微创内固定治疗胫骨下段骨折

目的探讨微创内固定治疗胫骨下段骨折的临床疗效。方法对58例胫骨下段骨折患者采用微创经皮钢板内固定(MIPPO)技术进行手术治疗。根据Johner-Wruhs评分标准评价疗效。结果患者均获得随访,时间9~18个月。末次随访时根据Johner-Wruhs评分标准评价疗效:优40例,良14例,一般3例,差1例,优良率93.1%。结论遵循生物力学内固定理论的指导原则,采用MIPPO技术治疗胫骨下段骨折,可取得较满意的临床疗效。     

钢板结合异体骨板治疗股骨干内固定术后再骨折

目的：探讨钢板结合异体骨板治疗股骨干钢板内固定术后再骨折的疗效。方法：股骨干钢板内固定术后再骨折13例,其中男8例,女5例;年龄14～57岁,平均31.2岁。粉碎性骨折7例,斜形骨折4例,横形骨折2例。8孔股骨有限接触加压钢板5例,8孔上肢有限接触加压钢板2例,6孔股骨有限接触加压钢板2例,8孔兰氏钢板4例。钢板断裂均发生在骨折端邻近钉孔处。全部采用有限接触加压钢板（LC-DCP）加对侧异体脱蛋白骨板股骨双固定及自体髂骨移植术。结果：13例均获得随访,时间16～40个月,平均32个月,平均骨折愈合时间为9个月,均恢复下肢行走和负重的功能。术后1年膝关节功能按Merchan标准评定：优7例,良4例,可1例,差1例,优良率84.6%（11/13）。结论：自体髂骨植骨钢板结合骨板内固定治疗股骨干再骨折效果好,可以达到骨折牢固固定的目的。     

股骨近端解剖型钢板治疗股骨粗隆下不稳定性骨折

目的:探讨股骨近端解剖型钢板治疗股骨粗隆下不稳定骨折的临床价值.方法:自2001年1月～2003年6月采用切开复位、股骨近端解剖型钢板内固定治疗股骨粗隆下不稳定骨折23例.根据术前术后X线片及术后髋关节功能、站立及行走等恢复情况评价内固定效果.结果:17例获得随访,随访时间6个月～3年,根据黄公怡评定标准,优9例,良6例,差2例.结论:股骨近端解剖型钢板治疗高位股骨粗隆下不稳定骨折具有安全可靠、能允许术后早期部分负重等特点,是治疗高位股骨粗隆下骨折的理想选择.     

组织工程肋骨移植修复胸壁巨大缺损

目的　应用组织工程技术构建的肋骨和带蒂皮瓣移位修复 1例 2 5岁女性患者胸壁巨大韧带样纤维瘤切除后 ,合并软组织、肋骨缺损的早期效果。方法　经髂骨穿刺抽取骨髓组织 ,按 Houghton法分离培养骨髓基质干细胞 ,经定向诱导分化为成骨样细胞 ;用同种异体肋骨经去细胞、去抗原、部分脱钙和冻干处理 ,制成保存天然框架的生物衍生骨支架 ,将 5× 10 6 /ml骨髓基质干细胞与骨支架材料联合培养 6天 ;待完整切除肿瘤后 ,用膈肌瓣修复胸膜腔 ,组织工程肋骨修复 3根肋骨 ,同侧带蒂侧腹壁皮瓣移位修复胸壁软组织缺损。结果　手术经过顺利 ,伤口 期愈合。术后 3个月随访 ,植入组织工程肋骨在体内逐渐发育成成熟肋骨 ,心肺功能显著改善。结论　应用自体骨髓基质干细胞构建的组织工程肋骨在个体化治疗中显示了优越性。     

Rip hump correction and rotation of the lumbar spine after selective thoracic fusion

In this study a series of 32 patients with idiopathic scoliosis, managed with selective thoracic fusion, was reviewed. Classified according to King and instrumented with the H-frame, the patients were evaluated for curve correction, rib hump correction and postoperative shift in lumbar rotation. Age and follow-up averaged 19.4 and 2.4 years, respectively. The 32 patients had an average primary and lumbar curve correction of, respectively, 66% (6.0% correction loss) and 53% (3.4% correction loss). The respective values for postoperative rib hump correction and shift in apical lumbar rotation averaged 8° and 9.4° in type II King curves, 4.4° and 3.5° in type III and 11° and-5° in Type IV. Significant differences were noted between the curve types in rib hump correction and shift in lumbar rotation. The study showed that en bloc postoperative rotation of the compensatory lumbar segment, directed towards the rib hump, positively influences rib hump correction. This en bloc rotation of the unfused lumbar segments is induced by the correcting forces applied by the instrumentation. The unfused lumbar spine of a patient with a King type II curve shows a larger lumbar rotation shift and subsequent rib hump correction than that of a patient with a King type III curve. Together with factors such as lateral angulation, rib-vertebra angles and structural limitations, the rotational dynamics of the unfused lumbar spine seem to form an important component in the understanding and surgical management of scoliosis.     

Preoperative and early postoperative three-dimensional changes of the rib cage after posterior instrumentation in adolescent idiopathic scoliosis

Rib cage deformity is an important component of scoliosis, but few authors have reported the three-dimensional (3-D) effect of surgical procedures with posterior instrumentation systems on the shape of the rib cage. The objective of this prospective clinical study was to measure the short-term 3-D changes in the shape of the rib cage at the apex of the curve after corrective surgery of adolescent idiopathic scoliosis by a posterior approach using a multi rod, hook and screw system. The 3-D shape of the spine and rib cage was modelled pre- and postoperatively using a 3-D reconstruction technique based on multi-planar radiography in a group of 29 adolescents with idiopathic scoliosis. Geometrical indices describing the scoliotic deformity of the rib cage were computed from these models and were compared pre- and postoperatively using Student's t-tests. The frontal spinal curve correction averaged 53% in the frontal plane, while no significant change was noted in the sagittal plane. Significant changes were noted in the shape of the rib cage: rib hump at the apex and at the adjacent lower level were improved (36% and 38%), and small but significant differences were detected in rib frontal orientation in the concavity of the curves at the apex and adjacent lower rib levels. Multi rod, hook and screw instrumentation systems, such as Cotrel-Dubousset instrumentation, are effective in producing significant improvements in the 3-D shape of the rib cage, but these changes are less important than those observed at the spine level.     

复杂胫骨平台骨折2种手术治疗方法的比较分析

目的比较双切口双钢板内固定术与膝前正中切口锁定钢板内固定术治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折的手术效果。方法 76例SchatzkerⅤ、Ⅵ型胫骨平台骨折采用膝前正中切口锁定钢板内固定术治疗38例（A组）,采用双切口双钢板内固定术治疗38例（B组）。比较2组手术时间、术中出血量、住院时间、术后至开始负重时间、骨折愈合时间、胫骨平台内翻角（TPA）、胫骨平台内侧后倾角（PSA）、并发症及末次随访时Rasmussen膝关节功能评分。结果 B组手术时间、术中出血量、住院时间、术后至开始负重时间少于A组,B组术后TPA、PSA小于A组,差异均有统计学意义（P〈0.05）;但2组骨折愈合时间比较差异无统计学意义（P〉0.05）。B组出现钉道感染、关节强直、膝内翻畸形、骨折延迟愈合的患者较A组少,差异有统计学意义（P〈0.05）;2组切口感染、皮肤坏死、内固定松动断裂、膝关节不稳、骨坏死及骨折不愈合并发症比较差异无统计学意义（P〉0.05）。末次随访时Rasmussen膝关节功能评分：A组优5例,良16例,可10例,差7例,优良率55.3%;B组优14例,良15例,可6例,差3例,优良率76.3%;B组Rasmussen膝关节功能评分优于A组,差异有统计学意义（P〈0.05）。结论对于SchatzkerⅤ、Ⅵ型胫骨平台骨折,双切口双钢板内固定术手术时间短,治疗效果较好,并发症较少。     

3D镜像打印结合微创技术治疗成人锁骨中段骨折

目的：探讨3D镜像打印结合微创经皮钢板内固定（minimally invasive percutaneous plate osteosynthesis,MIPPO）技术治疗成人锁骨中段骨折的临床疗效。方法：2019年10月至2020年10月采用3D镜像打印结合MIPPO技术治疗32例成人锁骨AllmanⅠ型移位骨折患者,其中男19例,女13例;年龄19~55（34.12±16.42）岁;按Allman分型,Ⅰb型14例,Ⅰc型18例;左侧17例,右侧15例。观察患者的并发症、手术时间、切口长度、术中出血量、透视次数和骨折愈合时间情况,并于术前,术后1、6个月采用Constant-Murley肩关节评分进行临床疗效评价。结果：32例患者均获得随访,时间6~8（6.67±2.13）个月。无刀口感染及术区皮肤麻木等并发症发生。手术时间（35.37±4.28） min;切口长度（3.78±0.45） cm,术中出血量（37.23±4.76） ml,透视次数（3.12±0.47）次,骨折愈合时间（8.18±2.58）周。术后1、6个月Constant-Murley肩关节评分分别为81.08±3.92、98.03±1.05,与术前54.62±5.25比较差异有统计学意义（P<0.05）。术后6个月根据Constant-Murley肩关节功能评分,结果优30例,良2例。结论：3D镜像打印可有效辅助MIPPO技术治疗成人锁骨AllmanⅠ型移位骨折,具有创伤小、并发症少等优点,可缩短手术时间,提高手术可操作性,是治疗成人锁骨AllmanⅠ型移位骨折的较好方法。     

论著胸外科胸壁重建肋骨骨折内固定有关的肋骨几何形态学研究

目的采用X线计算机断层摄影术（CT）测量成年人第3～9肋的几何形态,为肋骨内表面解剖型接骨板提供设计参数。方法选择2012年5～7月在河北省人民医院行胸部CT扫描的患者20例,男10例、女10例,汉族,身高167～180（173±8）cm,年龄16～58（37±18）岁,排除外伤及其他导致肋骨外形及密度异常的疾病。胸部CT扫描后,重建骨性胸廓三维图像,对肋骨几何形态进行分析与测量。结果将肋骨按如下方法分为3个区：肋头～37．5％点（1区）,25．0％点～75．0％点（2区）,50．0％点～100．0％点（3区）。肋骨长轴整体弯曲度最大值均出现在1区,其中第3肋最大[（20．24±2．86）／m）],第8肋2区最小[（6．14±0．96）／m],第7～9肋中2区弯曲度小于其他两区,第3～6肋弯曲度最小值出现在3区。肋骨沿其长轴都有扭转,数值是30°～50°肋骨的铺展角先下降后逐渐上升。髓腔面积变化范围是从肋骨后部的27．59mm2。到前部的55．91mm2。结论多层螺旋CT三维重建肋骨像能准确显示并测量肋骨的形态特征,为临床肋骨内固定器械的设计提供实用的影像学测量方法。     

解剖型钢板治疗胫骨远端骨折

胫腓骨骨折发生率很高,约占长骨骨折的10％。胫腓骨远端骨折在胫腓骨骨折中最为常见,由于涉及干骺端的骨折,髓内钉治疗有其局限性。2002年3月～2003年7月,笔者采用解剖型钢板治疗胫骨远端骨折12例,取得了良好疗效。