手术治疗髌骨粉碎骨折膝关节远期功能及肱骨近端粉碎骨折治疗研究
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摘要
髌骨是人体最大的籽骨，在伸膝过程中有重要作用。髌骨位于膝前皮下，易受直接或间接暴力损伤，髌骨骨折是常见的关节内骨折，占全身骨折的2.21%。髌骨骨折导致伸膝装置的连续性被破坏且髌股关节面不平。髌骨骨折是关节内骨折，预后将对患者的膝关节功能及其生活质量产生重要影响。髌骨骨折的治疗原则都是解剖复位，坚强固定，早期活动。尽快恢复膝关节功能，避免或减少髌骨骨折造成的创伤性关节炎的发生。随着骨科内固定技术的不断发展，许多新的手术方法和新型内固定物被广泛使用，使得髌骨骨折的治疗效果明显提高。20世纪前髌骨骨折的治疗是存在争议的，非手术治疗常常被采用，Dowd等人认为保守治疗预后较差，骨折愈合率低且致残率高。由于外科手术中无菌技术的提高，两种手术方案被提出：髌骨切开复位钢丝固定和髌骨全切。随后，切开复位内固定成为治疗髌骨骨折的首选。
严重的粉碎性髌骨骨折常采用髌骨完全切除术作为治疗方法，但对于其疗效和远期愈后，一直存在争议。部分学者认为当髌骨粉碎性骨折不能良好复位并稳定固定时，可以采取髌骨完全切除术进行治疗，满意率约为80%。而在1980后，随着内固定技术的不断进步，其后的研究对此产生了争论，认为该术式的临床结果并不理想，仅仅可以作为治疗髌骨粉碎性骨折的最后措施。以上学者的研究结果均仅针对患侧的预后功能，髌骨粉碎性骨折患侧完全切除术对健侧膝关节远期功能的影响及其影像学改变极少见文献报道。本研究通对髌骨粉碎骨折髌骨切除和髌骨内固定健侧和患侧膝关节的影像学评分和功能评估进行对比分析。研究髌骨粉碎骨折髌骨全切和切开复位内固定对膝关节远期健患侧的功能恢复情况及影像学改变。
临床上对髌骨骨折治疗要求也越来越高，原则上最大限度地保留髌骨及充分恢复其的功能。大多数移位的髌骨骨折可以采用切开复位内固定术治疗。对于严重的髌骨骨折、尤其是下极严重粉碎性骨折，常采用部分切除术治疗。国内外较少见文献报道髌骨部分切除术的长期疗效和髌股关节的退化程度。本研究通过膝关节功能评分和MRI评分来判断髌骨部分切除术的远期疗效。
随着我国进入老龄化社会，老年人口基数迅速增加，使老年髌骨骨折患者增多。然而，老年髌骨骨折患者由于骨质疏松，骨质较差，复位内固定时骨折块易碎裂，内固定物易松动脱出，可能出现骨折不愈合和延迟愈合。大多数老年髌骨骨折患者克氏针张力带术后进行数周外固定。但是，治疗过程中长时间使用外固定支具，对关节功能的恢复极为不利，容易造成关节僵直，影响膝关节功能的恢复。本研究通过对早期功能锻炼和石膏固定膝关节功能评分和术后并发症发生情况进行对比分析，探讨老年髌骨骨折患者早期功能锻炼和石膏固定对患者的影响。
第一部分华北地区成年汉族人髌骨CT三维重建测量在性别鉴定中的应用
目的：通过对257例成年汉族人髌骨进行计算机断层扫描（CT）三维重建测量，通过判别分析，找到进行男女性别判别的方法。
方法：选择自愿参加测试的2011年1月-2013年12月在河北省第三医院创伤急救中心就医的志愿者，自愿参加测试。对这些受试者进行CT扫描三维重建测量髌骨的高度和宽度、髌骨厚度和内外侧关节面的宽度。通过统计处理找出单项指标和多项指标的判别分析函数和判断符合率。
结果：华北地区成年汉族人髌骨5项指标平均值男性大于女性，差异显著（P＜0.01），单项判别中髌骨内侧关节面宽判别函数为Y1=-82.08+7.95X4；Y2=-60.29+6.78X4，判断符合率：83.3%。多项判别分析函数为Y1=-296.24+2.94X1+6.78X2+0.119X3+3.01X4+4.70X5；Y2=-261.06+2.82X1+6.72X2+0.07X3+2.08X4+4.33X5，判断符合率达89.10%。
结论：髌骨内侧关节面宽度单项判别分析判断符合率达83.3%；通过多项判别分析函数判别分析判断符合率达89.10%。通过对髌骨形态学的测量分析，找到了通过髌骨对性别进行判别的可靠方法。
第二部分髌骨部分切除患者膝关节远期功能与影像学改变研究
目的:目的：探讨髌骨部分切除患者膝关节的远期功能和影像学改变。
方法：回顾性分析1987年1月至2002年1月手术治疗的29例髌骨部分切除患者资料，男21例，女8例；平均年龄为45.8岁（29～71岁）。末次随访时对所有患者进行MRI检查并对患者膝关节功能进行检查和问卷调查，采用改良Whole-Organ磁共振成像评分（WORMS）对患者的MRI进行影像学分析，并采用膝关节损伤和骨关节炎评分（KOOS）和Bostman评分对膝关节功能进行评估。，使用Biodex-Ⅱ型(美国)等速测力系统对患者双膝伸膝峰扭矩和屈曲角度进行测量。
结果：29例患者术后获8～18年（平均13年）随访。29例患者患侧膝关节改良WORMS评分平均为（13.8±5.8）分，其中轻度关节炎24例，中度5例；健侧WORMS评分平均为（12.3±5.5）分，其中轻度关节炎26例，中度3例，两侧比较差异无统计学意义（t=1.001，P=0.321）。KOOS评分中疼痛评分平均为（88.0±6.4）分、症状为（86.9±5.7）分、日常生活为（89.9±5.2）分、娱乐及运动功能为（83.6±7.6）分、膝关节相关生活质量为（80.5±8.5）分。Bostman评分平均为（27.4±3.6）分，其中优20例，良9例。患侧膝关节平均屈曲为128.3°±5.5°，健侧为128.8°±4.2°；患侧膝关节峰扭矩平均为（105.4±12.2）牛·米，健侧为（106.6±9.1）牛·米，以上项目两侧比较差异均无统计学意义（P＞0.05）。
结论：髌骨部分切除术不会造成严重的髌股关节退变和创伤性关节炎，膝关节功能评分显示远期疗效优良。对于难以复位和复位不良的髌骨骨折，可行髌骨部分切除术。
第三部分切开复位内固定对比髌骨切除术治疗髌骨粉碎骨折双侧膝关节远期功能和影像学表现
目的:本研究通对髌骨粉碎骨折髌骨切除和髌骨内固定健侧和患侧膝关节的影像学评分和功能评估进行对比分析。研究髌骨粉碎骨折髌骨全切和切开复位内固定对膝关节远期健患侧的功能恢复情况及影像学改变。
方法:回顾性分析1987年1月至2002年1月我院治疗的髌骨粉碎骨折的患者52例，其中髌骨全部切除患者24例(切除组)；髌骨切开复位内固定患者28例（固定组）。末次随访时对所有患者进行MRI检查并对患者膝关节功能进行检查和问卷调查，采用改良Whole-Organ磁共振成像评分（WORMS）对患者的MRI进行影像学分析。并采用美国膝关节协会评分（aks）对膝关节功能进行评估，使用Biodex-Ⅱ型(美国)等速测力系统对患者双膝伸膝峰扭矩和屈曲角度进行测量。
结果:全切组24例患者术后获11～26年（平均17.3年）随访。固定组28例患者术后获随访12-22年（平均15.5年）。末次随访时全切组24例患者患侧改良WORMS评分平均为（6.58±1.05）分；健侧平均为（4.71±0.53）分。固定组28例患者患侧改良WORMS评分平均为（8.11±1.21）分；健侧平均为（4.43±0.28）分，两侧比较差异无统计学意义。全切组患侧AKS膝关节评分中健侧膝关节AKS评分为165.08±2.23分，患侧为152.75±2.87分；固定组AKS膝关节评分中健侧膝关节评分为165.08±2.23分，患侧为149.14±2.66分；全切组与固定组两侧比较差异无统计学意义。全切组患侧膝关节屈曲平均为119.9°±3.01°，健侧膝关节屈曲平均为123.5°±2.71°；固定组患侧膝关节屈曲平均为115.32°±3.11°，健侧膝关节屈曲平均为127.14°±1.6°，全切组与固定组两侧比较差异无统计学意义（P=0.238，患侧比较P=0.298，P＞0.05，表1）。全切组患侧膝关节伸膝峰扭矩平均为（96.08±2.32）牛·米，健侧为（106.46±1.8）牛·米；内固定组患侧膝关节伸膝峰扭矩平均为（99.18±1.98）牛·米，健侧为（105.25±1.63）牛·米，全切组与固定组两侧比较差异无统计学意义。
结论：患者经过长时间的康复与代偿后，髌骨切除患者与内固定患者患侧膝关节功能无差别，全切组的患侧股四头肌肌力略差。MRI影像结果却提示内固定组患者患侧膝关节出现的关节退变。两组健侧的膝关节功能代偿性增加，是健侧膝关节加速退变的主要原因。
第四部分老年髌骨骨折术后膝关节早期功能锻炼对比辅助外固定治疗的功能康复及并发症研究
目的:老年髌骨骨折术后采用石膏固定与早期功能锻炼两种康复方案的患者膝关节功能及并发症进行对比分析，探讨老年髌骨骨折患者早期功能锻炼和石膏固定对膝关节影响。
方法:回顾性分析1987年1月至2002年1月119例患者，其中男性99例，女性20例，64例患者给予石膏外固定，55例患者术后进行早期功能锻炼。末次随访时对所有患者采用膝关节损伤和骨关节炎评分（KOOS）和Bostman评分对膝关节功能进行评估。并通过电子病历系统对这些患者的伤口感染、下肢静脉血栓和内固定失败等并发症进行登记研究。
结果:随访时间从36至98个月，平均随访53个月。两组患者中年龄，性别，损伤的机制，损伤类型，受伤至手术时间和住院时间没有差异。按照Bostman评分标准，早期活动组得分高于石膏固定组，但并无统计学差异(P=0.721)。早期活动组优良率为79.69%（51/64）;石膏固定组为81.82%(45/55)，也没有统计学差异。KOOS评分中早期活动组略高于石膏固定组，没有统计学差异。石膏固定组患者屈曲为114.64°±18.31°(59°~135°)，早期活动组为116.36°±18.60°(54°~135°)，两组也没有统计学差别（P=0.612）。两组患者伸膝活动均不受限。石膏固定组没有内固定失败发生；早期活动组中有14例内固定失败发生，其中10例进行了二次切开复位内固定，手术后给予石膏或支具外固定。另外4例患者，给予石膏固定直至骨折愈合。有14例发生感染，其中石膏固定组9例，早期活动组5例。浅表感染12例（石膏固定组8例，早期活动组4例），深部感染两例（每组各一例）。浅表感染给予换药和使用抗菌药物后均已得到控制，并且伤口愈合。两组间无统计学差异。石膏固定组术后出现下肢静脉血栓栓塞13例，深静脉血栓1例，早期活动组静脉血栓栓塞5例，没有深静脉血栓出现。
结论：老年骨质较好且非粉碎骨折固定较为坚强的患者不应给予石膏外固定，早期活动内固定失败率低，功能恢复理想。老年粉碎骨折固定不够坚强的患者术后应给予石膏外固定，石膏外固定能减少内固定失败对膝关节功能较小，但患静脉血栓的发生率升高。对于血栓高危老年髌骨骨折患者，应积极进行防血栓治疗，尽早进行下肢功能锻。
第五部分自体髂骨移植结合锁定钢板内固定治疗肱骨近端粉碎骨折
目的:本研究目标是通过锁定钢板内固定结合自体髂骨移植对比单纯锁定钢板治疗肱骨近端粉碎骨折是否有更好的肩关节功能。
方法:我院创伤中心就诊的40例肱骨近端粉碎骨折患者随机分为两组，18例患者使用角度锁定钢板加髂骨植骨（实验组），22例仅单独采用角度锁定钢板（对照组）。术后给予肩关节活动范围（ROM）的评估，视觉模拟评分法（VAS）对疼痛进行分。和SF-36测量调查表[15]。最后记录这些患者是否回到了他们之前的工作和活动能力。
结果:没有患者术后感染，所有骨折均得到解剖复位，坚强固定后骨折远端内外翻角度小于5度。实验组患者临床及放射学检查均取得骨折愈合。实验组中没有肱骨头塌陷骨坏死及螺钉穿出关节面。骨折愈合放射学检查实验组为（4.66±1.63）个月，明显早于对照组（5.98±1.57）个月（P <0.05，表2）。术后实验组测量ROM也显著优于对照组，包括屈（（148.00±18.59）与（121.73±17.20）度），伸（（49.00±2.22）比（42.06±2.06））度，内旋（（45.00±5.61）比（35.00±3.55）度），外旋（（64.00±9.17）比（52.14±5.73）度）。SF-36评分中，实验组（（88.00±5.71）分）显著高于对照显组（（69.45±9.45）分，P <0.001）。平均VAS疼痛程度实验组（mean rank,10.50）显著低于对照组（meanrank，47.19）（P <0.001）。实验组除一例患者外（17/18，94.4%）均回到了以前的活动状态或职业。与此相反，对照组中4例患者不能回到在他们以前的活动状态或职业。
结论：自体髂骨移植结合锁定钢板内固定治疗肱骨近端粉碎骨折手术操作简单，预后较好且并发症率低。
As the largest sesamoid bone in human body, patella plays an importantrole in the knee extension movements. Patella is located subcutaneously of theanterior knee joint, and it is easy to get direct or indirect violent injury. Hencethe patellar fracture is one of the most commonly observed fractures,accounting for2.21%of the total body fracture. As a type of intra-articularfracture, patellar fracture will result in destroying the continuous of the kneeextension system and evenness of the patellofemoral joint surface. Therefore,the prognosis of patients’ patellar fracture will result in significant impact onthe knee function and even life quality. To restore knee function as soon aspossible and avoid or reduce traumatic arthritis, the treatment principles forpatella fractures include anatomical reduction, strong fixation, and earlymobilization. With the continuous development of orthopedic fixationtechnology, a large number of newly discovered surgical techniques andfixation materials has been applied into the treatment of patellar fracture andmade the treatment results improved significantly. Before the20th century, thetreatment of patella fractures was controversial; the most commonly usedtreatments were non-operative methods like extension splinting and rest.Dowd etc. thought the traditional treatment had a bad prognosis with a lowersymphysis possibility and a higher disability expectation. As a result twosurgical plans were proposed with the improvement of sterile surgicaltechniques: patellar fracture open reduction and internal fixation with steelwire, and patellectomy. Later, the patellar fracture open reduction and internalfixation with steel wire became the primary choice for the treatment of patellafracture.
As a treatment of the extreme comminuted patella fracture, patellectomyis often applied. However taking the long term efficacy and prognosis into consideration, this resection treatment is controversial. Some scholars believedthat under the condition that the comminuted patella fractures cannot be stablyfixed, patellectomy can be applied as the treatment. And under this conditionthe satisfaction rate was about80%. However after the1980s, with theprogress of internal fixation techniques, a discussion on this operation wasbrought up believing that the clinical results of the patellectomy were not ideal.And this patellectomy can only be served as the final treatment. The previousfindings have only been focusing on the prognostic features of the patellarfractures, but the long term impact of the ipsilateral patellectomy on thefunction of the contralateral knee and the imaging changes has been rarelyreported. By comparing and analyzing the ipsilateral and contralateral side ofthe comminuted fractured patella with patellectomy and patella internalfixation treatments, our study is focusing on the function recovery andimaging changes in the two situations.
The requirement for clinical treatments on patellar fracture is increasing;in principle the treatment should maximally retain the patella and restore itsfunction. Most displaced patella fracture can be treated with open reductionand internal fixation. Partial patellectomy are usually applied for seriouspatella fracture, particularly severe fracture of the interior patella. Thelong-term efficacy of partial resection and degeneration of petallofemoral jointare rarely reported in publications. This study will evaluate the long-termefficacy of partial patellectomy by MRI scoring and the knee function scoring.
As China entering the aging society, the population of the aged people isincreasing rapidly, as a result the number of aged patients with patella fractureis also increasing. However, due to the problem from osteoporosis and poorbone quality of the aged patients, when applying the reduction and fixationtreatment, the fractured fragments were easy to be broken and internalfixations are easy to loosen. All these result in a non-or delayed close up ofthe fractured bones. Most of the aged patients with patella fracture need anadditional several weeks’ Kirschner wire plus tenson bend after the operationperformed. However, the long-term applied external fixation equipment during the treatment will result in the extreme unfavorable impact on the jointfunction recovery, as result, the cause of joint stiffness and impact on the kneefunction restore. This study is mainly discussing the effects of early functionalexercise and plaster fixation on the aged patients with patella fractures, via thescoring the early functional exercise and plaster fixation and analyzing thepostoperative complication during the recovery.
PART ONE: Gender determination from the patella CT threedimensional reconstruction measurement from Han adults in the NorthChina
Objective: The objective of this part is to determine adults’ gender, byapplying discrimination analysis to the received computed tomography (CT)three-dimensional reconstruction from257Han adults.
Method: The257Han adults were patients in Hebei Province TraumaCare Centers volunteered to participate in the test, from January2011toDecember2013. CT scans were applied to the volunteers and thethree-dimensional reconstructions were composed of the height and width,thickness, and the lateral patellar articular surface of the patella. After appliedto statistical analysis, the discriminant analysis functions and determinecompliance rates of mono-and multi-indicators were identified.
Result: In patella of the Han adults in the North China, the fiveindicators showed significant (P <0.01) larger mean values in men than inwomen. Discriminant analysis functions of medial articular surface of thepatella as a mono-indicator were Y1=-82.08+7.95X4and Y2=-60.29+6.78X4, with a determine compliance rate of83.33%. Discriminant analysisfunctions of multi-indicators were Y1=-296.24+2.94X1+6.78X2+0.119X3+3.01X4+4.70X5; Y2=-261.06+2.82X1+6.72X2+0.07X3+2.08X4+4.33X5, with a determine compliance rate of89.10%.
Conclusion: The determine compliance rate was83.33%when usingmedial articular surface of the patella as the mono-indicator in thediscriminant analysis; while the determine compliance rate was89.10%whenusing the multiple discriminant analysis. A reliable way of determining gender was figured out by a morphological measurement study on patella.
PART TWO: Long-term functional and imaging changes in patients’knees with partial patellectomy
Objective：To investigate long-term functional and imaging changes inpatients’ knees with partial patellectomy.
Methods:29cases of patients with partial patellectomy in our hospitalfrom January1987to January2002were retrospectively reviewed. There were21males and8females, with an average age of45.8(range29-71years). Meanfollow-up was13years (range,8-13years). In order to analysis the functionof patients’ knee, such examinations as MRI, physical examination andquestionnaire. As well as the KOOS score and Bostman score and modifiedWORMS score, were carried out in the study.
Result:The average Modified WORMS score in29cases of affectedknee was13.79±5.80points, included mild arthritis24cases, moderate5casesand severe0; score of unaffected sides was12.31±5.48, included mildarthritis26cases, moderate3cases and severe0. no statistical differencesshowed in the two groups (P=0.321). The average KOOS score of pain was88.0±6.37points, symptom was86.9±5.65points, daily life was89.9±5.15,entertainment and sports was83.6±7.55points and the quality of life related toknee joint function was80.5±8.46.The average Bostman score was27.41±3.621points, included20patients reached excellent,9good and0bad.Flexion degree of involved sides was128.34°±5.50°, the uninvolvedknee was128.76°±4.223°, no statistical differences showed in the two groups(P=0.173). Flexion degree of involved sides was105.35±12.18Nm, theuninvolved knee was106.59±9.09Nm, no statistical differences showed in thetwo groups (P=0.175).
Conclusion: partial patellectomy does not cause serious jointdegeneration and traumatic arthritis; Function score of knee shows finecurative effect. Partial patellectomy can be used for patellar fractures thatreplacement is difficult or malreduction.
PART THREE: ORIF contrast patellectomy treatment of comminutedfracture of the patella forward bilateral knee function and radiographicmanifestations
Objective: By comparing and analyzing the evaluations of imaging andfunctional scores between patellectomy of comminuted patella fracture andcontralateral and ipsilateral knee patella of internal fixed fractured patella, thisstudy mainly focus on the function recovery and imaging changes in the twosituations.
Method: Review analysis on the52patients accepting treatments ontheir comminuted fractured patella from January1987to January2002in ourhospital, including24patellectomy patients (resection group) and28patellaORIF patients (fixed group). MRI was performed on all patients at the finalfollow-up along with a knee function test and recovery surveys. A modifiedWhole-Organ Magnetic Resonance Imaging Score (WORMS) was performedin the patients MRI imaging analysis and American Knee Society Score (AKS)was applied to the knee function evaluation. The Biodex-II (USA) iso-kineticdynamometer system was applied for measuring knee joints’ extension peaktorque and buckling angle.
Result: The24patients in patellectomy group got11to26yearfollow-ups (mean was17.3years). The28patients in fixed group got12to22year follow-ups (mean15.5years). In the final follow-up of the patellectomygroup, the mean WORMS’s scores were6.58±1.05at ipsilateral side, and4.71±0.53at contralateral side. While the mean scores for the fixed group were8.11±1.21at ipsilateral side, and4.43±0.28at contralateral side. There wasno significant difference between the two groups at ipsilateral andcontralateral sides. The mean AKS’s scores were152.75±2.87at ipsilateralside and165.08±2.23at contralateral side of the patellectomy group; whilethe mean AKS’s scores for the fixed group were149.14±2.66at ipsilateralside, and165.08±2.23at contralateral side. There was no significantdifference between the two groups at ipsilateral and contralateral sides. Themean knee buckling angels were119.9°±3.01°at ipsilateral side and123.5°±2.71°at contralateral side of the resection group; while the angels for the fixed group were115.32°±3.11°at ipsilateral side, and127.14°±1.6°atcontralateral side. There was no significant difference between the two groupsat ipsilateral and contralateral sides (overall P=0.238, ipsilateral P=0.298, P>0.05, see Table1). The mean knee joints’ extension peak torque were96.08±2.32N m at ipsilateral side and106.46±1.8N m at contralateral side ofthe patellectomy group; while those for the fixed group were99.18±1.98N m at ipsilateral side, and105.25±1.63N m at contralateral side. There wasno significant difference between the two groups at ipsilateral andcontralateral sides.
Conclusion: After a long rehabilitation and compensation, patients withpatellectomy and internal fixation showed no functional difference within theipsilateral and contralateral sides. The patients in patellectomy group showedslightly lower muscle force at their quadriceps. However knee degenerationwas observed at the ipsilateral side within the patients in fixation group. Theincrease of functional compensatory increase at both side of the knee joint isthe major reason for this accelerated degeneration.
PART FOUR: Study of functional rehabilitation and complication ofpostoperative knee patella fracture in aged patients with early exerciseversus auxiliary external fixation.
Objective: Discussing the effects of early functional exercise and plasterfixation on the aged patients with patella fractures, via scoring the earlyfunctional exercise and external plaster fixation and analyzing thepostoperative complication during the recovery.
Method: Review analysis on the119aged patients accepting treatmentson their patella from January1987to January2002in our hospital, including99male cases and20female cases. Among these patients64were treated withexternal plaster fixation (plaster group) and55were applied to early functionalexercise (exercise group) after the surgical treatment. KOOS and Bostmanscoring were applied to all patients in their final follow-up as an evaluation ofthe patients’ knee function. Additionally, the complications including woundinfection, venous thrombosis, failure internal fixation, etc. were recorded and analyzed with the Electronic Medical Recording System.
Result: The follow-up time ranged from36months to98months, withan average of53months. There was no significant difference in age, gender,injury mechanism, injury type, time from injury to surgery, and hospitalizationtime between the two groups. According to Bostman standard, exercise groupgot a higher score than the plaster group, but no statistically significantdifference was observed (P=0.721). The excellent-to-good rates were79.69%(51/64) for exercise group and81.82%(45/55) for plaster group, no significantdifference was observed either. The KOOS score of exercise group wasslightly higher than that of plaster group without a significant difference. Themean knee buckling angels were116.36°±18.60°(54°~135°) for theexercise group and114.64°±18.31°(59°~135°) for the plaster group, nosignificant difference was observed (P=0.612). Extension activity was notlimited in either group. No internal fixation failure occurred in the plastergroup, but14cases of internal fixation failure occurred in the exercise group.A secondary ORIF was applied to10of the14patients with an external plasterfixation or brace; while the other four were treated with a plaster fixation untilfracture healing. There were14patients got wound infection;9were in theplaster group and5in the exercise group. Among the14infected patients,12got superficial infections (8in the plaster group and4in the exercise group),2got deep infections (1patient per group). Superficial infection was controlledby applying medication change and antimicrobial agents, and the wound washealed in all cases with no significant difference in two groups. There were13patients developed venous thrombosis and1developed deep vein thrombosisin plaster group; while in the exercise group5patients developed venousthrombosis and no deep vein thrombosis development.
Conclusion: The aged patients with good bone quality and stronginternal fixation can get good functional rehabilitation and low fixation failurerate by applying early post-surgical exercise rather than external plasterfixation, under the condition that the fracture was non-comminuted fracture.The aged patients with less poor internal fixation should be treated with fracture. External plaster fixation can reduce fixation failure rate with littleaffect on the knee function; however, the patients treated with external plasterfixation has a higher possibility in developing vein thrombosis. For agedpatients with higher risk of vein thrombosis development and patella fractures,anti-thrombotic therapy and lower limb exercise should be applied as soon aspossible.
PART FIVE: Locking plate fixation combined with iliac crest boneautologous graft for proximal humerus comminuted fracture
Objective: The aim of this study was to evaluate the clinical andradiographic outcomes of a locking plate and crest bone autologous graft fortreating proximal humerus comminuted fractures.
Method: We assessed the functional outcomes and complication rates in40patients with proximal humerus comminuted fractures. Eighteen patientswere treated with a locking plate and an autologous crest bone graft(experimental group), and22were treated with only the locking plate and nobone graft (control group). Postoperative assessments included radiographicimaging, range of motion analysis, pain level based on the visual analoguescale (VAS), and the SF-36(Short Form (36) Health Survey), as well aswhether patients could return to their previous occupation.
Result: All fractures healed both clinically and radiologically in theexperimental group. There was no more than2mm collapse of the humeralhead, and no osteonecrosis or screw penetration of the articular surface. Incontrast, two patients had a nonunion in the control group, and they eventuallyaccepted total shoulder replacements. The average time from surgery toradiographic union was significantly shorter in the experimental group((4.66±1.63) months) compared with the control group ((5.98±1.57) months)(P<0.05). For the experimental versus controls groups, the mean shoulderactive flexion (148.00±18.59vs.121.73±17.20) degrees, extension (49.00±2.22vs.42.06±2.06) degrees, internal rotation (45.00±5.61vs.35.00±3.55) degrees,external rotation (64.00±9.17vs.52.14±5.73) degrees, and abduction (138.00±28.78vs.105.95±15.66) degrees were all significantly higher (allP<0.001). The median SF-36in the experimental group ((88.00±5.71) points)was significantly higher than that of the control group ((69.45±9.45) points;P<0.001). The median VAS pain level (mean rank,10.50) in the experimentalgroup was lower than that (mean rank,47.19) of the control group (P<0.001).All but one patient (17of18,94.4%) in the experimental group returned totheir previous activities or occupations, and that one patient changed to adifferent occupation because of slight restrictions to activities. On the otherhand, four patients could not return to their previous activities or occupationsin the control group.
Conclusion: Locking plate fixation combined with an iliac crest bonegraft is an effective technique for treating proximal humerus comminutedfractures.
严重的粉碎性髌骨骨折常采用髌骨完全切除术作为治疗方法，但对于其疗效和远期愈后，一直存在争议。部分学者认为当髌骨粉碎性骨折不能良好复位并稳定固定时，可以采取髌骨完全切除术进行治疗，满意率约为80%。而在1980后，随着内固定技术的不断进步，其后的研究对此产生了争论，认为该术式的临床结果并不理想，仅仅可以作为治疗髌骨粉碎性骨折的最后措施。以上学者的研究结果均仅针对患侧的预后功能，髌骨粉碎性骨折患侧完全切除术对健侧膝关节远期功能的影响及其影像学改变极少见文献报道。本研究通对髌骨粉碎骨折髌骨切除和髌骨内固定健侧和患侧膝关节的影像学评分和功能评估进行对比分析。研究髌骨粉碎骨折髌骨全切和切开复位内固定对膝关节远期健患侧的功能恢复情况及影像学改变。
临床上对髌骨骨折治疗要求也越来越高，原则上最大限度地保留髌骨及充分恢复其的功能。大多数移位的髌骨骨折可以采用切开复位内固定术治疗。对于严重的髌骨骨折、尤其是下极严重粉碎性骨折，常采用部分切除术治疗。国内外较少见文献报道髌骨部分切除术的长期疗效和髌股关节的退化程度。本研究通过膝关节功能评分和MRI评分来判断髌骨部分切除术的远期疗效。
随着我国进入老龄化社会，老年人口基数迅速增加，使老年髌骨骨折患者增多。然而，老年髌骨骨折患者由于骨质疏松，骨质较差，复位内固定时骨折块易碎裂，内固定物易松动脱出，可能出现骨折不愈合和延迟愈合。大多数老年髌骨骨折患者克氏针张力带术后进行数周外固定。但是，治疗过程中长时间使用外固定支具，对关节功能的恢复极为不利，容易造成关节僵直，影响膝关节功能的恢复。本研究通过对早期功能锻炼和石膏固定膝关节功能评分和术后并发症发生情况进行对比分析，探讨老年髌骨骨折患者早期功能锻炼和石膏固定对患者的影响。
第一部分华北地区成年汉族人髌骨CT三维重建测量在性别鉴定中的应用
目的：通过对257例成年汉族人髌骨进行计算机断层扫描（CT）三维重建测量，通过判别分析，找到进行男女性别判别的方法。
方法：选择自愿参加测试的2011年1月-2013年12月在河北省第三医院创伤急救中心就医的志愿者，自愿参加测试。对这些受试者进行CT扫描三维重建测量髌骨的高度和宽度、髌骨厚度和内外侧关节面的宽度。通过统计处理找出单项指标和多项指标的判别分析函数和判断符合率。
结果：华北地区成年汉族人髌骨5项指标平均值男性大于女性，差异显著（P＜0.01），单项判别中髌骨内侧关节面宽判别函数为Y1=-82.08+7.95X4；Y2=-60.29+6.78X4，判断符合率：83.3%。多项判别分析函数为Y1=-296.24+2.94X1+6.78X2+0.119X3+3.01X4+4.70X5；Y2=-261.06+2.82X1+6.72X2+0.07X3+2.08X4+4.33X5，判断符合率达89.10%。
结论：髌骨内侧关节面宽度单项判别分析判断符合率达83.3%；通过多项判别分析函数判别分析判断符合率达89.10%。通过对髌骨形态学的测量分析，找到了通过髌骨对性别进行判别的可靠方法。
第二部分髌骨部分切除患者膝关节远期功能与影像学改变研究
目的:目的：探讨髌骨部分切除患者膝关节的远期功能和影像学改变。
方法：回顾性分析1987年1月至2002年1月手术治疗的29例髌骨部分切除患者资料，男21例，女8例；平均年龄为45.8岁（29～71岁）。末次随访时对所有患者进行MRI检查并对患者膝关节功能进行检查和问卷调查，采用改良Whole-Organ磁共振成像评分（WORMS）对患者的MRI进行影像学分析，并采用膝关节损伤和骨关节炎评分（KOOS）和Bostman评分对膝关节功能进行评估。，使用Biodex-Ⅱ型(美国)等速测力系统对患者双膝伸膝峰扭矩和屈曲角度进行测量。
结果：29例患者术后获8～18年（平均13年）随访。29例患者患侧膝关节改良WORMS评分平均为（13.8±5.8）分，其中轻度关节炎24例，中度5例；健侧WORMS评分平均为（12.3±5.5）分，其中轻度关节炎26例，中度3例，两侧比较差异无统计学意义（t=1.001，P=0.321）。KOOS评分中疼痛评分平均为（88.0±6.4）分、症状为（86.9±5.7）分、日常生活为（89.9±5.2）分、娱乐及运动功能为（83.6±7.6）分、膝关节相关生活质量为（80.5±8.5）分。Bostman评分平均为（27.4±3.6）分，其中优20例，良9例。患侧膝关节平均屈曲为128.3°±5.5°，健侧为128.8°±4.2°；患侧膝关节峰扭矩平均为（105.4±12.2）牛·米，健侧为（106.6±9.1）牛·米，以上项目两侧比较差异均无统计学意义（P＞0.05）。
结论：髌骨部分切除术不会造成严重的髌股关节退变和创伤性关节炎，膝关节功能评分显示远期疗效优良。对于难以复位和复位不良的髌骨骨折，可行髌骨部分切除术。
第三部分切开复位内固定对比髌骨切除术治疗髌骨粉碎骨折双侧膝关节远期功能和影像学表现
目的:本研究通对髌骨粉碎骨折髌骨切除和髌骨内固定健侧和患侧膝关节的影像学评分和功能评估进行对比分析。研究髌骨粉碎骨折髌骨全切和切开复位内固定对膝关节远期健患侧的功能恢复情况及影像学改变。
方法:回顾性分析1987年1月至2002年1月我院治疗的髌骨粉碎骨折的患者52例，其中髌骨全部切除患者24例(切除组)；髌骨切开复位内固定患者28例（固定组）。末次随访时对所有患者进行MRI检查并对患者膝关节功能进行检查和问卷调查，采用改良Whole-Organ磁共振成像评分（WORMS）对患者的MRI进行影像学分析。并采用美国膝关节协会评分（aks）对膝关节功能进行评估，使用Biodex-Ⅱ型(美国)等速测力系统对患者双膝伸膝峰扭矩和屈曲角度进行测量。
结果:全切组24例患者术后获11～26年（平均17.3年）随访。固定组28例患者术后获随访12-22年（平均15.5年）。末次随访时全切组24例患者患侧改良WORMS评分平均为（6.58±1.05）分；健侧平均为（4.71±0.53）分。固定组28例患者患侧改良WORMS评分平均为（8.11±1.21）分；健侧平均为（4.43±0.28）分，两侧比较差异无统计学意义。全切组患侧AKS膝关节评分中健侧膝关节AKS评分为165.08±2.23分，患侧为152.75±2.87分；固定组AKS膝关节评分中健侧膝关节评分为165.08±2.23分，患侧为149.14±2.66分；全切组与固定组两侧比较差异无统计学意义。全切组患侧膝关节屈曲平均为119.9°±3.01°，健侧膝关节屈曲平均为123.5°±2.71°；固定组患侧膝关节屈曲平均为115.32°±3.11°，健侧膝关节屈曲平均为127.14°±1.6°，全切组与固定组两侧比较差异无统计学意义（P=0.238，患侧比较P=0.298，P＞0.05，表1）。全切组患侧膝关节伸膝峰扭矩平均为（96.08±2.32）牛·米，健侧为（106.46±1.8）牛·米；内固定组患侧膝关节伸膝峰扭矩平均为（99.18±1.98）牛·米，健侧为（105.25±1.63）牛·米，全切组与固定组两侧比较差异无统计学意义。
结论：患者经过长时间的康复与代偿后，髌骨切除患者与内固定患者患侧膝关节功能无差别，全切组的患侧股四头肌肌力略差。MRI影像结果却提示内固定组患者患侧膝关节出现的关节退变。两组健侧的膝关节功能代偿性增加，是健侧膝关节加速退变的主要原因。
第四部分老年髌骨骨折术后膝关节早期功能锻炼对比辅助外固定治疗的功能康复及并发症研究
目的:老年髌骨骨折术后采用石膏固定与早期功能锻炼两种康复方案的患者膝关节功能及并发症进行对比分析，探讨老年髌骨骨折患者早期功能锻炼和石膏固定对膝关节影响。
方法:回顾性分析1987年1月至2002年1月119例患者，其中男性99例，女性20例，64例患者给予石膏外固定，55例患者术后进行早期功能锻炼。末次随访时对所有患者采用膝关节损伤和骨关节炎评分（KOOS）和Bostman评分对膝关节功能进行评估。并通过电子病历系统对这些患者的伤口感染、下肢静脉血栓和内固定失败等并发症进行登记研究。
结果:随访时间从36至98个月，平均随访53个月。两组患者中年龄，性别，损伤的机制，损伤类型，受伤至手术时间和住院时间没有差异。按照Bostman评分标准，早期活动组得分高于石膏固定组，但并无统计学差异(P=0.721)。早期活动组优良率为79.69%（51/64）;石膏固定组为81.82%(45/55)，也没有统计学差异。KOOS评分中早期活动组略高于石膏固定组，没有统计学差异。石膏固定组患者屈曲为114.64°±18.31°(59°~135°)，早期活动组为116.36°±18.60°(54°~135°)，两组也没有统计学差别（P=0.612）。两组患者伸膝活动均不受限。石膏固定组没有内固定失败发生；早期活动组中有14例内固定失败发生，其中10例进行了二次切开复位内固定，手术后给予石膏或支具外固定。另外4例患者，给予石膏固定直至骨折愈合。有14例发生感染，其中石膏固定组9例，早期活动组5例。浅表感染12例（石膏固定组8例，早期活动组4例），深部感染两例（每组各一例）。浅表感染给予换药和使用抗菌药物后均已得到控制，并且伤口愈合。两组间无统计学差异。石膏固定组术后出现下肢静脉血栓栓塞13例，深静脉血栓1例，早期活动组静脉血栓栓塞5例，没有深静脉血栓出现。
结论：老年骨质较好且非粉碎骨折固定较为坚强的患者不应给予石膏外固定，早期活动内固定失败率低，功能恢复理想。老年粉碎骨折固定不够坚强的患者术后应给予石膏外固定，石膏外固定能减少内固定失败对膝关节功能较小，但患静脉血栓的发生率升高。对于血栓高危老年髌骨骨折患者，应积极进行防血栓治疗，尽早进行下肢功能锻。
第五部分自体髂骨移植结合锁定钢板内固定治疗肱骨近端粉碎骨折
目的:本研究目标是通过锁定钢板内固定结合自体髂骨移植对比单纯锁定钢板治疗肱骨近端粉碎骨折是否有更好的肩关节功能。
方法:我院创伤中心就诊的40例肱骨近端粉碎骨折患者随机分为两组，18例患者使用角度锁定钢板加髂骨植骨（实验组），22例仅单独采用角度锁定钢板（对照组）。术后给予肩关节活动范围（ROM）的评估，视觉模拟评分法（VAS）对疼痛进行分。和SF-36测量调查表[15]。最后记录这些患者是否回到了他们之前的工作和活动能力。
结果:没有患者术后感染，所有骨折均得到解剖复位，坚强固定后骨折远端内外翻角度小于5度。实验组患者临床及放射学检查均取得骨折愈合。实验组中没有肱骨头塌陷骨坏死及螺钉穿出关节面。骨折愈合放射学检查实验组为（4.66±1.63）个月，明显早于对照组（5.98±1.57）个月（P <0.05，表2）。术后实验组测量ROM也显著优于对照组，包括屈（（148.00±18.59）与（121.73±17.20）度），伸（（49.00±2.22）比（42.06±2.06））度，内旋（（45.00±5.61）比（35.00±3.55）度），外旋（（64.00±9.17）比（52.14±5.73）度）。SF-36评分中，实验组（（88.00±5.71）分）显著高于对照显组（（69.45±9.45）分，P <0.001）。平均VAS疼痛程度实验组（mean rank,10.50）显著低于对照组（meanrank，47.19）（P <0.001）。实验组除一例患者外（17/18，94.4%）均回到了以前的活动状态或职业。与此相反，对照组中4例患者不能回到在他们以前的活动状态或职业。
结论：自体髂骨移植结合锁定钢板内固定治疗肱骨近端粉碎骨折手术操作简单，预后较好且并发症率低。
As the largest sesamoid bone in human body, patella plays an importantrole in the knee extension movements. Patella is located subcutaneously of theanterior knee joint, and it is easy to get direct or indirect violent injury. Hencethe patellar fracture is one of the most commonly observed fractures,accounting for2.21%of the total body fracture. As a type of intra-articularfracture, patellar fracture will result in destroying the continuous of the kneeextension system and evenness of the patellofemoral joint surface. Therefore,the prognosis of patients’ patellar fracture will result in significant impact onthe knee function and even life quality. To restore knee function as soon aspossible and avoid or reduce traumatic arthritis, the treatment principles forpatella fractures include anatomical reduction, strong fixation, and earlymobilization. With the continuous development of orthopedic fixationtechnology, a large number of newly discovered surgical techniques andfixation materials has been applied into the treatment of patellar fracture andmade the treatment results improved significantly. Before the20th century, thetreatment of patella fractures was controversial; the most commonly usedtreatments were non-operative methods like extension splinting and rest.Dowd etc. thought the traditional treatment had a bad prognosis with a lowersymphysis possibility and a higher disability expectation. As a result twosurgical plans were proposed with the improvement of sterile surgicaltechniques: patellar fracture open reduction and internal fixation with steelwire, and patellectomy. Later, the patellar fracture open reduction and internalfixation with steel wire became the primary choice for the treatment of patellafracture.
As a treatment of the extreme comminuted patella fracture, patellectomyis often applied. However taking the long term efficacy and prognosis into consideration, this resection treatment is controversial. Some scholars believedthat under the condition that the comminuted patella fractures cannot be stablyfixed, patellectomy can be applied as the treatment. And under this conditionthe satisfaction rate was about80%. However after the1980s, with theprogress of internal fixation techniques, a discussion on this operation wasbrought up believing that the clinical results of the patellectomy were not ideal.And this patellectomy can only be served as the final treatment. The previousfindings have only been focusing on the prognostic features of the patellarfractures, but the long term impact of the ipsilateral patellectomy on thefunction of the contralateral knee and the imaging changes has been rarelyreported. By comparing and analyzing the ipsilateral and contralateral side ofthe comminuted fractured patella with patellectomy and patella internalfixation treatments, our study is focusing on the function recovery andimaging changes in the two situations.
The requirement for clinical treatments on patellar fracture is increasing;in principle the treatment should maximally retain the patella and restore itsfunction. Most displaced patella fracture can be treated with open reductionand internal fixation. Partial patellectomy are usually applied for seriouspatella fracture, particularly severe fracture of the interior patella. Thelong-term efficacy of partial resection and degeneration of petallofemoral jointare rarely reported in publications. This study will evaluate the long-termefficacy of partial patellectomy by MRI scoring and the knee function scoring.
As China entering the aging society, the population of the aged people isincreasing rapidly, as a result the number of aged patients with patella fractureis also increasing. However, due to the problem from osteoporosis and poorbone quality of the aged patients, when applying the reduction and fixationtreatment, the fractured fragments were easy to be broken and internalfixations are easy to loosen. All these result in a non-or delayed close up ofthe fractured bones. Most of the aged patients with patella fracture need anadditional several weeks’ Kirschner wire plus tenson bend after the operationperformed. However, the long-term applied external fixation equipment during the treatment will result in the extreme unfavorable impact on the jointfunction recovery, as result, the cause of joint stiffness and impact on the kneefunction restore. This study is mainly discussing the effects of early functionalexercise and plaster fixation on the aged patients with patella fractures, via thescoring the early functional exercise and plaster fixation and analyzing thepostoperative complication during the recovery.
PART ONE: Gender determination from the patella CT threedimensional reconstruction measurement from Han adults in the NorthChina
Objective: The objective of this part is to determine adults’ gender, byapplying discrimination analysis to the received computed tomography (CT)three-dimensional reconstruction from257Han adults.
Method: The257Han adults were patients in Hebei Province TraumaCare Centers volunteered to participate in the test, from January2011toDecember2013. CT scans were applied to the volunteers and thethree-dimensional reconstructions were composed of the height and width,thickness, and the lateral patellar articular surface of the patella. After appliedto statistical analysis, the discriminant analysis functions and determinecompliance rates of mono-and multi-indicators were identified.
Result: In patella of the Han adults in the North China, the fiveindicators showed significant (P <0.01) larger mean values in men than inwomen. Discriminant analysis functions of medial articular surface of thepatella as a mono-indicator were Y1=-82.08+7.95X4and Y2=-60.29+6.78X4, with a determine compliance rate of83.33%. Discriminant analysisfunctions of multi-indicators were Y1=-296.24+2.94X1+6.78X2+0.119X3+3.01X4+4.70X5; Y2=-261.06+2.82X1+6.72X2+0.07X3+2.08X4+4.33X5, with a determine compliance rate of89.10%.
Conclusion: The determine compliance rate was83.33%when usingmedial articular surface of the patella as the mono-indicator in thediscriminant analysis; while the determine compliance rate was89.10%whenusing the multiple discriminant analysis. A reliable way of determining gender was figured out by a morphological measurement study on patella.
PART TWO: Long-term functional and imaging changes in patients’knees with partial patellectomy
Objective：To investigate long-term functional and imaging changes inpatients’ knees with partial patellectomy.
Methods:29cases of patients with partial patellectomy in our hospitalfrom January1987to January2002were retrospectively reviewed. There were21males and8females, with an average age of45.8(range29-71years). Meanfollow-up was13years (range,8-13years). In order to analysis the functionof patients’ knee, such examinations as MRI, physical examination andquestionnaire. As well as the KOOS score and Bostman score and modifiedWORMS score, were carried out in the study.
Result:The average Modified WORMS score in29cases of affectedknee was13.79±5.80points, included mild arthritis24cases, moderate5casesand severe0; score of unaffected sides was12.31±5.48, included mildarthritis26cases, moderate3cases and severe0. no statistical differencesshowed in the two groups (P=0.321). The average KOOS score of pain was88.0±6.37points, symptom was86.9±5.65points, daily life was89.9±5.15,entertainment and sports was83.6±7.55points and the quality of life related toknee joint function was80.5±8.46.The average Bostman score was27.41±3.621points, included20patients reached excellent,9good and0bad.Flexion degree of involved sides was128.34°±5.50°, the uninvolvedknee was128.76°±4.223°, no statistical differences showed in the two groups(P=0.173). Flexion degree of involved sides was105.35±12.18Nm, theuninvolved knee was106.59±9.09Nm, no statistical differences showed in thetwo groups (P=0.175).
Conclusion: partial patellectomy does not cause serious jointdegeneration and traumatic arthritis; Function score of knee shows finecurative effect. Partial patellectomy can be used for patellar fractures thatreplacement is difficult or malreduction.
PART THREE: ORIF contrast patellectomy treatment of comminutedfracture of the patella forward bilateral knee function and radiographicmanifestations
Objective: By comparing and analyzing the evaluations of imaging andfunctional scores between patellectomy of comminuted patella fracture andcontralateral and ipsilateral knee patella of internal fixed fractured patella, thisstudy mainly focus on the function recovery and imaging changes in the twosituations.
Method: Review analysis on the52patients accepting treatments ontheir comminuted fractured patella from January1987to January2002in ourhospital, including24patellectomy patients (resection group) and28patellaORIF patients (fixed group). MRI was performed on all patients at the finalfollow-up along with a knee function test and recovery surveys. A modifiedWhole-Organ Magnetic Resonance Imaging Score (WORMS) was performedin the patients MRI imaging analysis and American Knee Society Score (AKS)was applied to the knee function evaluation. The Biodex-II (USA) iso-kineticdynamometer system was applied for measuring knee joints’ extension peaktorque and buckling angle.
Result: The24patients in patellectomy group got11to26yearfollow-ups (mean was17.3years). The28patients in fixed group got12to22year follow-ups (mean15.5years). In the final follow-up of the patellectomygroup, the mean WORMS’s scores were6.58±1.05at ipsilateral side, and4.71±0.53at contralateral side. While the mean scores for the fixed group were8.11±1.21at ipsilateral side, and4.43±0.28at contralateral side. There wasno significant difference between the two groups at ipsilateral andcontralateral sides. The mean AKS’s scores were152.75±2.87at ipsilateralside and165.08±2.23at contralateral side of the patellectomy group; whilethe mean AKS’s scores for the fixed group were149.14±2.66at ipsilateralside, and165.08±2.23at contralateral side. There was no significantdifference between the two groups at ipsilateral and contralateral sides. Themean knee buckling angels were119.9°±3.01°at ipsilateral side and123.5°±2.71°at contralateral side of the resection group; while the angels for the fixed group were115.32°±3.11°at ipsilateral side, and127.14°±1.6°atcontralateral side. There was no significant difference between the two groupsat ipsilateral and contralateral sides (overall P=0.238, ipsilateral P=0.298, P>0.05, see Table1). The mean knee joints’ extension peak torque were96.08±2.32N m at ipsilateral side and106.46±1.8N m at contralateral side ofthe patellectomy group; while those for the fixed group were99.18±1.98N m at ipsilateral side, and105.25±1.63N m at contralateral side. There wasno significant difference between the two groups at ipsilateral andcontralateral sides.
Conclusion: After a long rehabilitation and compensation, patients withpatellectomy and internal fixation showed no functional difference within theipsilateral and contralateral sides. The patients in patellectomy group showedslightly lower muscle force at their quadriceps. However knee degenerationwas observed at the ipsilateral side within the patients in fixation group. Theincrease of functional compensatory increase at both side of the knee joint isthe major reason for this accelerated degeneration.
PART FOUR: Study of functional rehabilitation and complication ofpostoperative knee patella fracture in aged patients with early exerciseversus auxiliary external fixation.
Objective: Discussing the effects of early functional exercise and plasterfixation on the aged patients with patella fractures, via scoring the earlyfunctional exercise and external plaster fixation and analyzing thepostoperative complication during the recovery.
Method: Review analysis on the119aged patients accepting treatmentson their patella from January1987to January2002in our hospital, including99male cases and20female cases. Among these patients64were treated withexternal plaster fixation (plaster group) and55were applied to early functionalexercise (exercise group) after the surgical treatment. KOOS and Bostmanscoring were applied to all patients in their final follow-up as an evaluation ofthe patients’ knee function. Additionally, the complications including woundinfection, venous thrombosis, failure internal fixation, etc. were recorded and analyzed with the Electronic Medical Recording System.
Result: The follow-up time ranged from36months to98months, withan average of53months. There was no significant difference in age, gender,injury mechanism, injury type, time from injury to surgery, and hospitalizationtime between the two groups. According to Bostman standard, exercise groupgot a higher score than the plaster group, but no statistically significantdifference was observed (P=0.721). The excellent-to-good rates were79.69%(51/64) for exercise group and81.82%(45/55) for plaster group, no significantdifference was observed either. The KOOS score of exercise group wasslightly higher than that of plaster group without a significant difference. Themean knee buckling angels were116.36°±18.60°(54°~135°) for theexercise group and114.64°±18.31°(59°~135°) for the plaster group, nosignificant difference was observed (P=0.612). Extension activity was notlimited in either group. No internal fixation failure occurred in the plastergroup, but14cases of internal fixation failure occurred in the exercise group.A secondary ORIF was applied to10of the14patients with an external plasterfixation or brace; while the other four were treated with a plaster fixation untilfracture healing. There were14patients got wound infection;9were in theplaster group and5in the exercise group. Among the14infected patients,12got superficial infections (8in the plaster group and4in the exercise group),2got deep infections (1patient per group). Superficial infection was controlledby applying medication change and antimicrobial agents, and the wound washealed in all cases with no significant difference in two groups. There were13patients developed venous thrombosis and1developed deep vein thrombosisin plaster group; while in the exercise group5patients developed venousthrombosis and no deep vein thrombosis development.
Conclusion: The aged patients with good bone quality and stronginternal fixation can get good functional rehabilitation and low fixation failurerate by applying early post-surgical exercise rather than external plasterfixation, under the condition that the fracture was non-comminuted fracture.The aged patients with less poor internal fixation should be treated with fracture. External plaster fixation can reduce fixation failure rate with littleaffect on the knee function; however, the patients treated with external plasterfixation has a higher possibility in developing vein thrombosis. For agedpatients with higher risk of vein thrombosis development and patella fractures,anti-thrombotic therapy and lower limb exercise should be applied as soon aspossible.
PART FIVE: Locking plate fixation combined with iliac crest boneautologous graft for proximal humerus comminuted fracture
Objective: The aim of this study was to evaluate the clinical andradiographic outcomes of a locking plate and crest bone autologous graft fortreating proximal humerus comminuted fractures.
Method: We assessed the functional outcomes and complication rates in40patients with proximal humerus comminuted fractures. Eighteen patientswere treated with a locking plate and an autologous crest bone graft(experimental group), and22were treated with only the locking plate and nobone graft (control group). Postoperative assessments included radiographicimaging, range of motion analysis, pain level based on the visual analoguescale (VAS), and the SF-36(Short Form (36) Health Survey), as well aswhether patients could return to their previous occupation.
Result: All fractures healed both clinically and radiologically in theexperimental group. There was no more than2mm collapse of the humeralhead, and no osteonecrosis or screw penetration of the articular surface. Incontrast, two patients had a nonunion in the control group, and they eventuallyaccepted total shoulder replacements. The average time from surgery toradiographic union was significantly shorter in the experimental group((4.66±1.63) months) compared with the control group ((5.98±1.57) months)(P<0.05). For the experimental versus controls groups, the mean shoulderactive flexion (148.00±18.59vs.121.73±17.20) degrees, extension (49.00±2.22vs.42.06±2.06) degrees, internal rotation (45.00±5.61vs.35.00±3.55) degrees,external rotation (64.00±9.17vs.52.14±5.73) degrees, and abduction (138.00±28.78vs.105.95±15.66) degrees were all significantly higher (allP<0.001). The median SF-36in the experimental group ((88.00±5.71) points)was significantly higher than that of the control group ((69.45±9.45) points;P<0.001). The median VAS pain level (mean rank,10.50) in the experimentalgroup was lower than that (mean rank,47.19) of the control group (P<0.001).All but one patient (17of18,94.4%) in the experimental group returned totheir previous activities or occupations, and that one patient changed to adifferent occupation because of slight restrictions to activities. On the otherhand, four patients could not return to their previous activities or occupationsin the control group.
Conclusion: Locking plate fixation combined with an iliac crest bonegraft is an effective technique for treating proximal humerus comminutedfractures.
引文
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