SandersⅢ、Ⅳ型跟骨骨折手术治疗疗效分析

[目的]评价SandersⅢ、Ⅳ型跟骨骨折手术治疗的临床疗效.[方法]对31例39足SandersⅢ、Ⅳ型跟骨骨折采用跟骨钛钢板内固定,必要时行一期植骨,最短随访18个月,最长29个月,平均随访24个月,采用Maryland Foot Score系统进行术后功能评价.[结果]SandersⅢ、Ⅳ型跟骨骨折全部愈合.其中优22足,良13足,可3足,差1足,优良率89.7％.术后并发症:切口延迟愈合3例,感染1例.[结论]跟骨骨折钛钢板内固定,必要时行一期植骨是治疗SandersⅢ、Ⅳ型跟骨骨折的良好方法.     

复杂跟骨骨折的手术治疗

目的：探讨跟骨解剖钢板治疗SandersⅡ、Ⅲ、Ⅳ型跟骨骨折的疗效。方法：2004年11月-2009年1月,对有完整资料的27例32足关节面移位的跟骨骨折,采用扩大的外侧“L”形入路行切开复位植骨解剖钢板内固定治疗。anders分类：Ⅱ型4足,Ⅲ型22足,Ⅳ型6足。结果：所有患者术后获6-48个月（平均22．9个月）随访,骨折全部愈合。按Maryland足部评分标准评价手术效果：优20足,良7足,可5足,优良率84％。术后并发切口延迟愈合1例,无感染及皮肤坏死发生。结论：一期植骨,开放复位可塑形跟骨钛板内固定,术后早期关节功能锻炼,是治疗严重粉碎性骨折的良好方法。     

跟骨爆裂骨折手术植骨固定近期疗效临床

目的探讨涉及距下关节的跟骨爆裂骨折手术植骨固定的适应证、方法、植骨材料选择以及对手术效果的影响。方法按照Sander分型标准,筛选符合型和型涉及距下关节的跟骨爆裂骨折患者。自2006年1月至2009年12月我科共计手术复位植骨内固定治疗跟骨骨折18例20足,均使用国产跟骨钛钢板固定,自体骨植骨15足,异体骨植骨5足。结果随访6个月,15足采用自体骨植骨者有1足皮肤伤口延期愈合,5足使用异体骨植骨者均有皮肤切口延期愈合,其中1足切口感染,1足出现骨髓炎。按照Maryland foot Score指标评价,以每一足为分析基数,优13足,良4足,可3足（均系型骨折）,优良率85.0%。结论对于跟骨爆裂骨折,手术内固定时均需植骨,植骨以取自体骨为佳。     

跟骨钢板内固定并植骨治疗跟骨关节内骨折的疗效分析

目的探讨跟骨钢板内固定并植骨治疗跟骨关节内骨折的临床疗效。方法对93足全部按SANDERS分型:未植骨组Ⅱ型9足,Ⅲ型22足,Ⅳ型14足。植骨组48足,Ⅱ型12足,Ⅲ型23足,Ⅳ型13足。手术前后对BOHLER角、GISSANE角、跟骨水平全长、轴长和体宽等指标进行比较,评价术后功能。结果术后功能评价:未植骨组优19足,良18足,差8足,优良率达82.22%。植骨组优30足,良14足,差4足,优良率达91.67%。结论跟骨钢板内固定并植骨与未植骨在治疗跟骨关节内骨折远期疗效上差异有统计学意义。     

距下关节塌陷性跟骨骨折的手术治疗

目的探讨距下关节塌陷性跟骨骨折的手术治疗效果。方法自2006年5月至2010年10月我院收治72例77足距下关节塌陷性跟骨骨折患者,按照Sanders分型,Ⅱ型44例49足,Ⅲ型24例24足,Ⅳ型4例4足。骨折均行切开复位植骨内固定,内固定材料选用Y形跟骨钛板,植骨材料均为自体骨。结果术后随访4～48个月,骨折全部愈合,愈合时问为8-20周;74足切口获I期愈合,切口皮肤部分坏死2例2足,换药后自行愈合。1足切口感染,形成溃疡,皮肤软组织缺损,钢板外露,于术后5个月取除内固定,腓肠神经营养血管逆行皮瓣移植,治愈。按美国足踝创伤协会的足部评分标准评定,优52足,良12足,中10足,差3足,优良率为83．12％。结论距下关节塌陷性跟骨骨折应采取手术治疗,植骨使关节面解剖复位,可减少并发症,提高生活质量。     

钢板内固定加同种异体骨植骨配合切口持续高负压引流治疗跟骨关节内骨折

目的探讨钢板内固定加同种异体骨植骨配合切口持续高负压引流治疗跟骨关节内骨折的疗效。方法采用切开复位、跟骨钢板内固定加同种异体骨植骨配合切口内置引流管持续高负压引流治疗32例跟骨关节内骨折患者(35足)。结果 32例均获得随访,时间2~50个月。骨折全部愈合。术后腓肠神经损伤1例,无皮瓣坏死。按美国足踝骨科协会的足踝临床评分系统评分:优29足,良5足,可1足,优良率97%。结论切开复位钢板内固定加同种异体骨植骨配合切口内置引流管持续高负压引流,是治疗跟骨关节内骨折效果可靠的方法。     

异型钢板治疗有移位的跟骨骨折

目的探讨切开复位异型钢板内固定治疗跟骨骨折的疗效。方法对30例（30足）SandersⅡ～Ⅳ型跟骨骨折患者采用外侧L型切口入路、开放复位、异型钢板内固定。部分Ⅲ、Ⅳ型骨折患者自体骨移植。结果30例均获随访,时间8～12个月,按MarylandFootScore评价系统评价术后功能：优12足,良11足,可5足,差2足,优良率77．6％。结论切开复位异型钢板内固定对Ⅱ-Ⅳ型跟骨骨折疗效肯定,部分Ⅲ、Ⅳ型骨折者疗效欠佳。     

锁定钢板结合植骨治疗SanderⅢ、Ⅳ型跟骨骨折

目的探讨切开复位锁定钢板内固定结合植骨治疗SanderⅢ、Ⅳ型跟骨骨折的疗效。方法对32例跟骨骨折患者（36足）采用切开复位锁定钢板内固定并髂骨植骨治疗。结果术后切口均无感染。32例均获随访,时间6—18（10．4±3．3）个月。未发现关节面塌陷、复位丢失、螺钉固定不良现象。功能及疗效按照Maryland足部评分系统评价：优22例,良6例,可3例,差1例,优良率为87．5％。结论锁定钢板内固定结合髂骨植骨治疗SanderⅢ、Ⅳ型跟骨骨折是一种有效的方法,充分的术前准备、熟悉跟骨的解剖形态、术中精准的复位、内固定的技巧、时机的掌握是手术成功的关键。     

植骨钛板内固定治疗跟骨骨折24例

目的分析切开复位加植骨钛板内固定治疗跟骨骨折的疗效。方法对我院2005年8月至2008年1月期间24例累及关节面跟骨骨折做切开复位钛钢板内固定加自体骨植骨治疗的患者进行随访分析。24例患者中,男17例18足,女7例,年龄20～56岁,平均31．3岁。按Sanders分型,Ⅱ型9例,Ⅲ型12例13足,Ⅳ型3例。全部病例均行切开复位解剖钢板内固定加植骨治疗,并在患者出院后进行随访。结果随访时间6～36个月,平均21．2个月,骨折全部愈合。术后患足功能按Maryland Foot Score评分标准,优18例,良2例3足,中3例,差1例,优良率83．3％。结论通过植骨及钛板内固定可恢复跟骨塌陷骨折距下关节面的完整,重建跟骨高度及Bohler角,提供稳定性,可行早期功能锻炼,是治疗跟骨骨折的较好的方法。     

跟骨钛板内固定治疗粉碎性跟骨骨折

[目的]探讨切开复位解剖型钛板治疗粉碎跟骨骨折的疗效。[方法]46例56足SandersⅢ、Ⅳ型跟骨骨折均采用外侧大切口跟骨钛板固定,保护腓肠神经,钢板外侧固定,术后测量Bhler角和Gissane角,评价骨折复位效果。[结果]全部病例无感染,2足切口皮肤坏死,骨折全部愈合,根据美国足踝外科协会AOFAS评分,优26足,良22足,可6足,差2足,优良率86%。[结论]切开复位钛板内固定治疗粉碎跟骨骨折,方法简单,疗效满意。     

两种不同处理方法对同种异体骨移植作用的实验研究

[目的]探讨两种不同处理方法对同种异体骨移植修复大段骨缺损疗效的实验研究。[方法]选取健康成年新西兰大白兔48只,随机分2组,实验1组:血管束植入同种异体骨修复组,实验2组:带血运骨膜包裹同种异体骨修复组。观察术后组织学切片,成骨量,生物力学,X线片等变化。比较两种术式修复骨缺损的差异。[结果]术后X线片观察实验2组较实验1组骨痂增加明显,光镜组织学检查实验2组较实验1组骨痂形成早,骨髓腔再通时间短。两组成骨量均在8周时达到峰值,实验2组在各时段成骨量均大于实验1组。三点弯曲试验结果示实验2组优于实验1组。[结论]带血运骨膜瓣包裹异体骨修复骨缺损优于单纯血管束植入同种异体骨修复骨缺损,带血运骨膜瓣包裹异体骨是修复大段骨缺损的较理想的方法。     

锁定钢板联合自体髂骨植骨治疗股骨干骨不连13例

目的观察13例股骨干骨不连患者采用自体髂骨块联合锁定钢板双固定治疗后的临床疗效。方法 13例股骨干骨不连患者均采取自体髂骨取骨,联合锁定钢板采用双固定骨折端方法进行治疗。结果 13例患者随访时间12~26个月,平均18个月。骨折均获骨性愈合,1例患者伤口延迟愈合,经换药后愈合,无一例发生切口皮肤坏死、深部感染、内固定松动或断裂,无成角畸形。根据HSS膝关节评分为88~97分,平均93分,Rasmussen膝关节功能评分法进行综合评分:优10例,良2例,可1例,差0例。结论符合文献报道:自体髂骨块联合锁定钢板双固定治疗股骨干骨不连临床疗效确切,是一种经济、有效的治疗方法。     

Fixation of long bone segmental defects: a biomechanical study

OBJECTIVES: Obtaining stable fixation in cases of long bone non-union with segmental bone defects can be challenging. Bone quality is often sub-optimal. Locking plates and structural allografts have both been used clinically in these cases. The objective of this study was to determine the biomechanical characteristics of three constructs that have been employed in this context. METHODS: A biomechanical study was performed using 3rd Generation Composite Femurs as specimens. A diaphyseal segmental defect was created and fixed with one of three constructs: (1) lateral locking plate (LP); (2) lateral non-locking plate and medial allograft strut (S); (3) lateral non-locking plate and intramedullary fibula allograft (F). The "allografts" were fashioned from 3rd generation composite bones. Axial, torsional and bending stiffness as well as load to failure were determined using a materials testing machine. RESULTS: Overall, construct S was the stiffest and construct LP was the least stiff. Construct F had intermediate characteristics. Axial load to failure for construct S (6108N) and for construct F (5344N) was significantly greater than for construct LP (2855N). CONCLUSION: When maximal stiffness is desired, a construct with a structural allograft should be chosen over a locking plate. However, biological and anatomic factors must also be taken into account when using these constructs clinically.     

A study of the mechanical strength of long bone defects treated with various bone autograft substitutes: an experimental investigation in the rabbit

This study was designed to determine which of several bone grafting materials would be the most efficacious substitute for autogenous bone graft in the treatment of segmental long bone defects. The experimental model was a 1-cm defect in the rabbit ulna. The control group had nothing implanted in the defect. The six grafts tested were: (a) autogenous iliac crest bone, (b) autogenous cortical bone (ulna), (c) hydroxylapatite, (d) hydroxylapatite-demineralized bone matrix (allograft) composite graft, (e) freeze-dried bone (allograft), and (f) demineralized bone matrix (allograft). At 6 weeks postoperatively, the ulnas were harvested, examined radiographically, and tested mechanically in torsion. The radiographic examination proved to be of little value because some materials were radiodense at the time of implantation. The rates (percentage) of union, torques at failure, and energy to failure values were statistically significantly higher than control for all groups except hydroxylapatite. We concluded that demineralized bone matrix and hydroxylapatite-demineralized bone matrix composite graft compare favorably with cortical replacement (autograft) in mechanical strength and rate of union and therefore may be satisfactory substitutes for bone grafting. Freeze-dried bone did not appear to be as satisfactory because of its low mean energy to failure, but statistical analysis failed to confirm this opinion. Hydroxylapatite graft, when used alone, does not appear to be a suitable material for grafting segmental bone defects.     

长段同种异体骨与自体带血管组织组合治疗大段骨缺损的总结

目的 通过研究血管化及促进骨愈合的方法,解决大段异体骨移植骨吸收、骨不连及再骨折等并发症.方法 对四肢10 cm以上长段骨缺损21例,采用钢板、外固定架等常规方法将大段异体骨与自体骨固定,同时采用异体骨与自体血管束、带血供骨或骨膜组合的方法,使异体骨血管化,达到促进骨愈合、防止异体骨溶解、吸收等并发症作用.其中4例采用局部血管束植入一侧断端;4例采用带血管髂骨块嵌入长段骨中部;2例带血管髂骨植入一侧骨断端;2例带血管腓骨嵌入中部;6例带血管骨膜植入一侧断端;另外血管束或骨膜加骨块组合植入3例.结果 21例中经一次治疗骨性愈合14例,经二次手术痊愈6例,失败1例.出现骨吸收、不愈合及再骨折等并发症7例,合并感染4例.经随访功能、外观满意.结论 采用自体带血管骨(膜)与同种异体骨组合移植治疗长段骨缺损,可改善大段异体骨移植的骨吸收、骨不连等并发症,有利于骨折的早期愈合.为治疗长段骨缺损较为理想的方法.     

带血运骨膜管移植和骨充填物修复桡骨长段缺损的研究

目的：探讨联合应用带血运骨膜管移植和骨充填物治疗兔桡骨长段缺损的效果。方法：实验分两部分，分别选用幼兔和成年兔各40只，根据填充物的不同分为4组，将兔双侧桡骨干中段切除3cm制成骨长段缺损模型，保留切骨段骨膜，重新重原缝合后作带血运骨膜管移植模型，左侧分别用自体骨，同种异体脱钙骨，磷酸三钙陶瓷和羟基磷灰石进行填充，右侧不行任何填作为对照。观察3个月。通过X线片，髓强度，骨密度和组织学检查等方法，了解骨缺损的修复效果。结果：幼兔术后6周，所有实验组双侧的骨缺损均得到修复，术后12周，磷酸三钙陶瓷和羟基磷灰石组桡骨抗弯曲强度较差与自体骨组、同种异体脱钙骨组和对照侧比较具有统计学意义（P＜0．05）；骨愈合为膜内成骨和软骨成骨，以膜内成骨为主，成年兔；各组实验侧骨缺损修复率分别为：自体骨组50％；同种异体脱钙骨组40％；磷酸三钙陶瓷和羟基磷灰石组为30％。对照侧骨缺损修复率为42．5％，结论：幼兔单行单血运骨管移植或结合应用骨充填物均可有效修复骨长段缺损，但置换较慢的骨充填物不利于再生骨强度的恢复，成年兔带血运骨膜移植联合应用骨填充物不能有效修复骨长段缺损。     

Tendon reattachment to a metallic implant using an allogenic bone plate augmented with rhOP-1 vs. autogenous cancellous bone and marrow in a canine model.

Functionality of endoprosthetic reconstruction may be improved through secure and lasting soft tissue reattachment directly to the metallic implant surface. Tendon reattachment to the metallic surface of a titanium implant (enhanced tendon anchor, ETA) using autogenous bone plate as an interpositional structure between the tendon and metal, augmented with autogenous bone chips and marrow, provided successful mechanical and functional outcome. However, preparation of the autogenous bone plate is not practical in a clinical setting, but application of an allogenic bone plate could be an alternative. The autogenous cancellous bone and marrow may also be substituted by bone growth factors so that no autogenous bone graft is required. We hypothesized that the reconstitution of the direct tendon-bone insertion morphology in tendon reattachment to metallic implant could be achieved using allogenic cancellous bone plate augmented with autogenous cancellous bone and marrow, and that the autogenous bone grafts could be replaced by recombinant human osteogenic protein-1 (rhOP-1). In two canine groups the supraspinatus tendon was reattached unilaterally to a modified ETA implant with a highly porous metallic surface known as Tritanium Dimensionalized Metal. Allogenic bone plates saturated with rhOP-1-collagen putty were used in the OP-1 (OP) group, while plates saturated with autogenous cancellous bone and marrow were used in the bone marrow (BM) group. Functional, radiographical, mechanical and histomorphological analysis results were compared between both groups. At 15 weeks, gait analysis showed 78% and 81% recovery of preoperative weight-bearing in OP and BM groups, respectively. The calcified area around the tendon in OP group was 5.2 times larger than that in BM group (p<0.001). The ultimate tensile strength of the reattachment was 24% and 38% of the intact contralateral side in OP and BM groups, respectively, without significant difference between them. There was evidence of tendon-bone insertion transitional zones, tissue ingrowth and adhesion to the metallic surface in both groups. In conclusion, the use of the allograft combined with rhOP-1 had a similar effect as combined with autogenous cancellous bone and marrow in the tendon reattachment to the metallic surface.     

Repair of long bone defects with demineralized bone matrix and autogenous bone composite

Background:

Repair of diaphyseal bone defects is a challenging problem for orthopedic surgeons. In large bone defects the quantity of harvested autogenous bone may not be sufficient to fill the gap and then the use of synthetic or allogenic grafts along with autogenous bone becomes mandatory to achieve compact filling. Finding the optimal graft mixture for treatment of large diaphyseal defects is an important goal in contemporary orthopedics and this was the main focus of this study. The aim of this study is to investigate the efficacy of demineralized bone matrix (DBM) and autogenous cancellous bone (ACB) graft composite in a rabbit bilateral ulna segmental defect model.

Materials and Methods:

Twenty-seven adult female rabbits were divided into five groups. A two-centimeter piece of long bone on the midshaft of the ulna was osteotomized and removed from the rabbits’ forearms. In group 1 (n=7) the defects were treated with ACB, in group 2 (n=7) with DBM, and in group 3 (n=7) with ACB and DBM in the ratio of 1:1. Groups 4 and 5, with three rabbits in each group, were the negative and positive controls, respectively. Twelve weeks after implantation the rabbits were sacrificed and union was evaluated with radiograph (Faxitron), dual-energy x-ray absorptiometry (DEXA), and histological methods (decalcified sectioning).

Results:

Union rates and the volume of new bone in the different groups were as follows: group 1 - 92.8% union and 78.6% new bone; group 2 - 72.2% union and 63.6% new bone; and group 3 - 100% union and 100% new bone. DEXA results (bone mineral density [BMD]) were as follows: group 1 - 0.164 g/cm², group 2 - 0.138 g/cm², and group 3 - 0.194 g/cm².

Conclusions:

DBM serves as a graft extender or enhancer for autogenous graft and decreases the need of autogenous bone graft in the treatment of bone defects. In this study, the DBM and ACB composite facilitated the healing process. The union rate was better with the combination than with the use of any one of these grafts alone.