一期清创植骨融合治疗胫骨平台骨折内固定后骨髓炎

<正>2009年1月~2012年6月,我科对11例胫骨平台骨折内固定后骨髓炎患者采用一期清创植骨融合治疗,疗效满意,报道如下。1材料与方法1.1病例资料本组11例,男9例,女2例,年龄23~57岁。病程3个月~4年。左侧4例,右侧7例。10例患者合并有窦道,11例患者均合并有膝关节功能障碍。4例使用钢板内固定,7例使用     

Prophylactic external fixation and extensive bone debridement for chronic osteomyelitis

There is universal agreement that treatment of osteomyelitis should consist of debridement, obliteration of dead space, tissue coverage and antibiotic therapy, with debridement as the most important factor for therapeutic success. Four patients, 27 to 72 years old, with chronic osteomyelitis after a fracture of the femur (two), or of the tibia (two), were included in this study. The patients had already undergone 5 to 15 (mean: 9) surgical procedures. The same surgical technique was used in all of them: sinuses were carefully excised down to the bone, and necrotic bone was aggressively resected until normal bleeding was seen. A prophylactic circular external fixation frame, built on one proximal and one distal ring connected to the bone by thin wires and half pins, was used to protect and support the limbs, significantly weakened by radical debridement. Bone grafting or distraction osteogenesis was not necessary. All wounds healed without complications, and the infection did not recur. The average follow-up period was 43 months (range: 38 to 54).     

Masquelet technique with external locking plate for recalcitrant distal tibial nonunion

ObjectiveIn the present retrospective study, we aimed to analyze the results of treatment for recalcitrant distal tibial nonunion using Masquelet technique with locking plate as a definitive external fixator.MaterialsWe included 15 consecutive cases of distal tibial nonunion treated at our hospital between January 2012 and December 2015. The reconstructive procedure comprised debridement of the nonunion site, deformity correction, stabilization with an external locked plate, defect filling with cement spacer for inducing membrane formation, and bone reconstruction using a cancellous bone autograft (Masquelet technique). All patients were followed-up for at least one year.ResultsFracture union occurred in all cases after a median of 6.5 months (range, 5–12 months). Mean ankle motion ranged from 12.3 (range, 5–20) degrees of dorsiflexion to 35 (range, 5–55) degrees of plantar flexion. At the final follow-up, the median Iowa ankle score was 83 (range, 68–91). Eight patients had excellent scores, six had good scores, and one had fail score.ConclusionAlthough the current study involved only a small number of patients and the intervention comprised two stages, we consider that the used protocol is a simple and valuable alternative for the treatment of recalcitrant distal tibial nonunion.     

Two stage management of Cierny-Mader type IV chronic osteomyelitis of the long bones

IntroductionCierny-Mader (C-M) type IV chronic osteomyelitis represents a complex clinical challenge with permeation of extensive bone and soft tissue involvement. Aggressive debridement through viable tissue margin includes en bloc resection improves the odds of eradication of infection, which creates large bone and soft tissue loss in treating this type of osteomyelitis. The potentially large defects increase reconstruction problems with traditional reconstruction technique. The newly staged induced membrane technique presents length-independent, potential as an alternative reconstruction method for segmental bone defects due to type IV chronic osteomyelitis. The purpose of this study was to assess the result and related factors of C-M type IV chronic osteomyelitis treated with staged methods of aggressive debridement and induced membrane technique.MethodsFrom January 2012 to January 2014, 36 consecutive adult patients of C-M type IV chronic osteomyelitis were treated by this staged method in our clinical center with a minimum of 2-years follow-up. The clinical and imaging results were retrospectively analyzed.ResultsFive patients had a second debridement and eight needed a local flap transfer to cover the wound in the first stage. Patients formed a mean of 5.5 cm (range: 2–10.9) segmental bone defect; Sixteen patients had autograft and twenty had autograft mixed allograft in the second stage. The mean follow-up time was 29.5 months (range: 24–45). No patients required amputation. Bone union was achieved in all patients. Clinical eradication of osteomyelitis was achieved in 35 (97%) patients, 35 (97%) patients were able to walk independently, and 31patients (86%) returned to work. Patients returned to a mean of 82% (46.3%–100%) lower extremity function. Bone union time was not dependent on the length of bone defect, but associated with the infection site (p = 0.005) and age (p = 0.005).ConclusionsStaged methods of aggressive debridement and induced membrane technique seems to be a simple, reliable and effective for the treatment of C-M type IV chronic osteomyelitis. Advanced age and poor soft tissue envelope may have adverse affects and are relative contraindications. The combined assessment and management of such patients with a plastic surgeon are advocated.     

Induced membrane technique combined with two-stage internal fixation for the treatment of tibial osteomyelitis defects

IntroductionThe purpose of this study was to observe the effects of induced membrane technique combined with two-stage internal fixation in the treatment of tibial osteomyelitis defects.MethodsA retrospective analyses for 67 cases of tibialosteomyelitis defects were admitted to our department between September 2012 to February 2015, which were treated with induced membrane technique. At the first stage, implanted with a PMMA cement spacer in the defects after radical debridement and fixed with reconstructive locked plate. Bone grafting and exchanged the plate with intramedullary nail at the second stage.ResultsIn current study, all patients were followed up for 18–35 months. Sixty-six patients achieved bone union with the average radiographic and clinical healing times of 5.55 ± 2.19 and 7.45 ± 1.69 months, respectively. Seven patients required a second debridement before grafting, while four patients experienced a recurrence of infection or a relapse following second stage treatment. Twelve patients experienced either knee or ankle dysfunctions and 2 patients faced delayed wound healing. Donor site complications includes pain and infection were found in 7 and 3 patients, respectively with delayed stress fracture in 1 patient only.ConclusionsInduced membrane technique for the treatment of tibial osteomyelitis defects, seems a reliable method. The use of reconstructive locked plate as a temporary internal fixation at the first stage and exchanged with intramedullary nail at the second stage, potentially achieves good clinical efficacy. Care should be taken to restore the joint function especially in distal tibia.     

外支架与微创内固定治疗胫骨干C3.3骨折的疗效比较

[目的]比较外支架和微创内固定治疗胫骨干C3.3骨折的疗效。[方法]回顾性分析2003年1月~2013年8月既适合外支架(A组,24例)又适合微创内固定(B组,30例)治疗患者的临床资料,比较两组患者一般资料、手术时间、患肢负重时间、骨折愈合时间、患肢功能恢复(Johner-Wruhs标准)、骨愈合困难和骨不连以及感染等并发症的发生率。[结果]随访18~48个月,平均24.2个月。两组患者的一般资料、开始负重时间、骨愈合困难和骨不连的发生率以及患肢功能恢复等方面比较,差异均无统计学意义(P>0.05),外支架仅在手术时间方面优于微创内固定,而微创内固定在骨折愈合时间、感染等并发症的发生率优于外支架,差异有统计学意义(P<0.05)。[结论]尽管二者的患肢开始负重时间、骨愈合困难和骨不连的发生率以及功能恢复方面无明显差异,但微创内固定的骨折愈合时间和感染等并发症的发生率优于外支架,而且,外支架还有护理康复不便等缺陷。因此,对于既可选用外支架、又可选用微创内固定作为最终固定方法治疗的胫骨干C3.3骨折,综合而言,微创内固定优于外支架。     

骨外固定加压治疗胫骨骨折内固定失败的疗效观察

目的:评估胫骨骨折内固定失败后骨外固定的疗效.方法:43例胫骨骨折内固定失败后采用骨外固定治疗.骨外交叉穿针时,伤口感染应先彻底清创,取出已松动内固定物.稳定性骨折可直接加压固定,不稳定性骨折可借助外固定器连接螺杆牵伸使骨周组织产生一定张力能维持骨折对位、对线,同时也将骨折达到稳定固定.小腿上段软组织缺损选用腓肠肌皮瓣或腓肠肌内侧头转位,中下段用邻近筋膜皮瓣覆盖.结果:43例中32例伤口Ⅰ期愈合(79%),骨折愈合时间为4～6个月(平均5.5个月).结论:骨外穿针骨折固定牢固,方法简便,对骨端血供干扰小,能早期功能锻炼,有利于骨愈合.同时,也便于术后对伤口观察和处理.     

Masquelet与Ilizarov技术修复感染性胫骨骨缺损比较

[目的]比较Masquelet技术与Ilizarov技术治疗胫骨感染性骨缺损的临床效果。[方法]回顾性分析2017年8月—2020年8月,本院治疗的胫骨感染性骨缺损60例患者的临床资料。依据术前医患沟通结果,35例采用Masquelet诱导膜技术,25例采用Ilizarov骨搬运技术。比较两组围手术期、随访及影像结果。[结果]两组均顺利完成手术,Masquelet组中透视总次数、手术切口愈合等级均显著优于Ilizarov组（P<0.05）。早期并发症方面,Masquelet为3/35 (8.57%),而Ilizarov组为9/25 (36.00%),两组差异有统计学意义（P<0.05）。两组平均随访时间（24.54±5.86）个月。Masquelet组恢复下地行走时间及完全负重活动时间显著早于Ilizarov组（P<0.05）。术后随时间推移,两组患者VAS评分均显著减少（P<0.05）,而Iowa膝关节评分、Iowa踝关节评分、SF-36得分均显著增加（P<0.05）。术后6个月和末次随访时,Masquelet组的VAS评分显著优于Ilizarov组（P<0.05）;相应时间点,两组Iowa膝关节评分、Iowa踝关节评分、SF-36得分差异均无统计学意义（P>0.05）。影像方面,Masquelet组骨缺损影像愈合时间显著早于Ilizarov组（P<0.05）。[结论] Masquelet技术与Ilizarov技术均可有效治疗胫骨感染性骨缺损,但本研究中Masquelet技术的临床效果优于Ilizarov技术。     

超关节外固定架结合有限内固定治疗胫骨平台骨折

目的：探讨超关节外固定架结合有限内固定治疗胫骨平台骨折的临床效果和应用价值。方法：1995年1月--2001年5月，对37例胫骨平台骨折行超关节外固定架牵引复位固定，同时作有限内固定。结果：全部病例获随访8月--46月，平均21月，骨折全部愈合，优22例，良13例，可2例，优良率94％(35／37)。结论：超关节外固定架结合有限内固定是治疗胫骨平台骨折较为理想的方法。     

有限内固定结合组合式外固定架治疗Ⅲ型Pilon骨折

1997-2003年采用有限内固定结合组合式外固定架治疗Ⅲ型Pilon骨折16例，取得较为满意效果，现报告如下。     

外固定支架结合有限内固定治疗胫骨Pilon骨折

目的 探讨外固定支架结合有限内固定治疗胫骨Pilon骨折的临床疗效。方法 对22例Pilon骨折患者采用微创手术治疗,利用外固定支架结合有限内固定固定骨折。结果 22例患者均获得随访,时间6-24个月,骨折全部愈合,无感染,踝关节功能良好。结论 外固定支架结合有限内固定治疗胫骨PilonⅠ,Ⅱ型骨折是一种有效的治疗方法,具有手术切口小,对骨折端血运破坏小,固定牢固等优点。     

Comparison of two-staged ORIF and limited internal fixation with external fixator for closed tibial plafond fractures

Objective

To compare the results of two-staged open reduction and internal fixation (ORIF) and limited internal fixation with external fixator (LIFEF) for closed tibial plafond fractures.

Methods

From January 2005 to June 2007, 56 patients with closed type B3 or C Pilon fractures were randomly allocated into groups I and II. Two-staged ORIF was performed in group I and LIFEF in group II. The outcome measures included bone union, nonunion, malunion, pin-tract infection, wound infection, osteomyelitis, ankle joint function, etc. These postoperative data were analyzed with Statistical Package for Social Sciences (SPSS) 13.0.

Results

Incidence of superficial soft tissue infection (involved in wound infection or pin-tract infection) in group I was lower than that in group II (P < 0.05), with significant difference. Group I has significantly less radiation exposure (P < 0.001). Group II had higher rates of malunion, delayed union, and arthritis symptoms, with no statistical significance. Both groups resulted similar ankle joint function. Logistic regression analysis indicated that smoking and fracture pattern were the two factors significantly influencing the final outcomes.

Conclusions

In the treatment of closed tibial plafond fractures, both two-staged ORIF and LIFEF offer similar results. Patients undergo LIFEF carry significantly greater radiation exposure and higher superficial soft tissue infection rate (usually occurs on pin tract and does not affect the final outcomes).     

混合式外固定器结合有限内固定治疗胫骨远端骨折

目的探讨混合式外固定器结合有限内固定治疗胫骨远端骨折的临床价值。方法2002年3月至2005年1月,使用混合式外固定器结合有限内固定治疗胫骨远端骨折22例,男17例,女5例;年龄20～48岁,平均33岁。所有骨折均在踝上5cm之内。关节内骨折18例,按Ruedi等分型标准,Ⅱ型4例,Ⅲ型14例;关节外骨折4例。闭合损伤18例,Tornetta等根据改良Tscherne分度方法对软组织损伤进行分度,Ⅱ度16例,Ⅲ度2例;开放性骨折4例,按Gustilo分度,Ⅱ度2例,Ⅲ度2例。对关节内骨折,先采用有限切开撬拨及点状复位钳钳夹复位带有关节面的移位骨块,钢针及螺钉固定;然后再用外固定器进行固定。对关节外骨折移位,仅通过外固定器复位固定。结果术后伤口一期愈合20例,2例开放性骨折患者伤口延迟愈合,经换药后4周愈合。术后2例针道感染患者,经扩创及保持针道引流通畅8周后去除外固定器,伤口愈合。22例全部获得随访,随访时间8～28个月,平均18个月。骨折平均愈合时间3.2个月。根据Tornetta等制定的评估标准,关节内骨折18例,优10例,良5例,可3例,优良率83%。关节外骨折4例,优3例,良1例。骨折畸形愈合1例,胫骨向前成角10°。干骺端骨折不愈合1例,经二次手术行自体骨植骨加钢板内固定后骨折愈合。结论使用混合式外固定器结合有限内固定治疗胫骨远端骨折,损伤小,对软组织的干扰少,皮肤坏死率和伤口感染率明显减少,可早期活动。     

有限内固定结合外固定支架与钢板治疗胫骨平台骨折的疗效分析

[目的]探讨有限内固定结合外固定支架与钢板在胫骨平台骨折治疗中的应用及其疗效.[方法]2007年1月～2011年1月从胫骨平台骨折患者中选取58例,男38例,女20例;年龄19～ 54岁,平均(42.7±8.9)岁,按Schatzker分型:Ⅳ型17例,Ⅴ型31例,Ⅵ10例,其中外支架组31例,钢板内固定组27例,术后随访6～17个月,平均14.1个月.[结果]有限内固定结合外支架固定组平均手术时间(57.4±12.1)min,平均术中出血量(161.3±17.0) ml,平均骨折愈合时间为(12.4±1.5)周,切口感染率为6％,针道感染率为9％,Lysholm评分:优21例,占67％,良8例,占25％,差2例.钢板内固定治疗组平均手术时间(105.4±23.8) min,平均术中出血量(252.4±28.9)ml,平均骨折愈合时间为(15.5±2.5)周,切口感染率为4％,Lyshol评分:优16例,占60％,良10例,占37％,差1例.手术时间、术中出血量、骨折愈合时间,评分组间比较有显著差异(P＜0.05),切口感染率、Lysholm评分组间无显著差异(P＞0.05).[结论]两种方法治疗胫骨平台骨折,功能恢复佳,疗效满意,外固定架是目前治疗胫骨平台开放性骨折较为理想的治疗方式,尤其适用于胫骨平台骨折合并有严重的软组织损伤与缺损患者.     

MIPPO技术结合LCP内固定治疗胫骨干开放性骨折

目的探讨微创经皮钢板接骨术（minimally invasive percutaneous plate osteosynthesis,MIPPO）结合锁定加压钢板（locking compression plate,LCP）内固定治疗胫骨干开放性骨折的疗效。方法 2005年3月-2009年5月,采用MIPPO技术结合LCP内固定治疗16例胫骨干开放性骨折患者。按Gustilo分型：Ⅰ型4例,Ⅱ型12例。结果所有患者获随访23个月（12～35个月）。按照Johner-Wruhs评分,优10例,良4例,可2例,优良率为87.5%。结论 MIPPO技术结合LCP内固定治疗胫骨干开放性骨折具有创伤小、固定可靠、并发症少、临床效果满意等优点,是治疗胫骨干开放性骨折的一种良好方法。     

关节镜辅助复位内固定与切开复位内固定治疗胫骨平台骨折的疗效比较

目的:比较关节镜辅助复位内固定（ARIF）和切开复位内固定（ORIF）治疗胫骨平台骨折的疗效。方法:回顾性分析2016年1月至2018年8月华中科技大学附属协和医院骨科收治的75例胫骨平台骨折患者的资料。男58例,女17例;年龄20~54岁,平均47岁。左侧42例,右侧33例。骨折根据Schatzker分型：Ⅰ型23例...     

有限内固定结合单臂外固定架治疗胫骨开放性骨折

胫骨开放性骨折常伴有严重的软组织损伤和污染,骨折移位明显,易发生感染、钢板外露和骨不连等,处理相当棘手.2003年1月～2008年12月,我科应用有限内固定结合单臂外固定架治疗胫骨开放性骨折25例,疗效满意.     

Comparative study of internal and hybrid external fixation in tibial condylar fractures

Background

The spectrum of injuries to the tibial plateau is so great that no single method of treatment has been proven to be uniformly successful. The purposes of this study were to evaluate the clinical results, to identify the advantages and disadvantages and to take out useful conclusions of the application of the internal and hybrid external fixation in the treatment of these fractures.

Method

Sixty tibial condylar fractures, of all types, according to Schatzker’s classification were treated with open reduction and internal fixation (30 patients) or with hybrid external fixation (30 patients). The following parameters were recorded: time of surgical procedure, time of postoperative hospitalization, time of starting of weight bearing on the affected extremity, complications, and postoperative functional (according to Knee Society Score) and radiological results (according to Rasmussen’s Radiological Score). The average time of follow-up was 12 months.

Results

Neither of the two methods showed superiority regarding the duration of the surgical procedure [mean difference 4.4 ± 5.4 (min), P = NS], the postoperative hospitalization time [0.6 ± 0.7 (days), P = NS], and the radiological and functional evaluation (χ², P = NS for all comparisons). However, the internal fixation method proved to be superior to the hybrid external fixation regarding the time of starting the weight bearing [3.1 ± 0.4 (weeks), P < 0.001].

Conclusion

Internal fixation showed superiority to the time starting of weight bearing as it occurred at an earlier time than that of hybrid external by almost 3 weeks whereas no other differences were identified in the other parameters regarding patients’ rehabilitation.     

早期严重胫骨平台骨折和开放复位内固定后继发关节炎施行全膝置换术

目的　探讨采用全膝关节置换治疗早期严重的胫骨平台骨折及骨折后创伤性膝关节炎的临床效果。方法　16例严重的胫骨平台骨折和继发创伤性膝关节炎患者行全膝关节置换术,并进行临床观察。结果　平均随访 32个月(12~62个月)。根据Martin评分,从术前平均 32分 (10 ~59分 )提高到随访时平均 80分(30~92分),功能评分从术前平均 46分(25~69分)提高到随访时平均 79分 (40 ~100分 )。膝活动度从术前的平均 58°增加到随访时的平均 88°。最后功能评价:优 8例(6例为早期行全膝关节置换手术, 2例为继发性创伤关节炎者),良 7例,差 1例。结论　严重的胫骨平台骨折和手术后继发创伤性膝关节炎采用全膝置换可挽救或明显改善功能,缓解疼痛。严重的胫骨平台骨折早期全膝关节置换临床效果优于继发创伤性膝关节炎。