llizarov骨搬运技术治疗胫骨骨缺损的疗效及术后延迟愈合或不愈合的影响因素分析

摘要 目的：探讨 llizarov骨搬运技术治疗胫骨骨缺损的疗效及术后延迟愈合或不愈合的影响因素分析。方法：选取 2016年 6月-2020年 10月本院收治的 90例胫骨骨缺损患者为研究对象,患者均给予 llizarov骨搬运技术治疗。对患者的手术效果指标、并发症发生率进行记录统计。并对患者进行门诊随访观察,统计患者延迟愈合或不愈合的发生情况,据此将患者分为愈合组和延迟愈合或不愈合组。采用单因素及多因素 Logistic回归分析患者术后延迟愈合或不愈合发生的影响因素。结果：患者住院时间为(12.11± 2.98)d、开始负重时间为(45.39± 7.78)d、完全负重时间(76.41± 11.23)d。患者术后并发症发生率为 8.89%(8/90)。经随访观察,共有 29例患者出现术后延迟愈合或不愈合,发生率为 32.22%（29/90）。而延迟愈合或不愈合组患者的伤口感染、合并软组织损伤、合并腓骨骨折、术后过早活动及有吸烟史的人数占比高于愈合组患者(P<0.05)。经多因素 Logistic回归分析显示：伤口感染、合并软组织损伤、合并腓骨骨折、术后过早活动、有吸烟史是患者术后延迟愈合或不愈合的危险因素(P<0.05)。结论：llizarov骨搬运技术治疗胫骨骨缺损的疗效较好,患者的手术时间短、术中失血量少、住院时间、开始负重时间均较短,并发症发生率低,治疗安全性较好,但患者易出现术后延迟愈合或不愈合现象,可能与伤口感染、合并软组织损伤、合并腓骨骨折、术后过早活动、吸烟史有关。     

Ilizarov method in combination with autologous mesenchymal stem cells from iliac crest shows improved outcome in tibial non-union

Autologous bone grafting and ilizarov technique are the preferred mode of treatment for bone nonunion, studies suggest that bone marrow derived mesenchymal stem cells can be effective in treatment of tibial non-union where there is length of bone defect. The current study investigates the beneficial clinical outcome of combining the ilizarov procedure with intraosseous injection of autologous mesenchymal stem cells. The open-label study enrolled 25 patients with infected tibial non-union at the Shanghai Fengxian District Central Hospital, Shanghai, China between April 2010 and July 2014. Patients were randomised to undergo the ilizarov procedure with (n = 11) or without (n = 13) intraosseous injection of bone marrow derived mesenchymal stem cells. All participants were followed prospectively until union was achieved (primary end point). The mean length of the bone defect in the Ilizarov group and Ilizarov group plus MSC group was 6.09 and 5.84 cm respectively. The mean time from the original injury to the time of the treatment for tibial non-union was 5–22 months (mean 13.5 months) for the Ilizarov group and 6–21 months (mean 13.5 months) for Ilizarov plus MSc group. All 24 patients were followed up for 12–34 months (mean 16 months). Both groups achieved the primary endpoint of stable union of the tibial fracture. No adverse events were observed in any of the group. Our study demonstrates that using autologous bone marrow derived mesenchymal stem cell as an add-on therapy to the ilizarov procedure shows significant clinical benefit in fixation of tibial non-union.     

Regeneration of the skeleton by recombinant human bone morphogenetic proteins

Recombinant human bone morphogenetic proteins (rhBMPs) have past a long journey in human orthopaedic surgery during the last 15 years. From the first reports of the use of rhBMPs in hostile environments such as critically-sized bone defects, avascular femoral head necrosis, unstable thoracolumbar vertebral fractures, instability between the atlas and axis due to rheumatoid arthritis; over the use for nonunions of long bones and the scaphoid, reconstructive and revision surgeries of the hip, acute fractures, allograft nonunions, congenital pseudarthrosis, and various approaches of lumbar and cervical spine fusions, rhBMPs overgrow to a safe and reliable device in the treatment of open tibial shaft fractures, nonunions of long bone fractures, anterior lumbar interbody fusion and revision posterolateral lumbar fusions. Systematic review of the published literature of rhBMPs is presented.     

镶嵌式外固定架治疗长骨骨不连17例体会

目的：探讨长骨骨不连的一种治疗方法。方法：2007年1月至2009年8月,采用镶嵌式外固定架治疗17例长骨骨不连。本组17例,男11例,女6例,年龄16-64岁,平均31岁。2例为血源性骨髓炎病理性骨折后,股骨、胫骨各1例;6例为创伤性骨髓炎后骨折不愈,肱骨1例,股骨1例,胫骨4例;9例为手术后无感染性骨不连,肱骨2例,股骨2例,胫骨5例;7例有不同程度畸形,6例有1.5-8cm骨短缩,其中2例同时行骨痂延长术。结果：全部病人均获随访,随访时间9-20个月,以1975年天津全国骨科会议制定的骨折愈合标准为依据,本组17例病人均获得临床愈合,骨不连处平均愈合时间为4～9月（平均6.2月）,1例延长8cm,另1例延长6cm。结论：利用镶嵌式外固定架治疗长骨骨不连一种简单有效的方法。     

A Challenge to Debate. III. The Inward and Outward Currents of a Space-Clamped Squid Axon

Fifteen patients with post-traumatic nonunions and a bone gap, eight of which were infected, were treated with bone grafting and electrostimulation using a stimulator connected to the external fixation pins. All nonunions healed with a median time of 9 months, and no recurrences of the osteomyelitis were observed.     

Bone Morphogenetic Protein for the Healing of Tibial Fracture: A Meta-Analysis of Randomized Controlled Trials

Purpose

To review the evidence from RCTs on clinical outcomes and benefit of acute tibial fracture and nonunion treated with and without BMPs.

Material

We searched multiple databases (MEDLINE, EMABSE, BIOSIS and Cochrane central) as well as reference lists of articles and contacted authors. Evaluated outcomes included union rate, revision rate, hardware failure and infection. The weighted and standard mean difference (WMD and SMD) or the relative risk (RR) was calculated for continuous or dichotomous data respectively. The quality of the trial was assessed, and meta-analyses were performed with the Cochrane Collaboration’s REVMAN 5.0 software.

Results

Eight RCTs involving 1113 patients were included. For acute tibial fracture, BMP group was associated with a higher rate of union (RR, 1.16; 95% CI, 1.04 to 1.30) and a lower rate of revision (RR, 0.68; 95% CI, 0.54 to 0.85) compared with control group. No significant differences were found in rate of hardware failure and infection. The pooled RR for achieving union for tibial fracture nonunion was 0.98 (95% CI, 0.86 to 1.13). There was no significant difference between the two groups in the rate of revision (RR, 0.48; 95% CI, 0.13 to 1.85) and infection (RR, 0.61; 95% CI, 0.37 to 1.02).

Conclusion

Study on acute tibial fractures suggests that BMP is more effective that controls, for bone union and for decreasing the rate of surgical revision to achieve union. For the treatment of tibial fracture nonunion, BMP leads to similar results to as autogenous bone grafting. Finally, well-designed RCTs of BMP for tibial fracture treatment are also needed.     

Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating

Background

The treatment of forearm fracture-nonunions continues to represent a therapeutic challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic location include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to prolonged immobilization. The present study was designed to assess the outcome of autologous bone grafting with compression plating and early functional rehabilitation in patients with forearm fracture non-unions.

Methods

Prospective follow-up study in 31 consecutive patients presenting with non-unions of the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected non-union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate (DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of radiographic bony union and functional outcome, as determined by the criteria defined by Harald Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months, with an average long-term follow-up of 3.6 years (range 2 to 6 years).

Results

Radiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5 months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume their previous work. Two postoperative infections occurred, and one patient developed a persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire cohort.

Conclusion

Revision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting and compression plating represents a safe and efficacious modality for the treatment of these challenging conditions.     

The role of primary bone grafting in complex craniomaxillofacial trauma

The role of craniofacial surgical techniques and immediate bone grafting in the management of complex craniofacial trauma has been reviewed. Four hundred and one patients with complex facial injuries have been treated. Two hundred and forty-one primary bone and cartilage grafts have been performed in 66 patients. Complex facial injuries should be managed by direct exposure, reduction, and fixation of all fractures utilizing interfragmentary wiring. Very comminuted or absent bone is replaced by immediate bone grafting, producing a stable skeleton without the need for external fixation devices. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O technique. Results of immediate bone grafting have been excellent, and complications are rare. All deformities should be corrected, whenever possible, during the initial operation. This one-stage reconstruction of even the most complex facial injuries will prevent severe postoperative traumatic deformity and disability that may be extremely difficult or impossible to correct secondarily.     

Late results of free-muscle flaps and delayed bone grafting in the secondary treatment of open distal tibial fractures

Since no current studies reflect the long-term function of patients accurately categorized and uniformly managed for the same degree and location of tibial injury, seven individuals with type IIIB open distal tibial fractures were studied prospectively for 2 to 4 years after debridement, free-muscle transfer, and delayed autologous bone grafting. Lymphedema, transient drainage, poor ankle motion, limb shortening, nonunion, and delayed union were all significant problems. On average, the patients endured over six operations, 2 months of hospitalization, and a year's course of physical rehabilitation. The study indicates that, although popular, such a regimen is not without important shortcomings. This experience has influenced our selection of and counseling for patients in whom we are contemplating such management.     

逆行交锁髓内钉联合单侧骨皮质锁定钢板固定治疗股骨髁上骨不连

目的:探讨逆行交锁髓内钉联合单侧骨皮质钢板固定治疗股骨髁上骨不连的临床疗效。方法:对25例股骨髁上骨不连,均采用逆行交锁髓内钉联合单侧骨皮质钢板固定加自体髂骨植骨治疗。结果:25例获12～24个月随访,平均12个月。4～8个月内均获骨性愈合。结论:应用逆行交锁髓内钉联合单侧骨皮质钢板固定后骨折端可获得坚强内固定,手术操作简便、安全,可早期进行膝关节和股四头肌功能锻炼,是一种治疗股骨髁上骨不连的有效方法。     

Delayed primary reconstruction of subtotal nail bed loss using a split-thickness nail bed graft on decorticated bone

Split-thickness nail bed grafting is the accepted method of treatment for injuries involving loss of nail bed tissue. The nail bed of the great toe may be used without donor-site morbidity, and nail bed grafting may be combined with other procedures for fingertip reconstruction. A case of fingertip avulsion injury with loss of the nail plate, nail bed, and periosteum over the exposed distal phalanx of the thumb was reconstructed by a split-thickness nail bed graft placed directly on granulating decorticated bone. The length, appearance, and function of the injured dominant thumb were preserved.     

Embryonic origin and Hox status determine progenitor cell fate during adult bone regeneration

The fetal skeleton arises from neural crest and from mesoderm. Here, we provide evidence that each lineage contributes a unique stem cell population to the regeneration of injured adult bones. Using Wnt1Cre::Z/EG mice we found that the neural crest-derived mandible heals with neural crest-derived skeletal stem cells, whereas the mesoderm-derived tibia heals with mesoderm-derived stem cells. We tested whether skeletal stem cells from each lineage were functionally interchangeable by grafting mesoderm-derived cells into mandibular defects, and vice versa. All of the grafting scenarios, except one, healed through the direct differentiation of skeletal stem cells into osteoblasts; when mesoderm-derived cells were transplanted into tibial defects they differentiated into osteoblasts but when transplanted into mandibular defects they differentiated into chondrocytes. A mismatch between the Hox gene expression status of the host and donor cells might be responsible for this aberration in bone repair. We found that initially, mandibular skeletal progenitor cells are Hox-negative but that they adopt a Hoxa11-positive profile when transplanted into a tibial defect. Conversely, tibial skeletal progenitor cells are Hox-positive and maintain this Hox status even when transplanted into a Hox-negative mandibular defect. Skeletal progenitor cells from the two lineages also show differences in osteogenic potential and proliferation, which translate into more robust in vivo bone regeneration by neural crest-derived cells. Thus, embryonic origin and Hox gene expression status distinguish neural crest-derived from mesoderm-derived skeletal progenitor cells, and both characteristics influence the process of adult bone regeneration.     

A new transplant bone for maxillary alveolar cleft

An innovative technique with distraction osteogenesis has been developed in our research group to explore autogenous bone transplantation into craniofacial bone defects. This technique was designed to investigate bone-marrow transplantion using a chondroid or fibula bone graft into simulated alveolar bone defects in mice in terms of the osteogenic process and activity. As an experimental model of maxillary alveolar bone cleft available for testing bone-inductive materials, a critical-size defect was formed in the pre-maxillary bone of male mice using a surgical trephine bur with a low-speed dental engine. Distraction osteogenesis was performed using an external fixation device. The osteotomy site was occupied by an external callus consisting of hyaline cartilage with a large quantity of chondroid bone. Moreover, bone remodelling with new bone formation was demonstrated 30 days after the transplantation. Bone adhesion was better in chondroid bone grafting than in fibula bone grafting. The present findings are the first to demonstrate the potential of chondroid bone transplantation as a new therapeutic system of bone grafting, suitable for bone substitutes in craniofacial bone defects.     

Advantages of intramedullar fixation in treatment of congenital tibial pseudoarthrosis--a case report

This report describes a case of a 29-year old patient with congenital pseudoarthrosis of the distal tibia previously treated unsuccessfully by a conventional surgical method. Tibial congenital pseudoarthrosis is a rare disease characterized by segmental osseous weakness resulting in deformation of the bone and spontaneous fractures which progresses to a tibial nonunion. In our case we used intramedullary stabilization with bone grafting and six month after operation congenital pseudarthrosis of the tibia healed.     

富血小板血浆联合同种异体骨治疗非感染性骨不连的临床应用

目的:评价富血小板血浆联合同种异体骨治疗非感染性骨不连的临床疗效。方法:回顾性分析我院创伤骨科2010年2月-2015年1月的非感染性骨不连患者,比较同种异体骨加富血小板血浆混合物与自体髂骨植骨治疗非感染性骨不连的疗效。结果:两组共随访非感染性骨不连患者69例,全部进行了术中断端植骨,其中富血小板血浆联合同种异体骨植骨组(PRP组)21例,其中愈合19例,未愈合2例,临床愈合率90.5%。自体髂骨植骨组(自体骨组)48例,愈合44例,4例未愈合,临床愈合率91.6%。PRP组平均手术持续时间为(108.73±13.91),自体骨组为(120.54±13.87)min,两组间有统计学意义(P0.05)。术后3月,PRP组患者X线骨痂评价标准平均评分值为(2.54±0.43)分,自体骨组为(2.62±0.45)分,两组间差异无统计学意义(P0.05)。结论:富血小板血浆混合同种异体骨植骨治疗骨不连较传统自体髂骨植骨可缩短手术时间,避免供骨区并发症,修复效果良好,为骨不连的治疗提供了一个新的方法。     

The role of free-tissue transfers in lower-extremity reconstruction

Eighty-five free flaps were performed in 76 patients for defects in the lower extremity. A new classification of lower-extremity defects was devised to help define the role of free-tissue transfers: group 1, soft-tissue defects; group 2, soft-tissue and bone loss less than 8 cm; group 3, massive soft-tissue and bone loss greater than 8 cm; and group 4, bone defect only. Each group was further divided into clean (A) and infected (B) wounds. Our overall results include resolution of the presenting problem in 82 percent; there were 17 flap losses (20 percent), persistent osteomyelitis in 8, and 10 amputations. This review has prompted us to limit our indications for limb salvage, particularly in group 3B, in patients with compound injuries that include loss of plantar sensation, and in patients with large segments of infected bone.     

Distraction osteogenesis of costochondral bone grafts in the mandible

Costochondral grafting for reconstruction of the Pruzansky type III mandible has given variable results. Lengthening of the rib graft by means of distraction had been advocated when subsequent growth of the grafted mandible is inadequate. This retrospective study reviews a series of patients with mandibular costochondral grafts who underwent subsequent distraction osteogenesis of the graft. A retrospective review identified two patient groups: group 1 consisted of individuals (n = 9) who underwent costochondral rib grafting of the mandible followed by distraction osteogenesis several months later at a rate of 1 mm/day. Group 2 consisted of patients with Pruzansky type II mandibles who had distraction osteogenesis without prior rib grafting (n = 9). The biomechanical parameters, orthodontic treatment regimens, and complications were examined versus patient age and quality of the rib graft. Distraction osteogenesis was successfully performed in six of the rib graft patients (group 1) and in all of the group 2 individuals. On the basis of the Haminishi scale, the computed tomographic scan appearance of the regenerate was classified as "standard or external" in six of the group 1 patients and as either "agenetic" or "pillar" (fibrous union) in the remaining three patients. In group 1, the average device was expanded 23 mm (range, 20 to 30 mm). Group 2 mandibular distraction results were all classified as either standard or external, and there was an average device expansion of 22.4 mm (range, 16 to 30 mm). The length of consolidation averaged 12.6 weeks in group 1, compared with 8.5 weeks in the traditional mandibular distraction patients (group 2). The mean shift of the dental midline to the contralateral side was 2.5 mm in group 1 versus 4.0 mm in group 2. Complex multiplanar and transport distractions were successfully performed on grafts of adequate bony volume. All four patients in group 1 with tracheostomies were successfully decannulated after consolidation. Rib graft distraction complications included pin tract infections in two patients, hardware failure with premature pin pullout in one patient, and evidence of fibrous nonunions in three young patients with single, diminutive rib grafts. In group 2, there were no distraction failures. Distraction osteogenesis can be successfully performed on costochondral rib grafts of the mandible; however, the complication rate is higher than in non-rib-graft patients. Performing the technique on older, more cooperative individuals seems to reduce this risk. In addition, placement of a double rib graft or an iliac bone graft of sufficient volume to create a neomandible with greater bone stock is an absolute requirement to decrease the risk of fibrous nonunion and provide a bone base of sufficient size for retention of the distraction device and manipulation of the regenerate.     

The evaluation of knee bone mineral density following open-wedge high tibial osteotomy

Examinations of bone density changes in selected knee bone ends were evaluated prospectively in a randomized group of 28 patients, aged from 41 to 65 (mean: 55.3 years), who had varus deformations of their mechanic limb axes, mean 8 degrees. The examinations were conducted during the preoperative period, 10 days, 3, 6, and 12 weeks, as well as 6 and 12 months after the procedure. A statistically significant increase in bone density was observed in the medial tibial condyle area, while a statistically insignificant decrease of bone density was noted in the medial femoral condyles. Bone density increased in the lateral tibial condyle area, whereas there were no density changes in the area of the lateral femoral condyles. The research results demonstrate that the relief achieved in ailments after high tibial osteotomies does not directly correspond to the bone density of the affected areas.     

Carbon dioxide (CO2) laser perforation of exposed cranial bone to stimulate granulation tissue

The technique of CO2 laser perforation of exposed bone has been discussed. The advantages of this rapid and safe technique, which minimizes patient anxiety, limits tissue destruction, and can be performed without anesthesia in an outpatient setting, suggest that it can be considered as a possible alternative treatment to stimulate the production of granulation tissue over exposed bone to allow healing by secondary intention or skin grafting.     

改良Masquelet技术治疗胫骨感染性缺损的临床疗效分析

摘要 目的：探讨和分析使用改良Masquelet技术在胫骨感染性缺损中的临床疗效。方法：回顾性分析2018.01-2022.01范围内,使用改良Masquelet治疗胫骨感染性缺损的共计21患者。通过骨愈合(Samantha X 线评分),软组织愈合,感染控制,下肢功能,并发症等方面对临床疗效进行评价。结果：21例患者均获得完整随访,随访时间为12-36个月,平均为18.6个月。所有患者均达到骨愈合标准（3.2±8.3个月）。Samantha X 线评分：1例为4分,8例为5分,12例6分。PALEY功能评分为：优9人,良11人,可1人,差0人,优良率为95.2%。患者中均未出现严重并发症(P>0.05)。结论：在胫骨感染性缺损的治疗中,改良Masquelet技术是一种简单,安全,有效的治疗方法,在临床中可以进一步推广。