钛板为锁骨中段骨折首选，效果极佳，可免除二次手术之苦。     

External fixation in fractured patients aged more than 60 years

Fractures account for significant morbidity and mortality among the elderly. Commonly, surgical procedures like internal fixation are not exempt of complications (infection, soft-tissue problems). In this study, we examined the use of external fixation (EF) in 28 patients aged more than 60 years with a total of 30 fractures. There were 16 men and 12 women with a mean age of 72 (61–85) years. The upper limb was involved in four cases and the lower limb in 26. In half of the cases, open fractures were present, which were classified according to Gustilo: eight type I, six type II, and one type III. Fracture healing, angular deviation and bone aspect in the pin site were accessed radiologically. Clinical criteria included fracture healing, pain and articular function. The average time for fracture union was 7 (2–18) months. The overall rate of complications was high (66.6%). The most common complications were malunion (20%), non-union or delayed union (20%) and superficial pin-tract infection (10%). However, severe complications were rare. No deep infection or soft-tissue problems occurred. We consider that EF can be used not only for open and comminuted fractures but also in closed and minimally comminuted fractures with a high risk of soft-tissue problem where no other fixation is suitable.     

Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail

Objective: Studies showed elastic stable intramedullary nailing (ESIN) of displaced midclavicular fractures has excellent outcomes, as well as high complication rates and specific problems. The aim was to discuss ESIN of midshaft clavicular fractures.Methods: Totally 60 eligible patients (aged 18-63 years) were randomized to either ESIN group or non-operative group between January 2007 and May 2008. Clavicular shortening was measured after trauma and osseous consolidation.Radiographic union and complications were assessed. Function analysis including Constant shoulder scores and disabilities of the arm, shoulder and hand (DASH) scores were performed after a 15-month follow-up.Results: ESIN led to a signifcantly shorter time to union, especially for simple fractures. In ESIN group, all patients got fracture union, of which 5 cases had medial skin irritation and 1 patient needed revision surgery because of implant failure. In the nonoperative group, there were 3 nonunion cases and 2 symptomatic malunions developed requiring corrective osteotomy. At 15 months after intramedullary stabilization, patients in the ESIN group were more satisfied with the appearance of the shoulder and overall outcome, and they benefited a lot from the great improvement of post-traumatic clavicular shortening. Furthermore,DASH scores were lower and Constant scores were significantly higher in contrast to the non-operative group.Conclusion: ESIN is a safe minimally invasive surgical technique with lower complication rate, faster return to daily activities, excellent cosmetic and better functional results,restoration of clavicular length for treating mid-shaft clavicular fractures, resulting in high overall satisfaction, which can be regard as an alternative to plate fixation or nonoperative treatment of mid-shaft clavicular fractures.     

锁骨远端解剖型锁定钢板微创内固定治疗锁骨中外1/3骨折

目的:探讨锁骨远端解剖型锁定钢板闭合复位、微创内固定治疗锁骨中外1/3骨折的临床疗效。方法:自2016年2月至2017年3月,采用锁骨远端解剖锁定钢板闭合复位、微创内固定治疗锁骨中外1/3骨折患者32例,其中男24例,女8例;年龄22～68(42.3±12.7)岁;根据Robinson分型:2A2型6例,2B1型18例,2B2型8例。术前均无血管、神经损伤。受伤至手术时间0～6(3.1±1.4) d。对比手术前后双侧锁骨长度以评价骨折复位情况,并于术后6个月采用Constant评分评价患肩功能恢复情况。结果:30例患者获得随访,时间11～18(13.3±2.2)个月。术后无血管、神经损伤、内固定失效、骨折端延迟愈合、不愈合等并发症出现。创面均Ⅰ期愈合,骨折愈合时间8～12(10.2±1.1)周。锁骨短缩长度由术前的(11.2±3.6)%减少至术后2 d的(0.4±0.3)%。10例患者于术后8个月行内固定拆除,术后无再骨折发生。Constant评分由术前的23.53±5.21提高至术后6个月的94.30±5.60,其中优26例,良4例。患者对术后瘢痕美观程度及患肩功能均表示非常满意。结论:采用锁骨远端解剖型锁定钢板闭合复位、微创内固定治疗锁骨中外1/3骨折,可取得良好的手术疗效,具有创伤小、术后恢复快,瘢痕小、不影响美观等优势。