骶骨部分切除对骶髂关节生物力学的影响

目的:评价骶骨部分切除对骶髂关节生物力学的影响;明确骶骨切除范围与稳定重建的关系.方法:7具成人尸体L5-骨盆标本;分别在完整状态、S2以下切除(A组)、1/2 S2以下切除(B组)、S1以下切除(C组)、1/2 S1以下切除(D组)、右侧骶髂关节切除(E组)等情况下通过858型MTS材料实验机给标本施加800N轴向压缩和7Nm轴向扭转载荷;记录完整状态及残留骶髂关节刚度;比较各组间的差异.结果:轴向压缩时;A组～E组残留骶髂关节刚度分别是完整状态组的98.7%、97.1%、94.4%、82.9%和55.2%;完整状态组、A组、B组和C组间的压缩刚度无显著性差异;D组和E组的轴向压缩刚度显著低于完整状态组.轴向旋转时;A组～E组残留骶髂关节刚度分别为完整状态刚度的90.7%、88.5%、81.9%、71.9%和44.5%;完整状态组、A组和B组间的旋转刚度值无显著性差异;C组、D组和E组的轴向旋转刚度显著低于完整状态组和A组.结论:骶骨切除范围与骶髂关节稳定性相关.骶骨向上切除至S1将导致骶髂关节旋转失稳.切除至1/2 S1将进一步引起残留骶髂关节的轴向压缩失稳.骶骨切除超过上述范围时应考虑局部稳定性重建.     

髂骨不同置钉方式在腰-髂重建结构中稳定性的生物力学研究

目的 评价髂骨单枚短钉、单枚长钉和双枚短钉技术对腰-髂固定结构稳定性的生物力学影响.方法 7具成人新鲜尸体L_(2-)骨盆标本用于实验.于L_(3-5)间行椎弓根钉固定,并将该结构定义为本研究的完整状态.完整状念测试后,制作骶骨全切的失稳模型,并进行三种髂骨钉技术的L_(3-)髂骨间钉-棒稳定重建,A组:双侧单枚髂骨短钉;B组:双侧单枚髂骨长钉;C组:双侧双枚髂骨短钉.三种髂骨置钉技术均在同一标本上按随机顺序建立,短钉和长钉的长度分别为70 mm和130 mm.在MTS材料实验机上,给标本施加800 N压缩和7 N·m扭转载荷,记录L_(3-)髂骨间的结构刚度并比较.结果 A、B、C组的结构压缩刚度分别是完整状态的73%、76%和108%,A组与B组间差异无统计学意义(P>0.05),然而A和B组的结构压缩刚度低于完整状态和C组,差异有统计学意义(P<0.05). A、B、C组的结构扭转刚度分别占初始状态的72%、79%和109%,A、B两组间、完整状态与C组间差异均无统计学意义(P>0.05);但是,A、B组的结构扭转刚度低于完整状态和C组,差异有统计学意义(P<0.05).结论骶骨完全切除后,单枚髂骨长钉难以恢复局部的初始稳定性,双侧双枚髂骨短钉在抗压缩和扭转方面均显著高于双侧单枚髂骨钉结构,并且可获得与初始状态同等的稳定性.     

髂骨双钉在腰-髂重建结构中的生物力学优势

目的 评价髂骨单钉与髂骨双钉技术对腰-髂重建结构稳定性的影响.方法 7具成人新鲜尸体L2-骨盆标本,于L3-L5行椎弓根钉固定,将该结构定义为完整状态.对完整状态进行测试后制作骶骨全切失稳模型,每一标本均应用四种髂骨钉技术行L3-髂骨钉-棒稳定重建:A组,髂骨单枚短钉;B组,髂骨单枚长钉;C组,置入髂骨上、下柱的髂骨双枚短钉;D组,置入髂骨下柱的髂骨双枚短钉.髂骨钉的安装及测试顺序随机产生.在MTS材料试验机上,对标本施加800 N压缩和7 N·m扭转载荷,记录L3-髂骨的结构刚度.结果 (1)轴向压缩下,四组的压缩刚度依次为完整状态的73%、76%、98%和112%,A组和B组低于完整状态及C组和D组(P<0.05).其中A组与B组差异无统计学意义,D组与C组差异有统计学意义(P<0.05).(2)在扭转测试中,四组的扭转刚度依次为完整状态的72%、79%、105%和109%,A组和B组低于其他三组(P<0.05).其中A组与B组,完整状态、C组与D组间的差异无统计学意义.结论 对骶骨完全切除所导致的失稳,单枚髂骨短钉与长钉均难以恢复局部的初始稳定性;而双枚髂骨短钉在抗压缩与抗扭转能力方面均高于单枚髂骨钉,可获得与初始状态等同的稳定性.     

骨盆韧带损伤对骶髂关节稳定性影响的生物力学研究

目的 探讨骨盆韧带损伤对骶髂关节稳定性的影响,为骨盆骨折的临床治疗提供理论依据. 方法取骨盆标本10具,完整保留关节及韧带结构,左侧组逐级离断耻骨联合、骶棘韧带、骶结节韧带、骶髂前韧带及骶髂前关节囊、骶髂骨间韧带,右侧组逐级离断耻骨联合、骶髂后长、后短韧带、髂腰韧带、骶髂骨间韧带,模拟人体单足站立位,力学机上给予轴向加载,测量并记录骶骨相对于髂骨的垂直位移及矢状面骶骨旋转角度(角移位). 结果左侧力学试验中,仅切断耻骨联合周围韧带、骶结节韧带,骶骨垂直位移、骶骨角位移,差异无统计学意义(P＞0.05).逐步切断骶髂前韧带、骶髂骨间韧带,骶骨的垂直位移数值由完整骨盆测量的(4.144±0.538)mm增至(5.853±0.368)mm;骶骨的旋转角度由骨盆完整时的0.226°±0.061°增至0.616°±0.086°,差异有统计学意义(P＜0.05).右侧力学试验中,逐次切断骶髂关节后部韧带,骶骨的垂直位移数值由完整骨盆测量的(3.610±0.696)mm增至(6.825±0.565)mm;骶骨的旋转角度由骨盆完整时的0.271°±0.094°增至0.746°±0.192°,差异有统计学意义(P＜0.05).结论 耻骨联合及其周围韧带的损伤对骶髂关节的稳定性无显著性影响;骶结节韧带、骶棘韧带对限制骶骨的角位移有很大作用;骨间韧带对骶髂关节稳定性的作用较大;骶髂后韧带与骨间韧带共同组成了骶髂关节后部韧带复合体,是骶髂关节周围韧带中的重要部分.     

髂骨钉在腰骶骨盆固定中的生物力学研究

目的 探讨髂骨钉与腰骶椎弓根钉连接技术在腰骶骨盆固定中的稳定性.方法 取6具新鲜冷藏的人尸体腰骶椎、骨盆标本,依次实施3种固定术式:①髂骨钉(B组);②L5 S1椎弓根钉棒系统(C组);③髂骨钉与L5椎弓根钉连接系统(D组).将上述三组分别与无固定组(A组)进行生物力学稳定性比较.结果 髂骨钉在腰骶骨盆固定中的稳定性最好,D组在各种运动状态下的活动度均明显减少,在6.4 Nm力矩下的三维运动度为:旋转(1.07±0.86)°、侧弯(0.95±0.47)、前屈(1.22±0.67)、后伸(1.80±0.73);与无固定组比较差异有非常显著性意义(P＜0.01).结论 应用髂骨钉与腰骶椎弓根钉连接技术是维持腰骶骨盆间稳定的理想术式.     

骶髂关节复合体损伤内固定治疗

骶髂关节复合体是联系躯干和下肢的重要枢纽,高能量骨盆损伤常影响骶髂关节复合体稳定性,恢复其稳定性对骨盆损伤治疗具有重要意义.骶髂关节复合体损伤手术内固定治疗方法众多,疗效不一.该文就骶髂关节复合体损伤手术内固定治疗作一综述.     

骶髂关节骨折脱位的手术治疗

目的报告骶髂关节骨折脱位切开复位内固定的方法和治疗效果.方法采用骶髂关节前部切口,显露骶髋关节前面,复位后应用骨盆钢板内固定并植骨融合.结果45例骶髂关节骨折脱位均施行切开复位内固定融合术,随访8～20个月,骶髂关节完全融合,骨盆稳定.结论骶髂关节的完整对骨盆环的稳定性起着重要作用,当发生骨折脱位时应及时手术治疗,恢复其稳定性.     

改良张力带钢板重建骨盆后环的生物力学研究

[目的]通过生物力学研究验证一种新的改良张力带钢板重建不稳定性骨盆后环损伤的效果,并与其他两种方法比较。[方法] 8具成人骨盆标本,制成不稳定性骨盆环损伤(AO分类C1.2)模型,随机依次应用三种不同内固定来重建骨盆后环:传统张力带钢板;改良张力带钢板;双骶髂螺钉。分别依次予以0～600 N垂直和0～8 N·m扭转加载,测量整体骨盆环垂直位移和扭转角度并计算轴向和扭转刚度;测量损伤侧骶髂关节在垂直、左右和前后方向上的位移以及在矢状面上的旋转角度。[结果]在垂直和扭转载荷下,改良张力带钢板固定后的整体骨盆环垂直位移和扭转角度均明显小于传统张力带钢板(P0.05),虽大于双骶髂螺钉,但差异无统计学意义(P0.05);改良张力带钢板固定后的整体骨盆环轴向刚度和扭转刚度均明显大于传统张力带钢板(P0.05),虽小于双骶髂螺钉,但差异无统计学意义(P0.05)。垂直载荷下,改良张力带钢板伤侧骶髂关节在垂直、左右、前后方向上位移以及在矢状面上的旋转位移明显小于传统张力带钢板(P0.05)。[结论]与传统张力带钢板相比,改良张力带钢板重建骨盆后环提供了更好的生物力学稳定性。     

骶髂关节脱位直视复位空心螺钉固定的基础研究及临床应用

目的研究总结直视复位、经皮空心螺钉固定骶髂关节脱位的解剖学基础、生物力学稳定性以及初步的临床疗效。方法采用12具(24侧)福尔马林固定的尸体标本,测量骶骨翼上缘L_4、L_5神经根前支和闭孔神经至骶髂关节的距离。采用6具新鲜尸体骨盆标本建立骶髂关节脱位模型,比较本固定法与传统后路经皮骶髂关节螺钉和前路钢板固定的稳定性。同期采用本固定法手术治疗17例Tile C型骨折患者,随访疗效。结果①L_4、L_5神经根及闭孔神经分别距离骶髂关节(20．24±1．12)mm、(23．80±1．43)mm、(16．26±2．07)mm；②本固定方式与后路经皮骶髂关节螺钉的稳定性无显著性差异,但优于前路钢板固定；③临床治疗17例患者,平均随访2．2年,根据Matta功能评定标准,功能恢复均为优良。结论该固定系统具有良好的生物力学稳定性,同时可避免神经损伤、临床效果好、操作简便,便于基层医院开展。     

骶髂关节解剖型棒-板内固定系统的生物力学评价

目的：探讨采用新型骶髂关节解剖型棒-板内固定系统（SABP）治疗骨盆骶髂关节骨折脱位的生物力学性能。方法：采集新鲜的冷冻尸体骨盆标本20具,造成骨盆骨折模型,采用实验应力分析方法,对SABP内固定和骶骨螺钉结合Galveston技术内固定、骶骨棒固定、重建钢板固定、骶髂关节螺钉等5种固定作对照比较,分别测定它们的刚度和强度,用以评价骨盆的稳定性。结果：采用新型骶髂关节解剖型棒-板内固定系统治疗骨盆骶髂关节骨折脱位,较骶骨螺钉结合Galveston技术内固定、骶髂关节螺钉、重建钢板固定、骶骨棒固定其骨盆的刚度分别高10%、11%、16%、21%,强度分别高12%、14%、21%、31%;应变分别小13%、14%、22%、25%,位移分别小10%、12%、16%、20%,差异有统计学意义（P〈0.05）,并且超过正常人骨盆标本,但差异无统计学意义（P〉0.05）。结论：采用新型SABP内固定装置治疗骨盆骨折,其强度、刚度最佳,优于其他内固定方法,是一种理想的新型内固定器械。     

Long-term results of various therapy concepts in severe pilon fractures

Introduction Intra-articular fractures of the tibia plafond are among the most challenging of orthopaedic problems. This is a retrospective case-control study of surgically treated pilon fractures which was undertaken to compare the internal fixation with the two external fixation methods. Methods This is a case-control study of 55 patients with 55 pilon fractures. There were 36 type C and 19 type B. Of these fractures, 24 were open and 31 closed. Three surgical protocols were used. In 20 patients, Group A, a half pin external fixator with ankle spanning was performed. The mean age of patients was 42.0 years (22.0–74.0), SD 14.1 and the mean follow-up was 77.7 months (38.0–132.0), SD 25.4. In 22 patients, Group B, a single ankle sparring ring hybrid external fixator under a small arthrotomy was performed. The mean age of patients was 48.4 years (28.0–76.0), SD 12.4 and mean follow-up was 67.9 months (36.0–132.0), SD 27.8. In 13 patients, Group C, a two-staged internal fixation was performed. The mean age was 45.6 years (30.0–66.0), SD 9.7 and the mean follow-up was 78.6 months (55.0–132.0), SD 25.4. We addressed the dissimilarity of the type of fracture in each group performing supplementary stratified analyses within each fracture type group. Results Group A had union in 6.9 months, group B in 5.6 months and group C in 5.1 months; P = 0.009. Six patients (Group A), two (Group B), and one (Group C) had limitation of ankle motion; P = 0.47. One patient from group C developed infection and the plate was removed. Four patients (Group A), one (Group B), and one (Group C) have developed posttraumatic arthritis (loss of joint space and pain); P = 0.25. Seven patients from Group A have reduced their activities; P = 0.004. In stratified statistical analysis by type of fracture, the associations noted for both fracture groups combined were also noted separately within each fracture group. Conclusion In this long term follow-up study, the two-staged internal fixation and the hybrid fixation with small arthrotomy were equally efficacious in achieving bone union. Patients in external fixation with the ankle spanning had a significantly higher rate of delayed union. Also more patients in this group have reduced their activities. Meeting at which the paper was presented: International Annual Meeting Of Orthopaedic Surgeons, 2003, Greece.     

Mechanical Testing of Seven Fixation Methods for Generation of Compression Across a Midtarsal Osteotomy: A Comparison of Internal and External Fixation Devices

The purpose of this study was to assess 7 methods of fixation for a midtarsal osteotomy. Polyurethane foam models (N = 6) and cadaver specimens (N = 4-7) were used to examine the force generated by the different constructs of fixation. A midtarsal osteotomy was performed on each specimen in the test groups. The osteotomies were fixated either with 2 parallel 0.062-in Kirschner wires and 40-mm-long, 4-mm partially threaded, cancellous, cannulated titanium screws, an external ring fixator (frame), a frame with wires tensioned (tension), a frame with wires tensioned and compressed toward the osteotomy (tension and compression), a frame with tension, compression, and parallel Kirschner wires, or a frame with tension, compression, and two 4.0 cannulated parallel screws, respectively. Each model was fixated, and the force generated by the construct across the osteotomy was recorded via the use of pressure-sensitive film. Statistical analysis of the data in the polyurethane foam group determined that the use of frame with tension, compression, and two 4.0 parallel cannulated screws was statistically superior to 1) frame, 2) frame with tension, 3) 2 parallel Kirschner wires, 4) two 4.0 cannulated parallel screws, and 5) frame with tension and compression. A cadaver study determined that the frame with tension, compression, and 2 parallel Kirschner wires was statistically superior to 1) frame and 2) two parallel Kirschner wires. These findings suggest that there is a difference in the force generated by the type of fixation construct across a midtarsal osteotomy.     

骨外固定加压治疗胫骨干骨不连

目的 :通过观察半环槽式外固定器治疗胫骨骨不连的治疗效果 ,评价加压外固定对骨损伤修复的作用。方法 :采用半环槽式外固定器骨外加压固定治疗胫骨干骨不连 49例 (男 37例 ,女 12例 ) ,骨不连时间为 7～ 132个月。其中 7例感染性骨不连偏侧性骨缺损者 ,行病灶清除开放性植骨 ;5例感染性骨不连行病灶清除、内固定物取出、小腿皮瓣转位 ;10例骨不连、骨缺损伴伤肢短缩者 ,行胫骨干骺端截骨或骨骺牵伸延长。结果 :植骨全部成活 ,创面植皮获Ⅰ期愈合 ,肢体延长幅度 4.5～ 13 .5cm ,平均 7.5cm ,达到预期目标 ,49例患者均于术后 2 .5～ 10个月 ,获得骨愈合 ,平均 5 .4个月。结论 :骨外固定加压治疗胫骨干骨不连不仅具有确实的效果 ,而且有以下优点 :(1)方法简便、创伤小、局部血运干扰少 ;(2 )在局部感染的条件下仍可使用 ;(3)骨端始终保持有均匀的压应力和肢体功能锻炼时产生的生理应力刺激 ,有利于促进骨愈合 ;(4)可配合肢体延长联合使用 ,既治愈了骨不连 ,又均衡了双下肢长度 ,有利于肢体功能恢复。     

Bone healing after metal plate fixation and external fixation of the osteotomized rabbit tibia

Controversy still exists as to the best method of treatment of long bone fractures. The purpose of the present study was to compare the effects on the healing bone of external fixation and metal plate fixation. In an experimental model on the rabbit tibia the stiffness of the fixation corresponded intentionally to that of the same methods in human fracture treatment.

A transverse, midshaft osteotomy was made on one tibia, and fixed with a steel plate (45 × 5 × 1 mm) or external mini-fixation. The animals were killed after 4, 6 or 12 weeks. The bone healing was evaluated by radiography, histology and biomechanical testing in three-point bending. There were no significant differences between plate fixation and external fixation in the pattern of bone healing, as it occurred by periosteal, in-tramedullary and intercortical callus after both methods. The stiffness increased more rapidly than the strength, and reached normal values after about 6 weeks. No significant differences in stiffness between the two methods were found. The strength was significantly greater after plate fixation than after external fixation at 6 weeks, while no significant differences were found at either 4 or 12 weeks.

It is concluded that the speed of bone healing was more rapid after plate fixation. However, in the later stages of healing the plated bones were secondarily weakened because of the stress-protecting effect of the plate.     

Ensuring precision in lower limb deformity correction through a combination of temporary external fixation followed by internal fixation: Results of a retrospective study

Background:

It is important to plan preoperatively when contemplating internal fixation following deformity correction. Surgeons often find it difficult to retain the achieved correction till the end of internal fixation. To maintain precise correction we used hybrid technique which uses both external and internal fixation. The objective of the study was to evaluate the effectiveness of this hybrid technique in achieving and retaining desired correction.

Materials and Methods:

In this retrospective study, we evaluated the magnitude of deformity with radiological parameters. We compared correction which was planned and correction which was achieved. The technique was used during surgery for corrective osteotomies. Before carrying out the osteotomy, rail fixator with two swivel clamps was applied. After osteotomy swivel clamps were loosened. Desired correction was achieved. While fixator held the fragments in corrected position, definitive internal fixation was carried out. External fixator was removed after completion of internal fixation. Position of mechanical axis ratio, mechanical lateral distal femoral angle and mechanical medial proximal tibial angle were measured before and 12 weeks after surgery. Student t-test was used to analyze the difference between correction which was planned and correction which was achieved.

Results:

There was no statistical difference between the desired correction and the correction achieved.

Conclusions:

Temporary use of external fixator while correcting angular deformities of lower limb allows to achieve accurate correction.     

Pilon骨折三种不同治疗方法疗效探讨

目的探讨Pilon骨折的三种不同治疗方法临床适应证及其疗效评价。方法对2000年2月至2006年3月间治疗的63例Pilon骨折患者进行回顾性分析。其中开放性损伤15例，闭合性损伤48例。根据骨折类型与周围软组织损伤程度，分别采用三种不同治疗方法：跟骨牵引加小夹板固定组（29例）均为闭合性骨折，内固定组（23例），外固定器组（11例）。结果所有患者均获得随访，随访8～31个月（平均15．3个月），骨愈合时间8～14周，平均10周。按Helfet疗效评价标准，本组优良者57例（90．5％），其中Ⅰ型骨折优良者26例，Ⅱ型骨折优良者15例，Ⅲ型骨折优良者16例。结论根据骨折类型及软组织条件，恰当选择固定方法是取得Pilon骨折满意疗效的关键，可有效避免并发症的发生。     

骨盆骨折的手术治疗

目的 :探讨骨盆骨折各种手术方法的适应证及治疗效果。方法 :选择 3 2例骨盆骨折手术治疗病人 ,根据Tile’s分型及病人情况选择手术方法。多发伤、Tile’sB型早期 (平均 6.2h )行骨折闭合复位及外固定架固定 ,单纯骨盆骨折、Tile’sC型在伤后 5～ 7d行开放复位 ,用 3 .5～ 4.5mm重建钢板、拉力螺钉固定。结果 :本组 3 0例得到随访 ,平均随访 2 3 .4个月 ,骨折均愈合良好 ,肢体功能恢复良好。结论 :对于骨盆骨折 ,无论采取哪一种治疗方法 ,只要适应证选择得当 ,均能获得良好效果。     

腓骨内固定结合外固定治疗Pilon骨折

目的:评价腓骨内固定结合外固定治疗Pilon骨折的效果。方法:对23例采用腓骨内固定结合外固定治疗的Pilon骨折患者进行随访分析。结果:21例随访19～50个月,平均27.5个月,骨折均愈合。根据Baird-Jackson标准:优8例,良10例,可3例,优良率85.7％。结论:腓骨内固定结合外固定在Pilon骨折治疗中具有独特的价值和良好的结果。     

Ruedi-AllgowerⅢ型Pilon骨折的疗效分析

目的回顾分析我院治疗Pilon骨折的病例,探讨Ruedi-Allgower型Pilon骨折的治疗方法。方法对2001年10月至2004年10月共16例Ruedi-Allgower型Pilon骨折给予有限内固定结合外固定治疗,同时术后给予必要的对症治疗与合理的功能锻炼。结果随访10~24个月,平均16个月。按照Mazur评分系统评估疗效,16例患者,优6例,良8例,中1例,差1例,优良率达87.5%。1例发生伤口感染,无深部感染;1例胫前软组织坏死,骨质裸露;1例外固定器针眼感染;1例关节退行性变。结论有限内固定结合外固定治疗Ruedi-Allgower型Pilon骨折,可以减少并发症,取得良好治疗效果。     

Pilon骨折20例手术治疗体会

目的 探讨Pilon骨折的手术方法及手术时机的选择.方法 回顾性分析根据骨折分型和软组织损伤程度应用不同内固定方法手术治疗的20例Pilon骨折病例.结果 所有病例临床观察平均18个月,均骨性愈合,Ruediand-Allgawer Ⅰ型优良率为100%,Ⅱ性型优良率为80%,Ⅲ型优良率67%.结论 根据患者年龄、全身状况,骨折及关节面软骨、软组织损伤程度等不同因素,选择适宜手术方法及手术时机治疗Pilon骨折,疗效满意.