加压交锁髓内钉治疗下肢长骨干骨折不愈合及延迟愈合

目的 分析下肢长骨干骨折不愈合及延迟愈合的原因,评价加压交锁髓内钉治疗下肢长骨干骨折不愈合及延迟愈合的效果. 方法 1998年2月-2006年12月,对21例股骨和胫骨干骨折不愈合及延迟愈合者采用加压交锁髓内钉治疗.其中股骨13例,胫骨8例,3例未植骨,仅扩髓加压,5例同时行膝关节松解. 结果 随访11.4～36个月,平均13.6个月,全部患者均骨性愈合,平均愈合时间8.7个月,无畸形、感染及再骨折出现.采用Klemm分级标准,优19例,良2例. 结论 下肢长骨干骨折不愈合及延迟愈合主要原因是手术适应证选择不当,手术内固定使用不当,断端血运和骨折愈合生物环境破坏.加压交锁髓内钉治疗下肢长骨干骨折不愈合及延迟愈合具有固定可靠,便于膝、踝早期功能活动,肢体可早期负重等优点.手术应用联合骨移植,扩髓及膝关节松解,可促进骨愈合,改善膝关节功能.     

胫骨下端螺旋形接骨板治疗肱骨近端延及中段的骨折

目的 探讨应用胫骨下段螺旋形接骨板治疗成年人肱骨近端延及中段骨折的固定技术并评价其临床效果.方法 选择2004年5月-2009年2月应用胫骨下段螺旋形接骨板治疗成年人肱骨近端延及中段骨折并获得随访的患者共15例,其中男10例,女5例;年龄19～65岁(平均38岁),总结其手术方法并对其肩关节功能进行评价.结果 15例患者随访7～24个月,平均13个月.结果 显示全部患者均骨性愈合,平均愈合时间4.7个月,未见内固定物松动或断裂.参照Neer肩关节功能评价标准:优7例,良好6例,优良率为87%.结论 应用胫骨螺旋形接骨板固定技术治疗成年人肱骨近端延及中段的骨折简单有效,创伤小.     

胫骨干骨折手术疗效分析

目的 探讨适合胫骨干骨折的手术治疗方法及并发症的预防措施。方法 回顾性分析手术治疗胫骨干骨折病例67例，根据选择手术方式不同，将病例分为交锁髓内钉、加压钢板和外固定支架3组，临床观察结合X线片评价骨折愈合、延迟愈合、不愈合作为判断临床疗效标准。结果 髓内钉组的骨折愈合率明显高于加压钢板和外固定支架组，外固定组的骨折延迟愈合率高于其他两组；并发症包括骨不连、关节僵硬及畸形愈合，发生率为22．4％，其中骨不连发生率为13．4％。结论 髓内钉内固定治疗胫骨干骨折的临床疗效优于加压钢板和外固定支架；骨不连为胫骨骨折常见并发症，应严格掌握适应证、规范手术操作。     

多功能外固定支架结合腓骨内固定治疗胫骨极远端近关节面部位骨折

目的：分析和观察多功能外固定支架结合腓骨内固定治疗胫骨极远端近关节面部位骨折的疗效。方法：采用多功能外固定支架结合腓骨切开复位内固定进行外固定治疗。结果：17例病人经过平均13个月随访全部骨性愈合,平均愈合时间4个月,去除外固定支架时间平均5个月。1例病人针道深部慢性感染,窦道刮除后置管闭合冲洗痊愈。2例病人术后3处针道浅部感染,换药、抗炎愈合。所有病人踝关节、趾间关节功能良好,无畸形。结论：多功能外固定支架结合腓骨内固定治疗胫骨极远端近关节面部位骨折操作简单,效果佳,愈合快。     

Ⅰ期内固定与外固定支架治疗胫骨GustiloⅢA型开放性骨折的对照研究

目的 探讨GustiloⅢA型胫骨开放性骨折的治疗方法及临床疗效.方法 对2008年1月~2011年1月我院收治并获得随访资料的55例GustiloⅢA型胫骨开放性骨折进行回顾性分析,其中A组27例采用清创,Ⅰ期应用非扩髓带锁髓内钉或锁定接骨板内固定,伤口深部置管冲洗,创面用负压封闭引流(VSD)材料封闭,持续负压引流...     

Treatment of type IIIa open fractures with Ilizarov fixation and delayed primary closure in high-velocity gunshot wounds.

A total of 142 patients with 163 Gustilo-Anderson type IIIa limb fractures resulting from high-velocity gunshot wounds were treated with primary delayed closure and Ilizarov fixation in our department between 1988 and 1998. Average follow-up was 72.4 months. The average union period in fractures without bone loss was 16.8 weeks. It took 2 months for each 1 cm of bone defect to heal in fractures with bone loss. All fractures healed with good anatomic alignment and functional outcomes. Complications included pin-track infection in 72 fractures (50.7%), post-traumatic osteomyelitis in 5 tibial fractures without bone loss (3.1%), delayed union in 25 fractures (15.3%), nonunion in 10 (4 with bone loss) fractures (6.1%), and refracture in 4 fractures (2.4%). Our results indicate that type IIIa limb fractures caused by high-velocity gunshot wounds can be treated with Ilizarov fixation and primary delayed closure with a low overall complication rate and a remarkably low infection rate.     

内外侧锁定钢板治疗中老年胫骨平台SchatzkerⅤ、Ⅵ型骨折疗效观察

目的通过应用锁定钢板治疗复杂中老年胫骨平台骨折,观察其临床疗效,探讨中老年胫骨平台复杂骨折的治疗方法。方法2009年3月～2012年6月,采用锁定钢板治疗中老年复杂胫骨平台骨折22例,男18例、女4例;年龄40～55岁,平均48岁。骨折按Schazker分型：Ⅴ型13例,Ⅵ型9例。术中取内后侧切口及前外侧切口,于胫骨前外侧及后内侧置入锁定钢板进行内固定。患者术后1个月、3个月,半年及1年常规摄x线片。术后3个月后逐渐完全负重,最后1次随访时按Honkonen—Jarvinen标准对患者进行评分。结果22例均获随访,时间12—24个月,平均18个月,骨折平均愈合时间5个月。骨折愈合20例,延迟愈合2例。结论锁定钢板治疗中老年复杂胫骨平台骨折提供了持续稳定的固定,防止骨折的Ⅱ期移位和膝关节力线改变,术后膝关节功能恢复满意。     

同种异体骨植骨加支撑钢板内固定治疗复杂胫骨平台骨折

目的探讨同种异体骨植骨加支撑钢板内固定治疗复杂胫骨平台骨折的方法及临床疗效。方法对16例复杂胫骨平台骨折患者全部采用同种异体骨植骨,并用支撑钢板稳定固定,术后根据韧带有无损伤早期结合CPM机行膝关节功能锻炼或石膏外固定。结果所有患者术后获10～62个月(平均38.2个月)随访,骨折均获骨性愈合,骨折愈合时间平均为4.5个月。膝关节功能参照Mechant评分标准,优9例,良5例,可2例,优良率为88%。结论对复杂胫骨平台骨折患者应严格评估软组织损伤程度及围手术期治疗,正确选择手术入路,解剖复位关节面的平整性,对骨折端予以坚强稳定的内固定,坚持生物学固定原则,骨缺损区行足量植骨并压实,有效修复交叉韧带、侧副韧带及半月板的损伤,避免术后胫骨平台发生Ⅱ期塌陷和膝关节机械轴的对线不良。     

脱钙骨基质治疗长骨骨折延迟愈合及骨不连的远期临床观察

目的 探讨脱钙骨基质治疗长骨骨折延迟愈合和骨不连的远期疗效。方法 从1984年至1994年用脱钙骨基质治疗长骨骨延迟愈合、骨不连共96例，其中采用手术植入治疗骨不连38例，经皮注射治疗骨折延迟愈合37例及骨不连21例。结果 96例患者均获随访，随访时间4-16年，平均7．5年。脱钙骨注射治疗骨折延迟愈合的37例中，骨折愈合35例，2例胚骨骨折未愈合，愈合率94．6％；脱钙骨注射治疗骨折骨不连21例中，骨折愈合17例，4例未发生愈合，其中胫骨3例、肱骨1例，愈合率81．0％，愈合时间3-8个月，平均4．5个月。脱钙骨基质移植治疗骨不连38例中，36例愈合，2例胫骨下1／3骨折未发生愈合，愈合率94．7％。结论 脱钙骨基质无论是采用注射移植还是手术方法移植，都能取得较好的效果，甚至达到自体骨移植的疗效。同时，脱钙骨基质的制备经过脱水、脱脂、脱钙、照射消毒等处理，比其他骨移植安全，免疫性小，可以长期保存，便于平时和战时应用。     

髓内扩张自锁钉与外固定架治疗胫骨开放性骨折的疗效评估

目的评估髓内扩张自锁钉(IESN)和外固定架治疗胫骨开放性骨折的疗效。方法自2003年10月—2005年9月采用髓内扩张自锁钉治疗胫骨开放性骨折41例,与38例采用外固定架治疗胫骨开放性骨折疗效进行对比分析。结果全部病例随访12~20个月,平均15.4个月,IESN组手术时间、术后平均发热时间和住院天数,骨折愈合时间分别为45min,2.3d,21d,9.5周,外固定架组分别为63min,3.2d,27d,13.2周。两组相比差异有统计学意义(t值分别为2.775,2.712,2.874,2.869,P均<0.01);IESN组无骨折延迟愈合及畸形愈合,无感染及内固定失败等并发症,而外固定架组出现9例感染,7例畸形愈合。结论髓内扩张自锁钉内固定在治疗胫骨开放性骨折中损伤小,并发症少,固定可靠,同时最大限度地保护骨断端血运,符合生物力学要求,在治疗胫骨开放性骨折中是一种有效的好方法。     

Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures

This paper reports the clinical outcome of the arthroscopic reduction and pull-out suture technique in acute and chronic displaced tibial spine anterior cruciate ligament (ACL) avulsion fractures. Between April 1997 and December 2000, 14 patients received an arthroscopic reduction and pull-out suturing of displaced tibial spine fractures (ACL avulsion fractures of tibia). Of 14 cases, ten were acute fractures and four were chronic nonunion fractures, in which all patients showed extension limitation. The mean follow-up period was 51 months (ranging from 30 to 80 months). At final follow-up, review of range of motion, Lachman test, anterior drawer test, KT-2000 arthrometer, Lysholm knee score, and Hospital for Special Surgery (HSS) score were evaluated. Compared to conventional pull-out suturing, several key modifications to surgical techniques were used. In all 14 patients, radiological bony union was detected at mean 12.3 weeks (range, 8–16 weeks) after surgery. All patients were able to return to their preinjury activity and sports level. At final follow-up, full range of motion was achieved in all patients. Anterior draw test, Lachman test, and KT-2000 (less than 3 mm side-to-side) were all negative in 13 patients. One female patient, who was 6 years old at the time of surgery, complained of no subjective instability, but showed Lachman grade I, and 5 mm side-to-side difference in KT-2000. She also revealed 10°̇ difference of genu recurvatum deformity. Two children (including the previously-mentioned 6-year-old female patient) showed leg-length discrepancy of 1 cm—the affected legs being longer—at final follow-up. The mean Lysholm knee scores were 95.6 (range, 92–100) and HSS knee scores were 96.4 (range, 91–100). Arthroscopic reduction with modified pull-out suturing technique in displaced tibial spine ACL avulsion fractures showed excellent union rate for both acute and chronic cases, without instability or extension limitations at minimum two-year follow-up.     

External skeletal fixation of the tibial shaft fractures

AIM: To present the possibility of a succesfful use of external skelatal fixation in treating the open and closed tibial shaft fractures with Mitkovi?'s external fixator. METHODS: External fixation was used in 115 patients with 118 fresh tibial shaft fractures, 82 males (71.3%) and 33 females (28.7%), average age 43.92 years (16-84). Open tibial shaft fractures were present in 37 (31.36%). All the fractures were treated with Mitkovi?'s external fixator type M 20. RESULTS: The results of external fixation were excellent or good in 94.07% of the cases, and bad in 5.08%. Pin tract infection appeared in 7 (5.93%) patients. In only 3 cases an external fixator was removed and treatment continued with the functional braces. Nonunion occurred in 6 (5.08%) patients, of which 4 were with open fractures (2 Gustilo type IIIB, 1 Gustilo type IIIA, 1 Gustilo type II) and 2 with the segment fractures. Compartment syndrome was observed in 1 (0.85%) patient with closed fracture. Malunion was found in 2 (1.69%) patients. CONCLUSION: External fixation of tibial shaft fractures is a simple and effective method to enable the safe healing of fractures, early mobilization of the patients, early weight-bearing, as well as early rehabilitation. Fixation of tibial shaft fractures was unilateral with convergent pins orientation, and there was also a possibility of compression and distraction.     

Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function

BACKGROUND: High tibial osteotomy has been associated with significant complications, including delayed union or nonunion, loss of correction, arthrofibrosis, and patella infera. HYPOTHESES: A technique for opening wedge osteotomy that incorporates an autogenous iliac crest bone graft will prevent delayed union or nonunion, allow early rehabilitation and weightbearing, and prevent knee arthrofibrosis and patella infera. Secondly, the authors' methods for calculating the desired correction of valgus alignment prevent undesired alterations in tibial slope. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 55 consecutive patients who underwent high tibial osteotomy were observed at a mean of 20 months postoperatively. Preoperative and postoperative measurements of radiographs were conducted by independent examiners for bony union, tibial slope, and patellar height. The osteotomy opening size ranged from 5 to 17.5 mm; 35 knees (64%) had openings < or =10 mm, and 20 knees (36%) had openings >11 mm. RESULTS: The osteotomy united in all patients. Three patients had a delay in union, which resolved by 6 to 8 months postoperatively. A loss of fixation occurred in 1 patient, who admitted to full weightbearing immediately after surgery; the osteotomy required revision. The iliac crest graft site healed without complications, and there were no infections, loss of knee motion, nerve or arterial injuries, alterations in tibial slope, or cases of patellar infera postoperatively. Full weightbearing was achieved at a mean of 8 weeks (range, 4-11 weeks) postoperatively. CONCLUSIONS: The operative technique including use of an autologous iliac crest bone graft in addition to a progressive rehabilitation program successfully prevented nonunion, change in tibial slope, and knee arthrofibrosis in this study.     

MR imaging in tibial shaft fractures. A potential method for early visualization of delayed union.

PURPOSE: To evaluate the relationship between MR findings at the fracture site during the healing process and the outcome of patients with tibial shaft fracture. MATERIAL AND METHODS: Twelve consecutive patients with an uncomplicated tibial fracture treated conservatively were imaged by MR 1 to 3 days, 1 week, 3 weeks, 6 weeks and 12 weeks after the trauma. MR imaging consisted of sagittal/coronal T1-weighted, T2-weighted, proton density, short-tau inversion recovery, and contrast-enhanced T1-weighted spin-echo images. The images were analysed for the extent of signal pathology in the bone marrow adjacent to the fracture, the extent of soft tissue oedema, and the intensity and homogeneity of the contrast enhancement of the callus. RESULTS: The differences between normal (n=7) and delayed union (n=5) were observed within 3 to 6 weeks after the trauma, mainly in the homogeneity of the callus in T2-weighted and contrast-enhanced images. CONCLUSION: MR imaging is a potentially valuable method for early visualization of delayed union in tibial shaft fractures.     

Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing

BACKGROUND: A chronic anterior midtibial stress fracture is a serious, difficult-to-treat injury that can adversely affect an athlete's career. HYPOTHESIS: The use of a reamed intramedullary nail for a chronic anterior tibial stress fracture is a safe and effective treatment for an athlete. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Seven collegiate-level athletes with 11 chronic anterior midtibial stress fractures were treated with reamed intramedullary nailing between 1997 and 2000. These patients were followed for a mean duration of 17 months. RESULTS: The mean age of the patients at the time of stress fracture diagnosis was 17 years. Seven of the fractures occurred in male athletes, whereas 4 occurred in female athletes. All patients had failed nonoperative treatment, including rest, activity modification, use of an orthosis, and low-intensity ultrasound stimulation, for a minimum of 4 months. Patients had experienced symptoms for a mean duration of 12 months. Clinical and radiological union occurred at a mean of 2.7 and 3 months, respectively. The mean duration for return to sports after surgery was 4 months. At last follow-up, all patients had full range of motion at the knee and ankle joints and were satisfied with the results. One patient developed bursitis at the tibial nail insertion site that was resolved with a steroid injection. Another patient sustained a traumatic fracture of the distal tibia 1 year after intramedullary nailing of the tibial stress fracture. This fracture healed with nonoperative treatment. No other complications were observed. CONCLUSION: Intramedullary nailing of the tibia for chronic stress fracture has a high union rate, allows for a low complication rate, and allows for an early return to competitive sports. This procedure is an excellent alternative treatment for those fractures that have failed nonsurgical treatment.     

Comparison of radiographic images. A new method for analysis of very small movements

A new method, shift comparisoN, for comparing 2 radiographic images is described. The method may be used for many purposes, but is particularly suitable for detecting small provoked motions between skeletal parts. Defective union in fractures or osteotomies is easily diagnosed by such a comparison. Films are exposed before and during the application of force to one of the fragments. By examining the films in the Shift Comparator small movements caused by the force may be detected. The technique has also been used for measuring the development of stability of union of tibial fractures by determining th deflection of the fracture caused by a bending moment.     

Delayed unions and nonunions of stress fractures in athletes

From 1971 to 1985, 369 athletes presented to us with stress fractures. Of these patients, 10% (37) were treated for development of delayed unions or nonunions. Twenty-seven of the patients were male and 10 were female. Their mean age was 23.1 years (range, 17 to 39). About half of the athletes were involved in endurance sports. The diagnostic criteria for a delayed union or nonunion were clinical and radiological evidence. There was a diagnostic delay of about 3.5 months in the series. Plain radiographs, tomography, and isotope scans were used in the diagnosis. Special radiographic views were also used. In 15 cases (10 hallux sesamoid bone fractures, 1 midtibial shaft fracture, 1 metatarsal V base fracture, 1 tarsal navicular fracture, 1 olecranon fracture, and 1 proximal tibial shaft fracture) nonoperative treatment was used. Operative treatment was used 22 times (5 sesamoid fractures, 5 midtibial fractures, 5 metatarsal V base fractures, 3 tarsal navicular fractures, 3 olecranon fractures, and 1 proximal tibial shaft fracture). Results were good or excellent in 32 cases (86.5%), moderate in 4 cases, and poor in 1 case.     

The unreamed intramedullary tibial nail in tibial shaft fractures of soccer players: a prospective study

Lower leg fractures are common and complex injuries in soccer players. Twenty-five mainly recreational soccer players who sustained a tibial shaft fracture were treated with the AO-UTN (Unreamed Tibial Nail). This prospective series included 25 males with a mean age of 28.1 years. These patients were prospectively followed for a mean period of 4.7 years. Clinical and radiographic data was collected. In addition, 20 patients completed an outcomes based questionnaire. In all but one case, the mechanism of injury was a contact with an opposing player. Shin guards provided little prevention against these fractures. The majority of these tibial shaft fractures were consistent with a short oblique or transverse fracture pattern. All fractures were stabilized with the UTN on the day of injury. Four patients had concurrent compartment syndromes and underwent a fasciotomy. Average time until bony consolidation was 11.3 weeks. No patients returned to competitive soccer activities earlier than five months after the initial injury (average 9.5). Only 11 out of 20 soccer players returned to the same level of sporting activity. Six patients never returned to playing soccer again after this injury, even without complications. The fracture of the tibial shaft in soccer players is a severe injury that can be treated safely with the UTN without major complications, but nevertheless only 50% of a mainly-recreational playing population return to the same competitive level as before the injury.     

Quantitative and qualitative assessment of closed fracture healing using computed tomography and conventional radiography

RATIONALE AND OBJECTIVES: Development of new agents to induce fracture healing requires more sensitive methods to detect early changes in fracture repair. The aims of this study were to determine quantitative and qualitative features of fracture healing using volumetric computed tomography (CT) and to compare them with conventional radiography during the weeks following uncomplicated fractures of the appendicular skeleton. MATERIALS AND METHODS: 39 otherwise healthy men and women with acute, closed fractures of the distal radius, tibial and/or fibular malleoli, or tibial shaft, were enrolled and underwent CT and X-ray imaging at 1, 2, 4, 8, 12, and 16 (tibial shaft only) weeks post fracture. Qualitative assessment included fracture line/margins, fracture gap, external callus appearance, callus-to-cortex ratio, bridging, and radiologic union. Quantitative assessment of CT density changes (Hounsfield units [HU]) in the fracture gap was performed in a subset of 8 fracture patients using MEDx multimodality image analysis software (Sterling,VA). The analysis was performed by drawing free form regions of interest (ROI) covering the fracture gap on baseline (week 1) images and by automated registration of the follow-up images to the baseline co-ordinate system. RESULTS: The mean time to achieve radiologic union on CT was slightly shorter than on X-rays for radial and tibial shaft fractures (7.3 vs. 8.0 weeks, P = .1). Blurring of the fracture margins and reactive sclerosis were the earliest signs of healing in both modalities. External callus formation was evident in 11 cases and was detected earlier with CT technique. Overall, CT images allowed for more complete and detailed visualization of healing compared with conventional X-rays, which were limited by cast and fixation hardware superimposition, especially in subjects with malleolar and distal radial fractures. Quantitative evaluation showed good intraobserver and interobserver reproducibility and a statistically significant correlation to qualitative changes. CONCLUSION: Our methods of fracture healing assessment are reliable tools that are able to detect early changes in normal bone healing and may serve as useful additions to subjective image analysis in monitoring fracture healing in clinical trials. CT shows some advantages over conventional X-rays in evaluation of early fracture healing.     

IMN与MIPPO治疗胫骨中下段骨折的生物力学性能及对骨折愈合的影响

目的比较交锁髓内钉(intramedullary nail,IMN)与微创经皮钢板内固定(minimally invasive percutaneous plate osteosynthesis,MIPPO)的生物力学性能以及在胫骨中下段骨折治疗中对骨折愈合的影响。方法 2013年1月—2015年12月郑州市第一人民医院骨二科收治的胫骨中下段骨折患者76例,按治疗方法不同分为IMN组(38例)和MIPPO组(38例),采用Mazur评分评价两组术后踝关节功能,统计两组术后下地时间、骨折愈合时间和愈合率。2014年2月选取郑州大学医学院解剖教研室提供的新鲜成人踝关节标本10具,建立胫骨中下段骨折模型,按随机数字法分为观察组和对照组,每组5例。分别采用IMN和MIPPO两种方法固定,进行三点弯曲实验、轴向压缩实验以及扭转强度实验,分析相关数据。结果两组均未发生内固定松动、断裂等内固定失败状况,IMN组患者出现骨折延迟愈合3例,骨折不愈合2例,愈合时间平均(13.6±2.1)周;MIPPO组患者骨折均愈合,愈合时间平均(11.3±1.7)周。术后1年两组患者踝关节功能比较差异无统计学意义(P0.05);MIPPO组弯曲偏移量、轴向压缩偏移量和扭转角度均大于IMN组,组间差异均有统计学意义(P0.05)。结论 MIPPO与IMN治疗胫骨中下段骨折各有利弊,MIPPO可减轻手术创伤,但力学性能不如IMN,临床使用时应严格掌握适应证。