自体髂骨解剖性重建在严重肱骨髁部创伤性骨缺损中的应用及远期随访

Application of autogenous iliac bone graft for anatomical reconstruction of severe bone defect in the humeral condyle:a long-term follow-up

目的：探讨采用自体髂骨进行解剖性重建在肱骨髁部严重创伤性骨缺损中的应用价值。方法回顾性分析1996年5月至2010年5月,第二军医大学长海医院收治的创伤后肱骨髁部严重骨缺损患者24例,其中男14例,女10例,年龄16~60岁,平均36.9岁；原始骨折按 AO/ASIF 肱骨髁部骨折分型：A 3型7例,B1型2例,C2型6例,C3型9例。受伤时间距重建手术时间7~55个月,平均24.7个月。术前曾行1次手术15例,2次手术6例,3次手术2例,3次以上1例。本次手术采用自体髂骨块解剖性重建肱骨髁的内和/或外侧柱,内固定21例,肘关节置换3例。术前肘关节活动度平均为：伸18.5°(5°~65°),屈90.5°(85°~125°)。结果24例患者均获随访,随访时间4.5~10.5年,平均5.2年。术后切口一期愈合,复查未发现植骨块移位、内固定松动、断裂、骨不连、畸形愈合、迟发性尺神经炎等并发症,其中1例肘关节前方发现异位骨化。术后平均骨愈合时间5.8个月(4~10个月)。末次随访时肘关节活动度平均为：伸9.5°(0°~40°),屈120.6°(105°~145°)。采用改良的 Cassebaum 评分系统评定肘关节功能：优9例,良8例,中6例,差1例,优良率72.4%。结论通过自体髂骨解剖性重建肱骨内外侧髁部的解剖形态,恢复肘关节力线,配合术后早期积极的功能锻炼,可以达到良好的骨折愈合,使肘关节的功能得到明显改善。

Background Due to the special anatomical and mechanical characteristics of the distal humerus,it is often difficult to obtain reliable fixation in this area after fracture.Especially with severe comminuted fractures and osteoporotic fractures in the elderly,early fracture displacement, malunion or nonunion are prone to occur after excessive activity,however,elbow anchylosis is usually cause by long period braking,contradictory treatment decisions often appear in the clinical practice. Although the incidence of nonunion of humeral condylar was low,it can still occur because of the limited choice of internal fixation materials and non-standardized treatment decision.Unstable fracture ends lead to bone resorption,scarring,and hardening,which often result in significant bone defect.In particular,in the case of early comminuted fracture or delayed treatment of open fracture,non-anatomical humeral condyle not only affects fracture healing,but also seriously reduces the function of the elbow joint.From May 1 996 to May 2010,Changhai hospital of the second military medical university treated 24 cases of patients with humeral condylar bone defect with autologous bone for anatomic reconstruction.The function and appearance of the elbow were satisfactory,and the report was as follows.Methods From May 1 996 to May 2010,24 patients (14 male,10 female)with humeral condylar nonunion and bone defect were retrospectively analyzed.The average age was 36.9 years old (range 1 6-60 years old).According to AO/ASIF system,primal fractures were classified. There were 7 cases type-A3,2 cases type-B1,6 cases type-C2 and 9 cases type-C3 fractures.The average span from trauma to this operation was 24.7 months (range 7-55 months).The approach of olecranon osteotomy was used in all patients. The medial and lateral humeral condyle was reconstructed with iliac autograft and shape memory compressive connector, cannulated nail, anatomical locking compressive plates were applied for fixation.Results 24 patients were followed for an average of 5.2 years (range 4.5-10.5 years).The averaged time of bone healing was 5.8 months (range 4-10 months).All the incisions healed primarily.There was no internal fixation failure,loss of reduction,secondary nonunion and tardive ulnar neuritis.Ectopic ossification before joint was found in one case and the elbow joint function was affected.According to the modified Cassebaum scoring system,the results were excellent in 9 cases,good in 8 cases,fair in 6 cases and poor in 1 case.The excellent and good rate was 72.4%.Conclusions The humeral condylar bone defects seriously affect the function of elbow joint.Anatomical reconstruction of medial and lateral condyle by autogenous iliac bone can restore the shape of elbow and alignment.Through early function exercise,elbow joint function can improve evidently.