目的 探讨术前计算机断层扫描血管造影(CTA)精准定位胫后动脉穿支皮瓣在手部创面中的应用价值.方法 回顾性分析2017年3月—2019年6月中国人民解放军联勤保障部队第九二〇医院骨科收治的8例手部软组织缺损患者临床资料,男性6例,女性2例;年龄20～55岁,平均35.6岁.致伤原因:机器绞伤4例,切割伤3例,电击伤1例.依据术前CTA观测胫后动脉穿支数量及穿出点位置,设计并切取游离胫后动脉穿支皮瓣修复手部创面,测量皮瓣切取面积,观察皮瓣移植术后成活情况,记录供区创面闭合方式,观察手功能恢复效果.结果 下肢CTA可观察到胫后动脉穿支平均数量为:左侧3.3支,右侧3.9支,每个穿支以距内踝距离精确定位.依据CTA观测结果设计胫后动脉穿支皮瓣,皮瓣均顺利切取,皮瓣切取面积:2cm×4cm～6cm×10cm,小腿供区6例直接缝合,2例植皮.术后皮瓣均存活,无血管危象、皮瓣坏死发生,供区创面均顺利愈合,手功能恢复良好.结论 术前CTA精准定位能准确观察并测量胫后动脉穿支血管走形、位置,为皮瓣设计提供了影像学依据.游离胫后动脉穿支皮瓣不牺牲主干血管,厚度适中,是修复手部创面理想的选择之一.

自体骨移植是治愈骨缺损疾病最好的方法之一,被认为是“金标准”,但由于需要二次手术、存在感染、来源有限等缺点[1],限制了自体骨移植的临床应用.β-磷酸三钙(β-TCP)与羟基磷灰石(HA)类似,其生物相容性非常好,理化特性也非常突出,与人体骨骼的成分相差无几.Pamela等[2]通过研究得出结论:含有吸收性磷酸钙的复合材料一般都具有十分优异的骨诱导性.Loin等[3]把β-TCP、自体骨依次移植到上颌提升术中手术部位,接下来对新生成的骨组织密度展开了长达半年的跟踪调查,结果发现两者基本一致.目前骨移植材料中β-TCP是具备良好的生物活性、骨传导性,此外还需要拥有较高的组织相容性,对骨组织生成、血管组织形成产生极大的积极影响,通过研究探讨得出结论:β-TCP是药物、离子传递中无可替代的重要载体,近年来被广泛用于临床,有极大研究前景[4].

[目的]介绍自制腰椎滑脱复位器辅助后路腰椎间融合术(PLIF)治疗腰椎滑脱症并骨质疏松患者的手术技术和初步临床疗效.[方法] 2017年6月～2018年12月,采用自制腰椎滑脱复位器辅助PLIF手术治疗腰椎滑脱症并骨质疏松患者21例.置钉、椎管减压完成后,将复位拉钩分别钩住重度滑脱椎体两侧的横突与上关节突连接部位,按压调节手柄,牵引柄随之向后运动,连接件带动复位拉钩向后提拉,从而将滑脱的脊柱向后牵拉复位,再行椎间融合术.[结果] 21例患者均顺利完成手术,1例术中横突劈裂,无严重并发症.随时间推移下肢VAS评分、腰背部VAS评分和ODI评分均显著减少(P＜0.05);影像检查显示术后患椎滑移距离较术前显著减少(P＜0.05),平均滑脱复位率(97.52±4.06)％.[结论]自制滑脱复位器辅助PLIF手术治疗腰椎滑脱症并骨质疏松近期疗效良好,是一种安全、有效的腰椎滑脱复位手术方式.

[目的]探讨一期经后路单侧椎板切除病灶清除、潜行扩大椎管减压、椎间植骨、椎弓根内固定治疗腰骶段结核的临床疗效.[方法] 2008年1月～2014年1月,采用一期后路单侧椎板部分切除潜行扩大椎管减压术治疗35例腰骶段结核患者.男22例,女13例,年龄23～68岁,平均(50.54±12.65)岁.病程2个月～10年,平均(20.80±18.46)个月.[结果]所有患者顺利手术,术中无严重并发症.手术时间(203.29±41.74) min,出血(686.00±225.21) ml.33例切口Ⅰ期愈合,2例切口感染,给予充分引流、冲洗换药、二次清创缝合,最终愈合.35例患者均获得随访,随访时间18～72个月,平均(30.11±14.69)个月.35例患者腰痛和下肢神经症状逐渐减轻,结核中毒症状较术前明显缓解,无结核复发.ASIA神经损害分级由术前C级5例、D级12例、E级18例,改善为末次随访时D级2例,E级33例(P＜0.05).末次随访时,VAS评分为(0.20±0.47),ODI评分(3.77±3.66),ESR(7.83±1.52) mm/h,CRP (2.43±0.98) mg/1,腰骶角(26.86±2.00)°,均较术前显著改善(P＜0.05).根据Bridwell分级标准,33例Ⅰ级骨性愈合,2例Ⅱ级骨性愈合.[结论]一期经后路单侧椎板切除病灶清除、椎管减压、固定融合术可以有效清除病灶、保留更多腰椎后柱结构、重建腰椎曲度并维持腰骶段的稳定性,是腰骶段结核可选择的治疗方案.

目的 探讨3D打印、逆向工程技术结合体外模拟手术辅助寰枢椎置钉治疗Ⅱ型齿突骨折的准确性和安全性.方法 回顾性分析2010年1月—2018年3月接受椎弓根螺钉内固定治疗的23例Ⅱ型齿突骨折患者临床资料.其中12例常规徒手置入C1,2椎弓根螺钉(徒手组);11例在利用3D打印和逆向工程技术实施体外模拟手术成功后,术中利用导航模板辅助置入C1,2椎弓根螺钉(导航组).记录手术时间、术中出血量、住院时间及置钉偏差率.手术前后采用疼痛视觉模拟量表(VAS)评分和美国脊髓损伤协会(ASIA)分级评估疗效.结果 所有手术顺利完成,术中无脊髓损伤、椎动脉损伤等严重并发症发生.所有患者随访超过6个月.导航组手术时间、术中出血量及置钉偏差率均低于徒手组,差异均有统计学意义(P<0.05).2组术后6个月VAS评分均较术前显著改善,差异有统计学意义(P<0.05),组间比较差异无统计学意义(P>0.05).徒手组术前ASIA分级D级4例、E级8例,导航组术前D级3例、E级8例,术后均为E级.结论 3D打印、逆向工程技术结合体外模拟手术辅助寰枢椎置钉治疗Ⅱ型齿突骨折,置钉方案完全个性化,提高了置钉的准确性和安全性,是一种安全有效的辅助置钉手段.

目的 观察股方肌骨瓣结合髂骨或股骨大转子植骨治疗股骨颈骨不连的疗效.方法 2006年8月至2016年3月,收治股骨颈骨折骨不连患者33例,男23例,女10例,年龄19～48岁,平均31.5岁,均为GardenⅣ型.术后采用Harris髋关节评分标准进行髋关节评分:总分100分,90～100分为优,80～90分为良,70～80分为可,70分以下为差.结果 33例患者术后获2～12年随访,平均(38.65±25.90)个月,患者全部临床愈合,愈合时间为4～ 16个月,平均愈合时间为(6.53±2.71)个月.术后无内固定松动失败,1例患者术后伤口感染,给伤口清创,放置万古霉素骨水泥棒后感染愈合.31例患者双下肢等长,无髋内外翻畸形;2例患者出现股骨颈短缩,髋内翻畸形.无股骨头坏死发生,末次随访,Harris髋关节评分标准评分65～95分,平均(88.54±7.46)分:优26例,良3例,可2例,差2例,优良率为89.9％.结论 股方肌骨瓣结合髂骨或股骨大转子植骨治疗股骨颈骨不连是一种操作简单、疗效确切的治疗方法.

目的 探讨胫骨双处截骨纵向搬移治疗胫骨干大段感染性骨缺损复合软组织缺损的疗效及并发症情况.方法 回顾性分析2009年5月至2016年5月收治的31例胫骨干大段感染性骨缺损复合软组织缺损资料,男27例,女4例,年龄2～58岁,平均33.4岁.胫前软组织缺损面积7 cm×8 cm～24 cm×12 cm,胫骨缺损长度6.5 cm～18.2 cm,平均11.4 cm.术后随访时间1～8年,平均32个月.随访观察骨及软组织愈合和并发症情况.结果 31例感染均愈合,骨缺损及软组织缺损创面全部愈合.4例出现骨断端延迟愈合,植骨后愈合,3例出现骨延长区伤口感染及成骨不良,经放置万古霉素骨水泥棒2个月及“手风琴”技术处理后愈合;其余骨缺损与软组织创面均顺利愈合.软组织愈合时间为65 d～190 d,平均70 d,骨愈合的时间为14～35个月,平均21.6个月;28例患者肢体长度完全恢复,3例患者患肢较健侧短1.5 cm.结论 对于8 cm以上的胫骨骨与软组织复合缺损,双处截骨纵向搬移可缩短治疗时间.主要并发症为骨会师端延迟愈合、成骨不良和胫骨力线偏移,经处理后恢复正常.

[目的]探讨多节段开窗椎管潜行扩大减压、椎体间及后外侧植骨融合内固定治疗退变性腰椎侧凸合并多节段腰椎管狭窄的临床疗效.[方法]回顾分析2003年4月～2013年6月收治的35例退变性腰椎侧凸合并多节段腰椎管狭窄患者施行多节段开窗椎管潜行扩大减压、椎体间及后外侧植骨融合内固定术,必要时辅助对侧椎板间小开窗减压.术前腰椎Cobb角24.2°±9.6°,腰椎侧凸角21.2°±8.8°,VAS评分(8.4±1.9)分,JOA评分(11.3±4.2)分.评价术前、末次随访时腰椎Cobb角及腰椎前凸角的矫正及维持情况,根据术前、末次随访时VAS评分、JOA评分评价临床疗效.[结果]本组患者未出现死亡、瘫痪、中枢神经系统感染等严重并发症,肺部感染、泌尿系统感染、术口愈合不良、术后神经症状等经积极处理后均得到治愈.35例患者均获得随访,术后随访12 ～ 60个月,平均19个月.末次随访时腰椎Cobb角减小至9.2°±4.5°,腰椎前凸角增加至33.8°±8.6°,矫正率分别为61.9％、37.2％,较术前相比差异均有统计学意义(P＜0.05);末次随访时VAS、JOA评分分别为(2.8±1.5)分、(27.8±4.5)分,改善率分别为66.6％、93％,差异有统计学意义(P＜0.05).[结论]多节段开窗椎管潜行扩大减压、椎体间及后外侧植骨融合内固定术,必要时辅助对侧椎板间小开窗减压治疗退变性腰椎侧凸合并多节段腰椎管狭窄安全,脊柱畸形的矫正和维持以及临床症状的改善令人满意.

Objective To discuss the clinical effect of stageⅠfocal clearance through anterior approach, autologous iliac crest graft and single self-locked titanium plate internal fixation in the treatment of tuberculosis of lumbosacral junction. Methods Nine cases with lumbosacral tuberculosis were treated by two pieces of autologous iliac crest through anterior approach and a single self-locked titanium plate anterior internal fixation. Before operation, these pa-tients received the anti-TB quadruple therapy with the combined use of isoniazide, rifampicin, pyrazinamide and ethambutol for at least two weeks. Surgery was performed after ESR was controlled below 35mm/1h and the body tem-perature returned to normal. Results The patients was followed up for 12~68 months. All symptoms of TB disap-peared and ESR returned to normal at the latest follow-up. The postoperative lumbosacral angle was 24. 3°~35. 1°, while that at the latest follow-up was 23. 7°~34. 0°. All patients received gradeⅠbone fusion, with no migration of bone graft, or loosening or breakage of titanium plate or screw. One case of Frankel grade C recovered to grade D, four patients with Frankel grade D recovered to grade E. Conclusions StageⅠfocal clearance through anterior ap-proach, autologous iliac crest graft and a single self-locked titanium plate internal fixation are safe and effective for the treatment of tuberculosis of lumbosacral junction. This method can gain good bone fusion and maintain excellent recon-struction of lumbosacral stability and deformity correction.

Objective To explore the treatment outcome of traumatic forefoot tissue loss reconstructions with free perforator flaps. Methods A total of 41 patients underwent traumatic forefoot tissue loss reconstructions with free perforator flaps. There were 5 types of free perforator flaps to be used in reconstructions:32 cases of free anterolateral thigh perforator flaps, 2 cases of free fibular flaps,5 cases of free lateral arm perforator flaps,1 case of free medial arm perforator flap and 1 case of free thoracodorsal artery perforator flap. Results Patients were followed up for (26. 7 ± 9. 3) months. There were 38 ca-ses postoperative healed well,3 cases to be re-explored,1 case healed and 2 cases failed. The overall functional and cosmet-ic outcomes were excellent. Conclusion Forefoot reconstruction with a free perforator flap provides satisfactory cosmesis, normal weight-bearing and gait good function.

Objective To evaluate the techniques of bifocal corticotomy and bone transport for large segmental defects of the infected tibia and soft tissue and their complications as well.Methods From May,2009 to May,2014,25 patients with large segmental defects of the infected tibia and soft tissue were treated at our center.They were 23 males and 2 females,from 2 to 52 years of age (average,31.2 years).All the cases were Gustilo type Ⅲ B.The defect size of the soft tissue ranged from 8 cm ×4 cm to 24 cm × 12 cm;the length of tibia defects was from 8.5 cm to 18.2 cm,averaging 12.3 cm.After debridement,the tibia was fixated with Ilizarov external fixator.Bifocal corticotomy was performed on the proximal and distal tibial metaphyses simultaneously.The transporting speeds for proximal and distal tibial segment were 1 mm/d and 0.6 mm/d initially,and lowered to 0.5 ～ 0.6 mm/d later until the 2 bone segments connected.The bone transport lasted for 40 to 150 days,averaging 69.6 days.Results The patients were followed up for 12 to 72 months (average,26.6 months).The soft tissue wound healed uneventfully and the bone defects were reconstructed.Of the 25 cases,22 obtained primary bone union.Nonunion of the bone segments occurred in one,wound infection and osteogenesis imperfect in bone lengthening area occurred in one,and cut and pull-out of K-wires in the osteoporotic tibial ends occurred in one.These complications were treated accordingly before bone union was achieved.The other complications were also treated accordingly,including serious pin tract infection in 2 cases,re-fracture after removal of the external fixator in one,and shift of the tibial alignment in 2 cases.Conclusions Bifocal corticotomy can decrease bone transport time for large segmental defects of the tibia and soft tissue.During the long treatment period,a surgeon must pay much attention to the technical details and management of complications.

目的 总结某部战士非特异性腰背痛分级治疗方法及疗效.方法 2008年6月～2012年12月,共治疗某部战士非特异性腰背痛患者264例,年龄18～31岁,均为男性.分级治疗方案以腰背痛分期为基础,以疼痛程度(VAS)和Oswestry障碍指数为指标,采取对应的分级治疗措施,包括物理治疗、药物治疗、腰背肌锻炼、局部封闭、岗位调换、心理治疗、手术治疗等.结果 治疗后,急性腰背痛有效率为98.1％,亚急性腰背痛为82.0％,慢性腰背痛为66.7％.结论 分级治疗是治疗非特异性腰背痛的有效措施,能有效减少急性非特异性腰背痛的慢性化.

2009年8月～2012年6月，笔者采用改良掌长肌肌腱移植治疗陈旧性腱性锤状指17例，疗效满意，报道如下。 <br>　　1材料与方法 <br>　　1．1病例资料本组17例，男15例，女2例，年龄15～37岁。左手4例，右手13例。损伤部位：食指9例，中指5例，环指2例，小指1例。治疗史：术前保守治疗无效6例，急诊手术时未对肌腱进行修补5例，未治疗6例。就诊时间：伤后1～26个月。临床表现：远侧指间关节（DIP）背侧肿胀，色素沉着，锤状指畸形明显（DIP屈曲30°～55°畸形），局部压痛，主动背伸不能，屈曲受限，被动活动范围正常，近侧指间关节（PIP）伴有不同程度的背伸。全部为闭合损伤或创面已愈合。X线片均证实无末节指骨基底部骨折。

目的 探讨青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗方法.方法 采用短缩尺骨、重建下尺桡关节法,对7例桡骨陈旧性骨折、短缩,下尺桡关节重度脱位患者进行治疗.术后对患者腕关节外形、功能进行随访.结果 所有患者外形恢复良好,功能评价优6例,良1例.结论 短缩尺骨、重建下尺桡关节法是治疗桡骨陈旧性骨折、短缩,下尺桡重度脱位的有效方法.

Objective To evaluate curative efficacy of vancomycin calcium sulphate or vancomycin cement applied topically to treat osteomyelitis after surgery of open tibial fracture.Methods From May 2005 to August 2013,418 patients with osteomyelitis following surgery of open tibial fracture were treated in our center.They were 257 males and 161 females,with an average age of 35.6 years (from 19 to 55 years).There were 163 cases of Gustilo type Ⅰ,132 cases of Gustilo type Ⅱ,56 cases of Gustilo type ⅢA,and 67 cases of Gustilo type Ⅲ B.The initial fractures were fixated at other hospitals with plate in 334 cases,with intramedullary nails in 21 cases,and with external fixators in 63 cases.By the Cierny-Mader classification,the osteomyelitis was type Ⅰ in 21 cases,type Ⅱ in 26 cases,type Ⅲ in 366 cases,and type Ⅳ in 5 cases.We removed the internal hardware and fixated all the fractures with external fixators.For the 266 patients without bone exposure,vancomycin calcium sulfate beads (n =201) or vancomycin cement (n =65) were inset into the wounds; for the other 152 patients with bone exposure,vancomycin calcium sulfate beads were inset into the wounds which were then repaired by flap transfer.Results Follow-ups ranged from 12 to 108 months (average,37.5 months).Of the 201 patients treated with only vancomycin calcium sulfate beads,osteomyelitis was healed in 174 (86.6％) and fracture united in all (100.0％).In the 65 patients treated with only vancomycin cement,osteomyelitis was healed in 57 (87.7％) and fracture united in all (100.0％).In the 152 patients treated with vancomycin calcium sulfate beads and flap transfer,osteomyelitis was healed in 131 (86.2％) and fracture united in 147 (96.7％).Osteomyelitis was healed for the 362 patients after an average time of 3.0 months (from 2 to 14 months).Fractures united for the 413 patients after an average time of 14.0 months (from 3.5 to 20.0 months).Pin track infection was found in 23 cases.Conclusions The optimal fixation for open tibial fracture complicated with osteomyelitis is external fixators.For the wounds without soft tissue defects,vancomycin calcium sulfate beads and vancomycin cement are similar in high therapeutic efficacy.For the wounds with soft tissue defects,combination of vancomycin calcium sulfate beads and flap transfer can lead to satisfactory treatment outcomes.

青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)是指10岁以上儿童至发育成熟前的一种伴有椎体旋转脊柱侧方弯曲的三维畸形.多发于青少年,发生率为3%[1],女性患者高于男性[2].其发生机制一直未明确,目前认为是多因素造成,如遗传、骨骼肌肉、生长发育、神经系统、内分泌系统异常等原因.近年来,遗传学方面的候选基因研究取得一些进展,本文对此方面研究进展做一综述.

<正>化脓性脊椎炎是一种少见的脊柱感染性疾病,年发病率约0.2～2.8/10000[1],原发性则更为罕见,目前国内外文献尚无确切发病率统计数据报道;因症状、体征缺乏特异性,难以早期诊断而错过最佳治疗时机,导致预后较差,特别是病灶位于颈椎者有较高致残率[2]。我们收治1例原发性洋葱伯克霍尔德菌(Burkholderia cepacia)颈椎化脓性脊椎炎伴颈脊髓腹侧脓肿病例,报道如下。

Objective To evaluate the medium-term efficacy of lumbar interspinous dynamic stabilization device( the Wallis system)on treatment of lumbar degenerative diseases. Methods Retrospective analysis the curative effect of 34 patients who use second generation Wallis system to treat lumbar degenerative disease from February 2008 to October 2010. The visual analogue scale( VAS) and Japanese Orthopaedic Association( JOA) scores were recorded before operation,3 months after operation,and at the last follow-up so as to evaluate the curative effect. The operative segment disc height( DH) and range of motion( ROM) of adjacent segment were evaluated preoperatively,postoperatively and at the last follow-up. Results 31 patients were followed up for 26 to 38 months,VAS scores at the last follow-up significantly decreased compared with scores in preoperation( P < 0. 05),but there was no significant difference compared with scores 3 months after operation. JOA scores at the last follow-up significantly increased cpmpare with preoperation( P < 0. 05),and there was no significant change compared with scores 3 months after operation( P > 0. 05). The DH and ROM of the last follow-up compared with data before and 3 months after operation showed no significant change( P > 0. 05). Conclusion Wallis system is of good curative effect in the treatment of degenerative disc disease. It can be used to alleviate the symptoms,delay in segmental height loss and maintain spinal stabilization.

<正>体育活动中轻微头颈部外伤后出现急性颈椎椎管内硬膜外出血比较少见,且早期极容易误诊为头颈部简单机械性外伤。椎管内出血后短时间内即可出现感觉运动功能的丧失,治疗效果多与救治时间和方法强相关。本院近期曾收治此类患者1例,现总结如下。

目的 采用蛋白质组学方法分析、寻找后纵韧带骨化症(OPLL)的特异性蛋白标志.方法 采用荧光差异双向电泳法研究OPLL患者及正常人韧带组织的双向电泳图像.采用飞行时间质谱进行鉴定并分析差异表达的蛋白质点.结果 两组样本均得到约1 100个蛋白质点,50个点表达有改变.切胶获得45 个蛋白质点的肽段样本,质谱鉴定为21个蛋白质或肽段.其中15个血液蛋白,其余6个蛋白中4个表达下调;2个表达上调.RT-PCR检测表明烟酰胺腺嘌呤二核苷酸依赖的激素脱氢酶, 伴肌动蛋白相关锚定蛋白及Ⅵ型胶原蛋白mRNA变化与电泳结果一致.结论 这些差异表达蛋白可能是OPLL的特异表达蛋白.