成人股骨髁上骨折的不同固定方式治疗研究进展

股骨髁上骨折多为高能量损伤引起,由于其解剖结构特殊、损伤复杂、骨折不稳定等特点,治疗难度很大。以往多采用非手术方法治疗,但效果不理想。近年来手术治疗取得了飞速发展,包括钢板螺钉内固定、髓内钉固定及外固定方法。为更好地指导应用,现对股骨髁上骨折不同类型固定方式治疗的研究进展进行综述。     

胸腰椎爆裂骨折的间接减压与直接减压疗效比较的Meta分析

目的 应用Meta分析评价胸腰椎爆裂骨折在后路手术对椎管的间接减压与直接减压两种方式的临床疗效,为临床治疗决策提供依据.方法 计算机检索PubMed(1990年1月至2012年5月)、Web of knowledge(1990年1月至2012年5月)、中国期刊全文数据库(1990年1月至2012年5月)、维普数据(库1994年至2011年5月)和万方数据库(1990年1月至2012年5月),获得有关后路间接减压内固定术和后路直接减压内固定术治疗胸腰椎爆裂骨折的临床对照研究,对入选文献进行质量评价,选择术中出血量、手术时间、术后引流量、术中和术后并发症的发生情况、伤椎前、后缘高度百分比及cobb角作为Meta分析的评价指标,采用RevMan 5.1进行分析. 结果 共纳入7项研究479例患者,全部为中文文献,均为随机对照试验,其中间接减压组249例,直接减压组230例.Meta 分析结果显示:与直接减压相比,间接减压治疗胸腰椎爆裂骨折的手术时间短[MD＝-57.31,95％ CI(-71.99,-42.63),P＜0.05]、术中出血量少[MD=-256.92,95％ CI(-293.58,-220.25),P＜0.05]、术后引流量少[MD=-110.30,95％CI(-186.60,-33.99),P=0.005]、并发症的发生率少[OR =0.16,95％ CI(0.07,0.36),P＜0.05],差异均有统计学意义.而两种治疗方式在伤椎前、后缘高度百分比、cobb角矫正方面比较差异均无统计学意义(P＞0.05). 结论 与后路直接减压比较,间接减压在愈后效果相似的情况下,具有手术时间短、术中出血量少、术后引流量少,术后并发症少、避免二次损伤等优势.     

综合性心理干预对晚期妊娠孕妇焦虑症状及血压、脉搏的影响

目的:探讨综合性心理干预对晚期妊娠孕妇焦虑症状及血压、脉搏的影响.方法:将150例有焦虑症状的晚期妊娠孕妇随机分为对照组和干预组各75例.对对照组进行常规孕妇学校有关妊娠、分娩知识的讲解,干预组孕妇在此基础上于孕28周后每周定时接受认知与支持疗法、拉玛泽减痛分娩法等心理干预措施.孕36周再次评定两组焦虑值评分.结果:干预组焦虑值评分低于对照组(P<0.05);干预组收缩压及舒张压均低于对照组(P<0.05);干预组脉搏低于对照组(P<0.05).结论:综合性心理干预在提高晚期妊娠孕妇心理健康水平的同时,可明显减轻其焦虑症状及降低血压、脉搏水平.     

医源性周围神经损伤的临床治疗

目的 回顾医源性周围神经损伤患者的临床治疗效果,总结经验和教训. 方法 对2004年-2010年医源性周围神经损伤患者72例进行回顾性分析,治疗方法包括保守治疗24例,手术松解21例,神经吻合27例. 结果 72例患者均获得随访3～24个月,平均10个月.神经恢复标准按中华医学会手外科学会上肢部分功能评定试用标准:优24例,良21例,可16例,差11例,优良率为64％. 结论 加强医源性周围神经损伤的风险意识,特别注意近几年开展的骨折复位微创治疗有增加神经损伤的风险.对于有可能出现医源性损伤的患者,一定要在术前制订详细的手术方案,争取Ⅰ期修复.     

The biomechanical effects of pedicle screw adjustments on the thoracolumbar burst fractures

The biomechanical effects of pedicle screw adjustments on the thoracolumbar burst fractures Shang jian, Ling xiaodong, Han xiguang, et al The First Affiliated Hospital Of Harbin Medical University Background: Posterior pedicle screw device is widely to apply treatment of thoracolumbar burst fractures. As the clinical operation is not based upon quantitative data of adjustments, the results are not optimal. At present, no study has assessed the associations between the device adjustments and the restoration of stiffness. Objectives: To investigate the biomechanical effects that adjustments of a pedicle screw device have on the burst fracture, and explore an optimal adjustment. Methods: Burst fractures were produced at L1 vertebra in twenty-four fresh calf spines (T12-L3). The specimens divided into four groups at random. Pedicle screw devices were attached to T13 and L2. Four device adjustments, consisting of distraction and extension, were applied. Adjustment 1 was pure 6° extension. Adjustment 2 was pure 5mm distraction. Adjustment 3 was 6° extension followed by 5mm distraction. Adjustment 4 was 5mm distraction followed by 6° extension. Analysis and evaluate the effect of each adjustment on the stiffness restoration, anatomical reduction and neural decompression for the burst fractures. Results: Pure extension (group 1) produced the closest segment height and the least restoration of the canal to the intact. Pure distraction (group 2) restored stiffness most, but only with 60% stiffness of the intact value, and lost the segmental angle most to the intact. The combination of extension-distraction (group 3 and group 4) produced the maximum reduction of the anatomy and restoration of the canal in the burst fracture, and the least stiffness restoration. The sequence of extension and distraction did not affect stiffness restoration, anatomical reduction and neural decompression. Conclusions: The device adjustments affected stiffness restoration, anatomical reduction and neural decompression. The combined extension-distraction adjustment may be the most suitable considering the anatomical reduction and neural decompression, but its stiffness decreased the most, if necessary; it should be considered to reconstruct L1 vertebral. Key words: Burst fracture, Pedicle screw, Stiffness, Adjustment 1. Introduction Nearly 90% of all spinal fractures occur in the thoracolumbar region, and burst fractures compose approximately 15% of such injuries. Burst fractures occur predominantly in the younger patients, incurring a high financial and society cost [1]. There have been many reports suggesting appropriate therapies for burst fracture. Surgery is still controversial, but is gradually being accepted. The ideal goal of the surgical treatment of burst fracture is neural decompression and anatomical reduction and ambulation as early as possible. Generally, surgical treatment is generally divided into two types: anterior and posterior. The anterior approach provides good decompression and solid fusion, but the operative risks relatively higher than that associated with the posterior approach. On the other hand, the posterior procedure of the thoracolumbar junction is well established, with advantages such as more safety and less being technically demanding. There are many surgical devices for the posterior approach. Nowadays, use of pedicle screw has become increasingly popular. Theoretically, pedicle screw fixation provides greater forces to be applied to the spine to reduce deformity because of its 3-column fixation characteristics. Short-segment fixation is the most common and most simple treatment of burst fractures. The need to fuse fewer segments is treated with short-segment fixation in comparison with longer-segment fixation [2]. Pedicle devices are used not only to provide temporary fixation, but also to restore the vertebral spinal alignment and to reduce the canal encroachment. The stabilizing potential of the pedicle screw device adjustments has been rarely studied. As the operation procedure is not based upon quantitative data, the results obtained are not optimal. A fracture vertebra does not transfer load as effectively as the intact vertebra [3]. Patients who undergo surgery using short-segment pedicle screw instrumentation for middle-column injury may experience implant failure. The compressive stiffness of the spine reflects the load-sharing between the implant and the injured spinal column. To our knowledge there are no experimental studies that have has assessed the associations between the device adjustments and the restoration of stiffness. We hypothesized that the pedicle screw adjustments affected the restoration of segment stiffness. The purpose of the current study was to investigate the effects that adjustments of a pedicle screw device had on the reduction of the burst fracture, including anatomical reduction, neural decompression, and especially stiffness restorations, then to explore an optimal adjustment. 2. Materials and methods 2.1. Specimen Preparation Twenty four thoracolumbar spinal specimens from twenty-one-day-old fresh calves were retrieved from an abattoir and frozen at −20 °C. There was no trauma history associated with any of these specimens. Of the specimens, ten were female and fourteen were male with an average age of 6.8 days (range, 5-9 days). After defrosting for twenty-four hours, the specimens were cut into five-vertebra segments (T11-L3), excess paravertebral muscle was removed. The ends of the specimen were set in 80-mm-diameter polymethylmethacrylate end plates to produce flat, parallel surfaces. The instrument used spinal internal fixation system (Beijing Orthopedic Innovation, Inc, China), the screw length and diameter were 5.0 mm and 35 mm respectively. 2.2 Experimental Burst Fracture Production Experimental burst fractures were produced at the L1 vertebra using an incremental impact protocol [4]. An impact mass, guided by a vertical tube, was dropped onto an impounder resting on top of the specimen. The average drop height was 1.4 m, resulting in an impact speed of 5.2 m/sec. A wedge of 8 ° wedge angle was placed between the impounder and the specimen top to force the latter into a flexed posture, so that the mechanism of loading was flexion-compression. Each specimen was impacted with an initial mass of 3.3 kg. If no burst fracture occurred, the mass was increased by 2.0 kg for the next impact. The burst fracture occurrence was monitored by measuring the canal encroachment on lateral radiograph taken after each impact. This incremental addition was continued until a burst fracture of requisite severity (10-80% encroachment,) occurred. 2.3 Pedicle Screw Device After burst fracture, two pairs of pedicle screws were inserted into the T12 and L2 pedicle using the standard clinical technique. In T13 the screws were inserted approximately 30-32 mm in depth and in L2 to a 35-mm depth. To avoid loosening of the interface between the specimen and the screw during repeated loads, polyester resin was poured. An internal fixator rod system was attached to left and right pairs of the screws. This pedicle screw system allowed us to independently apply two device adjustments (translation or angulation) in the positive or negative direction, or a combination. 2.4 Device Adjustments The specimens divided into four groups at random. Four device adjustments were chosen with combinations of translation and angulation. The choice was governed by 1) clinical relevance, 2) no injury to the specimen due to the result of any adjustment, 4) the decreased segmental height and angle of the burst fracture, and 3) only a finite number of adjustments could be studied. Burst fractures are caused by flexi- and -axial loading forces and thus seem best treated posteriorly with reduction and fixation by extension and distraction. Clinically, the burst fracture is often put in some extension to restore spinal lordosis and some distraction to restore spinal height, but seldom in flexion or distraction. We chose four device adjustments which were studied. (Table 1) The four device adjustments, from left to right, respectively, consist of 6° pure extension (0/6°E), 5 mm pure distraction (5D/0°), 6° extension was followed by 5 mm distraction (5D/6°E) and 5 mm distraction was followed by 6° extension(5D/6°E). Table 1 Four device adjustments Adjustments After Burst Fracture 1 2 3 4 Distraction（mm） 0 5 5 5 Extension（°） -6 0 -6 -6 Group 1, 2 were single adjustments, whereas group 3, 4 were combinations. 2.5 Biomechanical test and CT scan All specimens were subjected to five cycles of 0-250 N flexion-and axial-compression in a displacement-controlled mode at a rate of 25 mm/min on a testing machine (Instron 5569, China). Two load cycles were used to precondition the specimen. At each step on each load cycle, the specimen was allowed to creep for 30 seconds to reduce variations resulting from viscoelasticity of the spine. Load-displacement curves were automatically recorded. The axial-compression and flexion-compression curves were computed in the three conditions: intact, burst fracture, and burst fracture with each of the four device adjustments. The stiffness (N/mm) was defined as the linear slope of the curve (Fig. 1). Fig. 1 Diagrams of biomechanical setup (a: Axial compression. b: Flexion compression) All specimens in the three conditions, intact, burst fracture, and burst fracture with each of the four device adjustments, was taken for CT scanning and 3D reconstruction. (Fig. 2) Then according to the images, the segment height and angle (Fig 3), as well as the diameter of the L1 canal were measured. We defined this as the intact neutral posture, under no load. Therefore, height, angle and diameter were measured with the intact specimen in neutral posture. Fig.2 CT scanning (A2-C2) and 3D reconstruction (A1-C1) of a specimen in three conditions, intact, fracture, and fracture with the device adjustment Fig. 3 Definition of the segment height and angle (Line a is tangent to the lower endplate of T13. Line b is parallel to line and passes through the posterior-inferior corner of the L2 vertebral body. Line c is tangent to the lower endplate of T13) 2.6 testing protocol Three spinal conditions, intact, burst fracture, and burst fracture with each of the four device adjustments, were studied. A flow chart depicting testing sequence is provided in Fig. 4 Fig. 4 Experimental protocol showing the sequence of events for each specimen (CT & 3D: CT scanning and 3D reconstruction. AFCT: axial and flexion compression testing) 2.7 Statistical analysis Statistical analysis was performed using SPSS 10.0 software (SPSS/PC Ins, Chicago, IL, USA). Mean and standard deviations were computed of the segmental heights and angles, the diameter of the canal and the stiffness under axial- and flexion-compression. The differences among the four device adjustments were analyzed by one-factor analysis of variance. The differences within the same group were evaluated with t-tests. Significance was set at P<0.05. 3. Results Specimens experienced 3.4 times impact on average and the impact energy and speed on average by 94.2 J and 5.24 m/s respectively, then the L1 vertebral body produced burst fractures. The average intact axial-compression and flexion-compression stiffness were 380.7±58.5 N/mm and 339.2±42.1 N/mm respectively. After burst fractures, axial-compression and flexion-compression stiffness were 109.8±33.8 N/mm and 72.9±20.0 N/mm respectively. Both axial- and flexion-compression stiffness decreased significantly after injury as compared with intact spine (axial t=18.8, p<0.01; flexion t=16.6, p<0.01). We found the device adjustment to affect the burst fracture axial- and flexion-compression stiffness, but no adjustment provided stability close to the intact specimen (axial p<0.05; flexion p<0.05). Among the four device adjustments, 5 mm pure distraction (5D/0°) stabilized the most (axial p<0.05; flexion p<0.05), with a 28% and 35% relative decreasing of axial- and flexion-compression stiffness. The combined distraction-extension adjustments (5D/6°) stabilized the least (axial p<0.05; flexion p<0.05), and the sequence of applying distraction and extension did not affect the spinal stability (axial p>0.05; flexion p>0.05). Stiffness under flexion-compression was significantly lower than that under axial-compression in every state (p < 0.05). Table 2 Axial- and flexion-compression stiffness for intact, burst fracture and four device adjustments ( ±S, n=6). Intact Burst Fracture Adjustment After Burst Fracture 1 2 3 4 Axial-compression Stiffness(N/mm) 380.7±58.5 109.8±33.8 213.1±43.6 275.1±37.7 183.8±27.6 179.3±22.1 Flexion-compression Stiffness( (N/mm) 339.2±42.1 72.9±20.0 176.8±34.7 220.3±26.5 140.8±21.0 136.5±19.2 Fig. 5 Axial and flexion compression stiffness of each construct. The burst fracture decreased the segmental height on average by5.3±2.5 mm, and the segmental angle changed to kyphosis by 5.9±4.5°. The adjustments, with respect to the burst fracture, caused varying changes in the spinal posture. The combined distraction-extension adjustments (5D/6°) brought the burst fracture closer to the intact state than other adjustments (p>0.05). The postural changes due to group 3 versus 4 were not significantly different (p>0.05). Thus, the sequence of applying distraction and extension did not affect the spinal postural change. Pure adjustment caused spinal changes in spinal posture. For example, 5 mm pure distraction was accompanied by some kyphosis (height t=3.51, p<0.05; angle t=2.90, p<0.05), and 6° pure extension also produced some distraction (height t=2.97, p<0.05; angle t=3.54, p<0.05). Compared with the intact spine, pure distraction produced the segmental angle that deviated from the intact mostly (p<0.05); while pure extension produced the segmental height deviated from the intact mostly (p<0.05). Table 3 Changes in segmental height and segmental angle, from the burst fracture to the resulting postures due to the device adjustments ( ±S, n=6). Device adjustment 1 2 3 4 Segment height(mm) 1.9±0.8 2.9±1.8 6.0±1.3 5.8±1.4 Segment angle(°) -4.5±1.7 0.5±1.1 -3.8±1.9 -4.0±2.0 Fig. 6 Average changes in the posture from the burst fracture due to the four adjustments. On average, adjustment 2, 3, and 4 restored the canal diameter to approximately 70% of its intact value, but none restored to its intact values (Group 1: t=7.32, p<0.05; Group 2: t=4.92, p<0.05; Group3 t=3.39, p<0.05; Group 4: t=3.29, p<0.05). The combined distraction-extension adjustments (5D/6°) were found to produce the maximum restorations of canal diameter (p<0.05). The restorations due to group 3 versus 4 were not significantly different (p>0.05). Thus, the sequence of applying distraction and extension did not affect to decompress the canal (p<0.05). Table 4 Canal diameters for intact, burst fracture, and four device adjustment ( ±S, n=6). Intact Burst Fracture Adjustment After Burst Fracture 1 2 3 4 Canal diameter(mm) 14.2±1.1 8.3±2.0 9.7±2.1 10.1±2.7 11.1±2.2 11.3±1.9 Fig. 7 Restorations. The parameters indicate the magnitudes of restoration achieved as percentage of the intact values. Restoration (%) = 100 × DAdj/DIntact. DIntact: Intact canal diameter. DAdj: the canal diameter resulting from an adjustment. 4. Discussion Pedicle screw devices are versatile and used not only to provide fixation for an unstable spine, but also to reduce the canal encroachments and to restore the vertebral spinal alignment. These reductions and restorations are accomplished by adjusting the pedicle device, that is, by applying a combination of distraction and/or extension. In previous 3-dimensional testing studies the device adjustments affected the spinal construct stability differently in different directions [5]. But our results differ from the findings of previous studies because of the different load protocol used. We did not use the range of motion parameters in three planes of motion (flexion/extension, left/right lateral bending, and left/right axial rotation) because the compressive stiffness of the tested structure reflects the load-sharing between the implant and the injured spinal columns. Therefore, only the axial-compression and flexion-compression stiffness were calculated in the present study. The present biomechanical analysis showed that pedicle screw device fixation alone did not provide sufficient stability, especially under flexion-compression load. This may explain the fact that short-segment posterior instrumentation alone cannot completely prevent reduction loss and implant failure in treating burst fractures [3, 6]. The results of our study showed that compared with the intact spine, a 39% and 50% relative decrease of axial- and flexion-compression stiffness was noted after the burst fracture. Wang et al [7]. have also showed that despite fixation of the injured spine with pedicle screw instrumentation, the axial-compression and flexion-compression stiffness was still significantly lower than that of the intact spine. This may explain the fact that short-segment posterior instrumentation alone cannot completely prevent reduction loss and implant failure in treating burst fractures. Haher et al. [8] have shown that the anterior and middle column destruction of the spine reduces its load-carrying capacity (LCC) for flexion loads by 70%, while minimal change was observed in the LCC when the axis of loading was posterior to the posterior longitudinal ligament. Our study also demonstrated that the stiffness under flexion-compression was significantly lower than that under axial-compression, indicating mechanical properties in flexion were weaker. Thus patients should possibly be encouraged to rest in bed during the first three postoperative months. In this period, they should wear a brace when ambulating, and avoid activities that require bending forward. Although braces may not reduce loads on internal spinal fixation devices, they may protect the instrumented spine from the reflex overaction of the back muscles caused by sudden events, which substantially increases spine compressive loading [9-10]. In this way, the load on the anterior column may be reduced, and the incidence of early failure of implants may diminish. The adjustment combining 5mm distraction with 6° extension brought the spinal anatomy and the canal diameter closest to the intact state, while that provided axial- and flexion-compression stiffness smallest, compared to all other adjustments. Pure distraction achieved the maximum stability in axial- and flexion-compression stiffness. With this adjustment, posterior fixation could only restore the axial- and flexion-compression stiffness by 72% and 65% respectively. Transpedicular fixation alone cannot provide sufficient stability for thoracolumbar fractures. Posterior instrumentation combined with an anterior graft could offer as a possible solution. Wang et al. have showed that anterior graft with short-segment instrumentation for burst fracture greatly increases the biomechanical stability in the injured spine, thus suggesting that additional reconstruction of the anterior column may be necessary. The adjustments caused varying changes in anatomical reduction, neural decompression, especially stiffness restorations. The results of the study showed that the device adjustments of distraction and extension can be applied in any sequence, with the same results. For the decompression of the neural canal, the sequence of distraction and extension has been deemed important. Harrington et al. [11] suggested applying the distraction first, followed by extension. This was suggested based upon the concept that positioning the vertebra in lordosis without applying distraction significantly slackens the posterior longitudinal ligament. However, this concept was not based upon any quantitative data. Two limitations of the current study should be noted. The one is that the calf spine differs from the human spine anatomically, and mechanically. Despite these differences, the calf spine has been used widely to mode fractures because of its low variability and good bone quality. Another practicality of the calf model lies in structurally more closely replicated human anatomy in surgical techniques [12]. The other is that it was an in vitro study. The properties of the muscles and the muscle tone are absent. Also, the weight bearing and the dynamic muscle forces that will be present once the patient is up and performing daily activities also are absent. In clinical, the severity of the burst fracture can vary greatly. We have presented average results. The individual specimen results will vary from these average values. It is suggested that in future clinical studies the exact adjustments used in the pedicle screw devices be noted at the time of surgery. This will provide important information for subsequent further studies. References 1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8: 817-31. 2. Dai LY, Jiang SD, Wang XY, et al. A review of the management of thoracolumbar burst fractures. Surg Neurol 2007; 3: 221-31. 3. MeCormack T, Karaikovie E, Gaines RW. The load sharing classification of spine fractures. Spine 1994; 19: 1741-4. 4. Panjabi MM, Hoffman H, Kato Y, et al. Superiority of incremental trauma approach in experimental burst fracture studies. Clin Biomech 2000; 15: 73-8. 5. Oda T, Panjabi MM. Pedicle screw adjustments affect stability of thoracolumbar burst fracture. Spine 2001; 26: 2328-33. 6. Cunningham BW, Sefter JC, Shono Y, et al. Static and cyclical biomechanical analysis of pedicle screw spinal constructs. Spine 1993; 18: 1677-88. 7. Wang XY, Dai LY, Xu HZ, et al. Biomechanical effect of the extent of vertebral body fracture on the thoracolumbar spine with pedicle screw fixation: an in vitro study. J Clin Neurosci 2008; 15: 286-90. 8. Haher TR, Tozzi JM, Lospinuso MF, et al. The contribution of the three columns of the spine to spinal stability: a biomechanical model. Paraplegia 1989; 27: 432-9. 9. Mannion AF, Adams MA, Dolan P. Sudden and unexpected loading generates high forces on the lumbar spine. Spine 2000; 25: 842-52. 10. Chen HH, Wang WK, Li KC, et al. Biomechanical effects of the body augmenter for reconstruction of the vertebral body. Spine 2004; 29: 377-8 11. Harrington RM, Budorick T, Hoyt J, et al. Biomechanics of indirect reduction of bone retropulsed into the spinal canal in vertebral fracture. Spine 1993; 18: 692-9. 12. Wilke HJ, Krischak S, Claes L. Biomechanical comparison of calf and human spines. Orthop Res 1996; 14: 500-3.     

椎间撑开颈前路减压植骨钢板内固定术治疗脊髓型颈椎病

[目的]总结并探讨椎间撑开颈前路减压植骨术治疗脊髓型颈椎病的疗效。[方法]自2001年4月~2004年10月,应用CCR颈前路自动拉钩及Caspar椎体间撑开器系统,采用单节段单纯间盘切除、经椎间隙入路或多节段分别间盘切除、椎管潜式扩大减压、植骨、钛板内固定术治疗脊髓型颈椎病68例,随访并复查X线片,测量术前及术后12个月病变椎间隙高度,同时,采用日本矫形外科学会评分标准(JOA)评价手术前后脊髓功能,并统计比较。[结果]全部病例中51例获得随访其中症状明显好转50例,缓解1例,加重0例。术后12个月时,X线片显示全部病例植骨愈合、病变椎间隙骨性融合。同时,手术后病变椎间隙高度保持明显优于手术前,手术后脊髓功能JOA评分亦显著高于术前。本组无颈髓损伤、钢板和螺钉松动及椎前血肿等并发症发生。[结论]椎间撑开颈前路减压植骨钢板内固定术有利于术后颈椎病变椎间隙高度的保持,并可确切恢复、改善脊髓功能。     

注射器针头交叉固定断指再植71例

我科自１９９４年６月～１９９７年１２月,应用注射器针头交叉固定断指指骨,７１指成活６０指,成活率为８４５％,现报告如下：１材料与方法１１一般资料本组３８例７１指,男３１例,女７例。年龄５～４６岁,平均２７７岁。致伤原因：电锯伤９例、菜刀砍伤１７...     

吻合血管的末节断指再植

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