髌股关节是人体最大的滑车关节,其在伸膝的力学传导及增强下肢运动能力中至关重要.髌股关节由骨软骨界面结构、韧带支持结构、肌肉动力结构等构成.这些结构协同构成了髌股关节的功能,并共同参与维持髌骨运动轨迹的稳定.单个或多个结构的异常将造成髌股关节生物力学机制的失衡,最终产生髌股关节疼痛、髌骨不稳定等疾病.本综述拟从解剖构成、生物力学两个方面对髌股关节进行阐述.

目的 探讨膝关节屈曲位缝合切口对全膝关节置换术(TKA)早期临床效果的影响.方法 对2016年9月至2017年9月中国人民解放军西部战区总医院骨科行单侧TKA治疗的膝关节骨关节炎患者74例进行前瞻性随机对照研究.采用随机数字表法将患者分为2组:试验组37例,TKA术中采用膝关节屈曲90°连续缝合切口;对照组36例(1例患者退出研究)采用膝关节伸直位连续缝合切口.对2组患者手术切口长度、缝合时间、术后失血量、术后疼痛视觉模拟评分(VAS)、主动直腿抬高时间、屈膝90°时间、Hollander切口愈合评分(HWES)、患者切口自评满意度评分(Likert)、住院时间、拆线时间、术后并发症发生率、曲马多用量、美国特种外科医院膝关节评分(HSS)及术后膝关节活动度(ROM)进行比较.采用GraphPad Prism 6软件对数据进行处理.结果 2组患者在年龄、性别构成、侧别、体质量指数(BMI)以及术前膝关节ROM和VAS评分差异均无统计学意义(均P>0.05).两组患者在切口长度、术后失血量、主动直腿抬高时间、HWES评分、Likert评分、住院时间、拆线时间及术后并发症差异均无统计学意义(均P>0.05).两组患者均未出现切口裂开、切口延期愈合、浅表切口感染和假体感染等严重并发症.试验组患者术后屈膝90°活动时间、曲马多用量、术后48 h内活动痛VAS评分、术后24 h膝关节HSS评分和术后24 h膝关节ROM均优于对照组(均P<0.05),缝合时间长于对照组(P<0.05).结论 与膝关节伸直位连续缝合相比,TKA术中采用膝关节屈曲90°位连续缝合切口,切口愈合好,患者术后早期疼痛减轻,术后曲马多用量减少,利于患者进行早期膝关节功能恢复,且无明显不良反应,值得在临床上推广;但两者远期疗效无显著差异.

髌骨远端 1 / 4 的骨折为髌骨下极骨折,约占髌骨骨折的 9.3％～22.4％ [1],可使伸膝装置连续性遭到破坏,影响膝关节的功能 ( 图 1 ).髌骨下极骨折为关节外骨折 [2],治疗上有其特殊性,因此笔者在简要介绍髌骨下极的解剖结构、生物力学特性及骨折机制的基础上,检索相关文献,综述髌骨下极骨折治疗的最新进展,分析目前治疗方式存在的问题,探讨未来研究方向.

目的 应用基于奥马哈系统的延续性护理方法,处理老年髋臼骨折患者出院后康复过程中的护理问题并归纳整理干预措施,为促进老年髋臼骨折患者出院后的护理和科学康复方法提供依据.方法 选取2012年1月 ～2016年12月西部战区总医院骨科收治的老年髋臼骨折复位内固定患者122例,针对出院后的护理模式分为干预组58例和对照组64例进行前瞻性对照研究.对照组采用髋臼骨折术后常规护理方法;干预组应用以奥马哈系统为基础的延续性护理方法,对患者在生理领域、健康相关行为领域、社会心理领域及环境领域进行个性化的干预.两组患者均在手术后1、3和6个月门诊随访.对护理问题的改善成效评价采用Likert 5分法,从认知、行为、状况3方面来评价;采用Modified Merle D′Aubigne Postel Score量表对髋关节功能进行评分;并统计两组并发症情况.结果 与对照组相比较,干预组患者的疼痛、神经肌肉功能、身体活动、自我照顾4个护理问题均明显改善(P<0.05);干预组术后髋关节功能评分明显好于对照组(P<0.05);干预组术后关节僵硬、创伤性关节炎、坐骨神经损伤等并发症的发生率明显低于对照组(P<0.05).结论 运用以奥马哈系统为基础的延续性护理方法,可以在老年髋臼骨折术后院外康复的关键时期改善患者护理问题、加快恢复关节功能,实现以患者为中心的整体护理要求,明显提高老年髋臼骨折患者术后康复效果.

膝关节镜手术是目前国内外开展最广泛的骨科微创手术之一,因其创伤小、费用低、围手术期短等优点,得到了医患双方的高度认可.加速康复外科(ERAS)是外科发展的重要方向之一,1997年丹麦学者Kehlet等[1]首次提出ERAS的概念,原南京军区总医院黎介寿院士将其形象翻译为“加速康复外科或快速通道外科”[2].ERAS可明显改善患者手术效果及促进功能恢复,尽早尽快地提高患者的生活适应度和自信心.ERAS的核心理念在于通过一系列围手术期处理的优化措施,缓解机体对手术创伤的应激反应,使患者达到快速康复的目的.

Hyperglycemia-induced cartilage degeneration induces osteoarthritis (OA). Since oleanolic acid (OLA) have several pharmacological effects such as anti-inflammatory, anti-oxidant, we hypothesized it possesses protection against high glucose injured cartilage. We now report that OLA decreased type X collagen and reversed the cartilage degeneration in growth plate from db/db mice. OLA increased type Ⅱ collagen expression in a concentration-dependent manner (10–50 μΜ) in high glucose-treated chondrocytes. OLA prevented the high glucose induced cell injury and decreased the level of MMP-13, PGE2 and IL-6 due to decreasing mitochondrial membrane potential and stimulated the ATP production. Moreover, OLA treatment inhibited apoptosis. And the reversed SOD2 expression and activity may be ascribed to decreased SOD2 protein degradation by OLA treatment, via PPPAγ. In conclusion, OLA protected against the high-glucose-induced cartilage injury via PPARγ/SOD2 pathway.

目的：探讨采用切线位拉力螺钉内固定方法治疗累及四边体的髋臼骨折的临床效果。方法回顾分析成都军区总医院骨科2006年1月至2009年12月病例资料24例，均术前CT检查诊断为涉及四边体的髋臼骨折，全部病例均采用重建钢板结合切线位拉力螺钉内固定的方法手术采用Matta标准及Merled’Aabigne髋关节评分标准评价疗效。结果随访时间3~5年，髋臼复位质量按Matta标准评价：解剖复位19例，满意复位5例，解剖复位率达到79%。术后随访按照改良Merled’Aubigne髋关节评分标准评价术后功能：优16例，良6例，可2例，优良率91．1%。结论切线位拉力螺钉内固定手术治疗累及四边体的髋臼骨折操作简单、临床效果良好，有一定的临床推广价值。

目的 探讨手术治疗各种原因所致桡神经陈旧性离断伤的临床疗效.方法 对2007～2012年该院收治的21例陈旧性桡神经离断伤患者进行回顾性研究,采用中华医学会手外科学会上肢周围神经功能评定试用标准判定术后患者肢体功能恢复情况.结果 本组21例患者术后随访时间2～4年,采用神经吻合或神经移植术后其功能优良率按照桡神经功能评定标准均在80‰以上.结论 神经损伤的修复,原则上越早越好;对于错过早期手术时机的桡神经陈旧性损伤,采用显微外科手术技术予以修复,亦可取得较为理想的疗效,是治疗该类损伤的一种可行而合理的方法.

Objective To analye retrospectively the fixed fracture efficacy of intertrochanteric hip replacement and PFNA ( proximal femoral anti-rotation intramedullary nail) in the treatment of senior citizens with unstable intertrochanteric fractures and discuss its clinical significance. Methods From Jan. 2011 to Dec. 2013, 98 elderly patients with unstable intertrochanteric frac-tures were admitted. There were 52 cases PFNA internal fixation group (38 cases of typeⅢand 15 cases of type IV), and 46 ca-ses in hip replacement group (33 cases of typeⅢand 12 cases of type IV). Ooperative time, blood loss, blood transfusion, post-operative bed rest time, medical complications, postoperative Haris ratings were analysised after 1, 2, 8 and 16 weeks, with sta-tistical analysis. Results Compared with hip replacement surgery, the operative time, the blood loss and postoperative blood transfusion were less, and the bed rest time was short (P<0. 05) in PFNA group. The excellent rates after eight weeks and the former were better in the PFNA group than in hip replacement group, were better than the latter (P<0. 05). Conclusion The PFNA and hip replacement treatment of the unstable intertrochanteric fracture have their own characteristics. The PFNA is better than hip replacement, and clinically appropriate treatment choiceshould be individualized according to the patient's own condition.

Obesity is causally linked to osteoarthritis (OA), with the mechanism being not fully elucidated. miRNAs (miRs) are pivotal regulators of various diseases in multiple tissues, including inflammation in the chondrocytes. In the present study, we for the first time identified the expression of miR-26a in mouse chondrocytes. Decreased level of miR-26a was correlated to increased chronic inflammation in the chondrocytes and circulation in obese mouse model. Mechanistically, we demonstrated that miR-26a attenuated saturated free fatty acid-induced activation of NF-κB (p65) and production of proinflammatory cytokines in chondrocytes. Meanwhile, NF-κB (p65) also suppressed miR-26a production by directly binding to a predicted NF-κB binding element in the promoter region of miR-26a. Finally, we observed a negative correlation between NF-κB and miR-26a in human patients with osteoarthritis. Thus, we identified a reciprocal inhibition between miR-26a and NF-κB downstream of non-esterified fatty acid (NEFA) signalling in obesity-related chondrocytes. Our findings provide a potential mechanism linking obesity to cartilage inflammation.

Objective To compare the results and complication between minimally invasive and L incision approach of calcaneus fracture. Methods Total 48 patients with calcaneus fracture were enrolled in the study from Jul. 2008 to Jul. 2013. There were 27 case of SandersⅡand 29 cases of SandersⅢ. Group A was defined as minimally invasive approach and group B was defined as L incision approach. There were 18 cases of SandersⅡin group A and 9 cases in group B. There were 7 cases of SandersⅢ in group A and 22 cases in group B,respectively. In group A the minimally invasive and hollow screws were used and in group B plate with L incision were performed. The Bolher and Gissane angles were evaluated and final results were analyzed. AOFAS e-valuation was performed in every patient. Results The average follow up time was 15 months( range 9~48 months) . There was no significant difference of Bolher and Gissane angles between groups A and B(P>0. 05). And we got better results after operation than preoperative angles in two groups(P<0. 05). The average AOFAS of SandersⅡin group A higher than that of group B(P<0. 05). There was no significant difference of AOFAS of SandersⅢbetween two groups. AOFAS of SandersⅢwas higher than that of SandersⅡ(P<0. 05). One case with surface infection was found in group A. There were 6 cases with deep infection and two of them suffered osteomyelitis,and 4 patients of them healed with transfer of skin flap. Conclusion The minimally invasive approach to treat SandersⅡcalcaneus fracture got better result than traditional L incision approach. However the results of SandersⅢcalcane-us fracture had no significant difference between minimally invasive and L incision approach.

OBJECTIVE:To evaluate and compare the radiographic parameters between patients of adult acquired flatfoot and normal participants to provide rationales for diagnosis and operative reconstruction.METHODS:The adult acquired deformity group consisted of 85 patients (85 feet) and normal group 90 normal participants (90 feet) from January 2008 to May 2014. The weight-bearing anteroposterior and lateral foot radiographs were taken. And the following parameters were measured and compared: medial column length (MCL), lateral column length (LCL), medial column height (MCH), lateral column height (LCH), talonavicular uncoverage angle (TNUA), talus-first metatarsal angle (TMTA) and calcaneal pitch angle (CPA). Age and all parameters were included for Logistic regression analysis.RESULTS:On anteroposterior radiographs, the values of MCL for adult acquired deformity and normal groups were (103.5 ± 9.0),(105.8 ± 7.8)mm and LCL (94.6 ± 6.9),(96.2 ± 6.1)mm respectively.No significant difference existed in MCL or LCL (P > 0.05).However, significant inter-group differences existed in TMTA and TNUA (P < 0.01). The values of TMTA were (18.9 ± 2.5)°,(7.8 ± 2.2)° and TNUA (23.6 ± 3.2)°,(8.0 ± 2.2)°.On lateral radiographs, significant inter-group differences existed in MCH, LCH, CPA and TMTA (P < 0.01). And the values of MCH were (16.3 ± 1.7),(23.6 ± 2.8)mm, LCH (14.9 ± 1.1),(13.96 ± 1.39)mm, CPA (14.86 ± 2.76)°,(22.9 ± 1.9)° and TMTA (10.0 ± 2.0)°,(-3.6 ± 1.0)° respectively. According to Logistic regression analysis, the significance of parameters ranged from lateral TMTA (B = 0.032), anteroposterior TNUA (B = 0.014), anteroposterior TMTA (B = 0.015) to lateral MCH (B = -0.012), lateral CPA B (B = -0.009).CONCLUSION:No differences exist in anteroposterior MCL or LCL. There are positive differences in lateral TMTA, anteroposterior TNUA and anteroposterior TMTA. And negative differences exist in lateral MCH and lateral CPA between adult flatfoot and normal foot. Lateral TMTA may be an excellent radiographic identifier of patients with adult acquired flatfoot during diagnosis and treatment.

目的 探讨股骨颈骨折不同内固定方法的疗效并讨论其临床意义.方法 回顾性分析2008年1月至2013年12月股骨颈骨折214例患者的临床资料,男100例,女114例;年龄(56.1±26.6)岁.Garden分型包括Ⅰ型10例,Ⅱ型32例,Ⅲ型104例,Ⅳ型68例.分别采用三翼钉固定42例,加压螺钉固定50例,多针固定70例,带肌蒂骨瓣移植加内固定52例.对患者骨折愈合率、髋关节功能恢复率、股骨头坏死率进行对比分析.结果 214例平均随访3.5(1 ～9)年,骨折愈合178例(83.2％),不愈合36例(16.8％,Garden分型为Ⅱ型3例,Ⅲ型8例,Ⅳ型25例)中股骨头坏死30例(14.0％).髋关节功能优良150例(70.1％),功能可或差64例(29.9％).Ⅳ型股骨颈骨折的愈合率明显低于Ⅰ型、Ⅱ型、Ⅲ型(P均＜0.05),股骨头坏死率明显高于Ⅰ型、Ⅱ型、Ⅲ型(P均＜0.05).加压螺钉组、多针内固定组和带肌蒂骨瓣移植加内固定组骨折愈合率高于三翼钉组(P均＜0.05);与三翼钉组、加压螺钉组比较,多针内固定组和带肌蒂骨瓣移植加内固定组股骨头坏死率低(P均＜0.05),功能优良率较高(P均＜0.05).结论 内固定手术对股骨颈骨折有良好的疗效,多针内固定和带肌蒂骨瓣移植加内固定效果较好.股骨颈骨折应当选用合适的内固定治疗,以促进愈合和功能恢复,防止股骨头坏死.

目的 分析陈旧性Lisfranc损伤的产生及治疗方式.方法 从2007年5月～2011年5月共收治陈旧性Lisfranc骨折脱位15例,6例行切开复位内固定,9例行关节融合术.结果按美国骨科足踝外科协会 (AOFAS)中足部分的评分标准:60～70分1例、70～80分2例、80～90分9例、90～100分3例.结论 陈旧性Lisfanc损伤可出现中足塌陷及扁平足畸形,临床医生在遇到中足扭伤的患者时,要提高警惕,以免漏诊,早期及时的诊治是避免并发症的关健.

Objective To evaluate the results of the treatment of SandersⅡ、ⅢCalcaneal Fractures with Headless Forc-ing Screw Fixation. Methods From January 2009 to September 2012,23 cases(26 feet) of Sanders Ⅱ、Ⅲ Calcaneal Fractures were treated with Headless Forcing Screw Screw Fixations,All cases were given axial view\side position X ray examation,and CT scan. 18 patients were typeⅡand 8 patients were typeⅢby Sanders classification respectively. During follow-up,pain,functional outcome,range of motion,and change in footwear were evaluated with the use of the American Orthopaedic Foot&Ankle Society ( AOFAS) score. Results We reviewed the cases of 23 patients who had a combined total of 26 displaced intra-articular calcaneal fractures and a follow-up period of 7 to 24 months(mean 12. 6 months). All cases showed clinical healing during 9 to 16 weeks ( mean 10 weeks) . There were No infections occurred,no failure of internal fixationin. And the subtalar arthrodesis had been per-formed in four patients. At the time of follow-up,the Bohler's,Gissane's angle,calcaneal width and height were reduced close to nor-mal anatomic structure in X-ray. According to AOFAS Hindfoot score,the operation results were excellent in 14 feet,good in 9,and poor in 3. The AOFAS Hindfoot Score averaged 88. 7. The overall satisfactory results( excellent and good) were 88. 46%. Conclu-sion Headless Forcing Screw fixation of calcaneal fractures( Sanders Ⅱ,Ⅲ) is associated withminimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. The procedure is suit-able for most types of intra-articular fractures especially in patients with compromised soft tissues in which open reduction and in-ternal fixation is contraindicated.

Objective To evaluated the early clinical effects of open reduction and internal fixation for the treatment of intrarticular( subtalar joint) calcaneal fractures. Methods 34 feet of 30 patients with intraarticular fractures of the calcaneus we received. Twenty-one patients were males and nine were females( mean age 37. 6 years;range from 18 to 57 years) , and four pa-tients suffered from bilateral fractures. Anteroposterior, lateral, and tangential radiographs were obtained in all patients preopera-tively, and all patients experienced computed to mography( CT) scans. According to Pale y′s classification, there were 3 cases in typeⅠ,16 in typeⅡ,7 in typeⅢ,4 in typeⅣand 4 in typeⅤ. An extensile lateral incision was performed in all patients to provide an anatomic reduction with the use of rebuilt-plates, screws internal fixation. The 30 patients were followed up with an average time of 9 months( range from 6 to 36 months) . Results Radiographs obtained in the early postoperative period showed that com-plete anatomic reduction were achieved in 19 feet. According to the Maryland Foot Score, the results were excellent in 17, good in 13,fair in 3,and poor in 1 foot. None of patients required a subsequent operation due to surgery associated causes. Conclusion The treatment effects of intraarticular calcaneal fractures with ORIF are satsifactory.

Objective To investigate the methods and effects in repairing fracture of the fifth metatarsal base bone with Acutrak headless compression screws.Methods From May 2006 to October 2012,75 patients with fracture of the fifth metatarsal base bone were reduced and fixed using Acutrak headless compression screws.There were 38 males and 37 females with a mean age of 36 years (range,21-65 years).Injury arose from fall from height (35 cases),road traffic accidents (23 cases),and fall of heavy objects (17 cases).Fracture of the left foot occurred in 29 cases and the right foot in 46 cases.Results were evaluated using American Orthopedic Foot and Ankle Society (AOFAS) ankle and midfoot score.Results Seventy-two patients were followed up for mean 15 months (range,13 months5 years).Operative incision obtained primary healing without any complications.Mean AOFAS ankle and midfoot score increased to (93.0 ± 6.5) points (range,79-100 points) at postoperative 1 year,compared with the preoperative (28.0 ± 3.9) points (range,0-42 points) (t =7.650,P ＜ 0.05).Muscle force and valgus or abduction of mid-forefoot of the affected and unaffected sides demonstrated no significant difference after operation.Conclusion Acutrak headless compression screw system shows advantages of rigid fixation,few complications,and early healing in treatment of the fifth metatarsal base fracture.

Objective To investigate the therapeutic effect of arthroscopic reduction ACL reconstruction for treating tibial intercondylar eminence avulsion fracture using suture anchors. Methods Between February 2006 and December 2012,28 patients with tibial intercondylar eminence avulsion fracture were treated with arthroscopic reduction using suture fixation. According to Meyers-McKeever classification,7 cases of 28 were rated as type II,16 as type III,and 5 as type IV fractures. Anterior drawer test and Lachman test of all patients were positive. Lysholm scores were(55. 3 ± 1. 6),respectively. Assisted with anterior cruciate lig-ament-aimer,bone tunnels were built through the fracture fragments after fracture reduction,through which Ethibond 2 polyester sutures were guided into the joint by spine needles;after knot of 2 sutures or knot of only 1 suture was made,the other ends of su-tures were fastened together outside the joint. Results The incisions of all the cases healed by first intention with no complication of infection or deep venous thrombosis. Twenty-eight patients were followed up 12~36 months with an average of 25. 6 months. The X-ray examination indicated fractures healed in all the cases at 2~4 months( mean,3 months) . At 12 months after operation, extension and flexion spheres of knee activity were normal in 26 cases and were limited in 2 cases. The Lysholm score was(92. 5 ±2. 4),showing significant difference when compared with the preoperative score(t=42. 220,P=0. 000). Conclusion Suture fixation under arthroscope is an effective method with small invasion,reliable fixation,and simple operation for treating tibial inter-condylar anterior eminence fracture,and gave a simplicity,and effectiveness for anatomic ACL reconstruction.

Background It was reported that expansive pedicle screw (EPS) and polymethylmethacrylate-augmented pedicle screw (PMMA-PS) could be used to increase screw stability in osteoporosis. However, there are no studies comparing the two kinds of screws in vivo. Thus, we aimed to compare biomechanical and interfacial performances of EPS and PMMA-PS in osteoporotic sheep spine. Methodology/Principal Findings After successful induction of osteoporotic sheep, lumbar vertebrae in each sheep were randomly divided into three groups. The conventional pedicle screw (CPS) was inserted directly into vertebrae in CPS group; PMMA was injected prior to insertion of CPS in PMMA-PS group; and the EPS was inserted in EPS group. Sheep were killed and biomechanical tests, micro-CT analysis and histological observation were performed at both 6 and 12 weeks post-operation. At 6-week and 12-week, screw stabilities in EPS and PMMA-PS groups were significantly higher than that in CPS group, but there were no significant differences between EPS and PMMA-PS groups at two study periods. The screw stability in EPS group at 12-week was significantly higher than that at 6-week. The bone trabeculae around the expanding anterior part of EPS were more and denser than that in CPS group at 6-week and 12-week. PMMA was found without any degradation and absorption forming non-biological “screw-PMMA-bone” interface in PMMA-PS group, however, more and more bone trabeculae surrounded anterior part of EPS improving local bone quality and formed biological “screw-bone” interface. Conclusions/Significance EPS can markedly enhance screw stability with a similar effect to the traditional method of screw augmentation with PMMA in initial surgery in osteoporosis. EPS can form better biological interface between screw and bone than PMMA-PS. In addition, EPS have no risk of thermal injury, leakage and compression caused by PMMA. We propose EPS has a great application potential in augmentation of screw stability in osteoporosis in clinic.

OBJECTIVE:To investigate the effectiveness of arthroscopically assisted treatment of acute tibial insertion avulsion fracture of the posterior cruciate ligament (PCL) via posteromedial incision.METHODS:Between January 2010 and January 2012, 22 patients with acute tibial insertion avulsion of the PCL underwent arthroscopic reduction and fixation via posteromedial incision. There were 14 males and 8 females with an average age of 32 years (range, 18-48 years). The injury causes included traffic accident injury in 14 cases, sport injury in 4 cases, and falling injury in 4 cases. The disease duration ranged from 7 to 16 days (mean, 10 days). Of 22 patient, 14 had simple PCL injury, 6 had PCL injury with meniscus injury, and 2 with cartilage injury. The results of posterior drawer test were positive in all patients. The preoperative Lysholm score was 51.1 +/-3.4.RESULTS:All incisions healed by first intention without infection, deep venous thrombosis of lower limbs, or vessel and nerve injuries. All patients were followed up 12-24 months (mean, 18.4 months). X-ray films showed that all fractures healed with the healing time of 2-4 months (mean, 3 months). The Lysholm score was improved to 96.0 +/-2.2 at 6 months after operation, showing significant difference when compared with preoperative score (t=43.020, P=0.000).CONCLUSION:Arthroscopically assisted treatment of acute tibial insertion avulsion fracture of the PCL via posteromedial incision is a safe, easy, and effective method.