胫骨骨折患者术后血清小凹蛋白-1蛋白含量与延迟愈合关系的探究

目的:探讨胫骨骨折患者切开复位内固定手术后血清小凹蛋白-1(caveolin-1)蛋白含量与延迟愈合的关系。方法:自2018年4月至2020年6月收治接受切开复位内固定手术的134例胫骨骨折患者,根据骨折愈合情况分为延迟愈合组和正常愈合组。比较两组患者术前及术后1、4、8、12周时血清caveolin-1蛋白含量,采用Logistic回归模型分析骨折延迟愈合的影响因素,采用受试者工作特征(receiver operating characteristic,ROC)曲线分析血清caveolin-1蛋白对骨折延迟愈合的预测价值。结果:骨折后4个月时随访评估愈合情况,正常愈合93例,延迟愈合41例。术后1、4、8、12周时,延迟愈合组血清caveolin-1蛋白含量均低于正常愈合组(P<0.05);延迟愈合组与正常愈合组在吸烟、糖尿病、开放性骨折、Gustlio分型Ⅲ型方面比较差异有统计学意义(P<0.05);经Logistic回归分析,吸烟、糖尿病、开放性骨折、Gustlio Ⅲ型骨折及术后4、8周时血清caveolin-1蛋白含量降低是骨折延迟愈合的危险因素(P<0.05);经ROC曲线分析,术后4、8周时血清caveolin-1蛋白含量对骨折延迟愈合具有预测价值,预测的最佳截断值分别为12.45、12.52 ng/ml,对应的灵敏度为45.34%、43.90%,特异性为80.65%、87.10%(P<0.05)。结论:胫骨骨折患者切开复位内固定术后4、8周时血清caveolin-1蛋白含量降低与延迟愈合有关,术后4、8周时检测血清caveolin-1蛋白含量对延迟愈合具有预测价值。     

自体骨移植与骨形成蛋白治疗成人长骨骨折不愈合的Meta分析

目的：系统评价自体骨移植与骨形成蛋白治疗成人长骨骨折不愈合相关指标,为成人长骨骨折不愈合治疗提供参考依据。方法：计算机检索PuMed、Embase、Cochrane图书馆、中国知网（CNKI）、万方数据期刊全文数据库及中国生物医学文献数据库（CBM）发表的对于自体骨移植与骨形成蛋白治疗成人长骨骨折不愈合的随机对照试验,检索时间从建库至2019年3月。由2名研究者按照纳入和排除标准独立进行筛选文献,提取资料,并采用Jadad评价量表对纳入的文献进行质量评价。采用RevMan 5.3统计学软件对两种方法的感染发生率、成功愈合率、二次手术率、住院时间及术中失血量进行Meta分析。结果：共纳入7个随机对照试验研究,共652例患者,自体骨移植组有410例,骨形成蛋白组有242例。Meta分析结果显示：自体骨移植组与骨形成蛋白组在感染发生率［RR=1.32,95%CI（0.90,1.93）,P=0.16］,成功愈合率［RR=0.95,95%CI（0.84,1.08）,P=0.43］,二次手术率［RR=1.16,95%CI（0.43,3.12）,P=0.76］及住院时间［MD=0.69,95%CI（-0.38,1.75）,P=0.21］方面比较差异无统计学意义。自体骨移植组术中失血量明显高于骨形成蛋白组［MD=223.00,95%CI（32.72,413.28）,P=0.02］。结论：对于成人长骨骨折不愈合的治疗,骨形成蛋白可以获得和自体骨移植一样的骨折愈合率,同时可以明显减少术中失血量。骨形成蛋白可能更适合成人长骨骨折不愈合的治疗。     

胫骨平台骨折的手术治疗策略分析

目的探讨分析手术治疗胫骨平台骨折的策略。方法回顾性分析我院在2011年3月至2013年10月收治的30例胫骨平台骨折患者的手术治疗情况,其中13例患者行双柱支撑固定植骨手术治疗,17例患者行单柱支撑固定植骨手术治疗。结果本组所有患者术后经过1²年时间随访,参照Rasmussen膝关节功能评分,结果治疗优良者26例,优良率为86.7%,其中优17例,良10例,可2例,差1例。结论在确保骨折部良好血运的情况下,首先解剖复位胫骨平台,并进行支撑固定植骨手术治疗的手术治疗效果显著,固定更加持久、稳固,是一种安全有效的手术方法,值得在临床上进一步推广。     

Fibula head is a useful landmark to predict the location of posterior cruciate ligament footprint prior to total knee arthroplasty

Purpose

The hypothesis of our study is that a routine tibial cut during cruciate retaining TKA may result in a partial or a total removal of the PCL footprint. Therefore providing a reliable landmark is essential to estimate the probability of PCL damage with a tibial cut and to enable the surgeon to decide pre-operatively whether a cruciate retaining implant design is suitable.

Methods

In a case series of 175 cruciate retaining TKA, the routinely made standing postoperative AP-view radiographs were evaluated to determine the distance between fibula head and tibial cutting plane. In a second case series knee MRI of 223 subjects were consecutively used to measure the vertical distance between tibial attachment of PCL and fibula head. The probability of partial or total PCL damage was calculated for different vertical distances between tibial cut and fibula head.

Results

The vertical distance between the tibial cut and the most proximal point of the fibula head averaged 6.1 mm ±4.8 mm. The mean vertical distance from fibula head to proximal and to distal PCL footprint revealed to be 11.4 mm ±3.7 mm and 5.4 mm ±2.9 mm, respectively. The location of the insertion was not significantly different between subgroups such as age (<50 or >50 years), gender and side. Based on our results 11 (7 %) knees were considered at high risk of an entire PCL removal after implantation of a cruciate retaining TKA design.

Conclusions

Currently available routine tibial preparation techniques result in partial or total posterior cruciate ligament detachment. Fibula head as a landmark aids to predict the PCL location and to estimate its disruption pre- and postoperatively on AP-view radiographs.     

Effect of tibial drill-guide angle on the mechanical environment at bone tunnel aperture after anatomic single-bundle anterior cruciate ligament reconstruction

Purpose

The tibial drill-guide angle in anterior cruciate ligament (ACL) reconstruction influences the tunnel placement and graft-tunnel force, and is potentially associated with post-operative tunnel widening. This study aimed to examine the effect of the drill-guide angle on the stress redistribution at the tibial tunnel aperture after anatomic single-bundle ACL reconstruction.

Methods

A validated finite element model of human knee joint was used. The tibial tunnel with drill-guide angle ranging from 30° to 75° was investigated. The post-operative stress redistribution in tibia under the compressive, valgus, rotational and complex loadings was analysed.

Results

Compressive loading played a leading role on the stress redistribution at intra-articular tibial tunnel aperture. After ACL reconstruction, stress concentration occurred in the anterior and posterior regions of tunnel aperture while stress reduction occurred in the lateral and posteromedial regions under the compressive loading. Stress redistribution was partially alleviated by using the drill-guide angle ranging from 55° to 65°.

Conclusions

The present study quantified the effect of bone tunnel drill-guide angle on the post-operative stress redistribution. This phenomenon potentially contributed to tunnel widening. A tunnel drill-guide angle ranging from 55° to 65° was proposed based on the biomechanical rationale. It could serve as a helpful surgical guide for ACL reconstruction.     

外后侧弧形切口双肌间隙入路治疗胫骨后外侧平台塌陷骨折

 目的 探讨外后侧弧形切口双肌间隙入路治疗胫骨后外侧平台塌陷骨折的临床疗效。方法 回顾性分析 2009年 8月至 2013年 3月,采用外后侧弧形切口双肌间隙入路治疗 32例伴有后外侧劈裂、塌陷的胫骨平台骨折患者资料,男 15例,女 17例;年龄 28~77岁,平均 46.25岁;均为闭合性骨折,均未合并神经及血管损伤;受伤至内固定手术时间为 3~ 18 d,平均 7.13 d。通过外后侧入路在胫前肌、腘肌和比目鱼肌间隙两个间隙分别显露胫骨前外侧髁及后外侧髁,在直视下复位骨折,分别用“高尔夫”与“T”形锁定钢板固定胫骨前外侧和后外侧骨折。术后按 Rasmussen 评分评价胫骨平台骨折复位情况,按美国特种外科医院（hospital for special surgery, HSS）评分评价膝关节功能。结果 32例患者均获得随访,随访时间 6~36个月,平均 15.3个月。术后 X线片均示骨折复位良好,关节面未见明显塌陷。骨折全部愈合,愈合时间 6~ 14周,平均 11.2周。末次随访时,Rasmussen评分为 6~18分,平均 14.06分,其中优 14例,良 15例,可 3例,优良率为 90.62%（29/32）。HSS评分为 57~92分,平均 78.25分,其中优 11例,良 17例,可 3例,差 1例,优良率为 87.5%（28/32）。无一例发生腓总神经损伤及重要血管、神经损伤、手术区皮肤坏死、感染或内固定松动。结论 胫骨平台后外侧塌陷骨折采用外后侧弧形切口双肌间隙入路治疗,在一个切口内既可显露胫骨前外侧平台骨折又可兼顾后外侧塌陷骨折,无须腓骨小头截骨,创伤小,切口间皮瓣坏死及钢板外露的发生率低,是一个值得推广的入路。     

Fracture healing following high energy tibial trauma: Ilizarov versus Taylor Spatial Frame

Introduction

The optimal treatment of high energy tibial fractures remains controversial and a challenging orthopaedic problem. The role of external fixators for all these tibial fractures has been shown to be crucial.

Methods

A five-year consecutive series was reviewed retrospectively, identifying two treatment groups: Ilizarov and Taylor Spatial Frame (TSF; Smith & Nephew, Memphis, TN, US). Fracture healing time was the primary outcome measure.

Results

A total of 112 patients (85 Ilizarov, 37 TSF) were identified for the review with a mean age of 45 years. This was higher in women (57 years) than in men (41 years). There was no significant difference between frame types (p=0.83). The median healing time was 163 days in both groups. There was no significant difference in healing time between smokers and non-smokers (180 vs 165 days respectively, p=0.07), open or closed fractures (p=0.13) or age and healing time (Spearman''s r=0.12, p=0.18). There was no incidence of non-union or re-fracture following frame removal in either group.

Conclusions

Despite the assumption of the rigid construct of the TSF, the median time to union was similar to that of the Ilizarov frame and the TSF therefore can play a significant role in complex tibial fractures.     

Bilateral double osteotomy in severe torsional malalignment syndrome: 16 years follow-up

Background

Torsional malalignment syndrome (TMS) is a well defined condition consisting of a combination of femoral antetorsion and tibial lateral torsion. The axis of knee motion is medially rotated. This may lead to patellofemoral malalignment with an increased Q angle and chondromalacia, patellar subluxation and dislocation. Conservative management is recommended in all but the most rare and severest cases. In these cases deformity correction requires osteotomies at two levels per limb.

Materials and methods

From 1987 to 2002 in our institution three patients underwent double femoral and tibial osteotomy for TMS bilateral correction (12 osteotomies). All patients were reviewed at mean follow-up of 16 years.

Results

At final follow-up no patients reported persistence of knee or hip pain. At clinical examination both lower limbs showed a normal axis and a normal patella anterior position. Pre-operative femoral version measurement showed an average hip internal rotation of 81.5° (range 80°–85°) and average hip external rotation of 27.2° (10°–40°). Thigh–foot angle measurement showed an average value of 38.6° (32°–45°). At final follow-up femoral version measurement showed an average hip internal rotation of 49° (range 45°–55°) and average hip internal rotation of 44.3° (20°–48°) (Figs. 1, 2, 3, 4, 5, 6). Thigh–foot angles measurement showed an average value of 21.6° (18°–24°) outward.

Conclusion

We recommend a clinical, radiographical and CT scan evaluation of all torsional deformity. In cases of significant deformity, internally rotating the tibia alone is not sufficient. Ipsilateral outward femoral and inward tibial osteotomies are our current recommendation for TMS, both performed at the same surgical setting.     

Reamed or unreamed intramedullary nailing for tibial fractures: a meta-analysis

Objective：To compare the treating effects of different intramedullary nailing methods on tibial fractures in adults.Methods：Literature reports in both Chinese and English languages were retrieved （from the earliest available records to October 1,2013） from the PubMed,FMJS,CNKI,Wanfang Data using randomized controlled trials （RCTs） to compare reamed and unreamed intramedullary nailing for treatment of tibial fractures.Methodological quality of the trials was critically assessed,and relevant data were extracted.Statistical software Revman 5.0 was used for data-analysis.Results：A total of 12 randomized controlled trials,comprising 985 patients （475 in the unreamed group and 510 in the reamed group）,were eligible for inclusion in this meta-analysis.The results of metaanalysis showed that there were no statistically significant differences between the two methods in the reported outcomes of infection （RR=0.64; 95％CI,0.39 to 1.07;P=0.09）,compartment syndrome （RR=1.44; 95％CI,0.8to 2.41; P=0.16）,thrombosis （RR=1.29; 95％CI,0.43to 3.87; P=0.64）,time to union （WMD=5.01; 95％CI,-1.78 to 11.80; P=0.15）,delayed union （nonunion）（RR=1.56; 95％CI,0.97 to 2.49; P=0.06）,malunion （RR=1.75; 95％CI,1.00 to 3.08; P=0.05） and knee pain （RR=0.94; 95％CI,0.73 to 1.22; P=0.66）.But there was a significantly higher fixation failure rate in the unreamed group than in the reamed group （RR=4.29; 95％CI,2.58to 7.14; P＜0.00001）.Conclusion：There is no significant difference in the reamed and unreamed intramedullary nailing for the treatment of tibial fractures,but our result recommends reamed nails for the treatment of closed tibial fractures for their lower fixation failure rate.