骨间前血管腕背支骨膜瓣移位修复骨不连的临床应用

报道用骨间前血管腕背支骨膜瓣移位修复骨不连、骨坏死的手术方法及疗效。方法：根据应用解剖学研究，设计以骨间前动脉腕背支为蒂的骨膜瓣，顺行移位修复尺、桡骨骨不连，逆行移位修复手舟骨、月骨不连与骨坏死。结果：临床应用19例，随访1年，在术后3～6月均达到骨愈合和骨坏死修复，关节活动功能明显改善。结论：骨间前血管腕背支为蒂的骨膜瓣移位术适合邻近骨不连、骨坏死修复。     

月骨的血供及其临床意义

在87侧成人干燥月骨、12侧透明腕标本、20侧乳胶灌注标本上观察了月骨的血管孔、骨内、外动脉及其与周围结构的关系。掌侧的动脉是月骨的主要血供来源,在长期、反复强力伸腕的情况下容易受到损伤,这可能是月骨缺血性坏死的主要原因.     

Anatomical consideration of vascularized bone graft transfer from the medial calcaneus to the talus

To investigate the possibility of use of the calcaneal branches of the posterior tibial artery as the pedicle for the vascularized bone graft to the talus, a detailed anatomical study was carried out on 30 fresh cadaver feet. Although there are several branches from the posterior tibial artery to the calcaneus, the largest posterior branch was defined as the main calcaneal branch. We recognized frequently a large branch nourishing the superior part of the calcaneus and named it the superior calcaneal branch. Twenty feet had the superior calcaneal branches. Pedicled bone grafts using the superior calcaneal branch to the postero-medial portion of the talar body were possible in 18 of 20 feet. Pedicled bone grafts using the main calcaneal branches were possible in 9 of 12 feet in which the superior calcaneal branches were not available. Finally, vascularized bone grafts were judged to be feasible in 27 feet (90%).     

1、2伸肌间室支持带上动脉桡骨瓣治疗舟骨骨不连的数字解剖及疗效分析

目的　探讨1、2伸肌间室支持带上动脉（the first and second intercompartmental supraretinacular artery,1,2 ICSRA）桡骨瓣治疗舟骨骨不连的可行性及疗效。 方法　收集47例正常人腕关节CT数据,分别测量桡骨茎突尖端到舟骨长轴近极及远极距离,并与1,2 ICRSA血管蒂的长度进行对比,分析1,2 ICSRA桡骨瓣治疗舟骨骨不连的可行性。对23例舟骨骨不连患者实施1,2 ICSRA桡骨瓣结合Herbert钉内固定手术治疗,随访患者骨折愈合情况;采用Cooney腕关节评分评估患者局部症状和功能。 结果　桡骨茎突尖端到舟骨长轴近极和远极距离分别为（15.66±1.89）mm和（17.07±1.60）mm,均小于1,2 ICSRA血管蒂长度。23例患者术后舟骨均获得愈合;随访时间（51.08±11.30）月,末次随访时21例患者腕关节疼痛感消失,2例患者重体力劳动时有轻微疼痛,但症状较术前得到明显改善;Cooney腕关节评分优20例,良3例,从术前（62.39±7.21）分提高至术后（92.39±4.23）分,差异有统计学意义（t=17.213,P=0）。 结论　1,2 ICSRA桡骨瓣长度足以覆盖舟骨任何部位,该方法治疗舟骨骨不连具备可行性且疗效肯定。     

头状骨形态和血供的解剖学基础

目的　观察头状骨的形态和血供模式,探讨头状骨缺血性坏死的发生机制,为临床上头状骨移位治疗晚期Kienb?ck病提供解剖学依据。 方法　选取12例新鲜腕关节标本,从尺动脉或桡动脉灌注明胶-氧化铅溶液,经Micro-CT扫描,通过Mimics软件三维重建图像,观察头状骨形态和主要血供来源,测量头状骨和月骨的长度、宽度、厚度及近端关节面的直径、弧长和弧高,记录头状骨滋养血管孔的数量和分布情况,并对相关数据进行统计学分析。 结果　（1）F型头状骨75%（9例）,S型头状骨25%（3例）;（2）头状骨血供来源于掌侧和背侧,以背侧为主;（3）比较头状骨和月骨的长度、宽度和厚度及近端关节面的直径、弧长和弧高,具有明显的相关性;（4）头状骨滋养血管分布于距基底部2.2 mm处,其远端滋养孔数多于近端,差异有统计学意义（P<0.05）。 结论　头状骨的近端是以远端逆行供血为主,这是导致头状骨缺血性坏死的主要原因;头状骨移位治疗晚期Kienb?ck病具有可行性。     

腕部掌侧带血供皮瓣游离移植修复手指皮肤缺损的应用解剖研究

目的　介绍腕部掌侧皮肤带血供游离移植修复手指皮肤缺损的应用解剖学基础。 方法　解剖观测20例成人尸体上肢标本,2例标本做带骨骼动脉铸型,18例标本做肱动脉乳胶灌注。在手术显微镜下进行解剖,观测腕部掌侧皮肤的营养动脉、回流静脉、神经支配来源、其内的掌长肌腱。 结果　腕部掌侧皮肤主要由桡动脉掌浅支分支营养,静脉回流有深浅两种途径,神经支配以正中神经掌皮支为主,桡神经浅支为辅,游离移植可切取面积为2cm×4cm~2 cm×5cm[2cm×（4.42±0.58）cm]。桡动脉掌浅支起始处直径为 （1.25±0.24）mm, 与指动脉直径相仿。 结论　传统的腕部掌侧供皮区皮肤可以形成以桡动脉掌浅支为蒂的复合组织皮瓣游离移植修复手指的皮肤缺损。     

Anatomic basis of ulnar index metacarpal reverse flow vascularized bone graft for index distal bone loss

Well-known advantages of vascularized bone grafts led us to determine the anatomical basis of a metacarpal vascularized bone graft to find a solution for distal index bone loss. Seventeen adult human hands from fresh cadavers were dissected and analyzed. For each hand, we studied the second dorsal metacarpal artery, the ulnar dorsal proper digital artery of index, and the ulnar palmar proper digital artery of the index. Location, diameters, origins, and anastomoses were observed, and at the end, the vascularised bone graft was raised. The second dorsal metacarpal artery was present in all hands, always arising from the dorsal carpal arch with a 1-mm mean diameter. The ulnar dorsal proper digital artery of index was isolated on all dissections, with a subcutaneous location on the ulno-dorsal side of the proximal phalanx. The mean diameter of ulnar dorsal proper digital artery at the level of index proximal phalanx was 0.4 mm. We found anastomotic branches between the ulnar dorsal and palmar proper digital artery of index at the level of the proximal phalanx which permitted us to elevate a vascularised bone graft. We succeeded in removing the graft in all specimens. Its pivot point was always more distal than the middle of the proximal phalanx. The arc of rotation allowed the graft to reach the distal phalanx in 80% of the cases. This anatomical study has demonstrated the theoretical possibility of a reversed pedicled bone graft taken from the ulnar neck of the second metacarpal. This graft brings the following benefits: (a) the use of a minor vascular axis, (b) a surgical technique with a dorsal approach allowing the elevation and the use of the graft at the same time. It can be used on the index for failures of DIP joint arthrodesis, huge chondroma, or traumatology.     

Anthropometric characteristics of wrists joint surfaces depending on lunate types

It is well known that the lunate presents with two main types: lunate type I has one facet of its distal surface only for capitates, whereas lunate type II has two facets of the same surface for capitate and for hamate. Our previous anthropometric studies showed that the lunate type II wrists are of greater size than the lunate type I wrists. The aim of the present study was to determine whether the lunate types and the presence or absence of hamato–lunate joint correlate with anthropometric characteristics of the joint surfaces of other wrists. Sixteen sets of macerated wrists with the lunate type I and 21 with the lunate type II were studied. Two-thousand-four-hundred-and-forty-eight anthropometric measurements were done (for 68 anthropometric indicators) and 864 anthropometric indices were calculated (for 24 anthropometric indices) separately for the wrist joint surfaces. The absolute value of the anthropometric indicators of the joint surfaces of the separated wrists were greater in the wrists with the lunate type II, except for the indicators “Greatest length of the dorsal joint surface of pisiform”, “Width of the proximal joint surface, measured in the middle” and “Greatest width of the proximal joint surface” for the trapezoid and “Greatest height of the ulnar joint surface” for the capitate. The enlargement of the joint surfaces for the scaphoid was mainly in proximo-distal direction. The enlargement for the triquetrum and pisiform was mainly in radio-ulnar direction. The enlargement for trapezium, trapezoid and capitate was mainly in dorso-volar direction (except for the ulnar joint surface of capitate). The enlargement for hamate was mainly in radio-ulnar and dorso-volar directions (except for the joint surfaces for capitate and triquetrum). The calculated indices illustrate the quantitative proportions of the variations mentioned above. The anthropometric differences are a good reason to make a clear distinction between both types of wrist joint complexes—with or without a hamato–lunate joint.     

带蒂桡骨茎突瓣移位可吸收钉内固定治疗陈旧性腕舟骨骨折

目的介绍一种较有效的治疗陈旧性腕舟骨骨折的手术。方法1999年8月～2005年10月,采用桡动脉茎突返支为蒂的桡骨茎突瓣移位 可吸收螺钉内固定治疗陈旧性腕舟骨骨折11例,男9例,女2例,年龄18～47岁。结果术后随访9～42个月,平均20．4个月,X线片显示腕舟骨骨折均在术后2～3个月获得骨性愈合,愈合率达到100%,腕关节活动时无疼痛。结论手术操作方便,舟状骨骨折植入的带血管蒂骨瓣与植入的松质骨及舟状骨建立血供,成骨力强,骨的愈合时间短,可吸收钉内固定有固定可靠,不用二次手术取出,适用于陈旧性腕舟骨骨折的治疗。     

人体腕骨显微骨硬度分布特征的研究

目的 探讨人体腕骨显微骨硬度的分布特征及其临床意义。方法 纳入3具新鲜冰冻成人尸体标本(62岁男性、58岁男性、45岁女性),将右侧腕骨软组织剥离后,用慢速锯分别在舟骨、月骨、头状骨、钩骨、大多角骨和小多角骨切取厚3 mm的骨组织标本。舟骨选取舟骨结节、腰部内外侧和舟骨体部,月骨选取腕关节面、掌侧面、背侧面和远端,头状骨、钩骨、大多角骨和小多角骨选取外层皮质不同区域,应用德国KB-5型显微维氏硬度仪测试标本不同区域的硬度值,采用50 gf力加载50 s、维持12 s的标准操作方法进行硬度值测定,每个区域选取 5 个有效值,全体有效值的平均值作为该部位的骨硬度值。观察不同骨骼间及骨骼内部不同区域的骨硬度值差异。结果 3具标本中共取得舟骨、月骨、头状骨、钩骨、大多角骨和小多角骨标本切片18片,测量位点255个。腕骨不同骨骼骨硬度从高到低依次为钩状骨(39.04±5.79)HV、头状骨(38.98±6.17)HV、舟骨(37.72±5.85)HV、大多角骨(35.89±4.75)HV、月骨(33.65±5.42)HV及小多角骨(31.82±5.54)HV,不同骨骼间总体骨硬度差异有统计学意义(F=10.783,P＜0.01)。舟骨、月骨内部不同区域骨硬度分布近似,舟骨结节、腰部外侧、腰部内侧和舟骨体部骨硬度分别为(37.07±5.77)、(37.51±6.39)、(40.00±5.64)、(36.31±5.47)HV,其中腰部内侧骨硬度最大,舟骨体部骨硬度最小,4部位间骨硬度比较差异无统计学意义(F=1.129,P＞0.05)。月骨腕关节面、掌侧面、背侧面和远端骨硬度分别为(33.57±3.61)、(34.58±6.04)、(35.47±5.24)、(30.97±5.88)HV,其中背侧骨硬度最大,远端骨硬度最小, 4个部位间骨硬度比较差异无统计学意义(F=2.040,P＞0.05)。结论 健康人腕骨不同骨骼间硬度各有不同,舟骨和月骨内部各部位骨硬度分布均匀一致。测量腕骨显微骨硬度值,了解其分布特征,有助于了解腕骨微观生物力学性能,亦可指导腕骨骨折内固定方法的选择,设计制作更加符合人体生理状态下的腕部骨骼假体及建立腕部肌骨组织的有限元模型。临床试验注册 中国临床试验注册中心,注册号为ChiCTR-BPR-17010818。     

Alternative approaches for regional ulnar nerve blockade: a cadaveric study

Wrist blockade is a safe and effective alternative to general anesthesia in surgery of hand injuries. With regard to the ulnar nerve, the volar approach is used, where the needle passes through or medial to the flexor carpi ulnaris tendon; however, the ulnar artery is at risk because the needle may accidentally penetrate it, causing profuse bleeding. Alternatively, the wrist may be approached medially, the ulnar approach, and the needle tip placed posterior to the flexor carpi ulnaris tendon. To determine which of these methods may be preferable for avoiding ulnar artery injury, needles were inserted into the wrist area of cadaver hands (n = 57) using the volar and ulnar approaches; detailed dissection of the region around the inserted needles was subsequently carried out. The position of the ulnar nerve relative to the ulnar artery and injury to the artery was documented. Damage to the ulnar artery using the volar approach was 36.8% (21/57 cases) compared to no (0%) injury observed using the ulnar approach. At the level of the wrist crease just proximal to the pisiform bone, the ulnar nerve was medial to the artery in 92.9% (53/57) of cases, medial and posterior in 5.3% (3/57), and anterior to the artery in 1.8% (1/57) of cases. This study suggests that in cases where ulnar artery pulsation is not reliable, the ulnar approach may be preferable for ulnar nerve blockade due to an increased incidence of ulnar artery penetration with the volar approach.     

Palmar divergent dislocation of scaphoid and lunate

A 28-year-old man presented with a palmar divergent dislocation of the scaphoid and lunate. He was treated with an open reduction and an internal fixation with two Kirschner's wires after the 25th day of trauma due to a neurological injury. The results were satisfactory after 18 months follow up without any evidence of avascular necrosis and traumatic arthritis of the scaphoid and lunate. The patient had no limitation in motion or intermittent wrist pain. We reported this case with a brief review of relevant literatures.     

Measurement of intraarticular wrist joint biomechanics with a force controlled system

Pathologies of the wrist, such as fractures or instabilities, can lead to alterations in joint biomechanics. Accurate treatment of these pathologies is a frequent challenge for the surgeon. For biomechanical investigations, a test-setup that applies physiological loading of the wrist joint is necessary. A force controlled test-bench with agonistic and antagonistic muscle forces was built to move six fresh frozen human upper extremities through flexion and extension of the wrist joint. Tendon forces, range of motion, intraarticular contact area and contact pressure of the lunate and scaphoid facet as well as tendon excursion were investigated and compared with the current literature. During wrist motion the extensors exerted double the force of the flexors. Capsulotomy and sensor insertion decreased the range of motion from 63.4° (SD 14.1) to 45.9° (SD 23.7). The ratio of force transmitted through the radius and ulna was 77:23 and pressure distribution between the scaphoid and lunate facet showed a 70:30 relationship. The obtained data indicate a good agreement with the available literature. Therefore, the force controlled test-bench in combination with intraarticular radiocarpal measurements can be used to investigate the influence of wrist pathologies on joint biomechanics.     

Patterns of radiocarpal joint articular cartilage wear in cadavers

The radiocarpal joint transmits about 80% of the compression forces crossing the wrist. However, primary osteoarthritis of this joint is surprisingly uncommon, suggesting that articular cartilage wear is not sufficient to produce arthritic symptoms. By examining the distal radius, scaphoid, and lunate in aged cadavers, wear patterns were charted and measured, allowing assessment of radiocarpal joint wear and mechanics. Bilateral radiocarpal joints of 16 females and 14 males (age 77.7 ± 14.4, N = 30) were exposed and measurements of the wear recorded microscopically. Wear locations were mapped, and X-Y loci and wear areas calculated. Gender right and sides compared. Over 95% of distal radius wear showed distinct radial-scaphoid and radial-lunate wear areas. These bilateral areas were in the palmar half of the distal radius. One main central wear area was seen in 95% of the scaphoid, and 97% of the lunate articular surfaces that were examined. Articular wear showed a circular pattern and was minimal in 95.7% of the surfaces, and the lunate showed the largest wear area. Wear patterns in males and females support the literature that for most ADLs the wrist is in slight extension and ulnar deviation. There are gender differences, but wear areas between sides were similar. Female wear indicates their wrist is positioned more often in a more extended and ulnarly deviated position than males. The wear patterns suggest rotational movements of the scaphoid and lunate during wrist motion and that the wrist is most often used in neutral flexion/extension to slight extension.     

Direct comparison of contact areas, contact stress and subchondral mineralization in human hip joint specimens

 X-ray densitometric and CT osteoabsorptiometric findings suggest that in the human hip subchondral mineralization patterns change from bicentric to monocentric as a function of age. It has been hypothesized that these changes indicate an alteration in the geometric configuration of the joint from incongruous to congruous, possibly associated with the onset of osteoarthrosis. The purpose of this study was therefore to directly compare contact areas, contact stress and subchondral mineralization in the hip joint. Twelve specimens without cartilage lesions (ages 34–86 years) were investigated. Simulating the mid-stance phase, the contact areas were determined by polyether casting and the contact stress with Fuji film. The distribution of subchondral mineralization was assessed non-invasively with CT osteoabsorptiometry. At small loads the load-bearing areas were located at the periphery of the lunate surface. In some joints they were found in the acetabular roof and expanded, with higher loads, to the center of the lunate surface and the anterior and posterior horns. In other joints, the contact areas were recorded at lower loads in the anterior and posterior horns, and only at higher forces they merged in the acetabular roof. The maximal contact stress ranged from 8 to 9 MPa at 300% body weight. Maxima of subchondral mineralization were recorded in the acetabular roof, in the anterior and posterior horns, or in all three locations. There was no clear correlation between the distribution of contact and pressure, and the pattern of subchondral bone density. Incongruity is shown to strongly affect the distribution of contact and pressure in the human hip joint. However, the pattern of subchondral mineralization cannot be readily explained in terms of the contact areas and contact stress during mid-stance. Incongruity may give rise to tensile stresses in the subchondral bone, and the construction of the pelvis as a whole may play an important role in subchondral bone loads and adaptation. Accepted: 19 September 1996     

兔预构血管化股骨游离移植后琥珀酸脱氢酶的变化

目的探讨兔预构血管化骨游离移植后的骨生长及代谢变化。方法通过将兔腹壁浅动静脉束植入股骨干中,预构血管化骨,然后用酶组织化学技术对预构血管化骨与非血管化骨游离移植术后骨组织琥珀酸脱氢酶(SDH)代谢等情况,进行了比较实验研究。结果骨游离移植术后2周,琥珀酸脱氢酶的活性即发生变化。尤以2,3,4周血管化骨的琥珀酸脱氢酶活性明显高于非血管化骨(P<0.05)。结论早期观察兔预构血管化骨游离移植后骨细胞的SDH变化可了解移植骨组织的成活与生长情况。     

胫后动脉踝上穿支皮瓣修复足踝部创面

目的　报道胫后动脉踝上穿支皮瓣修复足踝部创面的临床效果。 方法　对13例足踝部创面的患者,采用胫后动脉踝上穿支皮瓣转位修复术,其中足背创面5例,足跟部创面3例,踝部创面5例。4例急诊外伤创面伴有骨、肌腱外露者急诊修复。5例急诊创面采用VSD负压吸引后亚急诊行皮瓣修复, 4例为术后皮肤坏死,二期行皮瓣修复。皮肤缺损面积为1.5 cm×2.0 cm~7.0 cm×14.0 cm,切取皮瓣面积为2.5 cm×3.5 cm~8.0 cm×15.0 cm。 结果 本组13例皮瓣全部成活,供区植皮均成活。术后随访时间6~18个月,平均10个月。皮瓣质地接近周围皮肤,外观无臃肿。供区皮肤直接缝合者,术后瘢痕较小;供区植皮者,无明显瘢痕增生。踝关节活动良好,患肢均可负重行走。 结论　采用胫后动脉踝上穿支皮瓣转位修复足踝部创面,具有手术操作简单、安全的特点,是一种较好的术式。     

Biomechanical analysis of the lumbar spine with anterior interbody fusion on the different locations of the bone grafts

The anterior lumbar interbody fusion is the common procedure in the management of the degenerated disc in the lumbar spine, but the biomechanical behavior of the fused segment would be changed because of the implantation of bone graft at the different locations. To investigate the biomechanical alteration, the study applied the finite element model to undergo the stress analysis.A three-dimensional finite element model of the lumbar spine was established, and modified to the three fusion models consisted of the bone graft at the anterior site, the middle site and the posterior site, respectively. The 12 N m flexion and the 10 N m torsion with pre-load 150 N were imposed on the L1 vertebral body.The results of the finite element model indicated that placing bone graft at anterior site could effectively resist flexion moment, and decreased the tensile force of the posterior ligaments about 15% above. Placing bone graft at posterior site could resist torsional moment, and also led to none of contact force of the facet joint in the fused segment. However, wherever the bone grafts were placed, stress slightly increased on the disc adjacent to interbody fusion about 5% below.     

Vascularized pedicled iliac crest graft for selected total hip acetabular reconstructions: a cadaver study

Bone grafting is an essential part of most total hip acetabular reconstructions. There are a limited number of surgical options, each with inherent disadvantages for the management of structural acetabular defects. In this cadaver study, the authors aimed to evaluate the availability of vascularized pedicled iliac crest graft for the purpose of acetabular reconstruction. The hip joints, ilia and deep circumflex iliac artery pedicles of six adult preserved cadavers were dissected bilaterally. A segment of the iliac crest was elevated on the vascular pedicle and its access to different parts of the acetabulum was evaluated. The average pedicle length was sufficient for coverage of the superior and anterior acetabular walls. The access to the posterior wall, however, required modification of the bone size. A vascularized pedicled iliac crest graft is suitable for the reconstruction of selected acetabular deficiencies.