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17 A Comparison of the Results of Total Hip and Knee Arthroplasty Performed on a Teaching Service or a Private Practice Service
有无教学参与的全髋、膝关节置换结果的比较
Background: Active participation of residents and fellows in the performance of total hip and total knee arthroplastiesmay affect the outcomes of these procedures. We evaluated the early clinical results and complications associatedwith primary total hip and knee arthroplasties at a hospital that had both university teaching and private practiceorthopaedic services.
背景：住院医师过多的参与全髋、膝人工关节置换可能会影响疗效。本研究对同一医院中有无教学参与的初次全髋、膝关节置换的早期临床结果和并发症进行比较。
Methods: We performed a retrospective study on a consecutive series of 347 patients who had undergone 230 totalhip and 171 total knee procedures performed by one attending surgeon. One hundred and sixty-nine patients underwentan arthroplasty during which a resident or fellow on a teaching service assisted the attending surgeon; duringthese procedures, the resident or fellow performed part of the arthroplasty under the direct supervision of the attendingsurgeon. Subsequently, 178 patients underwent an arthroplasty performed by the same surgeon without residentor fellow participation.
方法：对连续347名人工关节置换病人进行了回顾性研究，其中包括230例全髋关节和171例全膝关节，皆由同一名主治医师完成。有169例关节在置换过程中，部分操作在该主治医师的指导下由住院医师完成。随后的178例病人关节置换全部由同一名主治医生完成，没有住院医师参与。
Results: Significantly longer operative times were recorded for both total hip arthroplasty (average, seventy-threecompared with sixty-one minutes; p < 0.0001) and total knee arthroplasty (average, eighty compared with seventythreeminutes; p = 0.0028) when the procedures were performed with the participation of residents or fellows. For totalhip arthroplasty the complication rates were 8% for the teaching service and 10% for the private practice service,and for total knee arthroplasty they were 3% for each service. With the numbers studied, there were no differences inany clinical outcomes between the groups.
结果：当有住院医师参与时，手术时间有明显增加，全髋关节置换平均由61分钟增加到73分钟（ｐ<0.0001），全膝关节置换时间由73分钟增加到80分钟（ｐ＝0.0028）。有住院医师参与时，全髋关节置换并发症发生率为8％，没有者发病率为10％。而全膝关节置换的并发症发病率皆为3％。根据数据的分析，两者的临床结果没有差异。
Conclusions: Teaching and active participation from residents and fellows during total hip and total knee arthroplastydid not have a detrimental effect on the early clinical results, except for a longer surgical time.
结论：教学和住院医师的参与，除了手术时间增加外，对全髋关节和全膝关节置换的早期临床结果并没有不良影响。
19 Results of Polyaxial Locked-Plate Fixation of Periarticular Fractures of the Knee
多轴锁定钢板治疗膝关节周围骨折的结果
Background: Locked-plate fracture-fixation techniques and designs continue to evolve. Polyaxial locking plates thatallow screw angulation and end-point locking have become available; however, there are no clinical data documentingtheir strength and efficacy, to our knowledge. The purpose of this study was to evaluate the clinical performance of avariable-axis locking plate in a multicenter series of periarticular fractures about the knee.
背景：锁定钢板固定技术和设计在不断完善。多轴锁定钢板允许螺钉成角和末端锁定，但是据我们所知尚无临床数据证实它们的强度和作用。本研究通过多中心对使用可调轴向锁定钢板治疗膝关节周围骨折的结果进行研究，来评估其临床效果。
Methods: Between 2003 and 2005, fifty-four patients with a total of fifty-six fractures were treated with a polyaxiallocked-plate fixation system (DePuy, Warsaw, Indiana). There were twenty male patients and thirty-four female patientswith a mean age of fifty-seven years. There were twenty-five distal femoral fractures and thirty-one proximal tibial fractures.Twelve of the fractures were open. Clinical and radiographic data, including changes in alignment, hardware breakage,or other mechanical complications of the device, were retrospectively reviewed. Function was assessed with use ofthe Knee Society scores. One patient with a bilateral fracture died less than three months postoperatively, and two patientswere lost to follow-up prior to union. Fifty-two fractures in fifty-one patients were followed to union or for a minimumof six months; the mean duration of follow-up was nine months (range, six to twenty-five months).
方法：在2003到2005年间，有54个病人总共56例骨折使用多轴锁定钢板固定系统进行固定（Depuy，Warsaw，Indiana）。其中包括男性20名，女性34名，平均年龄57岁。25例为股骨远端骨折，31例为胫骨近端骨折。有12例为开放性骨折。对这些病例的临床和影像学资料，包括力线改变，内固定断裂和其他的内固定力学并发症等，进行回顾性分析。功能评分采用膝关节学会评分。其中一例双侧骨折病人在术后三月内死亡，另有两例病人在骨折愈合前失访。51名病人（52例骨折）随访至骨折愈合，或者至少6个月。平均随访时间为9个月（6-25月）。
Results: Forty-nine (94%) of the fifty-two fractures united. There were no mechanical complications. Most importantly,there was no evidence of varus collapse as a result of polyaxial screw failure. There were three deep infections andone aseptic nonunion. No plate fractured, and no screw cut out.
结果：52例骨折中有49例（94%）愈合，没有机械性并发症。最重要的是，没有1例有预示多轴固定系统失败的内翻塌陷出现。有3例出现深部感染，1例无菌性不愈合。没有钢板断裂和螺钉切割。
Conclusions: The variable-axis locking plates performed well, with a high rate of fracture union and no evidence ofvarus collapse due to failure of the polyaxial screw fixation, in a series of complex fractures about the knee. Complicationrates were similar to those for historical controls treated with fixed-trajectory locking plates. Polyaxial lockingplates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction.
结论：可调轴向锁定钢板固定效果良好，在治疗一系列膝关节复杂骨折中，骨折愈合率高，没有出现钢板失败所出现的内翻塌陷。并发症发生率类似于使用固定轨道锁定钢板的病例对照。多轴锁定钢板可以提供更多的固定选择，而没增加机械性并发症或者出现复位丢失。
Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation
股骨粗隆间髋部骨折股骨外侧壁完整性：二次手术重要的预测因子
Abstract
Background: Reoperations after intertrochanteric fractures are often necessitated by fracture displacement following mobilization of the patient. The biomechanical complexity of the fracture, the position of the implant, and the patient's characteristics are known to influence postoperative outcome. We investigated the importance of an intact lateral femoral wall as a factor in postoperative fracture displacement after fixation with a sliding compression hip screw.
研究背景：股骨粗隆间骨折的患者，活动后骨折移位常常不得不进行二次手术。我们知道，该骨折生物力学上的复杂性、内植物的位置以及患者的特征影响着手术后的结果。我们调查了滑动加压髋螺钉固定后，完整的股骨外侧壁作为术后骨折移位的一个（影响）因素的重要性。
Methods: Two hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135° sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters, the integrity of the lateral femoral wall, and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively.
方法：2002年至2004年间，214例连续的股骨粗隆间骨折患者都用4孔（侧面钢板）135°滑动加压髋螺钉进行处理。参考AO/OTA分类系统按术前X线片对骨折进行分类。手术后对大小粗隆的状况、股骨外侧壁的完整性和内固定物的位置进行评价。术后6个月内对由于技术失败而进行的再次手术进行记录。
Results: Only 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months, whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001).
结果：股骨外侧壁完整的168例患者中仅有3%（5例）术后6个月内进行了再次手术，而46例涉及股骨外侧壁骨折的患者中有22%（10例）进行了再次手术(p < 0.001)。多元Logistic回归分析联合人口统计和生物力学参数显示：股骨外侧壁受累对于再次手术是一个重要的预测因子(p = 0.010)。46例中的74%（34例）是在手术过程中股骨外侧壁自身发生了骨折。在103例AO/OTA分型31-A1.1、A1.2、A1.3或 A2.1的股骨粗隆间骨折中仅有3%存在股骨外侧壁骨折，与之相比，99例AO/OTA分型31-A2.2或 A2.3骨折中31%（31例）存在这一骨折 (p < 0.001)。
Conclusions: A postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently, we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device, and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall, especially in randomized trials comparing fracture implants.
结论：股骨粗隆间骨折后，我们发现手术后存在股骨外侧壁骨折是再次手术的一个主要的预测因子，我们推断，手术前或手术中股骨外侧壁骨折的患者应用滑动加压髋螺钉装置进行处理是不恰当的，并且，股骨粗隆间骨折的分类因此也应该根据其股骨外侧壁的完整性，尤其是对骨折内固定物进行比较研究的随机化试验。
Level of Evidence: Prognostic LevelⅡ. See Instructions to Authors for a complete description of levels of evidence.
可信度水平：预测类Ⅱ级。对于可信度水平的完整叙述可参考投稿须知。
Heterotopic Ossification Following Traumatic and Combat-Related Amputations
创伤及战伤相关截肢所致异位骨化
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Background: Although infrequently reported in amputees previously, heterotopic ossification has proven to be a common and problematic clinical entity in our recent experience in the treatment of traumatic and combat-related amputations related to Operation Enduring Freedom and Operation Iraqi Freedom. The purpose of the present study was to report the prevalence of and risk factors for heterotopic ossification following trauma-related amputation as well as the preliminary results of operative excision.
背景：虽然先前并没有经常报导，我们最近在处理peration Enduring Freedom和Operation Iraqi Freedom创伤及战伤相关截肢病例的经验表明，异位骨化是一个常见并且是非常麻烦的一个事件。本次研究的目的，就是报到创伤相关截至所致异位骨化的发生率和危险因素，以及手术取出后的预后。
Methods: We identified 330 patients with a total of 373 traumatic and combat-related amputations who had been managed at our centers between September 11, 2001 and November 30, 2005. We reviewed the medical records and radiographs of 187 patients with 213 amputations who had adequate radiographic follow-up. Additional analysis was performed for twenty-four patients with twenty-five limbs that required excision of symptomatic lesions. The mechanism and zone of injury, amputation level, timing of excision, use of prophylaxis against recurrence, and other confounding variables were examined. Outcomes were assessed by determining clinical and radiographic recurrence rates, perioperative complications, preoperative and follow-up pain medication requirements, and the ability to be fit with a functional prosthesis.
方法：我们在373名在2001年9月11日至2005年11月30日之间曾于我中心就诊的创伤和战伤所致截肢患者中找出了330个合适的案例。我们复习回顾了187名接受了充足的反射影像随访的患者的213例截肢案例的临床记录以及影像学资料。并且对其中的需要典型病灶切除的24名患者的25个肢体进行了额外的分析。同时我们对于其发生机制、损伤范围、截肢程度、取出术的时间、防止复发的预防措施以及其他的变量因素都进行了测定。通过确定临床和影像学复发率、围手术期并发症、术前和随访期间止痛药使用以及患者对假肢的适应能力，我们得到了研究的结果。
Results: Heterotopic ossification was present in 134 (63%) of 213 residual limbs, with twenty-five lesions requiring excision. A final amputation level within the zone of injury was a risk factor for both the development and the grade of heterotopic ossification (p < 0.05). A blast mechanism was predictive of occurrence (p < 0.05) but did not correlate with grade. All patients who had been managed with excision were tolerating the prosthetic limb at an average of twelve months of follow-up. Twenty-three limbs demonstrated no evidence of recurrence, and two limbs had development of clinically asymptomatic, radiographically minimal recurrences. Six patients experienced wound-related complications that required reoperation, and two patients required subsequent minor revision surgery. There was a significant decrease in the use of pain medication following surgery (p < 0.05).
结果：在136个患者(63%)的213个残肢中出现了异位骨化，其中有25个病灶需要摘除。对异位骨化的程度和发展情况而言，在受损区域的最终截肢程度是一个重要的危险因素(p < 0.05)。发生机制可以预测发生(p < 0.05),但是和等级没有关联。所有接受摘除术的病人在平均随访12个月后都对假肢耐受了。23个肢体一点也没有复发的征象，而另外2个肢体出现了临床不典型、影像学性的小复发。6个病人出现了创伤相关并发症并且需要再次手术，而另外2个病人需要小的纠正手术。手术后止痛药的使用也有了显著的减少(p < 0.05)。
Conclusions: Heterotopic ossification following trauma-related amputation is more common than the literature would suggest, particularly following amputations that are performed within the initial zone of injury and those that are due to blast injuries. Many patients are asymptomatic or can be successfully managed with modification of the prosthesis. For patients with refractory symptoms, surgical excision is associated with low recurrence rates and decreased medication requirements, with acceptable complication rates.
结论：创伤相关截肢导致的异位骨化比文献报道要常见得多，特别对那些在原发损伤部位截肢以及冲击波损伤而言。许多病人都表现不典型，或者可以通过假肢的调整来成功地控制。对于出现顽固性症状的病人而言，手术摘除可以带来低复发率、显著减少的止痛药用量以及可以接受的并发症发生率。
Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand Population
新西兰人群使用Ponseti方法后早期畸形足复发情况
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Background: Nonoperative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. The purpose of the current study was to examine the early rate of clubfoot recurrence following the use of the Ponseti treatment method in a New Zealand population and to analyze patient characteristics to identify factors predictive of recurrence.
背景：作为一种基本的治疗方法标准，非手术治疗典型畸形足已经在世界范围内越来被大家所接受。在北美，尤其是Ponseti方法被报道认为不论在短期还是长期疗效方面都取得了很大的成功。现在我们的研究的目的就在于在新西兰人群中测定使用Ponseti处理后畸形足的复发率，并且同时分析病人的特点从而找出可以预测复发的标志因子。
Methods: Fifty-one consecutive babies with a total of seventy-three clubfeet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any subsequent operative treatment, was analyzed with respect to the severity at presentation, the time of presentation, the number of casts needed to obtain the initial correction, any family history of clubfoot, ethnicity, and the compliance with postcorrection abduction bracing. Recurrence was classified as minor, defined as requiring a tendon transfer or an Achilles tendon lengthening, or major, defined as requiring a full posterior or posteromedial surgical release to achieve a corrected plantigrade foot.
方法：我们前瞻性地随访了51个患有73例畸形足并且同时接受了Ponseti方法治疗的连续的婴儿患者，每个患儿在开始治疗后，至少随访了2年。我们仔细分析了作为需要接受另外手术处理的标志的复发情况，主要包括症状出现的严重情况、症状出现的时间、达到初始矫正疗效的处理的次数、畸形足的家族史、种族倾向以及矫正后的伸展器械使用情况等几个方面。在复发的分型上，如果患者需要肌腱移植或者是Achilles肌腱强化，则定义为小复发；如果需要完全的后路或者后中路手术减压才能达到完全矫正，则称为大复发。
Results: Twenty-one (41%) of the fifty-one patients had a recurrence, which was major in twelve of them and minor in nine. The parents of twenty-six babies (51%) complied with the abduction bracing protocol, and only three of these children had a major recurrence. Compliance with abduction bracing was associated with the greatest risk reduction for recurrence (odds ratio, 0.2; p = 0.009). When the parents had not complied with the bracing protocol, the patient had a five times greater chance of having a recurrence. With the numbers studied, no significant relationships were found between recurrence and the severity at presentation, the time of presentation, the number of casts needed to obtain correction, ethnicity, or a family history of clubfoot.
结果：在51例患者中，有21例（41％）出现了复发，其中有12例是大复发，有9例为小复发。在26例父母使用了伸掌器械的患儿中，只有3例出现了大复发。对伸展器械的顺应性是导致复发的最重要的危险因子（优势比：0。2，p＝0.009）。而对于父母没有使用伸展器械的患儿，出现复发的比例是前者的5倍。通过研究所得的数据，我们没有发现复发与症状的严重程度、症状的持续时间、需要矫正所做处理的次数、种族以及畸形足的家族史有明显的关联。
Conclusions: Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. When the parents comply with the bracing protocol, the Ponseti method is very effective at maintaining a correction, although minor recurrences are still common. When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected.
结论：对于接受Ponseti方法处理的畸形足患儿，其对于矫正后伸展器械的顺应性是最重要的因素。当使用伸展器械时，虽然还会有小的复发，但Ponseti方法还是被证明是非常有效的。如果父母不使用伸展器械，则会使患儿出现这样那样的许多小复发和大复发。
Bone Graft Substitutes: Separating Fact from Fiction
骨移植替代物：让事实远离想象
Although great advances have been made in fracture care, treatment failures are not uncommon. Highenergy injuries that result in bone devitalization, or open fractures that are associated with bone loss, can be followed by postoperative infection or, if treated with inadequate methods, may result in the development of a pseudarthrosis.These complex problems require much care before healing can occur. Since the development and use of stainless steel in orthopaedics in the 1920s, surgeons have tried to use advances in metallurgy and implant design to assist fracture-healing. Nails were improved with locking technology, while simple plates were transformed into blade plates, compression plates, and now locking plates. External fixation was revolutionized by G. Ilizarov with the development of distraction osteogenesis. Stainless steel itself was altered to create vanadium, Vitallium, and now titanium alloys. While all of these techniques have decreased the rate of nonunion, they have not completely solved the problem because there are limits to what metal can do to affect the biology of fracture-healing.
尽管骨折的治疗已经取得了伟大的进步，但治疗的失败却并不罕见。高能量损伤导致骨失活，以及开放性骨折合并骨丢失，可以继发术后感染，或者如果采用不适当的方法治疗，会导致假关节形成。这些复杂的问题在愈合之前需要更多的关注。自从1920年代不锈钢开发并用于骨科，医生们开始尝试利用冶炼技术和内固定设计方面的进步来促进骨折愈合。钢钉被改进成为带有锁钉技术的，而简单的钢板也被改进为接骨板、加压接骨板以及现在的锁定钢板。外固定架被G. Ilizarov革新为具有牵张成骨功能的。不锈钢本身也被调整为钒、铝以及现在的钛合金。尽管所有这些技术已经减少了骨不联，但并没有完全解决问题，因为金属对于骨折愈合的生物学的影响有限。
Although the biologic approach to fracture-healing seems intuitive, surgeons have had limited options for decades. An ideal bone-graft substitute must provide scaffolding for osteoconduction, growth factors for osteoinduction, and progenitor cells for osteogenesis. Autologous bone-grafting was described by Fred Albee in 19151. Bone-grafting requires additional surgery, can be painful, and is not without complications. Although Albee also described the use of calcium phosphates as an alternative to bone in the 1920s, it was not until 1965, when Marshall Urist identified “bone formation by autoinduction”2, that new options unfolded. Twenty-three years later, Wozney et al.3 and Luyten et al.4 discovered the proteins responsible for this phenomenon, BMPs-2, 3, and 4. Today these proteins can be harvested from a variety of bone
sources or synthesized through recombinant gene therapy, and they are available to the practicing orthopaedist.
尽管骨折愈合的生物学措施似乎是直觉上的，但几十年来医生们尚有一些有限的选择。一个理想的骨移植替代材料必须提供骨传导支架、骨诱导性生长因子及具有成骨活性的祖细胞。自体骨移植曾被Fred Albee于1915年论述过。但骨移植需要额外的手术，可能会增加痛苦，而且不能排除并发症。尽管Albee也曾在1920年代提出过使用硫酸钙作为骨的替代品，但直到1965年Marshall Urist确定了“自身诱导的成骨”，新的选择展现在了我们的面前。23年后Wozney小组及Luyten小组发现了引起这一现象的蛋白BMPs-2、 3和4。现在这些蛋白可以通过不同的骨资源获取，或者通过重组基因的方法来合成，目前已应用于骨科临床。
There has been an explosion of commercial products for the orthopaedic surgeon to choose from. Calcium phosphate ceramics, calcium sulfate, bioactive glass, biodegradable polymers, and recombinant human BMPs (OP-1 and BMP-2) are
all offered as solutions to the problem of bone-healing. While the actions of each product can be confusing, suggested combination therapy can be simply baffling, especially when there are few objective scientific data. Hospital administrators are equally perplexed, particularly by the costs of these products, and in many cases they refuse to allow the surgeon to use them even though they are thought to be useful.
对于骨科医生来说，目前可选的商用产品已经有了大规模的激增。磷酸钙陶瓷、硫酸钙、生物活性玻璃、可生物降解聚合物以及重组人BMP(OP-1和BMP-2)都被用作骨愈合问题的解决方案。但是每一种产品的作用可能会令人疑惑，这表明联合治疗可能会是种简单的阻碍，特别是当缺乏客观的科学数据时。医学行政管理人员也同样感到困惑，特别是对于这些产品的价格，在许多情况下他们会拒绝医生使用这些产品即便是这些产品被认为是有用的。
This issue is of critical importance to the orthopaedic surgeon involved in fracture care and treatment of nonunions. As the leaders in fracture care in North America, the Orthopaedic Trauma Association has responded by charging a committee under the leadership of Dr. William De Long to generate a white paper to more clearly identify the issues surrounding these products and their use. This initial report was expanded into the Current Concepts Review5 in this issue of The Journal to offer the information to the general orthopaedic community. It is hoped that, after reading this review, surgeons will be better able to make decisions based on sound scientific principles and to understand the limitations as well as the benefits of these commercially available bone-graft substitutes. In the end, it is the responsibility of the physician to prescribe the correct treatment for the patient, and that decision must be made on the basis of fact, not fiction.
这一问题对于从事骨折治疗和骨不联处理的骨科医生具有关键性的重要意义。作为北美骨折治疗方面的领导者，骨科创伤协会已经任命了一个以Dr. William De Long领导的委员会以产生一个白皮书，从而能够清楚的辨别关于这些产品及它们的使用中产生的问题。这一初期的报告在本期杂志的Current Concepts Review部分进一步得到拓展从而为整个骨科界提供信息。希望通过阅读这篇综述，医生们能够以可靠的科学原则作为依据更好的做出决定，同时能够更好的理解商用骨移植替代产品的局限及优势。最后，为患者提供正确的治疗是医生的责任，而所做出的决定必须是以事实为依据的，而不是想象。
作者：Roy Sanders, MD
Past President, Orthopaedic Trauma Association
Tampa, Florida
Fresh Stored Allografts for the Treatment of Osteochondral Defects of the Knee
新鲜冻存同种异体骨治疗膝关节骨软骨缺损
Background: Osteochondral allograft reconstruction of articular cartilage defects is a well-established cartilage repair strategy. Currently, fresh osteochondral allograft tissue is commercially available to clinicians approximately thirty days following graft harvest. Little clinical information is available on the outcome of patients who have been treated with fresh allografts stored for several weeks or more. The purpose of this study was to prospectively analyze the clinical outcome and graft morphology of patients who received fresh, hypothermically stored, allograft tissue for the treatment of symptomatic chondral and osteochondral defects of the knee.
研究背景：骨软骨同种异体骨重建关节软骨缺损是一个修复关节面软骨很好的方法。目前，可以通过商业途径获得的新鲜骨软骨同种异体骨组织从采取标本到应用到临床约30天时间。但目前获得的关于接受冻存几个星期或更长时间的新鲜同种异体骨治疗的病人的疗效方面的临床资料还很少。这项研究的目的就是前瞻性分析接受用新鲜低温冻存的同种异体骨组织治疗有症状的膝关节软骨和骨软骨缺损的病人的临床疗效和移植物的形态学变化。
Methods: Nineteen patients with symptomatic chondral and osteochondral lesions of the knee who were treated with fresh osteochondral allografts between 1999 and 2002 were prospectively followed. The mean age at the time of surgery was thirty-four years. Validated outcomes instruments (the Activities of Daily Living Scale and the Short Form-36) were used; all patients must have had a baseline functional score prior to surgery and a minimum two-year follow-up evaluation. All grafts were obtained from commercial vendors; the mean preimplantation storage time of the graft was thirty days (range, seventeen to forty-two days). The mean lesion size was 602 mm2. Magnetic resonance imaging was used to evaluate the morphologic characteristics of the implanted grafts.
方法：从1999到2002年随访了19位接受新鲜骨软骨同种异体骨治疗有症状的膝关节软骨和骨软骨病变的病人，手术时的平均年龄为34岁。采用有效的临床疗效评分方法（日常生活活动评分和简表36），所有的病人都必须进行术前基本功能评分和最少随访两年的功能评估。所有的移植物都从厂商获得，移植前平均储存时间为30天（从17天到42天不等）。病灶平均大小为602 mm2。采用磁共振评估移植物的形态学特征。
Results: The mean duration of clinical follow-up was forty-eight months (range, twenty-one to sixty-eight months). The mean score (and standard deviation) on the Activities of Daily Living Scale increased from a baseline of 56 ± 24 to 70 ± 22 at the time of the final follow-up (p < 0.05). The mean Short Form-36 score increased from a baseline of 51 ± 23 to 66 ± 24 at the time of final follow-up (p < 0.005). With the numbers studied, we could not correlate graft storage time, body mass index, lesion size, lesion location, or patient age with the functional outcome scores. At a mean follow-up interval of twenty-five months, cartilage-sensitive magnetic resonance imaging demonstrated that the normal articular cartilage thickness was preserved in eighteen implanted grafts, and allograft cartilage signal properties were isointense relative to normal articular cartilage in eight of the eighteen grafts. Osseous trabecular incorporation of the allograft was complete or partial in fourteen patients and poor in four patients. Complete or partial trabecular incorporation positively correlated with Short Form-36 scores at the time of follow-up (r = 0.487, p < 0.05).
结果：平均临床随访时间为48个月（从21到68个月不等）。日常生活活动的平均评分（和标准差）从术前的56 ± 24增加到随访结束时的70 ± 22 (p < 0.05)。平均简表36评分从术前的51 ± 23增加到到随访结束时的66 ± 24(p < 0.05)。因为研究数量的关系，我们没办法将移植物的储存时间、病人的体重指数、病变的大小、病变的部位、病人的年龄与功能评分的结果联系起来。在平均间断随访25个月的时候，对软骨很敏感的磁共振显示18位病人移植的软骨还保持正常的关节软骨厚度，其中8个病人移植的同种异体软骨与正常的关节软骨保持相等的信号强度。14个病人移植的同种异体骨中全部或部分骨小梁已长入，4个病人移植的同种异体骨中骨小梁长入情况较差。全部或部分骨小梁已长入的病人与随访时简表36评分之间的相关性有统计学意义(r = 0.487, p < 0.05)。Conclusions: Fresh osteochondral allografts that were hypothermically stored between seventeen and forty-two days were effective in the short term both structurally and functionally in reconstructing symptomatic chondral and osteochondral lesions of the knee.
结论：储存17－42天新鲜低温冻存的骨软骨同种异体骨短期内在结构和功能上能有效重建有症状的膝关节软骨和骨软骨病变。
Pelvic Reconstruction with a Structural Pelvic Allograft After Resection of a Malignant Bone Tumor
恶性骨肿瘤切除术后利用同种异体骨盆结构移植物行骨盆重建Background: Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis.
背景:由于相关并发症太多,骨盆恶性肿瘤切除后骨盆弓的重建仍然是外科中的巨大挑战. 本研究的目的在于评价利用同种异体骨移植重建骨盆手术的功能后果和并发症的发生率Methods: Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors, sixteen of which were high-grade sarcomas, and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score.
方法:对24名病人进行骨盆恶性骨肿瘤切除后同种异体骨移植盆腔重建手术. 对生存下来的病人进行最少24个月的随访. 其中19个为原发恶性骨肿瘤, 在这19个病人中16个高度恶性的肉瘤,,另外5人为孤立的转移灶.利用临床和放射手段对病人进行评估, 同时利用肌肉骨骼肿瘤协会评分进行功能评估.
Results: The mean age of the patients at the time of the index surgery was thirty-four years, and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation, eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients, and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision, with nine of these revisions related to the reconstruction.
The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device, and five of them had normal function with no or only a slight limp.
结果: 进行该手术时病人的平均年龄为34岁, 平均随访时间为41个月. 转子周区有累及的18个病人利用人工髋关节(13)或骨软骨同种异体移植物(5)进行了重建. 另外6个病人切除范围累及了髂骨.所有的病人都接受了经消毒而未进行二次辐射的大块同种异体骨.在我们最后一次进行评估时,8名病人正处于无病生存期, 7名病人局部复发.6名病人存在神经学的不足,三名病人发生深部感染. 16名骨移植病人中3名发生了骨不连. 所有病例均未发生移植物溶解或骨折.11名病人进行了手术修正, 其中9名病人的修正涉及到了手术重建区. 最近一次随访时,平均肌肉骨骼肿瘤协会评分的最大可能得分为73%. 11个年龄小于20岁的病人的平均得分为83%, 另外13个年龄稍大的病人的得分为65%. 10名病人可以在无任何辅助设备的情况下行走, 另有5名病人稍有跛行或没有,功能正常
Conclusions: Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results, especially in young patients. Nonunion was the most common allograftrelated complication.
结论:肢体缩短手术后行骨盆重建手术相关并发症非常多,因此对患原发骨肉瘤的病人进行这类手术一定要慎重考虑. 骨盆同种异体移植物可以重建骨盆的解剖结构并能够产生很好的功能结果, 尤其是在年青的病人.但骨不连是移植物发生率最高的并发症Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
置信水平:治疗水平Ⅳ级. 可以阅读对作者的指导来获得对置信水平的全面描述
Developmental Biology in Orthopaedics. Summary of the 2006 AAOS Research Symposium
[b]矫形外科中的发育生物学.2006年AAOS研究讨论会摘要
在胎儿正常发育过程中, 各种不同的细胞通路相互协调作用, 保证细胞有秩序的增殖,运动,甚至死亡, 从而发育成为器官.在过去的10年里, 关于肌肉骨骼系统的发育问题取得了大量的进展. 关于这些途径以及它们如何调控细胞行为的知识可以应用于肌肉骨骼系统病理状态和修复过程. 这些重要的通路中许多都可以作为治疗的靶点. 有趣的是, 这种方法帮助我们发现了很多具有致畸作用的因子.识别这些重要因子在肌肉骨骼系统中的重要作用可以帮助我们快速找到新的治疗方法. 基因修饰的生物,例如转基因小鼠,在这种工作中具有重要的作用.由于这种生物在开始发育的时候就具有遗传缺陷,所以它们即可以用来研究发生在成熟过程中信号转导的重要所用,也可以用来研究病理和修复过程. 因此, 由美国矫形外科医师学会, 矫形外科研究和教育基金会,矫形外科研究协会,NIH, 加拿大健康研究院,shriners儿童医院, kyphon,stryker等发起,在多伦多召开了本次矫形外科中的发育生物学会议,回顾矫形外科中的发育生物学的相关知识水平. 探讨如何将这种信息应用到矫形外科疾病中, 并推动矫形外科研究者和发育生物学研究者之间的合作. 与会者还就值得研究的领域达成了共识.
发育开始与卵子受精. 受精后的细胞称为合子.合子进行快速的有丝分裂和细胞分化, 形成一个大约包括100个细胞的球状体---囊胚. 随后,囊胚经历原肠胚形成, 在此期间,细胞移行形成三个胚层, 内胚层,中胚层和外胚层. 胚层确定后, 器官发生开始. 在此期间, 神经板皱褶形成神经管, 然后体节开始形成.每个体节最终发育成一个椎骨以及相邻神经根相关组织. 体节形成是在一种分节时钟的推动下完成的, 这种时钟调节基因使其以周期的模式表达从而产生每一个体节的边界.
由于体节形成单个的椎体, 这就很容易理解体节的发生可以导致先天性的脊柱问题, 例如先天性脊柱侧凸. 几个研究者正在试图通过研究体节的发育来理解脊柱记性.例如, 研究表明一种调控分节时钟的基因deta-like3突变将会导致分节时钟紊乱, 并最终导致脊柱肋骨发育不全. 随之而来的,各种不用严重程度的脊柱侧凸开始产生. 理解调控体节时钟的基因可以帮助我们深入理解先天性脊柱侧凸的成因.另外, 体节和椎体发生的知识可以帮助我们全方位的理解先天性和获得性脊柱疾病. 从转基因小鼠的研究中获得的有关体节时钟调控基因的知识对脊柱侧凸病人具有极大的应用潜力. 可以用来鉴别这种基因的一种方法是看其在体节发育过程中是否是被周期性调控的. 另外一种可行的方法是筛选暴露于化学致畸物的小鼠,从而获得突变的基因. 通过比较小鼠和人的表型可以使我们把有限的精力集中在最有可能导致特定人类疾病的基因上. 并且已经证明这种方法是正确的. 这些工作在发现椎体形成中的重要信号通路和提供诊断以及预后信息方面具有极大的应用前景. 最终, 我们还可以将这些方法应用于发现其他通路,并针对这些通路设计脊柱疾病的治疗方法.
在四肢发育过程中,多潜能细胞分化成不同的类型, 并且每一种都精确的定位在特定的位置上从而帮助肢体发育成合适的形态. 间充质细胞在肌肉骨骼系统发生和生后的发育中的重要作用引起了研究者们的广泛关注,因为在它们分化成肌肉骨骼系统的主要结构细胞, 骨细胞,软骨细胞和成纤维细胞. 长骨最初就是由这些多能间充质细胞的沉积形成的, 随后这些间充质细胞分化成软骨细胞构成未来长骨的软骨板. 关节的形成是前体组织中细胞死亡的过程. 近年来,研究者们利用遗传修饰的小鼠来鉴定选中的不同类型的发育中的细胞群最终分化成了何种成熟细胞. 经过修饰,这些小鼠的某些调节基因单元一旦开始表达,它酒会产生一种容易检测的蛋白. 有研究表明软骨细胞分化成两种成熟细胞,一种是关节衬套软骨,另一种为生长板. 多能细胞分化成成熟的细胞这一过程是由很多信号通路和基因调节的, 本次会议中讨论到的有sex-determining region Y-box family(SOX), runt-related transcription factor (RUNX), bone morphogenetic protein(BMP), transforming growth factor-(TGF-, fibroblast growth factor (FGF),and wingless-type MMTV (mouse mammary tumor virus) integration site
family (WNT)..在每一步的分化过程中, 都需要对这些信号通路进行近精细的调节以保证正确的细胞分化. 这一领域内的深入工作将使我们更加深入的理解这些分化过程中的调节过程, 而这些知识可以被应用到肌肉骨骼系统的修复领域.
成熟的关节软骨细胞修复功能优有限, 关于这些细胞是如何从未分化的前体细胞分化而来的知识将会帮助我们揭开调整关节软骨的生物学行为的机制来使成熟的软骨细胞以一种合适的方式增殖从而修复组织缺损. 目前, 对于这一过程的理解仍然处在初级阶段. 这个领域需要我们投入更多的精力;这些工作可以很快被应用于软骨修复,组织工程软骨替代和关节炎等领域. 基于这种考虑, 遗传工程小鼠将被应用的更加广泛, 因为基于这种技术我们可以很快很有效的发现特定的基因和信号通路. 一些研究这正在致力于小鼠关节炎模型的构建. 通过手术可以诱导骨关节炎, 还有很多方法,包括注入抗原等,可以用于诱发炎症性关节炎.
随着长骨的发育, 软骨生长板逐渐被骨细胞所代替------首先是位于骨中间的初级骨化中心, 然后是位于骨端的次级骨化中心. 位于初级骨化中心的软骨称为生长板, 在骨胎儿期和出生后的发育中提供长度的增加. 过去的10年中在胎儿期生长板发育中取得了巨大的进展. hedgehog signaling, parathyroid hormone-related protein (PTHrP), FGF,SOX9, TGF-, BMPs, WNTs, and matrix metalloproteinases (MMPs)的作用已经基本阐明. 可以任意进行基因敲除或定点在软骨内进行基因表达的遗传修饰小鼠在这方面应用起来非常有效. 解读来自遗传修饰的小鼠的数据目前还存在一定的困难,因为它们不仅导致靶基因的改变, 而且还会对细胞群的发育产生影像. 分析生长板的新方法, 例如对血流的详细研究, 给研究这些基因如何调控生长板的功能提供了新的视点, 其中一些研究结果甚至对传统的观点提出了挑战. 例如, 有研究表明生长板的血管化程度比以前认为的要高很多, 正是因为这种结构特点,才使局部的生长板调节因子可以长途奔袭至该处, 同时这在生长板对损伤的反应中也有重要的作用. 由缺氧诱导因子等基因介导的生长板软骨细胞缺氧状态在调控软骨细胞分化中起着重要的作用. 可以在人类或小鼠身上应用影像学技术将基因修饰的小鼠和人类关联起来.在这方面, 新的磁共振技术具有广泛的应用前景. 尽管我们已经获得了很多胎儿期生长板的知识,但是我们却儿童期的情况知之甚少;同样这也是一个值得关注的领域. 这些工作可以应用于肢体不等长以及身材短小症等领域. 事实上, 身材短小症被认为与突变对生长板功能的影像有关. 例如, FGF-突变导致将导致软骨发育全部不全. 以生长板中生长因子信号通路为靶点的药理学方法对这些疾患的药物治疗具有极大的应用潜力.
在发育过程中, 骨在软骨性骨板中的形成是一个基质降解和血管长入的过程.多能间充质细胞经过多个基因和多种调节通路的作用分化形成成骨细胞,这些基因和通路通常包括RUNX2, BMP, and WNT等. 这些细胞的来源尚不是完全清楚,但近来的研究表明骨膜细胞在这一过程中起着重要的作用. 调控基质降解和血管形成的调节因子,例如vascular endothelial growth factor [VEGF] and select MMPs 在这一过程中发挥核心作用. 在生后骨修复和再生过程中(例如骨骼愈合和牵拉骨形成技术)也需要这些因子的参与. 例如, 对小鼠进行研究发现,在骨形成过程中调控血管生成和缺氧状态的调节因子(HIF或VEGF)在骨坏死和牵拉成骨术中也同样起作用. 也正是因为这样, 对成骨细胞发育的调控途径及如何在再生过程中应用它们可以用作改善骨折愈合, 加速骨形成的速率,改善融合速率以及关节成型术中骨的长入.
干细胞也是一种多能细胞, 在其分裂产生的两种子细胞中, 一个保留干细胞的多能特性, 另一个可以分化成不同的细胞系. 在成熟动物的许多组织中有小量具有干细胞特性的细胞., 并且认为这些细胞在改种生物的一生中维持该组织的形态和功能. 但是早期干细胞与 这些成熟干细胞的发育模式有所不同. 最近对间充质干细胞的研究表明在损伤后的愈合过程中, 干细胞也可以分泌多种调剂因子, 使周围的成熟细胞帮助组织的愈合. 研发利用这些多能干细胞帮助骨和软骨修复的方法需要我们更多的努力. 这些细胞的来源各种各样, 一个来源是肌肉, 其内存在的干细胞称为卫星细胞; 经过某种形式的基因疗法,这些细胞不仅可以改变肌肉的行为, 它们还可以选择组织. 不同的年龄和性别可以通过影像肌肉强度和骨密度等因素来对多能干细胞的行为产生影像. 这一领域的研究在很多矫形状态有广泛的应用,尤其是与老龄相关的.
肌肉骨骼系统的肿瘤同样利用发育过程中的许多因子和通路来进行调节. 生长板发育过程中起重要作用的细胞通路, 不如缺氧状态激活的细胞通路,在软骨肿瘤中也起很重要的作用. 癌症也可能是由一定数量的干细胞来维持的, 就向正常组织那样. 针对这些干细胞研究治疗方法可以获得治疗肉瘤的更有效的方法.对肉瘤中肿瘤干细胞的进一步研究可以鉴别这些细胞和通路,并将其作为治疗的靶点来清除这些病变.
虽然在骨和关节发育领域我们已经取得了很多的进展,但是我们对肌腱和韧带的发育却知之甚少.近来的研究表明韧带来自在发育过程中关节周围细胞表达的特殊转录因子.它们初始是基本上是属于细胞外结构, 其最终的基质组成和强度受很多基因的调节. 这些肌腱中基因的转录调节, 机械环境以及调控基质组成的调节因子的表达速率都在修复和长期肌腱和韧带功能中具有重要的作用.在这一领域的研究可以发现一些有肌腱修复或保证组织工程肌腱替代最优化的通路.
本次论坛中的报告展示了过去几十年中肌肉骨骼系统发生研究中所取得的巨大进展.在接下来的这个年代, 在更深入研究发育的基础控制的基础上,我们还应该利用基因修饰生物,例如小鼠或鱼等, 对肌肉骨骼系统的病理改变和修复与再生领域进行广泛的研究. 发展靶向病毒载体和基于细胞的治疗策略将蛋白导入到特定的细胞群中将有助于我们将现在的研究结果应用在病人身上. 应用具有药效作用的物质针对发育中的重要调节通路---其中一些最初被认为具有致畸作用--进行治疗将很快被应用于临床. 肌肉骨骼系统发育生物学的研究目前正处在改良治疗方法转化的开端时期, 本次会议的与会者提出了未来工作的新领域, 在这些领域里我们有信心将现在的研究结果应用到病人治疗的新王国.
谢谢众位老师