股骨近端骨纤维结构不良的外科治疗

目的 探讨股骨近端骨纤维结构不良(fibrous dysplasia,FD)的有效治疗方法.方法 2001年1月-2006年1月,收治57例股骨近端FD患者.男29例,女28例;年龄8～50岁,平均22岁.单侧55例,双侧2例.单骨型35例,多骨型22例.按Guille分型:A型34例,B型8例,C型8例,D型7例.股骨近端FD伴髋内翻畸形14例,颈干角55～100°,平均78°,股骨相对长度较对侧短缩2.0～4.5 cm,平均3.2 cm.病程4个月～lO年,平均2.3年.股骨近端病变范围小、骨强度佳者,采用单纯病变刮除、打压式同种异体植骨14例;病变范围大、骨强度不佳者,采用病变刮除、打压式同种异体骨植骨、内固定43例,其中伴髋内翻畸形者,同时行外翻或内移外翻截骨矫形术.结果 术后57例均获随访,随访时间6个月～5年,平均2.8年.2例单纯病变刮除打压式植骨A型患者术后复发,经再次病变刮除、植骨、重建钉内固定后治愈;1例病变刮除打压式植骨联合内固定A型患者动力髁螺钉内固定物松动,经更换为重建钉后治愈.植骨区术后3个月均有轻度骨吸收,10～14个月植骨区骨结构渐致密.股骨近端FD伴髋内翻畸形股骨力线均完全矫正,截骨面均达骨性愈合,髋内翻畸形的颈干角矫正为95～130°,平均122°,股骨相对长度矫正后较术前延长1.8～3.6 cm,平均2.7 cm.术后49例患者步态正常;3例扶单拐行走,5例不扶拐跛行.52例疼痛消失,5例A型疼痛明显减轻.结论 病变刮除、髓腔内打压式植骨可有效恢复骨量、促进骨愈合及防止病理性骨折;病变范围大或骨强度不佳者,须联合有效内固定:伴有髋内翻畸形者,应同时截骨恢复股骨生物力线.     

股骨近端纤维结构不良的手术治疗

目的探讨股骨近端纤维结构不良的手术治疗方式。方法对19例股骨近端纤维结构不良的不同手术治疗方式及术后疗效进行回顾性分析。结果1例术后3d引流管口渗出血清样物质，加强抗感染、营养支持及换药处理后愈合。19例均获随访，时间13—58个月。复查X线片见缺损修复区内有新骨生成改变，骨折处骨愈合；1例术后20个月因外伤致股骨转子下内固定物旁骨折再次手术发现肿瘤复发，行再次刮除植骨内固定术后14个月愈合；除1例未行内固定的病例外，余患者术后患肢功能均得到良好恢复，8—12个月可弃拐行走。结论股骨近端纤维结构不良应积极手术治疗，在彻底刮除病变和充分植骨的基础上，强调内固定的应用。     

股骨纤维结构不良伴重度内翻畸形的外科治疗

[目的]探索一种治疗股骨纤维结构不良伴重度髋或及股内翻畸形的有效外科方法。[方法]自2000年8月~2005年7月共收治13例14个股骨纤维结构不良伴重度髋或及股内翻畸形患者,均采用股骨单处或双处外翻截骨矫形、病灶刮除、打压植骨、重建钉内固定治疗。[结果]所有病人随访8~41个月(平均21个月)。X线显示,14个股内翻畸形股骨力线几乎完全矫正;髋内翻畸形的颈干角由术前平均75°(55°~100°)矫正为术后120°(95°~130°);股骨相对长度由术前平均短缩3.4 cm(2.0~4.5 cm),矫正后延长2.8 cm(1.8~3.6 cm);14个股骨共19处截骨面均达骨性愈合。所有患者植骨区于术后3个月均有不同程度的吸收,术后10~14个月最明显。术前4例患者扶双拐行走,2例扶单杖行走,5例病理性骨折不能行走,2例不扶杖跛行;术后11例患者不扶拐行走,2例扶单杖行走。11例患者疼痛消失,2例疼痛明显减轻。所有患者无感染、畸形进展及再骨折。[结论](1)该治疗方法能够有效的矫正股骨畸形,恢复股骨生物力学力线,改善患肢功能;(2)能有效的去除病变,防止复发;(3)股骨髓腔内大量打压式植骨是促进骨愈合及防止病理性骨折的关键。     

植骨内固定治疗成人股骨近端纤维结构不良的临床研究

目的探讨成人股骨颈纤维结构不良的手术治疗效果。方法采用病灶彻底刮除、自体和同种异体骨植骨、动力髋螺钉（DHS）／股骨近端髓内钉（PFN）内固定治疗13例成人股骨近端纤维结构不良，对治疗方式及术后疗效进行回顾性分析。结果所有患者术后早期不负重活动，平均3个月骨折愈合，随访18～48个月，症状缓解，X线片显示骨皮质增厚，病损植骨区内有结实的骨化；仅4例有部分骨吸收，无临床复发。结论彻底刮除病灶、带皮质的自体和同种异体骨植骨加DHS／PFN内固定是治疗成人股骨近端纤维结构不良可靠的方法，疗效满意。     

扩大刮除术治疗软骨母细胞瘤的疗效观察

目的探讨扩大刮除术治疗软骨母细胞瘤的疗效。方法回顾性分析2011年1月—2016年5月,采用病灶扩大刮除术治疗的37例软骨母细胞瘤患者临床资料。男24例,女13例;年龄12~30岁,中位年龄17岁。原发患者32例,复发患者5例。患者均以局部疼痛为首发症状。病程2~8个月,平均4.9个月。病变部位:股骨远端10例,股骨近端7例,胫骨近端9例,肱骨近端5例,髌骨2例,距骨1例,跟骨1例,骨盆2例。根据良性骨肿瘤的Enneking分期均为3期。病灶长径为1.2~6.9 cm,平均3.2 cm。19例病变累及骺板。结果术后切口均Ⅰ期愈合,无相关并发症发生。患者均获随访,随访时间12~76个月,平均40.5个月。末次随访时国际肌肉骨骼肿瘤学会(MSTS)评分为(27.5±1.4)分,与术前(18.5±1.9)分比较,差异有统计学意义(t=23.462,P=0.000)。术后5个月复发1例(2.7%)。X线片复查示,6例出现部分植骨吸收,但植骨区关节面未见明显塌陷。3例骺板受累且病变位于膝关节周围者,出现肢体短缩畸形,但无内外翻畸形,膝关节活动未受影响。结论扩大刮除术治疗软骨母细胞瘤具有术后复发率低、肢体功能良好、骨骼发育畸形发生率低等优点,是治疗该疾病较好方法。     

Taylor空间支架矫正创伤后膝内、外翻畸形

  目的 探讨Taylor空间支架（Taylor Spatial Frame, TSF）矫正创伤后膝内、外翻畸形的临床疗效和精确度。方法 回顾性分析2006年6月至2010年12月,采用TSF矫正26例创伤后膝内、外翻畸形患者的病例,男19例,女7例;年龄19～62岁,平均39岁;创伤后膝内翻畸形20例,膝外翻畸形6例。21例行胫骨高位截骨,3例行股骨髁上截骨,2例同时行股骨髁上和胫骨高位截骨。安装TSF、测量支架的安装参数后截骨。术后7～10 d,根据电子处方,每天3次调节TSF支架上的可伸缩螺杆的长度,调节范围为0～3 mm。结果 经过7～35 d调节,20例畸形得到一次性完全矫正,患肢的胫骨、股骨力线恢复,肢体的成角、旋转和短缩畸形均得到矫正。6例尚残存轻微成角和短缩畸形,经第二次4～10 d的支架调整,畸形矫正。截骨处新骨生成和矿化良好,术后2.5～6.0个月去除外固定架。术后随访12～60个月,畸形无复发。术后11例发生针道感染,经应用敏感抗生素治疗,感染控制。1例去除外固定架后1.5个月发生股骨远端截骨处再骨折,经保守治疗骨折愈合。无一例患者发生血管神经损伤和继发性马蹄足畸形。结论 TSF矫正创伤后膝内、外翻畸形疗效确切,精确度高。     

颗粒打压植骨辅钢板内固定治疗股骨近端骨肿瘤或瘤样病损

目的 :评价颗粒打压植骨辅钢板内固定治疗股骨近端骨肿瘤或瘤样病损的临床可行性。方法 :2013年1月至2016年1月治疗股骨近端骨肿瘤或瘤样病损26例,均未发生病理性骨折,男12例,女14例;年龄8~62岁,平均34.2岁。病理结果:纤维结构不良11例,骨孤立性骨囊肿7例,骨巨细胞瘤3例,动脉瘤样骨囊肿3例,非骨化性纤维瘤1例,良性纤维组织细胞瘤1例。术前未进行病灶活组织检查,术后送慢病理,手术采取颗粒打压植骨辅钢板内固定。结果:26例均随访至恢复日常生活,随访时间8~42个月,平均25个月。参照骨与软组织肿瘤协会(MSTS)进行功能评估。术后末次复查股骨正侧位X线片,植骨边缘及植骨体部未见低密度影,植骨区骨愈合良好,所有患者未见复发及转移病灶,内固定物无松动、变形。髋关节功能恢复良好,所有患者无再骨折和畸形进展。结论:股骨近端肿瘤复发与病灶刮除植骨技术有关,刮除后采用化学、物理方法处理消灭残留的肿瘤细胞,利用此方法可以获得疾病的长期治愈,减少复发,恢复髋关节功能。     

儿童股骨近端肿瘤合并病理骨折的手术治疗

目的：总结儿童股骨近端病理骨折手术治疗的经验教训。方法：22例14岁以下的患者接受不同方式的手术治疗。平均随访35.4个月。结果：病变刮除、瘤壁残留肿瘤组织灭活,植骨术仍是目前治疗良性病变常用的手术方法,应避免损伤股骨头骨骺。多病灶型骨纤维结构不良经外翻截骨及内固定后可维持正常的颈干角和髋关节功能。肿瘤复发,植骨吸收是常见的并发症,结论：儿童股骨近端肿瘤合并病理骨折的手术治疗应考虑到病变的性质、侵袭范围、股骨近端的应力分布及儿童骨骺未闭合等特点。     

股骨近端外展截骨术治疗股骨颈或股骨粗隆间骨折后髋内翻畸形

目的探讨股骨近端外展截骨术治疗股骨颈或股骨粗隆间骨折后髋内翻畸形的临床疗效。方法回顾性分析自2009-01—2016-12采用股骨近端外展截骨术治疗的11例股骨颈或股骨粗隆间骨折后髋内翻畸形,术前均行髋关节X线片及CT检查,测量患髋颈干角及前倾角。结果 11例均获得随访,随访时间平均3(2～8)年。10例术后颈干角110°,平均126°;1例术后颈干角为103°。8例术后前倾角为10°～15°,平均13.5°;3例术后前倾角为5°～10°,平均8°。术后患肢短缩0.2～2.4 cm,平均1.1 cm。术后下肢短缩畸形获得不同程度矫正,其中4例患肢短缩1 cm,5例患肢短缩1～2 cm,2例患肢短缩2 cm。术后患肢短缩在2 cm以内患者步态于术后1年内得到不同程度改善。术后6～12个月所有患者髋部疼痛症状较术前不同程度缓解。结论股骨近端外展截骨术治疗股骨颈或股骨粗隆间骨折后髋内翻畸形可明显改善股骨颈干角、股骨近端旋转及下肢短缩畸形,能有效缓解患髋疼痛症状,改善患者步态,临床疗效满意。     

经Watson-Jones入路股骨近端防旋髓内钉联合病灶刮除植骨治疗股骨近端良性病变

目的探讨经Watson-Jones入路股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)联合病灶刮除植骨治疗股骨近端良性肿瘤和瘤样病变的可行性,评估治疗效果。方法回顾分析2008年1月—2015年1月采用经Watson-Jones入路PFNA联合病灶刮除植骨治疗的38例股骨近端良性病变患者临床资料。其中男24例,女14例;年龄15～57岁,平均28岁。病理类型:纤维结构不良20例,骨囊肿7例,动脉瘤样骨囊肿5例,骨巨细胞瘤3例,内生软骨瘤2例,非骨化性纤维瘤1例。临床表现:髋关节疼痛19例,病理性骨折12例,肢体短缩、髋关节内翻畸形4例,出现原有病灶复发3例。记录手术时间、术中出血量以及术后完全负重时间。随访摄X线片及三维CT,了解植骨融合情况及内固定物位置,采用疼痛视觉模拟评分(VAS)评价疼痛程度,国际骨与软组织肿瘤协会(MSTS93)评分标准评估下肢功能,Harris评分评估髋关节功能。结果手术时间为130～280 min,平均182 min;术中出血量为300～1 500 mL,平均764 mL。术后3例出现切口脂肪液化,均经正规换药顺利愈合,未造成深部感染;其余患者切口均Ⅰ期愈合。所有患者均于术后2～4周开始部分负重,完全负重时间为3～6个月,平均4.2个月。38例均获随访,随访时间24～108个月,中位随访时间60个月。影像学检查提示植骨均融合,融合时间为8～18个月,平均11.4个月。随访期间无病理性骨折、股骨头缺血性坏死、关节脱位、内固定物松动断裂等并发症发生,无肿瘤复发和远处转移。末次随访时,VAS评分、MSTS93评分和Harris评分均较术前显著改善,差异有统计学意义(P0.05)。结论经Watson-Jones入路刮除植骨后联合PFNA内固定治疗股骨近端良性病变,能够在彻底清除病灶的同时获良好力学稳定性,且术后并发症少,是一种安全有效的治疗方法。     

Multiple osteotomies and intramedullary nailing with neck cross-pinning for shepherd's crook deformity in polyostotic fibrous dysplasia: 7 femurs with a minimum of 2 years follow-up

Background In polyostotic fibrous dysplasia, particularly in lesions of the proximal femur, pathological fracture and coxa vara deformity (including shepherd's crook deformity) are likely to develop and progress.

Patients and methods In 7 femurs with shepherd's crook deformity (5 patients), we performed intramedullary nailing by using multiple osteotomies and two screws crossing the femoral neck.

Results Restoration of the neck shaft angle of the femur was obtained from an average of 92° prior to surgery to 129° after surgery. During the minimum 2-year follow up, no loss of neck shaft angle of the femur and no refracture occurred. All patients were able to return to normal activities of daily living.

Interpretation In polyostotic fibrous dysplasia, multiple osteotomies and intramedullary nailing with neck cross-pinning can be used to correct developed or progressing shepherd's crook deformity, and to prevent recurrence and refracture.     

Valgus osteotomy in combination with dynamic hip screw fixation for fibrous dysplasia with shepherd’s crook deformity

Background and objectives

The treatment of fibrous dysplasia with shepherd’s crook deformity is a big challenge. The purpose of this study was to investigate the clinical effect of valgus osteotomy in combination with dynamic hip screw (DHS) fixation to treat fibrous dysplasia with shepherd’s crook deformity.

Method

Twenty-one clinical cases of femoral fibrous dysplasia with shepherd’s crook deformity treated between April 2001 and May 2010 were retrospectively analyzed. The valgus osteotomy and internal fixation were performed for these patients. Six patients underwent DHS and trochanter stabilizing plate internal fixation, and the other 15 cases were stabilized by DHS fixation.

Results

Patients were followed for 19–128 months. The neck-shaft angle was corrected from 89° (range 65°–107°) preoperatively to 129° (range 119°–140°) postoperatively. Limb-length discrepancy was corrected from 3.0 (range 1.8–4.5) cm preoperatively to 0.7 (range 0–1.9) cm postoperatively. All osteotomies had healed at the final follow-up examination. The clinical scores, which were evaluated by the modified criteria of Guille, improved from an average of 2.9 (range 1–7) to 8.5 (range 6–10).

Conclusion

Our results demonstrate that valgus osteotomy in combination with DHS internal fixation is an easy and effective method for the treatment of fibrous dysplasia with shepherd’s crook deformity. It can restore the neck-shaft angle and re-establish the mechanical alignment of the femur to improve function.     

股骨近段纤维结构不良内翻畸形的手术疗效

目的 评估和分析股骨近段纤维结构不良内翻畸形手术治疗的临床疗效.方法 2000年8月至2009年5月,采用截骨矫形、病灶刮除、打压植骨、股骨重建钉内固定治疗21例(24个)股骨纤维结构不良伴重度内翻畸形患者,男12例,女9例;年龄14～39岁,平均22.7岁.其中15例为单纯髋内翻畸形,6例同时伴髋内翻及股骨内翻畸形.颈干角55°～105°,平均75°;股骨内翻角18°～45°,平均30°;患侧股骨长度较对侧短缩2.0～4.5 cm,平均3.4cm.其中13例患者因发生病理性骨折而行手术治疗.结果 21例患者均获得随访,随访时间21个月至7年,平均3年4个月.24个股骨共30处截骨面中,28处于术后3～6个月骨性愈合,2例双段远端截骨面各有1处在术后12个月时仍不愈合,经再次植骨3个月后骨性愈合.21例内翻畸形股骨力线均完全矫正,术后颈干角矫正为95°～135°,平均118°;股骨内翻角完全纠正.股骨长度较术前延长1.8～3.6 cm,平均2.8cm.术后无一例患者发生感染、畸形进展及再骨折.17例患者疼痛视觉模拟评分(visual analogue scales,VAS)由术前7～10分降至术后0分,4例VAS评分由术前8～10分降至术后3～4分.Harris髋关节功能评分优12例,良6例,可3例.结论 外翻截骨可有效矫正内翻畸形,股骨重建钉可稳定股骨,大量打压式植骨可有效恢复骨量.

Abstract：

Objective To evaluate and analyse the effectiveness of surgical treatment for fibrous dysplasia in proximal femur with severe varus deformity.Methods A retrospective study was performed in 21 patients (24 femora)of fibrous dysplasia who were treated in our hospital between August 2000 and May 2009.All patients had severe femoral varus deformity.The four-step procedures were performed orderlv as valgus osteotomy,lesion curettage,impacting of massive bone allograft,and fixation by femoral intramedullary nail.There were 6 patients with monostotic disease,15 with polyostotic diseases,including 12 males and 9 females with a mean age of 22.7 years(range,14-39 years).The average neck-shaft angle and femoral varus angle was 75°(range 55°-105°)and 30°(range,18°-45°),respectively.The average length of thigh shortened 3.4 cm(range,2.0-4.5 cm)compared with the contralateral thigh.Results All of the 21 patients were followed up from 21 months to 7 years with an average period of 3 years and 4 months.There were 30 osteotomy sites in 24 femurs,28 osteotomy sites showed bone union after 3-6 months from surgery.Two distal location of the double-level osteotomy showed nonunion,which received bone grafting again and got bone union after 3 months finally.The femoral mechanical alignments of the 21 patients had been recriticd.The average neck-shaft angle was 118°(range,95°-135°)postoperatively,the femoral varus angle disappeared.The average extremity lengthening was 2.8 cm(range,1.8-3.6 cm)postoperatively.There were no infection,recurrent fracture and progression of deformity.The visual analogue scales(VAS)score of 17 patients decreased to zero postoperatively from 7-10 preoperatively,and that of the other 4 patients decreased to 3-4 postoperatively from 8-10 preoperatively.The result of Harris hip functional score was excellent in 12 cases,good in 6,and fair in 3.Conclusion The valgus osteotomy can rectify varus deformity effectively.The reconstract nail of the fumer can support the stability of femur.Impacting of massive bone allograft can improve the capacity of the femur.     

Multiple osteotomies and intramedullary nailing with neck cross-pinning for shepherd's crook deformity in polyostotic fibrous dysplasia: 7 femurs with a minimum of 2 years follow-up

Background?In polyostotic fibrous dysplasia, particularly in lesions of the proximal femur, pathological fracture and coxa vara deformity (including shepherd's crook deformity) are likely to develop and progress.

Patients and methods?In 7 femurs with shepherd's crook deformity (5 patients), we performed intramedullary nailing by using multiple osteotomies and two screws crossing the femoral neck.

Results?Restoration of the neck shaft angle of the femur was obtained from an average of 92° prior to surgery to 129° after surgery. During the minimum 2-year follow up, no loss of neck shaft angle of the femur and no refracture occurred. All patients were able to return to normal activities of daily living.

Interpretation?In polyostotic fibrous dysplasia, multiple osteotomies and intramedullary nailing with neck cross-pinning can be used to correct developed or progressing shepherd's crook deformity, and to prevent recurrence and refracture.     

Fibrous dysplasia of the proximal femur: surgical management options and outcomes

Purpose

The management of proximal femoral deformity in fibrous dysplasia (FD) is a challenge to the orthopaedic surgeon. The purpose of this study was to analyze the various presentations of FD of proximal femur and the results of the various treatment modalities for the same.

Methods

This is a retrospective cohort study of 23 patients (24 femora) with FD who underwent surgery for the proximal femur. The study sample included 14 males, nine females. Ten patients had a monostotic disease, eight patients had polyostotic disease, and five patients had McCune-Albright syndrome.

Results

Group 1: shepherd crook deformity—included five patients who underwent femoral neck osteotomy. Four patients had intramedullary (IM) nailing with neck cross-pinning and all patients showed union. One patient was stabilized with external fixation, which failed. Group 2: nine patients (ten femora) presented with frank pathological fracture. Nine underwent fixation with IM nailing, one with locking plate and screws. Three patients had to undergo more than one procedure and all fractures showed good union. Group 3: nine patients who presented with bone cyst and pain. All patients underwent biopsy; four of them had curettage with bone graft.

Conclusion

Shepherd crook deformity can be treated by a well-planned osteotomy and fixation with intramedullary implants with neck cross-pinning. Frank pathological fractures fixation with an intramedullary nail has excellent results even if not accompanied by resolution of the fibrodysplastic lesion. More than one procedure may be required. External fixation is not an optimal choice for fixation of femoral osteotomies in FD.     

Prophylactic intramedullary nailing in monostotic fibrous dysplasia

Fibrous dysplasia of bone is an enigma with no known cure. Treatment currently consists of curettage and bone-grafting in an attempt to eradicate the lesion and to prevent progressive deformity. This study presents the results of prophylactic intramedullary nailing in 10 patients with monostotic fibrous dysplasia, pain increasing with movement, and scintigraphically established activity. Ten patients with monostotic fibrous dysplasia in their upper or lower extremities treated between 2001 and 2003 were included in the study. Seven patients were male and 3 were female; their mean age was 26.9 years. The mean duration of follow-up was 33.5 months. Closed intramedullary nail without reaming was used in all cases. Bone grafting was not performed. Patients were allowed full weight bearing on the affected extremities on the second postoperative day. Mean VAS for functional pain was 5.33 +/- 0.65 preoperatively and 2.26 +/- 0.57 at final follow-up (p < 0.05). Radiographs showed no changes in lesion size, and the intramedullary fixation appeared to be stable. Prophylactic intramedullary nailing appeared to be beneficial in monostotic fibrous dysplasia with scintigraphically proven activity and functional pain. It also avoids problems that may occur following pathological fracture.