Letournel分型复杂髋臼骨折的手术治疗

目的探讨Letournel分型复杂髋臼骨折的诊断和治疗。方法75例Letournel分型复杂髋臼骨折，术前经骨盆CT三维重建明确诊断分型后，分别采用前、后人路，前后联合入路及笔者改良的髂股入路显露并复位，AO重建钢板内固定。结果随访6个月～8年，平均3年10个月，按关节功能D’Aubigne和Postel6分法及X线片表现Epstein标准评价，优34例，良28例，可8例，差5例，优良率为82．57％。结论术前完善的影像学资料、骨盆模型标本的体外模拟、使用合理的手术入路、术中尽可能的解剖复位及AO重建钢板内固定是获得良好结果的基础。     

急性筋膜室综合征的诊断

急性筋膜室综合征是创伤骨科的急症，其发病的病理生理机制和治疗原则已有明确的认识和公认的结论。影响其预后的主要因素是早期诊断和外科处理的时机。本文对急性筋膜室综合征的临床物理诊断和仪器诊断方法进行了回顾和分析，指出临床评估的一些误区，提出正确的监测原则。     

人工全髋关节假体界膜组织细胞的间充质干细胞特性研究

目的 在人工全髋关节假体周围界膜来源的组织细胞培养中发现细胞具有间充质干细胞生长特性,因而进一步研究该细胞的部分干细胞学特性.方法 运用组织细胞培养、免疫组织化学和流式细胞术检测细胞表面相关抗原表达等方法鉴定界膜组织细胞的成纤维细胞特性和干细胞特性,并将培养的界膜成纤维细胞分别在成骨细胞培养基和成脂肪细胞培养基作用下进行分化诱导.结果 所有培养的界膜细胞都表达成纤维细胞特异性波形蛋白.其中少量细胞表达一些重要的间充质干细胞相关表面抗原,包括SSEA_4~+/CD45~-(0.1%)、Nanog~+(2.4%)、CD34~+(4.5%)和SH_2B~+(0.1%),这些细胞不表达CD133、Thy-1和SCF等造血干细胞相关表面抗原.在成骨化培养基作用下,细胞内部出现钙盐沉积,(24.5±5.5)%细胞表达碱性磷酸酶.细胞经成脂化培养基处理后,(16.0±6.5)%细胞内出现脂肪小滴聚集.结论 人工髋关节假体界膜组织细胞中有少部分细胞表达间充质干细胞相关表面抗原,能够在一定条件下向成骨细胞和脂肪细胞分化,表现出间充质干细胞的特性.

Abstract：

Objective By examining arthroplasty interface membrane-derived fibroblasts in vitro, we observed continuous morphological changes in cultured cells similar to the spontaneous differentiation of adult stem cells. This investigation is aimed to study whether the cells possess mesenchymal stem cell-like properties. Methods Tissue culture, immunohistochemistry and flow cytometry were used to characterize the cultured arthroplasty membrane-derived fibroblasts for their fibroblast and stem cell properties. The plasticity of these cells was also analyzed using osteogenic, adipogenic medium culture and histological techniques. Results All the cells in culture expressed vimentin. We found that 0.1% of the cultured interface membrane-derived fibroblasts possessed mesenchymal stem cell markers (SSEA4VCD45), 4.5% expressed CD34, and 2.4% were positive for Nanog. These cells did not contain cells positive for such hematopoietic stem cell markers as CD133, Thy-1 or SCF. After exposure to osteogenic differentiation cocktails, calcium deposition was found in many of the arthroplasty membrane-derived fibroblasts, and (24.5±5.5)% of the fibroblasts expressed the mineralization precursor enzyme (alkaline phosphatase). When cultured in adipogenic media, (16.0 ±6.5)% of the cells differentiated into lipid droplet- containing adipocytes. Conclusion A portion of arthroplasty interface membrane-derived fibroblasts express mesenchymal stem cell-related surface antigens. Under certain conditions, these cells can differentiate into osteoblasts or adipocytes,suggesting the properties of mesenchymal stem cells.     

陈旧性Lisfranc损伤的成因与治疗

目的 分析陈旧性Lisfranc损伤的形成原因,探讨其手术治疗方法及效果. 方法2004年8月至2008年6月共收治20例陈旧性Lisfranc损伤患者,男16例,女4例;年龄21～49岁.术前均行CT三维重建,按照Myerson分型:Ⅰ型3例,Ⅱ型13例,Ⅲ型4例.17例患者行切开复位内固定,采用克氏针或螺钉固定,3例行关节融合术.术后按照Maryland足功能评分标准进行疗效评定. 结果 18例患者术后获6个月～4年(平均27个月)随访,2例失访.18例患者术后无内固定断裂、再骨折脱位等并发症发生.按照Maryland足功能评分标准评定疗效:66～96分,平均85分;其中优3例,良12例,可3例,优良率为83.3%.疗效欠佳的主要表现为中足疼痛、活动度减少. 结论影像学表现不典型、治疗不及时、方法选择有误等均可能造成陈旧性Lisfranc损伤.解剖复位、牢固内固定、重建足弓、恢复维持足部内外侧纵弓及横弓解剖形态是治疗的关键.     

髋臼骨折手术失败原因分析

目的 分析可能导致髋臼骨折手术失败的因素.方法 根据Matta X线评定标准和Merle d'Aubigne & Postel髋关节功能评价标准,以髋臼骨折术后复位分级为不满意或未行复位及固定,髋关节临床评价为"差",发生股骨头半脱位或脱位、股骨头坏死等严重髋关节并发症为治疗失败.回顾性分析2000年2月至2008年2月收治的22例髋臼骨折手术失败病例,男14例,女8例;年龄18～72岁,平均38.6岁.从术前影像学诊断、手术入路选择、内固定方案三方面对失败原因进行分析.结果 10例因髋臼后壁骨折未予以有效复位及固定而导致手术失败,占45.5%(10/22);6例因髋臼后柱骨折未予以有效复位及固定而导致手术失败,占27.3%(6/22);3例前壁骨折复位不满意,占13.6%(3/22);2例髋臼前柱骨折未予以复位及固定,占9.1%(2/22);1例未行骨折复位及固定而行全髋关节置换,占4.5%(1/22).在手术失败病例中单纯依靠X线片进行诊断的漏诊及误诊率为90%,X线片结合CT检查的误诊率为8.3%.10例诊断错误者入路选择错误率为100%;12例诊断正确者,其中7例入路选择不正确,错误率为58.3%,另5例虽入路选择正确,但3例因复位及内固定不满意,2例因内固定选择错误而导致手术失败.结论 术前漏诊或误诊、手术入路选择错误、复位方法及内固定选择错误、手术操作掌握不充分是导致髋臼骨折手术失败的可能原因.     

关节置换术与内固定术治疗老年人移位型股骨颈骨折的系统评价

目的 系统评价关节置换术和内固定术治疗老年人移位型股骨颈骨折的疗效. 方法 计算机检索Medline(1966年1月至2009年9月),荷兰医学文摘(1966年1月至2009年9月),Cochrane图书馆(2008年第1期)、中国生物医学文献数据库(截止2009年9月),中国学术期刊网(截止2009年9月),手工检索相关参考文献及中文期刊,收集所有关节置换术与内固定术比较治疗老年人(>60岁)移位型股骨颈骨折的随机对照试验(RCT),筛选出符合纳入标准的文献,对其进行严格的质量评价后应用RevMan4.2.8软件进行Meta分析. 结果 共纳入18个RCT,包含2561例患者.Meta分析结果显示,关节置换术术后2年再手术率(RR=0.13,95%CI 0.09～0.17)、5年再手术率(RR=0.11,95%CI 0.06～0.22)及术后2年主要并发症发生率(RR=0.20,95% CI 0.15～0.27)、5年主要并发症发生率(RR=0.18,95% CI 0.1 1～0.30)均低于内固定术.但二者术后1个月和2年病死率差异均无统计学意义(RR=1.42,95%CI 0.89～2.24;RR=1.01,95%CI 0.86～1.18).结论 与内固定术相比,关节置换术治疗老年人移位型股骨颈骨折可明显降低术后主要并发症的发生率及再次手术率,但两种术式的术后2年病死率无明显差异.     

牵拉成骨技术治疗下肢大段骨缺损

目的 探讨应用牵拉成骨技术治疗下肢大段骨缺损的临床疗效.方法 回顾性分析2002年8月至2010年8月收治的11例下肢大段骨缺损患者临床资料,男10例,女1例;年龄14～53岁,平均34.5岁.均行牵拉成骨治疗,右侧胫骨7例,左侧胫骨3例,右侧股骨1例;骨缺损长度5～15cm,平均8.6 cm;9例治疗已结束,2例仍处于矿化阶段.结果 所有患者术后获7～48个月(平均27.3个月)随访.9例治疗结束患者,平均骨愈合指数为1.99个月/cm;根据Paley评价系统评价骨性结果:优6例,良3例,优良率为100%;功能结果:优4例,良4例,一般1例.结论应用牵拉成骨技术治疗大段骨缺损,手术操作简单,尤其是对于单纯骨干缺损患者,采用单边外固定支架治疗,且其手术操作更为简洁.

Abstract：

Objective To discuss the therapeutic effect of distraction osteogenesis for large bone defect of the lower extremity. Methods From August 2002 to August 2010, 11 patients with large bone defect at the lower extremity were treated with distraction osteogenesis. They were 10 men and one woman, aged from 14 to 53 years (average, 34. S years). The defect was at the right tibia in 7 cases, left tibia in 3 cases and right femur in one case. The lengths of bone defect ranged from 5 to 15 cm (average, 8. 6 cm). Results The patients were followed up for 7 to 48 months, with a mean period of 27. 3 months. The treatment of 9 cases was over, with a mean healing index of 1. 99 months/cm. According to the Paley evaluation system, the bony results were excellent in 6 and good in 3 patients; the functional results were excellent in 4, good in 4, and fair in one patient. Two cases were still in the mineralization period. Conclusion Treatment of large bone defects with distraction osteogenesis is simple and can obtain satisfactory therapeutic effects, especially when a monolateral external fixator is used for the simple shaft bone defect.     

改良Galveston技术与拉力螺钉固定单侧骶髂关节脱位的有限元分析

目的 通过对改良Galveston技术与拉力螺钉同定单侧骶髂关节脱位的三维有限元模型进行分析,比较其生物力学稳定性.方法基于CT扫描数据,利用Mimics10.01软件和Geomagic10.0软件埘骨盆模型进行几何重建;利用Solidworks2007软件对内固定器械进行几何重建.导人Hypermesh 10.0软件中进行刚格划分和装配,赋予材料属性.建立右侧骶髂关节脱位双侧L4-髂骨Galveston固定、双侧L5-髂骨Galveston固定、单侧L4-髂骨Galveston同定、单侧L5-髂骨Galveston固定和拉力螺钉固定5种有限元模型.最后导入Ansys10.0软件中,在L4椎体上方模拟施加500 N轴向压缩载荷,分析不同内固定方式的von Mises应力分布和应变分布.结果从应力和应变云图可知,双侧L4-髂骨Galveston固定、舣侧L5-髂骨Galveston固定、单侧L4-髂骨Galveston固定、单侧L5-髂骨Galveston固定及拉力螺钉固定后骨盆的最大应力值分别为1.690×109 Pa、1.310×109 Pa、0.834×109 Pa、0.836×109 Pa、1.584×109 Pa;骶骨相对于左侧髋骨的移位方向为向下、向前和向右,总位移依次为1.589×10-3m、1.871×10～m、2.404×10-3 m、2.468×10-3m、0.308×10-3m.结论各种内固定下 Von Mises应力集中分布于腰髂螺钉与骨质的结合部位.改良Galveston技术双侧固定较单侧固定应变小,无论是双侧固定还是单侧固定,固定于L4和L5的应变无明显差异,但均明显大于拉力螺钉吲定.

Abstract：

Objective To explore biomechanical properties of modified Galveston technique and lag screw fixation for dislocation of the unilateral sacroiliac ioint through finite element analysis. Methods Soft-ware Mimics 10.0l and Geomagic 10.0 was used to develop a geometric reconstruction of the pelvis based on the CT scan data.Geometric reconstructions of different internal fixations were also developed using software Solidworks 2007.The models were meshed,assembled and given the material properties through software Hypermesh 10.0.Five models of three-dimensional finite element(3D FE)were established for dislocation of the sacroiliac ioint:double L4-ilium Galveston fixation,double L5-ilium Galveston fixation,single L4-ilium Galveston fixation.single L5-ilium Galveston fixation,and lag screw fixation,Finally the models were imported to software Ansys 10.0.An axial load of 500 N was compressed above the L4 vertebral body.Stress-strain nephograms for the 5 different fixations were compared.and biomechanical stabilities of different internal fixations were analyzed. Results The stress-strain nephograms showed the maximum pelvic stresses in the 5 fixations were respectively 1.690×109Pa(double L4-1 Galveston),1.130×109Pa(double 1.584×109Pa(1ag screw fixation).Displacements of the sacrum were downward,forward,and rightward.The total displacements were respectively 1.589×10-3m,1.871×10-3m,2.404×10～m,2.468×10-3m and 0.308 ×103 m. Conclusions The maximum displacement in bilateral fixation is smaller than that in unilateral fixation with modified Galveston technique.In both bilateral and unilateral Galveston fixations for L4and L5,the maximum displacements are not significantly different,but they are larger than that in lag screw fixation.     

Distribution and property of nerve fibers in human long bone tissue

Objective： To observe the distribution of the nerve fibers in the bone tissue and the entry points of these fibers into the bone. Methods： The adult tibia was used for the ground sections which were afterwards made into the slice sections by decalcification in ethylenediamine tetraacetic acid （EDTA）. The ground sections were stained in silver and the slice sections were stained in silver and haematoxylin and eosin （HE） respectively. Then, the samples of the transmission electron microscope and the atomic force microscope were made and observed. Results ： In the human long bone tissue, many nerve fibers were distributed in the membrane, cortical bone, cancellous bone and marrow. The nerve fibers entered the bone from the nutrient foramen, and passed through the nutrient canal, Haversian＇ s canal and Volkmann＇ s canal, and finally into the bone marrow. In the nutrient canal, the nerve fibers, mainly the medullary nerve fibers, followed the blood vessel into the bone. In the cortical bone, the nerve fibers also followed the blood vessels and were mainly distributed along Haversian＇ s canal and Volkmann＇ s canal. In the bone trabecular and bone marrow, there were many nerve fiber endings arranged around the blood vessels, mainly around the tunica media of medium-size arteries in the marrow and around capillary blood vessels, and a few scattered in the bone marrow. There were sporadic nerve endings in epiphyseal plate and no nerve fibers permeated epiphysis to diaphysis. No distribution of nerve fibers could be found in cartilaginous part. Conclusions： There are many nerve fibers in bone and the nerve passageway is nutrient foramen, Volkman＇ s canal, Haversian＇ s canal and bone marrow.     

Suture Button装置修复下胫腓联合损伤的初步报告

[目的] 探讨Suture Button装置治疗下胫腓联合损伤后的手术方法及临床效果.[方法] 对截止于2007年9月利用Suture Button装置固定的下胫腓联合急、慢性损伤的13例病人进行连续随访观察,通过术后X线片数字化测量和标准的踝足功能评分,评估其疗效并探讨临床应用前景.[结果] 除1例病人因术后短期再次创伤意外,行2次手术更换为传统螺钉内固定外,其余病人均在术后6周开始部分负重功能锻炼,术后第3个月功能平均评分达到满意,术后第6、12个月功能平均评分达到优良,X线片未发现内固定失效.[结论] Suture Button装置治疗下胫腓联合损伤具有技术简单、手术时间短、内固定器物理特性符合人体正常解剖生理、固定强度足够、无需2次手术取出等多项优势,可能成为下胫腓联合损伤新的治疗标准.