肱三头肌筋膜重建环状韧带术治疗小儿陈旧性桡骨头脱位

目前重建环状韧带的手术方法较多,有简有繁,各有利弊。1988年以来,我科通过临床实践采用肱三头肌筋膜重建环状韧带治疗小儿陈旧性桡骨头脱位9例,疗效满意,介绍如下。     

桡骨头骨折假体置换早期疗效观察

目的探讨解剖型桡骨头假体置换治疗桡骨头粉碎性骨折早期疗效。方法 2015年10月—2017年8月,重庆医科大学附属第一医院骨科采用Acumed解剖型桡骨头假体置换治疗桡骨头粉碎性骨折11例。男性7例,女性4例;年龄24~58岁,平均37.3岁;左侧4例,右侧7例。按Mason分型,其中Ⅲ型8例,Ⅳ型3例(均为恐怖三联征),对3例"恐怖三联征"的患者辅以铰链式外固定支架。结果 11例患者均获得随访,随访时间3~23个月,平均14.2个月,肘关节平均屈伸范围为(110±15.2)°,前臂旋前平均(66.4±10.9)°,旋后平均(83.2±11.3)°。按照Mayo肘关节功能评分,优7例,良4例。结论解剖型桡骨头假体置换治疗桡骨头粉碎性骨折可获得比较满意的早期疗效。     

软组织固定重建内侧髌股韧带治疗青少年复发性髌骨脱位

目的:分析应用软组织固定技术重建内侧髌股韧带(medial patellofemoral ligament,MPFL)治疗青少年复发性髌骨脱位的临床疗效。方法:2014年3月至2016年10月期间对12例诊断为复发性髌骨脱位的青少年患者,取自体半腱肌腱行MPFL重建术。全部运用软组织固定技术完成重建。术后实施快速康复方案。术前及术后随访期间根据Lysholm、IKDC和Kujala膝关节功能评分评估临床效果。调查患者术后满意度及恢复体育活动情况。结果:所有患者均获得随访,时间为6~18个月(平均12个月)。全部12例患者均无再发脱位,最终随访时均恢复全范围活动度和正常的内侧结构稳定。术后Lysholm、IK-DC和Kujala膝关节功能评分均较术前有显著提高(P<0.01)。10例患者对手术效果非常满意,其余2例为满意。75%(9/12)的患者术后6月后可以恢复术前的体育运动水平(均非专业运动员)。结论:应用软组织固定技术重建MPFL获得了显著的临床疗效。该方法避免了骨隧道及内植入物的相关并发症。对于骨骺未闭的青少年患者,是一种安全、有效、牢靠的手术技术。     

伸牵引曲屈复位法治疗儿童创伤性桡骨头半脱位的效果

目的探讨伸牵引曲屈复位法治疗儿童创伤性桡骨头半脱位临床疗效。方法回顾性分析2017年1月—2018年11月鲁西骨科医院收治的桡骨头半脱位并行伸牵引曲屈复位法治疗的患儿470例,男性218例,女性252例;年龄0~8岁,平均4.2岁。观察患儿首次复位成功率、复位前后VAS评分、肘关节屈伸度、前后臂活动度。结果470例患儿首次复位成功413例,占87.87%,二次复位成功57例,占12.23%,复位失败0例;治疗前,患儿旋转手臂时平均VAS评分(5.37±1.13)分,治疗后(2.01±0.57)分,治疗前后比较差异有统计学意义(t=18.201,P<0.001);治疗后,患儿肘关节屈伸度伸直(8.03±6.55)°、曲屈(148.32±17.19)°显著高于其治疗前伸直(3.14±2.18)°、曲屈(33.76±16.86)°,患儿治疗后前臂活动度旋前(71.64±35.82)°、旋后(81.27±40.64)°显著高于其治疗前旋前(46.37±23.14)°、旋后(55.96±27.88°),P<0.05。治疗后其与健康儿童伸直(8.12±6.76)°、曲屈(149.76±17.25)°、旋前(72.75±36.38)°、旋后(80.5±40.44)°比较,差异无统计学意义,P>0.05。结论伸牵引曲屈复位法治疗小儿创伤性桡骨头半脱位具有较高成功率,对患儿疼痛的缓解效果较好,且治疗后能保证患儿关节功能基本恢复正常水平,值得临床推广。     

掌长肌腱重建喙锁韧带治疗急性肩锁关节Ⅲ度脱位二例

关于急性肩锁关节Ⅲ度脱位的治疗方法和手术选择 ,目前仍存在争议。根据肩锁关节脱位的病理特点 ,笔者通过张力带技术对肩锁关节进行固定 ,设计出用掌长肌腱重建喙锁韧带的手术方法 ,并对手术入路进行改进 ,疗效满意。报告如下。手术设计　 (1)麻醉和体位 :采用颈丛加臂丛麻醉或全麻。取仰卧位 ,肩部抬高 ,并将手术侧肩部垫高。 (2 )手术入路 :以肩峰、喙突以及锁骨中端内侧为标志 ,作肩前的弧形切口。 (3)手术步骤 :切开皮肤和皮下组织 ,于深筋膜表面将皮瓣向上翻起达锁骨上缘 ,切开深筋膜 ,显露三角肌和胸大肌间隙以及三角肌在锁骨远端的…     

改良髌骨双骨道及界面螺钉固定技术解剖重建内侧髌股韧带治疗创伤性髌骨脱位

目的:探讨改良髌骨双骨道及界面螺钉固定游离半腱肌腱解剖重建内侧髌股韧带治疗创伤性髌骨脱位的疗效。方法:2010年1月至2012年10月对30例创伤性髌骨脱位患者关节镜辅助下行内侧髌股韧带(MPFL)双束解剖重建,移植半腱肌腱,髌骨固定方式采用改良双骨道及界面螺钉挤压固定。结果:所有患者随访时间6~18个月,平均12个月。30例手术后均无再脱位,髌骨运动轨迹正常,关节活动无受限,恐惧试验阴性,未发生髌骨骨折,髌骨外移率、髌股适合角及外侧髌股角较术前改善(P<0.05)。结论:采用改良髌骨双骨道及界面螺钉固定技术解剖重建内侧髌股韧带,手术方式简单、损伤小、腱骨结合处固定良好、髌骨稳定性好、并发症少。     

关节镜下内侧髌股韧带紧缩增强术治疗青少年髌骨脱位——12例患者至少2.5年随访结果

目的:回顾性研究关节镜下紧缩、增强内侧髌股韧带(medial patellofemoral ligament,MPFL)手术方法治疗青少年髌骨脱位的临床效果。方法:2009年3月~2012年2月,对14例青少年髌骨脱位患者进行关节镜下内侧髌股韧带紧缩增强术治疗。关节镜下用2号Orthocord线经皮下与滑膜外绕行MPFL的髌骨止点下缘与股骨止点上缘,屈膝70°位打结固定,增强MPFL,联合外侧髌骨支持带松解术,矫正髌骨运动轨迹。患者均行Beighton评分、Q角测量、Insall指数测量、恐惧试验、髌骨外移试验、滑车发育不良分级、TT-TG距离测量。采用IKDC评分、Lysholm评分与Tegner评分,调查患者的满意度。结果:12例患者获得随访(3例首次髌骨脱位,术前均有游离体,9例复发性髌骨脱位),IKDC、Lysholm与Tegner评分均有显著提高(P<0.01),83.3%(10/12)患者在术后4~6个月时完全恢复到外伤前运动水平。9例对手术效果非常满意,3例满意。1例患者术后2年因外伤再次髌骨脱位,2例患者术后剧烈运动时出现髌骨不稳,3例术后恐惧试验阳性且髌骨外移试验阳性,无明确抵抗感。Beighton评分5.8±1.9分,Q角14.1°±4.8°,Insall指数1.17±0.13,TT-TG距离12.4±3.8 mm,91.7%的患者存在股骨滑车发育不良。结论:关节镜下MPFL紧缩增强术是一种适合青少年(骨骺未闭者更适合)髌骨脱位患者的、有效、安全、微创的手术方法。对于髌骨脱位的危险因素可以不做过多考虑,本技术也是一种很有价值的过渡性治疗方法。     

A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar dislocation

The management of patellar dislocation syndrome has traditionally been difficult. There are no golden standard methods for patellar dislocations probably due to the many etiologies. However, it is known that medial patellofemoral ligament (MPFL) is damaged when the patella is dislocated. The purpose of this study is to examine whether our method of MPFL reconstruction is useful for the treatment of dislocated patellae and unstable patellae. Forty-six knees (43 patients) of 68 knees (65 patients) that were operated on using our surgical procedure for MPFL reconstruction with the advancement of the vastus medialis or the MPFL reconstruction with Insalls procedure were followed up for at least 5 years. The patient age ranged from 6 to 43 years. These knees consisted of six habitual dislocation patellae, twenty-six recurrent dislocation patellae, ten traumatic dislocation patellae, and four unstable patellae. The patients were evaluated pre-operatively and more than three times post-operatively at 6, 12, 36, 60, or 120 months. No patient experienced patellar dislocation after surgery. Their post-operative Kujalas scores were significantly improved. On conventional X-ray and on stress X-ray evaluations, the mean values for congruence angle, tilting angle, lateral shift ratio, medial stress shift ratio, and lateral stress shift ratio at the final follow-up (60 or 120 months) were demonstrated to be within the normal range. We conclude that our MPFL reconstruction method with the advancement of the vastus medialis or with Insalls procedure might be recommended for the treatment of habitual, recurrent, and indeed any other type of patellar dislocation, as well as for unstable patellae.     

Congenital anterior dislocation of the radial head: a case with radiographic findings identical to traumatic dislocation

Differentiation of congenital unilateral dislocation of the radial head from a traumatic dislocation depends mainly on the radiographic findings. Here, we report a case of congenital unilateral anterior radial head dislocation with radiographic findings identical to traumatic dislocation.     

Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon

We studied patients who underwent primary anterior cruciate ligament reconstruction using either the contralateral (N = 434) or ipsilateral (N = 228) autogenous patellar tendon graft to determine the difference between groups for the return of range of motion, quadriceps muscle strength, and return to sports. The contralateral group had statistically significantly more flexion than the ipsilateral group at 1 week and 2 weeks postoperatively. The contralateral group had statistically significantly greater quadriceps muscle strength in the reconstructed knee at 1, 2, and 4 months postoperatively and in the donor knee at 1 and 2 months postoperatively. Mean KT-1000 arthrometer results were 1.9 +/- 1.3 mm for the contralateral group and 2.2 +/- 1.1 mm for the ipsilateral group. The mean time to return to sports at full capability in a competitive subgroup was 4.1 months for contralateral patients and 5.5 months for ipsilateral patients. Overall, 49% of patients in the contralateral group and 12% of patients in the ipsilateral group returned to their preinjury levels of activity by 4 months postoperatively. Our results indicate that the contralateral patellar tendon can be used to restore range of motion and strength sooner than an ipsilateral patellar tendon graft. Patients can also have a faster return to full capability in sports without compromising ultimate stability.     

Primary anterior cruciate ligament reconstruction using contralateral patellar tendon autograft

Primary ACL reconstruction using a contralateral patellar tendon autograft is an effective means of achieving symmetrical range of motion and strength after surgery. When the graft is harvested from the ipsilateral knee, the rehabilitation for the ACL graft and for the graft-donor site are different and have opposing goals. Rehabilitation for the ACL graft involves obtaining full range of motion, reducing swelling, and providing the appropriate stress to achieve graft maturation. Rehabilitation for the graft-donor site involves performing high-repetition strengthening exercises to regain size and strength, best achieved when begun immediately after surgery.     

部分腓骨长肌腱重建内侧髌股韧带治疗复发性髌骨脱位

目的 探讨关节镜辅助下自体部分腓骨长肌腱移植重建内侧髌股韧带(medial patellofemoral ligament,MPFL)治疗复发性髌骨脱位的疗效.方法 2009年5月-2010年4月治疗46例53膝复发性髌骨脱位患者,关节镜下进行外侧髌股支持带松解后,采用自体部分腓骨长肌腱游离移植重建MPFL,调整移植肌腱在不同角度下屈伸活动时的张力,关节镜下观察髌骨运动轨迹和股骨滑车与髌骨的对应关系,然后采用可吸收界面螺钉将肌腱端固定于股骨内侧髁的骨道内,同时行胫骨结节内移抬高术.了解髌股关节的稳定情况、脱位复发、患膝主观症状以及患肢整体功能康复情况.结果 术后随访平均18个月(12～24个月),膝关节稳定性增加,髌骨脱位无复发.恐惧试验阴性,髌骨轴位X线片和CT示髌股关节解剖关系恢复正常.手术前后Kujala 髌骨稳定度问卷评分术前(54.6±5.4)分,术后(92.3±8.9)分(t =55.41,P＜0.01).所有患者运动能力均较术前有所改善.术后CT检查对比发现,髌骨与股骨滑车适配角从术前的(27.8±8.1)°改善为(2.3±9.4)°(t=20.87,P＜0.01).肌腱供区踝关节活动良好,功能没有影响.结论 关节镜下外侧髌股支持带松解与自体部分腓骨长肌腱移植重建MPFL,结合胫骨结节内移抬高术能够有效治疗复发性髌骨脱位,并且避免了膝关节周围切取肌腱的潜在并发症.     

Evaluation of the coracoclavicular reconstruction using LARS artificial ligament in acute acromioclavicular joint dislocation

Purpose

The most appropriate procedure for surgical treatment of severe acromioclavicular (AC) joint dislocation was still not clear. The purpose of this study is to evaluate the outcomes of coracoclavicular (CC) reconstruction with ligament augmentation and reconstruction system (LARS) artificial ligaments for the treatment of acute complete AC joint dislocation.

Methods

Twenty-four patients (16 male and 8 female, ages ranged from 21 to 45) with acute complete AC joint dislocations were treated with CC reconstruction using LARS artificial ligaments. All these dislocations were unstable injuries. Clinical evaluation was used by the Constant scores and VAS. The radiographic evaluation consisted of Zanca radiographs for bilateral AC joint and axillary radiographs for the injured shoulder.

Results

All patients had follow-up times of 36 months (range 6–60). The Constant scores rose from 62.3 ± 6.9 preoperatively to 94.5 ± 9.3 at final evaluation (P < 0.05). Preoperative VAS scores were 5.1 ± 1.7, and the VAS scores at the last review were 0.7 ± 1.4 (P < 0.05). Follow-up radiographs showed anatomical reduction in 20 patients and slight loss of reduction in 4 patients. Calcification of CC ligament in 4 patients, degenerative change around the AC joint in 2 patient and clavicular osteolysis around screws in one patient were found.

Conclusions

LARS artificial ligament for reconstruction of CC can provide immediate stability and allow early shoulder mobilization with good functional results and few complications. This procedure was an effective and safe method to treat grade III and more AC joint dislocations.

Level of evidence

IV.

     

关节镜下自体髌腱移植重建前交叉韧带的疗效观察

目的探讨使用自体骨-1/3髌腱-骨移植重建损伤的前交叉韧带(ACL)的临床疗效。方法本研究包括40例单纯性前交叉韧带断裂伴症状性胫骨前脱位的病例,均采用自体骨-1/3髌腱-骨重建。术后进行为期6个月的康复训练。术前和术后随访时行患侧膝关节X线检查,行体格检查及功能评分。结果总共36例(90%)获得随访,时间平均31个月。30例(83%)Lachman征及旋转移位试验阴性。Lysholm评分由术前平均(55.7±3.1)分增加至术后最后一次随访时的(90.1±2.7)分(P0.001)。而Tegner评分则由术前平均(5.0±1.4)分增加至术后(6.25±1.2)分(P0.001)。与术前X线检查相比,无退行性改变。结论采用自体骨-1/3髌腱-骨重建前交叉韧带后2年以上随访结果发现,83%的患者膝关节不稳现象消失,至术后最后一次随访时膝关节功能评分较术前显著增加。以该方法重建ACL有效地恢复了受伤膝关节功能。     

Trans-physeal anterior cruciate ligament reconstruction in adolescents

Purpose

The aim of the study was to evaluate, in a group of adolescents, the onset of varus–valgus deviations in the sagittal plane after performing a trans-tibial trans-epiphyseal technique of ACL reconstruction with a follow-up of at least 2 years.

Methods

Seventy-one patients aged 12–15 years old (Tanner scale 3 and 4) have undergone ACL reconstruction with STG using arthroscopy. All patients were evaluated clinically using the visual analogue scale (VAS), the Lysholm score and the Tegner activity score at the time of surgery. All patients were reevaluated after a follow-up period of at least 2 years (T1) using the VAS, the Lysholm score, the Tegner activity score and radiographic studies in order to compare the operated limb with the healthy control limb.

Results

Valgus difference exceeding 2° in the knee axis between the operated limb and the healthy control limb was observed only in three patients (4.2 %: 95 % CI 0.88–11.86 %). The average difference was <1° (0.3°, 95 % CI 0.0–0.55).

Conclusion

The trans-tibial trans-epiphyseal technique of ACL reconstruction, according to the results obtained, seems to be a valid alternative procedure, when performed by a skilled orthopaedic surgeon, offering an excellent safety profile and at the same time very good clinical results.

Level of evidence

IV.