股骨上端肿瘤并发骨折的手术方法选择

[目的]探讨股骨上端肿瘤并发骨折的手术方法选择和疗效.[方法]2001年10月～2007年6月,收治股骨上端肿瘤并发骨折46例,其中采用先期外固定,骨折愈合后行肿瘤刮除植骨7例;肿瘤病灶清除植骨内固定11例;瘤体刮除,带血管腓骨移植6例;瘤体刮除,骨水泥填充,带锁髓内钉固定8例,瘤段切除,人工假体置换12例;髋关节离断2例.[结果]先期外固定,骨折愈合后肿瘤刮除植骨7例均获得随访,根据Enneking肢体功能评价标准,术后优良率85.7%;肿瘤病灶清除植骨内固定9例获得随访,优良率88.8%;瘤体刮除,带血管腓骨移植6例均获得随访,优良率83.3%;瘤体刮除,骨水泥填充,带锁髓内钉固定8例均获得随访,死亡5例,余3例;优良率66.6%;瘤段切除,人工假体置换术9例获得随访,死亡5例,肿瘤复发1例,术后优良率75%.[结论]股骨上端肿瘤并发骨折应根据肿瘤性质,破坏程度,骨折移位等情况,选择适宜的手术方法,良性肿瘤以刮除植骨为主,股骨颈部骨折以坚强的腓骨移植为首选,恶性肿瘤以人工假体置换术为主,转移癌以人工假体置换或带锁髓内钉固定为宜.     

原发性股骨近端溶骨性骨缺失的修复重建

目的总结和分析股骨近端原发性溶骨性骨缺损的手术修复方法。方法自1997～2003年我科共收治股骨近端原发性溶骨性骨缺损36例。根据肿瘤的性质及大小分别采用病灶刮除 自体(异体)皮松质骨植入8例；病灶刮除 自体(异体)皮松质骨 自体缝匠肌髂骨瓣复合植入 内固定术22例；病灶刮除 骨水泥填充 内固定5例；瘤段切除 人工双动股骨头置换1例。结果术后随访12～54个月，平均24个月，仅1例骨巨细胞瘤复发，关节功能评分33例优，3例良。结论根据肿瘤的性质和股骨近端骨缺损大小采取不同手术方式进行了病灶清除及功能重建，是一套有效的重建股骨近端骨缺损的方案。     

手术治疗股骨距碎裂的股骨颈骨折

目的探讨股骨距碎裂的股骨颈骨折的手术方法及疗效。方法手术治疗14例股骨距碎裂的股骨颈骨折患者,5例骨折无明显移位者行闭合复位折断式加压螺钉内固定;5例移位明显者术中将其切开复位后行股方肌骨瓣移植加空心加压螺纹钉内固定;4例行骨水泥型人工关节置换,其中2例去除股骨距骨块。结果14例获9个月~3年随访。前两种术式中9例股骨距骨折块达骨性愈合,闭合复位组中1例变成死骨;股骨颈骨折均愈合;发生股骨头坏死1例。行骨水泥型人工关节置换的4例中2例保留的股骨距骨块愈合,1例出现假体松动。结论合并股骨距碎裂的股骨颈骨折年龄较轻者应选择骨折复位内固定,老年患者则可选择人工关节置换,尽量保留股骨距的骨块。     

股骨头颈部肿瘤及瘤样病变的手术治疗

目的探讨股骨头颈部肿瘤及瘤样病变的手术治疗效果.方法对19例股骨头颈部瘤样病变及良性肿瘤患者行病灶刮除＋自体髂骨植骨术.结果 19例均获随访,时间1年3个月～4年,平均2.7年.患者术后6～9个月植骨融合,无股骨头坏死或塌陷,肿瘤无复发征象.结论对股骨头颈部良性肿瘤及瘤样病变采用病灶清除＋植骨可取得良好效果.     

股骨近端良性骨肿瘤和瘤样病变的手术治疗

股骨近端的良性骨肿瘤和瘤样病变并不少见，其病变亦多种多样，术前术后均易发生各种并发症。本文统计分析了我所１９８３年７月～１９９３年１０月收治的４９例股骨近端良性骨肿瘤和瘤样病变的病人，所有病人均经手术治疗，术后病理诊断。本组病人采用病变刮除，５０％氯化锌烧灼，皮质骨和／或松质骨植骨的方法治疗。不同的植骨方法对病变的预后有不同的影响，皮质骨植骨有助于防止术后髋内翻和病理骨折的发生。对于病变累及股骨头的病人，其病变较大可能发生股骨头无菌坏死，用单纯病变刮除，５０％氯化锌烧灼加植骨的方法难以奏效，需用更彻底的方法去除病变和功能重建，如人工股骨头置换。     

股骨转移瘤的外科治疗

目的：探讨手术治疗股骨转移性肿瘤的效果及意义。方法：回顾2000—2008年手术治疗的股骨转移性肿瘤患者24例,其中男15例,女9例,年龄（64±8．5）岁（35～77岁）。转移部位：股骨颈部5例,转子部7例,干部8例,髁部4例。股骨颈转移瘤行头颈切除骨水泥人工半髋关节置换术,其他部位转移瘤行瘤体刮除骨水泥填塞内固定术,其中选用交锁髓内钉12例,DHS4例,钢板2例,DCS1例。结果：所有患者中生活质量得到明显改善,疼痛缓解。结论：采用人lr假体置换或内同定手术可以缓解疼痛部分恢复患肢功能,便于减少长期卧床所致并发症,提高患者生存质量。     

手部内生软骨瘤16例分析

目的比较掌、指骨内生软骨瘤刮除植骨与单纯刮除术2种治疗方法的结果。方法1986年7月～1997年6月手术治疗掌、指骨内生软骨瘤16例,其中单发性内生软骨瘤10例,多发性内生软骨瘤6例,合并病理性骨折4例。单纯行肿瘤刮除术6例,肿瘤刮除松质骨条填塞植骨10例。结果术后随访15例,随访时间2年～12年6个月,平均6年8个月,肿瘤无一例复发及癌变。结论掌、指骨内生软骨瘤刮除术后可不必植骨,彻底刮除病变组织是防止内生软骨瘤复发的关键。     

带血管腓骨移植与加压螺旋钉内固定治疗股骨颈骨折骨不连

目的：总结加压螺旋钉内固定与带血管腓骨移植术治疗股骨基骨折骨不连的效果。方法：对46例股骨颈骨折骨不连在直视下解剖复位后,以直径9mm的加压螺旋钉固定,再将带有腓动静脉的腓骨跨过骨折线嵌入股骨头、颈部,螺丝钉固定,将腓动静脉与旋股外侧动静脉吻合,随访1－8年,结果：45例获得骨性愈合,1例失败。股骨头缺血坏死2例。结论：加压螺旋钉内固定结合带血管腓骨移植可有效的治疗股骨颈骨折骨不连。     

带旋髂深血管蒂髂骨植骨治疗股骨颈骨折和股骨大粗隆病损

目的 分析和总结带旋髂深血管蒂骼骨植骨治疗股骨颈骨折和股骨大粗隆病损的经验和体会。方法 采用带旋髂深血管蒂骼骨植骨治疗陈旧性股骨颈骨折不愈合、股骨颈骨囊肿、股骨大粗隆骨巨细胞瘤共27例。术中先解剖出旋髂深血管,于股骨颈前外侧开凿骨槽／清除肿瘤病变组织,取与骨槽／瘤位相应口径的带旋髂深血管蒂的髂骨块,嵌入骨槽／瘤床内,空隙部位用髂骨碎条块充填。结果 平均随访3年8个月（11个月－7年）,疗效满意。X线复查见股骨颈骨折愈合良好,肿瘤辞除后的骨缺损均修复。结论 带旋髂深血管蒂的髂骨植骨治疗股骨颈骨折和股骨大粗隆病损是一种可选择的行之有效的方法。     

股骨干骨折合并股骨颈骨折的临床特点及手术治疗

目的：探讨股骨干骨折合并股骨颈骨折的损伤机制，骨折特点及手术治疗。方法：回顾分析自1994年1月～2001年12月具有完整资料，经手术治疗的11例股骨干骨折合并股骨颈骨折患作为研究对象，其中男10例，女1例；平均年龄36．7岁。交通伤9例，高处坠落伤2例。全部在硬膜外麻醉下手术切开复位、内固定加股骨颈植骨，一期完成手术。其中松质骨螺钉(股骨颈) 普通接骨板2例；松质骨螺钉 AO接骨板3例；Richards钉 AO接骨板1例；股骨重建髓内钉内固定5例。全组术后3，6，12个月进行临床和影像学检查，判断疗效。结果：股骨干骨折除1例普通接骨板内固定出现钢板断裂，骨不连外，全部在3．5个月内获得愈合。股骨颈骨折均在1年内愈合。1例拆内固定3个月后出现股骨头变扁、塌陷。应用股骨重建髓内钉内固定患的临床和影像学检查优良率明显高于其它内固定的患。结论：股骨干骨折合并股骨颈骨折属高能量损伤，股骨颈骨折的症状隐匿，易造成漏诊。对高能量所致的股骨中段骨折患应常规摄骨盆后前位片，以免漏诊；对行股骨干交锁钉内固定术的患，应警惕发生医源性股骨颈骨折。内固定物中以股骨重建髓内钉为优。拆除内固定后要追踪摄片检查1a，警惕股骨头无菌性坏死的发生。     

Temporary Filling of Juxta-Articular Osteolytic Lesions with Bone Cement

Objective Extensive excochleation of juxta-articular osteolytic lesions. Temporary filling of the defect with bone cement to preserve joint function, to prevent fracture and recurrence. During the second sitting, the bone cement is removed and replaced preferably by autogenous bone grafts. Indications Juxta-articular osteolytic lesions which are benign or of low malignancy. Lesions of questionable malignancy as well as tumorlike conditions such as giant cell tumors, chondroblastomas, unicameral and aneurysmal bone cysts, which are all characterized by a high tendency of recurrence. Contraindications Malignant bone tumors, lesions invading the overlying soft tissues. Surgical Technique Stage 1: fenestration of bone, complete curettage or excisional biopsy. Filling of the defect with bone cement. Internal fixation if indicated. Stage 2: after freedom from recurrence of at least 1 year, removal of the bone cement and replacement with preferably autogenous bone grafts. Removal of the perifocal soft tissue membrane for histologic examination. In the presence of recurrence, the excochleation is repeated as well as the filling with bone cement. Results Between 1982 and 1999, the described technique was performed in 27 patients (ten men, 17 women, age 9-68 years). A total of 29 cement fillings were done, 23 for primary surgery, six for recurrences. The initial surgery was followed by three recurrences, two of which underwent repeat filling and remained free of recurrence for 24 and 102 months, respectively. A special tumor prothesis was used in one woman for recurrence of a giant cell tumor. The duration of follow-up varied between 1 and 151 months (average 49 months). The joint function was excellent 14 times, good ten times, and poor once. The following complications were encountered: two fractures, one draining sinus, one osteoarthritis, and one axial malalignment.     

带血供骨瓣移位治疗青壮年股骨颈骨折

目的:探讨青壮年股骨颈骨折的治疗方法,以减少骨折不愈合和股骨头坏死等并发症。方法:应用带血供骨瓣转移加压螺纹钉内固定治疗青壮年股骨颈骨折36例,其中带肌蒂骨瓣22例,带血管蒂骨瓣14例。结果:28例得到2～8年随访,按照中华医学会骨坏死学推荐的疗效评价标准。优21例,良5例,差2例,优良率为92.86％、结论:带血供 骨瓣移位治疗青壮年股骨颈骨折可促进骨折愈合、降低股骨头坏死妁发生率     

Pathological fractures of the knee]

The authors present the methods and results of treatment of 20 epiphyseal and low-metaphysis pathological knee fractures treated at the Department of Orthopedics of the Lublin University of Medical Sciences between 1962-1999. The average age was 39 years. Malignant tumours (2 lymphomas, 1 plasmocytoma, 1 hemangiopericitoma, 2 adenocarcinoma metastases) and benign lesions (10 giant cell tumours, 3 solitary bone cysts, 1 intraosseous extension of pigmented villonodular synovitis) causes 18 femur fractures and 2 tibia fractures. The fractures caused by lymphomas in 2 patients and plasmocytoma in 1 patients were treated with either a plaster cast or skeletal traction and healed within 16 weeks. Tumour resection and reconstruction with Rush rods, Kuntscher nail, plate and methylmetacrylate were performed in 2 cases. In 1 case with hemangiopericytoma hip exarticulation was performed. In 5 cases pain relief and weight bearing capacity of the limb was not achieved because of neoplasm recurrences; 5 deaths occurred within 6 months to 7 years after femur fracture because of pulmonary metastases. Benign bone lesions were treated by curettage of pathological tissues, burring bony walls of the lesions and filling the cavities with bone grafts or methylmetacrylate (1 case). Displaced fragments were reduced whenever possible. Limbs were immobilised in plaster casts. The follow-up period for patients with benign lesions was 8 years. All fractures healed. Arthritis with persistent pain and knee contracture was noted in 1 patient who underwent surgery 3 times for giant cell tumour recurrences, complicated by infection and varus deformity.     

广泛微孔涂层非骨水泥假体在股骨翻修的应用

目的报告采用广泛微孔涂层非骨水泥股骨假体对失败的骨水泥固定股骨假体翻修的近期效果。方法1998年至2003年,对20例骨水泥固定型人工髋关节置换后无菌性松动的股骨假体采用广泛微孔涂层假体进行翻修。翻修前使用国产假体18例,进口假体2例;全髋关节置换14例,人工股骨头置换6例。所有假体均为骨水泥固定,早期骨水泥技术固定18例,第二代骨水泥技术固定2例。原始疾病为股骨头无菌性坏死14例,股骨颈骨折6例。从初次关节置换到翻修手术的时间最短5年,最长17年,平均11.5年。其中4例患者为再次翻修。根据Paprosky分型,Ⅰ型3髋,Ⅱ型6髋,ⅢA型11髋。翻修假体,AML(DePuy)5髋,Solution(DePuy)7髋,Full-coated(Zimmer)6髋,Perfecta延长柄(WrightMed)2髋。翻修时患者平均年龄64岁(41～77岁),术后平均随访时间40个月(18～60个月)。结果Harris评分从术前平均34分改善为术后平均85分。根据Engh骨长入分级标准评定,术后X线表现骨性固定17例,稳定性纤维固定3例。无一例因松动需要再翻修的病例,骨皮质密度和厚度均明显增加。结论广泛微孔涂层假体在股骨干骺端和股骨髓腔同时存在缺损时,可以在相对正常的股骨远端髓腔获得轴向及抗旋转初始稳定,为骨长入和生物学固定创造条件。     

Prosthetic replacement in treatment of subcapital femoral neck fractures in the elderly

OBJECTIVE: To compare the results of femoral head replacement (FHR) and total hip replacement (THR) in treatment of subcapital femoral neck fractures (SFNF). METHODS: Between May 1987 and July 1998, 56 elderly patients (6 5-90 years; average 73.5 years) with SFNF were treated with prosthetic replacement. Six cases were treated with unipolar FHR, 18 cases with Bateman bipolar FHR, and 32 cases with Bateman bipolar THR. All domestic prostheses were installed with cement. RESULTS: There was no significant difference between the 2 groups in operating time and blood transfusion. Forty-nine patients were followed-up for an average of 5 years and 10 months. No wound infection or death was related to surgery. Complications in Group FHR were significantly higher than that i n Group THR. CONCLUSIONS: Since FHR is difficult to fit the bony acetabulum, it is only indicated for senile cases with poor conditions. However, the bi polar THR installed with cement is indicated for most elderly patients. Since th e femoral head and acetabulum can fit each other completely, it is more stable for taking weight-bearing earlier with less complications.     

部分臀中肌髂骨瓣重建青壮年股骨头颈部血供的临床研究

目的 探讨部分臀中肌髂骨瓣重建股骨头颈部血供的疗效.方法 2004年6月至2009年12月共收治20例股骨颈骨折或股骨头缺血性坏死患者,男15例,女5例;年龄25～56岁,平均38.6岁.股骨颈骨折组10例,男7例,女3例;骨折按Garden分型:Ⅱ型2例,Ⅲ型5例,Ⅳ型3例.受伤至手术时间为11～23 d,平均14.3 d.股骨头缺血性坏死组10例,男8例,女2例;股骨头缺血性坏死按Ficat分期:Ⅱ期6例,Ⅲ期4例.股骨颈骨折患者采用内固定治疗,股骨头缺血性坏死患者采用清除坏死骨、植骨治疗,两组患者均应用部分臀中肌髂骨瓣移植于股骨头颈部,以修复重建股骨头颈部血供.结果 20例患者术后获1～5年(平均3.1年)随访.股骨颈骨折组患者骨折均扶愈合,术后3个月髋关节Harris评分为81～97分,平均92分;其中优5例,良4例,差1例,优良率为90%.1例出现股骨头坏死.股骨头缺血性坏死绀患者症状明显改善,术后3个月髋关节Harris评分为73～95分,平均84分;其中优4例.良3例,可1例,差2例,优良率为70%.3例出现股骨头坏死加重,其中2例行关节置换术治疗.结论部分臀中肌髂骨瓣血供丰富、操作简单、安全可靠且术后不影响臀中肌功能,是一种重建股骨头颈部血供的有效方法.

Abstract：

Objective To study the therapeutic effect of partial gluteus medius-ilium flap in reconstruction of the blood supply to the femoral head and neck to treat femoral neck fracture and femoral head necrosis in young and middle-aged adults. Methods From June 2004 to December 2009, we treated 20 patients with femoral neck fracture and femoral head necrosis. They were 15 men and 5 women, aged from 25 to 56 years (mean, 38. 6 years). In the 10 cases of femoral neck fracture (group A), there were 7 men and 3 women, and 2 Garden type Ⅱ, 5 type Ⅲ and 3 type Ⅳ fractures. The duration from injury to surgery averaged 14. 3 days (from 11 to 23 days). In the 10 cases of femoral head necrosis (group B), there were 8 men and 2 women, and 6 ones of Ficat phase Ⅱ and 4 ones of phase Ⅲ. Group A were treated with reduction and hollow nail fixation. Group B were treated with removal of the necrotic bone and graft of iliac spongy bone.Partial gluteus medius-ilium flaps were used in both groups to reconstruct the blood supply to the femoral head and neck. Results The 20 patients were followed up for one to 5 years (mean, 3. 1 years). In group A,all fractures healed and the average Harris hip score 3 months postoperation was 92 (range, 81 to 97) .Femoral head necrosis occurred in one case. In group B, the symptoms were greatly improved and the average Harris hip score 3 months postoperation was 84 (range, 73 to 95). Deterioration was found in 3 cases, 2 of which had to sustain hip replacement. Conclusion The partial gluteus medius-ilium flap is effective in reconstruction of the blood supply to the femoral head and neck, because it keeps abundant blood supply, and is simple, safe and reliable to handle without sacrificing function of the gluteus medius.     

股骨头开瓣植骨治疗非创伤性股骨头坏死

目的报道成人非创伤性股骨头坏死的手术治疗。方法自1997年2月至1999年6月,采用经股骨头负重区开瓣死骨清除取髂骨植骨术治疗FicatⅡ～Ⅲ期非创伤性股骨头坏死10例,其中男8例,女2例;年龄30～47岁,平均39岁。Ficat分期Ⅱ～Ⅲ期,其中Ⅱa期3例,Ⅱb期5例,Ⅲ期2例。采用经股骨头负重区开瓣死骨清除,取髂骨植骨术。结果所有病人均获随访,平均随访10年,根据Harris临床评分,Ⅱa、Ⅱb期8例效果满意,优良率达85．5％。结论该手术对Ⅱa、Ⅱb期软骨面完好的病人效果优良。     

股骨干合并同侧股骨颈或股骨转子间骨折

目的探讨股骨干合并同侧股骨颈或股骨转子间骨折的临床特点和漏诊原因.方法 8例股骨干骨折分别采用普通髓内钉、钢板、带锁髓内钉固定.其中合并股骨颈、股骨转子间骨折的6例选用DHS、带锁髓内钉、空心螺钉固定;术前漏诊2例采用非手术治疗.结果 8例全部获随访,随访时间5个月～2年.股骨干及股骨颈、股骨转子间骨折均获骨性愈合,伤肢功能恢复满意.结论对高能量损伤造成股骨干骨折应常规摄骨盆前后位X线片及膝部X线片.一旦发现合并股骨颈或股骨转子间骨折,应争取早期手术内固定,效果满意.     

髓内延长修复儿童股骨骨髓炎后骨缺损

目的探讨髓内延长修复儿童股骨干化脓性骨髓炎后大段溶骨性缺损的疗效及其优越性。方法应用带锁髓内钉植入后进行骨痂延长术修复21例因化脓性骨髓炎导致的股骨骨缺损。结果随访6个月~2年,21例患者股骨骨缺损均获愈合并恢复了长度。结论植入带锁髓内钉后进行骨痂延长术是治疗儿童股骨骨髓炎后骨缺损的良好方法。