CT血管成像联合彩色多普勒超声设计游离股骨内侧髁骨瓣治疗难治性手舟骨骨折不愈合

Treatment of refractory scaphoid fracture nonunion with computed tomography angiography combined with color Doppler ultrasonography assisted distal femoral medial condylar bone flap

目的:探讨术前CT血管成像(CTA)联合彩色多普勒超声(CDU)血管定位技术辅助下游离带血管蒂的股骨内侧髁骨瓣的手术方法治疗难治性手舟骨骨折不愈合的临床效果。方法:回顾性分析2018年1月至2022年6月华北医疗健康集团邢台总医院骨三科应用以膝降动脉为血供的游离股骨内侧髁骨瓣转移修复手舟骨陈旧性骨折合并骨坏死患者病例资料。术前采用CTA联合CDU技术定位膝降动脉,依照定位结果及骨质缺损情况设计股骨内侧髁骨瓣并修复手舟骨陈旧性骨折。采用门诊和电话方式进行随访,依照视觉模拟评分(VAS)评价腕关节疼痛程度,依照改良Mayo评分法评价腕关节功能,手舟骨弓背畸形程度根据舟骨角评价,腕骨间稳定程度根据舟月角评价。正态分布计量资料以x±s表示,采用配对样本t检验比较术前CDU测定及术中实际测定的膝降动脉起始处血管管径、起始处至股骨内侧髁下缘距离,并比较手术前后疼痛VAS评分、腕功能Mayo评分、握力、腕关节活动度、舟月角、舟骨角。结果:共纳入12例患者,其中男9例,女3例;年龄23~56岁,平均36岁;右侧骨折7例,左侧5例;手舟骨腰部骨折8例,近极骨折4例。比较术前CDU测定和术中实际测量的膝降动脉起始处血管管径[(1.7±0.5)mm vs.(1.8±0.7)mm]、起始处至股骨内侧髁下缘距离[(11.9±2.1)cm vs.(12.1±1.9)cm],差异均无统计学意义(P>0.05)。术后所有患者均获得6个月~2年随访,平均13个月。全部患者经X线片检查显示手舟骨骨性愈合,平均愈合时间为15周。术后6个月随访时,比较手术前后疼痛VAS评分[(3.7±0.9)分vs.(0.5±0.1)分]、腕功能Mayo评分[(46.1±3.8)分vs.(86.2±6.1)分]、舟月角[(65.3±4.1)°vs.(47.9±3.5)°]、舟骨角[(37.1±3.9)°vs.(22.8±2.3)°]、腕关节屈伸活动度[(79.0±11.7)°vs.(118.5±15.8)°]、握力[(6.7±4.6)kg vs.(26.1±5.3)kg],差异均有统计学意义(P<0.05)。结论:游离带血管蒂的股骨内侧髁骨瓣为修复手舟骨陈旧性骨折伴有骨坏死的理想方法之一,术前血管定位技术有效指导了骨瓣设计、切取,保证术中操作快速、准确。

Objective To investigate the surgical method of preoperative computed tomography angiography(CTA)combined with color Doppler ultrasonography(CDU)vascular localization assisted by downstream vascularized medial femoral condylar bone flap and its clinical effect in the treatment of refractory scaphoid fracture nonunion.Methods Retrospective analysis of case data from January 2018 to June 2022 in the Department of Orthopedics at Xingtai General Hospital of North China Medical and Health Group,using a free medial femoral condylar bone flap with descending knee artery as the blood supply to repair old fractures of the scaphoid bone with bone damage.Prior to surgery,CTA combined with CDU technology was used to locate the descending knee artery,and the medial femoral condylar bone flap was designed based on the localization result and bone defects.Follow-up was conducted using outpatient and telephone method.The degree of wrist pain was evaluated using the visual analogue scale(VAS),wrist function was evaluated using the improved Mayo scoring method,the degree of scaphoid arch back deformity was evaluated based on the angle of the scaphoid bone,and stability between the carpal bones was evaluated based on the angle of the scaphoid moon.The normal distribution metric data was represented as Mean±SD,and paired sample t-tests were used to compare the preoperative CDU measurement and the actual intraoperative measurement of the vessel diameter at the origin of the descending knee artery,as well as the distance to the inferior edge of the medial femoral condyle.The VAS score for pain before and after surgery,the Mayo score for wrist function,wrist grip strength,range of motion,scaphoid angle,and scaphoid angle are also compared.Results A total of 12 patients were enrolled,including 9 males and 3 females;age ranged from 23 to 56 years old,with an average of 36 years old.There were 7 cases of right side fractures,5 cases of left side fractures,8 cases of scaphoid waist fractures,and 4 cases of proximal pole fractures.There was no difference between the preoperative CDU location and the actual vessel diameter at the origin of the descending geniculate artery[(1.7±0.5)mm vs.(1.8±0.7)mm]and the distance to the inferior border of the medial femoral condyle[(11.9±2.1)cm vs.(12.1±1.9)cm](P>0.05).All patients were followed up after the operation,the specific time ranged from 6 months to 2 years,with an average of 13 months.The X-ray films showed that the scaphoid bone healed in all patients after operation,and the average healing time was 15 weeks.After 6 months of follow-up,the VAS scores(3.7±0.9 vs.0.5±0.1),Mayo scores(46.1±3.8 vs.86.2±6.1),scapholunar angle[(65.3±4.1)°vs.(47.9±3.5)°],scaphoid angle[(37.1±3.9)°vs.(22.8±2.3)°],wrist flexion and extension range of motion[(79.0±11.7)°vs.(118.5±15.8)°],grip strength[(6.7±4.6)kg vs.(26.1±5.3)kg]were compared before and after surgery,the differences were statistically significant(all P<0.05).Conclusion The free medial femoral condyle bone flap with a vascular pedicle is one of the ideal method to repair the old navicular fracture with osteonecrosis.The preoperative vascular positioning technique effectively guides the design and cutting of the bone flap and ensures fast and accurate operation during the operation.