动力加压髁螺钉治疗股骨髁部骨折临床与实验研究

本研究结合１４例股骨髁间、髁上骨折以动力加压髁螺钉（Ｄynamic Ｃondylar Ｓcrew ＤＣＳ）固定。目的：为临床提供应用ＤＣＳ的实验数据。方法：采用成人新鲜尸体股骨髁部标本,按照ＡＯ/ＡＳＩＦ分类,模拟Ｙ形骨折模型,以ＤＣＳ固定,置于ＷＤ－１０Ｅ万能电子力学实验机上其抗拉伸、抗扭转、抗村缩、抗剪切强度。结果：ＤＣＳ有较好的固定强度。临床应用１４例,随访６个月至１年,优良率为８５．７１％。结论：ＤＣＳ适合于     

峡部植骨修复拉力螺钉张力带固定治疗青少年下腰椎峡部裂

目的　探讨青少年下腰椎峡部裂的治疗中直接峡部植骨修复拉力螺钉张力带固定手术方法及其价值。　方法　共 12例 ,年龄范围 12 0～ 2 6 0岁 ,平均 18 4岁。术中暴露峡部并清理缺损区的纤维组织 ,分别切除两侧 1 0～ 2 0mm骨质 ,暴露新鲜骨界面 ,间隙内植入髂骨块 ,以椎板下缘中线旁开 8mm为进钉点 ,向头端和外侧各 30°倾斜安装长度 35 0～ 4 5 0mm ,直径 3 5mm钛质拉力螺钉 ,穿越峡部缺损和植骨块直至穿透椎弓根的外上缘皮质并紧固。峡部缺损表面植入条状植骨条 ,采用高强度尼龙线在螺钉尾部和横突基底部间形成张力带结构 ,关闭切口并留置负压引流。手术后石膏腰围固定 2个月。　结果　手术平均时间为 (10± 5 5 )min ,失血量为 170ml,术后随访 12～ 36个月 ,平均 17个月 ,所有修复的 2 2个峡部均在术后 3个月愈合。　结论　峡部植骨修复拉力螺钉张力带固定治疗青少年下腰椎峡部裂是一种简单、安全、可靠的术式 ,结合了生物力学和生物学过程 ,具有创伤小和保留病变节段运动功能的优点。     

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

Clinical studies reported frequent failure with anterior instrumented multilevel cervical corpectomies. Hence, posterior augmentation was recommended but necessitates a second approach. Thus, an author group evaluated the feasibility, pull-out characteristics, and accuracy of anterior transpedicular screw (ATPS) fixation. Although first success with clinical application of ATPS has already been reported, no data exist on biomechanical characteristics of an ATPS-plate system enabling transpedicular end-level fixation in advanced instabilities. Therefore, we evaluated biomechanical qualities of an ATPS prototype C4–C7 for reduction of range of motion (ROM) and primary stability in a non-destructive setup among five constructs: anterior plate, posterior all-lateral mass screw construct, posterior construct with lateral mass screws C5 + C6 and end-level fixation using pedicle screws unilaterally or bilaterally, and a 360° construct. 12 human spines C3–T1 were divided into two groups. Four constructs were tested in group 1 and three in group 2; the ATPS prototypes were tested in both groups. Specimens were subjected to flexibility test in a spine motion tester at intact state and after 2-level corpectomy C5–C6 with subsequent reconstruction using a distractable cage and one of the osteosynthesis mentioned above. ROM in flexion–extension, axial rotation, and lateral bending was reported as normalized values. All instrumentations but the anterior plate showed significant reduction of ROM for all directions compared to the intact state. The 360° construct outperformed all others in terms of reducing ROM. While there were no significant differences between the 360° and posterior constructs in flexion–extension and lateral bending, the 360° constructs were significantly more stable in axial rotation. Concerning primary stability of ATPS prototypes, there were no significant differences compared to posterior-only constructs in flexion–extension and axial rotation. The 360° construct showed significant differences to the ATPS prototypes in flexion–extension, while no significant differences existed in axial rotation. But in lateral bending, the ATPS prototype and the anterior plate performed significantly worse than the posterior constructs. ATPS was shown to confer increased primary stability compared to the anterior plate in flexion–extension and axial rotation with the latter yielding significance. We showed that primary stability after 2-level corpectomy reconstruction using ATPS prototypes compared favorably to posterior systems and superior to anterior plates. From the biomechanical point, the 360° instrumentation was shown the most efficient for reconstruction of 2-level corpectomies. Further studies will elucidate whether fatigue testing will enhance the benefit of transpedicular anchorage with posterior constructs and ATPS.     

Systematic effects of surgical treatment of hip fractures: Gliding screw-plating vs intramedullary nailing

Aim

Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients.

Materials-methods

This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy).The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization.

Results

Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p > 0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism.

Conclusion

We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.     

Herbert螺钉治疗Pipkin''''s骨折

目的评价Herbert螺钉治疗髋关节后脱位合并股骨头骨折（Pipkin’s骨折）的疗效。方法1994年4月至2006年4月，应用Herbert螺钉经Gibson入路治疗此类患者共11例。据Pipkin’s分型，Ⅰ型3例，Ⅱ型4例，Ⅲ型1例，Ⅳ型3例。结果11例均获得随访，随访时间6个月～12年。采用Epstein评分方法，优3例，良5例，可2例，差1例，优良率72．7％。结论Herbert螺钉提供牢固的内固定，对关节软骨损伤小，是Pipkin’s骨折较理想的内固定材料。     

经伤椎置钉单节段椎弓根钉治疗胸腰段骨折

目的探讨经伤椎置钉单节段椎弓根钉治疗胸腰椎骨折的适应症及临床疗效。方法 2008年7月至2010年7月,对14例胸腰椎骨折采用后路单节段伤椎椎弓根螺钉内固定、经伤椎植骨融合。经过5～29（平均16.8）个月随访,随访内容有术前后VAS疼痛评分、神经功能ASIA评分、术前、术后随访时椎体的高度、伤椎的后凸畸形,内固定物的状况。结果所有患者均得到随访,术后VAS疼痛分级平均0-1分,其中0分8人,1分6人,无需服药治疗。神经功能均恢复至正常;X线检查术后椎体高度恢复满意,术后伤椎高度恢复了96%,随访椎体高度丢失0.4mm,丢失率为1.4%。无内固定物断裂、松动、脱出,所有病例均获得骨性融合,无假关节形成。结论选择好适应证,后路单节段伤椎内固定是治疗胸腰段骨折的有效方法之一。     

动力髋螺钉治疗股骨转子周围骨折

2003年1月-2006年12月,我院对37例股骨转子周围骨折患者行动力髋螺钉（DHS）治疗,术中无C臂X线机透视条件,简单点片定位,取得良好疗效。     

脊柱钉棒系统治疗骨盆后环损伤

目的探索脊柱钉棒系统应用于骨盆后环损伤治疗的效果。方法对36例骨盆后环损伤，按照Denis分型，Ⅰ型20例，Ⅱ型12例，Ⅲ型4例。按照Tile分型，B3型16例，C1型10例，C2型6例，C3型4例。应用脊柱钉棒系统固定治疗，将万向椎弓根钉从双侧髂后上棘处开槽置入髂骨后部内外板间，钉尾沉于骨质内，连接棒通过双侧骶棘肌隧道放置固定后，在骨盆后环处形成一个强有力的“内支架”有效固定。结果30例获得6～18个月随访，平均11个月，患者均无螺钉松动、断棒、骶髂关节再次脱位及内固定物引起的血管、神经损伤并发症。按刘利民等功能评定标准，优15例，良13例，中2例。结论脊柱钉棒系统治疗骨盆后环损伤，固定有效牢靠，操作简便，无需复杂定位，创伤小，恢复快，无透视条件的基层单位也可行手术，极有推广价值。     

Open reduction and internal fixation of intraarticular tibial plateau nonunions

The vast majority of tibial plateau fractures heal uneventfully, and no case series on intraarticular tibial plateau nonunions exists. The purpose of the present study was to evaluate the radiographic and clinical outcome of these nonunions following surgical treatment in a single surgeon series. Five patients with tibial plateau nonunions were treated at our institution using a specific treatment protocol consisting of open reduction and debridement, deformity correction, internal fixation including lag screws, bone graft augmentation, and selective knee joint arthrolysis. Patient outcomes were assessed using radiographs and the Knee Society questionnaire scores. Following surgical treatment of the nonunion, all healed at an average of 12.8 weeks, and average follow-up was 44 months. Preoperative coronal plane deformity was corrected in all patients. The final knee motion arc averaged 120 degrees postoperatively. Both the pain and function subscales of the Knee Society Rating scale improved significantly. Four of the five returned to their normal pre-injury activities, but two patients required total knee arthroplasty which was performed successfully after healing of the nonunion. With meticulous surgical technique and a standard protocol, healing may be reliably achieved. Arthrosis occurs frequently, and may occur primarily at the time of injury or from chronic alteration of intraarticular contact forces secondary to development of a nonunion.     

Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients

With the introduction of Locking Compression Plates (LCP), Minimally Invasive Plate Osteosynthesis (MIPO) has become widely used. The plates act as internal fixators in a bridging manner, thus resulting in secondary bone healing. We retrospectively evaluated the healing pattern and the clinical evolution of diaphyseal and distal tibial shaft fractures over two and a half years in 32 patients (6 females, 26 males). Fractures were classified according to AO classification and included all 42A-C, 43A-B and 43C1-2 types. For open fractures, Gustillo Anderson classification was used. Plates consisted of the 4.5mm LCP and 3.5mm LCP-Pilon form plate. Clinical and radiological assessment was performed at 6 weeks, and at 3, 6, 9, and 12 months. Two patients were lost to follow-up. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and posterior-anterior X-ray, and full, painless weight bearing. Ten patients at 3 months, 23 at 6 months, and 27 at 9 months met the criteria for a healed fracture. Plate bending was observed in one patient and called for re-operation at 5 months. Two patients required re-operation at 13 months secondary to pseudoarthrosis. Though MIPO seems more advantageous for soft tissue and bone biology, prolonged healing was observed in simple fracture patterns when a bridging plate technique was used.