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Rapid Prototyping: The Future of Trauma Surgery? 快速成型:创伤外科的未来?
Pub Date : 2003-11-01 DOI: 10.2106/00004623-200300004-00006
George A. Brown, K. Firoozbakhsh, T. Decoster, J. Reyna, M. Moneim
Surgeons frequently must perform delicate surgery without the benefit of a firsthand look at what they will be operating on. Fracture orientation can be difficult to conceptualize, especially in the acetabulum or spine. Anatomic reduction and stable fixation remain a challenge and have required long incisions with wide exposure, sometimes with increased postoperative morbidity1-9. The inadvertent penetration of screws into the hip joint, during the treatment of both complex acetabular fractures and posterior wall pelvic fractures, has been well documented10,11. Successful surgical correction of deformities of the hip joint before the onset of osteoarthritis requires accurate characterization of the anatomic deviations from normal as the first step in the planning of a corrective osteotomy. Pedicle screws inserted with a standard surgical technique have sometimes penetrated the wall or even missed the pedicle12-20. Diagnostic techniques such as radiography, computed tomography, and magnetic resonance imaging provide only two-dimensional images of fractures and may not depict subtle fractures.Advances in radiology combined with advances in computer technology have made the three-dimensional representation of anatomic structures in living subjects easily obtainable. With use of modern rapid prototyping techniques, computers can now accurately reproduce three-dimensional models of actual osseous anatomy, which can be invaluable for understanding the characteristics of the fracture, for preoperative contouring of plates, and for selection of screw trajectories. The surgical precision that is possible with use of computer image guidance for placement of screws or pins about the hip joint for the treatment of complex acetabular fractures and for insertion of pedicle screws is impressive1,2,21-27. However, this technology is not yet commonly used by surgeons because of its apparent complexity. Easy fabrication of accurate three-dimensional models of the osseous anatomy, easy …
外科医生经常必须在没有第一手资料的情况下进行精细的手术。骨折的方向很难确定,尤其是髋臼或脊柱。解剖复位和稳定固定仍然是一个挑战,需要长切口和大暴露,有时会增加术后发病率1-9。在复杂髋臼骨折和骨盆后壁骨折的治疗过程中,不慎将螺钉插入髋关节已经有了充分的记录10,11。在骨关节炎发病前成功地对髋关节畸形进行手术矫正,需要准确地描述解剖偏离正常的特征,作为矫正截骨术计划的第一步。采用标准手术技术置入椎弓根螺钉有时会穿透椎弓根壁,甚至错过椎弓根12-20。放射照相、计算机断层扫描和磁共振成像等诊断技术只能提供骨折的二维图像,可能无法描绘细微的骨折。放射学的进步与计算机技术的进步相结合,使得活体解剖结构的三维表现很容易获得。随着现代快速成型技术的使用,计算机现在可以准确地再现实际骨骼解剖的三维模型,这对于了解骨折特征、术前钢板轮廓和螺钉轨迹的选择是非常宝贵的。在复杂髋臼骨折的治疗中,使用计算机图像引导在髋关节周围放置螺钉或针以及置入椎弓根螺钉的手术精度令人印象深刻1,2,21-27。然而,由于其明显的复杂性,这项技术尚未被外科医生普遍使用。容易制作精确的骨骼解剖三维模型,容易…
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引用次数: 142
Anthropometric Measurements of the Human Knee: Correlation to the Sizing of Current Knee Arthroplasty Systems 人类膝关节的人体测量:与当前膝关节置换术系统尺寸的关系
Pub Date : 2003-11-01 DOI: 10.2106/00004623-200300004-00015
K. Hitt, John R. Shurman, K. Greene, J. Mccarthy, J. Moskal, T. Hoeman, Michael A. Mont
Background: There is a paucity of data concerning the morphological dimensions of the distal part of the femur, the proximal part of the tibia, and the patella. The objective of this study was to analyze the exact anatomic data collected from a large group of patients undergoing total knee arthroplasty and to correlate the measurements to the dimensions of current prosthetic systems. Methods: Eight different centers collected morphologic data from the distal part of the femur, the proximal part of the tibia, and the patella from 337 knees during total knee arthroplasty. Microcaliper measurements from templates and measuring guides were used to decrease intraobserver variation. The study included 188 women (209 knees) and 107 men (128 knees) who had a mean age of sixty-nine years. A characterization of the aspect ratio (the medial-lateral to anterior-posterior dimensions) was made for the proximal aspect of the tibia and the distal part of the femur. Known dimensions from six prosthetic knee systems were compared with the morphologic data. Results: A wide variation in the aspect ratio for the femoral component was seen among the six different prosthetic systems. For women, there was a significant association between the component size and the amount of medial-lateral overhang, with larger sizes having more overhang (p < 0.0001). Although the femoral aspect ratio for the morphologic data showed higher ratios for smaller knees and proportionally lower ratios for larger knees, the designs showed little change in the aspect ratio. The tibial aspect ratio from the morphologic data showed a higher ratio for smaller knees and a proportionally lower ratio for larger knees. The Duracon component tracked the decline in aspect ratio fairly well, whereas the other brands either did not change with anterior-posterior dimension or actually increased (NexGen). Gender differences in the morphologic data were shown by the variable tibial aspect ratios. A comparison of the bone dimensions from the study data and the dimensions of the implants indicated that the smaller sizes were too small while the larger sizes tended to be too large. The average overall unresected patellar thickness was 23.7 mm. Conclusion: The results of this study will allow manufacturers to make more appropriate determinations of the sizes and aspect ratios of components for use in total knee arthroplasty.
背景:关于股骨远端、胫骨近端和髌骨的形态尺寸数据缺乏。本研究的目的是分析从大量接受全膝关节置换术的患者收集的确切解剖数据,并将测量结果与当前假体系统的尺寸相关联。方法:收集337例膝关节全膝关节置换术中股骨远端、胫骨近端和髌骨的形态学资料。使用模板和测量指南的微卡尺测量来减少观察者内部的变化。该研究包括188名女性(209个膝盖)和107名男性(128个膝盖),他们的平均年龄为69岁。对胫骨近端和股骨远端进行了长宽比(内外侧尺寸到前后尺寸)的表征。从六个假膝系统的已知尺寸与形态学数据进行比较。结果:在六种不同的假体系统中,股骨假体的长径比有很大的变化。对于女性来说,部件尺寸与中外侧悬垂量之间存在显著关联,尺寸越大,悬垂量越大(p < 0.0001)。尽管形态学数据的股骨宽高比显示膝关节较小的比例较高,膝关节较大的比例较低,但设计显示股骨宽高比变化不大。从形态学数据来看,小膝关节的胫骨宽高比较高,大膝关节的比例较低。Duracon组件相当好地跟踪了纵横比的下降,而其他品牌要么没有随着前后尺寸的变化而变化,要么实际上增加了(NexGen)。不同性别的胫骨宽高比显示了形态学数据的差异。从研究数据和种植体尺寸的比较表明,较小的尺寸太小,而较大的尺寸往往太大。未切除髌骨的平均总厚度为23.7 mm。结论:本研究的结果将允许制造商对全膝关节置换术中使用的部件的尺寸和纵横比做出更适当的确定。
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引用次数: 375
Recombinant Human Bone Morphogenetic Protein-2: Use in Spinal Fusion Applications 重组人骨形态发生蛋白-2:在脊柱融合中的应用
Pub Date : 2003-08-01 DOI: 10.2106/00004623-200300003-00015
H. Sandhu, Safdar N. Khan
It has been several decades since Marshall Urist's discovery of osteoinductive activity within demineralized bone protein extracts. Initially described in Science in 1965 1, Dr. Urist's remarkable discovery, an unexpected byproduct of intended research on the competitive binding of radionucleotides during bone mineralization, suggested that morphogenetic activity resides among certain bone-matrix-derived proteins; this work continued with Urist's later identification of the active molecules as bone morphogenetic proteins 2,3. This was followed, in 1988, by the isolation of an individual protein, BMP-2, from a purified extract and its recombinant production 4. The long-awaited clinical use and commercial availability of bone morphogenetic proteins (BMPs) have only recently approached reality.Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been tested for use in spinal fusion in several completed prospective, randomized clinical trials, beginning in 1997. After rhBMP-2 was demonstrated to be equivalent to autogenous iliac bone graft with regard to both fusion rate and clinical outcome 5, a scientific advisory panel convened by the Food and Drug Administration (FDA) advised that rhBMP-2 be approved as the first complete bone-graft substitute for spinal fusion. At this time, rhBMP-2 carried on a type-I collagen sponge is approved for use in conjunction with a tapered, threaded intervertebral fusion cage (LT-Cage; Medtronic Sofamor Danek, Minneapolis, Minnesota) for the clinical treatment of degenerative lumbar disc disease.Preclinical proof-of-concept, feasibility, and efficacy studies laid the groundwork that established certain parameters for the clinical use of rhBMP-2. Each successive spinal fusion study contributed to the evolution of the design and dose of the carrier/protein combination. The site-specific characteristics of spinal fusion led to the development of specific carrier/rhBMP-2 combinations.This paper documents the preclinical and clinical progress of the development of rhBMP-2 as a viable complete bone-graft substitute and is a tribute to the pioneering …
自从Marshall Urist发现脱矿骨蛋白提取物中的骨诱导活性以来,已经过去了几十年。Urist博士的惊人发现最初于1965年发表在《科学》杂志上,这是对骨矿化过程中放射性核苷酸竞争性结合的研究的意外副产品,表明形态发生活动存在于某些骨基质衍生的蛋白质中;这项工作随着Urist后来鉴定出骨形态发生蛋白2,3的活性分子而继续。随后,在1988年,从纯化的提取物中分离出单个蛋白质BMP-2及其重组产物4。期待已久的骨形态发生蛋白(BMPs)的临床应用和商业可用性直到最近才接近现实。重组人骨形态发生蛋白-2 (rhBMP-2)从1997年开始在几个已完成的前瞻性随机临床试验中用于脊柱融合术。在rhBMP-2被证明在融合率和临床结果方面与自体髂骨移植物相当后,由美国食品和药物管理局(FDA)召集的一个科学咨询小组建议,批准rhBMP-2作为第一个完全的脊柱融合骨移植物替代品。此时,i型胶原海绵携带的rhBMP-2被批准与锥形螺纹椎间融合器(LT-Cage;Medtronic Sofamor Danek, Minneapolis, Minnesota)用于退行性腰椎间盘疾病的临床治疗。临床前概念验证、可行性和疗效研究为rhBMP-2的临床应用奠定了一定的参数基础。每次后续的脊柱融合研究都有助于载体/蛋白质组合的设计和剂量的演变。脊柱融合的部位特异性特征导致了特异性载体/rhBMP-2组合的发展。本文记录了rhBMP-2作为一种可行的完全骨移植替代物的临床前和临床进展,是对开创性…
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引用次数: 41
Uncemented STAR Total Ankle Prostheses: Three to Eight-Year Follow-up of Fifty-one Consecutive Ankles 无骨水泥STAR全踝假体:51个连续踝关节的3 - 8年随访
Pub Date : 2003-07-01 DOI: 10.2106/00004623-200307000-00019
T. Anderson, F. Montgomery, Å. Carlsson
Background: The feasibility of replacing the ankle joint has been a matter of speculation for a long time. In recent years, the designs of ankle prostheses have been improved, and three designs, all used without bone cement, currently dominate the market. However, documentation of the clinical results of the use of these prostheses is sparse. We reviewed the intermediate-term results of fifty-one consecutive Scandinavian Total Ankle Replacements (STAR). Methods: Between 1993 and 1999, fifty-one consecutive ankles were replaced with an uncemented, hydroxyapatite-coated STAR total ankle prosthesis. Clinical examination for the present study was performed by one surgeon who had not taken part in the operations. Standardized radiographs were used. Complications and failures were recorded, and patient satisfaction and functional outcome scores were determined for all patients with an unrevised implant. Results: Twelve ankles had to be revised. Seven were revised because of loosening of at least one of the components; two, because of fracture of the meniscus; and three, for other reasons. A component was exchanged in seven of the twelve revisions, whereas the ankle was successfully fused in the other five. An additional eight ankles had radiographic signs of loosening. The thirty-nine unrevised ankles (thirty-seven patients) were examined after thirty-six to ninety-seven months (median, fifty-two months). The patient was satisfied with the result after thirty-one of the ankle replacements, somewhat satisfied after two, and not satisfied after six. The median Kofoed score increased from 39 points before the surgery to 70 points at the time of the follow-up examination. A median follow-up score of 74 points was recorded when the system described by Mazur et al. and the AOFAS (American Orthopaedic Foot and Ankle Society) system were used. The median range of motion was approximately the same preoperatively and postoperatively. The estimated five-year survival rate, with revision for any reason as the end point, was 0.70. When radiographic loosening of either component was used as the end point, the estimated five-year radiographic survival rate was significantly better for the last thirty-one ankles treated in the series (p = 0.032). Conclusions: Total ankle replacement may be a realistic alternative to arthrodesis, provided that the components are correctly positioned and are of the correct size. However, the risks of loosening and failure are still higher than are such risks after total hip or total knee replacement. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
背景:长期以来,踝关节置换的可行性一直是人们猜测的问题。近年来,踝关节假体的设计得到了改进,目前主导市场的是三种不使用骨水泥的设计。然而,关于使用这些假体的临床结果的文献很少。我们回顾了51例连续的斯堪的纳维亚全踝关节置换术(STAR)的中期结果。方法:1993年至1999年间,51例连续踝关节被替换为未胶结的羟基磷灰石涂层STAR全踝关节假体。本研究的临床检查是由一名没有参与手术的外科医生进行的。采用标准化x线片。记录并发症和失败,并确定所有未修改种植体患者的患者满意度和功能结局评分。结果:12个踝关节需要修改。由于至少一个部件松动,7个部件进行了修改;二、因半月板骨折;第三,还有其他原因。在12次翻修中,有7次更换了一个组件,而在其他5次翻修中,踝关节成功融合。另外8个踝关节有影像学松动迹象。36至97个月(中位数为52个月)后对39例未修复的踝关节(37例患者)进行检查。患者踝关节置换术31次满意,2次比较满意,6次不满意。中位Kofoed评分从手术前的39分增加到随访检查时的70分。当使用Mazur等人描述的系统和AOFAS(美国骨科足踝协会)系统时,随访中位得分为74分。中位活动范围术前和术后大致相同。估计的5年生存率,以任何原因修订为终点,为0.70。当影像学上任意一种踝关节松动作为终点时,该系列中最后31例踝关节治疗的5年影像学存活率显著提高(p = 0.032)。结论:全踝关节置换术可能是一种现实的替代关节融合术,前提是组件位置正确,尺寸正确。然而,松动和失败的风险仍然高于全髋关节或全膝关节置换术后的风险。证据级别:治疗性研究,IV级(病例系列[无,或历史对照组])。有关证据水平的完整描述,请参见作者说明。
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引用次数: 317
User's Guide to the Surgical Literature: How to Use an Article About a Diagnostic Test 外科文献用户指南:如何使用一篇关于诊断测试的文章
Pub Date : 2003-06-01 DOI: 10.2106/00004623-200306000-00027
M. Bhandari, V. Montori, M. Swiontkowski, G. Guyatt
Clinical Scenario You are an orthopaedic surgeon who is asked to evaluate a sixty-five-year-old woman in the emergency department because of new-onset right hip pain that started one week ago. Seven months previously, the patient had had a right total hip arthroplasty for the treatment of osteoarthritis. The pain radiates to the thigh and buttocks. The patient reports that she slipped on a kitchen floor a few days ago but did not think that she had sustained a serious injury. In addition, she has been recovering from a sinus infection (a viral illness) for the past ten days. She is otherwise healthy except that she takes oral bisphosphonates for the treatment of osteoporosis. On examination, she has a temperature of 39°C. She walks most comfortably with a flexed posture. The range of motion of the right hip is normal. There is no erythema or draining sinus over the right hip and thigh. Anteroposterior radiographs of the pelvis and the right hip reveal a press-fit acetabular component and a cemented femoral stem with no evidence of loosening. Laboratory evaluations show a white blood-cell count of 12.1 cells/μL, of which 85% are neutrophils. Blood cultures are negative. You wonder whether the new onset of hip pain is the result of a soft-tissue injury, back pain radiating to the hip, prosthetic loosening that is not apparent on radiographs, or an infection of the hip joint. If the hip is truly infected, the patient will require an operative procedure for débridement of the wound and removal of the implants. While some of your colleagues would take all such patients to the operating room for exploration of the hip, you have been impressed by the number of cases in which you have found no infection. Because of such concerns, your practice is to routinely aspirate the hip in patients in whom an infection is suspected. Just as you are thinking about placing your patient’s name on the next day’s procedures list for an aspiration, the result of the C-reactive protein test comes back as 8 mg/dL (normal, ≤10 mg/dL). This finding raises some question as to
临床情景:你是一名骨科医生,因一周前开始新发的右髋关节疼痛,被要求对急诊部一位65岁的女性进行评估。7个月前,患者接受了右侧全髋关节置换术治疗骨关节炎。疼痛向大腿和臀部放射。病人报告说,她几天前在厨房地板上滑倒了,但没想到自己受了重伤。此外,她的鼻窦感染(一种病毒性疾病)已经恢复了十天。她除了服用口服双膦酸盐治疗骨质疏松症外,其他方面都很健康。经检查,她的体温为39℃。她以弯曲的姿势走路最舒服。右髋关节活动范围正常。右臀部及大腿未见红斑及引流窦。骨盆和右髋关节的正位x线片显示加压配合的髋臼组成部分和骨水泥固定的股骨干,无松动迹象。实验室检查显示白细胞计数12.1个/μL,其中85%为中性粒细胞。血培养呈阴性。你想知道新的髋关节疼痛是软组织损伤的结果,放射到髋关节的背部疼痛,假体松动在x光片上不明显,还是髋关节感染的结果。如果髋关节确实受到感染,患者将需要手术处理伤口并取出植入物。虽然你的一些同事会把所有这样的病人都带到手术室进行髋关节探查,但你对没有发现感染的病例数量印象深刻。出于这些考虑,你的做法是对怀疑感染的病人进行常规的髋关节抽吸。就在你考虑把病人的名字列在第二天的抽吸手术清单上时,c反应蛋白测试结果显示为8mg /dL(正常,≤10mg /dL)。这一发现提出了一些问题
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引用次数: 58
A Clinical Practice Guideline for Treatment of Septic Arthritis in Children: Efficacy in Improving Process of Care and Effect on Outcome of Septic Arthritis of the Hip 儿童脓毒性关节炎治疗临床实践指南:改善护理过程的疗效及对髋关节脓毒性关节炎预后的影响
Pub Date : 2003-06-01 DOI: 10.2106/00004623-200306000-00002
M. Kocher, R. Mandiga, Jane Murphy, D. Goldmann, M. Harper, R. Sundel, K. Ecklund, J. Kasser
Background: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children.Methods: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups.Results: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion.Conclusions: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.
背景:临床实践指南的发展是循证医学运动的核心原则。本研究的目的是为儿童脓毒性关节炎的治疗制定指南,并评估其在改善护理过程及其对儿童髋关节脓毒性关节炎预后的影响方面的疗效。方法:由跨学科专家委员会采用循证技术制定临床实践指南。通过比较使用指南前治疗的30名连续患有脓毒性髋关节关节炎的儿童的历史对照组和使用指南治疗的30名连续儿童的前瞻性队列组来评估疗效。比较两组间过程和结果的基准参数。结果:使用指南治疗的患者与未使用指南治疗的患者相比,初始和随访c反应蛋白检测的表现率明显更高(93%比13%和70%比7%),初始骨扫描率较低(13%比40%),推测引流率较低(13%比47%),推荐抗生素治疗的依从性较高(93%比7%)。改用口服抗生素的速度更快(3.9比6.9天),住院时间更短(4.8比8.3天)。两组之间在其他过程变量方面没有显著差异,在结果变量方面也没有显著差异,包括再次住院、复发感染、复发引流、骨髓炎的发展、脓毒性骨坏死或活动受限。结论:按照脓毒性关节炎临床实践指南治疗的患者在护理过程中变化较小,提高了护理效率,但预后无显著差异。证据等级:治疗性研究,III-2级(回顾性队列研究)。有关证据水平的完整描述,请参见作者说明。
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引用次数: 104
Keratotic Disorders of the Plantar Skin 足底皮肤角化性疾病
Pub Date : 2003-05-01 DOI: 10.2106/00004623-200305000-00027
R. Mann, J. Mann
Keratotic lesions on the plantar aspect of the foot develop beneath an osseous prominence and can result in substantial disability. This occurs because, during normal gait, the metatarsal head area is subjected to more prolonged stress than any other area on the plantar aspect of the foot. In the treatment of this disorder, it is imperative to establish the etiology, among many possibilities, and then address the specific pathology accordingly.
脚的足底角化病变在骨性突起下发展,可导致实质性残疾。这是因为在正常的步态中,跖骨头部区域比足底的任何其他区域承受的压力都要长。在这种疾病的治疗中,必须在许多可能性中确定病因,然后相应地处理具体的病理。
{"title":"Keratotic Disorders of the Plantar Skin","authors":"R. Mann, J. Mann","doi":"10.2106/00004623-200305000-00027","DOIUrl":"https://doi.org/10.2106/00004623-200305000-00027","url":null,"abstract":"Keratotic lesions on the plantar aspect of the foot develop beneath an osseous prominence and can result in substantial disability. This occurs because, during normal gait, the metatarsal head area is subjected to more prolonged stress than any other area on the plantar aspect of the foot. In the treatment of this disorder, it is imperative to establish the etiology, among many possibilities, and then address the specific pathology accordingly.","PeriodicalId":22625,"journal":{"name":"The Journal of Bone & Joint Surgery","volume":"92 S29","pages":"938–955"},"PeriodicalIF":0.0,"publicationDate":"2003-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91547102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 44
Instability After Shoulder Arthroplasty: Results of Surgical Treatment 肩关节置换术后不稳定:手术治疗的结果
Pub Date : 2003-04-01 DOI: 10.2106/00004623-200304000-00006
J. Sánchez-Sotelo, J. Sperling, C. Rowland, R. Cofield
Background: Currently, there is little available information regarding the surgical treatment of instability following shoulder arthroplasty. The purpose of the present study was to review the results of revision surgery performed for the treatment of instability after shoulder arthroplasty to better define the causes of instability and the risk factors for an unsatisfactory outcome.Methods: Between 1985 and 1999, thirty-three shoulders (seven of which had had a hemiarthroplasty and twenty-six of which had had a total shoulder arthroplasty) were treated surgically at our institution for anterior instability (nineteen shoulders) or posterior instability (fourteen shoulders). The primary arthroplasty had been performed for the treatment of degenerative arthritis in sixteen shoulders, arthritis of dislocation in six, acute fracture in four, rheumatoid arthritis in three, and other conditions in four.Results: The instability was attributed to abnormal capsular tension and/or rotator cuff dysfunction in twenty-one shoulders, component malpositioning in one shoulder, and a combination of both in eleven shoulders. One shoulder was treated with removal of the components. In the remaining thirty-two shoulders, each of the elements that was contributing to the instability was specifically addressed at the time of surgery. Revision surgery restored stability in nine of the thirty-two shoulders. Anterior instability was associated with a higher failure rate than posterior instability was (p = 0.04). Although eleven shoulders had additional surgery for the treatment of recurrent instability, only fourteen of the thirty-three shoulders were stable at the time of the final follow-up. According to the Neer rating system, there were four excellent, six satisfactory, and twenty-three unsatisfactory results.Conclusions: Soft-tissue imbalance is present in most cases of instability following shoulder arthroplasty, and component malpositioning plays an additional role in some cases. More than one-half of the shoulders in the present study remained unstable despite attempts at revision. Surgical treatment of instability following arthroplasty is associated with only a modest success rate.Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
背景:目前,关于肩关节置换术后不稳定的手术治疗的信息很少。本研究的目的是回顾翻修手术治疗肩关节置换术后不稳定的结果,以更好地确定不稳定的原因和导致不满意结果的危险因素。方法:1985年至1999年间,33例肩关节(其中7例做过半肩关节置换术,26例做过全肩关节置换术)因前路不稳定(19例)或后路不稳定(14例)在我院接受手术治疗。16例肩关节退行性关节炎,6例肩关节脱位,4例肩关节急性骨折,3例肩关节类风湿关节炎,4例肩关节其他情况。结果:21例肩关节不稳定是由于肩关节囊张力异常和/或肩袖功能障碍,1例肩关节部件错位,11例肩关节两者均有。其中一个肩关节被移除。在剩下的32个肩膀中,导致不稳定的每个因素在手术时都得到了明确的解决。翻修手术恢复了32个肩部中9个的稳定性。前路失稳的失败率高于后路失稳(p = 0.04)。虽然有11个肩部接受了额外的手术来治疗复发性不稳定,但在最后随访时,33个肩部中只有14个是稳定的。根据Neer评分系统,有4个优秀,6个满意,23个不满意的结果。结论:大多数肩关节置换术后不稳定的病例中存在软组织不平衡,在某些病例中,构件错位起额外的作用。在本研究中,超过一半的肩部尽管进行了矫正,但仍然不稳定。关节置换术后不稳定的手术治疗成功率不高。证据级别:治疗性研究,IV级(病例系列[无,或历史对照组])。有关证据水平的完整描述,请参见作者说明。
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引用次数: 108
Integration of Science into Orthopaedic Practice: Implications for Solving the Problem of Articular Cartilage Repair* 科学与骨科实践的整合:解决关节软骨修复问题的意义*
Pub Date : 2003-04-01 DOI: 10.2106/00004623-200300002-00001
J. Buckwalter
President Peterson, thank you for the honor of presenting the Fourth International Cartilage Repair Symposium Presidential Guest Lecture. I appreciate the opportunity to address the fascinating subject of integrating science into orthopaedic practice, a subject that should be the primary concern of surgeons and scientists seeking to restore damaged and diseased articular cartilage. It took more than 2000 years for a few thoughtful practitioners of the art of orthopaedics to value and apply principles and observations derived from basic research 1. Yet, in the short time since this occurred, the understanding that optimal patient care depends on science as well as art has transformed orthopaedic practice from a disparate array of manipulations and operations, best characterized as well-intentioned savagery, to a range of treatments that, in many instances, can be considered civilized. Equally important, we live in a time when the integration of knowledge from new basic research into orthopaedic practice has the potential to solve the most daunting clinical problems, including the pain and loss of mobility caused by the limited capacity of human joints to repair themselves.Individuals with varying experience and qualifications have practiced orthopaedics for more than twenty-five centuries 1,2. It would be reasonable to expect that, over this period of time, orthopaedic treatments would have become generally safe and effective. Yet, only 250 years ago, John Hunter (1728-1793), the individual regarded as the father of scientific surgery 3, noted that "surgery, namely operations, is like an armed savage that attempts to get by force that which civilized men would get by stratagem." 2 Orthopaedic operations in Hunter's day were painful, bloody, brutal, and extremely dangerous: the typical results, for patients who survived the operations, were disappointing and disabling 1. It was a situation that led to Hunter's comment that …
彼得森校长,感谢您荣幸地主持第四届国际软骨修复研讨会主席客座演讲。我很高兴有机会讨论将科学融入骨科实践的迷人主题,这应该是外科医生和科学家寻求修复受损和患病关节软骨的主要关注点。一些有思想的骨科从业者花了2000多年的时间才重视和应用基础研究中得出的原则和观察结果。然而,在这种情况发生后的很短时间内,人们认识到,最佳的病人护理既取决于科学,也取决于艺术,这一认识已经将骨科手术从一系列不同的操作和手术(最好的特征是善意的野蛮)转变为一系列在许多情况下可以被认为是文明的治疗。同样重要的是,我们生活在这样一个时代,新的基础研究知识与骨科实践相结合,有可能解决最令人生畏的临床问题,包括由人类关节自我修复能力有限引起的疼痛和活动能力丧失。具有不同经验和资格的个人已经从事骨科手术超过25个世纪了。我们有理由认为,在这段时间里,骨科治疗将变得普遍安全和有效。然而,仅仅在250年前,被视为科学外科学之父的约翰·亨特(John Hunter, 1728-1793)就指出:“外科学,即手术,就像一个武装的野蛮人,试图用武力得到文明人可以用计谋得到的东西。”在亨特的时代,整形手术是痛苦的、血腥的、残酷的,而且极其危险的。对于那些手术幸存下来的病人来说,典型的结果是令人失望的和致残的。正是这种情况导致了亨特的评论……
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引用次数: 25
Histological Assessment of Cartilage Repair: A Report by the Histology Endpoint Committee of the International Cartilage Repair Society (ICRS) 软骨修复的组织学评估:国际软骨修复学会(ICRS)组织学终点委员会的报告
Pub Date : 2003-04-01 DOI: 10.2106/00004623-200300002-00007
P. Mainil-Varlet, T. Aigner, M. Brittberg, P. Bullough, A. Hollander, E. Hunziker, R. Kandel, S. Nehrer, K. Pritzker, S. Roberts, E. Stauffer
Physical injury frequently causes tissue damage, including laceration. Repair of the damage usually results in the formation of a scar; complete anatomic healing and true regeneration are rare.Connective tissues tend to heal naturally and successfully only if the injury is minor. If the damage is more severe, then a good functional result can be achieved only if Nature is assisted by surgical intervention. The efficacy of such measures has been established in the cases of bone and tendon injuries but not in the case of cartilage damage 1. In the latter situation, we are still prejudiced by Hippocrates' opinion that "ulcerated cartilage is universally allowed to be a troublesome disease." 2 In addition, our view is necessarily colored by the scarcity of successful therapeutic modalities 3.Articular cartilage is a narrow layer of specialized connective tissue that permits smooth, frictionless movement of diarthrodial joints. It is comprised of a relatively small number of cells (chondrocytes) embedded in an abundant extracellular matrix 4. The latter consists predominantly of type-II collagen, proteoglycans, and water, along with smaller amounts of other collagen types and noncollagenous proteins. Histologically, articular cartilage is divided into three zones, which are distinguished by the shape of the chondrocytes and the arrangement of type-II collagen fibers. The superficial zone is characterized by flattened disc-like chondrocytes, a low proteoglycan content, and densely-packed, horizontally-arranged collagen fibrils of uniform diameter. This layer has been described as a tension-resisting diaphragm 5 by virtue of its tendency to curl when the articular cartilage is released from the subchondral bone 6. In the middle zone, chondrocytes attain a more rounded profile, proteoglycan content increases, and the collagen fibers decussate to provide an oblique transitional network between the superficial tangential zone and the deep radial zone. The deep radial zone is …
身体损伤经常导致组织损伤,包括撕裂伤。修复损伤通常会导致疤痕的形成;完全解剖愈合和真正的再生是罕见的。结缔组织只有在损伤轻微的情况下才会自然愈合。如果损伤较严重,那么只有在手术干预的辅助下,自然才能获得良好的功能效果。这些措施的有效性已经在骨和肌腱损伤的情况下得到了证实,但在软骨损伤的情况下还没有得到证实。在后一种情况下,我们仍然被希波克拉底的观点所偏见,即“普遍认为软骨溃疡是一种麻烦的疾病”。此外,我们的观点必然受到成功治疗方式缺乏的影响。关节软骨是一层狭窄的特化结缔组织,可使腹泻关节平滑、无摩擦地运动。它由相对少量的细胞(软骨细胞)包埋在丰富的细胞外基质中4。后者主要由ii型胶原蛋白、蛋白聚糖和水组成,还有少量的其他胶原蛋白和非胶原蛋白。组织学上,关节软骨分为三个区,以软骨细胞的形状和ii型胶原纤维的排列来区分。浅表区表现为扁平的盘状软骨细胞,蛋白多糖含量低,直径均匀的胶原原纤维密集堆积,水平排列。当关节软骨从软骨下骨中释放出来时,这一层具有弯曲的倾向,因此被描述为抗张力隔膜。在中间区,软骨细胞获得更圆的轮廓,蛋白多糖含量增加,胶原纤维相互交叉,在浅表切向区和深径向区之间提供倾斜的过渡网络。深径向区是…
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引用次数: 568
期刊
The Journal of Bone & Joint Surgery
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