置入胸椎"椎弓根-肋骨"单元螺钉的应用解剖和力学测试

目的探讨置入胸椎"椎弓根-肋骨"单元(简称PRU)螺钉的应用解剖和力学性能.方法测量35具尸体标本PRU横径(W)、纵径(H)、置入螺钉长度(L)和中心轴水平面成角(E).6具较新鲜标本,在T10、在T11和T12分别置入椎弓根螺钉(A组)、PRU螺钉(B组)和穿破椎弓根外侧皮质螺钉(C组),测量3组螺钉的最大拔出力F-max和拔出4 mm的能量吸收值E-4 mm.结果W为13.2～16.1 mm,L为38.5～52.7 mm,E为28.3°～15.4°,H为6.3～7.0 mm.A组F-max为808 N,E-4mm 1709 Nm,B组F-max 812 N,E-4mm 1720 N m,C组F-max 795 N,E-4mm 1687 Nm,经t检验,3组间差异无显著性意义(P＞0.05).结论PRU置入螺钉的安全范围明显大于椎弓根螺钉,同时具有良好的力学稳定性能.     

胸腰椎椎弓根螺钉固定技术的研究进展

20世纪70年代Roy—camille首先应用椎弓根螺钉固定治疗胸腰椎骨折，30年来椎弓根螺钉固定技术发展迅速，已广泛应用于多种脊柱疾病的治疗。由于置入螺钉与周围组织，如脊髓、神经、血管等关系密切，存在一定风险和并发症，直到1999年美国FDA才正式批准该项技术为经典的脊柱后路固定方法之一。近些年在应用解剖、螺     

Screw placement of pedicle of vertebral arch—pay great attention to segmental differences of the pedicle

OBJECTIVE: To investigate appropriate ways for screw placement of pedicle of vertebral arch in the horizontal plane. METHODS: Fifteen preserved thoracolumbar spine specimens (T(11)-L(5)) were used and divided into three groups at random. Firstly four anatomic parameters indicating screw positions in the horizontal plane were measured. Secondly the methods of Roy-camille, Magerl, and authors' segmental differences were used to place successively the screws of the pedicles with 5 mm, 6 mm, and 7 mm in diameter. Coincidences between the drilling point, drilling direction and pedicle axis, and ruptures of the pedicle as well as the length of the screw in the vertebral body were observed. RESULTS: Four anatomic parameters at various segments showed significant differences (P<0.05). The drilling point by the Roy-camille's method deviated medial to pedicle axis in most segments, and its drilling direction did not coincide well with most E-angles of the pedicles. The drilling point by Magerl's method coincided relatively well with pedicle axis in lumbar vertebrae, but there were still some differences between its drilling direction and E-angles of the pedicles. The method of segmental differences coincided the best with the pedicle axis. The lengths of screw in the vertebra were relatively long by both Magerl and segmental difference methods. When 5 mm diametral screw was used by the three methods, the rupture rate was very low. When 6 mm and 7 mm diametral screws were placed, the rupture rate was accordingly increased. Of the three methods, Roy-camille's method showed a relatively high rupture rate, while the method of segmental differences a comparatively low rupture rate. Various degrees of rupture of the pedicle of vertebral arch were found at the juncture of the thoracic and lumbar vertebrae when 6 mm or 7 mm diametral screws was used by any screw placement method. In contrast, the rupture was seldom seen at the lower lumbar vertebrae when 7 mm diametral screws were used. CONCLUSIONS: The segmental difference method is proved to have the anatomic safety and screw biomechanical stability. It is appropriate to choose different diametral screws, different drilling points and directions according to different segments of the vertebra.     

椎板开窗椎管减压治疗伴神经损伤胸腰椎爆裂骨折

目的探讨椎板开窗椎管减压治疗合并神经损伤胸腰椎爆裂骨折的手术效果。方法回顾性研究自2008-01—2013-06采用椎板开窗椎管减压、椎弓根钉内固定治疗的28例合并神经损伤的胸腰椎爆裂骨折。术后1周、12个月行X线片和CT检查,测量椎体前缘高度、椎管中矢径和椎管狭窄。末次随访时记录腰背痛VAS评分和神经功能Frankel分级恢复情况。结果 28例均获得平均20.1(18~36)个月随访。术后1周与术前比较,椎体前缘高度(t=27.040,P0.001)、椎管中矢径(t=22.620,P0.001)、椎管狭窄(t=20.470,P0.001)明显改善,差异有统计学意义(P0.05)。术后12个月与术后1周比较,椎体前缘高度少许丢失,差异有统计学意义(t=16.970,P0.001),但基本维持稳定;椎管中矢径(t=8.480,P0.001)、椎管狭窄(t=10.150,P0.001)进一步改善,差异有统计学意义(P0.05)。末次随访时,除2例完全性神经损伤外,不完全性神经损伤患者均有不同程度恢复,由术前分级(2.75±1.21)恢复至(0.86±1.30),差异有统计学意义(Z=-4.435,P0.001);腰背痛VAS评分为(2.25±0.17)分,较术前明显降低,差异有统计学意义(t=19.390,P0.001)。结论椎板开窗椎管减压、椎弓根钉内固定治疗合并神经损伤的胸腰椎爆裂骨折不仅保留了椎管结构和脊柱稳定性,而且可以使椎管得到有效减压。     

解剖倾斜位X线成像判断桡骨远端螺钉位置

目的　探讨腕关节解剖倾斜位X线成像判断桡骨远端螺钉位置的可靠性和临床价值。 方法　对标准X线平片可疑桡骨远端螺钉穿破关节31例患者的螺钉位置分别行CT扫描和腕关节解剖倾斜位X线摄片（简称ATX）检查。选择二位观察者依据ATX独立判断螺钉位置,并与CT扫描结果比较,计算ATX判断的敏感性、特异性和预估值,用一致性检验计算判断的可靠性。67例可疑螺钉穿破关节患者应用ATX判断螺钉位置穿破28例、未穿破39例。术中发现穿破者,立即更换螺钉位置;术后发现穿破者,骨折愈合后早日取出螺钉。 结果　观察者首次判断的敏感性为88.24%～94.12%,特异性为87.50%～106.25%,预估值为87.50%～100.00%;观察者间可信性Kappa系数为0.81～0.94,可重复性Kappa系数均为0.87,具有高度可信性和高度可重复性。随访16～30个月。末次随访,未穿破组腕关节功能（Sarmiento标准）优14例、良19例、可5例、差1例,穿破组优10例、良13例、可4例、差1例,两组差异无统计学意义（P>0.05）。 结论　ATX判断桡骨远端螺钉位置简便、实用、较可靠。     

两类桡骨远端die-punch骨折的影像学比较

目的　探讨两类桡骨远端die-punch骨折的影像学特点及其区别。 方法　分析2007年1月~2016年1月诊断为die-punch骨折的498例患者临床和影像学资料,依据“三柱理论”和骨折波及部位将其分为单柱和双柱die-punch骨折两类,比较其发生率、年龄、性别、治疗方法和功能恢复等方面差异。 结果　单柱die-punch骨折的发生率、平均年龄和功能恢复优良率分别为15.66%、35.42岁和96.15%,双柱die-punch骨折分别为84.34%、54.69岁和80.00%,二者比较差异均有统计学意义（P=0.000）;单柱die-punch骨折的男女比为48/30,手术保守比为62/16,双柱die-punch骨折分别为223/197和344/76,二者比较差异均无统计学意义（分别P=0.169和P=0.613）。 结论　桡骨远端die-punch骨折是轴向暴力经月骨传递到月骨窝致月骨窝骨折的统称。因暴力性质和大小、受伤时手腕位置和患者骨质等的不同,致有单柱和双柱die-punch骨折之分,两者在分型归类、严重程度、发生机理、暴力性质和程度、发生率、年龄和预后等方面均存在明显区别。     

青少年前交叉韧带重建2例报告及文献复习

目的探讨采用自体腘绳肌悬吊固定方法镜下重建青少年骨骺未闭合患者前交叉韧带(anterior cruciate ligament,ACL)的方法及疗效。方法在2010年6月、2011年4月采用自体腘绳肌悬吊固定方法重建2例青少年骨骺未闭患者,指导患者功能锻炼并对其进行随访,评定临床疗效。结果 2例患者分别获随访26、37个月,末次随访时,2例患者无不稳及疼痛主诉,膝关节稳定性良好,Lachman、ADT试验均阴性,活动范围分别为0~130°,0~142°,Lysholm膝关节评分分别由45、50分提高到术后的85、90分,未见任何内外翻畸形,肢体无缩短现象。结论采用腘绳肌悬吊固定方法重建青少年骨骺未闭患者前交叉韧带,可避免骨骺损伤,短期疗效满意,是重建骨骺未闭合青少年ACL的方法之一。     

切开取骨部位合理性选择探讨

目的探讨常用取骨部位切开取骨的数量、成分和并发症情况,为合理选择提供依据。方法回顾分析2008年1月至2016年4月在髂前或髂后或胫骨近端以切开方式行游离骨移植且达到一定数量标准取骨量的113例患者,其中男67例,女46例;年龄13～69岁,平均35.3岁。根据量杯中水体积变化测量所取骨的体积。记录术后取骨区并发症情况,局部疼痛采用视觉模拟评分(visual analogue scale,VAS)评价。结果取骨量髂后为(27.19±2.18)cc,胫骨近端为(21.66±2.07)cc,髂前为(18.18±1.76)cc,组间比较差异均有统计学意义(P0.05)。髂骨取骨的皮质骨和松质骨各占约50%,胫骨近端取骨几乎全为松质骨。髂前区发生并发症14例,髂后7例,胫骨近端3例,仅胫骨近端与髂前并发症发生率比较差异有统计学意义(P0.05)。切口痛随时间推移逐渐减轻,但髂前区疼痛持续时间相对较长。结论髂后和胫骨近端取骨量较多,且并发症发生率较低,对于需要较多自体骨移植者,应作为首选部位,而髂前取骨的量较少、并发症发生率较高,不推荐常规采用;对于完全需要松质骨移植者,首选胫骨近端取骨。