一期开放植骨治疗感染性骨折不愈合

目的 探讨一期开放植骨治疗感染性骨折不愈合的手术方法及要点,总结疗效,提高手术成功率.方法 对67例感染性骨折不愈合或骨缺损进行扩创、一期开放植骨,术后伤口深部置管冲洗、加强局部换药,静脉滴注敏感抗生素.结果 67例均获随访,时间10～48个月.其中52例创面于8～20周愈合,5例于术后6周行游离植皮闭合创面.平均8个月(4～14个月)骨折达骨性愈合.3例出现窦道渗液.结论 一期开放植骨治疗感染性骨折不愈合或骨缺损是一种积极、简单、实用、可靠的手术方法.     

自体骨植骨结合微型钢板治疗掌指骨粉碎性骨折

目的探讨应用自体骨植骨结合微型钢板治疗掌指骨粉碎性骨折的临床疗效。方法对51例58处骨折（掌骨骨折37例43处,指骨骨折14例15处）分别行切开复位、微型钢板内固定结合自体骨植骨手术治疗。结果所有患者术后随访4-12个月,切口均一期愈合,骨折均解剖复位、骨性愈合,无旋转及成角畸形．关节活动范围佳。根据TAF评分,优40例,良8例,羞3例,优良率为94．1％。结论对于复杂的伴有骨缺损的掌指骨粉碎性骨折,应用自体骨植骨结合微型钢板治疗具有成骨能力强、无免疫排斥反应、固定牢固可靠、早期功能锻炼等优点,疗效确切可靠。     

抗生素骨水泥间置器治疗髓内固定术后骨髓炎合并骨不连

目的探讨抗生素骨水泥间置器治疗髓内固定术后骨髓炎合并骨不连的临床疗效。方法 2002年6月-2006年5月,收治12例行切开复位交锁髓内钉内固定术后骨髓炎合并骨不连患者。男8例,女4例;年龄26～53岁,平均40.2岁。骨折部位:胫骨7例,股骨5例。髓内固定术后2周内感染7例,3个月内感染5例。患者于感染发生后1～24个月入院,平均5个月。细菌培养10例呈阳性,2例呈阴性。白细胞计数、红细胞沉降率、高敏C反应蛋白均高于正常值。一期手术取出内固定物,髓内插入抗生素骨水泥间置器临时固定;3～6个月待感染控制后,二期手术取出间置器,行自体髂骨植骨锁定钢板内固定术。结果患者两期手术切口均Ⅰ期愈合,无早期相关并发症发生。二期术后患者均获随访,随访时间24～48个月,平均34个月。二期术后3个月红细胞沉降率、白细胞计数以及高敏C反应蛋白均正常。X线片复查,骨折均在二期术后10～14周达临床愈合,平均12周。除1例患者膝关节屈曲约90°外,其余患者下肢功能均恢复正常。随访期间均无感染复发。结论采用抗生素骨水泥间置器临时固定可以有效控制感染,待感染控制后二期手术取出间置器行植骨内固定,是治疗髓内固定术后骨髓炎合并骨不连的有效方法之一。     

一期前路病灶清除植骨融合内固定术治疗下颈椎化脓性骨髓炎

目的:探讨一期前路病灶清除、感染椎体次全切、自体髂骨植骨融合、钛板固定术治疗下颈椎化脓性骨髓炎的疗效。方法:2004年1月至2009年6月共收治17例下颈椎化脓性骨髓炎患者,男性14例,女性3例;年龄42~78岁,平均56.5岁。17例患者均有颈痛,9例伴发热,6例伴脊髓损伤,5例伴神经根性损伤。影像学检查13例有硬膜外脓肿形成,4例椎前脓肿形成伴椎体广泛破坏。均于广谱或敏感抗菌素治疗7~14d后行一期前路病灶清除、感染椎体次全切除、自体髂骨植骨融合、钛板内固定术。术后抗菌素治疗12~14周,定期复查血白细胞计数、血沉和C反应蛋白、颈椎正侧位X线片及CT,术后12个月行MRI检查。结果:手术时间50~150min,平均110min,术中无血管及神经损伤发生;术后2例切口浅层感染,经换药后愈合,无食管漏等严重并发症发生。所有患者于术后1周内颈痛缓解,体温恢复正常。13例于术后12周前白细胞计数、血沉、C反应蛋白均降至正常;4例白细胞计数正常,但血沉及C反应蛋白至术后9个月才降至正常。所有患者于术后12个月复查CT,16例植骨融合;1例融合失败,24个月随访时假关系形成。随访18~24个月,平均20.3个月,术前有脊髓和神经根损伤患者神经功能均完全恢复正常,感染均无复发。结论:在规范、有效、充分的围手术期抗菌素治疗期间行一期前路病灶清除、感染椎体次全切除、自体髂骨植骨融合、钛板内固定术是治疗下颈椎化脓性骨髓炎的有效方法。     

一期开放松质骨植骨治疗感染性骨缺损的实验研究

目的 明确感染性骨折不愈合清创术后一期开放松质骨植骨的可行性，了解在感染的环境条件下，开放松质骨植骨愈合的组织病理变化过程。方法 新西兰白兔62只，制备双侧桡骨中段骨折，骨折端注射金黄色葡萄球菌制作感染性骨折模型，4周后经过x线片、病理、细菌培养来确定是否为感染。将确认为感染性骨折的47只兔，一侧桡骨行清创术并制造长度为1cm骨折端骨缺损，一期行自体松质骨植骨，伤口开放不闭合。另一侧桡骨不植骨为对照组。于第3、7天，第2、4、6、8、10、12周摄X线片，取材行EDTA脱钙，常规HE染色观察局部组织学变化。术后14周处死剩余兔取材行EDTA脱钙，常规HE染色组织病理检查及统计学分析。结果植骨术后第3、7天病理示绝大部分植骨条坏死。2周显示有新生骨痂生长。4周骨折愈合率：植骨组为20%，对照组为7％。6周骨愈合率分别为60％和20％。8～12周骨折愈合率分别为87％和67％。组织病理学显示在骨折愈合的不同阶段均可见缺损部位的炎症灶内有新骨形成和对松质骨条的替代过程。感染率：植骨组为13％，对照组为7％。骨痂面积：治疗组明显优于对照组(P＜0．01)。结论 一期开放植骨是治疗感染性骨缺损的一种简便、有效的方法。     

改良髂骨移植结合抗生素骨水泥技术治疗合并大段骨缺损指骨骨感染疗效分析

目的分析改良髂骨移植结合抗生素骨水泥技术治疗合并大段骨缺损指骨骨感染的临床疗效。方法回顾性分析2015年3月-2019年12月收治的7例合并大段骨缺损指骨骨感染患者的临床资料,通过改良髂骨移植结合抗生素骨水泥技术进行治疗。第一阶段行坏死感染骨的彻底清除,并放置抗生素骨水泥棒假体形成膜诱导;第二阶段在诱导膜内植入张力髂骨段及米粒松质骨块联合植骨行牢靠固定,可在术后早期去除内固定并行手功能康复训练。结果术后7例均获得门诊随访,随访时间6~12个月,平均(9±1.5)个月。第一阶段手术部伤口6例一期愈合,1例经再次扩创后二期愈合,第二阶段手术手部伤口均一期愈合。7例髂骨供区伤口均一期愈合,无股前外侧皮神经损伤。7例第二阶段手术后均定期复查X线片,无明显髂骨段植骨吸收,去除内固定时间为术后6~8周,平均(7±0.5)周,骨折愈合时间为术后8~12周,平均(10±0.5)周。末次随访均采用中华医学会手外科学会上肢功能关于手功能评定试用标准进行评价:优3例,良2例,可2例,优良率71.4%。结论改良髂骨移植联合抗生素骨水泥技术治疗合并大段骨缺损的指骨骨感染,可提高植骨后骨架支撑的稳定性,缩短移植骨的爬行替代过程和固定周期,为更好的手功能恢复提供有利条件。     

自制抗生素骨水泥髓内钉结合钢板外固定治疗胫骨感染性骨不连的疗效分析

目的分析自制抗生素骨水泥髓内钉结合锁定钢板(LCP)外固定治疗胫骨感染性骨不连的手术技术和临床效果。方法回顾性分析本院自2005-03—2014-07诊治的13例胫骨感染性骨不连。取出内固定、清创、扩髓并置入自制抗生素骨水泥髓内钉,6~12周后改用LCP外固定+自体骨、Wright人工骨混合万古霉素植骨。结果 13例均获得随访13~24个月,平均15.6个月。所有患者感染均得到控制,在拆除抗生素骨水泥髓内钉时细菌培养均为阴性,血常规、红细胞沉降率、C反应蛋白正常。受伤至抗生素骨水泥髓内钉置入的时间为8~12个月,平均10.3个月。抗生素骨水泥髓内钉放置时间为6~12周,平均8.3周。骨折最终均愈合,其中1例延迟愈合,LCP外固定后骨折愈合时间平均5.8个月。末次随访时根据Olerud-Molander评分标准评定踝关节功能:优10例,良3例。结论自制抗生素骨水泥髓内钉结合LCP外固定治疗胫骨感染性骨不连简单实用、效果确切,值得推广。     

抗生素骨水泥珠链结合外固定架治疗感染性骨折不愈合

目的：探讨抗生素骨水泥珠链植入结合外固定架固定治疗感染性骨折不愈合的疗效。,方法：回顾分析22例感染性骨折不愈合患者,男20例,女2例;年龄21±74岁,平均（34．7±11．6）岁。骨折部位：股骨粗隆间3例、股骨干6例、股骨髁上2例、胫骨干9例、肱骨干2例。治疗过程分为3个步骤：先取出内固定物,清创后植入抗生素骨水泥珠链,Ⅰ期闭合伤口;1周后再次清创,更换抗生素骨水泥珠链,行外固定架固定;3个月后取出抗生素骨水泥珠链,取髂骨植骨。结果：随访15～28个月,平均（19．98±4．16）个月。1例胫骨干骨折和1例股骨粗隆问骨折患者分别于植骨术后2、3个月感染复发,其余20例患者感染控制良好。22例患者骨折全部愈合,愈合时间为植骨术后8-24周,平均（15．09±4．13）周。结论：彻底清创、抗生素骨水泥珠链植入结合外固定架固定及Ⅱ期植骨是治疗感染性骨折不愈合简单而有效的方法、     

复合骨环外固定器治疗感染性骨缺损22例

目的：应用复合骨环植骨和骨外固定器加压外固定治疗感染性骨缺损。方法：对22例感染性骨缺损患的应用有效抗生素，彻底清除病灶的基础上，依骨缺损的长度一期支撑植骨，植骨材料为同种异体冷冻干燥四肢长骨皮质骨环加自体松质骨（简称复合骨环），修复创面后用骨外固定器加压固定。结果：所有病例均于术后3-14个月。平均7个月达到骨愈合，感染得到彻底控制，伤口愈合，并保证了肢体长度的均衡。结论：采用上述综合治疗措施。简化和缩短了治疗过程，一期植骨避免了为矫正肢体短缩而再行肢体延长术。复合骨环，骨外固定器应用于感染性骨缺损显示出独特的优越性。     

一期开放植骨治疗感染性骨折和骨不愈合

目的 报道一期开放植骨治疗感染性骨折和骨不愈合的手术疗效。方法 对２０例感染性骨折及骨折不愈合的表除坏死及感染的组织，用双平面外固定架或石膏管型固定骺折端，一期植入带皮持的松质骨并开放伤口，足量应用敏感抗生素。结果 平均随访３．５年，２０例中１９例骨折愈合，无感染复发。结论 与传统方法相比缩短了疗程，简化了治疗方法。     

Antibiotic-impregnated autogenic cancellous bone grafting is an effective and safe method for the management of small infected tibial defects: a comparison study

OBJECTIVE: Bone grafting plays an important role in reconstructing infected tibial nonunions. The effects of antibiotic-impregnated bone grafting in infection elimination and bone incorporation was reported in this retrospective study. METHODS: Ninety-six patients treated for infected tibial nonunions were evaluated. These patients were managed with local antibiotic bead therapy and staged antibiotic-impregnated autogenous cancellous bone graft or pure autogenous cancellous bone graft. Patients were randomized to antibiotic-impregnated bone grafting or bone grafting-only groups on the basis of whether the admission date was odd or even. Patients were divided into two groups (antibiotic-impregnated bone grafting group and pure cancellous bone grafting group), according to the procedure used in preparing the bone grafts. The antibiotic-impregnated bone grafting group included 37 men and 9 women whose average age was 36 years (range, 17 to 72 years). The average follow-up period was 4.8 years. By using the Cierny-Mader staging classification of chronic osteomyelitis, 32 of 46 patients (70%) were stage 4A, and 14 of 36 patients (30%) were stage 4B. The pure cancellous bone grafting group included 39 men and 11 women whose average age was 37 years (range, 18 to 72 years). The average follow-up period was 4.5 years (range, 4 to 6 years). Thirty-nine of 50 patients (78%) were stage 4A, and 11 of 50 patients (22%) were stage 4B. The bone defects in both groups ranged from 2 to 4 cm. RESULTS: Wound healing and bony union were achieved in the antibiotic-impregnated bone grafting group. Only two patients had recurrent infections. The infection arrest rate was 95.6%. However, 9 of 50 patients in the pure cancellous bone grafting group had recurrent infections. The infection arrest rate was 82%. The antibiotic-impregnated bone grafting group had significantly superior results (95.6% vs. 82% chi2 test, p < 0.05) in infection elimination than the pure cancellous bone grafting group. CONCLUSION: After 4 to 6 years of follow-up, our results suggest that the use of impregnating antibiotics have no adverse effects on autogenic cancellous bone graft incorporation and could help to eliminate infection effectively.     

Fibula and tibia fusion with cancellous allograft vitalised with autologous bone marrow: first results for infected tibial non-union

Background and aims  Autogenous bone grafting has been used in reconstructing bone defects and in stimulating fracture healing, producing high healing rates in the treatment of infected tibial non-unions. A novel therapeutic alternative is now available known as “vitalised allograft”, a cancellous bone graft procured from femoral heads from living human donors and “vitalised” through the injection of autologous bone marrow. The aim of this study is to summarise the initial results of the fibula and tibia fusion using vitalised cancellous allograft in the treatment of infected tibial non-unions. Patients and methods  We initiated a follow-up of 15 prospective non-randomized patients who received a vitalised allograft in the treatment of infected tibial non-unions in order to produce bony union. The patients included 13 men and 2 women with an average age of 48 years. All patients received a multi-stage surgical approach. After establishing an infection-free environment, allogenic cancellous bone grafting was performed, intended as the final surgical procedure in fibula and tibia fusion. Our follow-up included a clinical and radiographic investigation of the calf in four planes. We analysed union-rate and time required for bony consolidation, as well as recurrent infections, re-fractures, potential graft-resorption, and time needed for graft and bone remodelling. Results  With an average follow-up of 17.1 months, infection control was obtained in 14 of 15 patients, producing an infection arrest rate of 93.3%. Radiographs indicated consolidation in 11 out of 15 cases, with a union rate of 73.3%. Bone union was achieved on average in 17.1 weeks. Conclusions  Fibula and tibia fusion with allogenic cancellous bone grafting, vitalised through autogenic bone marrow, could well become an innovative treatment option for infected tibial non-unions. We need, however, to analyse a higher number of cases over a longer follow-up period in order to assess more accurately recurrent infections and re-fractures.     

Role of locking plates in treatment of difficult ununited fractures: a clinical study

Objective:To present our experience in treatment of difficult ununited long bone fractures with locking plate.Methods:Retrospective evaluation of locking plate fixation in 10 difficult nonunions of lon...     

Results of treatment of infected humeral nonunions: the Mayo Clinic experience

Between 1987 and 2001, 15 infected humeral nonunions were treated of which nine were distal, four were proximal, and two were midshaft. One patient was lost to followup. The remaining 14 patients were followed up for a mean of 37 months (range, 8-156 months). All patients were treated with debridement and intravenous antibiotics. Ten patients had surgical attempts at achieving bony union: external fixation (four patients), plating (two patients), external fixation and plating (two patients), tension band wiring (one patient), and bone grafting with shoulder spica casting (one patient). Three patients were treated definitively with a functional brace because of low functional demands and one patient had resection arthroplasty followed by delayed total elbow arthroplasty. Of the 10 nonunions treated with surgical attempts at achieving bony union, only seven healed. None of those nonunions in patients treated with a functional brace healed. At final followup, 12 of 14 patients had minimal or no pain and two patients had moderate pain, both with ununited fractures. Complications included one seroma and two cases of posttraumatic elbow stiffness for which the patients required capsular release. This study documents the challenges in achieving bony union in the infected humeral nonunion in contradistinction to the predictable union rates reported for aseptic humeral nonunions. Although pain relief was predictable in most patients, functional results generally were poor and bony union was difficult to obtain.     

Infected nonunions of long bones of the upper extremity: staged reconstruction using polymethylmethacrylate and bone graft impregnated with antibiotics

This case series evaluates 12 patients presenting posttraumatic infected nonunions affecting long bones of the upper extremity, treated with staged reconstruction using polymethylmethacrylate spacers with antibiotics in the first stage and bone graft impregnated with antibiotics in the definitive surgical procedure. Five nonunions affected the humerus, four the ulna and three the radius. All nonunions were atrophic. Patient’s age averaged 35.9 years. The size of the bony defect averaged 2.8 cm. Time between original trauma and revision surgery averaged 9.6 months. Follow-up averaged 19 months. All nonunions healed after an average of 5 months. DASH score at last follow-up averaged 15 points. Although two surgical procedures are needed, one to cure infection and another to achieve bony union, this approach for posttraumatic infected nonunions of long bones of the upper extremities represents a valid treatment alternative.     

Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity

Treatment of patients with posttraumatic infected nonunions or highly contaminated open fractures with segmental bone loss of the long bones of the upper extremity is demanding. The use of a 2-stage reconstruction technique, being the first stage characterized by thorough debridement, copious lavage, soft tissue coverage, and placement of a cement spacer with antibiotics at the infected site, and the second stage by cement spacer removal, internal fixation, and placement of bone graft with local antibiotics, is presented. We carried out this technique in 20 cases, in 12 cases the cement was molded to fit the defect and placed as a solid interposition mass, in 3 cases it was placed lateral to the affected bone, and in the remaining 5 cases a Rush nail covered with a cement mantle was used. Follow-up averaged 18 months. All nonunions and fractures healed after an average of 5 months. Disabilities of the arm, shoulder, and hand (DASH) score at last follow-up in nonunions averaged 14 points and 21 points in bone losses. Although generally 2 surgical procedures are needed, 1 to cure or prevent infection and another to achieve bony union, this approach for complex open fractures with segmental bone loss and for infected nonunions of the long bones of the upper extremity represents a valid treatment alternative.     

1，2伸肌室间支持带上动脉为蒂骨瓣移植治疗舟骨骨折不愈合

目的探讨1,2伸肌室间支持带上动脉（1,2 intracompartmental supraretinacular artery 1,2 ICSRA）的解剖特点及治疗舟骨骨折不愈合的临床疗效。方法2008年7月-2010年9月共收治确诊的舟骨骨折不愈合患者11例,均采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbert螺钉内固定进行治疗,观察患者的骨折愈合情况及并发症,并以DASH评分对腕关节功能进行评价。结果所有患者均获6～33个月随访,平均17个月。11例患者均获骨性愈合,骨折愈合时间为9～14周。平均12周。术后6个月DASH评分平均为6．5分,腕关节功能接近正常。结论慎重的选择适应证,熟悉相关解剖知识,仔细的手术操作,采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbeft螺钉内固定治疗舟骨骨折不愈合可取得满意的临床疗效。     

Resistant nonunions and partial or complete segmental defects of long bones. Treatment with implants of a composite of human bone morphogenetic protein (BMP) and autolyzed, antigen-extracted, allogeneic (AAA) bone.

Twenty-five patients with resistant nonunions including partial or complete segmental defects were treated with a composite alloimplant of human bone morphogenetic protein (h-BMP) and autolyzed, antigen-free, allogeneic bone (AAA). The series consisted of 16 females and nine males; average age was 45 years. Preoperative symptoms averaged 30 months (range, five to 83 months); 22 of 25 patients had failed multiple attempts at electrical stimulation. Twenty-three of 25 patients had an average of three prior failed surgical attempts at union (range, one to ten). There were ten segmental defects with an average length of 4 cm (range, 2-9 cm). The composite implant was incorporated as an onlay in 15 extremities and as an inlay graft supported by internal fixation in ten extremities. Seven patients received supplementary autogeneic cancellous bone grafting. Average healing time was six months (range, three to 14 months). Average follow-up time was 21 months (range, five to 82 months). Functional results were rated as excellent, 14; good, five; and fair, five. One failed to unite because of a recurrent infection. Union was obtained in 24 of 25 patients. There were five failures of the original operation that required reoperations; union eventually occurred in four of five extremities by repeat composite grafting and replacement of the failed internal fixation. Bony union between host bone and the composite implant began at an average of eight weeks postoperatively. Present results indicate that h-BMP/AAA composite implants represent adjunctive treatment of difficult nonunions. The h-BMP/AAA composite implants may be implanted in either partial or complete segmental defects of long bones.(ABSTRACT TRUNCATED AT 250 WORDS)     

自体松质骨加骨髓移植治疗陈旧性腕舟骨骨折不连的临床研究

目的观察自体松质骨加骨髓移植治疗陈旧性腕舟骨骨折不连及近端坏死型腕舟骨骨折的临床效果。方法随机选择14例陈旧性腕舟骨骨折不连患者，搔刮舟骨远、近两端死骨，保留皮质骨壳，取自体松质骨（桡骨远端或髂骨）移植至舟骨远、近两端，舟骨复位后交叉克氏针固定。髂骨内抽取自体红骨髓5ml，快速、加压注入舟骨骨折部位。术后6周开始，每周拍摄计算机X线片（CR-X）一次，至骨折愈合，并记录骨折愈合及恢复工作时间。结果术后随访10周～5年，14例陈旧性腕舟骨全部愈合，骨折愈合时间为8～12周，平均9．3周。13例腕关节活动度达到健侧腕部标准，活动时无疼痛，恢复了原来工作；1例较术前有改善，但腕关节活动未达健侧标准，且活动时疼痛。结论自体松质骨加自体骨髓移植治疗陈旧性腕舟骨骨折不连，较传统治疗方法，缩短了骨折愈合时间，提高了治愈率，保留了原解剖结构和生物力学特性，是一种有效的治疗方法。