股骨髁上后倾角截骨术远期并发症原因探讨

作者通过对股骨髁上后倾角截骨术（以下简称后倾角截骨术）术后１１～１５年３５８例３７６个膝的远期随诊观察及对膝关节影响的生物力学分析，确认后倾角截骨术导致膝关节载荷传导紊乱是产生该手术远期并发症的原因。为此，对该手术提出如下商榷意见：（１）截骨前应使膝关节屈曲角度减至１０°左右；（２）对于股骨下段向前弧度增大，绳肌肌力又在４级以上的患者，只做伸直截骨，二期行肌替代术；（３）对于连枷膝患者，如若做该手术，则应行连枷膝改造术。     

联合手术治疗较大儿童先天性髓脱位

应用一期联合手术，包括软组织彻底松解，切开复位关节囊成形，股同上端截骨术和骨盆截骨，治疗较大儿童先天性髋脱位４９例６４髋，其中男１２例１５髋，女３７例５４髋。手术时年龄２．５岁￣１１岁，平均６岁５个月。６岁以上２５例３０髋。随访时间为１￣１４．５年，其中５年以上３０例４６髋。随访结果：优３５髋（７６．１％），良６髋（１３．０％），可５个关节（１０．９％）。并发症有股骨头坏死２例，术后剧烈被动活动继     

来稿摘登

西安红十字医院骨科陈明凡等报告股骨髁上截骨术84例发生并发症12例。屈膝受限6例,腓总神经损伤3例,截骨部位角度不当2例,断端移位1例。作者认为:①掌握好手术适应证及手术方法。②如屈膝30°以上先行牵引。也可截骨同时将腓总神经穿入肌肉处松解。③石膏固定一般不超过8周,早期功能锻炼,可予防和减少并     

脊柱畸形矫形手术术后严重并发症发生情况及影响因素分析

目的研究脊柱畸形患者行矫形手术后严重并发症发生情况及影响因素。方法纳入2013年6月～2017年12月治疗的243例脊柱畸形矫形手术患者,根据术后是否发生严重并发症设为并发症组与非并发症组,调查两组患者病程、年龄等病历资料,两组经单因素及多因素Logistic回归分析确定其独立危险因素。结果 243例患者术后发生严重并发症30例,发生率12.35%;单因素分析显示,两组合并神经损伤、病程、FEV1/FVC、术中截骨、矫正率、主弯角度、手术时间、出血量、手术史差异均具有统计学意义(P0.05);多因素Logistic回归分析显示,合并神经损伤(OR=4.353)、病程10年(OR=3.665)、FEV1/FVC83%(OR=3.113)、术中截骨(OR=2.897)是术后发生严重并发症的独立危险因素。结论脊柱畸形患者行矫形手术后易发生严重并发症,合并神经损伤、病程10年、FEV1/FVC、术中截骨均会增加其发生风险。     

联合手术治疗较大儿童先天性髋脱位

应用一期联合手术，包括软组织彻底松解，切开复位关节囊成形，股骨上端截骨术和骨盆截骨，治疗较大儿童先天性髋脱位４９例６４髋，其中男１２例１５髋，女３７例５４髋。手术时年龄２．５岁～１１岁，平均６岁５个月。６岁以上２５例３０髋。随访时间为１～１４．５年，其中５年以上３０例４６髋。随访结果：优３５髋（７６．１％），良６髋（１３．０％），可５个关节（１０．９％）。并发症有股骨头坏死２例，术后剧烈被动活动继发骨化性肌炎１例。笔者认为，通过联合手术使股骨头完全复位、术后尽早活动、彻底松解软组织和股骨充分缩短对预后有重要意义。     

“脊灰”下肢复杂畸形的手术矫治与远期随访

目的： 本文报告作者从１９８４ ～１９９６ 年收治的６ 例成年 “脊灰”后遗症下肢畸形的手术矫治经验与远期随访效果, 以便技术推广交流。方法： 除采用传统手术方法外并自行设计与改良手术： ①胫骨高位截骨平台下沉术;②股、胫、腓联合截骨术。结果： 随访５ 年１ 个月～１２ 年５ 个月, 平均６ 年６ 个月, 从畸形矫正、功能改善、自我感觉、 Ｘ 线照片, ４ 个方面按百分制评估疗效, 优４ 例, 良２ 例。无合并症发生。结论： 本组病例在治疗上虽有一定难度, 但由于手术设计合理, 术后处理恰当, 仍取得满意效果。实践证明这种技术方法是切实可行的。     

股骨髁上反屈截骨术所致膝关节载荷传导紊乱的探讨（附358例远期随诊报告）

股骨髁上反屈角截骨术（以下简称反屈角截骨术）自１９７８年问世以来，确实给数以千计的脊髓灰质炎后遗症患者带来了福音，但临床实践及远期随诊观察表明，该手术也确给众多的手术后患者带来了远期严重的，甚至是难以挽回的（诸如骨性关节炎等）并发症。作者通过对术后１１～１５年３５８例３７６个膝的远期随诊观察及反屈角截骨术对膝关节影响的生物力学分析，确认反屈角截骨术导致膝关节载荷传导紊乱是产生该手术远期并发症的原因。为此，对该手术提出了有益商榷意见。１、截骨前应使膝关节屈曲角度减至１０°左右；２、对于股骨下段前弓弧度增大，绳肌肌力又在４级以上的患者，只做伸直截骨，二期行肌替代术；３、对于连枷膝患者，如若做该手术则应行连枷膝改造术     

先天性髋脱位术后继发股骨颈骨折8例报告

我院从１９８５～１９９８年手术治疗先天性髋脱位３７９例，其中８例术后继发股骨颈骨折，现就其发生原因及防治分析如下。１临床资料８例中男２例，女６例；年龄３５～１０岁，平均５２岁；左侧２例，右侧６例；行单纯切开复位４例，Ｃｈａｒｉｓ截骨２例，Ｓａｌ...     

强直性脊柱炎后凸截骨矫形致神经损伤并发症分析

 目的 探讨截骨矫形治疗强直性脊柱炎后凸畸形神经系统并发症的原因及预防措施。方法 回顾性分析2006年1月至2012年1月行截骨矫形术治疗126例强直性脊柱炎后凸畸形患者资料,其中18例术后发生神经系统并发症,男15例,女3例;手术时年龄25～56岁,平均36.8岁;术前后凸Cobb角57°～96°,平均76.3°;患者术前ASIA分级均为E级。回顾术中操作情况,分析术后发生神经并发症的原因。结果 18例患者均获得随访,随访时间6～49个月,平均35个月;术后后凸Cobb角为19°～38°,平均27°;获得截骨角度31°～76°,平均49.3°,外观得到明显改善。3例(2.4%,3/126)发生脊髓损伤,其中1例在T12截骨处产生矢状面移位,术中经调整上下螺钉高度和预弯棒角度,重新恢复截骨处的矢状面排列后患者无异常;1例截骨闭合后椎管狭窄导致脊髓受压,重新减压后患者随访无异常;1例术中发生医原性颈椎骨折脱位造成脊髓损伤,复位固定后6个月随访时ASIA分级为B级。15例(11.9%,15/126)发生神经根损伤,其中2例为截骨闭合时L3神经根受到挤压,1例为L3椎弓根置钉失误所致,以上3例患者表现为股四头肌乏力;其余12例表现为相应神经根区域皮肤麻木,主要原因是截骨时神经根受到过度牵拉,截除椎弓根下壁时过度激惹神经根;经脱水、神经营养治疗后恢复正常。结论 神经损伤是截骨矫形术中灾难性并发症。认识强直性脊柱炎的病理特点,避免截骨端发生位移,截骨处充分减压,正确摆放患者手术体位,能够有效降低神经损伤的发生。     

单纯后路经椎弓根截骨或脊椎切除的临床分析

目的探讨一期单纯后路经椎弓根脊柱截骨和脊椎切除操作的可行性和如何避免手术并发症的发生。方法回顾125例重度僵硬性脊柱畸形患者的临床资料,分析采用经椎弓根脊柱截骨技术或经椎弓根扩大蛋壳技术进行脊椎切除操作的可行性、手术时间、出血量、术中术后并发症。所有患者均采用经椎弓根内固定系统矫形固定。结果平均手术时间210min,术中失血平均1400ml。术中发生13例胸神经根损伤,术后无明显不适主诉。6例血气胸,经胸腔闭式引流治愈。6例硬膜撕裂,术后自然愈合。术后1例强直性脊柱炎患者腹部皮肤出现较大张力和水泡,经外敷硫酸镁2周治愈。1例术后发生伤口深部感染,经伤口清创冲洗,4周后治愈。1例发生截骨平面以下瘫痪,经脱水消炎治疗,4个月后完全恢复。并发症主要与初期手术操作有关,特别是椎体外侧壁和后壁截骨时,更易发生并发症。结论单纯后路经椎弓根脊柱截骨和脊椎切除操作简单,可行性好,明显缩短了手术时间,小心操作和掌握操作要点,能够避免手术并发症的发生。     

U形截骨术和下颌骨超长弧形截骨术矫正下颌角肥大伴长颏畸形的疗效对比分析

目的:探讨不同术式矫正下颌角肥大伴长颏畸形的应用效果。方法:选取笔者科室2017年1月-2019年1月收治的26例下颌骨肥大伴长颏畸形患者,分别采用U形截骨术和下颌骨超长弧形截骨术两种术式进行矫正,比较两组患者的疗效、术后并发症及满意度情况。结果:U形截骨术组总有效率为90.00%,下颌骨超长弧形截骨术组总有效率为100.00%,下颌骨超长弧形截骨术组总有效率高于U形截骨术组,两组比较差异有统计学意义(P<0.05)。采用U形截骨术后,其中5例患者出现下唇麻木或肿胀,1例有轻微皮肤软组织下垂;采用下颌骨超长弧形截骨术后,其中8例患者口唇有不同程度的麻木或肿胀,1例出现下颌部局部轻度血肿。所有患者均未出现严重并发症,两组患者术后并发症发生情况比较,无统计学差异(P>0.05)。术后6个月对所有患者进行随访,U形截骨术组患者满意度为80.00%,下颌骨超长弧形截骨术组患者满意度为100.00%,下颌骨超长弧形截骨术组满意度高于U形截骨术组,两组比较差异有统计学意义(P<0.05)。结论:相较于传统下颌角截骨术,U形截骨术以及下颌骨超长弧形截骨术均可进一步改善矫正效果,满足患者术前要求。其中,下颌骨超长弧形截骨术具有更佳的矫正效果,并能提高患者对矫正术后的满意度及预后质量。     

Ilizarov 技术矫治马蹄足畸形中胫距关节前脱位的治疗及预防

 目的 总结 Ilizarov 技术矫治马蹄足畸形中发生胫距关节前脱位的概率、治疗及预防方法。方法 回顾性分析 2011 年 10 月至 2012 年 4 月,应用 Ilizarov 技术矫治 38 例马蹄足畸形患者资料,其中 5 例于术后 14～28 d 发生胫距关节前脱位,男 4 例,女 1 例;年龄 19～30 岁,平均 23.8 岁;均为马蹄内翻足畸形患者。5 例患者初次手术采用 Ilizarov 技术矫治马蹄足畸形,同时行经皮跟腱延长术、经皮跖腱膜切断术、胫后肌松解、胫前肌移位,其中 4 例同期行距骨周围截骨术,1 例同期行第一跖骨基底截骨术,1 例同期行胫骨近端去旋转截骨术;发生胫距关节前脱位后,1 例经手法复位,4 例使用 Ilizarov 复位装置后继续按原计划牵伸调整外固定架矫形,直至满意。结果 5 例马蹄内翻足畸形患者在行 Ilizarov 技术矫形过程中发生胫距关节前脱位的概率为 13.2%（5/38）。5 例患者均获得随访,随访时间 6～12 个月,平均 10 个月,马蹄足畸形均完全矫正。末次随访时应用国际马蹄足畸形研究学组评分为 3～10 分,平均 4.8 分;其中优 2 例,良 3 例,优良率为 100%。无一例发生钉道感染、神经血管损伤、血栓等并发症。结论 胫距关节脱位是 Ilizarov 技术矫治马蹄足畸形中较常见的并发症,发生率约为 13%。发生胫距关节前脱位后,及时安装距骨复位装置可获得良好效果。围手术期管理应注意外固定铰链关节与踝关节瞬时旋转中心的匹配。     

Perioperative complications of the Scarf osteotomy

We reporting the perioperative complications during our early experience using the Scarf osteotomy to correct hallux valgus. A case note review was carried out for the first 100 Scarf osteotomy procedures completed by the senior author. There were six patients (6%) with perioperative complications. Four of these were intraoperative complications including a split first metatarsal in three cases, a shearing of the K-wire in one case and there were two cases of postoperative stress fracture. These complications should be considered by those beginning to master the Scarf osteotomy procedure and by surgeons teaching surgical trainees.     

后路截骨联合椎弓根内固定矫形治疗僵硬性脊柱侧后凸畸形

目的探讨经后路截骨联合椎弓根内固定矫形治疗僵硬性脊柱侧后凸畸形疗效。方法对26例僵硬性脊柱侧后凸畸形患者进行后路截骨、椎弓根内固定矫形。8例行后路Ponte截骨,13例行椎弓根截骨术(PSO)联合Ponte截骨,5例行全椎体切除术(VCR)。比较患者术前、术后和末次随访时Cobb角的变化及C7中垂线与骶骨中垂线距离的变化。结果患者均获得随访,时间12~60个月。侧凸Cobb角:术前30°~135°(90.7°±30.6°),术后12°~30°(18°±5.6°),矫正率为82.5%,末次随访13°~32°(20°±5.8°),丢失4.3%;后凸Cobb角:术前20°~60°(40.6°±18.5°),术后10°~26°(16.8°±6.2°),矫正率为85%,末次随访13°~30°(20.5°±7.0°),丢失3.7%;C7中垂线与骶骨中垂线距离:术前3.8~6.5(5.1±1.3)cm,术后0.3~1.3(0.7±0.3)cm,末次随访0.4~1.7(0.8±0.3)cm。所有患者未发生神经损伤等并发症,仅1例患者术后3个月出现内固定松动,经延长固定节段后骨性融合。结论术前充分的评估,选择合适的后路截骨方式,联合椎弓根内固定矫形治疗僵硬性脊柱侧弯,能有效矫正畸形和恢复脊柱冠、矢状面平衡。     

Osteotomies of the fifth metatarsal.

Although the literature is limited primarily to retrospective small case series of the operative technique of fifth metatarsal osteotomies with a short follow-up, some important information can be learned. Stabilization of the osteotomy with Kirschner wire fixation appears to decrease dorsal displacement of the distal fragment and distal osteotomies; this leads to decreased incidence of transfer metatarsalgia. Kirschner wire fixation is advocated. The proximal chevron osteotomy of the fifth metatarsal, although stable, has a 20% delayed union rate, most likely resulting from the unique vascular anatomy in this region. The radiographic and clinical results appear to be compatible between distal and proximal osteotomies. Based on this information, primary use of a proximal osteotomy technique is not recommended. The oblique diaphyseal osteotomy technique requires an incision for the osteotomy as well as a distal incision at the metatarsophalangeal joint for correction of this joint. Hardware removal was performed in most patients, and the complications included two cases of delayed union. Time to healing was reported to be 8 weeks, 1.5 times the reported time to healing in distal chevron osteotomies. A significant radiographic correction was noted with the oblique diaphyseal osteotomy; however, radiographic measurements can be altered with foot position and lack of x-ray standardization and technique. Kitaoka et al found no correlation with the degree of radiographic correction and post-operative clinical symptoms. The authors agree with Kitaoka et al that the oblique diaphyseal osteotomy should be reserved for patients who fail an initial distal osteotomy technique. Distal oblique osteotomies appear to have less stability and more complications with malunion, transfer metatarsalgia, and delayed union and should be abandoned for a more stable chevron technique. The distal chevron osteotomy has a small incidence of transfer metatarsalgia; however, it appears to improve the clinical radiographic appearance of [table: see text] the foot with a shortened time to healing (4 to 6 weeks). A biplanar technique can be employed with a distal chevron osteotomy to improve plantar callosity symptoms. More studies are needed to examine critically patient outcomes with uniplanar and biplanar techniques using the distal chevron osteotomy.     

Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus

The purpose of this multicenter study was to analyze the results of shoulder arthroplasty for the treatment of the sequelae of proximal humerus fractures and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fractures were treated with shoulder replacement with the use of the same nonconstrained, modular, and adaptable prosthesis: the Aequalis prosthesis (Tornier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic classification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, locked dislocations or fracture-dislocations (9 cases); type 3, nonunions of the surgical neck (6 cases); and type 4, severe malunions of the tuberosities (16 cases). The mean postoperative follow-up was 19 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (26%), fair in 18 cases (25%), and poor in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 patients (81%) stated that they were satisfied with the result. The most significant factor affecting functional outcome was greater tuberosity osteotomy (P <.005). Regarding both surgical treatment and postoperative prognosis, we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocation [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extracapsular/disimpacted fractures sequelae (associated with both surgical neck nonunions [type 3] and severe tuberosity malunions [type 4]) where the proximal humerus cannot be reconstructed without a greater tuberosity osteotomy. All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in which osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We conclude that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus should be performed without an osteotomy of the greater tuberosity when possible. If prosthetic replacement is possible without an osteotomy, surgeons should accept the distorted anatomy of the proximal humerus and adapt the prosthesis and their technique to the modified anatomy. A modular and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adapt to a large number of malunions and may help to avoid the troublesome greater tuberosity osteotomy in a higher proportion of cases.     

Correction of juxtaarticular deformities in children using the Ilizarov apparatus

Background Deformity correction using external fixation was performed for various disorders in children. We reviewed 18 children who underwent juxtaarticular deformity correction using the Ilizarov apparatus with either a transverse or focal dome osteotomy. The amount of deformity correction, external fixation time, external fixation index, length gained, and incidence of complications were examined.Methods A series of 27 operations were performed in lower limb segments on 10 femurs and 17 tibias in 10 boys and 8 girls. The mean age at operation was 12 years (5–18 years). Deformity corrections were performed using a transverse osteotomy in 16 segments and a focal dome osteotomy in 11.Results The average deformity corrected was 19° (6°–31°). Acute correction was done in 14 segments and gradual correction in 13 segments. The mean lengthening was 4.2 cm in 12 segments (2–8 cm). The mean external fixation time was 161 days (78–352 days). In acute corrections, the external fixation time with a focal dome osteotomy (101 days) tended to be shorter than with a transverse osteotomy (142 days).Conclusions Accurate limb alignment was obtained for all cases. A focal dome osteotomy by maximizing the area of bony contact was more effective than a transverse osteotomy for acute deformity correction.     

一期后路截骨矫形治疗儿童静止期脊柱结核性后凸（侧后凸）畸形

 目的 探讨一期后路截骨矫形治疗儿童静止期脊柱结核性后凸（侧后凸）畸形的疗效。方法 2002年1月至2012年12月手术治疗儿童静止期脊柱结核性后凸（侧后凸）畸形18例,男6例,女12例;年龄4~15岁,平均8.2岁;脊柱结核病程10个月～120个月,平均37.1个月。脊柱后凸畸形位于颈胸交界区2例、胸椎10例、胸腰段5例、腰椎1例。病变累及2个椎体3例、3~5个椎体9例、5个椎体以上6例。其中6例合并脊髓神经损害,Frankel分级C级2例、D级4例。均采后路截骨矫形植骨融合内固定术,经椎弓根截骨16例,全椎体切除截骨2例。术前、术后及随访时摄站立位全脊柱X线片,测量矢状面主弯后凸Cobb角、冠状面主弯侧凸Cobb角及躯干矢状偏移距离,记录脊柱融合固定节段和融合情况。结果 18例均获得随访,随访时间 11~97个月,平均27.8个月。固定节段为5~17个椎体,平均9.6个;融合节段为2~8个椎体,平均4.4个。矢状面后凸由术前平均71.6°矫正至14.5°,矫正率79.7％;冠状面侧凸Cobb角由术前平均9.4°矫正至0.7°。躯干矢状偏移距离由术前平均3.7 mm矫正至术后0.5 mm,平均矫正3.2 mm。末次随访时神经功能均获改善。围手术期主要并发症包括内固定松动4例,胃肠功能障碍2例,胸膜破损5例,脑脊液漏3例。结论 对儿童静止期脊柱结核件后凸（侧后凸）畸形采用后路截骨矫形及内固定是较为安全、有效的方法,融合范围选择和截骨矫形技术是成功的关键。     

Transpedicular wedge osteotomy for correction of thoracolumbar kyphosis in ankylosing spondylitis: experience with 78 patients

STUDY DESIGN: This is a retrospective study of surgical correction of thoracolumbar kyphosis caused by ankylosing spondylitis. OBJECTIVE: To report the surgical results of thoracolumbar kyphosis deformity corrected with transpedicular wedge osteotomy performed by a single surgeon at a university hospital. SUMMARY OF BACKGROUND DATA: There has not been a large series in the literature reporting on results of the Thomasen-type closing wedge osteotomy for correction of kyphosis deformity secondary to ankylosing spondylitis, nor has two-level osteotomy of this type in one patient ever been described. METHODS: From 1991 through 1998, 92 transpedicular wedge osteotomies were performed in 78 patients with ankylosing spondylitis for correction of fixed flexion deformity of the thoracolumbar spine. RESULTS: The mean amount of correction for each level of osteotomy was 34.5 degrees (range, 15 degrees -60 degrees ). The largest amount of overall correction for a single patient was 100 degrees. Most of the osteotomies (64 of 92) were done at L2 and L3. Fourteen patients with severe deformity required staged two-level osteotomy. Excellent and good results were obtained in 77 patients (98.7%) at the final follow-up. There was no mortality, nor were there any major neurological complications. CONCLUSIONS: Transpedicular wedge osteotomy can effectively and safely correct kyphotic deformity of the thoracolumbar spine caused by ankylosing spondylitis, regardless of rigidity of the spinal curves. Two-level osteotomy can provide sufficient correction for severe cases.     

Komplikationen der Chevron Osteotomie

BackgroundThe Chevron osteotomy is probably the most used technique fort he correction of hallux valgus. According to the literature complications mentioned beside the classical surgical complications are avascular necrosis, hallux varus, recurrent hallux valgus and malposition.MethodsThe therapy of complications after Chevron osteotomy is in most cases a surgical solution. Hallux varus and malposition are mostly corrected by a correctional osteotomy, the solution of a avascular necrosis ist he arthrodesis.ResultsThe incidence of complications after Chevron osteotomy is described with up to 28%. This does not correlate with patients satisfaction which is in general around 90%.ConclusionThe Chevron osteotomy is one of the most if not the most used technique fort he correction of hallux valgus. With the correct indication a high percentage of patient satisfaction can be achieved. The incidence of complications is in most studies not high and usually revisions are rare.