Role of locking plates in treatment of difficult ununited fractures： a clinical study

Objective： To present our experience in treatment of difficult ununited long bone fractures with locking plate. Methods： Retrospective evaluation of locking plate fixation in 10 difficult nonunions of long bone fractures was done. Fixation was done with locking plate for femoral shaft fracture （3 patients）, supracondylar fracture of femur （gap nonunion）, fracture of clavicle, fracture of both forearm bones （radius and ulna） fracture of ulna, fracture of shaft of humerus, fracture of tibial diaphysis and supracondylar frac- ture of humerus （one patient each）. Five fractures had more than one previous failed internal fixation. One patient had infected nonunion which was managed by debridement with cast immobilization followed by fixation with locking plate at six weeks. Seven fractures were atrophic, two were oligotrophic, and one was hypertrophic. Fibular autograft was used in 2 cases and iliac crest cancellous bone graft used in all the patients. Results： Minimum follow-up was 6 months （range, 6 months to 2.5 years）. Average time for union was 3.4 months （range 2.5 to 6 months）. None of the patients had plate- related complications or postoperative wound infections. Conclusion： Along with achieving stability with locking compression plate, meticulous soft tissue dissection, acceptable reduction, good fixation technique and bone grafting can help achieve union in difficult nonunion cases. Though locking plate does not by itself ensure bony union, we have found it to be another useful addition to our armamentarium for treating difficult fracture nonunions.

Treatment of nonunions of humeral fractures with interlocking intramedullary nailing

Objective： To introduce the experience of treating nonunions of humeral fractures with interlocking intramedullary nailing. Methods： Twelve patients with humeral nonunions were treated with interlocking intramedullary nailing. The time interval between trauma and surgery was 10.5 months on average. Open reduction with anterograde approach was performed. Axial compression was specially applied to the fracture site with humeral nail holder after insertion of distal locked screws. Iliac bone grafting was added. Results： The average follow-up period was 21 months （ranging 9-51 months）. All patients achieved osseous union 5.8 months after treatment on average. Eleven patients hadgood functions of the shoulder joints and the upper extremities. No patient experienced any permanent neurological deficit. Refracture of the original ununited region occurred in one patient after removal of the internal fixator one year later, but union was achieved after closed re-intramedullary nailing fixation. Conclusion： Humeral interlocking intramedullary nailing is an effective alternative treatment for humeral nonunion.

A segmental defect adaptation of the mouse closed femur fracture model for the analysis of severely impaired bone healing

Objective: To better characterize nonunion endochondral bone healing and evaluate novel therapeutic approaches for critical size defect healing in clinically challenging bone repair, a segmental defect model of bone injury was adapted from the threepoint bending closed fracture technique in the murine femur.Methods: The mouse femur was surgically stabilized with an intramedullary threaded rod with plastic spacers and the defect adjusted to different sizes. Healing of the different defects was analyzed by radiology and histology to 8 weeks postsurgery. To determine whether this model was effective for evaluating the benefits of molecular therapy, BMP-2 was applied to the defect and healing then examined.Results: Intramedullary spacers were effective in maintaining the defect. Callus bone formation was initiated but was arrested at defect sizes of 2.5 mm and above, with no more progress in callus bone development evident to 8 weeks healing. Cartilage development in a critical size defect attenuated very early in healing without bone development, in contrast to the closed femur fracture healing, where callus cartilage was replaced by bone. BMP-2 therapy promoted osteogenesis of the resident cells of the defect, but there was no further callus development to indicate that healing to pre-surgery bone structure was successful.Conclusions: This segmental defect adaptation of the closed femur fracture model of murine bone repair severely impairs callus development and bone healing, reflecting a challenging bone injury. It is adjustable and can be compared to the closed fracture model to ascertain healing deficiencies and the efficacy of therapeutic approaches.

Results of surgically treated talar fractures

Objective：Talar fractures present a great challenge to surgeons due to poor treatment outcome and high incidence of sequelae.The purpose of this study was to report the surgical treatment outcome of displaced talar fractures treated by internal fixation.Methods：Atotal of 30 patients with a mean age of 38 years presenting with talar body or neck fractures were studied retrospectively to assess postoperative outcome based on American Orthopaedic Foot ＆ Ankle Society AnkleHindfoot scale.Results：Postoperatively,malunion was found in 18 cases,infection in 5 cases and avascular necrosis in 12 cases.There were 12 cases with subtalar arthritis and 18 cases with both subtalar and malleolar arthritis.The average score of questionnaire was 64± 12.Functional score was 53± 15 and pain score was 65±13.Range of motion failure was detected as 15±4.Conclusion：Talar injuries can compromise motion of the foot and ankle and result in poor prognosis on longterm evaluation.Late complications subsequent to surgically treated talar body fractures are inevitable,and patients are supposed to be counseled about the adverse outcome.

Effects of intravenous inhalational anesthesia on the hemodynamic homeostasis as well as postoperative brain function and Th1/Th2 immunity in elderly patients with femoral neck fracture

Objective: To explore the effects of intravenous inhalational anesthesia on the hemodynamic homeostasis as well as postoperative brain function and Th1/Th2 immunity in elderly patients with femoral neck fracture. Methods: A total of 176 elderly patients with femoral neck fracture who received hip replacement in our hospital between July 2016 and June 2017 were divided into the total intravenous anesthesia group (n=86) and the intravenous inhalational anesthesia group (n=90) according to the anesthesia solution. The differences in introperative hemodynamic parameter levels as well as postoperative brain function index and Th1/Th2 cytokine contents were compared between the two groups. Results: During operation, hemodynamic parameters MAP and HR levels in intravenous inhalational anesthesia group were lower than those in total intravenous anesthesia group. 24 h after operation, serum brain function indexes MBP, S100B and NSE contents in intravenous inhalational anesthesia group were lower than those in total intravenous anesthesia group;serum Th1 cytokines IFN-γand IL-2 contents were higher than those in total intravenous anaesthesia group whereas Th2 cytokines IL-4 and IL-13 contents were lower than those in total intravenous anesthesia group. Conclusion: The intravenous inhalational anesthesia can effectively stabilize the intraoperative hemodynamics and reduce the postoperative brain function and Th1/Th2 immune function injury in elderly patients with femoral neck fracture.

外泌体介导的组织工程在骨修复中的作用

严重创伤、骨肿瘤等导致的骨不连及骨缺损治疗是骨科医生面临的难题,以细胞为基础的骨组织工程技术为骨缺损修复治疗提供有效方法。随着对干细胞在骨组织再生中作用的深入理解,研究人员发现干细胞外泌体释放是其引导骨再生的治疗机制之一。外泌体能够通过旁分泌信号在细胞间发挥通讯作用,调节骨形成过程中的骨再生和血管生成。本文阐述外泌体的生物学来源、成分及功能,从分子生物学角度探讨外泌体在骨修复中的调控作用,同时对外泌体在骨组织工程中促进骨缺损修复的研究成果进行总结,以期更加深入理解外泌体的作用机制,为骨缺损修复提供新的治疗思路。

TH油田酸压裂缝高度控制主要影响因素分析

为了防止在TH油田的压裂酸化过程中裂缝垂向上的过分延伸,更好地将裂缝控制在油气层内,文章建立了拟三维延伸模型,运用数值解着重分析了裂缝高度扩展的主要诸因素影响。研究结果表明:TH油田酸压裂缝高度普遍很大,地层应力差(一般小于2MPa)是主要因素,控缝高难度大,可采用人工隔层方式增大产层/遮挡层应力差;原采用的压裂液黏度偏高不适于控缝高,可以采取低粘度低滤失压裂液结合实际注液排量,成为控缝高有效手段。

儿童四肢长骨骨折弹性髓内钉内固定术后骨折延迟愈合的原因及治疗探讨

目的探讨应用弹性髓内钉(elastic stable intramedullary nailing,ESIN)技术治疗儿童四肢长骨骨折后出现骨延迟愈合的原因及预后,为骨折延迟愈合的治疗提供临床经验。方法回顾性分析江西省萍乡市人民医院小儿外科2015年7月至2020年4月应用ESIN技术治疗四肢长骨骨折,且术后复查发现骨折延迟愈合的9例患儿临床资料,收集患儿年龄、受伤机制、骨折部位、手术方式、出院后管理及后期康复情况等资料,收集针对骨折延迟愈合的原因进行相应治疗后的结果。结果9例患儿中,男6例,女3例;学龄前期(4~6岁)1例,学龄期(7~12岁)6例,青春期(13~18岁)2例;骨折部位:肱骨1例、尺桡骨2例、股骨2例、胫骨4例;高能量损伤(包括车祸伤、高处坠落伤和重物砸伤)7例,低能量损伤(摔伤、扭伤等)2例;开放性损伤3例,闭合性损伤6例;切开复位4例,闭合复位5例。9例患儿经处理后骨折均已完全愈合,愈合时间6~21个月,平均愈合时间10.5个月。2例尺桡骨双骨折延迟愈合患儿经延长石膏固定时间、制动后骨折愈合;2例胫骨骨折延迟愈合患儿经支具保护下适当负重后骨折愈合;1例股骨骨折延迟愈合患儿经取出ESIN改髋人字管型石膏外固定后骨折愈合;1例胫骨、1例肱骨及1例股骨延迟愈合患儿经抗感染、患肢制动后骨折愈合;1例胫骨延迟愈合患儿经断端自体骨植骨+石膏固定处理后骨折愈合。结论不同部位不同类型骨折后骨延迟愈合的治疗方式不同,本组病例采用了加强固定、增加断端应力刺激、抗感染、植骨重建等方法,均达骨性愈合。去除引起延迟愈合的因素、稳定骨折端是治疗成功的关键。

长链非编码RNAHAGLR与微RNA-19a-3p对股骨颈骨折内固定术后骨折不愈合的影响

目的:观察长链非编码RNA(longnon-coding RNA,lncRNA)HAGLR与微RNA(microRNA,miRNA)-19a-3p对股骨颈骨折内固定术后骨折不愈合的影响。方法:回顾性分析采用切开复位AO中空加压螺钉内固定治疗的股骨颈骨折患者的病例资料,包括性别、年龄、基础疾病(高血压、糖尿病、冠心病)、损伤类型、骨折类型、骨折愈合情况,以及采用实时定量PCR检测法测得的外周血液中lncRNA HAGLR和miRNA-19a-3p表达量。按照术后骨折愈合情况分为愈合组和不愈合组。先对2组患者的相关信息进行单因素分析,再采用Logistic回归分析研究骨折不愈合的影响因素,最后采用受试者操作特征(receiver operating characteristic,ROC)曲线分析评价外周血液中lncRNA HAGLR与miRNA-19a-3p表达量对骨折不愈合的预测价值。结果:①骨折不愈合影响因素的单因素分析结果。共纳入141例患者,男73例、女68例。愈合组120例,不愈合组21例。2组患者年龄、损伤类型、骨折类型的比较,组间差异均有统计学意义(t=3.395,P=0.001;χ^(2)=16.904,P=0.000;χ^(2)=4.727,P=0.030)。术后4周、8周、12周,愈合组外周血液中lncRNAHAGLR表达量均高于不愈合组(0.79±0.20,0.63±0.15,t=3.494,P=0.001;0.87±0.17,0.75±0.16,t=3.009,P=0.003;0.95±0.16,0.87±0.19,t=2.054,P=0.042),miRNA-19a-3p表达量均低于不愈合组(1.19±0.29,1.40±0.30,t=3.046,P=0.001;1.13±0.25,1.27±0.27,t=2.340,P=0.003;1.03±0.22,1.18±0.20,t=2.919,P=0.042)。②骨折不愈合影响因素的多因素分析结果。将损伤类型、骨折类型以及术后4周外周血液中lncRNA HAGLR和miRNA-19a-3p表达量作为自变量,将骨折是否愈合作为因变量,进行Logistic回归分析,结果显示高能量损伤、骨折移位、术后4周外周血液中miRNA-19a-3p表达量是股骨颈骨折内固定术后骨折不愈合的危险因素(β=2.582,P=0.005,OR=1.423;β=1.734,P=0.011,OR=1.272;β=136.44,P=0.001,OR=23.698),术后4周外周血液中lncRNAHAGLR表达量是股骨颈骨折内固定术后骨折不愈合的保护因素(β=-109.00,P=0.001,OR=0.000)。③lncRNA HAGLR和miRNA-19a-3p表达量对骨折不愈合的预测结果。ROC曲线分析结果显示,采用术后4周外周血液中lncRNAHAGLR和miRNA-19a-3p表达量预测骨折不愈合的灵敏度分别为61.67%、81.67%,特异度分别为80.95%、47.62%,曲线下面积分别为0.710(P=0.002)、0.673(P=0.012)。结论:股骨颈骨折内固定术后4周时外周血液中lncRNA HAGLR表达量下降、miRNA-19a-3p表达量升高提示骨折不愈合风险增加,这两项指标可用作预测股骨颈骨折内固定术后骨折不愈合的生物标志物。

冲击波在骨折不愈合或延迟愈合中的应用

Nonunion remains a major complication after skeletal trauma. In the last decade, extracorporeal shock wave therapy has become a common tool for the treatment of delayed unions or non-unions. With the help of a review of the literature, the current author gave an overview of indications, choices of devices, success rates and complications for ESWT in the treatment of non-unions. The conceivable mechanism was also outlined.

环形外固定架骨搬运治疗胫骨创伤后大段骨缺损

目的:探讨应用环形外固定架辅助骨搬运术治疗创伤后胫骨大段骨缺损的疗效。方法:自2002年至2011年采用骨搬运术对17例创伤性胫骨长段骨缺损进行治疗,男11例,女6例;年龄22～45岁,平均(31.00±2.35)岁。骨缺损范围5～13.1cm,平均(7.50±1.01)cm。观察外固定时间、骨性愈合时间、术后患肢延长长度。术后患肢功能恢复程度参照Paley评价标准进行功能评价。结果:全部病例获随访,时间12～48个月,平均(30.00±2.35)个月。17例患者均获得了良好的骨性愈合,骨性愈合时间为8～15个月,平均(10.10±0.59)个月;外固定时间12～16个月,平均(14.10±0.65)个月;术后患肢延长长度平均(7.50±1.01)cm。根据Paley等骨与功能分级方法评价功能,优9例,良6例,可2例。结论:骨搬运术是治疗胫骨创伤后大段骨缺损、成功重建肢体长度的有效方法,骨搬运术具有操作简单,对软组织损伤较小、软组织覆盖较简单、疗效肯定等优点,临床值得推广。

带锁髓内钉治疗股骨骨不连

目的:分析股骨骨不连原因,观察带锁髓内钉治疗股骨骨不连的临床效果。方法:2001年1月至2009年1月,采用带锁髓内钉治疗31例股骨骨不连,男19例,女12例;年龄18～73岁,平均32.5岁。其中骨不连发生在股骨干24例,股骨远端7例。股骨干骨不连采用标准带锁髓内钉治疗,股骨远端骨不连采用股骨髁上带锁髓内钉治疗。一般行切开带锁髓内钉固定及自体骨移植,所有病例均使用扩髓技术。结果:31例全部获得随访,时间14～72个月,平均23个月。30例获骨性愈合,愈合时间3～6个月,平均4.6个月;另1例髓内钉固定后再次给予植骨后愈合。髋关节功能全部正常,术后1年膝关节行HSS评分平均为(89.97±5.21)分。结论:采用带锁髓内钉治疗股骨骨不连具有固定可靠,稳定性好的优点,有利于肢体、关节早期功能锻炼。扩髓结合自体骨移植可获良好临床效果。

自体骨移植治疗四肢骨折术后骨不连失败因素分析

目的:探讨四肢骨折骨不连经植骨治疗后未达到骨愈合的原因,了解主要影响疗效的因素,为提高骨不连的治疗效果提供依据。方法:1995年1月至2011年12月收集四肢骨折术后骨不连接受自体骨移植手术治疗患者367例,其中男198例,女169例;年龄12～89岁,平均53.5岁;病程23～49个月。植骨治疗后摄X线片及CT扫描评估治疗效果,骨折仍未愈合的32例,其余的均后期骨愈合入院行内外固定拆除手术。通过Logistic回归分析考察年龄、性别、是否吸烟、营养状况、原发骨折类型、骨折的部位、骨不连的类型、是否更换固定方式、手术固定的类型、患者是否有影响骨折愈合的内外科疾病等因素对于患者植骨治疗成功率的影响。结果:纳入统计的患者为后期有再次入院记录(获得随访)。手术植骨治疗后随访6～12个月,失败率为8.72%。通过统计学分析吸烟与否、原发骨折类型、骨不连的类型、是否更换固定方式、原发内外科疾病等因素与植骨治疗后期愈合率有明确的相关。结论:吸烟、原发骨折类型、骨不连的类型、是否更换固定、原发疾病这些因素影响自体骨移植治疗骨不连疗效。在骨不连植骨治疗中应建议患者戒烟,同时治疗相关疾病。手术前分析原骨折及骨不连的情况并积极的治疗感染,制定更完善的手术方案,以及手术中尽可能更换固定方式均可以降低植骨治疗的失败风险。

骨搬移技术治疗下肢长骨干慢性骨髓炎伴骨缺损术后骨性愈合不良的原因分析及对策

目的:探讨骨搬移技术治疗下肢长骨干慢性骨髓炎伴骨缺损术后出现骨性愈合不良的原因及其相应对策。方法:回顾性分析2012年6月至2015年12月采用骨搬移技术治疗的38例下肢长骨干慢性骨髓炎伴骨缺损患者的临床资料,男23例,女15例;年龄20~56岁,平均36.5岁;股骨5例,胫骨33例;受伤至骨搬移时间2~19个月,平均7.4个月;骨缺损长度4~12 cm,平均7.3 cm;术后均经过1周"待机期"开始骨搬移,搬移方向由近端向远端30例,由远端向近端3例,双向搬移5例;并及时调整力线及骨搬移速度,患者坚持负重。定期随访,拍摄X线片,观察是否存在搬移间隙矿化成骨不良,对合端不愈合以及再发骨折等并发症;并采用Paley评分标准进行临床评价。结果:38例获得随访,时间12~36个月,平均23.1个月。骨髓炎无复发,但出现多种骨性愈合不良相关的并发症,其中骨搬移过程中发生搬移间隙矿化成骨不良3例,对合端不愈合17例,发生搬移间隙骨折5例,尚未拆除外固定架时发生骨折1例,拆除外固定架后发生骨折4例。带架时间9~27个月,平均16.3个月;外固定指数为1.7~2.7个月/cm,平均2.24个月/cm;根据Paley评分标准评定疗效:骨性结果优12例,良16例,中3例,差7例;功能结果优14例,良18例,中3例,差3例。结论:骨搬移技术有效解决了长骨干骨髓炎伴大段骨缺损的临床难题,但治疗周期长,对预后的影响因素多。因此,应严格适应证选择,同时应细致操作,全程监控,及时随访,并积极指导患者相应的预防策略,以期得到更满意的临床疗效。

萎缩性骨折不愈合的研究新进展

萎缩性骨折不愈合形成是一个复杂过程,既往研究认为萎缩性骨折不愈合主要是由于骨折断端血运缺乏引起,但也有研究发现萎缩性骨折不愈合的中晚期血运并不缺乏,更可能是由于早期成骨性因素降低和血运减少引起,具体发病机制有待进一步研究。目前有效治疗萎缩性骨折不愈合的措施,主要有植骨和固定、物理治疗、局部注射疗法等。多方位的预防则能有效减少萎缩性骨折不愈合的发生,但萎缩性骨折不愈合仍是骨科临床工作中的棘手问题,应给予充分的重视,并进行合理有效地防治。本文通过回顾分析近年萎缩性骨折不愈合的相关文献,对萎缩性骨折不愈合相关的病因、诊断和防治措施作一综述。

自体骨髓经皮注射移植治疗骨延迟愈合和骨不连

目的 :应用自体骨髓经皮注射治疗骨延迟愈合、骨不连 2 2例。方法 :3例肱骨、3例尺桡骨、2例股骨、13例胫骨 ,均为创伤后骨延迟愈合和骨不连 ;1例右侧先天性胫骨假关节术后再骨折 ;年龄 10～ 67岁 ,平均 3 0岁 ;骨折后至接受骨髓移植时间为 4～ 18个月 ,平均 12个月。手术时患者取俯卧位 ,从髂骨后翼穿刺 ,缓慢抽取骨髓液 3～ 5ml,每个穿刺点间隔 2cm ,总量 40～ 12 0ml,平均 70ml;经皮注入到X线定位的骨折处。术后石膏固定 4～ 12周 ,定期摄片检查。结果 :2例骨延迟愈合、骨不连在术后 2～ 9个月骨愈合 ,平均 6个月 ;逐渐负重和恢复肢体活动。 1例先天性胫骨假关节失败 ,再次手术。结论 :自体骨髓移植治疗骨延迟愈合和骨不连有效 ;该方法创伤小、简便有效。

手术治疗股骨髁上骨不连26例疗效分析

股骨髁上骨折骨不连是一种由高能量暴力导致的股骨髁至股骨干骺端的严重并发症。据国外相关资料报道,股骨髁上骨折后骨不连的发生率约为3.8%^[1]。至今仍是骨科治疗难题,其治疗效果往往难以令人满意。笔者收集本院自1997年6月至2007年6月26例股骨髁上骨不连患者，采用动力髁螺钉（dynamic condylar screw，DCS）加自体髂骨移植治疗取得了满意的疗效，报告如下。

富血小板血浆治疗股骨干缺血萎缩型骨不连:前瞻性随机对照临床试验

背景:以内外固定联合自体骨植骨治疗缺血萎缩型骨不连治疗周期长,且存在不能治愈情况。富血小板血浆含有多种生长因子以及大量白细胞,有助于促进组织愈合,但尚无其治疗缺血萎缩型骨不连有效性的临床研究。目的:观察富血小板血浆治疗股骨干缺血萎缩型骨不连的有效性。方法:一项正在青海大学附属医院进行的前瞻性开放性随机对照临床试验。招募92例符合标准的股骨干缺血萎缩型骨不连患者,按1∶1比例随机分为对照组和试验组。对照组采用常规手术方法治疗,试验组在常规手术的基础上在患者注射自体富血小板血浆。以术后9个月骨折愈合率为主要结局指标;以静息态和被动运动时的目测类比评分、愈合时间、治疗费用以及不良反应作为次要结局指标。研究方案已于2014-05-20经中国青海大学附属医院伦理委员会批准(批准号QHG0223A)。试验已取得患者的书面知情同意。结果与结论:目前已完成的部分试验结果显示,2组患者术后第1-3天时进行的目测类比评分及并发症情况接近,但试验组骨不连愈合率明显高于对照组,骨不连愈合时间显著短于对照组。试验结果旨在为临床使用富血小板血浆治疗缺血萎缩性骨不连的有效性提供客观数据。

钢板加异体骨板固定治疗股骨干骨折髓内钉固定术后骨折不愈合

目的 ：探讨采用钢板加对侧异体骨板固定治疗股骨干骨折交锁髓内钉固定术后骨折不愈合的临床疗效。方法：分析自2006年2月至2013年6月21例股骨干骨折髓内钉固定术后不愈合患者采用钢板加对侧异体骨板固定治疗,男12例,女9例;年龄18-62岁,平均34.8岁。骨折不愈合时间9-18个月,平均12.8个月。术后采用Merchan标准评定临床疗效。结果：21例患者伤口均Ⅰ期愈合,无感染、内固定物断裂、脂肪栓塞、旋转畸形及明显的短缩畸形等并发症。术后随访8-24个月,平均13.2个月。19例患者术后达到骨性愈合,平均愈合时间为6.2个月（4-9个月）,2例出现骨折延迟愈合,经7-13个月观察获得骨性愈合。术后1年膝关节功能按Merchan标准评定：优13例,良6例,差2例。结论 ：应用钢板加对侧异体骨板固定治疗股骨干骨折髓内钉固定术后骨折不愈合具有治愈率高,并发症少,术后功能恢复良好的特点,能够提高骨折稳定性及促进骨痂生长。

非手术治疗骨不连的现状及进展

虽然骨折的治疗手段有了很大的进步,但骨不连的发病率仍居高不下,是骨科临床医师面临的一个挑战。如何治疗骨不连一直受到学者们的关注,包括手术和非手术疗法在内的新的治疗手段不断涌现,取得了较好的临床疗效。特别是非手术疗法的发展,为无创治疗骨不连带来了希望。本文试图结合国内外相关文献对目前临床上较为常用的一些非手术疗法的现状和进展作一综述。