踝关节骨折的内固定治疗

踝部骨折是最常见的关节内骨折,约占全身骨折的3.92%,青壮年最易发生,因其承受应力大于髋、膝关节,对其治疗要求较髋、膝关节更高。其解剖复位的重要性越来越被临床医师所认识。我科在1998年10月～2003年10月治疗各类踝关节骨折119例,其中手术治疗86例,均取得良好疗效,现报告如下。临床资料1.一般资料:本组86例踝关节骨折中,男52例,女34例,年龄17～72岁,平均年龄37岁。根据Lauge Hanson分类,Ⅱ型旋后外旋型(typeSE)32例,Ⅲ型旋前外展型(typePA)28例,Ⅳ型旋前外旋型(typePE)26例,其中Pilon骨折11例,开放性骨折8例,单踝骨折29例。致伤原因…     

股骨近端髓内钉与动力髋螺钉治疗股骨粗隆间骨折的比较

目的：探讨股骨近端髋内钉（proximal femoral nail,PFN）与动力髋螺钉（dynamic hip screw,DHS）在治疗A1、A2和A3型股骨粗隆间骨折的各自特点。方法：股骨粗隆间骨折104例,其中PFN固定33例,男13例,女20例,年龄63～87岁,平均76岁;A1型12例,A2型18例,A3型3例。DHS固定71例中,男29例,女42例;年龄61-92岁,平均74．5岁;A1型32例,A2型34例,A3型5例。对两种术式的平均手术时间、切口长度、失血量、下地负重时间及并发症情况进行比较。结果：平均手术时间PFN（51．5±4．4）min,DHS（68．8±5．9）min;切口长度PFN（9．6±0．9）cm,DHS（15．5±1．5）cm;失血量PFN（179．0±12．9）ml,DHS（269．3±40．0）ml。PFN无髋内翻,DHS髋内翻1例、颈干角变小7例。PFN近端螺钉后退导致髋外侧疼痛6例。结论：DHS与PFN在A1型股骨粗隆间骨折内固定治疗中疗效基本相同。PFN手术损伤小于DHS,且抗张力强,不易并发髋内翻及头旋转,更适合A2、A3型粗隆间骨折.     

小切口全髋关节置换术治疗高龄股骨颈骨折

2003年1月～2005年12月,我们采用改良后外侧小切口行全髋置换术(THA)治疗 18例18髋股骨颈骨折患者,效果满意. 1 材料与方法 1.1 病例资料 本组18例(18髋),男3例,女15例,年龄56～77岁.左侧2例,右侧16例.受伤至手术时间6～13 d.16例使用非骨水泥型全髋关节,2例使用混合型假体(髋臼生物型假体、股骨骨水泥型假体),其中蛇牌人工关节7例,Depuy人工关节11例.     

儿童股骨干骨折并移位的骨牵引治疗

目的总结3～14岁儿童股骨干骨折并移位行股骨髁上骨牵引术的治疗体会.方法屈髋90度,屈膝90度,髋外展30～45度位股骨髁上骨牵引术治疗股骨干骨折.结果 86例患儿疗效均满意.结论该方法简单、有效,既避免了皮牵引的诸多并发症,又减少了切开复位对患儿的身心创伤.     

双极人工股骨头置换术治疗高龄移位股骨颈骨折的疗效观察

[目的]观察双极人工股骨头置换术治疗高龄移位股骨颈骨折的疗效.[方法]自2000年～2007年采用双极人工股骨头置换术治疗高龄移位股骨颈骨折患者86例,平均年龄73.9岁(71～89岁).骨折类型:头下型40例,经颈型21例,头颈型25例.Garden分型:Ⅲ型者44例,Ⅳ型者40例.均髋部骨质疏松较重.根据Harris评分标准判定其疗效.[结果]本组中25例术后2～5年因心脑血管疾病死亡.末次随访获得61例,平均随访时间3.2年(1～8年),术后无伤口感染和下肢深静脉血栓形成.髋关节Harris评分为87分,优良率为88.5%.发生股骨柄松动下沉7髋(11.5%),髋臼磨损9髋(14.8%),下沉和髋臼磨损的程度不严重,疼痛不重,均不需手术翻修.[结论]双极人工股骨头是治疗高龄移位股骨颈骨折的简单有效方法.     

异体骨移植修复髋关节翻修术中骨缺损的中期随访

[目的]探讨在髋关节翻修中采用异体骨修复骨缺损的中期疗效.[方法]对2000～2005年间采用异体骨修复髋关节翻修术中骨缺损而获得随访的22例22髋进行回顾性分析,其中男13例,女9例;年龄45～80岁,平均65.5岁.根据AAOS分型:髋臼缺损I型5髋,II型14髋,III型3髋;股骨缺损I型3髋,II型12髋,III型2髋,5髋无明显缺损.骨缺损重建方法:髋臼侧结构性植骨5髋;颗粒骨植骨12髋;钛网联合颗粒骨植骨5髋.股骨侧结构性植骨3髋;颗粒骨植骨12髋;钛网联合颗粒骨植骨2髋;5髋没有植骨.根据Harris评分和X线对其临床效果进行评估.[结果]术后平均随访61个月,Harris评分由翻修前平均45分增加至术后86分.1例出现伤口渗液;1例仍轻度疼痛.未见假体移位及透亮带,没有再翻修病例.[结论]全髋翻修中,根据骨缺损类型,选用相应异体骨修复骨缺损,中期随访效果满意.     

空心螺钉联合内侧支撑钢板治疗青壮年Pauwls Ⅱ、Ⅲ型股骨颈骨折

目的 观察空心螺钉联合内侧支撑钢板治疗青壮年PauwlsⅡ、Ⅲ型股骨颈骨折的疗效。方法 采用空心螺钉联合内侧支撑钢板治疗60例青壮年PauwlsⅡ、Ⅲ型股骨颈骨折患者(61髋),记录术后骨折复位、愈合情况以及并发症发生情况。结果 患者均获得随访，时间9～36个月。术后摄骨盆正、轴位X线片复查，依据Garden对线指数评估骨折复位情况，Ⅰ级复位50例(51髋),Ⅱ级复位7例(7髋),Ⅲ级复位3例(3髋)。术后随访过程中，内固定松动退出或断裂4例(4髋),其中PauwelsⅡ型3例(3髋)、Ⅲ型1例(1髋);股骨颈短缩5例(5髋),均为PauwelsⅡ型；髋内翻畸形3例(3髋),其中PauwelsⅡ型2例(2髋)、Ⅲ型1例(1髋);骨折不愈合7例(7髋),其中PauwelsⅡ型5例(5髋)、Ⅲ型2例(2髋);股骨头坏死12例(12髋),其中PauwelsⅡ型9例(9髋)、Ⅲ型3例(3髋);无明显并发症、骨折达骨性愈合者29例(30髋)。结论 空心螺钉联合内侧支撑钢板并非是治疗青壮年PauwlsⅡ、Ⅲ型股骨颈骨折的金标准，其远期疗效有待进一步临床观察。     

双极人工股骨头置换治疗高龄股骨颈骨折

2006年3月～2009年4月,我们对25例股骨颈骨折患者采用双极人工股骨头置换术,效果满意. 1 材料与方法 1.1 病例资料 本组25例,男12例,女13例,年龄75～93岁.左髋16例,右髋9例.均为外伤后股骨颈头下型骨折,移位明显,轻度骨质疏松症.Garden分型: Ⅲ型11例, Ⅳ型14例.致伤原因:跌摔伤19例,车祸撞伤3例,高处坠落伤3例.其中19例分别并存有不同程度的心、肺、脑等内科疾病.伤后至手术时间4～7 d.     

带血管蒂肌骨瓣结合空心螺纹钉治疗青壮年股骨颈骨折

1991～2007年,笔者采用带血管蒂肌骨瓣结合空心加压螺纹钉治疗青壮年股骨颈骨折68例,疗效满意. 1 材料与方法 1.1 病例资料本组68例(69髋),男44例,女24例.年龄18～52岁.单侧67例,双侧1例.骨折类型:头下型17髋,经颈型36髋,基底型16髋.按Garden分型:Ⅲ型47髋,Ⅳ型22髋.     

非骨水泥人工髋关节假体周围骨折

随着人工髋关节置换术在我国深入的开展,尤其是非骨水泥型假体的广泛应用,随之而来的假体周围骨折亦日益多见,其发生率2.5%～27.8%[1]。我院自1997年1月～1998年4月,对60例患者(62个髋关节)进行了非骨水泥人工髋关节置换术,发生假体周围骨折9例。现就其发生原因和处理进行分析和探讨。1　临床资料　　60例(62髋)中,男28例,女32例。左髋34个,右髋28个,双髋2例。年龄21～87岁,其中20～30岁2例(1例双髋),31～40岁7例,41～50岁7例,51～60岁14例(1例双髋),61～70岁15例,71～80岁11例,81～90岁4例。就诊原因:新鲜股骨颈骨折25例,陈旧性股骨颈骨折1…     

Capture of the screw during percutaneous screw insertion

The simple technique to maintain the engagement of the screw and the screw driver during percutaneous locking screw insertion is presented. The method can capture the screw when the screw becomes disengaged. This will be helpful when percutaneous screw insertion is performed in the narrow and deep location of the bone such as a locking screw at the upper part of the femur during retrograde femoral nailing.     

Complications of the variable screw plate pedicle screw fixation

In this study, 124 consecutive cases of posterior spinal fusion with variable screw plate fixation were reviewed. In 33 patients (27%), 41 complications were identified. Urinary tract infection without sequelae developed in 13 patients. Dural tear occurred in seven patients and wound hematoma in five. Wound infection developed in three patients; one was subfascial requiring instrument and graft removal. Neurologic deficit developed in seven patients (6%), in five of whom the deficit was due to manipulation and reduction of neural elements. Two of the seven deficits were believed to be caused by misplaced pedicle screws. Variable screw plate fixation is a formidable procedure with a significant complications rate.     

Interference screw fixation using bioabsorbable screw as void filler

We evaluated interference screw fixation in a plug-tunnel construct using bioabsorbable screws as void fillers with different percentages of the screw removed. Nine-millimeter tunnels in a closed-cell foam block were filled with a 10-mm bioabsorbable screw, and 10-mm revision tunnels were placed in parallel with tunnel overlap resulting in removal of 10%, 25%, or 50% of the screw diameter. Synthetic bone plugs were fashioned to fit 10-mm tunnels. In all groups, the plugs were secured in standard interference fixation with a 9-mm metal screw between the void-filling bioabsorbable screw and plug. Failure loads for the control group (no revision tunnel) averaged 926 +/- 44 N, 10% (1024 +/- 129 N) and 25% (932 +/- 129 N) groups were not significantly different; failure load in the 50% diameter group (780 +/- 72 N) was significantly lower than all other groups (p < 0.001). Using a bioabsorbable screw as void filler provided mean load to failure not different from that of standard reconstruction when 10 and 25% of the diameter of the void-filling screw was removed. Load to failure was significantly lower when 50% of the void-filling screw diameter group was removed. This may be applicable in anterior cruciate ligament reconstruction where a previous tunnel void has to be addressed.     

Iliosacral screw complications

Potential complications due to iliosacral screws are numerous. Problems occur as a result of poor preoperativeplanning, inadequate intraoperative fluoroscopic imaging, inaccurate posterior pelvic reductions, posterior pelvic anatomical variations, and other reasons. Local nerve or vascular structures are at risk during screw insertions, and fixation failures are associated with insufficient anterior and posterior pelvic stability. Inadequate fixation may result in screw failure and/or delayed or nonunions. Removal of intact or broken screws can also be difficult.     

寰椎椎弓根螺钉技术和侧块螺钉技术的临床疗效比较

目的：探讨寰椎椎弓根螺钉和侧块螺钉固定技术的临床疗效。方法：2006年1月-2010年1月,行寰椎椎弓根螺钉固定技术32例（A组）,行寰椎侧块螺钉固定技术28例（B组）。通过术中失血量,手术时间,颈枕区疼痛缓解,JOA评分和术后植骨融合情况评定疗效。结果：两组患者在JOA评分,颈枕区疼痛缓解WAS评分）和植骨融合率方面无明显差异。A组术中失血量和手术时间明显低于B组,有统计学意义。B组中有3例术后出现颈枕区疼痛加重。结论：寰椎椎弓根螺钉固定技术显露范围小,简化了操作程序,减少了术中、术后的并发症。在设计手术方案时,应优先考虑椎弓根螺钉技术,而侧块螺钉技术可以作为一种补充。     

Transpedicular screw fixation

Spinal fixation employing transpedicular screws has recently been the focus of increased attention at various institutions throughout the world, but concerns about the safety and efficacy of transpedicular screws linger. This study was undertaken to address some of these concerns. The study included evaluation of the internal and external morphology of the vertebral pedicles, which revealed that adequate bone stock is generally available at T2, T7, T12, and L1-L5 spinal levels to accept screws in the 4-7-mm diameter range. The pedicle was observed to be composed of abundant cancellous bone internally with relatively thick cortical walls. The method of pilot hole preparation for pedicle screws was also examined. Screws inserted in pilot holes prepared with a 3.4-mm blunt probe (ganglion knife) resulted in higher pullout forces in eight of 10 trials as compared with those with pilot holes prepared using a 3.2-mm drill. Furthermore, the probes afford greater control of hole depth and alignment. Fatigue studies on three screw designs revealed a graduation of strength between a 7.0-mm pedicle screw, a 5.5-mm pedicle screw, and a modified 6.5-mm cancellous lag screw. The modified cancellous lag screw has an inherent stress riser that affected fatigue life. It was noted that extreme care must be exercised to prevent bending of the pedicle screws during implantation. If bending occurs one can expect a 50% reduction in the number of cycles to failure.