脊柱后路内固定器治疗胸腰段非稳定性骨折疗效分析

自１９８７年以来使用Ｈａｒｒｉｎｇｔｏｎ棒、Ｌｕｑｕｅ棒、Ｄｉｃｋ钉及Ｄｉｃｋ钉加后路植骨四种方法治疗非稳定性胸腰段脊柱骨折９６例。随访２￣７年，四个治疗组对脊髓损伤效果类似，在矫正脊柱矢状面后凸畸形方面术后短期内均能获得满意效果。但术后２年，三组单纯内固定对脊柱矢状面后凸矫正度均有显著丢失，仅Ｄｉｃｋ钉加后路植骨组有效控制了后凸矫正度的丢失（Ｐ〈０．００１）。作者认为，坚强的后路内固定加充分植骨     

经前路松解联合后路固定治疗特发性脊柱侧凸

目的:评价经前路松解联合后路矫形对特发性脊柱侧凸的治疗效果。方法:回顾性分析我院收治的51例(男16例,女35例;年龄8～17岁,平均13.2岁)特发性脊柱侧凸行前路松解及后路脊柱畸形矫形植骨融合术患者的临床资料及治疗结果。结果:本组中行前路松解、植骨,阻滞椎间盘平均2.4个。联合后路椎弓根钉(钩)-棒系统内固定,植骨、融合。术后特发性脊柱侧凸Cobb角<90°者额状平面平均矫正率为57%,矢状面后凸平均矫正率为50%;Cobb角>90°者额状平面平均矫正率为71%,矢状面后凸平均矫正率为74%。术后随访10～35个月,平均随访21.6个月,无矫正度的丢失及其他神经系统及血管损伤并发症。结论:脊柱前路松解安全、有效,联合后路相适应内固定系统矫形、植骨治疗特发性脊柱侧凸可获得满意治疗效果。     

后路植骨椎弓根系统治疗退变性脊柱侧凸畸形

目的: 探讨后路植骨椎弓根系统治疗退变性脊柱侧凸畸形的效果。方法: 分析 2000 ~2004年经后路植骨中华长城椎弓根系统治疗 24例退变性脊柱侧凸畸形的病例并随访, 24例中全部病例均使用中华长城钉棒系统, 取自体骨或加用异体骨植骨。结果: 全部病例术后平均侧凸矫正率为 81. 2%, 疼痛缓解率 98. 6%, 未出现假关节。随访期间内固定物无松动断裂, 矫正度数无丢失。结论: 后路植骨椎弓根钉棒系统是治疗退变性脊柱侧凸的一种安全显效的方法, 术中椎弓根钉的准确安放, 充分的植骨是保证疗效的关键。     

颗粒骨经椎弓根椎体内外植骨融合内固定治疗胸腰椎骨折

目的探讨脊柱后路颗粒骨经椎弓根椎体内外植骨短节段椎弓根钉内固定治疗胸腰椎骨折可行性。方法将70例胸腰椎骨折随机分为两组:A组(n=20)采用颗粒骨经椎弓根椎体内植骨融合短节段椎弓根钉内固定;B组(n=50)采用单纯短节段椎弓根钉内固定。对后凸畸形角度及矫正角度、椎体前缘高度以及椎管矢状径进行测量,采用Frankel功能分级和Denis疼痛分级方法进行神经功能改变的评价。结果后凸畸形术后矫正度数较术前两组均很明显。随访中,A组矫正度数的丢失明显小于B组(P=0.0001)。术后伤椎前缘高度百分比增加值两组比较有显著差异(P<0.001)。术后随访中,A组伤椎椎体前缘高度无丢失(P<0.001),B组伤椎椎体前缘高度有丢失(P<0.05)。采用Denis疼痛分级,两组术后均有很好的改善。采用Frankel功能分级,术后神经功能变化,A组患者平均提高优于B组。结论脊柱后路颗粒骨经椎弓根椎体内外植骨结合内固定治疗胸腰椎骨折植骨融合率高,能有效恢复椎体高度和防止术后矫正度丢失。     

后路半椎体全切术治疗青少年先天性脊柱侧凸畸形

目的：评价后路半椎体切除治疗青少年半椎体所致先天性脊柱侧凸的临床疗效。方法回顾性分析2007-06-2011-0621例青少年半椎体畸形采用一期后路半椎体全切除术患者的临床资料,均行后路半椎体切除加植骨融合钉棒内固定术。结果冠状面主弯cobb角术前平均为40.3°,术后平均为15.4°,末次随访平均为16.3°,矫正率为61.7％;矢状面后凸cobb角术前平均为33.3°,术后平均为11.8°,末次随访平均为12.6°,矫正率为64.5％;局部侧凸cobb角术前平均为36.2°,术后平均为14.7°,末次随访平均为15.3°,矫正率为59.3％。末次随访时所有患者植骨均融合,一例出现椎弓根切割,无假关节形成,无内固定断裂,近期随访丢失率低。结论后路半椎体切除可去除病因,同时矫正冠状位和矢状位畸形,是治疗青少年半椎体引起的先天性脊柱侧凸的有效方法。     

Lenke 5型脊柱侧凸前路单棒矫形术中放置钛网对术后矢状面重建的影响

目的 探讨放置钛网对Lenke 5型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis, AIS)行选择性前路单棒矫形加植骨融合术后矢状面重建的影响.方法 40例Lenke 5型AIS患者,根据术中植骨方式分为两组,均接受选择性前路单棒矫形术.术中椎间融合植骨时,A组患者放置钛网,B组则单纯以剪碎的自体肋骨和髂骨骨粒植骨.A组女19例,男1例;年龄12～18岁.B组女17例,男3例;年龄13～20岁.两组患者获得1.5年以上的随访.对术前、术后和末次随访时的冠状面矫形与矢状面重建指标进行分析.结果 在术后和随访中,两组患者主弯的矫正率大于70%,继发弯也获得较满意的自发性纠正.无内固定相关和假关节形成等并发症发生.两组患者术后和随访中也获得较满意的矢状面重建.其中,术后和随访中胸椎后凸增加,胸腰交界性后凸轻微变化,腰椎前凸无明显丢失,内固定近端后凸成角轻度增大,内固定区成角前凸轻度减小,这些指标在两组间差别无统计学意义.末次随访时,A组患者SVA和L1到C7PL线的距离平明显小于其术前和术后的测量值,而这些指标在B组均无显著变化.结论 选择性前路单棒矫形加椎间植骨融合术是治疗Lenke 5型脊柱侧凸的有效方法.与自体植骨相比,钛网植骨可较好地改善矢状面的整体平衡.     

后路半椎体全切术治疗青少年先天性脊柱侧凸畸形

目的：评价后路半椎体切除治疗青少年半椎体所致先天性脊柱侧凸的临床疗效。方法回顾性分析2007-06-2011-0621例青少年半椎体畸形采用一期后路半椎体全切除术患者的临床资料,均行后路半椎体切除加植骨融合钉棒内固定术。结果冠状面主弯cobb角术前平均为40.3°,术后平均为15.4°,末次随访平均为16.3°,矫正率为61.7％;矢状面后凸cobb角术前平均为33.3°,术后平均为11.8°,末次随访平均为12.6°,矫正率为64.5％;局部侧凸cobb角术前平均为36.2°,术后平均为14.7°,末次随访平均为15.3°,矫正率为59.3％。结论后路半椎体切除可去除病因,同时矫正冠状位和矢状位畸形,是治疗青少年半椎体引起的先天性脊柱侧凸的有效方法。     

一期后路内固定侧前方病灶清除植骨治疗胸腰椎结核

目的：观察椎弓根钉系统内固定加侧前方病灶清除治疗胸腰椎结核的疗效。方法：14例均采用椎弓根钉系统后路内固定加侧前方病灶清除植骨融合与脊髓减压术。结果：随访6个月～4．5年，结核全部治愈，植骨均融合，纠正后凸角度平均25．2°，丢失角度平均2．8°。结论：后路椎弓根系统内固定能有效矫正脊柱后凸畸形，稳定脊柱，促进植骨融合。     

后路短节段椎弓根内固定加植骨融合治疗儿童先天性脊柱后凸

[目的]探讨后路短节段椎弓根钉内固定加植骨融合矫正儿童先天性半椎体脊柱后凸畸形的可行性及短期疗效评价。[方法]对2001年11月～2006年1月挑选的13例先天性半椎体脊柱后凸儿童进行后路短节段椎弓根钉内固定加植骨融合畸形矫正术，男8例，女5例；平均10．4岁（5～13岁）。Cobb’s角平均为42．7^o（28^o～48^o）。术后支具固定8个月。[结果]术后X线片随访12个月-5年3个月（平均2年3个月）。矢状面Cobb＇s角由平均42．7^o矫正至平均9．3^o，畸形矫正率达到78．2％。随访过程中矫正的Cobb’s角平均增大1．6^o，无椎弓根切割，无神经损伤，没有发生植骨不愈合的病例，没有患者出现侧凸畸形。[结论]后路短节段椎弓根钉内固定加植骨融合矫正儿童先天性脊柱后凸，手术创伤小，短期效果可靠，但应严格掌握手术指征。     

经伤椎多方位植骨及后路GSS钉-棒系统内固定治疗胸腰椎骨折

目的探讨经伤椎多方位植骨及后路GSS钉-棒系统内固定治疗胸腰椎骨折的临床疗效。方法采用后路GSS钉-棒系统内固定加经伤椎多方位植骨治疗胸腰椎骨折20例(A组),单纯后外侧植骨20例及5例未行植骨(B组)。结果两组在椎体前、后缘高度的恢复,手术前、后Cobb角的矫正复位丢失,螺钉松动率,断钉率等指标中差异均具有统计学意义(P<0.05)。结论经伤椎多方位植骨及后路GSS钉-棒系统内固定治疗胸腰椎骨折,重建了脊柱前、中、后柱的稳定性,可有效地恢复及维持椎体高度,提高骨折椎体密度,防止内固定松动失败及矫正度丢失。     

Anterior Kostuik-Harrington distraction systems for the treatment of kyphotic deformities

Based on the biomechanical principles of anterior distractive forces combined with instrumentation to decrease sagittal bending moments, an anterior system using a modification of Harrington instrumentation has been developed for the correction of kyphotic deformities. It has been used in the treatment of acute burst fractures in 100 cases, posttraumatic kyphosis in 45 cases, Scheuermann's kyphosis in 36 cases, rigid round backs in three cases, acute rigid kyphosis (congenital) in four cases, postlaminectomy in 21 cases, flat back syndrome in 56 cases, kyphosis secondary to tumor in ten cases, and kyphosis secondary to osteoporosis with fracture in four cases. A total of 279 cases have been treated with anterior instrumentation. Complications include breakage of 35 screws and four rods. There have been no early or late vascular or neurologic sequelae related to instrumentation. The biomechanical basis for the treatment of kyphotic deformities includes an anterior distractive force to resist compressive loads and, where possible, segmental fixation to decrease sagittal bending moments combined with bone grafts far from the neutral axis. This system provides these benefits with minimal risk and morbidity.     

Delayed posterior internal fixation of unstable pelvic fractures

Fifteen patients with unstable pelvic fractures were treated with immediate anterior external fixation followed by delayed posterior fixation, including five sacroiliac lag screws, six transiliac rods, and four iliac plates. Initial anterior external fixation aided in resuscitation of hemodynamically unstable patients and allowed early mobilization. Delayed posterior internal fixation avoided infection and hemorrhage but failed to achieve anatomic reduction of disrupted sacroiliac joints and sacral fractures. Followup examination confirmed maintenance of fixation and fracture healing but pain and persistent neurologic deficits were common findings. Lumbosacral nerve plexus injuries occurred in patients with fractures through the sacral foramina. Fixation of these fractures with sacroiliac screws and transiliac rods caused overcompression and the resulting foraminal encroachment may be a factor in the lack of neurologic recovery. In this study, delayed posterior internal fixation was not associated with perioperative morbidity and achieved better reductions than those obtained with external fixation alone. Delaying the fixation, however, increased the difficulty of obtaining anatomic reduction of certain posterior arch disruptions.     

Experimental Rupture of the Achilles Tendon: Comparison of Experimental Ruptures in Rats of Different Ages and Living Under Different Conditions

24 patients with Th12-L1 fractures treated with a Dick internal fixator were analyzed to assess predictors of poor outcome. 4 patients had fixation without bone transplantation, 20 patients had a posterior fusion, and 12 of them had additional transpedicular spongioplasty. There were fractures of the transpedicular screws in 4 and screw migration in 2 cases. The increase in the local kyphosis angle was greater than the increase in the anterior compression angle and this did not correlate with spongioplasty or fusion. Fixation failure was in all cases related to a disproportionate increase in the local kyphosis angle. There was no difference between the patients with transpedicular spongioplasty and posterior fusion and the other patients with respect to results and complications. Bony collapse was not the major cause of failure and consequently there was no measurable contribution of transpedicular spongioplasty. We found that the Dick internal fixator for unstable fractures was associated with a higher complication rate than earlier reported.     

Recurrent kyphosis after posterior stabilization of thoracolumbar fractures: 24 cases treated with a Dick internal fixator followed for 1.5-4 years

24 patients with Th12-L1 fractures treated with a Dick internal fixator were analyzed to assess predictors of poor outcome. 4 patients had fixation without bone transplantation, 20 patients had a posterior fusion, and 12 of them had additional transpedicular spongioplasty. There were fractures of the transpedicular screws in 4 and screw migration in 2 cases. The increase in the local kyphosis angle was greater than the increase in the anterior compression angle and this did not correlate with spongioplasty or fusion. Fixation failure was in all cases related to a disproportionate increase in the local kyphosis angle. There was no difference between the patients with transpedicular spongioplasty and posterior fusion and the other patients with respect to results and complications. Bony collapse was not the major cause of failure and consequently there was no measurable contribution of transpedicular spongioplasty. We found that the Dick internal fixator for unstable fractures was associated with a higher complication rate than earlier reported.     

采用旋转加原位弯棒原理重建脊柱骨折矢状面形态

目的 探讨使用钉钩加原位弯棒技术治疗胸腰椎骨折,在恢复椎体高度的同时对脊柱矢状面形态满意重建的原理和疗效。方法 自１９９７年７月起使用ＣＤ和ＴＳＲＨ治疗胸腰段骨折脱位４８例,其中男４１例,女７例,年龄１７～５４岁。手术方法（以Ｌ１为例）：在Ｔ１２和Ｌ２置入椎弓根螺钉,Ｔ１１和Ｌ２安置偏心椎板钩,对棒按照固定区正常矢状面形态预弯,置入双侧椎弓根螺钉孔内,此时棒的预弯平面位于冠状面上。先用撑开力恢复伤     

Fractures of the posterior wall of the acetabulum: treatment using cannulated screws

A total of 19 patients (16 males, 3 females) who had fractures of the posterior wall of the acetabulum were treated by open reduction and internal fixation. Their mean age was 40 years. There were five single-fragment fractures and 14 comminuted. Fifteen patients were treated by fixation with cannulated screws only and four were treated with cannulated screws and reconstruction plates. Reduction and fixation of fragments was facilitated, and soft tissue dissection minimized, by the use of cannulated screws. Clinical results were excellent in nine hips, very good in one, good in six, and poor in three after follow-up of more than 2 years. We think that preservation of the blood supply to the fracture fragments and careful placement of the fixation components is as important as rigid fixation of the fragments for the successful treatment of posterior-wall fractures of the acetabulum. The use of cannulated screws may be helpful for this purpose.     

改良Wiltse入路经伤椎椎弓根植骨内固定术治疗胸腰椎爆裂性骨折

目的 探讨改良Wiltse入路经伤椎椎弓根植骨内固定术治疗胸腰椎爆裂性骨折的临床疗效.方法 回顾性分析2015年1月—2018年12月收治的126例胸腰椎爆裂性骨折患者临床资料.其中64例采取改良Wiltse入路经伤椎椎弓根植骨内固定术治疗(观察组),62例采取常规后路内固定术治疗(对照组).记录2组手术时间、术中出血...     

B、C型桡骨远端骨折的治疗

目的 探讨AO分类B、C型桡骨远端骨折的治疗方法。方法 对93例B、C型桡骨远端骨折采用手法复位石膏固定、闭合性复位经皮克氏针内固定及切开复位钢板螺钉内固定。结果 全部病例均随访2年以上。优良率：手法复位石膏固定组为82．05％，经皮克氏针内固定组为81．82％，切开复位钢板螺钉内固定组为80．95％。结论 手法复位能达到解剖或近似解剖复位并经石膏固定可达到良好固定者应采用非手术治疗；Bl、B3、C1型中的Colles骨折应采用闭合性复位经皮克氏针内固定；B2、Cl、C2型中的Simth骨折应采用切开复位钢板螺钉内固定；C3型骨折因干骺端粉碎应采用松质骨移植恢复桡骨的长度；伴有严重的骨质疏松的患者避免用内固定治疗。     

Mechanical performance of the Dick internal fixator: a clinical study of 75 patients

Summary A consecutive series of 75 patients with fractures of the thoracolumbar spine, stabilized with the Dick internal fixator, was studied retrospectively. Posttraumatic kyphosis was measured on the preoperative lateral radiograph by the Cobb angle and the wedge angle and the results were compared with angles measured on the radiographs after instrumentation and after removal of the implants. The presence and number of broken Schanz screws was noted. In the whole group, an average correction of kyphosis of 15.5° was obtained, but 7.6° was lost again at follow-up. In comparing the kyphotic angle with the wedge angle, we found that this loss was almost exclusively situated in the upper intervertebral disc space. In the group of patients with transpedicular intravertebral bone grafting, the relative loss of correction in the wedge angle was smaller than in the group without bone grafting, while the relative loss of correction of the kyphotic angle was similar. Schanz screw breakage was present in 13.3% of patients, occurring in 4.6% of inserted screws. In the group of patients with broken Schanz screws, the loss of correction in the wedge angle was somewhat higher, but not markedly different from that of the patient group without breakage of screws. Risk of screw breakage was enhanced by laminectomy and reduced by transpedicular bone grafting. Screw breakage or important loss of correction did not influence the neurological outcome of the patients. The Dick internal fixator is a very reliable implant, even in patients with highly unstable fractures. To minimize the risk of screw breakage, transpedicular bone grafting is recommended; laminectomy, however, should only be done under certain strictly defined conditions.     

一期后路经关节螺钉联合前路钢板固定治疗下颈椎骨折脱位

目的 探讨一期后路经关节螺钉联合前路钢板固定技术治疗下颈椎骨折脱位的效果. 方法 自2005年10月至2007年5月对12例下颈椎骨折脱位患者采用一期前后路联合手术.单纯脱位者,先行后路复位经关节突螺钉固定,再改行前路椎间隙减压,植骨融合,钢板内固定;椎体骨折伴脱位者,前路先行椎体次全切除,植骨融合,钢板内固定,然后行后路经关节螺钉固定脱位节段,小关节间行植骨融合.术前ASIA分级:A级21例,B级6例,C级3例,D级1例. 结果 12例患者获6～21个月(平均14.8个月)随访,椎间及小关节间植骨全部愈合.无螺钉松动及神经、血管并发症.术后除1例完全性瘫痪患者神经功能无恢复外,其余11例均有一级以上恢复.术后ASIA分级:A级1例,B级1例,C级4例,D级4例,E级2例. 结论 下颈椎经关节螺钉联合前路钢板固定融合术,具有操作简单安全、固定可靠、植骨融合率高等优点,是治疗下颈椎骨折脱位较为理想的术式.