【作者】 李正疆；

【导师】 鲁晓波；

【作者基本信息】 泸州医学院 ， 外科学， 2009， 硕士

【摘要】 目的:通过临床三种治疗方法的随访比较,论证自体骨髓复合人工骨联合髂骨骨膜移植治疗四肢骨不连的优势,为后期本方法的临床推广使用提供客观依据与临床经验支持。方法:1,不同时间搜集四肢骨不连患者,共50肢,其中难治性骨不连17肢;2,术前对患肢功能进行评分:根据“骨不连手术治疗前后功能评定标准”(附表一),按疼痛,日常生活,局部软组织情况,X片表现及患者满意度五个标准进行评分,并作好记录;3,50例患者随机分成三组,其中A组(联合组)17例,B组(骨髓组)20例,C组(髂骨组)13例。术中去除骨端纤维连接组织、硬化骨部分、再通髓腔,选择髓内钉或钢板、外固定支架固定;4,A组根据骨折断面大小,取带旋髂深血管髂骨骨膜,与伤肢骨不连处相应血管吻合(显微镜下进行);然后抽取自体骨髓与人工骨颗粒混和均匀,填充骨折断端,B组取自体骨髓复合人工骨植于骨折断端;C组自体髂骨植于骨折断端。5,术后使用抗生素3-5天;术后24~48小时疼痛缓解后,指导患肢部分被动活动;术后3天开始嘱患者进行患肢关节主动伸屈活动;6,术后常规换药、拆线,观察伤口愈合情况;记录住院治疗时间;7,术后1、3、6、9、12个月复查X片(均设定在相同条件下摄CR片);术后1、6、12月行CT骨密度测定,存于移动硬盘。8,记录固定物撤除时间,固定物撤除4周行骨不连处相同条件下患肢功能评分。9,用SPSS14.0统计软件包对数据进行分析。10,参加本课题的所有患者均属自愿,并签定相关法律文书。11,所有临床治疗及功能恢复标准参考国际或国内权威机构的相关文书。结果:所有患者获随访12~28个月,平均17.5个月。骨折愈合时间5.5~14个月,平均7.5个月。CR片示45肢骨折愈合,无旋转、成角及短缩畸形。1例肢体因关节僵硬、瘢痕挛缩等原因,骨折愈合后遗留功能障碍,5例患者随访12~14月骨折未愈和,4例经二次自体骨髓复合人工骨联合髂骨骨膜移植术后,分别与术后7~8月骨折愈合。1例长段骨缺损经行带血管蒂腓骨瓣移植,术后7月骨折愈合。第一次手术A组优良率为88.2%、B组70.0%、C组61.5%。结论:用三种方法治疗四肢骨不连,自体骨髓复合人工骨联合髂骨骨膜移植治疗愈合时间最短,患者满意度最高,效果最佳。自体骨髓复合人工骨移植与单纯取髂骨植骨相比,二者治愈率相当,但自体骨髓复合人工骨移植术具有创伤小,住院时间短的优点。更多还原

【Abstract】 bjective: To demonstrate the Advantage of autologous bone marrow integrating artificial bone and ilium periosteum transplantation for treate nonunion of extremities according to the clinical follow-up. And to supply an objective basis and theoretical support for followed clinical expansion. Methods : 1. To collecte the 50 cases patients of nonunion of extremities including 17 cases of refractory nonunion. 2. To comprehensively grades the patients according to the functional evaluation standard of the patients of nonunion before and after surgical treatment. The score system includs 5 indexes such as pain, daily Life, local soft tissue conditions,the features of X-ray film and patient satisfaction. All the data should be recorded accurately. 3. The 50cases were divided into 3 groups: group A (combined group) 17 cases, group B (bone marrow group) 20 cases, and group C (iliac bone group) 13 cases. Removed the fibrous tissue and sclerotic bone between the fracture site.And get throught the medullary cavity. To fixation the fracture with intramedullary nail, plate or external fixator. 4. The payients of group A were cut out of the Vascular Pedicled Iliac Periosteal according to the area of fracture face to anastomosis with corresponding vascular in the regional(Done it under the microscope). The bone marrow was aspirated from patients of group A were mixed uniform with artificial bone.Then placed it between the fracture site. The bone marrow aspirated from the patients of group B was placed into the fracture site after mixed uniform with artificial bone. The iliac bone from group C was placed into fractue site directly. 5. Using antibiotics 3-5 days after operation. To guide the limb passive training partly. The affected limb began to train actively extension and flexion activity after 3 days postoperation. 6. Conventional postoperative dressing change, suture removal and observed the wound healing condition. Record hospitalization time Accurately. 7. Made CR film 1、3、6、9、12 months after operated(All the CR films were made under the same condition.). Determining the bone mineral density of affected part 1,6,12 months postop. The data was Stored in mobile hard disk. 8. Recorded the time of the fixture removed. Determining for the affected limb function score 4 weeks after fixture removed under the same condition. 9. To data analysis by statistical package of SPSS 14.0. 10. All the patients take part in this subject are voluntary. And identificated to signing the relevant legal instruments. 11. All the standards of clinical treatment and functional recovery were referenced to international or national Authoritative relevant instruments. Results: All the patients were received follow-up,the time ranged from 12-28 months, minimum 17.5 months. The bone healing time ranged from 5.5 to 14 months, minimum 7.5 months. The CR films shown that 45 cases healed without spiral,angulation and shortened deformity. One case left over dysfunction after fracture healed because of ankylosis and scar contracture. Five cases did not heal postoperation 12-14 months. Four cases were healed 7-8 months after 2nd operated with autologous bone marrow integrating artificial bone and ilium periosteum transplantation. One case of long bone defect was healed 7 months after operated with fibula flap with vascular pedicle. The excellent and good rate of 1st operation was 88.2% in group A, 70.0% in group B and 61.5% in group C. Conclusion: Among the three methods using autologous bone marrow integrating artificial bone and ilium periosteum transplantation to treat the nonunion of the extremities have the advantages of the shortest healing time, the highest patient satisfaction and the best efficacy. The cure rate was equivalent between the two operational methods of autologous bone marrow integrating artificial bone transplantation and iliac bone transplantation. And compared with iliac bone transplantation purely, the method of autologous bone marrow integrating artificial bone transplantation has the advantages of small trauma and shorten hospitalization time.更多还原