单侧髋关节完全脱位患者下肢不等长及膝关节畸形的特点

目的 观察骨骼发育成熟的单侧发育性髋关节完全脱位的患者脱位侧下肢长度的变化特点及伴随膝关节畸形的情况.方法 选择201 1年3月至2012年12月因单侧髋关节完全脱位接受治疗且符合纳入排除标准的28例患者作为观察对象,其中男性6例,女性22例;年龄13.4～66.2岁,平均29.8岁.脱位侧为中低位脱位(HartofilakidisⅡ型)17例(60.7％),高位脱位(HartofilakidisⅢ型)11例(39.3％).患者均行站立位双下肢全长正位X线检查,于X线片上进行双侧股骨及胫骨绝对长度、下肢相对长度的测量,并观察脱位侧与非脱位侧膝关节畸形情况.对股骨绝对长度、胫骨绝对长度、双下肢相对长度及双侧膝外翻角采用配对资料t检验进行统计学分析;对膝外翻分布规律及不同脱位程度下肢相对长度的分布规律采用x2或校正x2检验.结果 脱位侧股骨绝对长度较非脱位侧延长者17例(60.7％),最长延长32.7 mm,平均延长9.5 mm,差异无统计学意义(t=1.328,P=0.197).脱位侧胫骨绝对长度较非脱位侧延长者21例(75.0％),最长延长10.9 mm,平均延长4.5 mm,差异有统计学意义(t=3.039,P=0.006).脱位侧下肢相对长度较非脱位侧延长者20例(71.4％),最长延长25.0 mm,平均延长9.4 mm,差异有统计学意义(t=2.451,P=0.022).脱位侧膝外翻角为3.±4°,非脱位侧膝外翻角为-3°±4°,双侧对比差异有统计学意义(t=5.642,P=0.000);其中脱位侧膝外翻畸形12例,膝内翻1例;而非脱位侧膝内翻畸形15例,膝外翻畸形1例,差异有统计学意义(x2=18.139,P=0.000).结论 大多数单侧髋关节完全脱位患者脱位侧患肢长度较非脱位侧延长,其中股骨和胫骨均有延长.脱位侧出现膝外翻畸形的发生率较高,而非脱位侧膝内翻的发生率高.     

半骺板阻滞术治疗儿童膝关节成角畸形的矫正速率与临床疗效分析

目的探讨半骺板阻滞术治疗儿童膝关节成角畸形的矫正速率及临床疗效。方法纳入自2016-03—2018-03采用8字形钢板半骺板阻滞术治疗的22例(36膝)膝关节成角畸形,膝内翻畸形6例(9膝),膝外翻畸形16例(27膝)。测量手术前后膝间距或踝间距、膝关节中心到下肢力线的距离、股胫角,计算矫正速率。结果 22例均获得至少2年随访。膝内翻畸形患儿末次随访时膝间距、膝关节中心到下肢力线的距离、股胫角明显小于术前、术后1周和术后3个月,膝外翻畸形患儿末次随访时踝间距、膝关节中心到下肢力线的距离、股胫角均小于术前、术后1周和术后3个月,差异有统计学意义(P0.05);患儿术前、术后1周、术后3个月上述指标比较差异无统计学意义(P0.05)。膝内翻畸形患儿矫正速率为(0.32±0.12)°/月,膝外翻畸形患儿矫正速率为(0.48±0.09)°/月,术后9～12个月膝内翻与膝外翻畸形改善效果最明显。膝外翻畸形患儿的矫正速率明显高于膝内翻畸形患儿,差异有统计学意义(P0.05)。结论半骺板阻滞术治疗儿童膝关节成角畸形效果满意,并发症较少,安全可靠,建议膝内翻畸形患儿矫正速率控制在(0.32±0.12)°/月,膝外翻畸形患儿矫正速率控制在(0.48±0.09)°/月。     

膝部截骨组合式外固定支架固定治疗膝外翻13例

[目的]观察股骨髁上、胫骨近端单独或联合截骨组合式外固定支架固定治疗膝外翻13例临床疗效.[方法]13例病人男8例,女5例;年龄8～24岁,单侧10例,双侧3例,共16个膝.术前膝外翻畸形平均26°,立位双踝之间的距离最大者50cm.手术方法:单纯实施股骨髁上截骨11膝,股骨髁上+胫骨结节下双截骨5膝.[结果]16膝随访14～42个月,平均26个月,畸形完全矫正无并发症者14膝,大部矫正者2膝.[结论]术前认真分析X线片,制定周密的手术方案,术中正确操作,应用组合式外固定支架固定截骨段,对治疗不同程度的膝外翻可获得良好疗效.     

膝内外翻畸形的X线分析及临床应用

膝内、外翻畸形是下肢骨关节常见畸形之一,它常见于佝偻病,骨发育障碍,膝关节退行性骨病,小儿麻痹后遗症,外伤等。畸形明显者,临床需要截骨治疗,截骨前准确测量膝关节畸形角度、范围、部位、程度,以确定截骨的部位和方法。膝内、外翻畸形的Ｘ线研究既往报告很少,作者回顾性分析我院手术治疗40例64侧膝内、外翻病例,并与正常人进行比较,观察Ｘ线表现,提出Ｘ线分型,为临床手术治疗提供客观依据。1　资料和方法1.1　一般资料　本组40例64侧病例中,膝内翻22例36侧,男9例、女13例,单膝患病6例,双膝患病16例,年龄5～40岁,平均18.7岁;膝外翻18例28…     

后方稳定型全膝人工关节置换术30例分析

[目的]探讨后方稳定型全膝人工关节置换术(posterior stabilized knee arthroplasty,PSKA)治疗膝关节疾患的优点及术中、术后应注意的一些问题.[方法]2001年10月～2006年1月,共计PSKA 30例,男3例(5膝),女27例(32膝),其中双膝7例.年龄54～78岁.术前诊断全部为膝关节骨性关节炎,伴有骨质缺损4膝.术前X线膝关节测量膝内翻畸形28例,膝外翻2例,屈曲畸形28膝,有膝关节手术史4膝.30例随访12～60个月,平均21个月.根据美国特种外科医院(the hospital for special surgery,HSS)膝关节百分评分系统进行评估[1].[结果]术前平均62分,术后平均89分,活动范围术前平均89°,术后平均115°,其中优30膝,良5膝,中1膝,差1膝.手术优良率94.8%.[结论]PSKA可增加膝关节活动度和最大屈曲度,并限制其向后半脱位.它不但用于原发的膝关节疾病,还应用于膝关节手术后的患者.髌骨并发症在PSKA最常见,对于骨质疏松者,术中髌骨强力翻转易导致髌腱止点撕脱、上移,术后伸膝无力应予重视.强调术后的功能锻炼对膝关节功能恢复的重要性.     

股骨颈骨折术中透视判断空心钉位置的临床研究

目的 探讨在术中透视下空心钉钉头与股骨头边缘的安全距离,避免内固定物穿出股骨头.方法 2007年11月至2008年4月统计30例患者术后正、侧位X线片空心钉在股骨头的实际分布情况.分析股骨头的二维垂直透视影像与三维空间结构的关系,建立立体几何公式,根据统计的分布情况进行计算,确定不同空间位置的空心钉在正位透视上应距离股骨头边缘的数值,以确保空心钉位于股骨头内.结果 空心钉处于股骨头的不同位置,即使正、侧位透视下空心钉头都在股骨头影像内,实际穿出股骨头的风险是不同的.股骨头平均直径为49.8 mm.侧位居中时,只要正位透视空心钉在股骨头影像内,就不会穿出股骨头.侧位为22.5°时,正位在22.5°以内透视下钉头应距股骨头边缘超过2.2 mm;正位>45°时,距离应超过9.6 mm.侧位为45°时,正位在22.5°以内透视下钉头应距股骨头边缘超过8.2 mm;正位>45°时钉头应距股骨头边缘超过17.7 mm.侧位为67.5°时,正位透视下钉头应距股骨头边缘超过23.1 mm.结论 当侧位空心钉中置时,只要正位影像下空心钉在股骨头范围内,空心钉就不会穿出股骨头.正侧位角度(尤其是侧位角度)较大时,正位透视空心钉头要距离股骨头边缘较大.     

重度膝外翻的外科治疗

目的 :报道 18例重度膝外翻的外科治疗 ,作者对重度膝外翻的畸形成因、截骨平面选择和固定方法进行探讨。方法 :18例病人男 7例 ,女 11例 ,年龄 12～ 3 4岁 ,双侧者 16例 ,共 3 4个膝。术前膝外翻畸形平均 42° ,立位双踝之间的距离最多者 5 5cm。手术方法 :单纯实施股骨髁上截骨者 16膝 ,股骨髁上 胫骨结节下双截骨 18膝。结果 :2 7膝平均随访 16个月 ,畸形完全矫正无并发症者 2 3膝 ,大部矫正者 3膝 ,并发 8°膝内翻者 1膝。结论 :术前精密的手术设计、正确的手术操作、用骨外固定器固定截骨段 ,对不同类型的重度膝外翻可达良好治疗效果。     

婴幼儿先天性斜形距骨诊断与治疗

[目的] 了解和认识婴幼儿先天性斜形距骨.[方法] 31例患者经体格检查,可见平足外翻,内侧纵弓塌陷,不伴有仰趾畸形,而且无肌腱挛缩,无畸形僵硬,被动手法可以恢复正常足弓.足部X线正位片显示距骨轴心线向内倾斜,与第1跖骨相交成角;侧位片距舟关节(半)脱位,距骨-第1跖骨轴线失常;最大跖屈内翻侧位片距骨-第1跖骨轴线恢复正常,均明确诊断为婴幼儿先天性斜形距骨.其中27例采用手法反向牵拉板正,4例手法无效而采用手术切开复位,31例均穿戴特制矫形靴或矫形足托(垫)治疗.[结果] 31例患者均获得痊愈,随访1～2年,平均10个月.随访末期足外形均恢复良好,跟骨无外翻,内侧纵弓恢复.踝足趾功能无障碍,足内外翻肌力平衡,步态稳定,单足负重站立无足外翻.足X线正位片距骨-第1跖骨轴角正常者26例,≤10°者5例.Kite角正常者29例,小于20°者2例.侧位片距舟关节对应良好者31例,距跟角小于25°者6例.[结论] 婴幼儿先天性斜形距骨患者经手法或手术治疗,可以获得痊愈,本病预后良好.     

内外翻限制性假体在复杂初次膝关节置换中的应用

[目的]回顾性分析内外翻限制性假体(varus-valgus constrained implant,VVC)在复杂初次膝关节置换中的应用经验,总结VVC假体使用的适应证及临床效果.[方法]2003年1月-2007年1月使用VVC假体行复杂膝关节初次置换18例(19膝),其中外翻膝11例,强直膝7例(8膝).所有患者均使用假体延长柄(12例使用带偏心距的延长杆),并采用骨水泥固定延长杆.11例外翻膝均使用了金属楔垫或自体骨植骨填补骨缺损.[结果]平均随访47.5个月(24～72个月),出院时所有患者疼痛消失,关节稳定,力线纠正,HSS评分从术前平均37.1分,提高到术后的平均88.2分.最近一次随访患者均能完成主动伸直,最大屈曲度平均107°(80°～130°),其中强直膝最大屈曲度平均98°(75～120°),无感染及脱位并发症,患者满意率为100%.[结论]内外翻限制性假体在膝关节通过软组织平衡技术无法获得相等的屈伸间隙或相等的内外侧紧张度时使用,在很多复杂初次膝关节置换中可以获得很好地临床效果.     

儿童陈旧性桡骨头脱位3D打印模型形态比较研究

目的观察3D打印模型在评价儿童陈旧性桡骨头脱位尺骨、桡骨畸形中的作用。方法收集自2016年1月至2017年12月7例桡骨头脱位儿童病例资料,7例均为男性;年龄3～13岁,平均(9.0±0.4)岁;均为BadoⅠ型;左侧3例,右侧4例。受伤至手术时间为2个月～5年。通过双侧尺桡骨全段三维CT扫描,获得数据后通过MIMICS 10.01软件行患侧尺骨与健侧尺骨的三维畸形比较测量。再行3D打印出双侧尺桡骨模型,更直观地观察双侧尺桡骨的形态。结果软件测量显示患侧尺骨存在三维畸形改变。3D打印的双侧尺桡骨模型显示桡骨近端向前或前外脱位,与尺骨的三维形态结构改变。患侧尺骨形态明显改变,表现在正位观尺骨外翻,侧位观尺骨明显前弓,轴位观尺骨旋后。患侧尺骨近端的外侧桡切迹模糊,凹陷不明显。患侧桡骨形态没有明显改变。测量患侧尺骨的长度,1例明显短于健侧。桡骨的长度与健侧比较,没有明显差异。结论 3D打印模型可三维显示陈旧性桡骨头脱位儿童尺骨、桡骨畸形形态,指导术前手术设计。     

严重肢体不等长50例治疗效果

目的 提高严重肢体不等长的治疗效果,减少术后并发症。方法 治疗５０例患者,比较不同平面的骨干延长,不同截骨方式,不同延长速度和频率的疗效。结果 平均延长９．５ｃｍ,其中单段最长１６ｃｍ,分段最长１８ｃｍ。     

The Prognosis in Congenital Lower Limb Hypertrophy

Twenty-eight patients with congenital total hypertrophy and ten patients with lower limb hypertrophy with congenital vascular abnormalities are reviewed. The pattern of increase in leg length discrepancy during growth and its influence on surgical management is discussed and the clinical features of the affected limbs are described. In congenital total hypertrophy the maximal increase in leg length discrepancy occurs before the age of 10 years. Those patients who have a leg length discrepancy of more than 2.5 cm at age 4 years are likely to develop significant limb overgrowth that will require eventual surgical correction. In patients with congenital vascular abnormalities the change of leg length discrepancy was variable in degree and unpredictable in pattern, even in those with similar venous anomalies. The outcome for the limb was determined by the nature of the vascular anomaly which should be accurately defined by angiography.     

Rinsing of allograft bone does not improve implant fixation

Background and purpose Impacted morselized allograft bone is a well-established method for reconstructing bone defects at revision surgery. However, the incorporation of bone graft is not always complete, and a substantial volume of fibrous tissue has been found around grafted implants. We hypothesized that rinsing the bone graft may improve graft incorporation by removing the majority of immunogenic factors present in blood, marrow, and fat.

Methods We implanted a cylindrical (10- × 6-mm) porous-coated Ti implant into each proximal tibia of 12 dogs. The implants were surrounded by a 2.5-mm gap into which morselized fresh frozen allograft bone was impacted. The bone graft was either (1) untreated or (2) rinsed in 37°C saline for 3 × 1 min. After 4 weeks, the animals were killed and implant fixation was evaluated by mechanical push-out and histomorphometry.

Results The groups (rinsed vs. control) were similar regarding mechanical implant fixation (mean (SD)): shear strength (MPa) 2.7 (1.0) vs. 2.9 (1.2), stiffness (MPa/mm) 15 (6.7) vs. 15 (5.6), and energy absorption (kJ/m²) 0.5 (0.2) vs. 0.6 (0.4), The same was evident for the new bone formation on the implant surface and around the implant: ongrowth (%) 6 vs. 7 and ingrowth (%) 9 vs. 9. Although not statistically significant, a 61% reduction in fibrous tissue ongrowth and 50% reduction in ingrowth were found in the rinsed group.

Interpretation Within the limits of this experimental model, we did not detect any benefits of rinsing morselized allograft bone prior to impaction grafting.     

The morphologic characteristics of nerve shortening following traumatic bone loss

Little is known about peripheral nerve shortening secondary to joint contracture or traumatic bone loss. We used the rat sciatic nerve as a model to study nerve shortening secondary to leg shortening. Nerve shortening was induced by surgically removing 16 mm of the femur. The histology of the ipsilateral and contralateral (control) sciatic nerves were compared at 1 h, 3 weeks, and 6 weeks. Transverse semithin sections of sciatic nerve were prepared and examined; single fibers also were teased from the nerve for study. The epineurium was shortened about 25% at 6 weeks. Axonal diameter was unchanged at 1 h, but increased over time, and was 0.68 µm larger than controls at 6 weeks (p < 0.05). In teased‐fiber preparations, internodal length decreased 2.3% at 6 weeks, but not significantly. Peripheral nerve shortening secondary to leg shortening shortens the epineurium, but does not effect on internodal length. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 472–476, 2009     

干骺端潜行截骨延长288例

目的;介绍一种治疗肢体不等长的新方法。方法：应用自行研制的“针锯”潜行截骨,用自行研制的“多平面双轨多功能延长器”对短肢进行缓慢延长,使双下肢得以平衡。结果;288例肢体不等长患者,均达到所需延长长度,最短延长3cm,最长11.5cm,平均4.6cm。功能恢复满意。结论：干骺端潜行截骨延长方法安全,可靠,无骨不连接,骨萎缩和迟缓连接等并发症,不需要作内固定和植骨,是肢体延长的一种好方法。     

股骨下端“L”形截骨一次性和逐渐性相结合延长治疗股骨短缩畸形

目的 解决一次性延长因血管、等并发症难以达到延长目的,而逐渐性延长治疗时间持续太长等问题。方法 肌下干骺端行“Ｌ”形坎骨,术中延长２￣３ｃｍ,剩余部分术后继续逐渐延长。结果 １８例延长的和蔗为３．０￣８．５ｃｍ。步态正常者９例,膝关节活动正常８例。平均住院日为３４．５天,远低于逐渐性延长组５６．７天。结论一瓷生和逐渐性相结合延长的方法并发症少、治疗疗程明显缩短,最较理想的截骨延长方法。     

A Simple Method Using a PACS to Minimize Leg Length Discrepancy in Primary THA : A Method to Minimize Leg Length Discrepancy

We determined whether a PACS-based method (head-lesser trochanter distance [HLD]) better equalized leg length discrepancy (LLD) after primary THA than a conventional method. We retrospectively reviewed 312 patients (379 hips) with osteonecrosis or primary osteoarthritis who underwent primary cementless THA: 198 patients (240 hips) underwent THA using the HLD method, while the conventional group consisted of 114 patients (139 hips) in whom we measured with the method of McGee and Scott. We then compared the LLDs in the two groups. We observed no difference in the mean postoperative LLD. A higher percentage of patients in the HLD group had an LLD less than 6 mm: 81% vs 68% hips, respectively. HLD method decreases the possibility of an LLD over 6 mm after THA.     

大龄臀肌筋膜挛缩症的手术治疗

目的；探讨在龄臀肌筋膜挛缩症的临床特点及手术治疗效果。方法：回顾性分析23例大龄臀肌筋膜挛缩症手术治疗的临床资料。本组病例男9例，女14例，年龄15－43岁，病程10－35年。结果：随访时间3月－3年，平均1年8个月。手术治疗效果满意，髋关节功能恢复正常或接近正常。伴发骨盆倾斜所致下肢假性不等长9例（占39．12％），要后畸形矫正；术前肢体等长，术后出现肢体不等长2例。病变范围均累及臀中肌，臀小肌。结论：大龄臀肌筋膜挛缩症患中，因骨盆倾斜所致肢体假性不等长表现的相对较多，应重视此伴发症的处理。术中注意重点松解臀中肌，臀小肌的挛缩，延误治疗可能会影响骨关节的发育或引起骨关节的继发性病变。     

ASSESSING LEG LENGTH DISCREPANCY AFTER FEMORAL FRACTURE: CLINICAL EXAMINATION OR COMPUTED TOMOGRAPHY?

INTRODUCTION: Femoral shaft fractures treated with intramedullary nailing often heal with a leg length discrepancy (LLD). LLD is commonly evaluated by clinical examination and computed tomography (CT) scanogram. We assessed the correlation between these two techniques of calculating LLD. METHODS: We reviewed 35 skeletally mature patients who sustained a femoral shaft fracture between January 1997 and December 1999. Leg length was measured clinically with direct measurement and a block test. Each patient was asked whether they felt they walked with a limp and whether they felt they had a leg length discrepancy. Each patient underwent a CT scanogram to measure femoral and total leg length. The correlation between clinical examination and scanogram was analysed using the Pearson Product Moment Correlation. RESULTS: Of the 35 patients, 15 patients (43%) had a measurable LLD. There was a positive correlation between direct leg length measurement and the block test (P = 0.003), and between the block test and patient perception of limp and LLD. CT scanogram was performed on 29/35 patients. There was no correlation between CT scanogram and clinical measurement of leg length or between CT scanogram and patient perception of LLD or limp. DISCUSSION: Leg length discrepancy commonly occurs following treatment of femoral shaft fractures. We found that there was a strong correlation between direct leg length measurement and the block test, and between both methods of clinical leg length measurement and patient perception of a limp or LLD. Our study found no correlation between CT scanogram and clinical leg length measurement or patient perception of limp or LLD. CONCLUSION: Our study shows that physical examination (direct measurement and the block test) is more reliable and clinically relevant than CT scanogram measurement in the assessment of LLD after femoral fracture.     

The Impact of Leg Length Discrepancy on Patient Satisfaction and Functional Outcome Following Total Hip Arthroplasty

A series of 191 patients undergoing THA with a standardised stem were studied. The effect of leg length discrepancy (LLD) on patient function (Oxford Hip Score), health measures (Short Form 12) and satisfaction (Self-Administered Patient Satisfaction Scale) at a mean 3.8 years of follow up (range 3.3 to 4.9) is reported. 8.9% of cases had shortening, 0.5% no LLD and 90.6% had lengthening. In 21.5% the LLD was more than 10 mm, in 37.1% 5–10 mm, and in 40.9% 0–5 mm. There was no significant difference in patient reported outcome measures (PROMs) according to LLD. Correlation of recorded measurements between multiple observers was excellent (0.93). LLD following total hip arthroplasty remains common but in this series, was not correlated with PROMs.