前路减压n—HA／PA66支撑体植骨融合内固定治疗胸腰椎爆裂骨折的中期疗效

【摘要】目的观察前路减压纳米羟基磷灰石／聚酰胺66（n—HA／PA66）支撑体治疗胸腰椎爆裂骨折的中期疗效。方法回顾性分析我科2008年1月至2009年11月行前路减压、n—HA／PA66支撑体植骨融合内固定术治疗的46例胸腰段爆裂骨折患者。男33例,女13例,平均年龄54．5岁。收集患者术前及术后胸腰椎正侧位X线片、三维CT等影像学资料以及使用Frankel分级标准评价神经功能恢复情况等临床资料;通过侧位x线片测量融合节段高度及融合节段后凸角,通过CT三维重建评价植骨融合情况。结果本组病例随访平均50（42～64）个月,至末次随访植骨融合率为97．8％。术前、术后1周、术后6个月及末次随访的平均伤椎上下椎间高度分别为94．3mm、108．0mm、106．9mm、106．2mm;平均后凸角分别为18．2°、5．7°、6．0°、6．3°。患者术后1周的融合节段高度及后凸角均较术前显著改善（P〈0．001）;术后1周、6个月及末次随访的融合节段高度及后凸角比较差异无统计学意义fP〉0．05）,至末次随访时支撑体下沉平均为1．7mm。患者神经功能术前：A级3例、B级6例、C级16例、D级19例、E级2例;至末次随访：A级1例、B级2例、c级3例、D级14例、E级26例,末次随访时Frankel分级较术前有不同程度的改善。结论n—HA／PA66支撑植骨内固定能有效恢复及维持融合节段生理高度及弧度、促进植骨融合、方便术后手术节段的影像学观察,是一种较为理想的胸腰段植骨材料。使用前路减压、n—HA／PA66支撑体植骨融合内固定术治疗胸腰椎爆裂骨折的中期临床效果满意。     

Biomechanical Study of Intramedullary Versus Extramedullary Implants for Four Types of Subtrochanteric Femoral Fracture

ObjectivesTo compare the biomechanical performance of proximal femoral nail anti‐rotation (PFNA), the “upside‐down” less invasive plating system (LISS), and proximal femoral locking plate (PFLP) in fixing different fracture models of subtrochanteric fractures.MethodsThirty composite femurs were divided into three equal groups (PFNA, PFLP, and reverse LISS). The implant‐femur constructs were tested under axial compression load (0–1400 N) from models I to IV, which represented the Seinsheimer type I subtrochanteric fracture, type IIIa subtrochanteric fracture with the posteromedial fragment reduced; type IIIa subtrochanteric fracture with the posteromedial fragment lost; and type IV subtrochanteric fracture, respectively. Axial stiffness was analyzed for each group. Each group was then divided into two subgroups, one of which underwent torsional and axial compression failure testing, while the other subgroup underwent axial compression fatigue testing. The torsional stiffness, failure load, and cycles to failure were analyzed.ResultsPFNA had the highest axial stiffness (F = 761.265, p < 0.0001) and failure load (F = 48.801, p < 0.0001) in model IV. The axial stiffness and failure load of the PFLP were significantly higher than those of the LISS (p < 0.0001, p = 0.001). However, no significant difference in axial stiffness was found between models I to III (model I: F = 2.439, p = 0.106; model II: F = 2.745, p = 0.082; model III: F = 0.852, p = 0.438) or torsional stiffness in model IV (F = 1.784, p = 0.187). In fatigue testing, PFNA did not suffer from construct failure after 90,000 cycles of axial compression. PFLP and LISS were damaged within 14,000 cycles, although LISS withstood more cycles than PFLP (t = 3.328, p = 0.01).ConclusionThe axial stiffness of the three implants was similar in models I to III. The biomechanical properties of PFNA were the best of the three implants in terms of axial stiffness, failure load, and fatigue testing cycles in model IV. The axial stiffness and failure load of the PFLP were better than those of the reverse LISS, but PFLP had fewer cycles in the fatigue tests than the reverse LISS.     

The novel infra‐pectineal buttress plates used for internal fixation of elderly quadrilateral surface involved acetabular fractures

ObjectivesIn geriatric acetabular fractures, the quadrilateral surface (QLS) was frequently involved in acetabular fracture patterns and accompanied by medial displacement. It was important to buttress the medial displaced QLS and reconstruct the congruity of the affected acetabulum. To evaluate the clinical effectiveness of the novel infra‐pectineal quadrilateral surface buttress plates for the treatment of geriatric acetabular fractures.MethodsTwenty‐three geriatric patients who were treated for acetabular fractures involving QLS with the novel infra‐pectineal buttress plates (NIBP) through a single supra‐ilioinguinal approach between January 2015 and June 2019 were retrospectively analyzed; all patients received at least 1 year''s follow‐up. All patients were aged ≥60 years old and including 18 males and five females. Radiologic and clinical outcomes of patients involved in the study were collated and analyzed according to the Matta scoring system and the Merle D''Aubigné–Postel scoring system. The functional recovery scoring was compared using q‐test.ResultsAll 23 consecutive patients had relatively satisfactory clinical treatment effectiveness. Average ages, length of incision, operation time, and intraoperative blood loss were 69.8 ± 6.1 years, 12.1 ± 2.6 cm, 166.5 ± 43.5 min, and 500 (500,700) ml, respectively. According to the Matta scoring system, 14 cases of reduction were graded as excellent, five as good, and four as fair. At the last follow‐up, the clinical outcome evaluation was excellent in 13 cases, good in seven cases, and poor in three cases with the use of the Merle D''Aubigné–Postel scoring system. The difference of modified Merle D''Aubigne‐Postel score at 3 months, 6 months and last follow up was statistically significant (F = 21.56, p < 0.05). Postoperative lateral femoral cutaneous nerve injury occurred in three patients and heterotopic ossification occurred in one patient.ConclusionsFor the treatment of geriatric acetabular fractures, the NIBP could provide stable and effective fixation to the QLS involved acetabular fractures, and related satisfactory clinical results with few complications were noted.     

侧后方入路椎体部分切除减压与重建术治疗胸腰椎骨折

目的探讨胸腰椎侧后方入路椎体部分切除减压与内固定手术治疗胸腰椎骨折的临床效果。方法2002年8月～2006年9月对32例胸腰椎骨折患者行胸腰椎侧后方入路椎体部分切除减压内固定手术。结果所有病例术后获得10～26个月的随访,26例椎体近解剖复位,6例复位良好。无感染、无胸膜粘连和断钉等并发症,全部椎体间骨性融合。神经功能恢复Frankel分级,除5例A级及4例E级无变化外,其余均有1—2级改善。结论侧后方入路椎体部分切除减压内固定具有减压直接彻底、重建脊柱序列及脊髓神经功能恢复满意等特点,可用于治疗椎管占位明显或陈旧性的胸腰椎骨折。     

预测骨质疏松性椎体压缩骨折经皮椎体成形术后残余背痛的列线图

目的: 构建预测骨质疏松性椎体压缩性骨折(osteoporotic vertebral compression fractures,OVCFs)经皮椎体成形术(percutaneous vertebroplasty,PVP)后残余背痛(residual back pain,RBP)的列线图。方法: 回顾性分析2020年1月至2022年12月245例接受PVP治疗的OVCFs患者的临床资料,男47例,女198例,年龄65~77(71.47±9.03)岁,根据是否发生RBP分为RBP组与无RBP组。收集患者的性别、年龄、合并症情况、骨折发生节段、身体质量指数(body mass index,BMI)、骨密度(bone mineral density,BMD)、视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)等一般资料;以及术前与术后24 h的影像学参数,包括椎体前缘高度(anterior vertebral height,AVH)、椎体前缘高度比(anterior vertebral height ratio,AVHR)、Cobb角、椎体内真空裂(intravertebral vacuum cleft,IVC)、胸腰筋膜(thoracolumbar fascia,TLF)损伤、椎旁肌脂肪变性、骨水泥注射量、骨水泥渗漏、骨水泥弥散形态、椎体前缘高度恢复比(anterior vertebral height recovery ratio,AVHRR)、Cobb角变化等。对以上因素进行单因素分析,再采用多因素Logistic回归模筛选术后发生RBP的独立危险因素,并完成Nomogram模型的构建与验证,分别采用受试者工作特征(receiver operating characteristic,ROC)曲线和校准曲线进行模型的预测性能和准确性的判定,另采用Hosmer-Lemeshow (H-L)检验进行评估,计算ROC曲线下面积(area under curve,AUC),使用Harrell一致性指数(C指数)评价模型的预测效能,使用决策曲线分析(decision curve analysis,DCA)评价模型的临床实用性。结果: RBP组34例,无RBP组211例。两组性别、年龄、合并症、骨折节段、BMI、BMD、VAS及ODI、AVH、AVHR、Cobb角等比较,差异均无统计学意义(P>0.05)。单因素分析结果显示:RBP组6例出现IVC,无RBP组13例,RBP组IVC比例高于无RBP组(χ²=5.400,P=0.020);RBP组6例出现TLF损伤,无RBP组11例,RBP组TLF损伤比例高于无RBP组(χ²=7.011,P=0.008);RBP组椎旁肌脂肪变性3-4级为18例,无RBP组为41例,RBP组高于无RBP组(χ²=21.618,P<0.001),RBP组骨水泥弥散形态为团块型比例高于无RBP组(χ²=6.836,P=0.009)。多因素Logistic回归分析结果显示,存在IVC (χ²=4.974,P=0.025)、合并TLF损伤(χ²=5.231,P=0.023)、椎旁肌脂肪变性Goutallier分级>2级(χ²=15.124,P<0.001)以及骨水泥弥散形态为团块型(χ²=4.168,P=0.038)为PVP术后发生RBP的独立危险因素。模型ROC曲线得出原始模型AUC为0.816[OR=2.862,95% CI (0.776,0.894),P<0.001],通过200个自举样本进行模型内部验证,得出C指数值为0.936,校准曲线显示预测概率曲线与实际概率曲线接近,H-L拟合优度检验结果为χ²=5.796,P=0.670,DCA分析结果显示当阈值在6%~71%时决策曲线位于None线与All线上方。结论: 存在IVC、合并TLF损伤、椎旁肌脂肪变性Goutallier分级>2级以及骨水泥弥散形态为团块型为PVP术后发生RBP的独立危险因素,本研究所构建的PVP术后发生RBP的风险预测模型具有较好的预测性能和较好的临床实用性。     

严重骨盆骨折的救治

目的探讨严重骨盆骨折的治疗方法和疗效。方法总结、分析从1992年1月至2007年12月收治的严重骨盆骨折患者106例。按照Tile分型B型47例,C型59例。其中骶髂关节脱位或分离21例,髋臼骨折伴中心性脱位19例,8例耻骨联合明显分离。106例均有不同程度创伤性休克,58例并发腹膜后血肿,26例并发肝脾破裂或肠管破裂或尿道损伤。结果106例经综合治疗,103例救治成功,死亡3例。病情稳定后19例髋臼骨折伴中心性脱位患者14例行手术治疗,根据Matta的复位标准：解剖复位10例,良好复位3例,差1例。根据美国矫形外科研究院髋关节功能评定标准：优9例,良2例,可2例,差1例;8例耻骨联合明显分离患者行切开复位钢丝或钢板内固定,分离纠正。结论早期正确的诊断、多学科协同抢救患者生命是治疗严重骨盆骨折的关键,可降低死亡率;病情稳定后部分病例行再手术内固定,可降低病残率。     

A retrospective assessment of the clinical efficacy of different internal fixation methods in the treatment of distal fibula fractures in the elderly

An ankle fracture is a fracture of the distal tibia or fibula that forms the ankle joint, usually associated with ligament and soft tissue injury, and is a common type of lower limb fracture and one of the most common types of fracture in the elderly. Although ankle fractures are one of the most common injuries seen by orthopedic trauma surgeons, there is no uniform protocol for the diagnosis and treatment of ankle fractures in the elderly, and there are many controversial indications for surgery. The aim of this study is to assess the clinical efficacy of different internal fixation methods in the treatment of distal fibular fractures in the elderly, in an effort to improve the rational selection and application of clinical acts. A retrospective analysis was performed on 68 cases of patients who suffered an ankle fracture and were treated with different internal fixation methods according to the fracture types and individual differences in distal fibula fractures. The postoperative therapeutic effect assessment was performed in terms of clinical examination, imaging evaluation, and AOFAS ankle-hind foot function scoring. There was no unhealed bone, ankle instability and loose/fractured internal fixation. Fracture healing time was 2.7 to 4.0 months (average 3.2 months). AOFAS score was 88.3 ± 6.2, of which, 34 excellent cases, 30 good cases, and 4 fair cases. Ankle activity dorsiflexion 6º~18º, average 15º; plantar flexion 26º~47º, average 37º. A good clinical efficacy could be achieved from the most appropriate individualized internal fixation for distal fibula fractures of elderly patients.     

Vitamin B12 as a novel risk biomarker of spinal fractures

Spinal fractures are common intra-articular fractures. Osteoporosis is a common and frequent disease among the elderly with a poor prognosis and a high risk of spinal fractures. However, the underlying factors for spinal fractures in patients with osteoporosis are unclear. A total of 105 patients with osteoporosis were recruited. Clinical and followed-up information was recorded. And vitamin B12, vitamin B2, vitamin A, and vitamin B9 in the blood were tested. Pearson’s chi-squared and spearman tests were performed to analyze the correlation between spinal fractures and relative parameters. Univariate and multivariate logistic regression, univariate and multivariate Cox proportional hazards regression analysis. There exists strong relation between the expression level of vitamin B12 and spinal fractures. Pearson’s chi-square and Spearman correlation test showed a strong association between vitamin B12 and vitamin B9 and a spinal fracture. Univariate logistic regression analysis showed that vitamin B12 and vitamin B9 were significantly associated with a spinal fracture. Multivariate logistic regression analysis showed that vitamin B12 was associated considerably with a spinal fracture. In addition, Cox regression analysis showed that vitamin B12 expression was significantly associated with maintenance time from recovery to recurrence (MTRR) of spinal fractures in patients with osteoporosis. Enhanced vitamin B12 is significantly correlated with the poor prognosis of patients with osteoporosis and the increasing incidence of a spinal fracture. The higher the vitamin B12, the higher the risk of spinal fracture and the shorter the time to spinal fracture recurrence.