椎间盘镜下异体松质骨复合自体红骨髓植骨治疗骨不连及骨缺损

目的探讨椎间盘镜下异体松质骨复合自体红骨髓植骨治疗四肢长骨干骨不连及骨缺损的临床疗效。方法2003年9月～2006年9月,选择25例创伤后骨不连、骨缺损患者,其中胫骨9例,股骨13例,肱骨3例。骨不连、骨缺损引起须植骨长度1～6 cm,平均2.7 cm,均在椎间盘镜下行瘢痕清除,然后在骨缺损部位植入异体松质骨,再于髂骨取自体红骨髓15～20 ml注入植骨处。结果25例随访12～36个月,平均25个月,切口均一期愈合,无一例发生神经血管损伤症状。除2例术后内固定失败外,余23例骨不连、骨缺损均获骨性愈合,植骨生长良好,骨愈合时间4～9个月,平均5.1月,无感染及再出现骨不连。结论椎间盘镜下异体松质骨复合自体红骨髓植骨治疗骨不连和骨缺损,无须自体髂骨取骨,局部创伤小,血运破坏小,并发症少,骨愈合率高,是一种微创有效的治疗方法。     

抗感染活性骨与自体骨在骨不连治疗中的对比研究

目的 对比研究抗感染活性骨(ARBX)与自体骨治疗四肢长骨非感染性骨不连的疗效.方法 通过病例回顾研究,比较ARBX与自体髂骨植骨治疗非感染性骨不连的疗效.结果 两组随访95例,随访时间平均4年6个月.ARBX植骨29例,其中26例完全愈合,3例未愈合,骨性愈合率为89.7%;自体髂骨植骨66例,其中60例完全愈合,6例未愈合,骨性愈合率为90.9%.结论 ARBX植骨与自体髂骨植骨治疗四肢非感染性骨不连的疗效相当;ARBX具有良好的骨传导、骨诱导作用,是一种良好的植骨材料.     

体外培养经皮移植自体骨髓间充质干细胞治疗四肢骨不连

目的:探讨体外培养经皮移植自体骨髓间充质干细胞(MSCs)治疗四肢骨折骨不连的效果。方法:12例四肢骨折骨不连患者采用体外培养经皮移植自体MSCs治疗。结果:9例获得了骨性愈合,骨折愈合平均时间为5个月(4~7月),X线显示骨折线消失,骨痂形成。骨折愈合率为75%(9/12)。结论:体外培养经皮移植自体MSCs治疗四肢骨折骨不连创伤小、安全、并发症少,临床效果满意。     

Ilizarov methodology for infected non union of the Tibia: Classic circular transfixion wire assembly vs. hybrid assembly

Introduction:

Conventional wire fixation of Ilizarov rings often fails to provide 90-90 configuration because of vital structures, which is essential for optimum stability. Hybrid assembly with half pins is an alternative. The aim of this study is to compare the results of Hybrid assembly with that of conventional classic circular transfixion wire Ilizarov assembly in 50 cases of infected nonunion of tibia between 1994 and 2003.

Materials and Methods:

This study includes two groups with 25 patients in each group: Group (A) conventional Ilizarov assembly and Group (B) hybrid Ilizarov assembly. Thirty-five cases developed infected nonunion following road traffic accidents while others after fall (6) bullet injury (4), infected osteosynthesis (3) and assault (2). There were 45 males and five females with mean age (18 to 56 years). All active cases (n=28) were treated by debridement including removal of implants in infected osteosynthesis. Twenty out of 22 cases in the quiescent group (non draining for last three consecutive months) were treated without open debridement; only two cases required open debridement for various reasons. All the cases were finally treated as atrophic aseptic nonunion with bone defect and were classified according to ASAMI.Type B1: length of the limb maintained with bone gap (14 cases in both Group A and B) and Type B3: combined shortening with defect (five and seven cases in Group A and B respectively), were treated by bifocal osteosynthesis. Only one case in the B3 group was treated by trifocal osteosynthesis to shorten the time. Type B2: segments in contact with limb shortening (total nine cases; five and four cases in Group A and B respectively) with shortening up to 2 cm (total five cases) were treated with monofocal osteosynthesis while shortening up to 5 cm and beyond (total four cases) were treated with bifocal osteosynthesis.

Results:

The cases were followed up for two to six years and the results were evaluated by Paley criteria of bony results (union, infection, deformity and leg-length discrepancy) and Functional Results (significant limp, equinus rigidity of the ankle, soft-tissue dystrophy, pain and inactivity). In both the groups, 24 cases out of 25, had excellent to good bony result with Group B having twice more excellent result than Group A. Functional results were found to be similar in both the groups. Although persistence of infection and Grade III pin tract infection (PTI) were slightly higher in Group B, complications like delayed consolidation of regenerate, refracture, deformity and aneurysm of vessel were less in this group.

Discussion and Conclusion:

Ilizarov methodology produced a satisfactory result in infected nonunion of the tibia. Hybrid assembly was a fruitful advancement in the Ilizarov armamentarium. The results were comparable to Conventional assembly in terms of docking site problems, corticotomy site problems, PTIs and other problems.     

下肢骨折内固定术后隐性感染致骨不连

目的探讨下肢骨折内固定术后隐性感染致骨不连的治疗方法。方法2000年-2005年,共收治下肢骨折内固定术后隐性感染致骨不连患者8例,男5例,女3例;年龄24岁～72岁,平均年龄47.3岁;均为闭合性骨折。予以内固定取出,同时行病灶清刮、伤口灌洗术,其中2例胫骨骨折患者取出原内固定物后即行植骨加单边外固定支架重新固定,2例股骨骨折患者取出内固定后即予植骨加桥接钢板内固定,3例胫骨骨折、1例股骨骨折患者取出内固定后予下肢管形石膏托固定,Ⅱ期再行植骨内固定。8例患者根据伤口分泌物细菌培养结果行静脉抗炎治疗。结果术后1例伤口窦道形成,其余7例患者切口正常愈合。4例予Ⅰ期自体髂骨植骨加固定,术后3例骨折愈合,1例6个月未见骨痂生长,再予植骨、交锁髓内钉固定。另4例未Ⅰ期固定者3个月后均未见骨痂生长,再予行切开植骨内固定术,术中未见肉芽样组织及渗出。所有8例患者在植骨固定术后平均22.4个月骨折愈合。结论隐性感染是造成骨折不愈合的重要原因之一,及时病灶清刮、伤口灌洗,根据时机植骨固定是促进骨折愈合的正确方法。     

Percutaneous screw fixation for scaphoid nonunion in skeletally immature patients: a report of two cases

Nonunion of the scaphoid waist in skeletally immature patients is rarely diagnosed. We report 2 cases of scaphoid nonunion in skeletally immature patients who underwent percutaneous screw fixation without bone graft. In stable nonunions with minimal sclerosis, percutaneous screw fixation without bone graft can be an alternative to the conventional open procedure in skeletally immature patients, with successful union and clinical outcome.     

Volar wedge grafting for scaphoid nonunion with collapse

Fractures of the scaphoid waist that fail to heal tend to collapse into a flexed posture. The so-called "humpback deformity" of the bone is accompanied by collapse of the proximal carpal row with dorsal tilt of the lunate. It is possible to restore scaphoid height and carpal alignment by insertion of a tricortical wedge of graft from the iliac crest. In this article, we demonstrate the surgical technique of volar wedge grafting for scaphoid nonunion.     

Pediatric scaphoid nonunion

PURPOSE: To report the outcome of pediatric scaphoid nonunions treated with a Herbert screw and bone graft. METHODS: This is a retrospective review of 12 cases of scaphoid nonunion in 12 skeletally immature patients treated with a uniform approach consisting of open reduction, iliac crest bone grafting and Herbert screw fixation. All patients were boys and presented with nonunions of the scaphoid waist. The final follow-up evaluation was at a mean of 32 months, ranging from 22 to 45 months, and consisted of assessing anatomic snuffbox tenderness, wrist arc of motion, grip strength, calculation of the Modified Mayo Wrist score, and assessment of union based on plain radiographs. RESULTS: At the latest follow-up evaluation, all patients were pain free (including absence of snuffbox tenderness) except one who experienced slight discomfort during extreme activities. There was no statistically significant difference in the arc of motion between the surgically treated and healthy sides, and the average grip strength was 96% that of the contralateral extremity. Clinical and radiographic union was present in all cases at a mean of 3.4 months after surgery. The Modified Mayo Wrist score was excellent in 11 patients and good in 1. There were no complications. CONCLUSIONS: Open reduction and internal fixation with a Herbert screw reliably obtained union in all patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

A biomechanical comparison of scaphoid fixation with bone grafting using iliac bone or distal radius bone

PURPOSE: Although many scaphoid fractures may be treated by immobilization, complex scaphoid fractures generally require bone grafting with internal fixation. A preferred source of bone graft for scaphoid grafting is the iliac crest. Donor site morbidity from iliac crest harvest, however, is a known complication, and the comparable strength and osteogenic properties of bone harvested from other sites are unclear. To this end, we have conducted a cadaveric comparative investigation of the strength of scaphoid nonunions with bone graft and internal fixation using either iliac crest bone or distal radius bone. METHODS: Ten paired, human, fresh-frozen cadaveric wrists were used to create a standard midwaist wedge osteotomy into which identically shaped distal radius or iliac crest bone wedges were internally fixed using headless compression screws. After bone density and computed tomography assessment of the bones, benchtop biomechanical testing was conducted to compare the strength of the scaphoids after iliac and distal radius grafting, at 2-mm displacement, and at failure. RESULTS: Analysis of scaphoid length, width, height, weight, density, and screw placement revealed no statistical differences between both bone graft groups. Although not significant, scaphoid nonunions grafted with distal radius bone evidenced a reduced load (3.23 +/- 0.26 Nm) to 2-mm displacement compared with iliac crest bone (5.97 +/- 0.68 Nm). Similarly, though not significant, scaphoids grafted with distal radius bone showed a reduced load (4.18 +/- 0.30 Nm) to failure compared with iliac crest bone grafting (6.42 +/- 0.66 Nm). Although no significance was found between the 2 grafting methods, a trend toward greater strength in the iliac crest graft group was observed. CONCLUSIONS: Given the comparable biomechanical strength shown between iliac and distal radius bone in this study and the simplified surgical technique of distal radius harvesting, the data justify use of distal radius bone as a viable alternative donor source in scaphoid fracture treatment.