石门县人民医院科普号

摘要: 腰椎间盘突出症是骨科临床中的常见病,腰椎间盘切除术已成为治疗该病的重要手段而被广泛应用。然而，诸如定位错误、神经根损伤、椎间盘炎、腰椎失稳等严重手术失误与并发症时有出现，成为骨科医师的一大困扰。分析腰椎间盘手术失败的原因及再手术问题，辩证思考腰椎间盘切除术的必要性与合理性,为临床实践和进一步研究提供思路。关键词：腰椎，椎间盘移位，手术后并发症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腰椎间盘突出症(LDH)是腰腿痛的重要原因，也是骨科临床中的常见病。自从1934年Mixter和Barr首先通过手术证实和治愈腰椎间盘突出压迫神经根所致的坐骨神经痛以来，腰椎间盘突出症的手术治疗得到了广泛应用，并取得了80%—90%的治愈效果。国内也于1946年由方先之教授率先开展腰椎间盘切除术，随后该手术得到了较普遍开展。同时手术方法不断创新，如显微镜下椎间盘切除术、经皮穿刺椎间盘切除术、化学溶解术以及近年来迅速发展的显微内窥镜下椎间盘切除术（MED）等。然而，广泛的手术治疗获得了较好疗效的同时，亦出现了不少腰椎间盘切除术手术失败，文献报道其失败率达到了2.4%—14.3%[1]。诸如神经根损伤，椎间盘炎，腰椎失稳等严重并发症的不断出现，以及腰椎间盘切除术后的再手术问题一直困扰着骨科医师和患者，这不能不引起人们对它的审视与思考。1、腰椎间盘突出症手术失败的常见原因1.1 诊断失误毫无疑问，错误的或是片面的诊断必须会导致错误的或不恰当的治疗，临床上腰椎间盘突出症的诊断并不困难，然而误诊和漏诊却并不少见。究其原因，其一为与腰椎间盘突出症临床表现相同或相似的疾病众多，要一一鉴别并非易事。腰椎间盘突出症主要的临床症状为腰痛伴或不伴腿痛，首先，几乎所有的腰部或腰椎疾病都可出现腰腿痛。如急性腰扭伤、慢性腰肌劳损、椎间小关节滑膜炎症、第三腰椎横突综合征、梨状肌综合征等，另外,脊柱或脊髓肿瘤、脊柱结核也需与之鉴别；其次，其它部位如盆腔内脏疾病也常可刺激骶部神经丛引起腰骶部疼痛，从而引起下肢的反射痛。常见的有盆腔炎、子宫脱垂等；还有某些全身性疾病如强直性脊柱炎，当病变侵犯骶髂关节、脊柱、髋关节时，亦可出现腰痛或腿痛。当然，事物与事物之间有共性，也有个性，上述每种疾病也会有其不同的个性，是共性与个性的统一。只要我们善于识别和发现其区别即个性，是完全可以作出正确的诊断的。发现个性也就是临床上鉴别诊断的过程，这个过程离不开科学的思维方法。这需要我们在详细询问病史，认真全面的体格检查以及恰当的影像和实验室检查的基础上，运用科学的诊断思维方法。当然，那种过份依赖影像资料而忽视临床表现的做法是十分有害的。1.2 手术技术失误1.2.1 定位错误致误切正常的椎间盘 造成的的原因有：（1）忽视移性椎，如骶椎腰化或胸椎腰化等不引起重视，致定位错误。因此，术前腰椎Ｘ线摄片应为常规准备；（２）经验不足或过于自信，这是造成定位错误的主要原因。其实，椎间盘定位的方法有许多如：术前利用腰椎侧位片上髂嵴最高点与棘突的关系，术前用双手触压双髂嵴之横形连线与棘突纵轴线的交点定位，一般为腰3.4水平。亦可无菌操作下，棘突上插入针头后摄片定位；或术中触摸向后隆起斜坡骨为骶骨；或以Kocker钳夹棘突上提时腰椎可活动，而骶椎不能活动。1.2.2 减压不彻底 术中减压不彻底，未能完全解除脊髓或神经根的压迫，必然导致手术效果不佳或症状缓解后又复发。常见原因有：（1）单个间隙髓核切除欠干净，残留髓核碎片再次脱出压迫神经根；（2）腰椎间盘突出伴有侧隐窝或神经根管狭窄者，行髓核摘除术时未同时扩大侧陷窝及神经根管减压；（3）对于多间隙椎间盘突出者，只处理一处，而遗漏了其它一处或多处，其手术原则是当一个病变的椎间盘有明显的突出并能解释全部临床表现时，可以不探查其它椎间隙，否则应进一步探查。因此，术前和术中不能仅满足于某一处病变的处理而忽略了其它，要全面的看待和处理问题，防止片面化。1.2.3 减压过度 有的手术医生担心神经减压不彻底致疗效差而走向另一极端——盲目过度减压，其结果是适得其反。过度减压必然增加手术创伤并影响脊柱的稳定性，术后腰椎失稳并不少见[2]，许多术后患者因腰椎失稳而情况更糟：腰腿痛较术前加重，功能障碍，劳动力丧失等，他们甚至不得不接受风险和创伤更大的植骨内固定稳定手术。研究表明，一侧腰椎小关节突被切除达1/3以上，即可致腰椎失稳。因此，过多切除小关节突或盲目扩大切除腰椎后方结构范围都是十分有害的。减压与稳定是一对矛盾的统一体，在减压术中，一定要维护或重建腰椎的稳定性。1.2.4 脊髓神经根损伤 常见原因有：（1）术者操作经验不足或不认真，至脊髓神经根损伤；（2）术野显露不清楚，如椎静脉丛的出血未控制时盲目操作；（3）枪式咬骨钳使用不当，咬除黄韧带时误伤脊髓和神经根，以及尖刀切开椎间盘时误伤脊髓和神经根等。此并发症后果严重，可引起下肢功能障碍甚至瘫痪。另外，术中探查时，对神经根过重过久的牵拉，可致神经牵拉伤。1.2.5 椎间盘炎 腰椎间盘切除术为无菌手术，发生椎间隙感染的机会并不多。但一旦发生，病人术后会出现剧烈的腰痛，不能活动腰部和下肢，十分痛苦。常见原因一是术前准备不充分，如患者全身存在感染性疾病或术野邻近部位存在感染灶，细菌容易侵入伤口致感染，因此不宜急于手术，应先控制感染后再择期行腰椎间盘切除术；二是无菌观念不强，未能遵守无菌操作规程，外来细菌带入手术部位引起感染；三是椎间隙内异物存留。另外也可由手术器械物品消毒不严格、院内交叉感染等引起。[3]2、腰椎间盘切除术后的再手术问题腰椎间盘手术失败的原因是复杂和多方面的。虽是同一病例，可能是由几种因素同时作用的结果，但对这些因素必须有先后和主次之分，不可混为一谈，否则影响再次手术治疗的效果。张佐伦[4]行再次腰椎手术55例，其原因分析为：原间隙髓核未取尽12例；遗漏一处突出腰椎间盘15例；未能解除中央管、侧隐窝及神经根管狭窄10例，术后瘢痕压迫或椎管狭窄5例；定位错误3例等。鲁玉来[1]提出再次手术的指征为：（1）神经症状明显，伴有运动障碍或马尾神经综合征者；（2）合并腰椎椎管、侧隐窝、神经根管狭窄者；（3）合并椎体后缘骨质增生，黄韧带肥厚，后纵韧带或突出椎间盘钙化及瘢痕增生所致椎管狭窄、硬膜囊受压者；（4）第一次手术定位错误，突出腰椎间盘遗漏或再次发生新的腰椎间盘突出者；（5）腰椎不稳严重影响工作和生活者。再次手术的成功率是有限的，而且再次手术对脊柱又增加了一次破坏，术后腰椎不稳的发生率必然上升。且二次手术的难度加大，若是进行第二次手术者最好同时做腰椎融合术，以免术后腰椎不稳而发生腰痛。脊柱外科医生在术前必须要有一个观念，那就是你只有一次成功的机会，第一次手术效果总是最好的。椎间盘切除术手术结果完全依赖于术前仔细选择合适的患者、可外科治疗的病变诊断的准确性、有效而不复杂化的手术以及良好的术后康复等。失败的腰椎手术的每一次分析，都强调失效的主要原因是不恰当的外科治疗或病情的诊断，然而，我们必须承认，对大多数有腰椎手术失败的患者而言，没有需要手术的必要，患者和医生们日益增加的企图，即“试试，试试，再试试”是不值得推荐的努力。外科手术也能造成疼痛及功能障碍，而且随着手术次数的增加，患者出现疼痛和功能障碍加重的机会也越来越多。因此，再手术的决策，必须基于明确的、客观存在的外科治疗的病变，对于保守治疗失败，症状严重、悲观、绝望以及寻求帮助等都不可以作为成功进行再次脊柱外科手术的指征。总之，第一次手术需慎重，手术失败后的再手术更需要慎之又慎。3、教训与启示3.1正确处理好手术与非手术治疗的关系腰椎间盘切除术手术失败给患者造成巨大的身心痛苦，也给患者家庭和社会造成巨大损失，同时也易引发各种医疗纠纷，不利于和谐社会的建立。医生尤其是脊柱外科医生需要牢固树立“以人为本”、“以病人为中心”的思想，严格把握好手术指征，以高度的责任感和认真负责的态度仔细选择手术病人。其实有约80%的腰椎间盘突出症可能通过非手术疗法治愈或暂时缓解，如牵引、推拿、理疗、药物等都有一定效果，这已得到专业医生的公认。腰椎间盘突出症治疗方法的选择取决于该病的不同病理类型、病理阶段和临床表现，以及病人的年龄和身心状况等综合因素，手术与非手术疗法各有其适应症。最近，有人发现到突出的椎间盘髓核组织（HNP）未经手术切除而缩小，称为突出椎间盘的再吸收[5,6]。大多数学者认为突出髓核的再吸收与病人下腰痛及根性神经痛的缓解呈正相关。虽然目前其再吸收的机制尚不清楚，但进一步研究掌握HNP再吸收的发生、发展规律，将在临床上为更多的腰椎间盘突出症病人进行非手术治疗增加重要依据。非手术疗法是本病的基本疗法，而那种盲目扩大手术适应症和手术范围的做法是十分有害的。对于大多数可以用非手术疗法治愈的患者，采用手术治疗，无疑是一种过度医疗，就如对一名很可能成功顺产的产妇不采用顺产而采取剖腹产一样，无疑增加了患者的身心痛苦和经济负担，甚至导致严重并发症。因此，对于每个腰椎间盘突出症患者，要结合具体病情具体分析，采用最优化的治疗方案。3.2 正确看待腰椎间盘切除术腰椎间盘切除术是切除了退变及病变椎间盘的髓核。然而，椎间盘在脊椎的承重、复杂运动、缓冲振荡等生理功能中发挥着重要作用。尽管椎间盘切除术解决了许多腰椎间盘突出症患者的腰腿痛，但切除术所带来的手术入路对脊柱骨与韧带的损伤，椎间隙高度的下降以及随后带来脊柱生物学功能紊乱，产生脊柱失稳及临近节段加速退变[2.7]，还有术后瘢痕形成对神经根产生新的压迫及术后神经根粘连等问题，对脊柱外科医生提出了新的挑战。Kirkaldy等提出脊柱的三关节复合体理论[8]，认为椎间盘及其后方两个小关节构成的三关节复合体在脊柱的稳定性中发挥重要作用。当椎间盘切除后，必定会使三关节复合体受累，进而通过连锁反应影响脊柱的稳定性。近年来椎间盘切除术后的修复受到越来越多的研究和重视。人工椎间盘置换术及人工髓核置入术在临床上已有不少成功的报道[9]。因此，腰椎间盘切除术本身还不尽完美，还有许多相关领域值得我们去研究和探索。实践没有止境，认识也没有止境，随着研究的深入，将会有更新更好的手段征服腰椎间盘突出症。4、结束语腰椎间盘切除术目前仍然是治疗腰椎间盘突出症的重要手段。骨科医生应树立高度的责任感，努力提高手术质量，精益求精，为减少甚至是避免各种失误与并发症而不懈努力。同时，加强腰椎间盘突出症的基础与临床研究，不断创新，为腰椎间盘突出症患者提供更加科学、安全、可靠的治疗。参考文献：略

毛炳焱 刘平均 胡志喜 王文聪 贺用礼 晏平华 李际才 丁原 刘林【摘要】 目的 探讨胫后动脉内踝上皮支皮瓣修复足跟皮肤软组织缺损的临床效果。方法 自2000年7月～2008年3月应用胫后动脉内踝上皮支皮瓣修复各种原因所致足跟部皮肤软组织缺损12例。 结果 12例皮瓣术后全部存活，皮瓣面积最小7cm×5cm，最大为14cm×8cm。随访6～12月，效果满意。 结论 胫后动脉内踝上皮支皮瓣血运可靠，穿支点比较固定，手术操作简便安全，且不牺牲重要血管，是一种比较理想修复足跟部皮肤软组织缺损的方法。【关键词】 外科皮瓣； 胫后动脉； 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 足跟部外伤容易造成跟腱或者踝关节外露，以及外伤后足跟部瘢痕挛缩成为临床上修复整形治疗的难点，随着显微外科技术的发展和人体解剖研究的深入，临床上常采用皮瓣转位或皮瓣移植来修复整形创面[1 ~ 3]。通常采用的皮瓣，存在蒂部臃肿，牺牲较重要血管、神经，且术后影响小腿主要肌群的活动。而胫后动脉内踝上皮支皮瓣能较好的解决上述问题，且将损伤降低。自2000年7月至2008年3月我科应用胫后动脉内踝上皮支皮瓣修复各种原因所致足跟部皮肤软组织缺损12例，效果满意，现报告如下：1 临床资料和方法1.1 一般资料 本组12例，男性7例，女性5例，年龄23～36岁。手术原因：摩托车钢丝绞伤5例，交通事故4例，慢性溃疡1例，瘢痕挛缩2例。所有病例在清创后或瘢痕切除后均合并跟骨骨折或跟腱外露，7例合并跟腱损伤，2例合并跟骨骨折，2例合并伤口感染。本组均采用择期手术修复。1.2 手术方法1.2.1 创面准备 彻底清除创面感染及不健康瘢痕组织，术前常规行创面细菌培养加药敏，以指导术后用药，跟骨骨折予克氏针或镙钉固定，修复跟腱。1.2.2 皮瓣设计 点：术前用超声多普勒血流探测仪探测胫后动脉内踝上所有皮支的穿出点，通常选取内踝上5cm或7cm为旋转点；线：内踝后与股骨内髁连线为轴线；面：在髌骨下缘与内踝上缘之间，前后均不超出正中线。确定点线面后，测量旋转点至创面最近距离为血管蒂长度，剪裁出创面大小布样，亚甲蓝画出皮瓣边界。一般血管蒂放大1.0cm～1.5cm，皮瓣放大约1.0cm，血管蒂部设计成网球拍状，蒂部宽度在1.5cm～2.0cm左右。1.2.3 皮瓣切取 首先切开血管蒂及皮瓣后缘，解剖至深筋膜下，在比目鱼肌与趾长屈肌间找到胫后动脉，确定皮支穿出点，再切开皮瓣前缘，于深筋膜下解剖出皮瓣，结扎大隐静脉近心端，切取范围较大时可携带合适长度隐神经，皮瓣转移均采用明道处理，显微吻合隐神经与创面皮神经，受区条件允许，可将大隐静脉与皮下同流静脉吻合。皮瓣供区采用韧厚皮植皮加压打包，直径小于5.0cm供区均可直接缝合。2 结果 全组12例皮瓣均存活，其中3例将大隐静脉与皮下同流静脉吻合，5例将远、近心端均结扎，6例仅将大隐静脉近心端结扎，术后行大隐静脉吻合者肿胀情况比未行吻合者轻，结扎大隐静脉远、近心端皮瓣肿胀情况较仅结扎近心端者轻。供区植皮均一期愈合。术后随访6～12月皮瓣血运良好，质地软，耐磨，外形不臃肿，功能恢复满意。3 典型病例患者唐某，女，36岁。摩托车钢丝绞伤右足跟部后皮肤变黑坏死34天，足跟区可见大小约3cm×4cm皮肤变黑坏死，并少许渗液，术前创面细菌培养送检后，扩创后跟踺外露，皮肤软组织缺损约4cm×6cm，设计面积为5cm×7cm胫后动脉内踝上皮支皮瓣修复，旋转点位于内踝上5cm处，供区直接缝合。术后皮瓣存活，创面一期愈合（图一、二），足外形功能恢复满意。4 讨论3.1 胫后动脉内踝上皮支皮瓣的解剖学依据 黄继峰[4]等通过解剖发现，胫后动脉在小腿内侧距内踝尖5cm～12cm，15cm～18cm，22cm～24cm均有肌间隙皮动脉穿出。张惠发[5]等通过对30例经动脉内灌注红色乳胶成年下肢标本的研究，发现在内踝最突出点上方3.0±1.1cm，6.2±1.4cm，8.6±+1.4cm处胫后动脉肌间隙皮支稳定穿出，3支出现率达86.6%，外径在0.5mm～2.5mm，并且在5.0cm、9.0cm左右有骨皮穿支发出，这就为胫后动脉内踝上皮支皮瓣提供了可靠的解剖学依据。本组病例术前均采用超声多普勒血流探测仪探测胫后动脉内踝上所有皮支的穿出点，术中也证实穿出点基本在内踝尖上5cm～7cm，皮瓣面积最大在14cm×8cm，术后皮瓣均血运良好。3.2 胫后动脉内踝上皮支皮瓣中大隐静脉的处理 在胫后动脉内踝上皮支皮瓣中对于大隐静脉的处理，众说不一，对于吻合大隐静脉与受区皮下同流静脉的手术方式，能使皮瓣维持在一个“有灌有流”的良性状态，能带走皮瓣中有害物质，减轻皮瓣水肿，这是可以肯定的。对于大隐静脉在血管蒂部结扎与否，一般认为大隐静脉为足的主要回流静脉，结扎可减少皮瓣静脉血灌注，减轻皮瓣静脉回流压力。但Sasa[6]通过实验发现，动脉血氧一般仅25％ ～30％在组织细胞中被利用，而静脉中血氧能满足组织细胞需要，因此在蒂部保留大隐静脉有利于皮瓣的成活。宋建星[7]等实验中的血气分析结果表明静脉血与皮瓣组织间存在营养物质的交换。本组手术中6例仅将大隐静脉近心端结扎，术后皮瓣血运良好，虽皮瓣肿胀情况较远、近心端结扎者严重，但笔者认为不会影响皮瓣存活，相反可能在术后3～4d内有助营养皮瓣，提高皮瓣存活率。3.3 胫后动脉内踝上皮支皮瓣在修复足跟皮肤软组织缺损中的优缺点 唐举玉[8]等通过对选择修复足跟区皮瓣供区的研究发现，目前在对于修复足跟皮肤软组织缺损的各种手术方式中，胫后动脉内踝上皮支皮瓣具有质地较好，耐磨，可部分修复感觉，术后皮瓣外形不臃肿，不影响穿鞋；皮支血管穿出点较稳定，外径较粗大，血供可靠，不牺牲重要血管，手术安全简便；更为重要的是在足跟较小面积缺损修复中，供区可直接缝合；且不影响小腿主要肌群的活动。但对于大面积的缺损，供区需一期植皮，术后影响美观。3.4 手术注意事项胫后动脉内踝上皮支皮瓣在修复足跟皮肤软组织缺损手术中应注意以下几方面：① 术前超声多普勒血流探测仪探测胫后动脉内踝上所有皮支的穿出点，以防止术中出现高位皮支穿出点。术中尽可能保留胫后动脉的各个肌间隙皮穿支，必要时可改携胫后动脉的游离或逆行岛状皮瓣修复。② 解剖皮瓣一般先从血管蒂部开始，切开皮瓣后缘，明确胫后动脉皮穿支位置后，有利于更好的切取皮瓣。③ 由于该皮瓣血管蒂偏短，在蒂部设计时，尽量设计成球拍状，采用明道转移。④ 受区条件允许尽可能吻合大隐静脉和隐神经，有利于术后皮瓣管理和皮瓣感觉恢复。5 参考文献1 王成琪，王剑利，张敬良，等．皮瓣移植术的回顾与展望．中华显微外科杂志，2000，23(1)：12-14．2 魏长月，胡淑文，郭德亮．带感觉神经的小腿内侧皮瓣的解剖及其在修复足跟部软组织缺损中的应用 [J]．解剖与临床，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 黄继锋，王增涛，郭德量，等．胫后动脉皮支筋膜皮瓣的解剖及临床应用[J]．中国修复重建外科杂志， 2000，14(4)：218．5 张发惠，郑和平，宋一平，等．内踝区动脉网的显微解剖与隐神经营养血管远端蒂皮瓣的设计 [J]． 中国临床解剖学杂志，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．静脉皮瓣术后早期微循环重建的实验研究 [J]．第二军医大学学报，1990，11：197-199．8 唐举玉，李康华，刘俊，等． 内踝上皮瓣修复足跟软组织缺损 [J]．中国现代手术学杂志， 2006，10(1)14-

良性前列腺增生（BPH）是泌尿外科常见的老年男性疾病之一，尿频、尿急、尿痛、夜尿次数增多、排尿困难等症状，严重影响患者的生活质量，手术治疗BPH的“金标准”是经尿道前列腺电切术。近年来，PKPR等使用双级等离子电切系统治疗BPH的新方法已在临床上广泛采用，并在县市级医院普及，其数量占基层泌尿外科病房患者总数1/4以上。随着设备的不断更新换代，经尿道前列腺切除术的发展经历了几个阶段，分别从电切到激光、汽化电切、汽化切割等。这些方法都遵循着共同的原理，利用电能转化为热能时对活体组织的不同效应而达到切除前列腺组织的目的。TURP工作原理为单极高频电热能切割，通过局部高热达到切割止血的目的，电切局部温度高达400℃以上，在切除前列腺组织的同时破坏尿道黏膜的完整性，可直接导致局部剩余组织的凝固碳化。PKRP是英国Gyrusg公司于1998年研制的新科技，是TURP技术的延伸和发展，很快就在临床上得到广泛的应用。其工作原理是高频电流通过两个电极时释放射频能量，激发导体递质，形成围绕电极的高聚焦等离子体区，能将靶组织内有机分子键打断，从而产生较快的切割作用；同时还能使之接触的组织产生汽化，形成深度达3-5mm均匀凝固层，使深层小血管、静脉及毛细血管迅速闭合，从而起到良好的止血作用。由于TURP切割温度高，导致局部组织形成凝固层且达到显著的止血效果，但对尿道周围组织有一定的损伤作用，诱发手术后下尿路症状，创面愈合较慢。相对于TURP，PKRP切割时靶器官表面的温度低，具有切割范围精准、热穿透表浅 、对周围组织破坏轻微等特点，所以手术后下尿路症状较TURP明显减少。等离子球体对于组织的效应与组织阻抗是，密切相关的，包膜的阻抗与前列腺增生组织具有一定差别，前列腺组织切除效率较高，而包膜较低，当切割包膜时，会出现“打滑”现象，不易切穿包膜，使得手术更加安全。TURP切割面一般形成焦痂或者碳化较PKRP明显，其术后近期切割面发生感染、再次出血的可能性较PKRP更高，术后痂皮脱落期一般为3个月左右，术后切割面修复速度PKRP明显快于TURP。不论应用哪种手术方式，术后创面上皮修复一般至少需要3周左右，3个月以上才能达到完全上皮化，术后创面裸露浸泡于尿液中，水肿、坏死组织脱落，上皮组织重新生长覆盖，直至疤痕愈合，加之导尿管的刺激损伤，近期血尿、尿频、尿急、尿痛等尿路刺激征状较重，远期可出现尿道疤痕狭窄，再增生等情况。从上述尿道创面的恢复规律可以看到，留置导尿管1周创面根本就没有愈合，留置尿管的作用只是为了膀胱冲洗，避免膀胱内血块形成。并不是术后1周拔除导尿管后排尿通畅，就完全恢复了。较多的患者在前列腺电切术后，因为血尿、尿频、尿急、尿痛等尿路刺激征状较重，多次门诊就诊。复查小便常规，并没有尿路感染，服用抗生素治疗无效，开始对手术是否成功产生了怀疑，对术后恢复失去可信心，是完全没有必要的。术后血尿、尿频、尿急、尿痛等尿路刺激征，会随尿路的完全上皮化逐步减轻。少数患者可能出现尿道及膀胱颈的瘢痕狭窄，尿线明显变细，这是需要返院尿扩或者行膀胱颈瘢痕松解。

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-up37.一项包括73名胸腰椎爆裂骨折行后路短节段固定融合或不融合患者的随机临床试验表明，尽管2/3的融合患者在末次随访时有植骨供骨区疼痛表现，但临床或影像学结果方面无差异。Pelvic and Acetabular Fractures骨盆和髋臼骨折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.回顾>63,000来自两家I级创伤中心的患者，分析骨盆骨折在患者死亡率中的作用38。骨盆骨折与死亡率显著相关，两家中心的死亡率优势比分别为2.4和2.0。这些优势比与腹部损伤相关的死亡率优势比相当，但小于血液动力学休克、严重脑损伤、老年患者相关的优势比。当结合前面提到的风险因素对死亡率进行分析时，除了血液动力学休克和严重脑损伤外，骨盆骨折独立与死亡率相关。尽管骨盆骨折与死亡率相关，它只是多发伤患者整体护理中要考虑的因素之一38。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篇来自OTA年会的重要论文回顾了侧方挤压型骨盆损伤的治疗。Sembler等研报道了一系列120名伴轻微移位(<10mm)侧方挤压型骶骨压缩性骨折患者39。所有患者伤愈前可即时活动、允许可耐受的负重并行X线检查。只有1名患者非手术治疗失败，其严重的疼痛与骶骨移位增加5mm相关。其余119名患者愈合良好，伴极轻微移位。包括早期负重的非手术治疗，适用于单侧挤压型骶骨压缩骨折39。另外一项报告回顾了来自2家I级创伤中心的117名高能创伤造成的骶骨骨折患者40。这些骶骨骨折为骨盆环侧方挤压伤，初始移位<5 mm。治疗医师决定对这些患者实行包括负重训练的非手术治疗。与前一系列患者对比，117名患者中有23名在骨折愈合时移位>5 mm。以骶骨后方皮质出现明显骨折线为象征的完全性骶骨骨折，骨折移位发生率为50%。完全性骶骨骨折合并双侧上下耻坐骨支骨折，骨折移位发生率为为68%。不完全性骶骨骨折不伴有耻坐骨支或单侧耻坐骨支骨折则无骨折移位。这些研究结果强调了仔细分析骨折类型和单侧挤压型骶骨骨折允许负重前患者特征的重要性。阐明与功能相关的骶骨残留移位以确定手术治疗在侧方挤压型骶骨骨折中的作用需要进一步研究。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.老年髋臼骨折患者的治疗存在争议。以一名外科医师的经验，髋臼骨折在65岁以上患者中的发病率在1993~2007间(24%)较之1980~1993间(10%)增长了2.4倍41。老年患者中累计前柱更为常见，游离的四边形骨折块、髋臼顶压缩与前柱损伤有关；粉碎性和边缘嵌插折与后柱损伤有关41。这些因素使老年髋臼骨折患者的内固定治疗充满争议。一篇综述证实，年龄≥65岁的髋臼骨折患者，接受治疗后，1年死亡率为25%42。幸存的患者中85%行手术治疗，大多数行切开复位内固定术。28%的生存患者平均2.5年后行全髋关节置换术。尽管许多研究报告了轻微功能问题和一定程度的髋部疼痛，这些行切开复位内固定的患者的Western Ontario and McMaster大学骨关节炎指数(WOMAC)和SF-8评分与常人标准类似。第三项研究验证切开复位内固定合并全髋关节成形术病例的回顾性结果，患者平均年龄72岁43。18名患者随访至少1年，仅一名患者术后3周髋臼假体失败需要翻修手术。末次随访时，Harris髋部评分为88分，X线片显示髋臼杯轻微的向内垂直移位，无证据显示髋臼假体松动。对于适合的患者，对骨盆内固定和关节成形术技术有经验的医师能够安全地进行切开复位内固定和全髋关节成形术，且并发症轻微，能够避免二次手术。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.股骨近端骨折给社会带来沉重的负担。过去的一年，许多陈述或发表的研究有助于我们充分理解这种复杂损伤的诊治问题。最近内科学年鉴中一项meta分析调查了>700,000髋部骨折患者的死亡率44。在髋部骨折后最初3个月，所有原因引起的死亡相对风险度为女性5.75，男性7.95。死亡相对风险度在最初两年显著降低，但是伤后10年与性别和年龄均匹配的对照组相比，是持续上升的。与女性相比，男性死亡相对风险度一直较高。一项对国家住院病人样本中97,894名患者的回顾性研究分析了外科医师和医院规模对髋部骨折后并发症发生率和死亡率的作用45。小规模医院(每年少于7例)相对大规模医院(每年超过15例)，其死亡率调整优势比为1.24。未发现小规模和大规模医院间死亡率的显著差异。患者并发症发生率在小规模和大规模医院的外科医师间存在差异。肺炎、压疮、输血需求发生率的增加与小规模医院外科医师相关。类似的，肺炎、术后感染、输血需求发生率的增加与小规模医院相关。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.股骨近端骨折的治疗，特别是股骨颈骨折尚存争议，特别是关于初次关节成形术的作用。最近，一项先前报道过的对关节成形术和内固定术治疗移位的股骨颈骨折随访10年的随机对照试验业已出版46。总的来说，45.6%行内固定的幸存患者骨折治疗失败，92例失败病例中仅有4例发生在2~10年。与之相对，8.8%行关节成形术的患者治疗失败，7例失败病例中5例发生在2~10年。关节成形术组中这些迟发的失败病例是行全髋关节成形术的患者。最初行关节成形术的患者中仅5.2%发生复发性脱位，与全髋关节成形术和半髋关节成形术后所发生比率相当。关节成形术组和内固定组10年死亡率相同，关于髋部活动性疼痛或关于继发于髋部症状的关节活动度减少两组间无显著差异。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等回顾来自挪威髋部骨折登记系统数据的4335名行内固定术或半髋关节成形术治疗的移位型股骨颈骨折老年患者，术后随访至少1年47。内固定组与半关节成形术组1年死亡率无显著差异(27% : 25%)。内固定组二次手术率为22.6%，半关节成形术组二次手术率为2.9%。以EQ-5D指数评分评价患者功能结果，1年随访时，半关节成形术组更为良好。这些数据进一步支持对于移位型股骨颈骨折老年患者的治疗，半关节成形术优于内固定术。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.近期有两项随机试验对比了半关节成形术治疗股骨颈骨折中使用或不使用骨水泥的效果。第一项研究包括随机应用骨水泥假体(Thompson)或非骨水泥假体(Austin-Moore)的400名患者48。总的来说，使用骨水泥的半关节成形术患者在第8周以目测类比评分法评价，疼痛较轻，Charnley疼痛评分在第3、6、12、24月较低。 与未使用骨水泥的半关节成形术患者相比，使用骨水泥的患者无严重关节活动度丢失。第二项研究包括223名患者，证实应用更现代的羟基磷石灰涂层非骨水泥假体(Corail; DePuy)临床结果显著不同49。Harris髋部评分在非骨水泥假体组与骨水泥假体(SPECTRON; Smith & Nephew)组在随访3月和12月时无差异。以EQ-5D指数评分评价的功能结果在3月、12月亦无差异。Austin-Moore非骨水泥假体在现代髋部半关节成形术中较少使用，主要应用于功能要求较低、需要控制疼痛要求“尽快”置换的患者。一项髋部骨折行半关节成形术的研究未证实标准入路与微创入路在失血量、输血需求或术后72小时血红蛋白水平方面存在显著差异50。标准手术入路患者术后2年功能结果良好。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.囊外骨折也成为一个争论的来源，最初是关于头状髓内针取代髋部滑动螺钉不断扩大的作用。髓内针技术的支持者强调髓内针微创的本质和改进的生物力学特征。髋部滑动螺钉的支持者指出其技术成熟且价格低廉。一项mata分析将几种微创术式(髓内针植入术，经皮钢板固定术，微创髋部滑动螺钉植入术和外固定术)与传统髋部滑动螺钉植入进行对比51。组间固定失败率和死亡率方面无显著差异。尽管输血的相对风险在微创组较低，与单独髓内针植入(第4项研究)相关的输血相对风险和传统髋部滑动螺钉相比无显著差异。一项对比通过微创技术(切口长度2.5cm)和标准切口(切口长度10~15cm)植入髋部滑动螺钉的小型随机对照试验业已发表52。微创组患者失血量和输血率均降低，术后第3日疼痛较轻，躯体功能改善。术后3月在影像学结果和功能评分方面无差异。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 themselves53.一项对比γ钉和髋部压力螺钉的meta分析强调，可能由于患者选择、外科技术和 植入物本身的改进，术后股骨干骨折发生率逐渐降低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等报告一系列高能所致股骨颈-干骨折大量病例54。在这项包括2897名股骨干骨折患者的研究中，合并股骨颈骨折的发病率为3.2%；88%的患者合并其他系统损伤，75%合并其他部位骨科损伤。1/4的股骨颈骨折术前未做出明确诊断。薄层CT扫描的患者中18%发生漏诊。股骨颈骨折患者12.1%发生骨不连或畸形愈合，其中一半患者属诊断延误。对股骨颈骨折的诊断要求高度的警觉，仅依靠薄层CT对所有病例做出诊断是不充分的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.另外一项研究包括1126名股骨干骨折行髓内针治疗的患者，与对照组的92名股骨骨折完全愈合患者相比，46名患者发生骨不连(总病例数的4%)55。开放性骨折和吸烟是预示骨不连的诱因。有趣的是，72%的股骨骨折骨不连患者由于其它损伤而推迟负重练习。基于这项研究的结果，作者称，只要可能，他们将更为积极的主张股骨干骨折行髓内针固定的患者早期负重训练。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.关于股骨顺行性髓内针对比逆行性髓内针的相对益处，在外科医师间尚存争议。最近一项随机研究评估了顺行性和逆行性股骨髓内针术后膝关节功能56。组间在膝关节屈曲(顺行组和逆行组分别为132°和134°)、Lysholm评分、等功能肌肉活动能力方面无差异。无论何种治疗，老年患者与年轻患者相比，Lysholm评分较低，膝关节屈曲受限。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.与股骨干骨折不同，关于股骨远端骨折的争议较少，锁定钢板看似已被广泛采用。Ricci等在一项包括305名患者的研究中分析了与锁定钢板治疗股骨远端骨折相关的风险因素57。总的来说，9%的患者发生骨不连，而另外6%患者需要有计划的分阶段植骨。糖尿病史是骨不连唯一独立预测因子。8%的病例植入物失败，60%发生在近端骨折部分。植入物失败独立预测因子包括糖尿病史、OTA A3型骨折、人体质量指数、不锈钢板和钢板长度过短。当钢板长度为10孔或以上时、骨折近端骨干覆盖钢板达8孔或以上长度时、近端使用更多螺钉时、钢板近端部分螺钉密度(螺钉数占螺钉孔数的百分比) <60%时，近端植入物失败很少发生57。这些数据对外科医师应用股骨远端锁定钢板提供了有用的指导。Tibia and Tibial Plateau胫骨和胫骨平台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.最近若干研究评估了与胫骨骨折相关的骨筋膜室综合症。Park等回顾了一家单独I级创伤中心胫骨骨折治疗超过34月的全部病例58。作者确定了基于解剖位置的骨筋膜室综合症发病率。胫骨干骨折导致骨筋膜室综合症发生率最高(8.1%)，胫骨近端骨折次之(1.6%)。“年龄递减”是单独预示骨筋膜室综合症的唯一因素。然而，其他人报告称，胫骨近端骨折引起骨筋膜室综合症发生率更高59。Stark等回顾了67例胫骨平台双髁骨折和17例内侧髁骨折-脱位病例，所有患者均于伤后48小时内行外固定架治疗59。骨筋膜室综合症发生率为27%：53%(9/17)为内侧髁骨折-脱位；18%(9/50)为胫骨平台双髁骨折。9名内侧髁骨折-脱位合并骨筋膜室综合症患者中，6名(67%)发生在外固定架治疗后。另一项研究突出强调在胫骨骨折患者中诊断骨筋膜室综合症方面的明显不同60。7名受过相似训练的骨科医师治疗386名胫骨干骨折，10.4%的患者诊断为骨筋膜室综合症。然而，外科医师对骨筋膜室综合症的诊断率差异较大，范围在2% ~24%。这些诊断上的差异可能有助于解释文献中骨筋膜室综合症发生率的不同。作者发现患者为男性是骨筋膜室综合症一项独立预测因素。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，引进了一项新的胫骨骨折愈合评估方法。胫骨骨折影像学愈合评分(RUST)是一个基于放射学的评分系统，设计用来将胫骨骨折愈合评估标准化。评分基于骨折线在影像学表现上消失，同时有无骨痂表现，如果出现骨痂，是否为桥接性。4层皮质的每一层均独立评估，每层皮质分数总和相加即为总分。观察者内和观察者间可信度被认为是“真实的”(同类相关系数各自为0.88和0.86)。经过进一步的评估，RUST评分可能最终有助于将临床治疗和骨科研究标准化。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.最近一项回顾性研究对比髓内针和经皮锁定钢板治疗关节外胫骨近端骨折的有效性62。两组结果存在轻微差异，髓内针组较锁定钢板组开放性骨折所占比率更大(55% : 35%)。锁定钢板组较之髓内针组(94% : 77%)术后骨不连发生率更高(p = 0.10)。尽管这些差异(如果真实)有重要的临床意义，但是由于患者样本小，骨不连发生率的差异不能被证明。尽管另外的骨折复位技术(比如锁定螺钉)常规应用，36%的患者髓内针术后发现顶点前方力线不稳>5°，表明复位不良继续成为髓内针治疗胫骨近端骨折的并发症之一。与之相对，锁定钢板术后顶点前方力线不稳占15%。有症状的植入物移位发生率锁定钢板组较髓内针组更高(15% : 5%)，但由于患者样本较小，这种差异并不显著。尽管作者基于他们的数据得出结论，在治疗关节外胫骨近端骨折方面髓内针和锁定钢板均无巨大的优势，他们也强调大量潜在的重要临床差异需要前瞻性试验验证，并已着手进行。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分类法代表了描述踝部骨折的标准命名法，最近许多研究将其作为主题，试图确定是否会在实际中发生其机械性描述所预期的损伤。在一项研究中，23具新鲜冷冻尸体在足旋前位置下进行测试63。一组单纯施以外旋力，而另一组施以外旋-外展力。在两组均出现腓骨远端短的斜行折，典型描述为旋后-外旋性损伤。典型的旋前-外旋骨折即腓骨近端骨折发生在内踝损伤之后，并且仅在外展力作用下发生。作者认为，典型描述为旋后-外旋性损伤的骨折在足旋前位时发生，瞬间外展力可能是决定骨折类型的重要因素63。一项在2009 OTA年会上提出的研究利用在互联网(youtube.com)可用的踝部损伤视频剪辑分析Lauge-Hansen分类系统预测实际损伤机制的准确性64。作者从损伤视频确定足的位置和变形力，对比记录的损伤机制与结合影像学的骨折类型。当视频剪辑显示为旋后-内收型损伤，与旋后-内收影像学类型100%相符(5/5)，当视频剪辑显示为旋前-外旋性损伤，与标准的旋前-外旋影像学类型仅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。一项研究评价了X线平片充分评估三踝骨折的可靠性65。8名有经验的骨科创伤学专家回顾了22名三踝骨折患者。只有考虑到后外侧骨折块大小时，观察者内可重复性、观察者间可信度和准确性被认为良好。与CT扫描相比，骨折的其它特征，包括骨折线延伸至后内侧面，骨软骨骨折块粉碎，骨折块有压缩表现，无法显示可重复性和可靠性且缺少准确性。尽管没有数据表明常规性CT扫描可改善临床结果，作者仍主张对所有三踝骨折患者常规行术前CT扫描。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.两项研究关注踝部骨折的短期和长期临床结果。一项包括在California治疗的57183名患者的研究描述了与踝部骨折手术治疗相关的并发症发生率66。短期并发症确定为术后90天内再次入院，在复杂型糖尿病和周围血管疾病患者中最高发。在最初90天，复杂型糖尿病患者增加了伤口感染 (7.71%)和切开复位内固定翻修(4.43%)的风险。同样的研究证实，三踝骨折与单纯外踝骨折相比，术后5年踝关节融合或置换优势比为2.07。医院规模不能成为短期或长期临床结果的预测因子。一项瑞士的研究对比了旋后-外旋IV型踝部骨折合并内踝骨折患者与内踝正常的旋后-外旋IV型踝部骨折合并部分或完全三角韧带撕裂患者的长期临床结果67，平均随访13年，旋后-外旋IV型踝部骨折合并部分或完全三角韧带撕裂患者功能结果优于合并内踝骨折患者。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.踝部韧带联合损伤继续成为讨论的根源，在过去一年，关于此主题已提出或发表诸多研究。一项包括347名踝部骨折患者的研究显示，需要联合韧带固定的患者，术后6月和1年在短期骨肌肉功能评估(SMFA)功能障碍指数和美国足踝骨科协会(AOFAS)评分结果方面，与不需要稳定韧带联合的患者相比较差68。在2009 OTA会议提出的一项研究分析了韧带联合复位不良导致的功能结果69。68名之前接受踝关节临床评估和双向CT扫描的患者，超过2年后，韧带联合仍稳定。总的来说，39.1%的韧带联合损伤后复位不良。韧带联合损伤复位不良患者在SMFA、Olerud和Molander问卷评分方面现显著降低。基于这些数据，作者建议术中直接显露韧带联合，尽管未提供此种方式引起不同结果的证据。另外一项研究中，在所有病例中均直接显露韧带联合并复位，尽管可以通过多种方式(后踝骨折块切开复位内固定，韧带联合锁定螺钉固定，或二种术式联合)稳定韧带联合70。作者将影像学结果与同一机构的既往在X线透视下复位评估的患者作为对照组相对比，发现影像学结果显著改善(复位不良发生率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.关于应用螺钉稳定韧带联合方面存在诸多争论。Miller等报告了一系列25名应用2枚锁定螺钉和1/3管状锁定板经四层皮质固定以稳定韧带联合损伤的患者，认为有必要取出韧带联合锁定螺钉71。韧带联合植入物常规于术后4个月取出，患者在客观运动范围和功能评分方面可即时获得改善71。另外两项研究，包括使用传统皮质骨螺钉，不支持常规取出所有韧带联合螺钉。一篇回顾性综述称，平均随访30月后，韧带联合螺钉断裂的患者AOFAS评分高于韧带联合螺钉完整的患者72。在研究中，使用3.5mm螺钉，但螺钉数目和皮质层数各异，螺钉松动亦包括在螺钉完整组内。另一项回顾性研究中，对比螺钉松动或断裂患者与螺钉完整或螺钉已取出患者临床结果73。多种形态螺钉的使用，限制了结果的阐明。通常，螺钉完整患者功能评分低于螺钉松动、断裂或已取出患者。作者认为，他们的数据并不支持常规取出松动或断裂的螺钉，这也许在决定是否取出完整的韧带联合螺钉方面有一定作用。最后，一项对先前报道的对比4层与3层皮质固定的随机临床试验随访性研究已发表74。最初的64名患者中48名获得随访，平均8.4年。患者使用1枚4.5mm固定4层皮质的螺钉或2枚3.5mm固定3层皮质的螺钉均获得韧带联合稳定。随访时，2组患者功能评分无差异。有趣的是，患者CT影像上韧带联合宽度较之对侧踝关节差异≥1.5mm(预示着复位不良或最初复位失败)时，功能结果的修正AOFAS评分更差(p = 0.056)。由于不同的螺钉大小、数量和固定方式，使得这些研究难以被完全阐明。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.最近一项包括9项I级或II级研究的系统性回顾，报道了早期活动对踝部骨折手术治疗结果的影响75。在早期随访时(9~12周)，早期活动组踝关节活动范围显著改善。然而，在1年时，活动范围的差异已不明显。早期活动组患者能够更早的返回工作岗位，且深静脉血栓发生率亦呈下降趋势(p = 0.12)。早期活动组患者较之制动患者有着更高的感染发生率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.最近报道的数据提示，与踝关节骨折相关的关节内损伤位置和深度可预测功能结果76。踝关节骨折行手术治疗患者应用关节镜术中评估关节内病理状况，一组患者的临床结果平均记录12.9年。总的来说，关节镜下可发现81%患者合并软骨损伤，最常发生的部位是距骨。存在任何软骨损伤和AOFAS评分<90的优势比为5.0。损伤的深度和位置是后期骨性关节炎的重要预测因子。损伤位置深、距骨前方损伤和AOFAS评分<90的优势比为12.3。作者未发现损伤的数量与较差的功能结果间存在相关性。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.过去一年间，若干关于根骨骨折治疗的研究已报道或提出。Potter和Nunley介绍了大量手术治疗的根骨骨折患者平均随访12.8年的功能结果77。报道称18%的患者经历再次手术，最常见的原因是内植物导致手术部位疼痛。仅2名(3%)患者施行了距下关节融合术。平均修正AOFAS评分为65.4分，当患者基于劳工赔偿身份分级时无差异。当患者基于损伤机制分级时，3项功能评分中有2项存在差异。高处坠落致跟骨骨折患者功能评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.一项随机试验评估了磷酸钙骨空隙填充剂治疗有移位的关节内跟骨骨折的有效性78。切开复位内固定+注射磷酸钙与单独切开复位内固定相对比。两组患者Bohler角均逐渐减小，随访6月和1年时，单独切开复位内固定组患者Bohler角减小更为明显。与单独切开复位内固定组相比，切开复位内固定+注射磷酸钙组患者很大程度上维持了术后即刻Bohler角，但这种维持并未能改善功能结果。在6月和1年时，两组患者在SF-36和下肢测量法(LEM)方面无差异。2年时，两组患者疼痛程度方面无差异。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.两项研究评估了跟骨骨折行距下关节融合术。第一项研究强调跟骨骨折初次治疗对接下来距下关节融合的影响79。根据表现出来的畸形愈合类型，最初行非手术治疗的患者需要行撑开距下关节融合术。最初行切开复位内固定的患者可以行原位距下关节融合术。两组患者在平均随访6月后进行对比。最初行切开复位内固定的患者感染率显著降低，功能结果(Maryland足部评分和AOFAS踝-后足部评分)显著改善。最后，报道了跟骨骨折行非重建性原位距下关节融合术的中长期临床结果80。超过17年时间中，35名此类骨折(Sanders III型或IV型)患者行切开复位内固定联合原位距下关节融合术。15名患者获得随访，平均9.8年。平均AOFAS踝-后足部评分随访时为79.8。距跟高度与功能结果评分相关。Evidence-Based Orthopaedics骨科循证医学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.期刊的编辑人员回顾了大量最近出版的关于骨肌系统被认为证据水平为I级或II级研究。回顾超过100种医学期刊以鉴别这些文章，所有研究均有高质量的研究设计。与骨科创伤有关的12篇I级和II级文章列表附加于本综述标准参考文献之后。以此创伤骨科领域循证医学的方式，我们提供每篇文章的简短注释以帮助引导你进一步阅读

The field of musculoskeletal trauma continues to benefit from advances in basic science, improved methods of treatment(both operative and nonoperative), innovation in surgical devices,and more sophisticated research methodology, with emphasis on comparative clinical trials and appropriate assessment of outcomes. The emphasis on evidence-based management continues in the literature and in presentations at academic conferences.骨肌创伤领域继续受益于基础科学的进步、治疗方法的改进(手术治疗和非手术治疗)、外科器械的创新、高级的研究方法学以及强调对比性临床试验和适当的疗效评估。文献以及学术会议陈述继续强调循证医学的应用。For this year’s summary of advances in orthopaedic traumatology, the authors again reviewed all issues of Acta Orthopaedica, Clinical Orthopaedics and Related Research, Injury,The Journal of Bone and Joint Surgery (both American and British volumes), Journal of Orthopaedic Trauma, Journal of Shoulder and Elbow Surgery, and The Journal of Trauma. Selected articles from other journals were also included. Finally, presentations from the annual meetings of the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS) were reviewed. Articles and presentations that represent Level-I and Level-II evidence are reviewed in this article along with other articles of clinical importance in the opinion of the authors.为总结本年度骨科创伤学进展，作者回顾了矫形学报、临床骨科及相关研究、损伤、JBJS(美版和英版)、骨科创伤杂志、肩肘外科杂志和创伤杂志的全部内容，并从其它杂志选择部分文章。最后，回顾骨科创伤协会(OTA)、美国骨科医师学会(AAOS)年会的部分陈述。本文回顾了代表I级和II证据的文章和陈述。还有其它一些文章，其作者的观点有重要的临床意义。Outcomes结果The rigorous documentation of outcome, especially from the patient’s perspective, has been one of the major advances in orthopaedic surgery over the past decade. Two studies investigated differences between patient and surgeon perceptions of outcome after orthopaedic trauma. One study evaluated patients six months after they had sustained a“major”fracture1. Surgeons were more satisfied with their patients’ progress than the patients themselves were. The only factor associated with surgeon satisfaction was fracture-healing. Objective injury and treatment factors were not associated with patient satisfaction in terms of progress. Attributing blame of the injury to others was associated with patient satisfaction in terms of progress, whereas blame, the use of a lawyer, and female sex were associated with patient satisfaction in terms of recovery1.对临床结果特别是来自患者的期望的严格记录，成为过去十年中骨外科主要进步之一。两项研究调查了骨科创伤后患者和外科医师对临床结果感受的差异。一项研究评估了持续6月后仍未愈合的严重骨折患者状况1。外科医师对患者病情进展的满意程度要高于患者本人。唯一与外科医师满意度相关的因素是骨折愈合。就病情进展来说，客观的损伤和治疗因素与患者满意度无关，将损伤过失归因于他人与患者满意度有关；就病情恢复来说，雇佣律师应对过失、患者为女性与患者满意度有关1。The Lower Extremity Assessment Project (LEAP) investigators reported data, obtained from their observational study of patients with limb-threatening lower extremity injury, that documented the discrepancy between patient and surgeon perceptions of functional and cosmetic outcomes2. Several factors were predictive of discordance; some were associated with higher surgeon satisfaction whereas others were associated with greater patient satisfaction. Self-reported patient dissatisfaction with overall medical care was predictive of discordance in the perception of both overall and cosmetic outcomes between patients and surgeons.下肢评估项目(LEAP)的研究者们利用对严重下肢创伤患者的观察性研究得到数据，记录了患者和外科医师对功能和外观临床结果的不同感受2。若干因素预示着不一致性，一些与外科医师较高的满意度有关，而另外一些与患者较高的满意度有关。患者自我报告对全程医疗服务不满预示着患者和外科医师之间对于总体和外观结果感受的不一致性。A third study assessed the outcomes of “after-hours”treatment of tibial and femoral shaft fractures with intramedullary nailing3. Patients undergoing femoral or tibial nailing at night had a higher rate of unplanned reoperation than those managed during the day, and patients with femoral fractures that were treated at night had a greater need for interlocking screw removal in comparison with those who were managed during the day (27% compared with 3%). The authors concluded that allocating resources to increase daytime surgery for non-emergency intramedullary nailing cases has the potential to decrease the rate of minor complications.第三项研究评估了胫骨和股骨干骨折于夜间行髓内针治疗的结果3。在夜间应用股骨或胫骨髓内针治疗的患者较日间手术者有更高的非预期性再手术率，在夜间治疗的股骨骨折患者较日间患者更有必要取出锁定螺钉(27% : 3%)。作者认为，增加日间非急诊的髓内针手术资源配置可能会减少一些轻度并发症。Polytrauma多发伤The concepts and proper application of damage-control orthopaedics continue to be defined. In one series of polytrauma patients undergoing treatment of femoral fractures, “normalizing lactate” was considered to be indicative of adequate resuscitation and the indication to proceed with primary intramedullary nailing of the fracture4. Overall, 88% of patients underwent femoral nailing with reaming at an average of fourteen hours after admission, whereas 12% underwent provisional external fixation.Adult respiratory distress syndrome occurred in 1.5% of patients, which was lower than the rate among historic controls. Adult respiratory distress syndrome was also less common than expected in patients with pulmonary injury and in the most severely injured patients. These findings indicate that simple measures of resuscitation (in this case, serum lactate) are reasonable indicators of when a patient is physiologically able to undergo nailing for the treatment of a femoral fracture.继续明确损伤控制骨科的概念并合理应用。对于接受股骨骨折治疗的一系列多发伤患者，“乳酸正常”被认为是机体充分复苏的预示和进行初步骨折髓内针固定的指征4。就总体而言，88%的患者平均在住院后14小时进行股骨髓内针内固定治疗，另外12%暂行外固定治疗。成人呼吸窘迫综合症（ARDS）发生率为1.5%，低于以往对照。ARDS在肺部损伤和最严重的创伤患者中的发生率与预计相比，并不常见。这些发现表明，衡量机体复苏的简单指标(本病例中为血清乳酸含量)是患者生理上能够接受髓内针治疗股骨骨折的合理标志。Another study challenged the idea that external fixation is the only effective method of provisional femoral fracture stabilization when employing damage-control orthopaedics5. There was no difference in terms of adult respiratory distress syndrome, multisystem organ failure, and pneumonia in polytrauma patients undergoing delayed stabilization of a femoral fracture that had been treated initially with skeletal traction or placement of an external fixator. There also were no differences when patients with associated chest trauma were compared. The authors concluded that, unless a patient is already undergoing general anesthesia, there is no significant advantage of external fixation as compared with skeletal traction.另一种研究对基于损伤控制骨科学的外固定是暂时稳定股骨骨折的唯一有效方法的观念提出挑战5。首先行骨牵引和外固定而延迟股骨骨折内固定的多发伤患者在ARDS、多系统器官衰竭、发生肺炎方面并无不同。当与胸部损伤相关的患者对比时，亦无不同。作者认为，除非患者已经行全麻，否则外固定与骨牵引相比无明显优势。Open Fractures, Wound Management, and Infection开放性骨折，伤口处理和感染A continued source of controversy in orthopaedic trauma is whether increased time to surgical debridement increases the infection rate in patients with open fractures. The LEAP investigators evaluated their cohort of patients with severe lower extremity trauma and found that the time from injury to debridement was not predictive of infection6. However, the time from the injury to admission to the definitive treatment center was a significant predictor of infection. Because of the observational nature of this study, the reasons for this finding are not clear, and the authors concluded that their data “should not be interpreted as an argument that operative debridement of open fractures should not be accomplished urgently.”是否外科清创术时间的增加也增加了开放性骨折患者的感染率是创伤骨科持续争论的焦点。LEAP的研究者们评估了一组严重下肢创伤患者，发现自受伤至清创的时间不能成为感染的预测因子6。然而，自受伤至住院部治疗中心是感染的重要预测因子。由于这项研究观察的性质，这些发现的理由并不明确，并且作者认为他们的数据“不应该被理解成一种论据，即开放性骨折的不应该急诊行手术清创”。Vacuum-assisted wound closure (also referred to as negative-pressure wound therapy) is now commonly used for the initial treatment of open fracture wounds, despite the fact that there are few data regarding the efficacy of this approach. Stannard et al. randomized sixty-two severe open fractures to treatment with negative-pressure wound therapy or sterile moist saline solution dressings until ultimate closure or coverage7. Overall, 5.4% of patients managed with negative pressure wound therapy developed an infection, compared with 28% of patients in the control group, a finding that was statistically significant and clinically important. Patients managed with negative-pressure wound therapy also had improved outcomes as measured with the Short Form-36 (SF-36).真空辅助伤口闭合(即伤口负压疗法)现在常规用于开放性伤口的初始治疗，尽管关于此疗法的有效性的数据很少。Stannard等随机对比62例应用伤口负压疗法或无菌湿盐水敷料治疗的严重开放性骨折，直至伤口最终闭合或被组织覆盖7。总体上，应用伤口负压疗法的患者中感染率为5.4%，对照组为28%，这个发现在统计学和临床方面均有重要意义。以SF-36量表衡量负压疗法患者的临床效果亦有改善。Diabetes is a recognized risk factor for complications following fracture surgery. Karunakar and Staples recently presented the effects of stress-induced hyperglycemia on the rates of infection in 110 nondiabetic orthopaedic trauma patients8. Overall, 25% of the patients developed an infection, including pneumonia (seventeen patients) and wound infection (eleven patients). Sixty-four percent of patients with a hyperglycemic index of ≥3.0 developed an infection, compared with 21% of patients with a hyperglycemic index of 是公认的引起骨折手术并发症的危险因素。Karunakar和Staples介绍了压力诱发高血糖在110名非糖尿病骨科创伤患者感染率中的作用。总体上，25%的患者并发感染，包括肺炎(7名)和伤口感染(11名)。其中64%高血糖指数≥3.0的患者并发感染，高血糖指数80) was associated with a dramatic reduction in the incidence of delirium as compared with deep sedation (bispectral index, 80)与深镇静(双频谱指数150,000 fractures in female patients who were more than fifty years old. The overall rate of diagnosis and subsequent treatment of osteoporosis was 19.3%. However, patients with wrist fractures were less likely to be evaluated and managed for osteoporosis as compared with the overall cohort. The authors believed that a “care gap” exists and suggested that further efforts and initiatives should be directed toward improving the evaluation and subsequent treatment of osteoporosis that may be manifested early by a fracture of the wrist.许多老年人骨折由于骨质疏松导致，但是韩国一项大型保险数据库研究认为，对骨质疏松进一步评估和治疗的可能性取决于患者脆性骨折的类型14。作者分析了超过150,000例年龄超过50岁的女性骨折患者，诊断为骨质疏松并进一步治疗的患者占19.3%。然而，与总队列相比，很少对腕部骨折患者进行骨质疏松进行评估和处理。作者相信存在一个“医疗缺口”，并建议进一步的努力和行动应该直接用于改善骨质疏松的评估和治疗，这可能早已被腕部骨折病例所证明。Pediatric Fractures儿童骨折Two recent studies presented different views of the controversial issue of the ‘‘pulseless hand’’ associated with pediatric supracondylar humeral fractures. Choi et al. analyzed 1255 consecutive children who had operative treatment of a supracondylar humeral fracture15. In this large group, only thirty-three patients (2.6%) presented with absent distal pulses; twenty-four of them had a pink, perfused hand. None of the twenty-four children with absent distal pulses but a wellperfused hand required vascular intervention. Of these twenty-four patients, thirteen regained a palpable pulse after fracture reduction and the other eleven maintained adequate distal perfusion. Nine other children presented with absent pulses and a poorly perfused hand. Four of these nine patients required vascular intervention, and two developed compartment syndrome. Thirty-two of the thirty-three patients were available for follow-up at a median of eight weeks, and all were noted to have satisfactory perfusion. The second study, by Blakey et al., evaluated the longer-term follow-up for twentysix children who had been referred to their institution with a history of a ‘‘pink pulseless hand’’ associated with a supracondylar humeral fracture16, which is a different patient population than was reported by Choi et al.15. The range of time between the injury and referral was broad (four days to three years). Twenty-three (88%) of the twenty-six patients developed some degree of ischemic contracture. The authors advocated an aggressive approach toward children with a ‘‘pink pulseless hand’’ in order to avoid such complications16. On the surface, these two studies seem contradictory. However, one had short-term follow-up, whereas the other had much longer follow-up, and, most importantly, the two study populations were very different. Additional research is needed to clearly identify whether there is a subset of patients with a “pink pulseless hand” who are at greater risk of long-term morbidity and should potentially be managed with urgent vascular exploration.与儿童肱骨髁上骨折相关的“无脉手”问题尚存争议，最近2项研究提出了此问题的不同观点。Choi等分析了1255名行手术治疗的肱骨髁上骨折患儿的连续病例15。在本组中，仅有33名患儿(2.6%)表现为远端脉搏消失；24名患儿手掌充盈良好，呈粉红色，无远端脉搏消失，但是充盈良好的手掌需要血管介入。这24名患儿中，13名在骨折复位后可再次触及脉搏，另外11名可维持足够的远端充盈。其他9名患儿脉搏消失且手部充盈不佳，其中4人需要血管介入，2人发展为骨筋膜室综合症。33人中的32人获得随访，平均8周，全部患儿均手部充盈良好。Blakey等进行了第2项研究，对26名既往肱骨髁上骨折后‘‘粉红色无脉手’’患儿进行长期随访并评估16，这与Choi15报道的患儿群体不同。患儿从损伤至医疗处置的时间范围广(4天~3年)。23名(88%)发展为某种程度的缺血性痉挛。作者提倡对‘‘粉红色无脉手’’行有创治疗以避免并发症16。表面来看，这2项研究是矛盾的。然而，一项为短期随访，另一项为长期随访，更重要的是，2项研究所选的群体不同。要明确一组“粉红色无脉手”患儿是否有长期处于病态的高风险和是否应该急诊行血管探查的问题需要进一步的研究。Several studies evaluated aspects of pediatric femoral fractures. Basener et al. performed a meta-analysis of sixteen articles (564 children) documenting that growth disturbance after distal femoral physeal fractures is common17 (see the Evidence-Based Orthopaedics section at the end of this article). Keeler et al. presented a series of eighty pediatric femoral fractures in patients with a mean age of 12.9 years who were managed with reaming and statically locked antegrade nailing with use of a lateral trochanteric entry portal18. All fractures healed without evidence of malunion, and no patient had evidence of osteonecrosis or of altered proximal femoral anatomy. The authors concluded that antegrade femoral nailing via a lateral trochanteric portal is safe and effective for children who are more than eight years old. However, the starting point that those authors used was very lateral and fairly distal on the trochanter, increasing risk of deformity.一些研究评估了儿童股骨骨折方面的问题。Basener等对16篇文章(564名儿童)进行mata分析，这些文章记录了股骨干骺端骨折后生长障碍为患儿所共有17(见本文最后循证医学部分)。Keeler等介绍了80名股骨骨折患儿病例，平均年龄12.9岁，术式采用经大转子外侧入路扩髓并置入静力性顺行锁定髓内针18，全部骨折愈合良好，无骨不连、骨坏死及股骨近端解剖结构改变的证据。作者得出结论，经大转子外侧入路置入顺行股骨髓内针对年龄8岁以上儿童是安全有效的。然而，那些作者起始使用的入路在转子极外侧和远端，增加了畸形愈合的风险。Proximal Part of the Humerus肱骨近端Fractures of the proximal part of the humerus continue to be a source of debate, and a particular problem is predicting outcome. A recent study evaluated the ability of the initial shoulder radiographs to predict the outcome of nonoperative treatment of proximal humeral fractures19. In a study of fiftyfive patients with minimally displaced proximal humeral fractures, the authors found a correlation between worse outcome scores (Constant-Murley and Disabilities of the Arm, Shoulder and Hand [DASH] scores) and changes in angulation during the first week after the injury on the trans-scapular ‘‘Y’’ radiograph but not on the anteroposterior radiograph.Patients with the poorest scores had a mean change in angulation of 30° on the scapular ‘‘Y’’ radiograph, compared with no change for those with the best outcome scores. Although change in angulation is just one of many items to consider, this change can be measured objectively and does appear to be predictive of outcome. Surgeons should take special care to assess changes in angulation on the lateral radiographs.肱骨近端骨折继续成为争论的源头，一个值得注意的问题是结果预测。最近一项研究评估了最初肩部X线平片预测非手术治疗肱骨近端骨折临床效果的能力。一项研究包括55名轻微移位的肱骨近端骨折患者，其作者发现，较差的临床结果评分(Constant-Murley和臂肩手失能评分[DASH评分])和伤后一周穿肩胛位而非前后位X线平片上骨折成角变化存在相关性。评分最差的患者肩胛位X线平片骨折平均成角30°，与之相对，评分最佳的患者无成角变化。尽管成角变化是应该考虑的诸多因素之一，此种变化能够客观地进行测量，似乎可以成为预后的预测因子。外科医师在评估侧位X线片上成角变化应特别注意。Locked plating has become commonplace for the treatment of proximal humeral fractures. A number of larger case series were recently published regarding the outcome of locked plating, although comparative studies are still lacking20-22.Taken together, all of these studies emphasize that final outcomes are not achieved for at least one year and that complications occur in one-third of patients, with screw penetration(either at the time of surgery or later), varus collapse, and osteonecrosis being most common20-22. Complications are more frequent in patients who are more than sixty years old and in those with more complex fracture patterns20. In general, varus malunion is associated with poor functional outcomes20.应用锁定钢板治疗肱骨近端骨折已成为常规疗法。尽管缺少对比性研究，最近一项关于锁定钢板的大样本病例研究结果已经发布20-22。总的来说，所有这些研究都强调最终临床结果在一年时并未达到，1/3患者出现并发症，螺钉贯穿(术中或术后)，内翻畸形和骨坏死最为常见20-22。并发症更常见于60岁以上和骨折类型复杂的患者20。一般而言，内翻畸形与功能效果不良相关20。Elbow肘Traditional fixation of intra-articular distal humeral fractures has relied on fixation with two plates oriented at 90° to one another. Recently, anatomic precontoured plates designed to be placed parallel to each other on the medial and lateral surfaces of the distal part of the humerus have been made available. A comparison of these two methods in a small randomized clinical trial showed no differences in terms of the ranges of elbow flexion and extension, the Mayo Elbow Performance Score, time to union, or complications23. Both methods seem to provide adequate stability, and either method can be used to achieve stable and anatomic reconstruction of the distal part of the humerus.传统的肱骨远端关节内骨折内固定依靠互成90°角的两块钢板。最近，一种平行置于肱骨远端中间和侧方表面的解剖塑型钢板设计完成。对比两种方法的小样本随机临床试验显示，在肘关节屈伸范围、Mayo肘关节功能评分、愈合时间、并发症方面无差异。两种方法均可提供足够的稳定性，任何一种方法均可用于完成肱骨远端稳定及解剖重建。Complex elbow injuries remain an area of active research.A recent study focused on Mason type-II injuries of the radial head,in which part of the radial head is displaced >2 mm24. The injuries were grouped according to whether or not there was cortical contact between the fractured fragment and the rest of the radius. Overall, 75% of the cases did not have cortical contact, and, of these, 91% were part of a complex elbow fracture pattern with associated fractures and/or ligamentous injury. In contrast, just 33% of the fractures with cortical contact were considered to be part of a complex injury.Therefore, complete loss of cortical contact in radial head fractures should alert the clinician that the radial head fracture may be just one part of a complex injury pattern and that additional evaluation and expert management are needed.复杂的肘部损伤还有进行积极研究的空间。最近一项研究集中于Mason II型桡骨头损伤，即桡骨头移位>2 mm24。损伤根据骨折块与桡骨是否存在皮质连续性分组，75%的病例不存在连续性骨皮质，这其中91%为合并骨和/或韧带损伤的复杂肘部损伤。与之相对，仅33%的复杂损伤骨皮质存在连续性。因此，完全失去骨皮质连续性的桡骨头骨折应作为对临床医师的警示，桡骨头骨折仅作为复杂损伤的一部分，需要额外的评估和专家进行处置。Three groups of investigators reported the results of long-term studies of elbow injuries involving the radial head25-27.In one study, good to excellent elbow function was seen in thirteen of sixteen patients who had had internal fixation of a stable Mason type-II radial head fracture between fourteen and thirty years earlier (mean duration of follow-up, twentytwo years)25. However, as the authors themselves pointed out, these long-term results of surgery for the treatment of stable, isolated partial articular radial head fractures were not better than the reported results of nonoperative treatment, and there were major complications of surgery in this series. Another study evaluated the results of radial head resection following a Mason type-II or III radial head fracture; the duration of follow-up ranged from fifteen to thirty-nine years26. No patient had complications or a reoperation, and the clinical result was graded as good or excellent in 92% of cases. The average carrying angle of the elbow was twice that of the contralateral elbow (21° compared with 10°), and a minor amount of radial shortening (average, 3.1 mm) was a typical finding. Radial head resection in young patients with isolated radial head fractures without instability can yield satisfactory long-term results. In the final study, twenty-one patients with a Mason type-IV fracture-dislocation, without a type-II or III coronoid process fracture, were evaluated after a mean duration of follow-up of twenty-one years (range, fourteen to forty-six years)27. All patients underwent closed reduction and had the elbow immobilized for two to six weeks. Eleven patients underwent complete radial head excision, two had partial radial head excision, and two others had an anular ligament repair. At the time of long-term follow-up, only one patient had severe impairment of the elbow, and no patient experienced instability or recurrent dislocation. The authors concluded that most patients who have a Mason type-IV fracture-dislocation of the elbow, without an associated coronoid fracture, have a good long-term outcome.三组调查者报告了对合并桡骨头骨折的肘部损伤的长期研究结果25-27。在第一项研究中，对16名稳定的MasonII型桡骨头骨折行内固定术后患者随访14~30年(平均22年)，其中13名患者肘部功能良好25。然而，正如作者所述，对于部分累及关节的单纯稳定型桡骨头骨折，手术治疗效果与非手术治疗相比，无明显优势，并且本组手术患者合并较严重并发症。另外一项研究评估MasonII型、III型桡骨头骨折行桡骨头切除术患者，随访14~39年26，患者无并发症及二次手术发生，92%的患者临床结果评分良好。平均肘关节提携角是对侧的2倍(21° : 10°)，并有轻度桡骨短缩(平均3.1 mm)。单纯稳定型桡骨头骨折青年患者行桡骨头切除术远期临床结果满意。最后一项研究中，评估21名MasonIV型骨折-脱位，无II或III型喙突骨折患者，平均随访21年(范围14~46年)27。所有患者行闭合复位并肘关节制动2~6周。11名患者行完整桡骨头切除，2名患者行部分桡骨头切除，另有2名患者行环状韧带重建。长期随访中，仅有1名患者出现严重的肘部损害，所有患者均无肘部不稳和复发性脱位。作者认为，大多数肘关节MasonIV型骨折-脱位，不合并喙突骨折患者，远期临床结果良好。Distal Part of the Radius桡骨远端There is wide variation in the rate of distal radial fracture depending on demographic group, with the highest rates in whites and females28. There is also wide geographic variation in incidence. According to Medicare data, operative intervention for distal radial fractures in the elderly has increased fivefold in the last decade, although nonoperative treatment remains most common29.Treatment modality varies widely across regions within the United States but is not affected by race.依据人口统计学数据，桡骨远端骨折发病率差异巨大，高发于白人和女性28，发病地区亦有很大差异。根据Medicare的数据，尽管非手术治疗最为常用，需要手术干预的老年桡骨远端骨折患者在过去10年增长了5倍29。治疗方式在美国地区多样化，但与人种无关。Many options exist for the treatment of distal radial fractures, without much evidence to choose among them.Several studies during the past year compared treatment methods and provided further guidance for surgeons who treat these injuries. In one randomized study of fifty patients, fragment-specific fixation provided better results at the time of the one-year follow-up than did closed reduction and external fixation in terms of grip strength, motion, and the rate of malunion30. However, there were no differences in terms of the DASH score at one year. In another study of patients with unstable fractures, early results as measured with DASH scores were better after volar plating than after closed reduction and pinning31. However, at the time of the one-year follow-up,the differences between groups had disappeared. A third randomized study compared three methods of treatment: external fixation, radial column plating, and volar plating32. In addition to DASH scores, grip and lateral pinch strength were measured. Treatment with a volar plate was associated with improved early outcomes, but there were no differences between groups at later follow-up periods (six months and one year). A final study used decision analysis methodology to show that volar plating was the preferred strategy in most scenarios,but the magnitude of differences was small33. In general, the long-term gains in quality-adjusted life-years outweighed the risk of surgical complications. Older patients who might tolerate a malunion may be better managed nonoperatively.桡骨远端骨折的治疗有多种方式可供选择，关于选择哪种没有太多证据。去年有很多研究对比治疗方法并对治疗此种损伤的外科医师提供进一步的指导。一项对55名患者进行的随机研究显示，对具体的骨折块进行固定者在1年随访期时，在握力、运动和畸形愈合发生率方面优于闭合复位和外固定治疗者30。然而，术后1年DASH评分无差异。另外一项对不稳定骨折患者的研究显示，以DASH评分衡量的早期结果掌骨板固定优于闭合复位克氏针固定31。然而，在一年后随访时，组间差异消失。第3项随机研究对比三种治疗方法：外固定、桡骨板固定、掌骨板固定32。测量DASH评分、握力和手指夹持力。掌骨板固定早期效果良好，各组间在随后的随访中(6月和1年)无差异。最后一项研究应用决策分析方法，显示掌骨板固定在大多数病例中是优先被选择的策略，但差异等级较小33。大体上，质量调整生命年的增长优于手术并发症的风险。可耐受畸形愈合的老年患者可能通过非手术治疗妥善处理。Spine Trauma脊柱创伤A topic of consistent debate is ‘‘clearance’’ of the spine in a patient with blunt trauma. A meta-analysis of the published literature concluded that an alert, asymptomatic patient without another distracting injury and no neurologic deficit can be cleared without radiographic assessment if he or she can complete a functional neck range-of-motion examination without pain or the elicitation of neurologic signs and symptoms34.Two Level-I diagnostic studies assessed screening tests for spine injury. In the first, the diagnostic accuracy of magnetic resonance imaging findings (as determined by a radiologist) for detecting injury to the posterior ligament complex of the cervical spine was evaluated, with use of intraoperative findings as the diagnostic standard35. The level of agreement between magnetic resonance imaging and intraoperative findings varied between fair (for injury to the ligamentum flavum, facet capsules, and cervical fascia) to moderate (for injury to the supraspinous and interspinous ligaments). In general, magnetic resonance imaging was found to be sensitive for the evaluation of injury, but the positive predictive value and specificity were lower because of “over-reading” of injuries on magnetic resonance imaging. Using magnetic resonance imaging findings alone as a guide to treatment could lead to unnecessary surgery, and other factors should be part of the decision-making process. Another study tested the reliability of nonreconstructed computed tomography of the abdomen and pelvis as a screening tool for thoracolumbar spine injuries in blunt trauma patients with altered mental status36. Such patients were studied with a protocol that included standard anteroposterior and lateral radiographs of the thoracolumbar spine in addition to standard 5-mm computed tomography slices of the chest, abdomen, and pelvis and ≤2-mm reconstructed slices dedicated to the spine. Compared with the dedicated computed tomography reconstructions, nonreconstructed 5-mm computed tomography slices had a sensitivity of 89% and specificity of 85% for the detection of all fractures, which was much greater than those of radiographs (37% and 76%, respectively). None of the fractures that were missed on nonreconstructed computed tomography examination required surgery or other intervention, and the authors concluded that computed tomography reconstructions do not need to be routinely performed in this setting unless further clarification is needed for an abnormality that has already been detected. 关于脊柱钝性创伤患者讨论的一贯性主题是 “损伤排除率”问题。一篇应用meta分析的已发表文献认为，如果患者能够完成颈部功能运动范围检查，无疼痛或未引出神经阳性体征和症状，动作灵活、无症状、不伴随其它损伤且无神经损伤症状可不需要影像学检查排除34。两项I级诊断研究评估了脊柱损伤筛选试验。第一项研究中，评估MRI影像表现(由放射科专家确定)对诊断颈椎后方韧带复合体损伤的准确性，以术中发现作为诊断标准35。MRI和术中发现的一致性水准在尚可(黄韧带、关节囊、颈筋膜损伤)和中等(棘上韧带、棘间韧带损伤)之间不同。一般而言，MRI对损伤的评价较为敏感，但是由于损伤在MRI上往往表现过重，导致阳性预测值和特异性较低。仅应用MRI表现来指导临床治疗可能导致对患者实行不必要的手术，其他因素必须作为决策制定过程的一部分。另一项研究测试非重建CT作为伴有意识改变的胸腰椎钝性损伤患者筛查工具的可靠性36。这些患者的研究方案包括标准前后位，侧位X线平片，以标准的5-mmCT层面扫描胸部、腹部和骨盆，并以≤2-mm层面进行脊柱重建。与CT重建相比，5-mm层面的非重建CT对所有骨折检测的敏感度为89%，特异性为85%，远优于X线平片(各自为37%和76%)。非重建CT对需要手术和其它治疗的骨折无一例漏诊。作者认为，此类病例不需要把CT重建作为常规检查，除非对已检查到的异常表现需要进一步的明确。

近日，我院骨一科为一位93岁的高龄患者顺利实施了“左股骨转子间粉碎性骨折”开放复位锁定钢板内固定术，现已痊愈出院。93岁的龚老爷爷在菜市场不慎摔倒，当即左髋部肿痛并活动障碍，急由我院120急救车接送入院。经CT扫描，确诊为“左股骨转子间粉碎性骨折”，随即住入我院骨一科。在对患者进行全面检查后，发现患者肺功能差、肾功能不全，而且患者高龄，手术耐受性很差，手术风险很大。大外科主任刘平均主任医师及骨一科副主任李际才副主任医师、向家云主治医师等经过慎重研究，决定进行开放复位锁定钢板内固定术。术前心血管内科、呼吸内科大力协助，术中麻醉科全力配合，手术非常顺利，仅用了不到90分钟，龚老便被平安的送回病房。老年患者多有不同程度的骨质疏松，股骨转子间骨折发生率较高。传统方法多采用牵引治疗，卧床时间长，不但易并发坠积性肺炎、尿路感染、深静脉栓塞、褥疮等并发症，而且护理困难，导致死亡率高。现代观点普遍认为，对于老年甚至是高龄患者发生股骨转子间骨折后，争取尽早手术。早期手术方便护理，有利于早日下床活动，大大减少卧床时间，因而减少并发症，降低死亡率，并改善生活质量。有些保守思想甚至认为患者如此高龄，没有治疗意义，而且手术风险大、费用较高，便放弃治疗。我们认为，高龄患者股骨转子间骨折，只要经过精心准备，尽早手术，是很有可能的康复的。另外，本次手术采用新型锁定钢板系统内固定，具有“自我锁定”功能、固定牢固、操作简便、利于早期功能锻炼等优点，特别适用于老年及高龄患者的粉碎性骨折、骨质疏松性骨折。据悉，该例手术患者是我院骨科手术中年龄最大的患者之一。该手术的成功开展，标志着我院骨科在敢于技术创新、挑战高风险手术方面又迈出了重要一步。

[摘要] 目的 探讨腰椎间盘突出症伴椎管狭窄的手术策略及其疗效，为改进手术操作，提高手术质量提供参考。方法 对2001-2008年间手术治疗并资料完整、获得随访的126例腰椎间盘突出症伴有椎管狭窄的患者进行回顾性分析，通过电话、信函及门诊随访的方式进行了6个月-7年的随访。结果 疗效评定参照侯树勋⑴评价标准，优64例、良32例、可21例、差9例。并发症有腰椎间盘突出复发3例，椎管内血肿2例，脑脊液漏2例，腰椎10滑脱及腰椎失稳各1例。无定位错误、椎间隙感染及神经根损伤。结论 在处理中老年腰椎间盘突出症时要重视腰椎管狭窄，并作椎管彻底减压，同时最大限度维护脊柱的稳定性。[关键词] 腰椎 ； 椎间盘移位 ； 椎管狭窄Surgical treatment of lumbar disc herniation associated with lumbar canal stenosis in 126 cases 【Abstract】 Objective To analyze the effect of surgical treatment of lumbar disc herniation associated with lumbar canal stenosis in order to improve operative procedure and obtain a better outcome. Methods The data of 126 cases of lumbar disc herniation associated with lumbar canal stenosis were reviewed from 2001 to 2008, which being followed up 6 months to 7 years by telephons ,letters and out-patient clinic. Results According to HOU Shu-xun⑴ evaluation criterion ,the results were excellent in 64 cases, good in 32 cases ,fair in 21 cases and poor in 9 caes. Surgical complications included recurrence of lumbar disc herniation in 3 cases, incision hematoma in 2 cases, leakage of cerebrospinal fluid in 2 cases, and lumbar slippage,lumbar destabilization appeared in one case respectively. Conclusion Lumbar canal stenosis should be throught highly of when we treat with lumbar disc herniation in elders, It’s also important to protect spinal stability utmostly when vertebral canal be decompressed thoroughly. 【Key words】 Lumbar vertebrae ; Intervertebral disk displacement; Spinal stenosis腰椎间盘突出症伴椎管狭窄多为中老年患者，其手术治疗方法尚有争议，手术并发症较多，手术效果还有待提高。我们在2001-2008年间手术治疗腰椎间盘突出症伴椎管狭窄患者196例，对其中资料完整并获得随访的126例患者进行回顾性分析。现报告如下：1.资料与方法1．1一般资料本组共126例，男86例，女40例，年龄35~78岁，平均57.6岁。病程2月~26年。临床表现以腰痛为主者32例，腰痛伴一侧或双侧下肢胀痛、麻木者60例，仅有一侧或双侧下肢胀痛，麻木者34例，其中有109例表现有不同程度的间歇性跛行，无一例出现马尾神经综合症。所有病例均行腰椎X线摄片、CT或（和）MRT检查。腰椎间盘突出间隙：L3-4 15例，L4-5 41例，L5S1 27例，L3-4+L4-5 15例，L4-5+L5S1 18例，L3-4+L5S1 4例，L3-4+L4-5+L5S1 6例。突出类型：中央型35例，旁侧型91例，其中14例有椎间盘或后纵韧带钙化；腰椎管狭窄情况：中央椎管狭窄32例，周围椎管（包括侧隐窝和神经根管）狭窄94例。椎管狭窄节段范围：单节段74例，双节段38例，多节段14例。1．2手术指征及手术方法的选择所有患者均进行了至少一个月的保守治疗症状无明显改善，且临床体征与影像资料符合，无手术禁忌症。手术方法有三种：①开窗髓核摘除+侧隐窝扩大术：对于一个或多个间隙腰椎间盘突出并周围椎管狭窄者，可采用一处或多处，一侧或双侧椎板间开窗，摘除突出之髓核，咬除肥厚的黄韧常及增生内聚的部分关节突 ，本组采用该术式76例，其中30例在后路显微椎间盘镜（MED）下完成；②半椎板切除髓核摘除+椎管扩大术：对于多个相邻节段椎间盘突出并椎管狭窄，可采用切除症状侧或双侧，一个或多个半椎板，摘除髓核并行中央椎管及周围椎管的潜行扩大减压，本组采用该术式35例，其中17例伴有中央椎管狭窄；③全椎板切除术，对伴有严重的中央型椎管狭窄者，采用一个或多个节段全椎板切除减压，摘除突出的髓核并探查扩大侧隐窝，本组共15例，其中9例加作钉棒系统内固定cage植骨融合术。1．3 术后处理 术后常规卧床休息3~4周。术后第3天开始床上练习直腿抬高，术后1~2周开始行腰背肌功能锻炼，3~4周后戴腰围或腰部支具下床活动。2．结果本组57例获得随访，随访方式采用电话、信件及门诊随访。随访时间6个月~5年。疗效评定标准参照侯树勋⑴评价标准 。优：随访时完全恢复正常，无残余症状，恢复正常生活和工作；良：术后近期完全恢复，1~5年后在劳累或天气变化时偶有腰痛、腿痛或下肢麻木等症状，对生活、工作无明显影响；可：术后主要症状消失，但残留小腿麻木或疼痛，或劳累及天气变化时有腰腿痛，对生活、工作有一定影响；差：术后症状无改善或术后主要症状改善，近期内腰腿痛复发，间歇性跛行等症状。结果优64例，良32例，可21例，差9例。术中、术后并发症发生情况：腰椎间盘再突出3例，脑脊液漏2例，椎管内血肿2例，腰椎10滑脱1例，腰椎失稳1例，无定位错误、椎间隙感染及神经根损伤发生。3、讨论3．1 文献报告，腰椎间盘突出症合并腰椎管狭窄者约占腰椎间盘突出症37.6%⑵，且以中老年人为主。但临床中往往只重视腰椎间盘突出症的诊断和处理，而忽视了腰椎管狭窄，导致诊疗失误及手术效果不佳。中老年人常有腰椎退变，而腰椎退变始于椎间盘。椎间盘退变致椎间盘高度下降，椎间隙狭窄，纤维环松弛，椎体间滑移增加，并由此产生脊柱相应结构的代偿性变化：①小关节突压力与摩擦力增加，在反复损伤与修复中关节突骨性关节炎，小关节囊松弛肥厚，关节突增生内聚，致神经根管狭窄；②后柱应力增加，黄韧带肥厚甚至椎板增厚，形成中央椎管狭窄而挤压脊髓和神经根引起相应症状；③上位椎体椎弓根下沉，压迫神经根；④下位椎体上关节突上移前倾，增生肥大，顶压神经根。本组126例均为中老年人，说明对于中老年人腰椎间盘突出症，要考虑伴有椎管狭窄的可能。术者术前要详细询问病史，认真体查，仔细阅读影像资料，做到心中有数，才能减少失误。3．2腰椎管狭窄以周围椎管狭窄为多见，本组94例，占74.6%，且腰椎间盘突出也以旁侧型居多，故侧隐窝成为手术处理的重点。侧隐窝狭窄除去椎间盘突出因素外，还有黄韧带肥厚、关节突增生、内聚等。忽视侧隐窝的处理往往导致减压不彻底，术后症状难以消除。术中应彻底解除对硬膜囊和神经根的压迫，直到神经根松弛，可横向移动达1cm左右⑶。但也不应盲目扩大减压范围，否则不仅增加了手术时间及出血量，更重要的是可能破坏脊柱的稳定性。金大地等⑷认为关节突单侧切除1/3者，不影响脊柱的稳定性，而双侧关节突切除大于1/2者可出现不稳。我们认为，对腰椎管狭窄，下列情况应考虑行内固定：①广泛全椎板减压术后，需行两个以上节段的脊柱融合；②伴有假性滑脱10以上；③复发性腰椎管狭窄，伴有医源性滑脱者；④术中切除双侧小关节突大于1/2者。本组有9例腰椎间盘突出并严重的中央椎管狭窄，术中见黄韧带、关节突、椎板均有明显增生增厚，行全椎板切除术+钉棒系统内固定cage植骨融合术，术后随访2~4年，疗效优良。3．3手术方式的选择要结合术中的具体情况决定。一般来说，大多数的腰椎间盘突出伴周围椎管狭窄，可通过一处或多处、一侧或双侧开窗髓核摘除同时侧隐窝或神经根管减压解决，甚至可在后路显微椎间盘镜（MED）下完成⑸。只有在严重的椎管狭窄尤其是中央型椎管狭窄处理困难时，半椎板或全椎板减压才有必要。我们认为有两个手术基本原则必须坚持：一是彻底解除压迫；二是最大限度地减少创伤，维护脊柱的稳定性。本组有2例术前诊断为L4-5椎间盘突出并中央椎管狭窄症，在行全椎板减压后探查L4-5椎间盘仅有轻度膨出，故未行髓核摘除术，术后病人恢复良好，随访3年，仅劳累后腰痛，下肢麻木，胀痛症状无复发，病人主观满意。另外，手术目的以解决引起现有临床症状的问题为主，不要只根据影像资料而盲目扩大手术范围。参考文献：1.侯树勋，李明全，白巍，等.腰椎髓核摘除术远期疗效评价.中华骨科杂志，2003 ，23（9）：513—516.2.李新奎，王全平，朱锦宇，等.腰椎间盘突出并椎管狭窄症手术失误及再手术治疗.中华骨科杂志，1997，17（5）：315.3.李超.腰椎间盘突出症再次手术探讨.中国矫形外科杂志，2000，7（2）：202.4.金大地主编.现代脊柱外科手术学.北京:人民军医出版社，第一版，2001，12.5.彭耀庆，张朝跃，詹瑞森，等.老年性腰椎间盘突出症的临床分型与脊柱内窥镜手术疗效.湖南医科大学学报，2001，26（4）：345-346.