摘要: 腰椎間盤突出癥是骨科臨床中的常見病,腰椎間盤切除術(shù)已成為治療該病的重要手段而被廣泛應(yīng)用。然而，諸如定位錯誤、神經(jīng)根損傷、椎間盤炎、腰椎失穩(wěn)等嚴(yán)重手術(shù)失誤與并發(fā)癥時有出現(xiàn)，成為骨科醫(yī)師的一大困擾。分析腰椎間盤手術(shù)失敗的原因及再手術(shù)問題，辯證思考腰椎間盤切除術(shù)的必要性與合理性,為臨床實(shí)踐和進(jìn)一步研究提供思路。關(guān)鍵詞：腰椎，椎間盤移位，手術(shù)后并發(fā)癥Analysis and Consideration of the Causes of Operation Failure about Lumbar Disc HerniationAbstract:Lumbar discectomy now has been widely used as a important method on the treatment of lumbar disc herniation(LDH). However, many serious complications and operative failure have accured occasionally, such as mislocalization, discitis, injury of never root, segmental instability and so on, which have been difficult problems to ours. In order to find a better way for clinical practice and further study, we shoud consider the necessity and reasonability of lumbar discectomy carefully.Key Words:Lumbar vertebrae, Intervertabral disk displacement, Postoperative complications腰椎間盤突出癥(LDH)是腰腿痛的重要原因，也是骨科臨床中的常見病。自從1934年Mixter和Barr首先通過手術(shù)證實(shí)和治愈腰椎間盤突出壓迫神經(jīng)根所致的坐骨神經(jīng)痛以來，腰椎間盤突出癥的手術(shù)治療得到了廣泛應(yīng)用，并取得了80%—90%的治愈效果。國內(nèi)也于1946年由方先之教授率先開展腰椎間盤切除術(shù)，隨后該手術(shù)得到了較普遍開展。同時手術(shù)方法不斷創(chuàng)新，如顯微鏡下椎間盤切除術(shù)、經(jīng)皮穿刺椎間盤切除術(shù)、化學(xué)溶解術(shù)以及近年來迅速發(fā)展的顯微內(nèi)窺鏡下椎間盤切除術(shù)（MED）等。然而，廣泛的手術(shù)治療獲得了較好療效的同時，亦出現(xiàn)了不少腰椎間盤切除術(shù)手術(shù)失敗，文獻(xiàn)報道其失敗率達(dá)到了2.4%—14.3%[1]。諸如神經(jīng)根損傷，椎間盤炎，腰椎失穩(wěn)等嚴(yán)重并發(fā)癥的不斷出現(xiàn)，以及腰椎間盤切除術(shù)后的再手術(shù)問題一直困擾著骨科醫(yī)師和患者，這不能不引起人們對它的審視與思考。1、腰椎間盤突出癥手術(shù)失敗的常見原因1.1 診斷失誤毫無疑問，錯誤的或是片面的診斷必須會導(dǎo)致錯誤的或不恰當(dāng)?shù)闹委?，臨床上腰椎間盤突出癥的診斷并不困難，然而誤診和漏診卻并不少見。究其原因，其一為與腰椎間盤突出癥臨床表現(xiàn)相同或相似的疾病眾多，要一一鑒別并非易事。腰椎間盤突出癥主要的臨床癥狀為腰痛伴或不伴腿痛，首先，幾乎所有的腰部或腰椎疾病都可出現(xiàn)腰腿痛。如急性腰扭傷、慢性腰肌勞損、椎間小關(guān)節(jié)滑膜炎癥、第三腰椎橫突綜合征、梨狀肌綜合征等，另外,脊柱或脊髓腫瘤、脊柱結(jié)核也需與之鑒別；其次，其它部位如盆腔內(nèi)臟疾病也常可刺激骶部神經(jīng)叢引起腰骶部疼痛，從而引起下肢的反射痛。常見的有盆腔炎、子宮脫垂等；還有某些全身性疾病如強(qiáng)直性脊柱炎，當(dāng)病變侵犯骶髂關(guān)節(jié)、脊柱、髖關(guān)節(jié)時，亦可出現(xiàn)腰痛或腿痛。當(dāng)然，事物與事物之間有共性，也有個性，上述每種疾病也會有其不同的個性，是共性與個性的統(tǒng)一。只要我們善于識別和發(fā)現(xiàn)其區(qū)別即個性，是完全可以作出正確的診斷的。發(fā)現(xiàn)個性也就是臨床上鑒別診斷的過程，這個過程離不開科學(xué)的思維方法。這需要我們在詳細(xì)詢問病史，認(rèn)真全面的體格檢查以及恰當(dāng)?shù)挠跋窈蛯?shí)驗(yàn)室檢查的基礎(chǔ)上，運(yùn)用科學(xué)的診斷思維方法。當(dāng)然，那種過份依賴影像資料而忽視臨床表現(xiàn)的做法是十分有害的。1.2 手術(shù)技術(shù)失誤1.2.1 定位錯誤致誤切正常的椎間盤 造成的的原因有：（1）忽視移性椎，如骶椎腰化或胸椎腰化等不引起重視，致定位錯誤。因此，術(shù)前腰椎Ｘ線攝片應(yīng)為常規(guī)準(zhǔn)備；（２）經(jīng)驗(yàn)不足或過于自信，這是造成定位錯誤的主要原因。其實(shí)，椎間盤定位的方法有許多如：術(shù)前利用腰椎側(cè)位片上髂嵴最高點(diǎn)與棘突的關(guān)系，術(shù)前用雙手觸壓雙髂嵴之橫形連線與棘突縱軸線的交點(diǎn)定位，一般為腰3.4水平。亦可無菌操作下，棘突上插入針頭后攝片定位；或術(shù)中觸摸向后隆起斜坡骨為骶骨；或以Kocker鉗夾棘突上提時腰椎可活動，而骶椎不能活動。1.2.2 減壓不徹底 術(shù)中減壓不徹底，未能完全解除脊髓或神經(jīng)根的壓迫，必然導(dǎo)致手術(shù)效果不佳或癥狀緩解后又復(fù)發(fā)。常見原因有：（1）單個間隙髓核切除欠干凈，殘留髓核碎片再次脫出壓迫神經(jīng)根；（2）腰椎間盤突出伴有側(cè)隱窩或神經(jīng)根管狹窄者，行髓核摘除術(shù)時未同時擴(kuò)大側(cè)陷窩及神經(jīng)根管減壓；（3）對于多間隙椎間盤突出者，只處理一處，而遺漏了其它一處或多處，其手術(shù)原則是當(dāng)一個病變的椎間盤有明顯的突出并能解釋全部臨床表現(xiàn)時，可以不探查其它椎間隙，否則應(yīng)進(jìn)一步探查。因此，術(shù)前和術(shù)中不能僅滿足于某一處病變的處理而忽略了其它，要全面的看待和處理問題，防止片面化。1.2.3 減壓過度 有的手術(shù)醫(yī)生擔(dān)心神經(jīng)減壓不徹底致療效差而走向另一極端——盲目過度減壓，其結(jié)果是適得其反。過度減壓必然增加手術(shù)創(chuàng)傷并影響脊柱的穩(wěn)定性，術(shù)后腰椎失穩(wěn)并不少見[2]，許多術(shù)后患者因腰椎失穩(wěn)而情況更糟：腰腿痛較術(shù)前加重，功能障礙，勞動力喪失等，他們甚至不得不接受風(fēng)險和創(chuàng)傷更大的植骨內(nèi)固定穩(wěn)定手術(shù)。研究表明，一側(cè)腰椎小關(guān)節(jié)突被切除達(dá)1/3以上，即可致腰椎失穩(wěn)。因此，過多切除小關(guān)節(jié)突或盲目擴(kuò)大切除腰椎后方結(jié)構(gòu)范圍都是十分有害的。減壓與穩(wěn)定是一對矛盾的統(tǒng)一體，在減壓術(shù)中，一定要維護(hù)或重建腰椎的穩(wěn)定性。1.2.4 脊髓神經(jīng)根損傷 常見原因有：（1）術(shù)者操作經(jīng)驗(yàn)不足或不認(rèn)真，至脊髓神經(jīng)根損傷；（2）術(shù)野顯露不清楚，如椎靜脈叢的出血未控制時盲目操作；（3）槍式咬骨鉗使用不當(dāng)，咬除黃韌帶時誤傷脊髓和神經(jīng)根，以及尖刀切開椎間盤時誤傷脊髓和神經(jīng)根等。此并發(fā)癥后果嚴(yán)重，可引起下肢功能障礙甚至癱瘓。另外，術(shù)中探查時，對神經(jīng)根過重過久的牽拉，可致神經(jīng)牽拉傷。1.2.5 椎間盤炎 腰椎間盤切除術(shù)為無菌手術(shù)，發(fā)生椎間隙感染的機(jī)會并不多。但一旦發(fā)生，病人術(shù)后會出現(xiàn)劇烈的腰痛，不能活動腰部和下肢，十分痛苦。常見原因一是術(shù)前準(zhǔn)備不充分，如患者全身存在感染性疾病或術(shù)野鄰近部位存在感染灶，細(xì)菌容易侵入傷口致感染，因此不宜急于手術(shù)，應(yīng)先控制感染后再擇期行腰椎間盤切除術(shù)；二是無菌觀念不強(qiáng)，未能遵守?zé)o菌操作規(guī)程，外來細(xì)菌帶入手術(shù)部位引起感染；三是椎間隙內(nèi)異物存留。另外也可由手術(shù)器械物品消毒不嚴(yán)格、院內(nèi)交叉感染等引起。[3]2、腰椎間盤切除術(shù)后的再手術(shù)問題腰椎間盤手術(shù)失敗的原因是復(fù)雜和多方面的。雖是同一病例，可能是由幾種因素同時作用的結(jié)果，但對這些因素必須有先后和主次之分，不可混為一談，否則影響再次手術(shù)治療的效果。張佐倫[4]行再次腰椎手術(shù)55例，其原因分析為：原間隙髓核未取盡12例；遺漏一處突出腰椎間盤15例；未能解除中央管、側(cè)隱窩及神經(jīng)根管狹窄10例，術(shù)后瘢痕壓迫或椎管狹窄5例；定位錯誤3例等。魯玉來[1]提出再次手術(shù)的指征為：（1）神經(jīng)癥狀明顯，伴有運(yùn)動障礙或馬尾神經(jīng)綜合征者；（2）合并腰椎椎管、側(cè)隱窩、神經(jīng)根管狹窄者；（3）合并椎體后緣骨質(zhì)增生，黃韌帶肥厚，后縱韌帶或突出椎間盤鈣化及瘢痕增生所致椎管狹窄、硬膜囊受壓者；（4）第一次手術(shù)定位錯誤，突出腰椎間盤遺漏或再次發(fā)生新的腰椎間盤突出者；（5）腰椎不穩(wěn)嚴(yán)重影響工作和生活者。再次手術(shù)的成功率是有限的，而且再次手術(shù)對脊柱又增加了一次破壞，術(shù)后腰椎不穩(wěn)的發(fā)生率必然上升。且二次手術(shù)的難度加大，若是進(jìn)行第二次手術(shù)者最好同時做腰椎融合術(shù)，以免術(shù)后腰椎不穩(wěn)而發(fā)生腰痛。脊柱外科醫(yī)生在術(shù)前必須要有一個觀念，那就是你只有一次成功的機(jī)會，第一次手術(shù)效果總是最好的。椎間盤切除術(shù)手術(shù)結(jié)果完全依賴于術(shù)前仔細(xì)選擇合適的患者、可外科治療的病變診斷的準(zhǔn)確性、有效而不復(fù)雜化的手術(shù)以及良好的術(shù)后康復(fù)等。失敗的腰椎手術(shù)的每一次分析，都強(qiáng)調(diào)失效的主要原因是不恰當(dāng)?shù)耐饪浦委熁虿∏榈脑\斷，然而，我們必須承認(rèn)，對大多數(shù)有腰椎手術(shù)失敗的患者而言，沒有需要手術(shù)的必要，患者和醫(yī)生們?nèi)找嬖黾拥钠髨D，即“試試，試試，再試試”是不值得推薦的努力。外科手術(shù)也能造成疼痛及功能障礙，而且隨著手術(shù)次數(shù)的增加，患者出現(xiàn)疼痛和功能障礙加重的機(jī)會也越來越多。因此，再手術(shù)的決策，必須基于明確的、客觀存在的外科治療的病變，對于保守治療失敗，癥狀嚴(yán)重、悲觀、絕望以及尋求幫助等都不可以作為成功進(jìn)行再次脊柱外科手術(shù)的指征?？傊谝淮问中g(shù)需慎重，手術(shù)失敗后的再手術(shù)更需要慎之又慎。3、教訓(xùn)與啟示3.1正確處理好手術(shù)與非手術(shù)治療的關(guān)系腰椎間盤切除術(shù)手術(shù)失敗給患者造成巨大的身心痛苦，也給患者家庭和社會造成巨大損失，同時也易引發(fā)各種醫(yī)療糾紛，不利于和諧社會的建立。醫(yī)生尤其是脊柱外科醫(yī)生需要牢固樹立“以人為本”、“以病人為中心”的思想，嚴(yán)格把握好手術(shù)指征，以高度的責(zé)任感和認(rèn)真負(fù)責(zé)的態(tài)度仔細(xì)選擇手術(shù)病人。其實(shí)有約80%的腰椎間盤突出癥可能通過非手術(shù)療法治愈或暫時緩解，如牽引、推拿、理療、藥物等都有一定效果，這已得到專業(yè)醫(yī)生的公認(rèn)。腰椎間盤突出癥治療方法的選擇取決于該病的不同病理類型、病理階段和臨床表現(xiàn)，以及病人的年齡和身心狀況等綜合因素，手術(shù)與非手術(shù)療法各有其適應(yīng)癥。最近，有人發(fā)現(xiàn)到突出的椎間盤髓核組織（HNP）未經(jīng)手術(shù)切除而縮小，稱為突出椎間盤的再吸收[5,6]。大多數(shù)學(xué)者認(rèn)為突出髓核的再吸收與病人下腰痛及根性神經(jīng)痛的緩解呈正相關(guān)。雖然目前其再吸收的機(jī)制尚不清楚，但進(jìn)一步研究掌握HNP再吸收的發(fā)生、發(fā)展規(guī)律，將在臨床上為更多的腰椎間盤突出癥病人進(jìn)行非手術(shù)治療增加重要依據(jù)。非手術(shù)療法是本病的基本療法，而那種盲目擴(kuò)大手術(shù)適應(yīng)癥和手術(shù)范圍的做法是十分有害的。對于大多數(shù)可以用非手術(shù)療法治愈的患者，采用手術(shù)治療，無疑是一種過度醫(yī)療，就如對一名很可能成功順產(chǎn)的產(chǎn)婦不采用順產(chǎn)而采取剖腹產(chǎn)一樣，無疑增加了患者的身心痛苦和經(jīng)濟(jì)負(fù)擔(dān)，甚至導(dǎo)致嚴(yán)重并發(fā)癥。因此，對于每個腰椎間盤突出癥患者，要結(jié)合具體病情具體分析，采用最優(yōu)化的治療方案。3.2 正確看待腰椎間盤切除術(shù)腰椎間盤切除術(shù)是切除了退變及病變椎間盤的髓核。然而，椎間盤在脊椎的承重、復(fù)雜運(yùn)動、緩沖振蕩等生理功能中發(fā)揮著重要作用。盡管椎間盤切除術(shù)解決了許多腰椎間盤突出癥患者的腰腿痛，但切除術(shù)所帶來的手術(shù)入路對脊柱骨與韌帶的損傷，椎間隙高度的下降以及隨后帶來脊柱生物學(xué)功能紊亂，產(chǎn)生脊柱失穩(wěn)及臨近節(jié)段加速退變[2.7]，還有術(shù)后瘢痕形成對神經(jīng)根產(chǎn)生新的壓迫及術(shù)后神經(jīng)根粘連等問題，對脊柱外科醫(yī)生提出了新的挑戰(zhàn)。Kirkaldy等提出脊柱的三關(guān)節(jié)復(fù)合體理論[8]，認(rèn)為椎間盤及其后方兩個小關(guān)節(jié)構(gòu)成的三關(guān)節(jié)復(fù)合體在脊柱的穩(wěn)定性中發(fā)揮重要作用。當(dāng)椎間盤切除后，必定會使三關(guān)節(jié)復(fù)合體受累，進(jìn)而通過連鎖反應(yīng)影響脊柱的穩(wěn)定性。近年來椎間盤切除術(shù)后的修復(fù)受到越來越多的研究和重視。人工椎間盤置換術(shù)及人工髓核置入術(shù)在臨床上已有不少成功的報道[9]。因此，腰椎間盤切除術(shù)本身還不盡完美，還有許多相關(guān)領(lǐng)域值得我們?nèi)パ芯亢吞剿?。?shí)踐沒有止境，認(rèn)識也沒有止境，隨著研究的深入，將會有更新更好的手段征服腰椎間盤突出癥。4、結(jié)束語腰椎間盤切除術(shù)目前仍然是治療腰椎間盤突出癥的重要手段。骨科醫(yī)生應(yīng)樹立高度的責(zé)任感，努力提高手術(shù)質(zhì)量，精益求精，為減少甚至是避免各種失誤與并發(fā)癥而不懈努力。同時，加強(qiáng)腰椎間盤突出癥的基礎(chǔ)與臨床研究，不斷創(chuàng)新，為腰椎間盤突出癥患者提供更加科學(xué)、安全、可靠的治療。參考文獻(xiàn)：略

毛炳焱 劉平均 胡志喜 王文聰 賀用禮 晏平華 李際才 丁原 劉林【摘要】 目的 探討脛后動脈內(nèi)踝上皮支皮瓣修復(fù)足跟皮膚軟組織缺損的臨床效果。方法 自2000年7月～2008年3月應(yīng)用脛后動脈內(nèi)踝上皮支皮瓣修復(fù)各種原因所致足跟部皮膚軟組織缺損12例。 結(jié)果 12例皮瓣術(shù)后全部存活，皮瓣面積最小7cm×5cm，最大為14cm×8cm。隨訪6～12月，效果滿意。 結(jié)論 脛后動脈內(nèi)踝上皮支皮瓣血運(yùn)可靠，穿支點(diǎn)比較固定，手術(shù)操作簡便安全，且不犧牲重要血管，是一種比較理想修復(fù)足跟部皮膚軟組織缺損的方法。【關(guān)鍵詞】 外科皮瓣； 脛后動脈； 足跟部； 移植Repair skin and soft tissues defect in heel with flap of cutaneous branches of posterior tibial artery on the part of superior medial malleolus MAO Bing-yan,LIU Ping-jun,HU Zhi-xi, et al.( Department of Orthopaedics.Affiliated Shimen Hospital of Changsha Medical School ,Hunan Province 415300 ,China ) 【Abstract】 Objective To investigate a flap ofcutaneous branches of posterior tibial on the part of superior medial malleolus to repair skin and soft tissues defect in heel. Methods From July 2000 to March 2008, a flap based medial supramalleolar branches of posterior tibial were used to repair 12 cases which suffered skin and soft tissue defect in heel due to various trauma. Results With 6 to 12 months follow-up,all of the 12 cases were survived and evaluated as satisfactory,the size of the flap ranged from 14cm× 8cm to 7cm× 5cm. Conclusions The flap of cutaneous branches of posterior tibial artery on the part of superior medial malleolus is a satisfied method to repair skin and soft tissues defeet in heel and does not sacrifice the major arteries. The flap can be used with reliable nutrition, and with branches artery locationg permanent, and it is simple and safty to be performed. 【Key words】 Surgical flap ； Posterior tibial artery ； Heel ； Transplantation 足跟部外傷容易造成跟腱或者踝關(guān)節(jié)外露，以及外傷后足跟部瘢痕攣縮成為臨床上修復(fù)整形治療的難點(diǎn)，隨著顯微外科技術(shù)的發(fā)展和人體解剖研究的深入，臨床上常采用皮瓣轉(zhuǎn)位或皮瓣移植來修復(fù)整形創(chuàng)面[1 ~ 3]。通常采用的皮瓣，存在蒂部臃腫，犧牲較重要血管、神經(jīng)，且術(shù)后影響小腿主要肌群的活動。而脛后動脈內(nèi)踝上皮支皮瓣能較好的解決上述問題，且將損傷降低。自2000年7月至2008年3月我科應(yīng)用脛后動脈內(nèi)踝上皮支皮瓣修復(fù)各種原因所致足跟部皮膚軟組織缺損12例，效果滿意，現(xiàn)報告如下：1 臨床資料和方法1.1 一般資料 本組12例，男性7例，女性5例，年齡23～36歲。手術(shù)原因：摩托車鋼絲絞傷5例，交通事故4例，慢性潰瘍1例，瘢痕攣縮2例。所有病例在清創(chuàng)后或瘢痕切除后均合并跟骨骨折或跟腱外露，7例合并跟腱損傷，2例合并跟骨骨折，2例合并傷口感染。本組均采用擇期手術(shù)修復(fù)。1.2 手術(shù)方法1.2.1 創(chuàng)面準(zhǔn)備 徹底清除創(chuàng)面感染及不健康瘢痕組織，術(shù)前常規(guī)行創(chuàng)面細(xì)菌培養(yǎng)加藥敏，以指導(dǎo)術(shù)后用藥，跟骨骨折予克氏針或鏍釘固定，修復(fù)跟腱。1.2.2 皮瓣設(shè)計 點(diǎn)：術(shù)前用超聲多普勒血流探測儀探測脛后動脈內(nèi)踝上所有皮支的穿出點(diǎn)，通常選取內(nèi)踝上5cm或7cm為旋轉(zhuǎn)點(diǎn)；線：內(nèi)踝后與股骨內(nèi)髁連線為軸線；面：在髕骨下緣與內(nèi)踝上緣之間，前后均不超出正中線。確定點(diǎn)線面后，測量旋轉(zhuǎn)點(diǎn)至創(chuàng)面最近距離為血管蒂長度，剪裁出創(chuàng)面大小布樣，亞甲藍(lán)畫出皮瓣邊界。一般血管蒂放大1.0cm～1.5cm，皮瓣放大約1.0cm，血管蒂部設(shè)計成網(wǎng)球拍狀，蒂部寬度在1.5cm～2.0cm左右。1.2.3 皮瓣切取 首先切開血管蒂及皮瓣后緣，解剖至深筋膜下，在比目魚肌與趾長屈肌間找到脛后動脈，確定皮支穿出點(diǎn)，再切開皮瓣前緣，于深筋膜下解剖出皮瓣，結(jié)扎大隱靜脈近心端，切取范圍較大時可攜帶合適長度隱神經(jīng)，皮瓣轉(zhuǎn)移均采用明道處理，顯微吻合隱神經(jīng)與創(chuàng)面皮神經(jīng)，受區(qū)條件允許，可將大隱靜脈與皮下同流靜脈吻合。皮瓣供區(qū)采用韌厚皮植皮加壓打包，直徑小于5.0cm供區(qū)均可直接縫合。2 結(jié)果 全組12例皮瓣均存活，其中3例將大隱靜脈與皮下同流靜脈吻合，5例將遠(yuǎn)、近心端均結(jié)扎，6例僅將大隱靜脈近心端結(jié)扎，術(shù)后行大隱靜脈吻合者腫脹情況比未行吻合者輕，結(jié)扎大隱靜脈遠(yuǎn)、近心端皮瓣腫脹情況較僅結(jié)扎近心端者輕。供區(qū)植皮均一期愈合。術(shù)后隨訪6～12月皮瓣血運(yùn)良好，質(zhì)地軟，耐磨，外形不臃腫，功能恢復(fù)滿意。3 典型病例患者唐某，女，36歲。摩托車鋼絲絞傷右足跟部后皮膚變黑壞死34天，足跟區(qū)可見大小約3cm×4cm皮膚變黑壞死，并少許滲液，術(shù)前創(chuàng)面細(xì)菌培養(yǎng)送檢后，擴(kuò)創(chuàng)后跟踺外露，皮膚軟組織缺損約4cm×6cm，設(shè)計面積為5cm×7cm脛后動脈內(nèi)踝上皮支皮瓣修復(fù)，旋轉(zhuǎn)點(diǎn)位于內(nèi)踝上5cm處，供區(qū)直接縫合。術(shù)后皮瓣存活，創(chuàng)面一期愈合（圖一、二），足外形功能恢復(fù)滿意。4 討論3.1 脛后動脈內(nèi)踝上皮支皮瓣的解剖學(xué)依據(jù) 黃繼峰[4]等通過解剖發(fā)現(xiàn)，脛后動脈在小腿內(nèi)側(cè)距內(nèi)踝尖5cm～12cm，15cm～18cm，22cm～24cm均有肌間隙皮動脈穿出。張惠發(fā)[5]等通過對30例經(jīng)動脈內(nèi)灌注紅色乳膠成年下肢標(biāo)本的研究，發(fā)現(xiàn)在內(nèi)踝最突出點(diǎn)上方3.0±1.1cm，6.2±1.4cm，8.6±+1.4cm處脛后動脈肌間隙皮支穩(wěn)定穿出，3支出現(xiàn)率達(dá)86.6%，外徑在0.5mm～2.5mm，并且在5.0cm、9.0cm左右有骨皮穿支發(fā)出，這就為脛后動脈內(nèi)踝上皮支皮瓣提供了可靠的解剖學(xué)依據(jù)。本組病例術(shù)前均采用超聲多普勒血流探測儀探測脛后動脈內(nèi)踝上所有皮支的穿出點(diǎn)，術(shù)中也證實(shí)穿出點(diǎn)基本在內(nèi)踝尖上5cm～7cm，皮瓣面積最大在14cm×8cm，術(shù)后皮瓣均血運(yùn)良好。3.2 脛后動脈內(nèi)踝上皮支皮瓣中大隱靜脈的處理 在脛后動脈內(nèi)踝上皮支皮瓣中對于大隱靜脈的處理，眾說不一，對于吻合大隱靜脈與受區(qū)皮下同流靜脈的手術(shù)方式，能使皮瓣維持在一個“有灌有流”的良性狀態(tài)，能帶走皮瓣中有害物質(zhì)，減輕皮瓣水腫，這是可以肯定的。對于大隱靜脈在血管蒂部結(jié)扎與否，一般認(rèn)為大隱靜脈為足的主要回流靜脈，結(jié)扎可減少皮瓣靜脈血灌注，減輕皮瓣靜脈回流壓力。但Sasa[6]通過實(shí)驗(yàn)發(fā)現(xiàn)，動脈血氧一般僅25％ ～30％在組織細(xì)胞中被利用，而靜脈中血氧能滿足組織細(xì)胞需要，因此在蒂部保留大隱靜脈有利于皮瓣的成活。宋建星[7]等實(shí)驗(yàn)中的血?dú)夥治鼋Y(jié)果表明靜脈血與皮瓣組織間存在營養(yǎng)物質(zhì)的交換。本組手術(shù)中6例僅將大隱靜脈近心端結(jié)扎，術(shù)后皮瓣血運(yùn)良好，雖皮瓣腫脹情況較遠(yuǎn)、近心端結(jié)扎者嚴(yán)重，但筆者認(rèn)為不會影響皮瓣存活，相反可能在術(shù)后3～4d內(nèi)有助營養(yǎng)皮瓣，提高皮瓣存活率。3.3 脛后動脈內(nèi)踝上皮支皮瓣在修復(fù)足跟皮膚軟組織缺損中的優(yōu)缺點(diǎn) 唐舉玉[8]等通過對選擇修復(fù)足跟區(qū)皮瓣供區(qū)的研究發(fā)現(xiàn)，目前在對于修復(fù)足跟皮膚軟組織缺損的各種手術(shù)方式中，脛后動脈內(nèi)踝上皮支皮瓣具有質(zhì)地較好，耐磨，可部分修復(fù)感覺，術(shù)后皮瓣外形不臃腫，不影響穿鞋；皮支血管穿出點(diǎn)較穩(wěn)定，外徑較粗大，血供可靠，不犧牲重要血管，手術(shù)安全簡便；更為重要的是在足跟較小面積缺損修復(fù)中，供區(qū)可直接縫合；且不影響小腿主要肌群的活動。但對于大面積的缺損，供區(qū)需一期植皮，術(shù)后影響美觀。3.4 手術(shù)注意事項(xiàng)脛后動脈內(nèi)踝上皮支皮瓣在修復(fù)足跟皮膚軟組織缺損手術(shù)中應(yīng)注意以下幾方面：① 術(shù)前超聲多普勒血流探測儀探測脛后動脈內(nèi)踝上所有皮支的穿出點(diǎn)，以防止術(shù)中出現(xiàn)高位皮支穿出點(diǎn)。術(shù)中盡可能保留脛后動脈的各個肌間隙皮穿支，必要時可改攜脛后動脈的游離或逆行島狀皮瓣修復(fù)。② 解剖皮瓣一般先從血管蒂部開始，切開皮瓣后緣，明確脛后動脈皮穿支位置后，有利于更好的切取皮瓣。③ 由于該皮瓣血管蒂偏短，在蒂部設(shè)計時，盡量設(shè)計成球拍狀，采用明道轉(zhuǎn)移。④ 受區(qū)條件允許盡可能吻合大隱靜脈和隱神經(jīng)，有利于術(shù)后皮瓣管理和皮瓣感覺恢復(fù)。5 參考文獻(xiàn)1 王成琪，王劍利，張敬良，等．皮瓣移植術(shù)的回顧與展望．中華顯微外科雜志，2000，23(1)：12-14．2 魏長月，胡淑文，郭德亮．帶感覺神經(jīng)的小腿內(nèi)側(cè)皮瓣的解剖及其在修復(fù)足跟部軟組織缺損中的應(yīng)用 [J]．解剖與臨床，1998，3(3)：132-133．3 Latifoglu 0，Ayhan S，Yavuzer R，et a1． Distally based fasciecutaneous flaps in reconstructionof heel defects：pitfalls revisited [J]．Ann Hast Surg，2000，44(6)：682-683．4 黃繼鋒，王增濤，郭德量，等．脛后動脈皮支筋膜皮瓣的解剖及臨床應(yīng)用[J]．中國修復(fù)重建外科雜志， 2000，14(4)：218．5 張發(fā)惠，鄭和平，宋一平，等．內(nèi)踝區(qū)動脈網(wǎng)的顯微解剖與隱神經(jīng)營養(yǎng)血管遠(yuǎn)端蒂皮瓣的設(shè)計 [J]． 中國臨床解剖學(xué)雜志，2004，22(6)：568-572．6 Sasa M．Survival and blood flow evaluation of canine venous flaps [J]．Plast Reconstr Surg， 1988，82：319-322．7 宋建星．靜脈皮瓣術(shù)后早期微循環(huán)重建的實(shí)驗(yàn)研究 [J]．第二軍醫(yī)大學(xué)學(xué)報，1990，11：197-199．8 唐舉玉，李康華，劉俊，等． 內(nèi)踝上皮瓣修復(fù)足跟軟組織缺損 [J]．中國現(xiàn)代手術(shù)學(xué)雜志， 2006，10(1)14-

A randomized clinical trial of seventy-three patients with thoracolumbar burst fractures undergoing posterior shortsegment fixation with or without fusion demonstrated no differences in terms of clinical or radiographic outcomes, although two-thirds of the fusion patients had donor-site pain from the bone graft at the time of the latest follow-up37.一項(xiàng)包括73名胸腰椎爆裂骨折行后路短節(jié)段固定融合或不融合患者的隨機(jī)臨床試驗(yàn)表明，盡管2/3的融合患者在末次隨訪時有植骨供骨區(qū)疼痛表現(xiàn)，但臨床或影像學(xué)結(jié)果方面無差異。Pelvic and Acetabular Fractures骨盆和髖臼骨折The effect of pelvic fracture on patient mortality was analyzed in a review of >63,000 patients from two level-I trauma centers38. Pelvic fracture was significantly associated with mortality, with odds ratios for mortality of 2.4 and 2.0 at the two centers. These odds ratios were equivalent to the mortality odds ratio associated with an abdominal injury but were less than the odds ratios associated with hemodynamic shock, severe head injury, and advanced age. When analyzed in combination with the other aforementioned risk factors for mortality, pelvic fracture was independently associated with mortality with the exception of a patient in hemodynamic shock with a severe head injury.While pelvic fracture is associated with mortality, it is only one factor to be considered in the overall care of the polytraumatized patient38.回顧>63,000來自兩家I級創(chuàng)傷中心的患者，分析骨盆骨折在患者死亡率中的作用38。骨盆骨折與死亡率顯著相關(guān)，兩家中心的死亡率優(yōu)勢比分別為2.4和2.0。這些優(yōu)勢比與腹部損傷相關(guān)的死亡率優(yōu)勢比相當(dāng)，但小于血液動力學(xué)休克、嚴(yán)重腦損傷、老年患者相關(guān)的優(yōu)勢比。當(dāng)結(jié)合前面提到的風(fēng)險因素對死亡率進(jìn)行分析時，除了血液動力學(xué)休克和嚴(yán)重腦損傷外，骨盆骨折獨(dú)立與死亡率相關(guān)。盡管骨盆骨折與死亡率相關(guān)，它只是多發(fā)傷患者整體護(hù)理中要考慮的因素之一38。Two highlight papers from the OTA annual meeting reviewed the treatment of lateral compression injuries of the pelvis. Sembler et al. presented a series of 120 patients with unilateral lateral compression fractures of the sacrum that were impacted and minimally displaced (<10mm)39. All patients were immediately mobilized, were allowed weight- bearing as tolerated, and were followed radiographically until healing had occurred. Only one patient had a failure of nonoperative treatment, with 5 mm of additional sacral displacement associated with severe pain. The remaining 119 patients had uneventful healing with minimal further displacement. Nonoperative treatment, including early weight-bearing, is appropriate for impacted unilateral lateral compression-type sacral fractures39. Another presentation reviewed 117 patients from two level-I trauma centers who had sacral fractures resulting from high-energy trauma40. These sacral fractures were part of a lateral compression pelvic ring injury and were initially displaced <5 mm. Patients were also managed nonoperatively with weight-bearing as determined by the treating physician. In contrast to the first series, twenty-three of 117 fractures had further displacement (>5 mm) at the time of healing. It was noted that a complete sacral fracture, typified by a visible fracture line in the posterior cortex of the sacrum, was associated with displacement 50% of the time. A complete sacral fracture combined with bilateral superior and inferior rami fractures was associated with displacement 68% of the time. An incomplete sacral fracture with no rami fractures or unilateral ramus fracture did not displace. The results of these studies highlight the importance of careful analysis of the fracture pattern and patient characteristics prior to allowing immediate weight-bearing after lateral compression sacral fractures. Further research is needed to define functionally relevant residual sacral displacement to determine what role operative treatment has, if any, in certain lateral compression sacral fractures.2篇來自O(shè)TA年會的重要論文回顧了側(cè)方擠壓型骨盆損傷的治療。Sembler等研報道了一系列120名伴輕微移位(<10mm)側(cè)方擠壓型骶骨壓縮性骨折患者39。所有患者傷愈前可即時活動、允許可耐受的負(fù)重并行X線檢查。只有1名患者非手術(shù)治療失敗，其嚴(yán)重的疼痛與骶骨移位增加5mm相關(guān)。其余119名患者愈合良好，伴極輕微移位。包括早期負(fù)重的非手術(shù)治療，適用于單側(cè)擠壓型骶骨壓縮骨折39。另外一項(xiàng)報告回顧了來自2家I級創(chuàng)傷中心的117名高能創(chuàng)傷造成的骶骨骨折患者40。這些骶骨骨折為骨盆環(huán)側(cè)方擠壓傷，初始移位<5 mm。治療醫(yī)師決定對這些患者實(shí)行包括負(fù)重訓(xùn)練的非手術(shù)治療。與前一系列患者對比，117名患者中有23名在骨折愈合時移位>5 mm。以骶骨后方皮質(zhì)出現(xiàn)明顯骨折線為象征的完全性骶骨骨折，骨折移位發(fā)生率為50%。完全性骶骨骨折合并雙側(cè)上下恥坐骨支骨折，骨折移位發(fā)生率為為68%。不完全性骶骨骨折不伴有恥坐骨支或單側(cè)恥坐骨支骨折則無骨折移位。這些研究結(jié)果強(qiáng)調(diào)了仔細(xì)分析骨折類型和單側(cè)擠壓型骶骨骨折允許負(fù)重前患者特征的重要性。闡明與功能相關(guān)的骶骨殘留移位以確定手術(shù)治療在側(cè)方擠壓型骶骨骨折中的作用需要進(jìn)一步研究。The treatment of the geriatric acetabular fracture is controversial. In one surgeon’s experience, the proportion of these fractures occurring in patients more than sixty years of age increased 2.4 times when the period from 1980 to 1993(10% of cases) was compared with the period from 1993 to 2007 (24% of cases)41. Involvement of the anterior column is more frequent among older patients, who are also more likely to have separate quadrilateral plate fragments, roof impaction in association with anterior fractures, and both comminution and marginal impaction in association with posterior fractures41. These factors make internal fixation of acetabular fractures more problematic in the elderly. A review of patients with an age of more than sixty-five years who underwent treatment of acetabular fractures demonstrated a one-year mortality of 25%42. Of the surviving patients, 85% had been managed operatively, most with formal open reduction and internal fixation. Twenty-eight percent of the living patients had undergone eventual total hip replacement at an average of 2.5 years later. The patients who had open reduction and internal fixation had Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC) and SF-8 scores similar to population norms, although many had reported mild functional problems and some level of hip pain. A third study examined the results of a retrospective case series of patients (average age, seventy-two years) who were managed with combined open reduction and internal fixation and primary total hip arthroplasty43. Among the eighteen patients with at least one year of follow-up, there was only one acetabular failure requiring revision surgery, three weeks after the index procedure. At the time of the latest follow-up, the mean Harris hip score was 88 and radiographs showed minimal medial and vertical displacement of the cup, with no evidence of acetabular loosening. In appropriate patients, surgeons who are experienced in both techniques of internal fixation of the pelvis and arthroplasty can safely perform combined open reduction and internal fixation and total hip arthroplasty with minimal complications and can potentially avoid the need for a second procedure.老年髖臼骨折患者的治療存在爭議。以一名外科醫(yī)師的經(jīng)驗(yàn)，髖臼骨折在65歲以上患者中的發(fā)病率在1993~2007間(24%)較之1980~1993間(10%)增長了2.4倍41。老年患者中累計前柱更為常見，游離的四邊形骨折塊、髖臼頂壓縮與前柱損傷有關(guān)；粉碎性和邊緣嵌插折與后柱損傷有關(guān)41。這些因素使老年髖臼骨折患者的內(nèi)固定治療充滿爭議。一篇綜述證實(shí)，年齡≥65歲的髖臼骨折患者，接受治療后，1年死亡率為25%42。幸存的患者中85%行手術(shù)治療，大多數(shù)行切開復(fù)位內(nèi)固定術(shù)。28%的生存患者平均2.5年后行全髖關(guān)節(jié)置換術(shù)。盡管許多研究報告了輕微功能問題和一定程度的髖部疼痛，這些行切開復(fù)位內(nèi)固定的患者的Western Ontario and McMaster大學(xué)骨關(guān)節(jié)炎指數(shù)(WOMAC)和SF-8評分與常人標(biāo)準(zhǔn)類似。第三項(xiàng)研究驗(yàn)證切開復(fù)位內(nèi)固定合并全髖關(guān)節(jié)成形術(shù)病例的回顧性結(jié)果，患者平均年齡72歲43。18名患者隨訪至少1年，僅一名患者術(shù)后3周髖臼假體失敗需要翻修手術(shù)。末次隨訪時，Harris髖部評分為88分，X線片顯示髖臼杯輕微的向內(nèi)垂直移位，無證據(jù)顯示髖臼假體松動。對于適合的患者，對骨盆內(nèi)固定和關(guān)節(jié)成形術(shù)技術(shù)有經(jīng)驗(yàn)的醫(yī)師能夠安全地進(jìn)行切開復(fù)位內(nèi)固定和全髖關(guān)節(jié)成形術(shù)，且并發(fā)癥輕微，能夠避免二次手術(shù)。Fractures of the Proximal Part of the Femur股骨近端骨折Fractures of the proximal part of the femur impose an extremely large societal burden, and many studies have been presented or published in the past year that contribute to our overall understanding of the care of these complicated injuries.A recent meta-analysis in the Annals of Internal Medicine examined the mortality after hip fracture in >700,000 patients44. The relative risk of death from all causes in the first three months after hip fracture was 5.75 for women and 7.95 for men. The relative risk of death decreased dramatically over the first two years but continued to be elevated compared with age and sex-matched controls at ten years. Men continued to have a higher relative risk of mortality over time compared with women. A retrospective study of 97,894 patients in the Nationwide Inpatient Sample analyzed the effect of surgeon and hospital volume on morbidity and mortality after hip fracture45. The adjusted odds ratio for mortality for a low-volume surgeon (fewer than seven procedures per year) relative to a high-volume surgeon (more than fifteen procedures per year) was 1.24. A significant difference in mortality between low and high-volume hospitals was not found. Differences in morbidity were found between low and high-volume surgeons, with increased rates of pneumonia, decubitus ulceration, and transfusion requirements associated with low-volume surgeons. Similarly, increased rates of pneumonia, postoperative infection, and transfusion requirements were associated with low-volume hospitals.股骨近端骨折給社會帶來沉重的負(fù)擔(dān)。過去的一年，許多陳述或發(fā)表的研究有助于我們充分理解這種復(fù)雜損傷的診治問題。最近內(nèi)科學(xué)年鑒中一項(xiàng)meta分析調(diào)查了>700,000髖部骨折患者的死亡率44。在髖部骨折后最初3個月，所有原因引起的死亡相對風(fēng)險度為女性5.75，男性7.95。死亡相對風(fēng)險度在最初兩年顯著降低，但是傷后10年與性別和年齡均匹配的對照組相比，是持續(xù)上升的。與女性相比，男性死亡相對風(fēng)險度一直較高。一項(xiàng)對國家住院病人樣本中97,894名患者的回顧性研究分析了外科醫(yī)師和醫(yī)院規(guī)模對髖部骨折后并發(fā)癥發(fā)生率和死亡率的作用45。小規(guī)模醫(yī)院(每年少于7例)相對大規(guī)模醫(yī)院(每年超過15例)，其死亡率調(diào)整優(yōu)勢比為1.24。未發(fā)現(xiàn)小規(guī)模和大規(guī)模醫(yī)院間死亡率的顯著差異。患者并發(fā)癥發(fā)生率在小規(guī)模和大規(guī)模醫(yī)院的外科醫(yī)師間存在差異。肺炎、壓瘡、輸血需求發(fā)生率的增加與小規(guī)模醫(yī)院外科醫(yī)師相關(guān)。類似的，肺炎、術(shù)后感染、輸血需求發(fā)生率的增加與小規(guī)模醫(yī)院相關(guān)。The treatment of proximal femoral fractures, especially those of the femoral neck, remains a source of controversy, especially with regard to the role of primary arthroplasty. Recently, the ten-year follow-up results of a previously reported randomized trial comparing arthroplasty with internal fixation for the treatment of displaced femoral neck fractures were published46. Overall, 45.6% of the surviving patients who were managed with internal fixation had a failure of fracture treatment, but only four of ninety-two failures occurred between two and ten years. In comparison, 8.8% of the patients who were managed with arthroplasty had a failure of treatment, and five of seven failures occurred between two and ten years. These late failures in the arthroplasty group were in patients who had undergone total hip arthroplasty. Only 5.2% of the initial patients who were managed with arthroplasty experienced recurrent dislocation, with relatively equal numbers occurring after total hip arthroplasty and hemiarthroplasty.The mortality rate was the same for the arthroplasty and internal fixation groups at ten years, and no significant differences were noted between the groups with regard to hip pain when walking or with regard to reduced mobility secondary to hip symptoms.股骨近端骨折的治療，特別是股骨頸骨折尚存爭議，特別是關(guān)于初次關(guān)節(jié)成形術(shù)的作用。最近，一項(xiàng)先前報道過的對關(guān)節(jié)成形術(shù)和內(nèi)固定術(shù)治療移位的股骨頸骨折隨訪10年的隨機(jī)對照試驗(yàn)業(yè)已出版46?？偟膩碚f，45.6%行內(nèi)固定的幸存患者骨折治療失敗，92例失敗病例中僅有4例發(fā)生在2~10年。與之相對，8.8%行關(guān)節(jié)成形術(shù)的患者治療失敗，7例失敗病例中5例發(fā)生在2~10年。關(guān)節(jié)成形術(shù)組中這些遲發(fā)的失敗病例是行全髖關(guān)節(jié)成形術(shù)的患者。最初行關(guān)節(jié)成形術(shù)的患者中僅5.2%發(fā)生復(fù)發(fā)性脫位，與全髖關(guān)節(jié)成形術(shù)和半髖關(guān)節(jié)成形術(shù)后所發(fā)生比率相當(dāng)。關(guān)節(jié)成形術(shù)組和內(nèi)固定組10年死亡率相同，關(guān)于髖部活動性疼痛或關(guān)于繼發(fā)于髖部癥狀的關(guān)節(jié)活動度減少兩組間無顯著差異。Gjertsen et al. reviewed 4335 elderly patients from the Norwegian Hip Fracture Register who had a displaced femoral neck fracture and who had been managed with internal fixation or bipolar hemiarthroplasty and followed for a minimum of one year47. Mortality at one year was not significantly different between the internal fixation and hemiarthroplasty groups (27% compared with 25%). The reoperation rate was 22.6% for patients managed with internal fixation, compared with 2.9% for patients managed with hemiarthroplasty. Patients who had undergone hemiarthroplasty had better functional outcomes at one year as measured on the EQ-5D index score. These data further support hemiarthroplasty as being superior to internal fixation for the treatment of displaced femoral neck fractures in this patient population.Gjertsen等回顧來自挪威髖部骨折登記系統(tǒng)數(shù)據(jù)的4335名行內(nèi)固定術(shù)或半髖關(guān)節(jié)成形術(shù)治療的移位型股骨頸骨折老年患者，術(shù)后隨訪至少1年47。內(nèi)固定組與半關(guān)節(jié)成形術(shù)組1年死亡率無顯著差異(27% : 25%)。內(nèi)固定組二次手術(shù)率為22.6%，半關(guān)節(jié)成形術(shù)組二次手術(shù)率為2.9%。以EQ-5D指數(shù)評分評價患者功能結(jié)果，1年隨訪時，半關(guān)節(jié)成形術(shù)組更為良好。這些數(shù)據(jù)進(jìn)一步支持對于移位型股骨頸骨折老年患者的治療，半關(guān)節(jié)成形術(shù)優(yōu)于內(nèi)固定術(shù)。Two recent randomized trials compared hemiarthroplasty with or without cement for the treatment of femoral neck fracture. The first study randomized 400 patients to treatment with either a cemented (Thompson) or uncemented(Austin-Moore) stem48. Overall, patients who had a hemiarthroplasty with cement had less pain on the visual analog scale at eight weeks and a lower Charnley pain score at three, six, twelve, and twenty-four months. Patients who had a hemiarthroplasty with cement also did not experience as great a loss of mobility in comparison with patients who had undergone a hemiarthroplasty without cement. The second study, which included 223 patients, demonstrated very different results in association with the use of a more modern uncemented stem with a hydroxyapatite coating (Corail; DePuy)49. The Harris hip score was not found to be different between the group with the uncemented stem and the group with the cemented stem (SPECTRON; Smith & Nephew) at three and twelve months of follow-up. There also were no differences in terms of functional outcomes as measured with the EQ-5D index score at three and twelve months. The uncemented Austin-Moore stem should have little use in modern hip hemiarthroplasty, with its main application being as a “quick” endoprosthesis in a patient with minimal functional demands but in need of pain control. A study of hemiarthroplasty after hip fracture did not demonstrate significant differences in terms of blood loss, transfusion requirements, or seventy-two-hour postoperative hemoglobin levels between standard and minimally invasive approaches50. Better functional results were documented at two years postoperatively in patients managed with a standard approach.近期有兩項(xiàng)隨機(jī)試驗(yàn)對比了半關(guān)節(jié)成形術(shù)治療股骨頸骨折中使用或不使用骨水泥的效果。第一項(xiàng)研究包括隨機(jī)應(yīng)用骨水泥假體(Thompson)或非骨水泥假體(Austin-Moore)的400名患者48?？偟膩碚f，使用骨水泥的半關(guān)節(jié)成形術(shù)患者在第8周以目測類比評分法評價，疼痛較輕，Charnley疼痛評分在第3、6、12、24月較低。 與未使用骨水泥的半關(guān)節(jié)成形術(shù)患者相比，使用骨水泥的患者無嚴(yán)重關(guān)節(jié)活動度丟失。第二項(xiàng)研究包括223名患者，證實(shí)應(yīng)用更現(xiàn)代的羥基磷石灰涂層非骨水泥假體(Corail; DePuy)臨床結(jié)果顯著不同49。Harris髖部評分在非骨水泥假體組與骨水泥假體(SPECTRON; Smith & Nephew)組在隨訪3月和12月時無差異。以EQ-5D指數(shù)評分評價的功能結(jié)果在3月、12月亦無差異。Austin-Moore非骨水泥假體在現(xiàn)代髖部半關(guān)節(jié)成形術(shù)中較少使用，主要應(yīng)用于功能要求較低、需要控制疼痛要求“盡快”置換的患者。一項(xiàng)髖部骨折行半關(guān)節(jié)成形術(shù)的研究未證實(shí)標(biāo)準(zhǔn)入路與微創(chuàng)入路在失血量、輸血需求或術(shù)后72小時血紅蛋白水平方面存在顯著差異50。標(biāo)準(zhǔn)手術(shù)入路患者術(shù)后2年功能結(jié)果良好。Extracapsular fractures also have been a source of controversy, primarily related to the expanding role of cephalomedullary nails instead of sliding hip screws. Proponents of nailing techniques highlight the minimally invasive nature and improved biomechanical characteristics of nails. Proponents of sliding hip screws point out their familiar technique and their lower cost. A meta-analysis compared several minimally invasive approaches (intramedullary nailing, percutaneous plating, minimally invasive sliding hip screw placement, and external fixation) to traditional insertion of a sliding hip screw51. No significant differences were found between groups in terms of the rates of fixation failure or mortality. Although the relative risk of blood transfusion was lower in the combined minimally invasive group, the relative risk of blood transfusion associated with intramedullary nailing alone (four studies) was not significantly different from that associated with the standard sliding hip screw. A small randomized controlled trial comparing sliding hip screw placement via a minimally invasive technique (length of incision, 2.5 cm) with a standard incision (length of incision, 10 to 15 cm) was recently published52. Patients in the minimally invasive group had decreased blood loss and a decreased transfusion rate, with less pain and improved physical functioning on the third postoperative day. No differences were seen in terms of radiographic outcomes or functional scores at three months.囊外骨折也成為一個爭論的來源，最初是關(guān)于頭狀髓內(nèi)針取代髖部滑動螺釘不斷擴(kuò)大的作用。髓內(nèi)針技術(shù)的支持者強(qiáng)調(diào)髓內(nèi)針微創(chuàng)的本質(zhì)和改進(jìn)的生物力學(xué)特征。髖部滑動螺釘?shù)闹С终咧赋銎浼夹g(shù)成熟且價格低廉。一項(xiàng)mata分析將幾種微創(chuàng)術(shù)式(髓內(nèi)針植入術(shù)，經(jīng)皮鋼板固定術(shù)，微創(chuàng)髖部滑動螺釘植入術(shù)和外固定術(shù))與傳統(tǒng)髖部滑動螺釘植入進(jìn)行對比51。組間固定失敗率和死亡率方面無顯著差異。盡管輸血的相對風(fēng)險在微創(chuàng)組較低，與單獨(dú)髓內(nèi)針植入(第4項(xiàng)研究)相關(guān)的輸血相對風(fēng)險和傳統(tǒng)髖部滑動螺釘相比無顯著差異。一項(xiàng)對比通過微創(chuàng)技術(shù)(切口長度2.5cm)和標(biāo)準(zhǔn)切口(切口長度10~15cm)植入髖部滑動螺釘?shù)男⌒碗S機(jī)對照試驗(yàn)業(yè)已發(fā)表52。微創(chuàng)組患者失血量和輸血率均降低，術(shù)后第3日疼痛較輕，軀體功能改善。術(shù)后3月在影像學(xué)結(jié)果和功能評分方面無差異。A meta-analysis of Gamma nails compared with compression hip screws emphasized the decreasing rates of femoral fracture that have occurred with time, likely because of improvements in patient selection, surgical techniques, and the implants themselves53.一項(xiàng)對比γ釘和髖部壓力螺釘?shù)膍eta分析強(qiáng)調(diào)，可能由于患者選擇、外科技術(shù)和 植入物本身的改進(jìn)，術(shù)后股骨干骨折發(fā)生率逐漸降低53。Other Femoral Fractures其它股骨骨折Cannada et al. reported on a large series of high-energy femoral neck-shaft fractures54. In that study of 2897 patients with a femoral shaft fracture, the overall prevalence of associated femoral neck fracture was 3.2%; 88% of patients had injuries to another body system and 75% had other orthopaedic injuries.One-fourth of the femoral neck fractures were not identified preoperatively. Missed injuries occurred in 18% of the patients who had thin-cut computed tomography scans. Nonunion or malunion occurred in association with 12.1% of femoral neck fractures, and half of these cases were in patients who were diagnosed late. A high degree of vigilance is required to diagnose a femoral neck fracture, and even thin-cut computed tomography is not sufficient to make the diagnosis by itself in every case54.Cannada等報告一系列高能所致股骨頸-干骨折大量病例54。在這項(xiàng)包括2897名股骨干骨折患者的研究中，合并股骨頸骨折的發(fā)病率為3.2%；88%的患者合并其他系統(tǒng)損傷，75%合并其他部位骨科損傷。1/4的股骨頸骨折術(shù)前未做出明確診斷。薄層CT掃描的患者中18%發(fā)生漏診。股骨頸骨折患者12.1%發(fā)生骨不連或畸形愈合，其中一半患者屬診斷延誤。對股骨頸骨折的診斷要求高度的警覺，僅依靠薄層CT對所有病例做出診斷是不充分的54。In another study involving 1126 femoral shaft fractures that were treated with intramedullary nailing, forty-six patients with femoral nonunions (4% of the total number of cases) were compared with a matched control group of ninety-two patients with healed femoral fractures55. Open fracture and tobacco use were found to be predictive of nonunion. Interestingly,72% of patients who developed nonunions of femoral fractures had delayed weight-bearing as a consequence of other injuries. On the basis of the results of this study, the authors reported that they have become more aggressive with early weight-bearing whenever possible after intramedullary nailing of femoral shaft fractures.另外一項(xiàng)研究包括1126名股骨干骨折行髓內(nèi)針治療的患者，與對照組的92名股骨骨折完全愈合患者相比，46名患者發(fā)生骨不連(總病例數(shù)的4%)55。開放性骨折和吸煙是預(yù)示骨不連的誘因。有趣的是，72%的股骨骨折骨不連患者由于其它損傷而推遲負(fù)重練習(xí)?；谶@項(xiàng)研究的結(jié)果，作者稱，只要可能，他們將更為積極的主張股骨干骨折行髓內(nèi)針固定的患者早期負(fù)重訓(xùn)練。Controversy still exists among surgeons with regard to the relative benefits of antegrade versus retrograde nailing of the femur. A recent randomized study evaluated knee function after antegrade and retrograde femoral nailing56. No differences in knee flexion (132° and 134° in the antegrade and retrograde groups, respectively), Lysholm scores, or isokinetic muscle performance were noted between the groups. Older patients also tended to have lower Lysholm scores and decreased knee flexion compared with younger patients, irrespective of treatment.關(guān)于股骨順行性髓內(nèi)針對比逆行性髓內(nèi)針的相對益處，在外科醫(yī)師間尚存爭議。最近一項(xiàng)隨機(jī)研究評估了順行性和逆行性股骨髓內(nèi)針術(shù)后膝關(guān)節(jié)功能56。組間在膝關(guān)節(jié)屈曲(順行組和逆行組分別為132°和134°)、Lysholm評分、等功能肌肉活動能力方面無差異。無論何種治療，老年患者與年輕患者相比，Lysholm評分較低，膝關(guān)節(jié)屈曲受限。Unlike femoral shaft fractures, there has been little controversy regarding distal femoral fractures, for which locking plates seem to have been widely adopted. Ricci et al. analyzed the risk factors associated with failure of locked plating for the treatment of distal femoral fractures in a study of 305 patients57. Overall, 9% of patients developed a nonunion, whereas another 6% required a planned staged bone-grafting procedure. A history of diabetes mellitus was the only independent predictor of nonunion. Implant failures occurred in 8% of cases; 60% of failures occurred in the proximal fragment. Independent predictors of implant failure included diabetes, an OTA A3 fracture pattern, body mass index, a stainless steel plate, and a shorter plate length. Proximal implant failure was less likely when plate length was ten holes or longer, when eight holes or more covered the proximal diaphyseal fragment, when more proximal screws were utilized, and when the screw density (percentage of screw holes filled) was <60% in the proximal portion of the plate57. These data provide useful guidelines for surgeons using locked plates in the distal part of the femur.與股骨干骨折不同，關(guān)于股骨遠(yuǎn)端骨折的爭議較少，鎖定鋼板看似已被廣泛采用。Ricci等在一項(xiàng)包括305名患者的研究中分析了與鎖定鋼板治療股骨遠(yuǎn)端骨折相關(guān)的風(fēng)險因素57?？偟膩碚f，9%的患者發(fā)生骨不連，而另外6%患者需要有計劃的分階段植骨。糖尿病史是骨不連唯一獨(dú)立預(yù)測因子。8%的病例植入物失敗，60%發(fā)生在近端骨折部分。植入物失敗獨(dú)立預(yù)測因子包括糖尿病史、OTA A3型骨折、人體質(zhì)量指數(shù)、不銹鋼板和鋼板長度過短。當(dāng)鋼板長度為10孔或以上時、骨折近端骨干覆蓋鋼板達(dá)8孔或以上長度時、近端使用更多螺釘時、鋼板近端部分螺釘密度(螺釘數(shù)占螺釘孔數(shù)的百分比) <60%時，近端植入物失敗很少發(fā)生57。這些數(shù)據(jù)對外科醫(yī)師應(yīng)用股骨遠(yuǎn)端鎖定鋼板提供了有用的指導(dǎo)。Tibia and Tibial Plateau脛骨和脛骨平臺Several recent studies evaluated compartment syndrome associated with tibial fractures. Park et al. reviewed all of the tibial fractures that were treated over a thirty-four-month period at a single level-I trauma center58. The authors determined the rate of compartment syndrome on the basis of anatomic location. Tibial shaft fractures were associated with the highest rate of compartment syndrome (8.1%), followed by proximal tibial fractures (1.6%). "Decreasing age" was the only factor that was found to independently predict compartment syndrome. However, others have reported much higher rates of compartment syndrome in association with proximal tibial fractures59. Stark et al. retrospectively reviewed sixty-seven bicondylar tibial plateau fractures and seventeen medial condylar fracture-dislocations that were all treated with initial application of a spanning external fixator within the first fortyeight hours59. The overall rate of compartment syndrome was 27%: the rate was 53% (nine of seventeen) in patients with medial condylar fracture-dislocations and 18% (nine of fifty) in patients with bicondylar tibial plateau fractures. Of the nine patients with medial condylar fracture-dislocations who developed compartment syndrome, six (67%) developed compartment syndrome after the application of an external fixator. Another study highlighted the apparent variation in the diagnosis of compartment syndrome in patients with tibial fractures60. Among 386 tibial shaft fractures that were treated by seven orthopaedic surgeons with similar training, compartment syndrome was diagnosed in 10.4% of the cases. However, the rate of diagnosis of compartment syndrome varied widely by surgeon, ranging from 2% to 24%. This variation in diagnosis also may help to explain the large differences in the rate of compartment syndrome found throughout the literature.The authors also found that male sex was an independent predictor of compartment syndrome.最近若干研究評估了與脛骨骨折相關(guān)的骨筋膜室綜合癥。Park等回顧了一家單獨(dú)I級創(chuàng)傷中心脛骨骨折治療超過34月的全部病例58。作者確定了基于解剖位置的骨筋膜室綜合癥發(fā)病率。脛骨干骨折導(dǎo)致骨筋膜室綜合癥發(fā)生率最高(8.1%)，脛骨近端骨折次之(1.6%)。“年齡遞減”是單獨(dú)預(yù)示骨筋膜室綜合癥的唯一因素。然而，其他人報告稱，脛骨近端骨折引起骨筋膜室綜合癥發(fā)生率更高59。Stark等回顧了67例脛骨平臺雙髁骨折和17例內(nèi)側(cè)髁骨折-脫位病例，所有患者均于傷后48小時內(nèi)行外固定架治療59。骨筋膜室綜合癥發(fā)生率為27%：53%(9/17)為內(nèi)側(cè)髁骨折-脫位；18%(9/50)為脛骨平臺雙髁骨折。9名內(nèi)側(cè)髁骨折-脫位合并骨筋膜室綜合癥患者中，6名(67%)發(fā)生在外固定架治療后。另一項(xiàng)研究突出強(qiáng)調(diào)在脛骨骨折患者中診斷骨筋膜室綜合癥方面的明顯不同60。7名受過相似訓(xùn)練的骨科醫(yī)師治療386名脛骨干骨折，10.4%的患者診斷為骨筋膜室綜合癥。然而，外科醫(yī)師對骨筋膜室綜合癥的診斷率差異較大，范圍在2% ~24%。這些診斷上的差異可能有助于解釋文獻(xiàn)中骨筋膜室綜合癥發(fā)生率的不同。作者發(fā)現(xiàn)患者為男性是骨筋膜室綜合癥一項(xiàng)獨(dú)立預(yù)測因素。A new assessment tool for the evaluation of tibial fracture-healing was recently introduced61. The Radiographic Union Score for Tibial Fractures (RUST) is a scoring system that is based on radiographs and is designed to standardize the assessment of tibial fracture-healing. The scoring is based on the presence or absence of a fracture line as well as the presence or absence of callus and, if present, whether the callus is bridging. Each of the four cortices is assessed independently, and a total score is then calculated on the basis of the sum of the scores for each cortex. Intraobserver and interobserver reliability were found to be "substantial" (intraclass correlation coefficient, 0.88 and 0.86, respectively). Pending further evaluation, the RUST score may ultimately help to standardize clinical treatment as well as orthopaedic research.最近，引進(jìn)了一項(xiàng)新的脛骨骨折愈合評估方法。脛骨骨折影像學(xué)愈合評分(RUST)是一個基于放射學(xué)的評分系統(tǒng)，設(shè)計用來將脛骨骨折愈合評估標(biāo)準(zhǔn)化。評分基于骨折線在影像學(xué)表現(xiàn)上消失，同時有無骨痂表現(xiàn)，如果出現(xiàn)骨痂，是否為橋接性。4層皮質(zhì)的每一層均獨(dú)立評估，每層皮質(zhì)分?jǐn)?shù)總和相加即為總分。觀察者內(nèi)和觀察者間可信度被認(rèn)為是“真實(shí)的”(同類相關(guān)系數(shù)各自為0.88和0.86)。經(jīng)過進(jìn)一步的評估，RUST評分可能最終有助于將臨床治療和骨科研究標(biāo)準(zhǔn)化。A recent retrospective study compared the efficacy of intramedullary nailing and percutaneous locked plating for the treatment of extra-articular proximal tibial fractures62. The two groups were slightly different, with a greater proportion of open fractures in the nailing group than in the plating group(55% compared with 35%). There was a trend (p = 0.10) toward higher union rate after the index procedure in the plating group as compared with the nailing group (94% compared with 77%). Although this difference would be of clinical importance if true, the difference in union rates could not be "proved" because of the small number of patients.Interestingly, all closed fractures in both groups healed after the index procedure. Apex anterior malalignment of >5° was found after 36% of the nailing procedures, although additional fracture-reduction techniques (such as blocking screws) were commonly utilized, indicating that malreduction continues to be a complication of nailing of proximal tibial fractures.In contrast, apex anterior malalignment was present after 15% of the plating procedures. There was a higher rate of symptomatic implant removal in the plating group than in the nailing group (15% compared with 5%), but this difference also did not reach significance because of the small number of patients. Although the authors concluded, on the basis of their data, that no overwhelming advantage exists for either nailing or plating for the treatment of extra-articular proximal tibial fractures, they did highlight a number of potentially important clinical differences that require validation in prospective trials that are under way.最近一項(xiàng)回顧性研究對比髓內(nèi)針和經(jīng)皮鎖定鋼板治療關(guān)節(jié)外脛骨近端骨折的有效性62。兩組結(jié)果存在輕微差異，髓內(nèi)針組較鎖定鋼板組開放性骨折所占比率更大(55% : 35%)。鎖定鋼板組較之髓內(nèi)針組(94% : 77%)術(shù)后骨不連發(fā)生率更高(p = 0.10)。盡管這些差異(如果真實(shí))有重要的臨床意義，但是由于患者樣本小，骨不連發(fā)生率的差異不能被證明。盡管另外的骨折復(fù)位技術(shù)(比如鎖定螺釘)常規(guī)應(yīng)用，36%的患者髓內(nèi)針術(shù)后發(fā)現(xiàn)頂點(diǎn)前方力線不穩(wěn)>5°，表明復(fù)位不良繼續(xù)成為髓內(nèi)針治療脛骨近端骨折的并發(fā)癥之一。與之相對，鎖定鋼板術(shù)后頂點(diǎn)前方力線不穩(wěn)占15%。有癥狀的植入物移位發(fā)生率鎖定鋼板組較髓內(nèi)針組更高(15% : 5%)，但由于患者樣本較小，這種差異并不顯著。盡管作者基于他們的數(shù)據(jù)得出結(jié)論，在治療關(guān)節(jié)外脛骨近端骨折方面髓內(nèi)針和鎖定鋼板均無巨大的優(yōu)勢，他們也強(qiáng)調(diào)大量潛在的重要臨床差異需要前瞻性試驗(yàn)驗(yàn)證，并已著手進(jìn)行。Ankle踝部The Lauge-Hansen classification represents the standard nomenclature describing ankle fractures and has been the subject of much recent work attempting to determine whether its mechanistic descriptions actually produce the expected injuries. In one study, twenty-three fresh-frozen cadavers were tested with the foot in a position of pronation63. One group had a pure external rotation force applied, whereas the other group had a combined external rotation-abduction force applied.Short oblique fractures of the distal part of the fibula, typically described as supination-external rotation injuries, were seen in both groups. The classic pronation-external rotation fracture, a proximal fibular fracture occurring after a medial-sided injury, occurred only after the addition of an abduction force.The authors concluded that fractures that are typically described as supination- external rotation injuries could be produced with the foot in the pronated position and that the abduction moment may be an important factor in determining the fracture pattern63. A study presented at the 2009 OTA Annual Meeting utilized video clips of ankle injuries publicly available on the Internet (youtube.com) to analyze the accuracy of the Lauge-Hansen classification system for predicting the actual mechanism of injury64. The authors determined the position of the foot and the deforming force from the injury video and compared the documented mechanism of injury with the resultant radiographic fracture pattern. While video clips judged to show supination-adduction injuries corresponded to supination-adduction radiographic patterns 100% of the time (five of five), video clips judged to show pronation-external rotation corresponded to the classic pronation-external rotation radiographic pattern only 50% of the time (three of six). Lauge-Hansen分類法代表了描述踝部骨折的標(biāo)準(zhǔn)命名法，最近許多研究將其作為主題，試圖確定是否會在實(shí)際中發(fā)生其機(jī)械性描述所預(yù)期的損傷。在一項(xiàng)研究中，23具新鮮冷凍尸體在足旋前位置下進(jìn)行測試63。一組單純施以外旋力，而另一組施以外旋-外展力。在兩組均出現(xiàn)腓骨遠(yuǎn)端短的斜行折，典型描述為旋后-外旋性損傷。典型的旋前-外旋骨折即腓骨近端骨折發(fā)生在內(nèi)踝損傷之后，并且僅在外展力作用下發(fā)生。作者認(rèn)為，典型描述為旋后-外旋性損傷的骨折在足旋前位時發(fā)生，瞬間外展力可能是決定骨折類型的重要因素63。一項(xiàng)在2009 OTA年會上提出的研究利用在互聯(lián)網(wǎng)(youtube.com)可用的踝部損傷視頻剪輯分析Lauge-Hansen分類系統(tǒng)預(yù)測實(shí)際損傷機(jī)制的準(zhǔn)確性64。作者從損傷視頻確定足的位置和變形力，對比記錄的損傷機(jī)制與結(jié)合影像學(xué)的骨折類型。當(dāng)視頻剪輯顯示為旋后-內(nèi)收型損傷，與旋后-內(nèi)收影像學(xué)類型100%相符(5/5)，當(dāng)視頻剪輯顯示為旋前-外旋性損傷，與標(biāo)準(zhǔn)的旋前-外旋影像學(xué)類型僅50%相符(3/6)。In recent years, the posterior malleolus has received more attention. One study assessed the reliability of radiographs to adequately evaluate trimalleolar ankle fractures65. Twenty-two patients with trimalleolar ankle fractures were reviewed by eight experienced orthopaedic traumatologists. Intraobserver reproducibility, interobserver reliability, and accuracy were considered to be "good" only when considering the size of the posterolateral fragment. Other characteristics of the fracture, including extension of the fracture line into the posteromedial corner of the plafond, the presence of loose osteochondral fragments, and the presence of impaction, failed to display reproducibility and reliability and also lacked accuracy when compared with the computed tomography scan. The authors advocated routine preoperative computed tomography scanning for all trimalleolar ankle fractures, although no data were presented to indicate that the routine use of computed tomography would improve outcomes.近些年，后踝引起更多的注意。一項(xiàng)研究評價了X線平片充分評估三踝骨折的可靠性65。8名有經(jīng)驗(yàn)的骨科創(chuàng)傷學(xué)專家回顧了22名三踝骨折患者。只有考慮到后外側(cè)骨折塊大小時，觀察者內(nèi)可重復(fù)性、觀察者間可信度和準(zhǔn)確性被認(rèn)為良好。與CT掃描相比，骨折的其它特征，包括骨折線延伸至后內(nèi)側(cè)面，骨軟骨骨折塊粉碎，骨折塊有壓縮表現(xiàn)，無法顯示可重復(fù)性和可靠性且缺少準(zhǔn)確性。盡管沒有數(shù)據(jù)表明常規(guī)性CT掃描可改善臨床結(jié)果，作者仍主張對所有三踝骨折患者常規(guī)行術(shù)前CT掃描。Two studies addressed the short and long-term outcomes of ankle fractures. A study of 57,183 patients who were managed in California outlined the complication rates associated with the surgical treatment of ankle fractures66. Short-term complications, defined as readmission within ninety days after surgery, were highest for patients with complicated diabetes and peripheral vascular disease. Patients with complicated diabetes had an increased risk of wound infections (7.71%) and revision open reduction and internal fixation (4.43%) in the first ninety days. The same study also demonstrated that patients with a trimalleolar ankle fracture had an odds ratio of 2.07 for requiring an ankle fusion or replacement within five years as compared with patients with isolated lateral malleolar fractures. Hospital volume did not appear to be predictive of short or long-term complications. A Swiss study compared long-term outcomes after operative treatment of supination-external rotation type-IV ankle fractures with a medial malleolar fracture and supination-external rotation type-IV ankle fractures with an intact medial malleolus and a partially or completely torn deltoid ligament67. After a mean duration of follow-up of thirteen years, patients with a supination-external rotation type-IV ankle fracture with a partially or completely torn deltoid ligament did better functionally than those with a medial malleolar fracture.兩項(xiàng)研究關(guān)注踝部骨折的短期和長期臨床結(jié)果。一項(xiàng)包括在California治療的57183名患者的研究描述了與踝部骨折手術(shù)治療相關(guān)的并發(fā)癥發(fā)生率66。短期并發(fā)癥確定為術(shù)后90天內(nèi)再次入院，在復(fù)雜型糖尿病和周圍血管疾病患者中最高發(fā)。在最初90天，復(fù)雜型糖尿病患者增加了傷口感染 (7.71%)和切開復(fù)位內(nèi)固定翻修(4.43%)的風(fēng)險。同樣的研究證實(shí)，三踝骨折與單純外踝骨折相比，術(shù)后5年踝關(guān)節(jié)融合或置換優(yōu)勢比為2.07。醫(yī)院規(guī)模不能成為短期或長期臨床結(jié)果的預(yù)測因子。一項(xiàng)瑞士的研究對比了旋后-外旋IV型踝部骨折合并內(nèi)踝骨折患者與內(nèi)踝正常的旋后-外旋IV型踝部骨折合并部分或完全三角韌帶撕裂患者的長期臨床結(jié)果67，平均隨訪13年，旋后-外旋IV型踝部骨折合并部分或完全三角韌帶撕裂患者功能結(jié)果優(yōu)于合并內(nèi)踝骨折患者。The treatment of ankle syndesmosis injuries continues to be a source of debate, and several studies on this topic were presented or published in the past year. A retrospective study of 347 ankle fractures revealed that patients who required syndesmotic fixation had worse outcomes on the Short Musculoskeletal Function Assessment (SMFA) Dysfunction Index and American Orthopaedic Foot and Ankle Society (AOFAS) score at both six months and one year as compared with patients with ankle fractures not requiring syndesmotic stabilization68. A study presented at the 2009 OTA meeting analyzed the functional consequences of syndesmotic malreduction69. Sixty-eight patients who had undergone syndesmotic stabilization more than two years previously underwent clinical assessment and bilateral computed tomography of the ankle. Overall, 39.1% of syndesmotic injuries were found to be malreduced. The patients with malreduced syndesmotic injuries scored significantly lower on both the SMFA and Olerud and Molander questionnaires. On the basis of these data, the authors recommended direct visualization of the syndesmosis, although they offered no evidence that such an approach would have a different outcome. In another study, the syndesmosis was directly visualized and reduced in all cases, although stabilization was performed in several ways (open reduction and internal fixation of a posterior malleolar fragment, locking syndesmotic screw fixation, or combination of the two)70. The authors compared their radiographic results with those for a historic control group of patients from the same institution who had had fluoroscopic assessment of reduction and found significant radiographic improvement (malreduction rate,16% compared with 52%)70.踝部韌帶聯(lián)合損傷繼續(xù)成為討論的根源，在過去一年，關(guān)于此主題已提出或發(fā)表諸多研究。一項(xiàng)包括347名踝部骨折患者的研究顯示，需要聯(lián)合韌帶固定的患者，術(shù)后6月和1年在短期骨肌肉功能評估(SMFA)功能障礙指數(shù)和美國足踝骨科協(xié)會(AOFAS)評分結(jié)果方面，與不需要穩(wěn)定韌帶聯(lián)合的患者相比較差68。在2009 OTA會議提出的一項(xiàng)研究分析了韌帶聯(lián)合復(fù)位不良導(dǎo)致的功能結(jié)果69。68名之前接受踝關(guān)節(jié)臨床評估和雙向CT掃描的患者，超過2年后，韌帶聯(lián)合仍穩(wěn)定。總的來說，39.1%的韌帶聯(lián)合損傷后復(fù)位不良。韌帶聯(lián)合損傷復(fù)位不良患者在SMFA、Olerud和Molander問卷評分方面現(xiàn)顯著降低?；谶@些數(shù)據(jù)，作者建議術(shù)中直接顯露韌帶聯(lián)合，盡管未提供此種方式引起不同結(jié)果的證據(jù)。另外一項(xiàng)研究中，在所有病例中均直接顯露韌帶聯(lián)合并復(fù)位，盡管可以通過多種方式(后踝骨折塊切開復(fù)位內(nèi)固定，韌帶聯(lián)合鎖定螺釘固定，或二種術(shù)式聯(lián)合)穩(wěn)定韌帶聯(lián)合70。作者將影像學(xué)結(jié)果與同一機(jī)構(gòu)的既往在X線透視下復(fù)位評估的患者作為對照組相對比，發(fā)現(xiàn)影像學(xué)結(jié)果顯著改善(復(fù)位不良發(fā)生率16% : 52%)70。Much debate continues about the management of screws that are used to stabilize the syndesmosis. Miller et al. reported the necessity of removing locked syndesmotic screws in a series of twenty-five patients who had undergone stabilization of a syndesmotic injury with two locking quadricortical screws through a locking third tubular plate71. The syndesmotic implant was routinely removed at four months, and patients experienced immediate improvement in the objective range of motion and improvement in functional scores71. Two other studies, involving the use of traditional cortical screws, did not support the routine removal of all syndesmotic screws. In a retrospective review, patients with a "broken" syndesmotic screw had higher AOFAS scores than patients with an "intact" syndesmotic screw after a mean duration of follow-up of thirty months72. In that study, 3.5-mm screws were used, but the number of screws and the number of cortices purchased varied, and loose screws were included in the "intact" syndesmotic screw group. In another retrospective study, the outcomes for patients with loose screws or broken screws were compared with those for patients whose screws were intact and patients whose screws had been removed73. A variety of screw configurations were used, which limits the interpretation of the results.In general, functional scores were lower for patients who had intact screws as compared with those who had loose or broken screws or who had undergone screw removal. The authors concluded that while their data did not support the routine removal of loose or broken screws, there may be a role for the removal of intact syndesmotic screws. Finally, a follow-up study of a previously reported randomized clinical trial comparing quadricortical with tricortical syndesmotic fixation was published74. Forty-eight of the original sixty-four patients were evaluated after an average duration of follow-up of 8.4 years. The patients had syndesmosis stabilization with either a single 4.5-mm quadricortical screw or two 3.5-mm tricortical screws. At the time of follow-up, no differences were detected in functional scores between the two groups. Interestingly, patients who had a difference in syndesmotic width of ≥1.5mm(signifying a malreduction or loss of initial reduction) on computed tomography as compared with the contralateral ankle tended to have worse functional outcomes on the modified AOFAS score (p = 0.056). Interpretation of these studies is difficult as different screw sizes, numbers, and modes of fixation were used.關(guān)于應(yīng)用螺釘穩(wěn)定韌帶聯(lián)合方面存在諸多爭論。Miller等報告了一系列25名應(yīng)用2枚鎖定螺釘和1/3管狀鎖定板經(jīng)四層皮質(zhì)固定以穩(wěn)定韌帶聯(lián)合損傷的患者，認(rèn)為有必要取出韌帶聯(lián)合鎖定螺釘71。韌帶聯(lián)合植入物常規(guī)于術(shù)后4個月取出，患者在客觀運(yùn)動范圍和功能評分方面可即時獲得改善71。另外兩項(xiàng)研究，包括使用傳統(tǒng)皮質(zhì)骨螺釘，不支持常規(guī)取出所有韌帶聯(lián)合螺釘。一篇回顧性綜述稱，平均隨訪30月后，韌帶聯(lián)合螺釘斷裂的患者AOFAS評分高于韌帶聯(lián)合螺釘完整的患者72。在研究中，使用3.5mm螺釘，但螺釘數(shù)目和皮質(zhì)層數(shù)各異，螺釘松動亦包括在螺釘完整組內(nèi)。另一項(xiàng)回顧性研究中，對比螺釘松動或斷裂患者與螺釘完整或螺釘已取出患者臨床結(jié)果73。多種形態(tài)螺釘?shù)氖褂茫拗屏私Y(jié)果的闡明。通常，螺釘完整患者功能評分低于螺釘松動、斷裂或已取出患者。作者認(rèn)為，他們的數(shù)據(jù)并不支持常規(guī)取出松動或斷裂的螺釘，這也許在決定是否取出完整的韌帶聯(lián)合螺釘方面有一定作用。最后，一項(xiàng)對先前報道的對比4層與3層皮質(zhì)固定的隨機(jī)臨床試驗(yàn)隨訪性研究已發(fā)表74。最初的64名患者中48名獲得隨訪，平均8.4年?；颊呤褂?枚4.5mm固定4層皮質(zhì)的螺釘或2枚3.5mm固定3層皮質(zhì)的螺釘均獲得韌帶聯(lián)合穩(wěn)定。隨訪時，2組患者功能評分無差異。有趣的是，患者CT影像上韌帶聯(lián)合寬度較之對側(cè)踝關(guān)節(jié)差異≥1.5mm(預(yù)示著復(fù)位不良或最初復(fù)位失敗)時，功能結(jié)果的修正AOFAS評分更差(p = 0.056)。由于不同的螺釘大小、數(shù)量和固定方式，使得這些研究難以被完全闡明。A recent systematic review of nine Level-I or II studies addressed the effect of early mobilization on the outcome of operative treatment of ankle fractures75. There was significantly greater range of motion at the time of early follow-up (nine and twelve weeks) in the early-motion group. However, this difference in range of motion was not significant at one year.Patients in the early-motion group returned to work earlier, and there also was a trend (p = 0.12) toward decreased rates of deep vein thrombosis in the early-motion group. Patients in the early-motion group did have a higher rate of infection than those who were managed with immobilization75.最近一項(xiàng)包括9項(xiàng)I級或II級研究的系統(tǒng)性回顧，報道了早期活動對踝部骨折手術(shù)治療結(jié)果的影響75。在早期隨訪時(9~12周)，早期活動組踝關(guān)節(jié)活動范圍顯著改善。然而，在1年時，活動范圍的差異已不明顯。早期活動組患者能夠更早的返回工作崗位，且深靜脈血栓發(fā)生率亦呈下降趨勢(p = 0.12)。早期活動組患者較之制動患者有著更高的感染發(fā)生率75。Recently reported data suggest that the location and depth of intra-articular lesions associated with ankle fractures predict functional outcomes76. Patients who underwent operative treatment of an ankle fracture had intra-articular pathology assessed intraoperatively via arthroscopy, and the long-term outcome for a subset of patients was documented at a mean of 12.9 years. Overall, 81% of patients had cartilage injury noted during arthroscopy, with the most common site being the talus. The odds ratio of having any cartilage injury and an AOFAS score of <90 was 5.0. The depth of the lesion and the location of the lesion were found to be significant predictors of later osteoarthritis. The odds ratio of having a deep lesion located on the anterior aspect of the talus and an AOFAS score of <90 was 12.3. The authors did not find a correlation between the number of lesions and a worse functional outcome.最近報道的數(shù)據(jù)提示，與踝關(guān)節(jié)骨折相關(guān)的關(guān)節(jié)內(nèi)損傷位置和深度可預(yù)測功能結(jié)果76。踝關(guān)節(jié)骨折行手術(shù)治療患者應(yīng)用關(guān)節(jié)鏡術(shù)中評估關(guān)節(jié)內(nèi)病理狀況，一組患者的臨床結(jié)果平均記錄12.9年?？偟膩碚f，關(guān)節(jié)鏡下可發(fā)現(xiàn)81%患者合并軟骨損傷，最常發(fā)生的部位是距骨。存在任何軟骨損傷和AOFAS評分<90的優(yōu)勢比為5.0。損傷的深度和位置是后期骨性關(guān)節(jié)炎的重要預(yù)測因子。損傷位置深、距骨前方損傷和AOFAS評分<90的優(yōu)勢比為12.3。作者未發(fā)現(xiàn)損傷的數(shù)量與較差的功能結(jié)果間存在相關(guān)性。Foot足Several studies regarding the treatment of calcaneal fractures were reported or presented during the past year. Potter and Nunley presented the long-term functional outcomes for a large cohort of patients with operatively treated calcaneal fractures who were evaluated at a median of 12.8 years77.Eighteen percent of patients reported having had a subsequent operation, with the most common reason being pain at the site of surgery due to the implant. Only two patients (3%) had gone on to subtalar arthrodesis. The mean adjusted AOFAS score was 65.4, and no differences were noted when patients were stratified on the basis of Workers’ Compensation status. A difference was noted in two of the three functional scores when patients were stratified on the basis of the mechanism of injury. Patients who sustained a calcaneal fracture secondary to a fall had higher functional outcome scores than did patients who sustained a fracture secondary to a motor-vehicle accident.過去一年間，若干關(guān)于根骨骨折治療的研究已報道或提出。Potter和Nunley介紹了大量手術(shù)治療的根骨骨折患者平均隨訪12.8年的功能結(jié)果77。報道稱18%的患者經(jīng)歷再次手術(shù)，最常見的原因是內(nèi)植物導(dǎo)致手術(shù)部位疼痛。僅2名(3%)患者施行了距下關(guān)節(jié)融合術(shù)。平均修正AOFAS評分為65.4分，當(dāng)患者基于勞工賠償身份分級時無差異。當(dāng)患者基于損傷機(jī)制分級時，3項(xiàng)功能評分中有2項(xiàng)存在差異。高處墜落致跟骨骨折患者功能評分高于交通事故引起跟骨骨折患者。A randomized trial was conducted to evaluate the effectiveness of calcium phosphate bone-void filler for the treatment of displaced intra-articular calcaneal fractures78. Open reduction and internal fixation plus an inj ectable calcium phosphate was compared with open reduction and internal fixation alone. While the Bohler angle decreased over time in both treatment groups, the decrease was significantly greater in the open reduction and internal fixation alone group at six months and one year of follow-up. While the group that had been managed with open reduction and internal fixation plus calcium phosphate maintained the immediate postoperative Bohler angle to a greater extent than did the group that had been managed with open reduction and internal fixation alone, this maintenance did not translate into improved functional outcomes. No differences were detected between the two groups in terms of the SF-36 or the Lower Extremity Measure (LEM) at six months and one year. No differences were detected between the two groups in terms of the pain scale at two years.一項(xiàng)隨機(jī)試驗(yàn)評估了磷酸鈣骨空隙填充劑治療有移位的關(guān)節(jié)內(nèi)跟骨骨折的有效性78。切開復(fù)位內(nèi)固定+注射磷酸鈣與單獨(dú)切開復(fù)位內(nèi)固定相對比。兩組患者Bohler角均逐漸減小，隨訪6月和1年時，單獨(dú)切開復(fù)位內(nèi)固定組患者Bohler角減小更為明顯。與單獨(dú)切開復(fù)位內(nèi)固定組相比，切開復(fù)位內(nèi)固定+注射磷酸鈣組患者很大程度上維持了術(shù)后即刻Bohler角，但這種維持并未能改善功能結(jié)果。在6月和1年時，兩組患者在SF-36和下肢測量法(LEM)方面無差異。2年時，兩組患者疼痛程度方面無差異。Two studies evaluated subtalar arthrodesis following a calcaneal fracture. One study highlighted the impact of the initial treatment of calcaneal fractures on subsequent subtalar fusion79. Patients who were initially managed nonoperatively required distraction subtalar arthrodesis tailored to the type of malunion that was present. Patients who were initially managed with open reduction and internal fixation were able to be managed with in situ subtalar arthrodesis. The two groups were compared after a mean duration of follow-up of more than sixty months. Patients who initially underwent open reduction and internal fixation had a significantly lower rate of infection and had significantly better functional outcomes (Maryland Foot Score and the AOFAS ankle-hindfoot score). Last, the intermediate-to-long-term results of primary subtalar fusion for nonreconstructible intra-articular calcaneal fractures were reported80. Over a seventeen-year period, thirty-five such fractures (all of which were classified as Sanders type-III or IV) were treated with combination open reduction and internal fixation/primary subtalar fusion. Fifteen patients were available for follow-up at a mean of 9.8 years. The mean AOFAS ankle-hindfoot score at the time of follow-up was 79.8. Talocalcaneal height was found to be associated with functional outcome scores.兩項(xiàng)研究評估了跟骨骨折行距下關(guān)節(jié)融合術(shù)。第一項(xiàng)研究強(qiáng)調(diào)跟骨骨折初次治療對接下來距下關(guān)節(jié)融合的影響79。根據(jù)表現(xiàn)出來的畸形愈合類型，最初行非手術(shù)治療的患者需要行撐開距下關(guān)節(jié)融合術(shù)。最初行切開復(fù)位內(nèi)固定的患者可以行原位距下關(guān)節(jié)融合術(shù)。兩組患者在平均隨訪6月后進(jìn)行對比。最初行切開復(fù)位內(nèi)固定的患者感染率顯著降低，功能結(jié)果(Maryland足部評分和AOFAS踝-后足部評分)顯著改善。最后，報道了跟骨骨折行非重建性原位距下關(guān)節(jié)融合術(shù)的中長期臨床結(jié)果80。超過17年時間中，35名此類骨折(Sanders III型或IV型)患者行切開復(fù)位內(nèi)固定聯(lián)合原位距下關(guān)節(jié)融合術(shù)。15名患者獲得隨訪，平均9.8年。平均AOFAS踝-后足部評分隨訪時為79.8。距跟高度與功能結(jié)果評分相關(guān)。Evidence-Based Orthopaedics骨科循證醫(yī)學(xué)The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I or II.Over 100 medical journals were reviewed to identify these articles, all of which have high-quality study design. A list of twelve Level-I and II articles that were relevant to orthopaedic trauma is appended to this review following the standard bibliography.We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.期刊的編輯人員回顧了大量最近出版的關(guān)于骨肌系統(tǒng)被認(rèn)為證據(jù)水平為I級或II級研究?；仡櫝^100種醫(yī)學(xué)期刊以鑒別這些文章，所有研究均有高質(zhì)量的研究設(shè)計。與骨科創(chuàng)傷有關(guān)的12篇I級和II級文章列表附加于本綜述標(biāo)準(zhǔn)參考文獻(xiàn)之后。以此創(chuàng)傷骨科領(lǐng)域循證醫(yī)學(xué)的方式，我們提供每篇文章的簡短注釋以幫助引導(dǎo)你進(jìn)一步閱讀