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曾紀(jì)洲主任醫(yī)師 北京潞河醫(yī)院 骨關(guān)節(jié)外科 全膝關(guān)節(jié)置換術(shù)后股骨遠(yuǎn)端假體周圍骨折的治療(2020)TheTreatmentofPeriprostheticDistalFemoralFracturesAfterTotalKneeReplacement?QuinziDA,ChildsS,LipofJS,SoinSP,RicciardiBF.TheTreatmentofPeriprostheticDistalFemoralFracturesAfterTotalKneeReplacement:ACriticalAnalysisReview[J].JBJSRev,2020,8(9):e2000003.轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/33151645/轉(zhuǎn)載文章的原鏈接2：https://journals.lww.com/jbjsreviews/abstract/2020/09000/the_treatment_of_periprosthetic_distal_femoral.5.aspx?Abstract??Periprostheticdistalfemoralfractureaftertotalkneearthroplastycarriessubstantialmorbidityandmortalityregardlessoffixationtechnique.??Surgicaltreatmentisfavoredinmostpatientscomparedwithconservativetherapybecauseofhighratesofnonunion,malunion,andreoperationaftercastingorbracing.??Internalfixationtechniquesincludingretrogradeintramedullarynailingandlockedplatingarefavoredforsurgicaltreatmentinmostfractureswhenbonestockinthedistalfragmentallowsforappropriatefixation.??Inthesettingofdeficientdistalfemoralbonestockorfemoralcomponentloosening,revisionarthroplastywithdistalfemoralreplacementisthefavoredtechnique.??Furtherstudieswithregardtotheuseofintramedullarynailing,lockedplating,anddistalfemoralreplacementarenecessarytorefinetheindicationsforeachtechniqueandtodefinetheuseofcombinationsofthesefixationtechniques.無論采用何種固定技術(shù)，全膝關(guān)節(jié)置換術(shù)后股骨遠(yuǎn)端假體周圍骨折的發(fā)病率和死亡率都很高。與保守治療相比，手術(shù)治療在大多數(shù)患者中更受青睞，因為手術(shù)治療的不愈合、不愈合率高，并且在鑄造或支具后再次手術(shù)。內(nèi)固定技術(shù)包括逆行髓內(nèi)釘和鎖定鋼板，在大多數(shù)骨折的手術(shù)治療中，當(dāng)遠(yuǎn)端碎片的骨量允許適當(dāng)?shù)墓潭〞r，首選內(nèi)固定技術(shù)。在股骨遠(yuǎn)端骨缺損或股骨假體松動的情況下，股骨遠(yuǎn)端置換術(shù)的翻修關(guān)節(jié)成形術(shù)是首選的技術(shù)。有必要進(jìn)一步研究髓內(nèi)釘、鎖定鋼板和股骨遠(yuǎn)端置換術(shù)的應(yīng)用，以完善每種技術(shù)的適應(yīng)癥，并確定這些固定技術(shù)的組合使用。?EpidemiologyPeriprostheticfractureisoneofthemostcommoncomplicationsaftertotalkneearthroplasty,withratesof0.3%to3.5%inthefirst4yearsafterthesurgicalprocedure1,2.Periprostheticsupracondylardistalfemoralfractureisthemostcommontypeofperiprostheticfractureaftertotalkneearthroplasty3.Thesefracturestypicallyoccuringeriatricpatientswithosteoporosis,withameanageof.70yearsandanincidenceoffemalepatientsof.70%inmoststudies4-6.Thesefracturesresultinsubstantialmortalityandmorbidity,withstudiesshowingamortalityrateofapproximately15%at1yearafterthesurgicalprocedure4,5.Despiteadvancesinimplantdesignandknowledgeoffracturemanagement,subsequentratesoflossofambulatoryindependence,needforsurgicalfixation,andpostoperativecomplicationsallremainhighinthispatientpopulation.Changesinfracturefixationdevicesandtotalkneereplacementdesign,particularlytheintercondylarbox,havechangedthewaythesefracturesaremanagedinthepast2decades;however,thereisstillconsiderablecontroversyastotheoptimalmethodstoaddresstheseinjuries.Thepurposeofourcriticalanalysisreviewwastopresentthecurrentconceptsoffracturefixationandprostheticreplacementmethodsforperiprostheticdistalfemoralfractureandprovideevidence-basedrecommendationsontheirmanagement.?ClassificationAnumberofclassificationsystemshavebeenutilizedtostandardizethedescriptionofperiprostheticdistalfemoralfractures,andmoststudieshaveutilizedclassificationsbySuetal.,RorabeckandTaylor,ortheOTA/AOtodescribethesefractures(TableI)7,8.Themostimportantconceptsfromtheseclassificationsystemswithregardtothetreatmentofthesefracturesarethepresenceofdisplacementorcomminution,theamountandqualityofavailablebonestockinthedistalfragment,andthepresenceofawell-fixedorloosefemoralcomponent.??TABLEICommonClassificationSystemstoDescribePeriprostheticDistalFemoralFractureAfterTKA7.SuET,KubiakEN,DewalH,HiebertR,DiCesarePE.Aproposedclassificationofsupracondylarfemurfracturesabovetotalkneearthroplasties.JArthroplasty.2006Apr;21(3):405-8.?NonoperativeManagementNonoperativemanagementofperiprostheticdistalfemoralfracturesiscurrentlyreservedfornondisplacedfracturesinotherwisenonambulatorypatients,thoseunsuitableforanesthesia,orthosewithwound-healingriskfactorstoogreattoundergoasurgicalprocedure9.Fracturesinthiscohortofpatientsmaybeduetofallsorevenlower-energyeventssuchastransfersassistedbystafforfamilymembers.Nonoperativemanagementmaybeundertakenwiththeuseofahingedkneebraceorcasting.Patientswhoundergoacourseofnonoperativemanagementmustbecloselyfollowedradiographicallytoensurethatthefracturedoesnothaveprogressivedisplacement,whichcanresultinskincompromise,andcloseclinicalfollow-upisnecessarytodecreasethelikelihoodofskinbreakdownorulcerationbeneaththeimmobilizationdevice.Historicalstudiesofnonoperativemanagementforperiprostheticdistalfemoralfracturesconsistedofcastingorfunctionalbracingwithorwithouttractionorclosedreduction9-11.Despitetheadvantagesofavoidingasurgicalprocedurewithnonoperativemanagement,nonunionsoccurinupto12%to40%ofcases,andhighratesofsubsequentsurgicalproceduresofbetween15%and30%havebeenreportedwithnonoperativetreatment,includingforimplant-relatedcomplicationsrequiringprostheticexchange,malunion,andnonunion,whichisgreaterthanformodernmethodsofinternalfixation9-12.Additionally,theclosedreductionofdisplacedfracturesresultsinhighratesofmalunion,particularlyinvarusalignment,whichoccurredinthemajorityofpatientstreatedwiththismethod9,11.Eveninthesettingofaminimallydisplacedfracture,nonoperativetreatmentcanresultinanincreasedriskofarthrofibrosis,withmanypatientslosingrangeofmotionaftertreatmentandhavingprogressivedisplacementovertime13.Giventheserisksandpoorresultsfromstudiesofnonoperativemanagement,mostpatientsundergosurgicalfixationfortheseinjuries.?OperativeTreatmentOperativetreatmentremainstheprimarymethodoftreatingperiprostheticdistalfemoralfracturesinthesettingofTKA.Theaimsofoperativemanagement,comparedwithnonoperativetreatmentwithcastingorbracing,aretoallowforearlymobilizationandtopreventlatedisplacement.Internalfixationremainsthemostcommonmethodofsurgicaltreatment,andexternalfixationisrarelyusedinthesettingofclosedfracturesbecauseoftheriskofinfectionandtheneedforkneejointimmobilization.Advancesinimplanttechnologyandapplicationofinternalfixationprincipleshaveimprovedtheoverallmanagementofthisfracturepattern14.Bothplate-and-screwconstructsand/orintramedullarynailconstructshavebeenusedwithvaryingdegreesofsuccess.?Plate-and-ScrewFixationOpenreductionandinternalfixation(ORIF)withplate-and-screwfixationhasbecomeroutineinthemanagementofperiprostheticdistalfemoralfractures.Earlierstudiessuccessfullyutilizedconventionalplatingtechniquesconsistingmostlyoffixed-angledevicesordynamiccondylarscrewstoimproveunionrates,toreducetheincidenceofmalunion,andtoacceleratetheadvancementofpost-treatmentambulatorystatuscomparedwithconservativetreatment13.Despitethisadvance,ratesoffailurewithconventionalfixationoccurredbetween7%and15%ofcases15.Additionally,ahighincidenceofbone-graftingwasneededwithconventionalplating(.50%insomeseries),andconventionalplatingneededmoreextensilesurgicalapproachescomparedwiththelessinvasiveapproachesachievablewithnewerplatedesigns15,16.BecauseoftheelderlypatientpopulationandpoorbonequalityproximaltoaTKR,internalfixationtechniquesthatareanalternativetoconventionalplatinghavebeensoughtinrecentyears.Thedevelopmentoflockingplatesallowedforaminimallyinvasiveapplicationofafixed-angleconstructforthedistalfragmentwithmanypointsoffixation,whichwasanimprovementoverpreexistingfractureplates(Fig.1)14,15.Additionally,lockedplatesallowedforbothrigidandbridgingtechniquesforthemetaphysealordiaphysealfracturecomponentandcanbeplacedutilizingminimallyinvasive,soft-tissue-sparingtechniques,although,inosteoporoticbonewithextensivecomminution,abridgingconstructismostsuccessful14,17,18.Thesurgicaltechniquecandictatewhethertheload-bearingconstructwillprovideabsoluteorrelativestabilitybasedonthetypeofscrews(lockingcomparedwithnonlocking),thespreadofscrews,andadjunctstotheplatesuchaslagscrewsandcables.Furthermore,inosteoporoticbone,lockingscrewoptionscanimprovefixationcomparedwithnonlockingscrewsandcanallowtheindirectreductionofthemetaphyseal-diaphysealjunctionandperiarticularfragments.Plate-and-screwconstructsalsohavetheabilitytobridgethefemur,decreasingthechanceofastress-riserbetweenipsilateraltotalhipreplacementstemsandsupracondylardistalfemoralfractures19.Inaddition,inverydistalfractures(e.g.,SuTypeIII),dual-platingconstructscanalsobeconsideredformorerigidfixationandearlymobilization20.??Fig.1Figs.1-Athrough1-ERadiographsshowingthemanagementofaSuType-Iperiprostheticdistalfemoralfracturewithalockedplate:preoperativeanteroposterior(Fig.1-A)andlateral(Fig.1-B)viewsandpostoperativeanteroposteriorviews(Figs.1-Cand1-D)andlateralview(Fig.1-E).??IntramedullaryNailFixationAnotheroptionfortreatingperiprostheticdistalfemoralfracturesisintramedullaryfixationwithantegradeorretrogradeintramedullarynail.Retrogradeintramedullarynailsareusedmorefrequentlybecausetheyhavemorereliablefixationinthedistalfemoralsegmentcomparedwithantegradenailswithlimiteddistallockingoptionsandscrewspread21.Theindicationforaretrogradeintramedullarynailinthissettingisawell-fixedimplantwithanopenboxthatwillaccommodateanappropriatestartingpointandnoipsilateraltotalhipreplacement(Fig.2).Comparedwiththeload-bearinglockingandnonlockingplates,theload-sharingintramedullarynailallowsforsecondarybone-healingthroughcallusformationandearlyweight-bearinginlength-stablefracturepatterns13.Otherbenefitsofretrogradeintramedullarynailsincludelimitedsurgicalexposure,minimalsoft-tissuestripping,andrelativeeaseofplacement21.Theuseofthistechniqueisrestrictedonthebasisofthepatient’spreexistingimplantdesignandpresenceofanipsilateraltotalhipreplacement21,22.Kneereplacementcomponentswithaclosedboxorposteriornotcharenotcompatiblewithretrogradeintramedullarynails,althoughmostmodernimplantshaveopen-boxdesigns23.InaSawbonesmodeltosimulateaperiprostheticfractureinatotalkneereplacement,itwastechnicallyfeasibletoplacethemajorityofretrogradeintramedullarynaildesignsthroughmanyofthemostcommonlyusedtotalkneereplacementdesigns;however,thisoftenresultedinexcessforceneededforinsertionanddamagetothenailasitpassesthroughtheimplantbox24.Additionally,mosttotalkneereplacementdesignsresultinnailinsertioninamoreposteriorstartingpointthaninanativekneeduetotheprostheticdesign,whichcarriesariskofanteriorcorticalperforationandextensiondeformity,whichishigherincruciate-retainingdesignscomparedwithposteriorstabilizeddesigns22,24.Pelfortetal.founda23%incidenceofanextensiondeformityof.10°withtheuseofretrogradeintramedullarynailsforperiprostheticdistalfemoralfractures;however,thisdidnotaffectradiographicunion,totalkneereplacementloosening,orpatient-reportedfunctioncomparedwiththosewithoutthisdeformityataminimumfollow-upof4years25.Anotherdisadvantageofretrogradeintramedullarynailsisachievingadequatefixationinfracturesdistaltotheanteriorflangeofthefemoralimplant.Thismaybedifficultwitharetrogradeintramedullarynailduetomorelimitedscrewoptions,andatleast2lockedscrewsshouldbeusedinthedistalfragmenttoreducetheriskofnonunionandimplantfailure26,27.??Fig.2Figs.2-Athrough2-DRadiographsshowingthemanagementofaSuType-Iperiprostheticdistalfemoralfracturewitharetrogradeintramedullarynail:preoperativeanteroposterior(Fig.2-A)andlateral(Fig.2-B)viewsandpostoperativeanteroposterior(Fig.2-C)andlateral(Fig.2-D)views.??CombinedIntramedullaryNailandPlate-and-ScrewConstructsRecently,increasedinterestincombinedlockingplateandintramedullaryfixationtechniquesbyeithercorticalallograftornail-platecombinationconstructshavebeenproposed.Biomechanicalstudieshavesuggestedthatalockedplatewithsupplementalintramedullaryfixationmayhavehighertorsionalstiffnessandlessmicromotionthanotherconstructs(Fig.3)28.LiporaceandYoonpreviouslypublishedtheirrecommendedstep-by-steptechniqueforimplementingthenail-platecombinationstrategyinfracturesmeetingsurgicalcriteria29.Theprocedureisinitiatedbyplacementofaretrogradeintramedullarynailthroughamidline,lateralparapatellarapproachwithsubluxationofthepatellaofsplittingthepatellartendon.Thishelpstorestorethetypicalrecurvatumdeformityandestablishfracturelength,alignment,androtation.Next,thelateralplatelengthisdeterminedwithfluoroscopicassistance,withtheproximalendstoppingatthebaseofthelessertrochanter.Platesareplacedviathetypicalsubmusculartechniqueusingthesamedistalincisionusedfornailplacement.Afterappropriateplatepositioning,distallockedscrewsarethenplaced,wheretypically1ofthevariableanglescrewscanbeinterlockedintothenail,unitizingthedistalportionoftheconstruct.Inselectpatients,surgeonscanchoosetobendtheproximalportionoftheplatetoallowforplacementofnonlockingscrewsintothefemoralneck,whichserveasbothprophylacticfixationaswellasplatereductionaids29??Fig.3Figs.3-Athrough3-DRadiographsshowingthemanagementofaSuType-IIperiprostheticdistalfemoralfracturewithacombinationofalockedplatewithanintramedullarynail:preoperativeanteroposteriorview(Fig.3-A)andpostoperativeanteroposteriorviews(Figs.3-Band3-C)andlateralview(Fig.3-D).??Thesuggestedbenefitofnail-platecombinationcomparedwithsingle-implantconstructsisearlierreturntoweight-bearingandmobilizationforhighlycomminutedlength-unstablefracturepatternsthattraditionallywouldbetreatedwithlockedplatingandprotectedweight-bearing30,31.Althoughadvantageousinpreventingmorbidityassociatedwithprolongedperiodsoflimitedweight-bearing,theprocedureexposespatientstoextendedsurgicaltimeandcost.Thereisarelativepaucityofliteratureregardingthistreatmentalgorithm;however,itremainsanexcitingprospectforpatientsappropriateforandamenabletofixation30,31?DistalFemoralReplacementProstheticreplacementisanothersurgicaloptionforperiprostheticdistalfemoralfractures.Theseinjuriestypicallyoccurinolder,medicallycomplexpatientswhoareunabletotolerateprolongedbedrestorweight-bearingrestrictions.Thetreatmentofthesepatientswithrevisionarthroplastyordistalfemoralreplacementhasbeenproposedtoallowearlymobilizationandweight-bearingwithouttheneedforbone-healing,whichmaybeadvantageousinthispatientpopulation.Limited,smallcaseserieshavedescribedrevisionarthroplastywithalong-stemtotalkneearthroplastyrevisioncomponentwithoutfemoralresection,whichmaybeanoptioninthesettingofaloosecomponentandpreservedcollateralligaments18.Mostcasesofarthroplastyforperiprostheticdistalfemoralfracturesinvolvedistalfemoralreplacement,whichconsistsoftheresectionoftheentiresupracondylarfemurproximaltothefracturesiteandreplacementwithahingedtotalkneeprosthesis(Fig.4).Inpriorstudies,authorshaverecommendeddistalfemoralreplacementinthesettingofperiprostheticdistalfemoralfracturesinthepresenceofseverelycompromisedbonequality,osteolysisorlooseningofthefemoralcomponent,lossoftheintegrityofthecollateralligaments,periprostheticfractureinthepresenceofarevisionfemoralcomponentorpreviousdistalfemoralreplacement,anddeficientdistalfemoralbonestock(typicallySuType-IIIfractures)32.Thebenefitsofadistalfemoralreplacementincludetheimmediaterestorationoflower-extremityalignmentandstability,relativelyshortoperativetimes,andimmediateweight-bearingwithlessrestriction33-38.Additionally,distalfemoralreplacementinthispopulationavoidsconcernsofmalunionornon-unionsecondarytoimpairedhealing.Concernsaboutdistalfemoralreplacementincludehighimplantcost,riskofimplantfailure,extensormechanismcomplications,andsoft-tissuecompromiseincludingperiprostheticjointinfection32-38.??Fig.4Figs.4-Athrough4-DRadiographsshowingthemanagementofaSuType-IIIperiprostheticdistalfemoralfracturewithadistalfemoralreplacement:preoperativeanteroposterior(Fig.4-A)andlateral(Fig.4-B)viewsandpostoperativeanteroposterior(Fig.4-C)andlateral(Fig.4-D)views.??Distalfemoralreplacementisperformedthroughasimilarapproachtotheindexsurgicalprocedure,typicallyanextensilemidlineoroccasionallylateral-basedincision.Thefemurandtibiaaresubperiosteallyexposedtotheleveloftheintendedresection.Theapproximatelengthofthedistalpartofthefemurtoberesectedismeasuredandismatchedtoanavailable,appropriateimplantlength.Implantsizingcanbeapproximatedbytheexplantedtibialcomponentandfemoralresection.Femoralrotationcanbechallengingtoreproduceandcanbeestimatedtomatchtheexistingimplantifthefracturecanbeapproximatedanatomicallyorcanbeestimatedtobedirectlyanteriortothelineaaspera.Thedistalfemoralcomponentandboneareremovedenblocifpossible,takingcaretomaintainasubperiostealdissectionposteriorlytoavoidneurovascularinjury.Theresidualproximalpartofthefemurisosteotomizedperpendiculartotheshaftandisreamedtoaccommodatetheappropriatestemsizeandfixationtype39.Thetibiaisexposedandthepreexistingimplantisremoved,preservingasmuchboneaspossible.Thetibiaispreparedaccordingtotheimplanttechnique.Theuseofcementlessdesignscomparedwithcementedstemsiscontroversial,withstudiessuggestingoverallsimilarintermediate-termsurvivorshipinthesettingofnononcologicreconstructionbutincreasedratesofearlyasepticlooseningonthefemoralsidewithcementlessdesigns,especiallyinthesettingofoncologicreconstruction40-42.NewercementlessimplantdesignssuchastheCompressCompliantPre-Stressimplant(Biomet),whichrelyoncompressionatthesiteofthefemoralresection,mayimprovetheoutcomesofcementlessfixation,butneedmorestudieswithlonger-termfollow-up43.Appropriatetrialsareplacedwithafocusonreproducingintraoperativelengthbasedonmaintainingappropriatesoft-tissuetensionwhileavoidingexcessivelengtheningtoavoidstressonneurovascularstructuresandoptimizingpatellartracking.?OutcomesofSurgicalTreatmentLockedPlateOutcomesutilizinglockedplatinghavebeenlargelypositiveandthesehavebecomefavoredoverconventionalplatingtechniques.Studiesoflockedplatinghavedemonstratedhighunionrateswithconsistentlylowercomplications,includingtheneedforrepeatsurgicalintervention,comparedwithconventionalplatingtechniquesandnonoperativetreatment12-14,30,44-51.Conventionalplatingshouldbelimitedtocaseswithsimplefracturepatternsandgoodbonestockproximalanddistaltothefracturesite,suchasinthesettingofasimplelateralormedialcondyleperioperativefracture.Systematicreviewsofperiprostheticdistalfemoralfracturestreatedwithlockedplatinghaveshownnonunionratesof5%to13%andmalunionratesofaround5%followingperiprostheticdistalfemoralfractures12,44,52.Theredoesnotappeartobeadifferenceinunionratesbetweendifferentlockedplatedesignswithregardtopolyaxialcomparedwithmonoaxiallockingscrews48.ArandomizedcontrolledtrialcomparedtheoutcomesofORIFwithpolyaxialandmonoaxiallockingscrewsinperiarticularlockingplatesandfoundnodifferenceintheunionratesutilizingthese2differentconstructsandcitedrespectoflocalfracturebiologyandAOprinciplesasbeingmoreimportantfactorsrelatedtounion48.Evenwithsuccessfulfractureunion,periprostheticdistalfemoralfracturescarrysubstantialmorbidityandmortalityforpatientsinadditiontolossoffunctionalindependence.Oneofthemostdevastatingcomplicationsthatoccursafterlockedplatingofperiprostheticdistalfemoralfracturesisdeepinfection,whichoccursinupto5%ofcases12,52.Mortalityrateshavebeenreportedtobeupto15%to25%after6months,andahigherCharlsonComorbidityIndexandolderageareassociatedwithahigherrateofmortality50,53,54.Postoperativelossorimpairmentofambulatorystatusisalsocommonafterlockedplatingforperiprostheticdistalfemoralfractures,withupto30%ofpreviouslyambulatorypatientsincreasingtheirneedforassistivedevicescomparedwiththeirpreoperativestatus,andthemajorityofpatientsrequiringsometypeofassistivedeviceafterthesurgicalprocedure5,54.?IntramedullaryNailWithregardtoretrogradeintramedullarynails,asimilarlyhighrateofsuccesshasbeenshowninselectpatternsandanaccommodatingtotalkneeimplant.Whencomparedwithconventionalplating,retrogradeintramedullarynailsappeartohavesuperiorratesofunionandlowerratesofreoperation.Herreraetal.conductedasystematicreviewof415casesofdistalfemoralperiprostheticfractureandfoundarelativeriskreductionof87%fornonunionand70%fortheneedforarevisionsurgicalprocedurewithretrogradeintramedullarynailscomparedwithtraditionalnonlockedplatingmethods(1.5%withretrogradeintramedullarynailscomparedwith12%withconventionplatingnonunionrate)12.Intramedullaryfixationrequireslesssurgicaldissectionandsoft-tissuestripping,whichmayprovideanadvantagewithregardtoinfectionrates.Therateofdeepinfectionwaslowwiththeuseofretrogradeintramedullarynailscomparedwiththatwithotherplatingtechniques(0%in65casescomparedwith5.7%withconventionalplating)12.Whencomparingretrogradeintramedullarynailswithlockedplating,moststudieshavenotconsistentlyfoundsignificantdifferencesinunionrateandreoperations12,14,44,49,52,55,56.Intheirsystematicreviewof719fractures,Ristevskietal.notedthatbothretrogradeintramedullarynailsandlockedplatingofferedadvantagesovernonoperativemanagement,andnosignificantdifferencebetweenthe2withregardtonon-unionratesortheneedforsecondarysurgicalprocedures,althoughatrendtowardimprovedunionrateswithretrogradeintramedullarynailswasfound44.Incontrast,therateofmalunionwassignificantlyincreasedwiththeuseofretrogradeintramedullarynails(16%)comparedwithlockedplates(8%)44.Inasystematicreview,Ebraheimetal.foundthatoverallunionratesweresimilarbetweenlockedplatesandretrogradeintramedullarynails,withoverallhealingratesof87%comparedwith84%inRorabeckandTaylortype-IIfractures52.Overallcomplicationswerehigherwithretrogradeintramedullarynails,withincreasedratesofmalunioncomparedwithlockedplates52.Infectionrateswere1%intheretrogradeintramedullarynailgroupcomparedwith4%intheconventionalplatinggroupinRorabeckandTaylortype-IIfractures52.Houetal.,intheircohortof52patients,foundasimilartimetounionof3.7monthsforretrogradeintramedullarynailscomparedwith4.0monthsforlockedplatingandnodifferenceinunionrates50.Inanothersystemicreview,Shinetal.foundsimilarratesofnonunionandmalunioninbothretrogradeintramedullarynailsandlockedplating49.?CombinedLockedPlateandIntramedullaryFixationAugmentationofplatefixationwithintramedullarystructuralallograftorintramedullarynailfixationhasshownfavorableresultsinlimitedstudies.Christetal.reportedonacohortof40patientswithperiprostheticdistalfemoralfracturestreatedwithORIFwithorwithoutendostealaugmentationwithfibularstrutallograft.Theyfoundahighrateofunionof94%,withnodifferenceinratesofunionwhencomparingthosewhoreceivedfibularallograftwiththosewhodidnot57.Hussainetal.reportedontheirseriesof9patientstreatedwitharetrogradeintramedullarynailandsoft-tissue-preservinglaterallockingplate(withoutinterfragmentarycompressionscrews,cables,orbone-grafting)withimmediatepostoperativeweight-bearing.Intheircohort,allpatientsachievedunionatameanof20weekswithoutareturntotheoperatingroomforasecondaryprocedure30.Althoughthesecasereportsandthesurgicaltechniquehavebeenreportedintheliterature,long-termoutcomesstudiescomparingnail-platecompositewithsinglesurgicaltechniquesarenotyetavailable31,45.Nevertheless,itremainsanintriguingandexcitingtechniqueforaskilledsurgeon.?DistalFemoralReplacementMoststudiesexaminingoutcomesofdistalfemoralreplacementperformedinthesettingofperiprostheticdistalfemoralfractureshavesmallpatientnumbers,withmostseriesincluding,20patients,multiplenononcologicindicationsfordistalfemoralreplacementwithinthestudy,andawiderangeofreportedoutcomeswithshort-termfollow-up32-39,58-65.Distalfemoralreplacementissuccessfulatrelievingpainandreestablishingkneerangeofmotionconsistentlyacrossstudies;however,functionaloutcomeshaveawidereportedrange.Moststudieshaveshowngoodrestorationofkneerangeofmotion(consistentlyachievinga90°to105°arcofmotion),appropriatepainrelief,KneeSocietyclinicalscoresof71to91points,andmeanOxfordkneescoresof22to27points(range,4to40points)4,32,33,36,58,59,61,64.Importantly,morbidityandmortalityofpatientswithperiprostheticdistalfemoralfracturesshouldnotbeoverlooked,especiallyinthesettingoffailure.Similartostudiesutilizinglockedplates,recentstudieshaveshown1-yearmortalityratesbetween5.8%and33%59,60,63.Complicationsofdistalfemoralreplacementincludingperiprostheticfracture,asepticloosening,extensormechanismcomplications,andperiprostheticjointinfectionhavebeenreportedin15%to30%ofcasesoverashort-termtointermediate-termfollow-upperiodinmostseriesfornononcologicindications35-37,39,58-65.Becauseofsmallstudysizesindistalfemoralreplacementforperiprostheticdistalfemoralfractures,complicationratesvarydependingonthestudy.Periprostheticfracturehasbeenreportedwitharateof1%to18%andiscommonlyassociatedwiththefragilenatureoftheseelderlypatients,manyofwhommeetthefragilityfractureclassificationbasedonWorldHealthOrganizationcriteria58.Infectioninthesettingofdistalfemoralreplacementhasbeenattributedtosoft-tissuecompromisefrompriorsurgicalprocedures,moreextensiveexposures,longeroperativetimes,andhigherpatientcomorbidityprofiles62.Infectionrateshavebeenreportedtobeaslowas0%to10%andashighas20%insomeseries,althoughthisriskishighestfordistalfemoralreplacementinthesettingofasepticlooseningorpreviousperiprostheticjointinfection36,61-63,65.Asepticlooseningisariskforprostheticreplacementbutnotforplatefixation.Wylesetal.foundthatthatthecumulativerateofasepticlooseningafterdistalfemoralreplacementforperiprostheticdistalfemoralfractureswas10%at5yearsdespitethelow-demandpopulationthattypicallyundergoesthisprocedureforperiprostheticdistalfemoralfractures63.Shorterstemlengthcomparedwithtotalconstructlengthmayincreasethisrisk63.Patellofemoralcomplicationsreportedafterdistalfemoralreplacementareincreasedcomparedwithconventionaltotalkneearthroplastyandincludeinstabilityormaltracking,patellarimpingement,andfracture.Carefulattentiontofemoralandtibialcomponentrotationandlateralsoft-tissuereleasewhennecessaryareimportanttoreducemaltracking,whichmayoccurin.10%to15%ofpatientsundergoingdistalfemoralreplacement66-69.Patellabajaiscommonafterdistalfemoralreplacementandmayleadtoprostheticimpingement,althoughitmaynothaveasubstantialeffectonfunctionaloutcomes68,69.Treatmentofthepatellaindistalfemoralreplacementhasnotbeenextensivelyinvestigated;however,Etchebehereetal.didnotfindadifferenceinpatellofemoralcomplicationsoranteriorkneepainwithunresurfacedcomparedwithresurfacedpatellaeafterdistalfemoralreplacementforbenignormalignantbonetumors,withsimilarratesofanteriorkneepain(around25%ofpatients)67.Theroleofpatellectomyisnotclearfrompreviousliterature,althoughitremainsasalvageoptionforcasesinwhichthepatellacannotberesurfacedoralignedappropriately.?LockedPlateComparedwithDistalFemoralReplacementComparingtheoutcomesoflockedplatingwiththoseofdistalfemoralreplacement,nonrandomizedretrospectivecohortstudieshaverevealednoconsistentchangesinpostoperativemobilitystatus,similarreoperationrates,andsimilar90and365-daymortalityrates,regardlessoftreatment4,34,66,70-73.Overall,regardlessofthetreatmentmodality,ageatthetimeoftheinjuryismorepredictiveoffunctionalstatusthandistalfemoralreplacementcomparedwithORIF,withpatients.85yearsofagehavingtheworstfunctionaloutcomes72.Furthermore,withregardtocost,patientsmanagedwithdistalfemoralreplacementcomparedwithfixationwithlockedplatingorretrogradeintramedullarynailshadasimilartotalcost,astheincreasedcostofthedistalfemoralreplacementimplantwasbalancedbythedecreasedoveralllengthofstaythatthesepatientsexperienced74.Recently,Darrithetal.foundhigherKneeSocietyfunctionalscoreswithORIF;however,therewasahigheroverallincidenceofrevisionsinthiscohortcomparedwithdistalfemoralreplacement66.Thebenefitsofdistalfemoralreplacementincludeimmediateweight-bearingandlessrestrictedmobilizationalongwithappropriatepainreliefandkneerangeofmotion.Despitethis,distalfemoralreplacementisacomplexsurgicaloptionthatposesuniquerisks,causingmanysurgeonstolabelitasasalvagedevice.Complicationratesarerelativelysimilarbetweenthe2groups;nonunionormalunionandinfectionweremorecommoninORIF,andinfection,patellofemoralcomplications,andasepticlooseningweremorecommonindistalfemoralreplacement4,34,54,66,70-73,75.UnlikeafailedORIF,whichcanbesalvagedwithdistalfemoralreplacement,afaileddistalfemoralreplacementcanbedifficulttosalvage,withincreasingbonelossduringrepeatoperationsandsubstantialsoft-tissuecompromiseinthesettingofinfection.Asaresult,webelievethatthecurrentevidencesupportsdistalfemoralreplacementprimarilyforelderly,sedentarypatientsandfracturesthatprecludeinternalfixation,includingcaseswithalooseimplantorminimaldistalperiprostheticbonestock61.?ConclusionsPeriprostheticdistalfemoralfracturescarrysubstantialmorbidityandmortalityregardlessoffixationtechnique.OurrecommendationsforcarearesummarizedinTableII.Surgicaltreatmentisfavoredinmostpatientscomparedwithnonoperativetherapybecauseofhighratesofnonunion,malunion,andreoperationaftercastingorbracing.Internalfixationtechniquesincludingretrogradeintramedullarynailsandlockedplatingarefavoredforthesurgicaltreatmentofmostfractureswhenthebonestockinthedistalfragmentallowsforappropriatefixation.Inthesettingofdeficientdistalfemoralbonestockorimplantloosening,revisionarthroplastywithdistalfemoralreplacementisthefavoredtechnique.Furtherstudieswithregardtotheuseofretrogradeintramedullarynails,lockedplating,ordistalfemoralreplacementarenecessarytorefinetheindicationsforeachtechniqueandtodefinetheuseofcombinationsofthesefixationtechniques.無論采用何種固定技術(shù)，股骨遠(yuǎn)端假體周圍骨折的發(fā)病率和死亡率都很高。表二總結(jié)了我們的護(hù)理建議。與非手術(shù)治療相比，手術(shù)治療在大多數(shù)患者中更受青睞，因為手術(shù)治療的不愈合、不愈合率高，而且在鑄造或支具后再手術(shù)的幾率也高。內(nèi)固定技術(shù)包括逆行髓內(nèi)釘和鎖定鋼板，在大多數(shù)骨折的手術(shù)治療中，當(dāng)遠(yuǎn)端碎片的骨量允許適當(dāng)?shù)墓潭〞r，首選內(nèi)固定技術(shù)。在股骨遠(yuǎn)端骨缺損或假體松動的情況下，股骨遠(yuǎn)端置換術(shù)的翻修關(guān)節(jié)成形術(shù)是首選的技術(shù)。有必要進(jìn)一步研究逆行髓內(nèi)釘、鎖定鋼板或股骨遠(yuǎn)端置換術(shù)的使用，以完善每種技術(shù)的適應(yīng)癥，并確定這些固定技術(shù)的組合使用。??TABLEIIRecommendationsforManagementofPeriprostheticDistalFemoralFracturesAfterTotalKneeArthroplastyAccordingtoWright76,gradeAindicatesgoodevidence(Level-Istudieswithconsistentfindings)fororagainstrecommendingintervention;gradeB,fairevidence(Level-IIorIIIstudieswithconsistentfindings)fororagainstrecommendingintervention;gradeC,poor-qualityevidence(Level-IVorVstudieswithconsistentfindings)fororagainstrecommendingintervention;andgradeI,insufficientorconflictingevidencenotallowingarecommendationfororagainstintervention.2024年08月09日63
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李穎副主任醫(yī)師 中國人民解放軍東部戰(zhàn)區(qū)空軍醫(yī)院 骨科 1、鋼板內(nèi)固定穩(wěn)定基本原理???鋼板作為一個接骨材料，主要為骨折端之間提供一個穩(wěn)定、連續(xù)的接觸界面。其主要起到保護(hù)、加壓、支撐、張力帶和橋接五大功能（AO內(nèi)固定第4版）。保護(hù)：拉力螺釘和保護(hù)鋼板達(dá)到絕對穩(wěn)定固定，保護(hù)鋼板的作用是分擔(dān)拉力螺釘承受的應(yīng)力，避免其承受彎曲力、剪切力和旋轉(zhuǎn)作用力，從而預(yù)防其發(fā)生疲勞失效。加壓：加壓鋼板的螺釘孔可以描述為斜行彎曲圓柱體的一部分。螺釘帽就像一個球，沿這個圓柱體的斜面滑落下來，隨著螺釘擰緊，它會擠壓釘孔的斜面，使鋼板連同己經(jīng)通過第一枚螺釘固定的骨折塊一起移動產(chǎn)生骨折加壓。隨著螺釘擰緊，它會擠壓釘孔的斜面，使鋼板連同己經(jīng)通過第一枚螺釘固定的骨折塊一起移動產(chǎn)生骨折加壓。支撐：支撐鋼板是為了對抗軸向負(fù)荷，沿與畸形軸線成?90°方向施加作用力的固定工具。在干骺端/骨骺部位的剪切或劈裂骨折，單純用拉力螺釘固定常常是不夠的。此時拉力螺釘固定應(yīng)聯(lián)合應(yīng)用起支撐或防滑動功能的鋼板。這樣可以保護(hù)螺釘避免承受經(jīng)骨折端的剪切應(yīng)力。還可以單獨應(yīng)用鋼板發(fā)揮支撐作用而不用拉力螺釘，對帶有動力加壓孔的鋼板，注意要將螺釘置入支撐位置。張力帶：張力帶的作用是將張力轉(zhuǎn)化為壓力。在骨折復(fù)位后，對側(cè)皮質(zhì)必須能夠提供骨性完整支撐，以避免內(nèi)固定承受反復(fù)的折彎力而發(fā)生固定失效。橋接：橋接鋼板可以提供骨折端的相對穩(wěn)定，使骨折通過外骨痂愈合，其本質(zhì)思想是鋼板只固定兩端的兩個主要骨折塊，而不處理骨折端，以最大化保護(hù)血運。在應(yīng)用這一技術(shù)時，要考慮到很多重要的生物力學(xué)原則。?我們在植入鋼板前需要綜合考慮骨骼性能、鋼板材料和幾何特性、板骨界面、板釘界面、固定螺釘數(shù)量及張力，折斷壓力、骨板位置及負(fù)荷關(guān)系等相關(guān)問題。這幾個問題是鋼板設(shè)計中需要考慮，要結(jié)合病人基礎(chǔ)骨質(zhì)條件選擇合適的鋼板。就手術(shù)技巧而言，手術(shù)中重要的是要考慮提供一個合適外來的平衡力矩。選擇合適的長度，達(dá)到一個理想的工作力矩和抗阻力矩平衡[1]?2、鋼板的分類2.1?中和鋼板、重建鋼板中和鋼板是指鋼板主要起到中和作用的鋼板，如早期的葫蘆鋼板等。螺釘是骨折加壓主要力量，鋼板輔助分擔(dān)力量，可任意塑形。?2.2支持鋼板、管型鋼板???支撐鋼板是為了對抗軸向負(fù)荷，沿與畸形軸線成?90°方向施加作用力的固定工具。在干骺端/骨骺部位的剪切或劈裂骨折，單純用拉力螺釘固定常常是不夠的。此時拉力螺釘固定應(yīng)聯(lián)合應(yīng)用起支撐或防滑動功能的鋼板。這樣可以保護(hù)螺釘避免承受經(jīng)骨折端的剪切應(yīng)力。還可以單獨應(yīng)用鋼板發(fā)揮支撐作用而不用拉力螺釘，對帶有動力加壓孔的鋼板，注意要將螺釘置入支撐位置。主要起到支撐作用的鋼板。如同大壩對于水庫的支撐作用。?1/3管型鋼板、?管型鋼板等面支撐型小鋼板也可以歸入此類，主要用于小骨干支撐，不能大段粉碎跨度大的骨折??2.3：異形鋼板隨著內(nèi)固定物的發(fā)展，人們根據(jù)解剖結(jié)構(gòu)的特點設(shè)計出適應(yīng)各種部位幾何形狀的異性鋼板。?2.4角鋼板與橋接鋼板此類鋼板以優(yōu)先恢復(fù)軸穩(wěn)定性為特點。比較有代表性的有：DHS、DCS??橋接鋼板：對于復(fù)雜的粉碎性骨折，橋接鋼板可以提供骨折端的相對穩(wěn)定，維持長度和對線；解決血供問題，其形狀有波浪鋼板等。對于這種彈性固定方式，為使固定強(qiáng)度最大化，應(yīng)選擇長鋼板，少用螺釘，以增加力臂，分散彎曲應(yīng)力。?2.5DCP與LC-DCP這一類鋼板又稱為加壓鋼板，以提供骨折端軸向加壓力為特點，分為靜力加壓和動力加壓兩大類，加壓方式又分垂直加壓、偏心加壓、動力加壓等，細(xì)分的種類較多，常見有動力加壓鋼板DCP(Dynamiticcompressionplate)、?LC-DCP（Limitecontactdynamiticcompressionplate）限制接觸型動力加壓板等。????2.6?LISS與LCPLISS鋼板（LessInvasiveStabilizationSystem，LISS）1990年AO開發(fā)了一種新型內(nèi)固定產(chǎn)品－微創(chuàng)固定系統(tǒng)（LISS）。由于使用體外螺釘孔瞄準(zhǔn)器，使手術(shù)對軟組織的損傷降低到最低程度。具有成角固定作用的自鉆螺釘可以提供更可靠的固定。??鎖定解剖板：此類鋼板與不同的解剖部位的特點，衍生出各類解剖鎖定板。其主要結(jié)構(gòu)特點是：角度穩(wěn)定、內(nèi)側(cè)壁支撐、框架式結(jié)構(gòu)、釘板間有冷融合效應(yīng)。并由此衍生出內(nèi)固定架的概念。?LCP（Lockingcompressionplate）鎖定加壓鋼板（LCP）為兩種完全不同的固定技術(shù)的結(jié)合，該內(nèi)植物包含兩種相反的接骨術(shù)原理，即以直接解剖復(fù)位為特點的傳統(tǒng)鋼板接骨術(shù)和橋接鋼板接骨術(shù)。其結(jié)構(gòu)特點是8字型螺釘孔，一邊鎖定一邊加壓。由于鎖定孔為非全包型，長期受力后釘板間冷融合的發(fā)生概率有所下降。因為方便和容錯性好主流鋼板?同樣，不同解剖型形狀變化后構(gòu)成解剖LCP。以其良好的結(jié)構(gòu)穩(wěn)定性和抗拔出性能而在臨床有廣泛的應(yīng)用。???2.7一些其他設(shè)計思路的鋼板：強(qiáng)生彈性板、萬向鎖定板、VLP多向鎖定板（施樂輝）、全球第一款遠(yuǎn)端鎖定螺釘（FCL）、ZimmerMotionLoc動態(tài)鎖定釘強(qiáng)生彈性板?VLP多向鎖定板（施樂輝）?3、鋼板技術(shù)在鋼板的使用過程還有以下的一些常見問題，目前在有限的生物力學(xué)實驗的基礎(chǔ)上已經(jīng)有一些階段性結(jié)論，歸納總結(jié)如下。3.1鋼板與骨的距離：動力加壓鋼板與鎖定板不同骨質(zhì)距離比較，5mm以內(nèi)的不影響整體受力。????前3組無明顯差異，距離5mm時軸向失敗強(qiáng)度減少50%??3.2鋼板螺釘分布的影響：骨折兩端3到4枚螺釘有較好的生物力學(xué)性能。???3.3鎖定與拉力釘?shù)闹冕旐樞颍合燃訅汉箧i定??3.4尾釘分布影響：穩(wěn)定盡量均勻分布，避免應(yīng)力集中導(dǎo)致醫(yī)源性骨折。?3.5單皮質(zhì)螺釘技術(shù)：單皮質(zhì)釘避免用在旋轉(zhuǎn)應(yīng)力部位，???上面已經(jīng)系統(tǒng)的回顧了AO內(nèi)固定的一些力學(xué)基礎(chǔ)，有時候我們在手術(shù)中覺得固定很牢固，很滿意，但是最后的骨愈合結(jié)果卻是不滿意。關(guān)于手術(shù)后固定的穩(wěn)定性以及最后的骨愈合前景，有沒有科學(xué)定量分析即時穩(wěn)定性及預(yù)測骨愈合前景的方法？有，具體的方法我們在下一回來講一講有關(guān)于“骨承載力分析”的技術(shù)。?2024年07月26日1784
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孫勝副主任醫(yī)師 北京朝陽醫(yī)院石景山院區(qū) 骨科 ????不同的骨折部位，克氏針固定的方法不一樣，注意的事項也會有很大的區(qū)別。但是從大的原則上來說有以下幾個方面：1、因為克氏針固定不像鋼板或者其他固定的手段堅固，這種手術(shù)固定之后，一般需要配合石膏外固定的保護(hù)，不能過早的活動。2、有的手術(shù)做完之后，克氏針的尾巴在皮膚外面，所以要做好克氏針部位碘伏消毒的處理，避免該部位出現(xiàn)感染。3、做完手術(shù)之后應(yīng)該定期拍片復(fù)查，盡早去掉克氏針，進(jìn)行功能康復(fù)鍛煉。4、針對于克氏針尾巴留在皮膚外面的，除了正常消毒處理之外，千萬注意不要碰水，碰水也是引起感染的原因。2023年08月26日79
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張永立副主任醫(yī)師 鄭州市骨科醫(yī)院 國醫(yī)苑 一、隨時觀察肢體感覺、顏色和溫度變化，判斷血運及壓迫情況。若出現(xiàn)下列情況，須緊急調(diào)整夾板外固定。1、外露的手指或腳趾溫度較正常手腳低，顏色發(fā)暗，或指甲發(fā)白，或感覺麻木需及時就診。2、肢體出現(xiàn)嚴(yán)重腫脹，或疼痛劇烈無法入睡，需及時就診。3、骨折處或被夾板包裹的皮膚感覺瘙癢難忍，需及時就診。二、夾板固定如果出現(xiàn)松動，甚至棉花及夾板脫落，移位等需及時就醫(yī)。三、夾板固定期間，根據(jù)骨折時間長短，需要做不同的康復(fù)鍛煉。比如手腕骨折早期需要握拳訓(xùn)練，小腿骨折需要大腿肌肉收縮訓(xùn)練等等。四、夾板固定時間并非一成不變，需要根據(jù)骨折錯位情況，愈合情況及時調(diào)整夾板方向和延長或縮短夾板固定時間。2023年08月12日282
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孫勝副主任醫(yī)師 北京朝陽醫(yī)院石景山院區(qū) 骨科 橈骨遠(yuǎn)端骨折是指距橈骨遠(yuǎn)端關(guān)節(jié)面3cm以內(nèi)的骨折，是臨床上最常見的骨折之一，約占急診骨折病人的1/6。直接暴力和間接暴力均可造成橈骨遠(yuǎn)端骨折，但多為間接暴力所致。主要發(fā)生在6-10歲和60-75歲兩個年齡階段。?橈骨遠(yuǎn)端的復(fù)位參數(shù)主要有三個，按照重要性排列如下：橈骨高度＞尺偏角＞掌傾角。麻醉：血腫內(nèi)麻醉：實際臨床患者中年輕的沒有基礎(chǔ)疾病的也可以不打麻醉藥，年齡大的尤其是有心腦血管疾病的還是要去手術(shù)室手法復(fù)位，以免能發(fā)生心腦血管意外。1.拔伸牽引，折頂側(cè)按：先由兩位醫(yī)師對抗?fàn)恳颈仨氉銐驈?qiáng)大的拉伸力量】，糾正橈骨短縮，根據(jù)X線片施加合理的牽引力度。如果是Colles骨折，以牽引第一掌骨為主。注意掌傾角尺偏角充分牽引后，由第三位醫(yī)師糾正前后移位，可以利用杠桿原理，先加大畸形、頂住一側(cè)皮質(zhì)，然后復(fù)位。2.目標(biāo)形態(tài)：藍(lán)線表示目標(biāo)軸線，紅線作為參考線，注意在復(fù)位過程中、石膏未堅固前始終保持這個位置。Colles骨折的復(fù)位后形態(tài)即Atlant位，也就是屈腕尺偏的位置。Smith骨折復(fù)位后的形態(tài)形似“如來神掌”，不同的是還要略微尺偏一點。Colles骨折和Smith骨折不同的復(fù)位方向側(cè)方擠壓：完成上述步驟后，予以尺橈骨遠(yuǎn)端側(cè)方擠壓，以糾正下尺橈分離和橈骨增寬畸形。固定：一定要用兩塊石膏托，前后固定，才可以起到夾板的作用。當(dāng)然管形石膏的固定強(qiáng)度是最大的，但是無法提供后續(xù)軟組織腫脹的冗余空間。通常的錯誤是：只用一塊石膏托做早期的固定，這與中醫(yī)學(xué)的小夾板固定原理也是格格不入的。石膏托的遠(yuǎn)端以達(dá)到掌指關(guān)節(jié)為恰到好處。繃帶纏繞方向和一般的“自近端向遠(yuǎn)端”不同，應(yīng)自骨折的位置開始，以防止復(fù)位丟失。以Colles骨折為例，展示了繃帶纏繞的方向。術(shù)后最初幾天要觀察軟組織腫脹情況，以免過緊。術(shù)后10～14天要更換成腕關(guān)節(jié)功能位石膏，此時僅需一塊石膏托即可。2023年07月17日319
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孫勝副主任醫(yī)師 北京朝陽醫(yī)院石景山院區(qū) 骨科 制定橈骨遠(yuǎn)端骨折的治療方案必須考慮很多因素。醫(yī)生必須仔細(xì)研究骨折的移位程度，粉碎程度，骨折類型，骨量丟失情況以及軟組織損傷情況；也必須考慮每個患者的健康狀況，日常生活的需要，以及運動量。1.非手術(shù)治療大部分橈骨遠(yuǎn)端骨折非手術(shù)治療就可以獲得滿意結(jié)果。微小移位的骨折干骺端有穩(wěn)固的支撐，可以選擇非手術(shù)治療。腕關(guān)節(jié)通過適當(dāng)塑形的石膏或者夾板制動，直到骨折愈合。常規(guī)隨訪可以保證維持骨折對線。移位或成角畸形的橈骨遠(yuǎn)端骨折應(yīng)該進(jìn)行復(fù)位。明顯的骨折移位，關(guān)節(jié)內(nèi)骨折移位>1～2mm，縮短>3mm，急性正中神經(jīng)卡壓等都需要進(jìn)行骨折復(fù)位。新鮮的橈骨遠(yuǎn)端骨折可以行血腫內(nèi)阻滯麻醉后進(jìn)行復(fù)位。24～48h的損傷，血腫內(nèi)阻滯非常有效。無菌操作條件下，直接向骨折部位注射0.5%利多卡因10～15ml。而超過48h的骨折，就需要區(qū)域阻滯或全麻。閉合復(fù)位技術(shù)要點：首先是縱向牽引，將嵌插的骨片拉出，將攣縮的軟組織拉開。前臂旋前位有助于背側(cè)移位的骨折塊復(fù)位，遠(yuǎn)折端向掌側(cè)移動有助于掌傾角的恢復(fù)，而腕關(guān)節(jié)尺偏有助于恢復(fù)橈骨遠(yuǎn)端的尺偏角。復(fù)位后，就可以用良好塑形的石膏固定。一般建議于稍旋前、腕關(guān)節(jié)屈曲、尺偏位固定。Colles骨折固定于掌屈5°～15°及最大限度尺偏位如下圖。復(fù)位后應(yīng)該拍片以評估骨折對線情況和石膏塑形的情況。可以接受的復(fù)位結(jié)果是：關(guān)節(jié)面移位＜2mm，適度的掌傾，以及橈骨長度的恢復(fù)。應(yīng)該告知患者抬高患肢，并且活動手指。為了確保骨折復(fù)位后的維持，必須每周復(fù)查。骨折端復(fù)位丟失，是不穩(wěn)定的表現(xiàn)。如果發(fā)生，就需要評估是否需要重新復(fù)位還是需要手術(shù)固定。2.手術(shù)治療不穩(wěn)定的橈骨遠(yuǎn)端骨折需要手術(shù)，以維持復(fù)位后的位置。手術(shù)指征主要包括：骨折有嚴(yán)重的移位，粉碎骨折，以及復(fù)位丟失。另外，涉及關(guān)節(jié)的剪切骨折和關(guān)節(jié)的壓縮骨折常常需要手術(shù)切開復(fù)位以恢復(fù)關(guān)節(jié)面的平整。(1)經(jīng)皮鋼針固定：采用閉合復(fù)位經(jīng)皮鋼釘內(nèi)固定治療恰當(dāng)?shù)牟环€(wěn)定的橈骨遠(yuǎn)端骨折也可以獲得滿意效果。復(fù)位后，在C臂機(jī)監(jiān)視下自橈骨莖突入克氏針突。背側(cè)進(jìn)針可以增加穩(wěn)定性，但是需要注意避免伸肌腱損傷。骨折出現(xiàn)愈合前，需要石膏外固定予以保護(hù)，骨折愈合后就可以拔除克氏針，開始理療。交叉克氏針固定是利用杠桿作用使骨折端復(fù)位固定。針要穿入對側(cè)皮質(zhì)，這樣給骨折復(fù)位有個支撐。從橈側(cè)和背側(cè)進(jìn)針可以分別減少橈偏和背傾。在只有一側(cè)皮質(zhì)粉碎骨折時交叉固定才有效。兩側(cè)或者更多的皮質(zhì)粉碎骨折或者有明顯的骨量丟失，建議使用交叉固定的同時使用外固定加以保護(hù)。經(jīng)皮鋼針固定不適合所有的患者。當(dāng)骨折并發(fā)骨量丟失和骨折粉碎嚴(yán)重，克氏針不能提供足夠的支撐，可以導(dǎo)致固定失敗和骨折的畸形愈合。另外還存在橈神經(jīng)淺支損傷的風(fēng)險。(2)外固定支架：外固定支架可以對抗肌肉牽拉的力量，也可以通過牽拉韌帶使骨折復(fù)位。即使在嚴(yán)重的干骺端粉碎骨折，也可通過外固定支架維持橈骨長度。但應(yīng)注意，牽拉可以復(fù)位主要的骨折片，但是不能使關(guān)節(jié)面骨折塊復(fù)位。橈骨外固定支架固定的標(biāo)準(zhǔn)方法是第二掌骨固定2根Schanz螺釘，近端橈骨干固定2個或2個以上螺釘。有研究表明，在橈骨遠(yuǎn)折端用一枚Schanz螺釘，無論是影像學(xué)檢查還是功能都獲得了更好的效果。為了減少外固定所生產(chǎn)的并發(fā)癥，需要注意一些細(xì)節(jié)：進(jìn)針點需要做足夠長的切口，以避免橈神經(jīng)淺支損傷。雖然屈腕是骨折復(fù)位所必需的，但是腕關(guān)節(jié)不宜過度屈曲位固定。另外不可過度牽引，月骨距離橈骨半月窩移位不能超過1mm。(3)切開復(fù)位內(nèi)固定：切開復(fù)位內(nèi)固定治療橈骨遠(yuǎn)端骨折已經(jīng)成為公認(rèn)的有效地治療手段。為橈骨遠(yuǎn)端設(shè)計的各種各樣的支撐鋼板，以及鎖定鋼板已廣泛用于臨床。(4)掌側(cè)鋼板與背側(cè)鋼板：鋼板應(yīng)該放在橈骨掌側(cè)還是背側(cè)尚無統(tǒng)一意見，然而多數(shù)主張放在掌側(cè)。相對于背側(cè)，掌側(cè)有更多的空間放置鋼板，而且有旋前方肌的保護(hù)。在背側(cè)放置鋼板比掌側(cè)更容易發(fā)生肌腱粘連和斷裂。掌側(cè)放置鋼板對掌側(cè)堅強(qiáng)皮質(zhì)復(fù)位非常重要。另外，背側(cè)皮質(zhì)較薄，只能提供較小的內(nèi)在支撐，而掌側(cè)皮質(zhì)較厚，骨折復(fù)位內(nèi)固定后可以起到重要的支撐作用。掌側(cè)放置鋼板最常用的手術(shù)入路是在橈側(cè)腕屈肌鞘的橈側(cè)切開。拉開旋前方肌就可以很好地暴露橈骨掌側(cè)面。掌側(cè)固定時，關(guān)節(jié)面復(fù)位比較困難。復(fù)位時應(yīng)避免重要的關(guān)節(jié)韌帶切開，在透視的幫助下，閉合復(fù)位多數(shù)可以成功。否則就要應(yīng)用關(guān)節(jié)鏡或切開關(guān)節(jié)進(jìn)行直視下關(guān)節(jié)復(fù)位。橈骨遠(yuǎn)端的背側(cè)入路最好是從第三背側(cè)伸肌間室切開。松解拇長伸肌腱后，腕和指的伸肌腱可以不用破壞腱鞘就可以拉開。背側(cè)鋼板可以直接支撐背側(cè)邊緣骨折和背側(cè)成角的干骺端骨折。切開腕關(guān)節(jié)背側(cè)關(guān)節(jié)囊可以更好的看見關(guān)節(jié)面。背側(cè)放置鋼板比較常見的一個問題就是發(fā)生伸肌腱功能障礙和斷裂。關(guān)節(jié)鏡也是治療橈骨遠(yuǎn)端骨折進(jìn)行關(guān)節(jié)面復(fù)位的一種選擇，而且可以評估并治療相關(guān)的軟組織損傷。(5)橈骨遠(yuǎn)端鎖定鋼板：人們對鎖定鋼板治療橈骨遠(yuǎn)端骨折有相當(dāng)大的興趣。鋼板可以允許帶螺紋的針或螺釘鎖定于鋼板遠(yuǎn)端帶螺紋的螺釘孔，構(gòu)成了一個固定角度的裝置，從而具有角穩(wěn)定性。通過鎖定鋼板固定角度的螺釘固定遠(yuǎn)端骨片，使橈骨遠(yuǎn)端骨折背側(cè)移位在掌側(cè)固定成為可能。鎖定鋼板增強(qiáng)了對關(guān)節(jié)骨折塊的支撐，并減少了骨移植的需要。掌側(cè)和背側(cè)都可以用鎖定鋼板。用鎖定鋼板可以允許早期活動，并且能維持解剖對位線良好，即使是有背側(cè)移位的骨折。(6)Trimed內(nèi)固定系統(tǒng)：Trimed內(nèi)固定系統(tǒng)是治療橈骨遠(yuǎn)端骨折的一個新的理念。由3個組件組成，分別放置于橈骨遠(yuǎn)端骨折中橈骨莖突，背側(cè)尺骨角，掌側(cè)關(guān)節(jié)唇以支持上述部位骨折塊。鋼板雖然模量很低，但是固定卻很牢固，其內(nèi)固定的強(qiáng)度甚至超過了外固定，可以為早期活動提供足夠堅強(qiáng)的支撐2023年07月17日207
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孫勝副主任醫(yī)師 北京朝陽醫(yī)院石景山院區(qū) 骨科 ?治療原則及治療方法的選擇治療原則主要是恢復(fù)關(guān)節(jié)面的平整性，維持和穩(wěn)定其解剖復(fù)位，同時最大可能地保護(hù)腕關(guān)節(jié)功能。橈骨遠(yuǎn)端骨折治療主要分非手術(shù)治療和手術(shù)治療。非手術(shù)治療非手術(shù)治療主要是指閉合復(fù)位石膏托固定、小夾板固定或支具固定等。手術(shù)治療手術(shù)指征：手法復(fù)位后短縮＞3mm，背側(cè)成角＞10°或關(guān)節(jié)面塌陷＞2mm。手術(shù)治療主要包括經(jīng)皮穿針內(nèi)固定術(shù)、外固定架固定術(shù)、切開復(fù)位內(nèi)固定術(shù)、髓內(nèi)釘內(nèi)固定術(shù)、人工腕關(guān)節(jié)置換術(shù)等。2023年07月17日73
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俞永林主任醫(yī)師 復(fù)旦大學(xué)附屬華山醫(yī)院 骨科 醫(yī)生原來說不開刀，為什么石膏或支具固定后骨折會發(fā)生移位而需要開刀？骨折以后醫(yī)生給予石膏或支具外固定，常常會出現(xiàn)移位。醫(yī)生原來說不開刀，復(fù)查時又說需要開刀，是因為骨折發(fā)生了移位。當(dāng)醫(yī)生發(fā)現(xiàn)骨折有移位時，如果移位不大，只有小幅度的側(cè)面位移，或者有成角移位，可以重新調(diào)整固定，例如調(diào)節(jié)壓力墊的高度和繃帶的松緊程度等。如果移位較大，就必須將石膏或者支具取下，用手法將其復(fù)位后重新固定。經(jīng)過上述努力不能成功，只能開刀(切開復(fù)位內(nèi)固定術(shù))。一般來說出現(xiàn)移位的話，可能見于以下幾種情況：1.上石膏以后，為了擦洗患者自主地將石膏或支具移動甚至取下后重新固定，影響了石膏或支具固定的效果。2.骨折部位的軟組織水腫消退,使原來的固定松動。3.由于不小心碰傷甚至再次跌倒，傷到了骨折的部位。所以,將骨折給予石膏或支具固定以后,需要定期進(jìn)行X線檢查，了解骨折有無移位。原來不需要手術(shù)的骨折,如果發(fā)生明顯移位,則需要手術(shù)。2023年07月09日150
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2023年06月21日72
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