Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture

Osteosynthesis of comminuted posterior acetabular wall fractures is a challenging task for surgeons. We report a series of eight cases of such fractures where the comminuted fragments were excised and the defect in the posterior acetabular wall was reconstructed with iliac crest strut graft. The graft was buttressed with a reconstruction plate on its posterior aspect. The patients were followed up every week until radiological signs of union were seen. Subsequent follow-up was after six months, one year and annually. Patients were evaluated clinically by Merle d’Aubigne and Postel score and radiologically by Matta score at their final follow-up. All fractures united radiologically after an average follow-up of 3.2 months. The clinical outcome after mean follow-up of 3.34 years (minimum two years and maximum five years) was as follows: two (25%) were excellent, two (25%) were very good, three (37.5%) were good and one (12.5%) was fair. Radiological grading at last follow-up showed excellent in one (12.5%), good in four (50%) and fair in three (37.5%) patients. No complication in the form of infection, heterotopic ossification, neurovascular injury or graft resorption was noticed. To conclude, excision of the small comminuted fragments and reconstruction of the wall using iliac crest strut graft is a viable alternative technique for reconstruction of the comminuted posterior acetabular wall fracture. The medium-term clinical and radiological results of this technique are satisfactory.     

联体解剖型钛板在髋臼后壁粉碎性骨折中的应用

目的探讨联体解剖型钛板内固定治疗髋臼后壁粉碎性骨折的临床疗效。方法自2013-05—2014-09采用联体解剖型钛板内固定治疗21例髋臼后壁粉碎性骨折(联体解剖板组),与自2010-01—2013-04采用重建钢板治疗的32例髋臼后壁粉碎性骨折的临床资料(重建板组)进行比较。结果联体解剖板组均获平均9.8(6~12)个月随访,本组手术时间(60±12.5)min,术中出血量(150±37.5)ml。末次随访髋关节功能按改良Merle d'Aubingne-Postel评分优良率85.7%。重建板组均获平均11.4(8~17)个月随访,本组手术时间(103±25.5)min,出血量(260±95.5)ml,髋关节功能按改良Merle d'Aubingne-Postel评分优良率84.4%。联体解剖板组手术时间(t=2.970,P0.05)、术中出血量(t=5.847,P0.05)均少于重建板,差异有统计学意义。2组治疗效果的优良率比较差异无统计学意义(P0.05)。结论采用联体解剖板固定治疗髋臼后壁粉碎性骨折能够获得与重建板相同的临床效果,且其手术时间、术中出血量较少,手术操作难度较低。     

K-L入路重建钢板交叉固定治疗髋关节后脱位伴髋臼后壁粉碎骨折

目的探讨经K-L入路采用3.5 mm重建钢板+T型弹性钢板交叉固定治疗髋关节后脱位伴髋臼后壁粉碎骨折的效果。方法采用K-L入路重建钢板交叉固定治疗25例髋关节后脱位伴髋臼后壁粉碎骨折患者。结果患者均获得随访,时间12~32个月,骨折均骨性愈合。Matta影像学评分:优19例,良4例,差2例。关节功能Merle d'Aubigné评分:优18例,良3例,可2例,差2例。结论 3.5 mm重建钢板+T型弹性钢板交叉固定能够为髋臼后壁提供足够的稳定性,利于患者早期功能锻炼,促进髋关节功能恢复,是治疗髋关节后脱位伴髋臼后壁粉碎骨折的有效方法。     

髂骨块移植治疗髋臼后壁缺损的远期疗效分析

目的探讨髋臼后壁粉碎骨折进行髂骨移植再造的可行性及远期疗效观察。方法1994年6月～2000年6月间应用髂骨移植再造后壁治疗髋臼后壁粉碎性骨折合并骨缺损13例,随访总结疗效及经验。结果所有患者经5～10年(平均8．5年)的随访,远期髋关节功能和异位骨化分别按d'Aubigne 6分法和Brooker标准评估。髋关节功能优8例,良3例,可2例,优良率为84．6%。其中异位骨化BrookerⅡ°1例。5年后并发创伤性关节炎2例,经保守治疗症状缓解,无切口感染、髋关节再脱位发生。结论髂骨块后壁再造是治疗髋臼后壁粉碎性骨折伴缺损的简单、安全、有效术式。如后期并发严重的创伤性关节炎,再造后壁也能为日后全髋关节置换创造良好的骨性基础。     

Comparison of the biomechanical stability of dense cancellous allograft with tricortical iliac autograft and fibular allograft for cervical interbody fusion

Several choices are available for cervical interbody fusion after anterior cervical discectomy. A recent option is dense cancellous allograft (CS) which is characterized by an open-matrix structure that may promote vascularization and cellular penetration during early osseous integration. However, the biomechanical stability of CS should be comparable to that of the tricortical iliac autograft (AG) and fibular allograft (FA) to be an acceptable alternative to these materials. The purpose of this study was to compare the initial biomechanical stability of CS to that of AG and FA in a one-level anterior cervical discectomy and interbody fusion (ACDF) model. Twelve human cervical spines (C3–T1) were loaded in six modes of motion and evaluated under three conditions: (1) intact, (2) after ACDF using CS, AG, and FA in alternating sequences, and (3) after ACDF with anterior plating. Three reflective markers were placed on the adjacent vertebral bodies. Intervertebral motion was measured with a video-based motion-capture system (MacReflex, Qualisys, Sweden). Torques were applied to a maximum of 2.0 N m. The range-of-motion and neutral-zone values measured in each loading mode were compared. No graft material displayed significant differences in biomechanical stability in any of the tested loading modes, suggesting that the initial stability of CS is comparable to that of AG and FA. Anterior cervical plating significantly increased biomechanical stability in all modes.An erratum to this article can be found at     

髋臼横形伴后壁骨折的诊断和治疗

目的探讨髋臼横形伴后壁骨折的诊断方法和治疗效果.方法15例髋臼横形伴后壁骨折,通过X线平片、CT平扫及重建图像确诊,均手术治疗,其中改良Kocher-Langenbeck(K-L)入路10例、前后联合入路5例,均采用钢板和拉力螺钉固定.结果随访1～4年(平均2年),关节功能按改良d'Aubigne和Postel功能评定标准,解剖复位者12例中关节功能优良10例、可2例;复位欠佳2例中关节功能良1例、可1例;不满意复位1例关节功能差.结论髋臼横形伴后壁骨折一般采用手术治疗,手术入路为改良K-L入路或前后联合入路,骨折固定方法应满足解剖复位、坚强固定和安全的要求.     

青少年特发性脊柱侧凸患者后路髂棘处取骨植骨并发症

目的探讨青少年特发性脊柱侧凸患者后路髂棘处取骨并发症的发生率。方法对1999～2002年201例后路取髂骨行脊柱植骨融合术的青少年特发性脊柱侧凸患者进行回顾性研究。其中85例患者获得随访，最短随访时间为2年。结果住院期间有2例发生局部感染，通过灌洗引流和清创得到恢复。1例发生髂骨内板穿透，未引起临床症状。3例发生持续性疼痛，1例发生麻木。总的并发症发生率为3。5％。在随访的85例患者中，21例(24。7％)有髂棘取骨处疼痛，其中13例(15．3％)影响日常生活。7例(8．2％)需要服用非甾体类抗炎药以缓解取骨部位疼痛。6例(7.1％)瘢痕周围的皮肤感觉过敏，15例(17．6％)有瘢痕周围皮肤麻木。结论尽管青少年脊柱侧凸患者住院期间髂棘取骨处并发症较低，但经过长期随访，疼痛及麻木的并发症明显增高，应值得更多关注。     

自制弹簧钢板在髋臼后壁骨折手术中的应用

目的探讨自制弹簧钢板在手术治疗髋臼后壁骨折中的应用及疗效。方法 2013年6月-2017年6月,收治髋臼后壁骨折患者38例。男27例,女11例;年龄28~68岁,平均53岁。致伤原因:交通事故伤18例,高处坠落伤15例,跌倒伤5例。其中,单纯后壁骨折4例,后壁骨折伴髋关节后脱位18例,后壁骨折伴后柱骨折10例,后壁骨折伴横断骨折6例。受伤至入院时间1~4 d,平均2.5 d;受伤至手术时间4~8 d,平均5 d。采用Kocher-Langenbeck入路(35例)和联合髂腹股沟入路(3例)复位骨折后,首先采用弹簧钢板压住固定后壁骨折,然后使用重建钢板压住弹簧钢板固定于后柱。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间12~36个月,平均28个月。发生创伤后坐骨神经损伤5例及术中牵拉致坐骨神经损伤2例,均在术后3个月完全恢复。影像学复查示骨折均愈合,骨折愈合时间10~16周,平均12周。随访期间无内固定物断裂和失效发生;末次随访时发生股骨头坏死2例,创伤性关节炎1例,骨化性肌炎1例。术后12个月根据Harris评分标准评价髋关节功能,获优27例,良5例,可2例,差4例。结论髋臼后壁骨折术中使用弹簧钢板固定后壁骨折块后,再使用重建钢板压住弹簧钢板固定于后柱,具有手术操作简便、固定可靠的优点。     

术前虚拟规划联合3D打印模板预塑形钢板治疗髋臼后壁骨折

目的:评估虚拟术前规划和3D打印模板预塑形钢板治疗髋臼后壁骨折的可行性和准确性。方法:回顾性分析2017年8月至2020年8月治疗的髋臼后壁骨折患者29例,根据是否采用术前虚拟规划和3D打印模板分为2组,3D打印组14例,男10例,女4例;年龄21～53岁;基于患者骨盆CT数据采用Mimics和3-Matic软件进行虚拟手术规划,虚拟复位骨折,设计后壁钢板模板及螺钉固定位置,模拟透视记录合适方位以指导术中透视,打印后壁钢板模板和带有后壁骨折块的钢板螺钉模型,然后根据模板预塑形钢板备用。常规组15例,男10例,女5例;年龄19～55岁;采用常规的方法术中折弯钢板适应骨折区域。比较两组术中出血量、手术时间、骨折复位质量和髋关节功能。结果:23例患者获得随访,时间12～30个月。两组患者骨折均愈合,愈合时间3～6个月。两组手术时间、术中出血量比较,差异均有统计学意义(P<0.05)。末次随访时髋关节功能Merle d’Aubign-Postel评分,3D打印组疼痛程度评分低于常规组(P<0.05);两组行走能力、髋关节活动度和总分比较,差异均无统计学意义(P>0.05)。3...     

平山病患者行颈椎前路自体髂骨植骨融合内固定术护理措施的改进

目的提高平山病患者手术与康复效果。方法将行颈椎前路自体髂骨植骨融合内固定术的160例平山病患者按时间段分为对照组和改进组各80例;对照组行常规围术期护理;改进组在此基础上组成医护小组,术前护理中融合健康教育与心理护理,术后强化、细化和量化体位护理、术区护理、取骨区护理及功能锻炼等。结果改进组术后取骨区疼痛评分、抑郁评分及住院时间显著少于对照组(均P<0.01),术后12个月功能改善率显著优于对照组(P<0.05)。结论改进后的护理措施可有效提高术后康复效果。     

重建钢板在髋臼后壁骨折中的应用

自1995年1月-2002年8月用重建钢板治疗髋臼后壁骨折24例，疗效满意，现报告如下。     

Continuous infusion of ropivacaïne: an optimal postoperative analgesia regimen for iliac crest bone graft in children

Background: Postoperative analgesia of iliac crest (IC) donor site can be performed by on site infiltrations of local anesthetics (LA) or morphine. Single injections or continuous infusions of LA proved their efficacy in adults, but was not reported in children. We prospectively evaluated the interest of a continuous infusion of 0.2% ropivacaïne at the IC donor site in terms of postoperative pain relief and rescue analgesics consumption. Methods: Sixteen consecutive patients, aged from 4 to 16 years scheduled for maxillar alveolar graft with IC bone, were included. After IC bone graft surgery under general anesthesia, they received a 0.2–0.4 ml·kg^?1 bolus of 0.2% ropivacaïne through the IC catheter; then a continuous infusion of 0.2% ropivacaïne at 0.125 ml·kg^?1·h^?1 was administrated for 48 h with disposable elastomeric pumps. Children systematically received paracetamol (15 mg·kg^?1 four times a day) and niflumic acid (40 mg·kg^?1 twice a day). Postoperative pain was evaluated using a Visual Analog Scale (>7 years old) or Children and Infants Postoperative Pain Score (between 4 and 7 years old) every 4 h until H48. Doses of rescue analgesics and adverse events (LA toxicity, catheter’s removal, nausea–vomiting) were also noted. Three months after surgery a blinded clinical research assistant reviewed all children and assessed functional recovery, neuropathic chronic pain symptoms or local complications. Results: The median value of IC graft pain scores was 0 during whole studied period. Of the patients, 31.2% did not require any rescue analgesics and 43.8% needed only once. No adverse events related to LA and no removal of catheter were noted. One child had nausea in the 48‐h postoperative period, and one child had neuropathic pain symptoms at 3 months at the donor site. Conclusion: Continuous infusion of 0.2% ropivacaïne through an IC catheter is an optimal and safe technique of regional postoperative analgesia after bone graft harvest in children.     

Long term results after surgical management of posterior wall acetabular fractures

Background

Posterior wall fractures are the most common of all acetabular fractures, and there is universal consensus that displaced fractures are best treated with anatomical reduction and stable internal fixation. Though early and mid term results for such studies are available, few shed light on long term results. This study was performed to evaluate long term functional and radiological outcomes in patients with posterior wall acetabular fractures and to determine factors that may contribute adversely to a satisfactory final outcome.

Materials and methods

We retrospectively analysed the hospital records for patients who underwent open reduction and internal fixation (ORIF) for posterior wall acetabular fractures. Twenty-five patients (20 men, five women), including one with bilateral posterior wall fracture, with a mean age of 41.28 ± 7.16 years (range 25–60 years) and a mean follow-up of 12.92 ± 6.36 years (range 5–22 years) who met the inclusion criteria formed the study cohort. Matta’s criteria were used to grade postoperative reduction and final radiological outcome. Functional outcome at final follow-up was assessed according to d’Aubigné and Postel score.

Results

Anatomic reduction was achieved in 22 hips, imperfect in four and poor in none. Radiological outcome at final follow-up revealed excellent results in ten hips, good in eight, fair in five and poor in three. The final d’Aubigné and Postel scores were excellent in 14 hips, good in six and fair and poor in three each. Patients with anatomical reduction had a favourable functional and radiological long term outcome. However, the presence of associated injuries in lower limbs and a body mass index (BMI) >25 adversely affected the final functional outcome. Osteonecrosis was seen in three patients, heterotopic ossification in two and Morel Lavallee lesion in one. One patient had postoperative sciatic nerve palsy, which recovered 6 weeks after surgery.

Conclusion

Anatomic postoperative reduction leads to optimal functional and radiological outcome on long term follow-up; however, the presence of associated lower-limb injuries and BMI >25 adversely affects a satisfactory final outcome in patients with posterior wall acetabular fractures.

Level of evidence

(Level 4) Retrospective case series.     

Associated lesions in posterior wall acetabular fractures: not a valid predictor of failure

Background

The general outcome of posterior wall acetabular fractures is still the source of discussion. Posterior wall fractures are recognized throughout the literature as being difficult to treat. The aim of the present study was to analyze in our own patients the relevance of the classical prognostic criteria for the outcome of isolated posterior wall fractures and those with associated lesions.

Materials and methods

A prospective cohort of 33 consecutive patients treated operatively between 1996 and 2006 in a single level 1 trauma center for a posterior wall fracture of the acetabulum was analyzed retrospectively. Included were posterior wall acetabular fractures or associated posterior wall fractures, such as the combinations of posterior column with posterior wall, transverse with posterior wall, or T-shaped fracture with posterior wall fracture. Outcome measurement of the postoperative survival of the hip joints until the primary outcome reoperation (total hip replacement or fusion) and secondary outcome diagnosis of symptomatic osteoarthritis were performed.

Results

Twenty-six of the 33 patients with posterior wall fractures also had a dislocated joint. Twelve had isolated and 21 associated fractures. Six patients were reoperated with a THA (four patients within 2 years and one after 10 years), and one arthrodesis was done to treat a hematogenous septic arthritis in a degenerative hip joint. Secondary arthritis was observed in 10 patients.

Conclusions

No difference was found between the outcome in cases of isolated posterior wall acetabular fracture and the outcome in those with associated lesions. The classical prognostic criteria were not found to be relevant to the outcome for our group.     

髋臼镍钛记忆合金三维内固定系统治疗陈旧性髋臼后壁骨折合并骨缺损

目的探讨应用髋臼镍钛记忆合金三维内固定系统(acetabular tridimensional memory alloy-fixationsystem,ATMFS)结合自体髂骨解剖重建髋臼后壁骨折合并骨缺损的临床效果。方法 2002年1月-2009年2月,收治17例陈旧性髋臼后壁骨折合并骨缺损患者。男11例,女6例;年龄20～60岁,平均41.7岁。骨折至该次入院时间为14～180 d,平均63 d。髋臼关节面移位均≥3 mm。骨缺损按照美国骨科医师协会(AAOS)髋臼骨折缺损分型标准:Ⅰ型4例,Ⅱ型6例,Ⅲ型5例,Ⅳ型2例。手术去除残留的髋臼后壁骨折块和增生软组织,复位股骨头后取自体游离髂骨植于后壁缺损处,ATMFS固定重建髋臼后壁,加用人工韧带重建髋关节囊韧带,防止股骨头再脱位。结果术后3 d骨折复位按照Matta影像评定标准:优8例,良6例,可2例,差1例,优良率为82.3%。术后切口均Ⅰ期愈合,无坐骨神经损伤发生。患者术后均获随访,随访时间1～8年,平均3.9年。术后2～6个月骨折均愈合,平均3.6个月。术后1例发生股骨头缺血性坏死,1例发生髋臼周围异位骨化。术后1年,患者髋关节功能按照Merle d’Aubigné-Postel的评分系统评价:获优9例,良6例,可1例,差1例,优良率为88.2%。结论 ATMFS结合自体髂骨游离移植,利用人工韧带重建髋关节囊韧带,是治疗髋臼后壁陈旧性骨折合并骨缺损的有效方法,它可以恢复髋关节的后方稳定,防止股骨头再脱位。     

Morbidity associated with anterior iliac crest bone graft harvesting in children undergoing orthopaedic surgery: a prospective review

Purpose

Autologous iliac crest bone grafting is an integral part of many orthopaedic surgical procedures. Several studies have documented morbidity and prolonged pain following iliac crest bone graft harvesting in adults; however, in children there is a paucity of information. The purpose of the present study was to quantify the degree of pain and morbidity associated with anterior iliac crest graft harvesting in children undergoing non-spinal orthopaedic surgery.

Methods

Patients were prospectively enrolled prior to orthopaedic surgery. A patient self-reported visual analogue score was used to record pain at specified time points following surgery. In addition, the patients were reviewed at 2 and 6 weeks, 3 months and 1 year after surgery to record any complications.

Results

Data was collected on 33 patients (34 graft sites). Only one patient (2.94 %) had a complication, namely an injury to the lateral femoral cutaneous nerve. This resolved 3 months after surgery. 89 % of patients had no pain at the iliac crest graft harvest site 3 months after surgery. The three patients who had pain at 3 months had visual analogue scores of 1.0, 1.1 and 1.3, respectively.

Conclusion

This series reveals a very low complication rate and minimal iliac crest graft harvest site pain in children undergoing non-spinal orthopaedic surgery. In addition, the pain experienced is short-lived.     

涉及髋臼顶的髋臼后壁骨折手术治疗效果

目的观察涉及髋臼顶的髋臼后壁骨折手术治疗效果。方法选择我院2011年~2017年髋臼后壁及髋臼顶骨折的36例患者,观察采用Kocher-Langenbeck入路切开复位重建钛板内固定治疗疗效。结果骨折复位按照Matta标准评价:解剖复位24例,复位满意10例,复位欠佳2例,随访时间6~20个月,平均12个月,所有骨折均固定愈合,内固定无松动,骨折移位2例,髋臼顶再骨折1例,评定关节功能参照Epstein标准,关节功能优22例,良8例,一般4例,差2例,结论涉及髋臼顶的髋臼后壁骨折不仅需要解剖复位,还需要对髋臼顶进行坚强的固定。