目的 外固定架治疗儿童马蹄足,可矫正严重、僵硬的畸形并已得到大量的临床验证.但畸形矫正后踝关节活动范围(range of motion,ROM)如何,报道较少,存在哪些影响因素尚不明确.方法 对外固定架矫正后的踝关节进行影像学测量,随访时踝关节最大背屈和最大跖屈时的胫跟角变化值认定为ROM,并以20° 为分界,标记为优和差,通过多因素分析,评价不同变量对治疗结果 的影响.设定可能影响结果 的自变量包括:手术时年龄、发病原因、有无手术史、畸形Dimeglio评分、外固定架固定时长、术中是否做跟腱切断术(tenotomy of achcilleus tendon,TAT)、随访时间.结果 2015年7月至2019年7月,本院小儿骨科共42例(46足),符合试验设计,纳入本研究.至末次随访,经影像学验证,踝关节ROM 20例优(43.5％),26例差(56.5％).单因素分析结果 显示,既往患足是否有手术史(χ2=8.248,P=0.004)、术中是否TAT(χ2=6.083,P=0.014)、不同病因对结果 的影响差异有统计学意义(χ2=11.944,P=0.001).而多因素分析结果 显示,仅病因分类(先天或后天畸形)与活动度结果 的关联差异有统计学意义(P=0.021),与先天性畸形相比,后天性畸形患足活动度好的可能性是前者的27倍.结论 外固定架是治疗儿童马蹄内翻足的有效手段,但并非所有患儿均可获得良好的关节功能,以影像学方法 对踝关节活动度进行评估,在各种因素中,发病原因对活动度结果 产生影响,先天性畸形患足活动度更差.

Objective:In this study, lengthening over nail (LON) and plating after lengthening (PAL) were compared by the process of treatment and therapeutic effect in the children's femoral lengthening cases,to guide treatment choices; and in the PAL group there was another comparison between different timeline of plate fixation after lengthening to formulate reasonable technical route.Methods:Since January 7, 2014 to September 10, 2018, a total of 21 cases of LON and PAL surgery had been carried out, including 12 males and 9 females. The average age at their operation was 12.43±3.12 years. There were 10 patients in the LON group and 11 patients in the PAL group, in the PAL group 5 cases was synchronous fixation, which means removal of the external fixator and plate fixation would be performed in the same surgery, 6 cases was asynchronous fixation, which means plate fixation would be performed at least 2 weeks later after the removal offixator to reduce the risk of infection. The recorded data includesgender, date of birth, reason of discrepancy and treatment history, age at surgery, lengthening distance, the length of duration with frame, healing time, total duration time and total blood loss of seriesoperations, ROM of the knee joint, complications, etc.Statistical analysis was made by SPSS 22.0 software, and then reasonable treatment strategies were proposed.Results:In the LON group, the medianlengthening distance was 7.10 (6.63, 7.70) cm, the median total duration time was 300 (240, 330) min, the medianspeed of healing was 1.12 (0.78, 1.72) month/cm, complications were found in 3 cases, the median ROM of knee joint was 125.00° (117.50°, 150.00°); in the PAL group, the data respectively were 6.00 (5.00, 8.00) cm, 260 (230, 465) min, 1.00 (0.75,1.71) month/cm, 3 cases, 100.00° (90.00°, 150.00°), the difference between them was not statistically significant (all P>0.05). 2. In the PAL group, the difference of number of surgeries, total duration time, total blood loss, complication rate, healing speed and postoperative function between synchronous and asynchronous fixation was not statistically significant (all P>0.05). Conclusion:They are similarbetween LON and PAL techniques in the process of treatment and therapeutic effect. The surgeons could make choices according to the growth potential of the patients and their own custom operation methods. In the case of the current sample size, there is no statistical difference in the therapeutic effect between the synchronous and asynchronous plate fixation in the PAL method, but the sample size needs to be increased for further study.

Objective:In this study, the feasibility of this method was evaluated in children with large distance femoral lengthening cases, and the acute correction and staging surgeries were compared at healing speed. At the same time the key points of surgical techniques would be summarized, so as to clarify the application value of this technology in children patients.Methods:Since July 7 of 2014 to January 16 of 2018, a total of 10 cases of Lengthening Over Retrograde Nail (LORN) surgery have been formulated and carried out, including 9 males and 1 females.The average age of the operation was 13.10±2.18 y. In all cases, the osteotomy point was located in the metaphysis of the distal femur, and the records from the first meeting to the end of follow-up included gender, date of birth, reason of discrepancy and treatment history, age at surgery, lengthing distance, the length of duration with frame, healing time, ROM of the knee joint, complications, et al. To compare the healing time of acute correction and staging surgery. Statistical analysis was made by SPSS 22.0 software, and then reasonable treatment strategies were proposed.Results:The average lengthing distance of 7.07±1.01 cm. The median time of the duration with frame was 8.5 (4,16) months, and the median follow-up time was 39 (34, 54) months. All cases obtained good clinical and imaging healing (1.70±1.10 month/cm vs. 1.16±0.54 month/cm), and all regained to normal walking function (136.67°±20.82° vs. 125.71°±26.37°), without the occurrence of fracture after therapy. There were no statistically significant differences in the speed of healing, range of joint motion or complication rate between acute correction and staging treatment. Conclusion:It is feasible for femoral lengthening surgery assisted by retrograde intramedullary nail in the treatment of femoral shortening deformityin children. The correction of mild angular deformity and lengthening surgery can be performed simultaneously. The osteotomy site was proposed at distal metaphysealof the femur for better quality of osteogenesis and shorter duration for fixator. It is safe to osteotomy and lengthening in the area of enchondroma.

目的 评价超声检查在儿童膝关节骨折诊断中的作用.方法 对2015年9月至2019年3月北京大学第四临床医学院北京积水潭医院小儿骨科收治的膝关节骨折患儿27例临床资料进行回顾性分析.其中男18例,女9例;平均年龄7岁4个月(9个月～13岁5个月).所有患儿在伤后2周内接受患侧膝关节X线和MRI检查以及双侧膝关节超声检查.以MRI结果作为诊断标准,将X线和超声检查结果分别与MRI结果进行比较.结果 MRI诊断结果为关节内骨折14例(胫骨髁间嵴骨折8例、髌骨骨折4例、膝关节骨软骨骨折2例),关节外骨折13例(股骨远端骺损伤6例、胫骨近端骺损伤6例、股骨远端骺损伤合并胫骨近端骨折1例).X线诊断准确率为96％(26/27).超声检查诊断准确率为74％(20/27),对关节内骨折和关节外骨折的诊断准确率分别为57％(8/14)和92％(12/13).超声与X线联合诊断的准确率为100％.结论 超声检查可准确诊断儿童股骨远端骨折、胫骨近端骨折和髌骨骨折,但是对儿童胫骨髁间嵴骨折和膝关节骨软骨骨折等关节内骨折的诊断准确率较低;辅以超声检查可提高X线检查对儿童膝关节骨折诊断的准确率;当X线和超声检查均未发现骨折而超声提示有膝关节积液(血)时,应进一步行CT或MRI检查,以免漏诊儿童膝关节内骨折.

目的 探讨外固定架在儿童胫骨远端干骺端开放性骨折中的临床治疗效果.方法 回顾性分析2010年10月至2015年6月北京积水潭医院采用外固定架治疗的28例胫骨远端干骺端开放性骨折患儿的病历资料,其中男17例,女11例.末次随访时,观察患儿的伤口愈合情况,外固定架结构的稳定性,针道感染情况,以及膝、踝关节活动度等;同时使用儿童疗效数据收集工具(PODCI)评估患儿的预后.结果 随访1年以上.28例患儿骨折均愈合,延迟愈合2例,平均愈合时间16周(12~28周).所有患儿骨折对位对线良好,未出现畸形愈合,术后均回归正常生活;肢体过度生长6例,但均未超过1cm;膝、踝关节活动均不受限.PODCI评分:移动能力和基本活动能力平均94分,运动功能平均86分,舒适度和(或)疼痛平均89分,个人满意度平均78分,总体功能平均91分(满分均为100分).术后发生针道感染(Paley Ⅰ级)7例,通过加强护理均得到控制.所有患儿的伤口均未发生感染,无外固定架失效情况.结论 对于儿童胫骨远端开放性骨折,外固定架具有固定牢固、允许早期功能锻练、利于伤口的观察及处理等优点.因此,外固定架是治疗儿童胫骨远端干骺端开放骨折的一种可选择的方法.

Objective To observe the pathological change of chondrocyte of the growth plate of the proximal femur in slipped capital femoral epiphysis (SCFE).Methods Modified Dunn osteotomy through surgical hip dislocation approach was used to treat 8 severe SCFE cases from June 2012 to June 2016.Proximal femoral growth plates and synovial tissue of 7 cases were prepared and sectioned for hematoxylin-eosin (HE) staining.Histomorphological changes were observed by microscope.Results Chondrocyte degeneration,necrosis and regeneration were noted at the growth plate of the proximal femur.Degeneration and necrosis were noted at the synovial tissue of hip joint.Conclusion It is more feasible for the surgical hip dislocation approach to obtain the specimens of the growth plate of the proximal femur in SCFE.Through observing the chondrocyte pathological change,it can play an important role in exploring the pathogenesis of SCFE.

Objective To review the cases of humeral varus to determine whether or not focal fibrocartilaginous dysplasia (FFCD) is the cause of humeral varus through radiology and pathology and observe whether or not proximal humeral osteotomy improves shoulder functions.Methods A total of 12 cases of humeral varus from 2002 to 2015 were summarized.Patients with history of infection and trauma were excluded.The average age was 12 years old and the mean follow-up period 3.8 years.The average degree of shoulder abduction was 53.3 degrees and shoulder flexion 90 degrees preoperatively.After preoperative examinations of radiology,computed tomography (CT) and magnetic resonance imaging (MRI),lesion resection and proximal humeral osteotomy were performed for correcting deformities and pathological examination for resected lesions.Results All cases had typical imaging manifestations.The postoperative pathological examinations demonstrated fibrous cartilage or fibrous tissue.And 12 cases were diagnosed as FFCD in proximal humerus.The average degree of shoulder abduction was 90 degrees and shoulder flexion 168.3 degrees preoperatively.The function of shoulder joint significantly improved.Conclusions The etiology of proximal humeral varus is FFCD,depending on typical manifestations of imaging and pathological examinations.Early diagnosis and resection of lesion may aid the recovery of upper limb length and shoulder function.And proximal humeral osteotomy can significantly improve shoulder functions.

Objective To evaluate the clinical efficacies of using 8-plate in correcting lower extremity deformities of children with hypophosphatemic rickets.Methods Between July 2008 and June 2012,a cohort of 17 children with lower extremity deformities from hypophosphatemic rickets was treated by 8-plate procedures.There were 6 boys and 11 girls with an average age of 6.6 (2-11) years.Results Among them,15 cases were corrected to neutral after a removal of hardware during a follow-up of 16 months.Only 2 patients of insufficient correction underwent corrective osteotomy.The average duration of radiographic and clinical follow-up was 28 (12-44) months.Thirty-three limbs underwent hemiepiphysiodesis and the average correction of femoral-tibia angle was 15 (7-30) degrees.Conclusions Correction of lower extremity deformities from hypophosphatemic rickets by 8-plate is a simple and effective procedure.

Objective We built the three-dimensional finite element model to analyze the patterns of calcaneal fractures in different hindfoot positions under different impact loads.Methods A 3D anatomically detailed non-linear finite element analysis of standard human foot model was set up,which was based on computed tomography( CT) scan data including skeletons,soft tissues and ligaments.The non-linear analysis was performed in ABAQUS6.8.1.During the analysis,we simulated several impact loads by giving the different velocities( 5m / s-8m / s) to the hindfeet in valgus and varus positions.Results In a valgus position,the stress focused on the posteromedial section of the posterior subtalar facet.In the varus position,the stress focused on anterolateral section.Under the same impact energy,the quantity of stress in varus position was significantly higher than the stress in valgus position.Conclusions Intraarticular calcaneal fracture exhibiting a medial primary fracture line is associated with a more severe fracture pattern.The position of hindfoot decides the location of primary fracture line.We can observe the stress more directly by building the finite element models and performing the impact analysis.The finite element analysis acts as an excellent method in biomechanical research.

OBJECTIVE To report and evaluate the results of subtalar distraction bone block fusion in the treatment of malunited calcaneus fracture. METHODS From September 2004 to January 2008, 32 cases of malunited calcaneus fracture were treated, among which 28 cases were classified type II and 4 cases type III by Stephens-Sander's classification. Preoperative X-ray and CT examination demonstrated a talocalcaneal angle of 18.1 degrees ± 2.3 degrees , and an AOFAS score of 36.3 ± 4.1. Subtalar distraction bone block fusion was performed in all cases in this series. Regular follow-up was done with talocalcaneal angle measurement and AOFAS scoring. RESULTS All the 32 patients had been followed-up of 34 months, ranging from 24 to 65 months, only to reveal a primary wound healing without infection in all but one, in which superficial skin necrosis occurred postoperatively and healed after dressing-changes. Bone healing at the fusion site was seen 3 months after operation in all cases. At the final follow-up, the talocalcaneal angle was 22.9° ± 1.9° and the AOFAS score 77.5 ± 4.1, both demonstrating a significant difference (P < 0.05), when compared with those before operation. CONCLUSION Subtalar distraction bone block fusion, together with the lateral wall decompression, can correct the main deformity and reduce major symptoms induced by the malunion of calcaneus fractures, being a convenient and practical option for the treatment of malunited calcaneus fracture.