为开阔临床医师视野，提供理论水平和借鉴临床经验，今后将陆续推出在读战友和临床感兴趣的战友利用业余时间创作的JBJS、spine等杂志的中英文对照稿供大家参阅鉴赏。感谢无私奉献的战友！战友的成长离不开您辛勤的汗水向无私奉献的战友致敬！！期待更多的战友参与活动一、规则：1、 愿意参与翻译工作的战友，请以回帖形式申请具体翻译的部分 ，为避免重复翻译，以每个主题加予序号（1、2、3....）为单位的形式认领 a、（每位战友每月限领1－2个专题，以减轻工作量，也给其他战友积极参与的机会）b、重复翻译者（未跟贴认领，导致其他战友重复翻译）未跟贴者无积分奖励。c、已经认领的显示为 红色尚未认领的显示为 黑色 认领翻译文献请到这里：2、 如对文中翻译不解处，请用蓝色字体标出，并欢迎其他战友校验、解答。3、译文发贴格式：主题：主题内容红色原文黑色译文蓝色4 、版权声明：本译文文字内容归网站（>3、翻译小组成员：感兴趣言而有信者即可参与4、日常事物处理：shamo5、daihatsu、心愿、小骨头注：各组员如有特殊情况无法及时完成工作，请提前pm版主，以便作出相应安排。三、积分奖励机制：（试行）1、摘要一篇，奖励1分；全文一篇奖励3分2、校验工作，摘要每1贴次1分，全文每1贴次3分。5、Exposure to Direct and Scatter Radiation with Use of Mini-C-Arm Fluoroscopy小型C臂X光透视机应用中X线直射、散射暴露Background: Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. Exposure of the orthopaedic surgical team to radiation during standard large-c-arm fluoroscopy has been well studied; however, little is known about the amount of exposure to which a surgical team is subjected with the use of mini-c-arm fluoroscopy. Moreover, there is controversy regarding the use of protective measures with mini-c-arm fluoroscopy.背景：小型C臂X光透视机已成为骨科医师的重要工具。骨科手术者在应用标准大型C臂X光透视机中的放射性暴露已经得到了较好的研究，而对于应用小型C臂X光透视机的放射性暴露量却知之甚少。此外，对小型C臂X光透视机应用防护措施仍然存在争议。Methods: We evaluated the use of mini-c-arm fluoroscopy during a simulated surgical procedure to quantify the relative radiation doses at various locations in the operative field. A standard calibrated mini-c-arm fluoroscope was used to image a phantom upper extremity with thirteen radiation dosimeters placed at various distances and angulations to detect radiation exposure.方法：在模拟手术过程中，我们对小型C臂X光透视机的辐射量进行评估，以确定手术范围不同区域的相对辐射剂量。在上肢模型的不同距离和角度放置13个辐射剂量计，记录带刻度的标准小型C臂X光透视机的放射性暴露。Results: After 155 sequential fluoroscopy exposures, totaling 300.2 seconds of imaging time, only the sensor placed in a direct line with the imaging beam recorded a substantial amount of measurable radiation exposure.结果：经过155次连续X线暴露，总计显像时间为300.2秒，仅在辐射束直线上可以测量到大量的射线照射。Conclusions: The surgical team is exposed to minimal radiation during routine use of mini-c-arm fluoroscopy, except when they are in the direct path of the radiation beam.结论：手术者在使用小型C臂X光透视机时会受到小剂量的射线，反对术者站在辐射束直线上。21、Radial Head Arthroplasty with a Modular Metal Spacer to Treat Acute Traumatic Elbow Instability金属隔片膜桡骨头置换术治疗急性创伤性肘关节不稳Background: The use of a metal radial head prosthesis to help stabilize an elbow with traumatic instability is appealing because internal fixation of multi fragment, displaced fractures of the radial head is susceptible to either early or late failure. The newer modular prostheses are easier to size and implant, but their effectiveness has not been investigated, to our knowledge.背景：应用内固定治疗桡骨头粉碎性骨折或移位骨折易于失败。因此，金属隔片膜桡骨头假体置换有助于创伤性肘关节不稳的固定。最新型的假体更易测量与置入，但据目前所知，其治疗效果尚未被证实。Methods: Twenty-seven patients in whom a radial head replacement with a modular metal spacer prosthesis had been performed to treat traumatic elbow instability were evaluated with use of the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons Elbow Evaluation Instrument (ASES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiographs were evaluated for arthrosis, periprosthetic radiolucency, and heterotopic ossification.方法：27例采用金属隔片膜桡骨头置换治疗创伤性肘关节不稳的患者，采用Mayo肘关节性能指数（MEPI）、美国肩肘外科医师协会肘关节评价法（ASES）以及臂、肩、手残疾调查问卷（DASH）进行评价，并用X线评价关节炎、假体周围透亮影和异位骨化的发生。Results: Seven patients underwent one or more subsequent operations to treat residual instability, heterotopic ossification and elbow contracture, ulnar neuropathy, or a misplaced screw. In two of these patients, the prosthesis was removed as part of an elbow contracture release or to treat infection. At an average of forty months postoperatively, elbow motion in the entire group of twenty-seven patients averaged 131° of flexion with a 20° flexion contracture, 73° of pronation, and 57° of supination. Stability was restored to all twenty-seven elbows, and twenty-two patients had a good or excellent result according to the MEPI. Seventeen patients had radiographic evidence of lucency around the neck of the prosthesis that was not associated with increased pain, thirteen patients had clinically inconsequential heterotopic ossification anterior to the radial neck, and nine patients had radiographic changes in the capitellum. 结果：7例患者因后遗不稳定、异位骨化、肘关节挛缩、尺神经损伤或螺钉移位接受再次或多次手术治疗。其中两例患者在松解肘关节挛缩或处理感染时取出了假体。经过平均40个月的随访，整组27例患者的肘关平均活动度为：屈曲131°、伸直20°、旋前73°、旋后57°。所有27例患者肘关节稳定性得到重建。根据MEPI评分，22例疗效优良。17例患者X线显示有假体颈周围透亮影，但与疼痛无关。13例出现无症状性桡骨头颈前方异位骨化。9例肱骨小头X线影像发生变化。Conclusions: An intentionally loosely placed modular metal radial head prosthesis can help to restore stability in conjunction with repair of other fractures and reattachment of the lateral collateral ligament to the epicondyle in the setting of traumatic elbow instability with a comminuted fracture of the radial head. While a prosthesis that is too large can cause problems, lucencies around the stem of the intentionally loose prosthesis and most changes in the capitellum do not appear to cause problems, at least in the short term.结论：伴有粉碎性桡骨头骨折的创伤性肘关节不稳治疗中，在修复其他骨折以及重建肱骨外髁侧副韧带止点的同时，人为宽松地置入桡骨头假体， 有利于重建肘关节稳定性。假体过大可能导致一些问题，但至少在短期内，假体周围透亮影和多数肱骨小头的变化不会导致其他问题。Proximal Femoral Replacement in Patients with Non-Neoplastic Conditions股骨近端置换在非肿瘤患者中的一个应用 Abstract Background: Numerous factors may give rise to the loss of femoral bone stock that can be encountered in revision hip arthroplasty. Proximal femoral replacement is an option for the treatment of severe proximal femoral bone loss. In this study, we sought to determine the outcome of reconstructive surgery with the use of a modular proximal femoral replacement (a so-called megaprosthesis) in patients with proximal femoral bone loss due to non-neoplastic conditions. 研究背景：很多因素可能引起股骨骨质的丢失，这有可能导致必须进行全髋翻修。股骨近端置换对于严重的股骨近端骨丢失是治疗上的一种选择。在这一研究中，用股骨近端假体（所谓的大假体）置换治疗由于非肿瘤原因导致股骨近端骨丢失的患者，我们试图检测这一重建手术的结果。Methods: A review of computerized databases from two institutions identified forty-eight patients with a mean age of 73.8 years who had undergone the placement of a modular megaprosthesis with or without bone-grafting. The indication for proximal femoral replacement was a periprosthetic fracture in twenty patients, reimplantation because of a deep infection in thirteen, a failed arthroplasty in thirteen, nonunion of an intertrochanteric fracture in one, and radiation-induced osteonecrosis with a subtrochanteric fracture in one. Three patients died before the minimum two-year follow-up interval had elapsed, and two additional patients were lost to follow-up. The mean duration of follow-up for the remaining study group of forty-three patients was 36.5 months. 方法：对从两个机构的计算机数据库中找出的48例患者进行了评估，其平均年龄为73.8岁，这些患者都曾接受大的假体置换拌或不伴骨移植。进行股骨近端置换的适应证是假体周围骨折28例，由于深部感染而进行再次手术13例，关节置换术失败13例，股骨粗隆间骨折不愈合1例，放射线诱导的骨坏死并伴有股骨粗隆下骨折1例。3例患者在达到最短两年随访之前就去世了，另外还有两例患者失访。研究组剩下的43例患者平均随访持续时间为36.5个月。Results: At the time of follow-up, there was a significant improvement in function as measured with the Harris hip score (p < 0.05). The proximal femoral replacement achieved an excellent or good functional outcome in twenty-two of the forty-three hips. The functional outcome was found to be fair in ten hips and poor in the remaining eleven. Ten patients required a reoperation or revision because of at least one complication. With revision used as the end point, the survivorship of the implant was 87% at one year and 73% at five years. 结果：随访的时候，通过Harris髋关节评分，发现其功能有了明显的改善(p < 0.05)。在43例髋关节中的23例，股骨近端置换达到了优秀或良好的功能结果。并发现功能结果可者为10髋，剩下的11髋则为差。10例患者由于至少1个并发症而必须进行再次手术或翻修。一翻修作为终点，1年时仍保留的假体为87%，5年时为73%。Conclusions: Patients with severely compromised bone stock in whom the use of a conventional prosthesis is precluded because of an inability to achieve adequate fixation may be candidates for proximal femoral replacement. Our short-term results suggest that this is a viable salvage procedure for these patients. 结论：骨质存在严重损害的患者，由于不能达到牢固的固定，而无法选择应用传统的假体，这时可以考虑选用股骨近端假体。我们的短期结果显示，对于这些患者这是一种可行的挽救性手术。Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. 可信度水平：治疗类IV级，可信度水平的完整描述见投稿须知（稿约）。Rapid-Inflation Intermittent Pneumatic Compression for Prevention of Deep Venous Thrombosis快速充气脉冲式气压预防深静脉血栓形成 Abstract Background: Current treatment regimens that are designed to prevent deep venous thrombosis in patients undergoing orthopaedic procedures rely predominantly on drug prophylaxis alone. The purpose of this randomized clinical study was to evaluate the effectiveness of a mechanical adjunct to chemoprophylaxis that involves intermittent compression of the legs. 研究背景：对于进行骨科手术的患者，为了预防深静脉血栓形成，当前的治疗方式主要依赖于单一的药物预防。这一随机临床研究的目的在于评价包括腿部脉冲式加压在内的机械性方式辅助药物治疗的有效性。Methods: During a twenty-two month period, 1803 patients undergoing a variety of orthopaedic procedures were prospectively randomized to receive either chemoprophylaxis alone or a combination of chemoprophylaxis and mechanical prophylaxis. Nine hundred and two patients were managed with low-molecular-weight heparin alone, and 901 were managed with low-molecular-weight heparin and intermittent pneumatic compression of the calves for varying time periods. Twenty-four percent of the patients underwent total hip or knee joint replacement. Screening for deep venous thrombosis was performed on the day of discharge with duplex-color-coded ultrasound. 方法：在22个月期间，进行各种骨科手术的患者都预期地随机地接受或者单一的药物预防或者药物预防联合机械预防。902例患者仅用低分子肝素进行处理，901例患者则不仅应用低分子肝素，还在不同时期对小腿进行脉冲式启动加压处理。24%的患者进行了全髋或全膝置换。所有患者在结束治疗的当天都进行彩色双功超声扫描，以检查其深静脉血栓形成的情况。Results: In the chemoprophylaxis-only group, fifteen patients (1.7%) were diagnosed with a deep venous thrombosis; three thromboses were symptomatic. In the chemoprophylaxis plus intermittent pneumatic compression group, four patients (0.4%) were diagnosed with deep venous thrombosis; one thrombosis was symptomatic. The difference between the groups with regard to the prevalence of deep venous thrombosis was significant (p = 0.007). In the chemoprophylaxis plus intermittent pneumatic compression group, no deep venous thromboses were found in patients who received more than six hours of intermittent pneumatic compression daily. 结果：单用药物预防组，15例患者（1.7%）被诊断为深静脉血栓形成，其中3例血栓形成是有症状的。药物预防加用脉冲式气动加压组，有4例患者（0.4%）被诊为深静脉血栓形成，其中1例是有症状的。两组间有关深静脉血栓形成发病率之间的差异有统计学意义(p = 0.007)。在药物预防加用脉冲式气动加压组，每天接受脉冲式气动加压超过6小时的患者，没有发现深静脉血栓形成。Conclusions: Venous thrombosis prophylaxis with low-molecular-weight heparin augmented with a device that delivers rapid-inflation intermittent pneumatic compression to the calves was found to be significantly more effective for preventing deep venous thrombosis when compared with a treatment regimen that involved low-molecular-weight heparin alone. 结论：与包括应用低分子肝素钠在内的单纯药物预防静脉血栓形成相比，应用低分子肝素钠的同时，联合一快速充气脉冲式气动加压装置应用于小腿，发现其对于预防深静脉血栓形成明显更加有效。Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence. 可信度水平：治疗类I级，可信度水平的完整描述见投稿须知（稿约）。[/color]我这篇超超长，建议版主多加点分[color=red]The Ulnar Nerve in Elbow Trauma肘外伤时的尺神经Robert Shin, MD1 and David Ring, MDIntroduction介绍•   The prevalence of ulnar nerve dysfunction after elbow injury is unknown because authors of published investigations have inadequately differentiated among acute injury-related, acute surgery-related, and delayed (subacute or chronic) ulnar neuropathies and these retrospective case series have not included careful evaluation of ulnar nerve function。由于已发表的研究调查的作者们不能充分区别急性外伤相关性、急性手术相关性和延迟性（亚急性或慢性）尺神经病变，而且这些回顾性病例系列没有对尺神经功能进行仔细评估，因此肘外伤后尺神经功能障碍的发生率还不清楚。•   Ulnar neuropathy is well documented after distal humeral fracture, but it can also develop following any complex elbow trauma。远端肱骨骨折后的尺神经病变已经被充分描述，但是任何复杂性的肘外伤后也可能发生。•   The ulnar nerve should be identified and protected during the treatment of a bicolumnar fracture of the distal part of the humerus, but current data are inconclusive regarding the value of routine anterior transposition of the nerve。肱骨远端“bicolumnar”（这个单词不知该如何翻，高手请指点，多谢）骨折的治疗期间应该注意识别和保护尺神经，但是目前还没有关于尺神经常规前置转位的价值的确定性数据。•   Although most delayed ulnar neuropathies present at a relatively late stage with weakness, with or without muscle atrophy, improved motor strength may be observed in some patients many years after ulnar nerve decompression。尽管大多数延迟性尺神经病变常在相对较晚的时间出现，表现为无力，伴或不伴肌肉萎缩，但是一些病人却仍可在尺神经减压术后多年观察到运动强度的改善。•   Ulnar nerve decompression and transposition are becoming an integral part of many posttraumatic reconstructive elbow procedures, but most recommendations for management of the ulnar nerve are based on retrospective reviews, anecdotal reports, and expert opinion。尺神经减压术和转位术正成为肘外伤后的许多重建性措施的一个完整部分，但是关于尺神经处理的大多数建议都是基于回顾性分析、无对照报道和专家的观点。The ulnar nerve is susceptible to compressive neuropathy at several anatomical sites at the elbow joint1-4. Elbow trauma places the nerve at risk for direct injury, operative injury, and subsequent compressive neuropathy. Optimal management of the ulnar nerve during operative treatment of an elbow injury is commonly discussed and debated, particularly with respect to the operative treatment of fractures of the distal part of the humerus5-7. The role of ulnar nerve dysfunction in posttraumatic stiffness and pain is also being increasingly recognized8-10. This paper reviews the published scientific data and current opinion available to guide patient care, with particular emphasis on areas where more data are needed。肘关节处有几个解剖位置易于发生压迫性神经病变。肘外伤使得尺神经有发生直接损伤、手术损伤和随后的压迫性神经病变的风险。肘外伤后手术治疗期间尤其是肱骨远端骨折后的手术治疗时尺神经的理想处理方式通常还存在争议。尺神经功能障碍在创伤后僵硬和疼痛中的作用也正被逐步认识。本论文将综述已发表的科学数据和当前的可用于指导病人保健的见解，尤其着重阐述需要更进一步数据的方面。Epidemiology流行病学The prevalence of acute and chronic ulnar nerve dysfunction after elbow trauma has not been documented definitively. Acute injury-related ulnar nerve palsy is uncommon in association with fractures of the distal part of the humerus and the olecranon (including fracture-dislocations of the olecranon), but it has been described as occurring in up to 10% of elbow dislocations11,12. This number seems too high, and the 1% prevalence of acute ulnar nerve palsy associated with elbow dislocation reported by Galbraith and McCullough13 is more consistent with our experience. A possible explanation for the difference in these numbers is the failure to distinguish among acute ulnar nerve palsy, postoperative ulnar nerve palsy, and delayed-onset ulnar nerve dysfunction, with the 10% figure reflecting all types of ulnar nerve dysfunction encountered from the time of injury through the long-term follow-up period。肘外伤后尺神经的急慢性功能障碍的发病率目前尚未阐明。肱骨远端骨折和鹰嘴骨折（包括鹰嘴的骨折脱臼）相关的急性损伤相关性尺神经麻痹不常见，但是有报道称它可以发生于10%的肘脱臼病人中。这个数字看起来很高，Galbraith和McCullough报道的1%的肘脱臼相关的急性尺神经麻痹的发病率和我们的经验更一致。Robinson et al. reviewed several series of adult patients with a fracture of the distal part of the humerus (320 patients in total) and found an overall rate of ulnar neuropathy of 12.3% (range, 0% to 50.9%), with an average of 5.4% (range, 0% to 15%) of these deficits being permanent14. The wide ranges and the failure to distinguish among the different types of ulnar nerve dysfunction limit the utility and interpretation of these findings。Robinson等回顾了肱骨远端骨折的成年病人（共有320例病人）的几个系列报道，发现尺神经病变的总发生率为12.3%（从0%-50.9%），这些缺陷中平均有5.4%（从0%-15%）为永久性的。波动幅度大和无法区别尺神经功能障碍的不同类型限制了这些发现的实用性和解释性。We cannot accurately describe the prevalence of acute injury-related ulnar nerve palsy, postoperative ulnar nerve palsy, and delayed-onset ulnar nerve palsy on the basis of the available published data. Future researchers should distinguish among these types of ulnar nerve dysfunction and define the prevalence of the problem according to these specific injury types。我们无法通过已发表的可用数据来准确描述出急性损伤相关性尺神经麻痹、手术后尺神经麻痹和延迟性尺神经病变的发生率。将来的研究员应该可以区别尺神经功能障碍的这些类型，并根据这些特异性的损伤类型定义它们的发生率。Anatomy解剖The ulnar nerve is derived from the C8 and T1 nerve roots. It is a terminal branch of the medial cord of the brachial plexus. In the midportion of the arm, it passes from the anterior to the posterior part of the arm, piercing the intermuscular septum approximately 10 cm above the medial epicondyle15. The nerve then passes through a fascial tunnel bounded laterally by the internal brachial ligament and inferiorly by an accessory origin of the medial head of the triceps from the medial intermuscular septum. The latter structure is commonly referred to as the arcade of Struthers, although it appears that Struthers never described it16-18. The arcade of Struthers averages 3.75 cm in length, ending approximately 3 to 10 cm above the medial epicondyle19. The reported prevalence of an arcade of Struthers is extremely variable, ranging between 25% (sixteen of sixty-four)20 and 70% (fourteen of twenty)21, indicating that its nature as a structure is disputed and difficult to characterize. The ulnar nerve passes under the medial epicondyle and enters the cubital tunnel beneath the fibrous arch bridging the two heads of the flexor carpi ulnaris (or the Osborne ligament)1,2,4. In the forearm, the ulnar nerve passes beneath the aponeurosis between the ulnar and humeral heads of the flexor carpi ulnaris。尺神经发自C8和T1神经根。它是臂丛内侧束的一个终末分支。在手臂中间部分，它在内上髁上方大约10cm处穿破肌间隔从手臂前面走行到其后面。然后尺神经从内侧肌间隔开始穿过一筋膜隧道，该隧道侧面界限为臂内侧韧带，下方为肱三头肌内侧头的副起源部分。侧面结构通常被说成是Struthers弓，尽管Structhers似乎从来都没有描述过它。Struthers弓平均长3.75cm，在内上髁上方3-10cm结束。报道的Struthers弓的发生率变化极大，从25%（64例中有17例）到70%（20例中有14例）不等，表明它作为结构的本性有争议，并且难于定义。尺神经在内上髁下面经过，进入尺侧腕屈肌（或Osborne韧带）的两个头之间的纤维性拱桥下面的肘管内。在前臂，尺神经在尺侧腕屈肌的尺骨头和肱骨头之间的腱膜下方经过。The blood supply to the ulnar nerve at the elbow is derived from three main pedicles, the superior ulnar collateral artery proximally, the inferior ulnar collateral artery in the midportion, and the posterior recurrent ulnar artery distally. These three vessels form an anastomotic extraneural network intimately associated with the ulnar nerve22. The superior ulnar collateral artery arises from the brachial artery about 18 cm proximal to the medial epicondyle. The inferior ulnar collateral artery arises from the brachial artery about 6.6 cm proximal to the medial epicondyle. The posterior recurrent ulnar artery arises from the ulnar artery about 7.3 cm distal to the medial epicondyle. In the study by Yamaguchi et al., twenty of twenty-two elbows did not have a direct anastomotic connection between the superior ulnar collateral artery and the posterior recurrent ulnar artery and fourteen of the twenty-two elbows did not have a communication between the superior ulnar collateral artery and the inferior ulnar collateral artery22. This is an important finding because division of the inferior ulnar collateral artery during anterior transposition of the ulnar nerve may devascularize a portion of the nerve. A study of ulnar nerve transposition in monkeys demonstrated a significant decrease (p < 0.05) in regional blood flow that took up to three days to return to normal23. Some have claimed that careful dissection can often preserve this blood supply during transposition24. Others have emphasized that there is an internal blood supply that is preserved during transposition22,25。肘部尺神经的血供主要来源于三个主要部分：近端来源于尺侧上副动脉，中间部分来源于尺侧下副动脉，远端来源于后面的尺侧返动脉。这三个血管构成了和尺神经密切相关的神经外解剖网络。尺侧上副动脉在内上髁近端大约18cm处起自肱动脉。尺侧下副动脉在内上髁近端大约6.6cm处起自肱动脉。后面的尺侧返动脉在内上髁远端大约7.3cm处起自尺动脉。在Yamaguchi等的研究中，22个肘中有20个肘的尺侧上副动脉和后面的尺侧返动脉之间没有直接的解剖联络，22个肘中有14个肘的尺侧上副动脉和尺侧下副动脉之间没有交通。这是一个重要的发现，因为尺神经前方转位的尺侧下副动脉可能会使得该神经的一部分去血管化。一项在猴身上进行的尺神经转位的研究发现了局部血流的明显下降（p<0.05），需要近三天恢复正常。一些学者声称转位期间的仔细游离经常可以保留这部分血供。其它学者也强调了转位期间有内部血供保留。The ulnar nerve does not innervate any structures in the upper arm. There are zero to three articular branches to the elbow, and these may begin proximal to the medial epicondyle26. The first branch to the flexor carpi ulnaris is found an average of 15 mm distal to the epicondylar axis27 and usually arises from the radial aspect of the nerve26. Typically, there are two to five branches to the flexor carpi ulnaris and the flexor digitorum profundus combined, occasionally with only one branch to the flexor carpi ulnaris27. Care must be taken to protect the first motor branch, in case it is the only branch to the flexor carpi ulnaris. Intraneural dissection of the first motor branch to the flexor carpi ulnaris can be performed safely and is occasionally required to fully mobilize the ulnar nerve。尺神经不支配上臂的任何结构。在肘部尺神经有0-3条关节支，这些分支可能在内上髁近端发出。分布到尺侧腕屈肌的第一个分支被发现起自上髁轴线远端平均15cm处，通常起自神经的桡侧面。较典型时有2-5条分支到尺侧腕屈肌和组合的指深屈肌，偶尔只有1条分支到尺侧腕屈肌。必须注意保护第一运动支，因为它可能是分布到尺侧腕屈肌的唯一分支。应该安全地对尺侧腕屈肌的第一运动支进行神经内分离，偶尔需要完整地移动尺神经。The dimensions of the ulnar nerve change with elbow flexion and extension. The cross-sectional shape changes from round to elliptical with increasing flexion, as the nerve flattens against the medial epicondyle28. The cross-sectional area of the nerve decreases up to 50) and the nerve elongates about 5 mm with full flexion30,31. The mean intraneural pressure is approximately 45% greater than the mean extraneural pressure with full elbow flexion, suggesting that intraneural pressure is the result of both traction and flattening (external pressure) of the nerve29。尺神经的尺寸随肘关节屈伸而改变。由于尺神经因抵抗内上髁而扁平，因此其横断面形状随着肘关节屈曲度增加而从圆形变为椭圆形。完全屈曲时该神经横断面面积减小到50%，伸长大约5mm。肘关节完全屈曲时平均神经内压力大约比平均神经外压力高45%，表明神经内压力是该神经牵引和变平（外部压力）的结果。Pathogenesis of Ulnar Neuropathy after Trauma外伤后尺神经病变的发病机理The ulnar nerve can be damaged by the initial injury or iatrogenically during operative treatment, or it may become symptomatic in a delayed fashion secondary to postoperative swelling, scarring, and thickening in its fibroosseous tunnel. It is important to evaluate peripheral nerve function carefully prior to any operation for the treatment of an elbow injury in order to distinguish injury-related from surgery-related palsies。尺神经可以被初始的损伤或手术治疗期间的医源性损伤所伤及到，或者继发于手术后肿胀、瘢痕或它的纤维骨性通道增厚，以延迟性的形式表现出症状。肘外伤后任何手术治疗前仔细评估外周神经功能来辨别损伤相关性和手术相关性麻痹很重要。Postoperative nerve palsies are often the result of traction on the nerve. Traction on the nerve should be carefully monitored and minimized. Retractors and loops around the nerve should be used with care, and assistants should be kept attentive. Although it can be argued that a wider loop such as a Penrose drain will apply less force per unit area than a smaller loop, our opinion is that it is not the pressure from the loop that places the nerve at risk, but rather the overall traction on the nerve. We believe that one is less likely to apply excessive traction through a smaller, more flexible loop such as a vessel loop。手术后神经麻痹是神经受牵引的经常性结果。神经的牵引应当仔细监测，并最小化。神经周围的牵引器和吊带应用时应该谨慎，助手应该留意。尽管你可以争辩较宽的吊带如烟卷式引流比小的吊带所产生的单位面积力量要小，但是我们的观点是：不是吊带产生的压力使得神经有风险，而是对神经的整体牵引。我们认为较小的、更柔韧的吊带如血管吊带产生过度牵引的可能性更小。Postoperative palsy can occur even when the nerve is handled gently. Furthermore, we have observed several postoperative ulnar nerve palsies after the nerves were transposed in the injury setting but none after transposition for treatment of idiopathic ulnar neuropathy. Given that some anatomical studies have suggested that a segment of the ulnar nerve may be devascularized during transposition, we have speculated that a traumatized nerve may be more susceptible to injury, by means of devascularization, than a chronically compressed nerve. More research is needed to better understand the pathogenesis of, and risk factors for, postoperative ulnar nerve palsy in the setting of acute elbow trauma. Delayed compressive neuropathies may be related to (1) implants placed on the medial column of the distal part of the humerus; (2) osteophytes, and exuberant fracture callus32, or heterotopic ossification (in which the ulnar nerve is occasionally entrapped)33,34; (3) constriction of the nerve by an incompletely divided flexor pronator aponeurosis or arcade of Struthers, or over an incompletely released medial intermuscular septum or medial triceps fascia (arcade of Struthers) after transposition; and (4) thickening or scarring of the normal fibroosseous tunnel in which the ulnar nerve lies35-40。即使神经被处理得很温柔的时候也可能发生术后麻痹。此外，我们在外伤时进行尺神经转位时观察到几例术后尺神经麻痹，但是没有病例是发生在自发性尺神经病变的转位治疗时。考虑到一些解剖学研究已经表明一段尺神经在转位期间可能被去血管化，我们推测受伤的神经可能要比受到慢性压迫的神经更易于受到去血管化的损伤。还需要进行更多的研究来更好地理解急性肘外伤背景下术后尺神经麻痹的发病机理和危险因素。延迟性压迫性神经病变可能和以下相关：1）置于肱骨远端部分内侧半的植入物；2）骨赘、高度增生的破碎性骨痂或异位骨化（这种情况下尺神经偶尔被受困）；3）转位术后分离不完全的旋前屈肌腱膜或Struthers弓、或释放不完全的内侧肌间隔或肱三头肌内侧筋膜（Struthers弓）导致的神经受压；4）尺神经所在的正常纤维骨性隧道的增厚或瘢痕形成。Delayed ulnar neuropathies have also been described in association with varus or valgus malunion of humeral fractures in children. In this setting, the ulnar nerve dysfunction has been referred to as a tardy ulnar nerve palsy41,42. Treatment recommendations may include humeral osteotomy in addition to ulnar nerve transposition, but the influence of the osteotomy on the ulnar neuropathy is debatable. Given the relationship between elbow trauma and subsequent ulnar neuropathy in the absence of varus or valgus deformity, the role of such deformity in the pathogenesis of ulnar nerve dysfunction can be questioned。延迟性尺神经病变已经被报道和儿童肱骨骨折的内翻或外翻畸形愈合相关。这种背景下，尺神经功能障碍被定义为缓慢的尺神经麻痹。治疗上的推荐包括尺神经转位+肱骨截骨术，但是截骨术对尺神经病变的影响还有争议。考虑到在没有内翻或外翻畸形时肘外伤和随后的尺神经病变之间的关系，因此这种畸形在尺神经功能障碍中的发病机理被质疑。Examination and Diagnostic Tests检查和诊断试验In patients with an ulnar neuropathy, numbness usually involves the small finger and the ulnar half of the ring finger. Sensory disturbance can be objectively and quantitatively evaluated with use of tests of threshold sensibility (Semmes-Weinstein monofilament testing)43 and innervation density (two-point discrimination testing). Semmes-Weinstein monofilament testing assesses the ability of the patient to sense pressure from filaments that bend at a known pressure. The normal value for this test is 2.83 MN (marking number), which is equivalent to ten times the log of the force in milligrams—in this case 68 mg. Patients who can detect only larger monofilaments have decreased sensation to light touch. Two-point discrimination can be assessed with a finger-blanching technique, in which two blunt points separated by a known distance are either held in one spot (static testing)44 or kept in motion (dynamic testing)45. The upper limit of normal has been described as 6 mm for the former46 and as 4 mm for the latter47. If sensation is normal on the dorsal ulnar aspect of the hand and wrist but not in the small finger, ulnar nerve compression at the wrist should be suspected。尺神经病变病人的麻木通常涉及到小指和环指的尺侧半。感觉障碍可以通过感觉阈值试验（Semmes-Weistein单纤维试验）和神经支配密度（两点辨别力试验）的使用来客观地和定量地评估。Semmes-Weinstein单纤维试验可以通过已知压力下弯曲的纤维来评估病人对感知压的能力。这个试验的正常值是2.83（标志数据），等价于毫克数表示的力量的对数的十倍-这种状况为68mg。仅能检测较大的单纤维的病人对轻度触摸的感觉减退。两点辨别力可以通过手指烫煮评估，这时被已知距离分开的两个迟钝的点可以为一束点（静态测试），也可以处于运动中（动态测试）。正常值得上限为：前者6mm，后者4mm。如果手和腕的背部尺侧部分的感觉是正常的，而不是小指，那么就应该怀疑腕的尺神经压迫。Atrophy and weakness reflect advanced nerve damage. Atrophy of the first dorsal interosseous muscle is usually more apparent than atrophy of the other intrinsic hand muscles innervated by the ulnar nerve, such as those in the hypothenar eminence and the other interosseous muscles. The strength of the first dorsal interosseous muscle can be tested by placing the patient's extended index finger in maximum radial deviation, having him or her resist forceful ulnar deviation, and comparing the resistance with that of the other hand. Weakness of the abductor digiti minimi and the flexor digitorum profundus to the small finger should also be assessed. The relative strength of the abductor digiti minimi can be tested conveniently with the confrontational test, in which the small fingers of both hands are held in abduction with maximal force, the small fingers are brought together, and, starting at approximately a 90° angle to each other, are pushed against one another. The test result is negative when both small fingers give way and collapse toward the ring fingers simultaneously. Unilateral giving-way is a positive result, suggesting weakness48。萎缩和无力反映了晚期神经损害。第一背侧骨间肌的萎缩通常要比其它内在的尺神经支配的手部肌肉更明显，如小鱼际肌和其它骨间肌。第一背侧骨间肌的力量可以通过将病人的延长的示指于最大辐射偏差来测定，使他或她抵抗有力的尺骨偏斜，同其它手比较抵抗力。小指展肌和指深屈肌到小指的无力也应该评估。小指展肌的相对力量可以通过对照试验方便的进行测试，两只手的小指处于最大力量的外展状态，聚拢小指，两指间以大约90度开始，然后两指互相推挤。当两个小指后退和同时朝向环指倒时为测试阴性。单侧的后退是阴性结果，表明无力。Static sensory or motor deficits may be absent in the early stages of compressive ulnar neuropathy. Symptoms can be provoked by sustained elbow flexion (the so-called elbow flexion test49), sustained pressure over the nerve in the cubital tunnel50, or tapping over the ulnar nerve at the cubital tunnel (to elicit the Tinel sign51). Novak et al. compared patients with electrodiagnostically confirmed idiopathic ulnar nerve compression with asymptomatic controls and found that a greater duration of elbow flexion or pressure over the nerve as well as the combination of both compression and flexion increased the sensitivity of provocative testing with little decrease in specificity (Table I)50. These findings are likely to apply to delayed posttraumatic ulnar neuropathy as well。静态感觉缺陷或运动缺陷在压迫性尺神经病变的早期可以不存在。症状可以被持久的肘屈曲（被称作为肘屈曲试验）和对肘管内神经的持续压力或对肘管内尺神经的持续叩击（为了引出Tinel征）所激发。Novak等比较了电反应诊断确诊为自发性尺神经压迫同无症状对照者，发现较长时间的肘关节屈曲或对神经的压迫还有压迫和屈曲联合增加了激发试验的敏感性，而特异性很少下降。这些发现可能也可以应用到延迟性外伤后尺神经病中。TABLE I Comparison of Sensitivities, Specificities, and Predictive Values of Provocative Tests for Ulnar Neuropathy* 尺神经病激发试验的敏感性、特异性和预测价值的比较________________________________________________________________________________  Sensitivity敏感性________________________________________  Specificity特异性________________________________________  Positive Predictive Value阳性预测价值________________________________________  Negative Predictive Value阴性预测价值________________________________________Tinel signTinel征  0.70  0.98  0.94  0.87Flexion test屈曲试验     30 seconds  0.32  0.99  0.93  0.74 60 seconds  0.75  0.99  0.97  0.89Pressure test压力试验         30 seconds  0.55  0.98  0.92  0.81 60 seconds  0.89  0.98  0.95  0.95Combined pressure and flexion test压力和屈曲试验联合       30 seconds  0.91  0.97  0.93  0.96 60 seconds________________________________________  0.98________________________________________  0.95________________________________________  0.91________________________________________  0.99________________________________________* Reproduced, with modification, from: Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg [Am]. 1994;19:817-20. Reprinted with permission.Neurophysiological testing provides objective confirmation of suspected ulnar neuropathy. Electromyography is used to evaluate motor nerve dysfunction. This test measures the electrical activity of a motor unit. Evidence of fibrillations suggests denervation of the motor end plates. Positive sharp waves appear approximately ten to twenty days after nerve injury and are also characterized by rest activity and increased insertional activity. Polyphasic motor unit potentials represent reinnervation and motor nerve recovery. Transient suppression of electromyographic activity may be demonstrated by noxious digital nerve stimuli. This period of electrical silence is known as a cutaneous silent period. Its presence is normal and indicates intact small fibers (A-delta), which are typically spared in compression neuropathy. Cutaneous silent periods become elongated with more severe nerve involvement. Most importantly, cutaneous silent periods confirm residual nerve continuity, which may not be apparent with use of other electromyographic parameters52,53。神经生理学试验为怀疑有尺神经病变者提供了客观的确诊方法。肌电图描记法可以用来评估运动神经功能障碍。这个试验测量一个运动单位的电活动性。肌纤维震颤的证据表明运动终板的去神经化。正尖波大约在神经损伤后10到20天时出现，也具有静息活动性和升高的嵌入活动性的特征。多相运动单位电位代表神经支配恢复术和运动神经恢复。暂时性的肌电图描记活性的抑制可以通过有害的数字化的神经刺激来说明。这个期间的电静息称为表皮静息期。它的存在是正常的，表示完整的细纤维（A-Δ），这在压迫性神经病中通常不存在。表皮静息期随神经损害加重而延长。最重要的是，表皮静息期确诊了余下的神经连续性，用其它肌电图描记参数可能不明显。Nerve conduction studies are used to evaluate sensory and motor nerve conduction amplitudes and velocities. Changes in sensory conduction are more sensitive indicators of neuropathy and correlate more directly with findings on physical examination. With both sensory and motor nerve conduction studies, the earliest sign of nerve dysfunction is a decrease in amplitude. This is closely followed by a decrease in motor velocity. Either absolute velocity across the elbow of <50 ms or slowing of velocity by >10 m/s compared with the value in the contralateral, unaffected arm suggests ulnar nerve compression. Additional features include an above-the-elbow to below-the-elbow segment being >10 ms slower than the below-the-elbow to wrist segment, a decrease in compound muscle action potential negative peak amplitude from below the elbow to above the elbow of >20%, and a substantial change in compound muscle action potential configuration at the above-the-elbow site compared with the below-the-elbow site54. Distal sensory and motor latencies of >2.4 and >2.6 ms, respectively, are also considered abnormal。神经传导试验用于评估感觉和运动神经传导幅度和速度。感觉传导的改变是神经病变的较敏感的指标，而且它和体检时的发现相关性更直接些。对于感觉和运动神经传导研究，神经功能障碍的最早征象是幅度的下降。然后紧跟着有运动速度的下降。通过肘的绝对速度小于50m/s或同对侧未受影响的手臂相比速度减慢超过10m/s，表明尺神经受压。另外的特点包括肘上到肘下段比肘下到腕段速度慢10m/s以上，从肘下到肘上复合肌肉动作电位负峰值下降超过20%，和同肘下相比肘上的复合肌肉动作电位位形发生实质性改变。远端感觉和运动潜伏期分别超过2.4和26ms也看作是异常。Classification分类McGowan55 classified ulnar nerve dysfunction into three grades. Grade 1 represents a minimal lesion with no detectable motor weakness of the hand. Grade 2 is characterized by an intermediate lesion in which a sensory disturbance is accompanied by interosseous muscle weakness and some wasting. Grade 3 is a severe lesion with profound weakness of the interossei。McGowan将尺神经功能障碍分为三级。I级代表轻微损害，手臂没有可察觉的运动无力。2级为中间阶段，特征是感觉障碍伴有骨间肌的无力和一定的消瘦。3级为严重病变，骨间肌极度无力。In 1990, Gabel and Amadio39 reviewed the results of reoperations done because of failed cubital tunnel releases in thirty patients and devised a 9-point scoring system to rate ulnar neuropathy preoperatively and postoperatively. The score is based on the summation of scores on 0 to 3-point scales for pain, sensory deficits, and motor deficits (Table II), with 9 points representing no evidence of neuropathy and 0 points representing the most severe neuropathy。1990年Gabel和Amadio回顾了由于肘管释放失败而进行再次手术的30例病人的结果，设计了一个9分的评分系统来估价术前和术后的尺神经病变。评分基于疼痛、感觉缺陷和运动缺陷各0-3分尺度的得分的总和，9分代表没有神经病变的证据，0分代表了最严重的神纪病变。TABLE II System Described by Gabel and Amadio39 for Rating Ulnar Neuropathy Gabel和Amadio描述的评价尺神经病变的系统________________________________________Score________________________________________  Pain________________________________________  Sensory________________________________________  Motor________________________________________0  Needs narcotics regularly需要规律服用麻醉药  2-pt. discrim. >10 mm, anesthesia两点辨别力>10mm,麻痹  Intrinsic paralysis with claw deformity (muscle grade, absent or trace; McGowan grade III)真正的瘫痪，爪样畸形（肌肉等级，无或微量；McGowan III级）1  Intermittent medication; constant pain间断性药物治疗，持续疼痛  2-pt. discrim. >6 mm; constant numbness两点辨别力>6mm,麻木  Obvious atrophy (muscle grade, fair or poor; McGowan grade II)明显萎缩（肌肉等级，中等或弱；McGowan II级）2  Intermittent pain间断性疼痛[/color]  2-pt. discrim. normal; intermittent paresthesias[color=blue]两点辨别力正常，间断性感觉异常  Weaker than on contralateral side (muscle grade, good)比对侧弱（肌肉等级，良好）3________________________________________  No pain无疼痛________________________________________  No numbness无麻木________________________________________  No weakness (muscle grade, normal; McGowan grade I)不存在无力（肌肉等级正常；McGowan I级）________________________________________In 1989, Dellon proposed a similar grading system56. The severity of the lesion is graded as mild, moderate or severe, depending on sensory and motor findings as well as the results of provocative maneuvers (Table III). Sensory findings include the presence of paresthesias, response to vibratory stimuli, and two-point discrimination. Motor findings include atrophy and the presence of objective weakness. Provocative tests include the elbow flexion test and the Tinel sign.1989年Dellon提出了一个类似的分级系统。病变的严重程度分为轻度，中度或重度，基于感觉和运动发现以及刺激法的结果。感觉发现包括感觉异常的存在，对振动刺激的反应和两点辨别力。运动发现包括萎缩和客观的无力的存在。刺激试验包括肘屈曲试验和Tinel征。TABLE III Classification of Ulnar Nerve Dysfunction According to Dellon56* ________________________________________________________________________________  Mild轻度________________________________________  Moderate中度________________________________________  Severe重度________________________________________Sensory感觉    Paresthesia感觉异常  Intermittent间断性 Intermittent间断性  Persistent持久性Vibration振动  Increased增加  Normal/decreased正常/降低  Decreased降低Two-point discrimination两点辨别力  Normal正常  Normal正常  Abnormal异常Motor运动      Weakness无力  Subjective clumsiness, loss of coordination主观的笨拙和不协调  Objective weakness of pinch and/or grip strength客观的捏挤和或抓握无力  Objective weakness of pinch and/or grip strength客观的捏挤和或抓握无力 Atrophy萎缩  No无  No无  Yes有Tests     Elbow flexion肘屈曲  ±  +  + Tinel  ±  +  +Finger crossing手指交错________________________________________  Normal正常________________________________________  Normal/abnormal正常/异常________________________________________  Abnormal异常________________________________________* Reproduced, with modification, from: Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg [Am]. 1989;14:688-700. Reprinted with permission. + = present, - = absent, and ± = present or absent.It is also useful to classify ulnar nerve dysfunction according to its time of onset in relation to the traumatic event. It is important to distinguish among acute injury-related ulnar neuropathies, postoperative surgery-related ulnar neuropathies, and delayed compressive ulnar neuropathies. Delayed ulnar neuropathy can be either subacute57 (onset within three months after the injury) or chronic (onset more than three months after the injury). Subacute ulnar neuropathy usually presents as loss of elbow motion and increasing pain with or without hand stiffness after an initial period during which pain was decreasing and motion was recovering well. Chronic ulnar neuropathy—whether posttraumatic or idiopathic—usually presents with advanced findings, with the patient having adapted to the symptoms. The surgeon should be mindful of the potential for ulnar nerve dysfunction at all stages of recovery from elbow trauma and remember to evaluate ulnar nerve function at each office visit.根据和创伤事件有关的尺神经功能障碍的发病时间对其进行分类也是有用的。辨别急性创伤相关性尺神经病变、手术相关性术后尺神经病变和延迟性压迫性尺神经病变三者很重要。延迟性尺神经病变可以为亚急性的（损伤后3个月内发病）或慢性的（损伤后3个月以后发病）。亚急性尺神经病变通常表现为在疼痛逐渐减轻和运动恢复良好的初始期之后出现肘关节运动的损失和疼痛渐增，伴或不伴手的僵硬。慢性尺神经病变-不管创伤后的或者是自发性的，通常表现为更高等的发现，病人已经适应了其症状。手术医生应该留意肘外伤后恢复期所有阶段都有发生尺神经功能障碍的可能，应该记住每次看病时都要进行尺神经功能的评估。Natural History自然病史While injury-related nerve palsies usually resolve, recovery from postoperative ulnar nerve palsies can be prolonged and incomplete. In our experience, patients with diabetes mellitus have been at particular risk for delayed or incomplete recovery58。损伤相关性神经麻痹通常可以消退，但是手术后尺神经麻痹的恢复可能会较长和不完全。我们的经验中，糖尿病病人发生延迟性或不完全性恢复的风险尤其高。In our opinion, subacute and chronic ulnar neuropathies and idiopathic cubital tunnel syndrome are slowly and inevitably progressive, as has been increasingly observed to be the case with idiopathic carpal tunnel syndrome. Furthermore, we believe that nonoperative treatment can help manage symptoms in the short term but cannot be relied on to prevent progression of the disease59. There is better evidence to support these concepts with regard to idiopathic carpal tunnel syndrome, but it is reasonable to expect other compressive peripheral neuropathies to behave in a similar fashion. In a clinical trial comparing operative treatment and splint immobilization in 176 patients with idiopathic carpal tunnel syndrome, 41% of those treated with the splint required surgery within eighteen months after enrollment60. In addition, several studies of idiopathic carpal tunnel syndrome have demonstrated either bilateral presentation or eventual development of nerve dysfunction on the contralateral side, suggesting that it is a bilateral disease61,62. Finally, a study of twins showed that genetics alone accounts for at least half of the risk of carpal tunnel syndrome developing63。以我们的见解来看，亚急性和慢性尺神经病变和自发性肘管综合征必然会缓慢进展，就像我们在自发性腕管综合征中观察到的一样。此外，我们认为非手术治疗可以在短期内处理症状，但是不能靠它来阻止疾病的进展。对于自发性腕管综合征有较好的证据支持这些概念，但是有理由期望其它的压迫性外周神经病变也存在类似的形式。在一个比较176例自发性腕管综合征的手术治疗和夹板制动的临床试验中，41%夹板处理病人在登记后18个月内需要手术治疗。此外，几个自发性腕管综合征得牙就业描述了双侧发病或最终的对侧神经功能障碍的发病，表明它是一个双侧性疾病。最后，一个双胞胎的研究表明单单遗传占了腕管综合征发病风险的至少一半。It is plausible that chronic idiopathic peripheral neuropathies reflect progressive structural compression that is genetically mediated and inevitable. It is also plausible that posttraumatic ulnar neuropathy is structural and progressive. These speculations must be confirmed by scientific data and may be relatively academic since most cases of posttraumatic ulnar neuropathy present at a fairly advanced stage with atrophy and weakness. Nonetheless, we recommend regular follow-up of patients with posttraumatic ulnar neuropathy if nonoperative treatment is chosen。慢性自发性外周神经病变可能反映了进展性的结构压迫，这是由遗传介导的，不可避免。也可能创伤后尺神经病变是结构性的和进展性的。这些推测必需被科学数据证实，由于大多数外伤后尺神经病变是在伴有萎缩和无力的中晚期，因此相对来说可能更学术一些。不过，我们仍然推荐对非手术治疗的外伤后尺神经病变病人进行规律的随访。Management of the Ulnar Nerve During Operative Treatment of Elbow Injury肘外伤手术治疗期间尺神经的处理Bicolumnar Distal Humeral Fractures肱骨远端双柱骨折Among elbow fractures, bicolumnar fractures of the distal part of the humerus are associated with the highest rate of both acute ulnar nerve palsy and delayed-onset chronic ulnar neuropathy following operative treatment5-7,64-79 (see Appendix). Surgeons handle the nerve in a variety of ways. All recommend initial exposure and protection of the nerve. Some advocate placing the nerve back into its epicondylar groove after internal fixation is completed7,76. Others transpose the nerve only when it is contused or if it lies directly on the medial plate6,77,78. Most support routine anterior transposition of the nerve5,79-84。肘骨折中，肱骨远端部分的双柱骨折与急性尺神经麻痹和手术治疗后的延迟发病的慢性尺神经病的高发病率有关。手术医生处理神经的方法多样。所有都推荐开始即暴露和保护神经。一些医生倡导在内固定完成后将神经置于上髁的沟槽内。其他医生仅当神经被挫伤或当神经直接位于内侧板上时才进行神经的转位。大多医生支持进行神经的常规前置术。The exact prevalence of postoperative ulnar nerve palsy cannot be stated accurately for the reasons mentioned earlier, but it may be as high as 13%5-7,67,70-79. We are beginning to analyze our experience, in which we have encountered what may be seven new iatrogenic postoperative ulnar nerve palsies in thirty-two patients (a rate of 22%) with a bicolumnar distal humeral fracture in whom a complete subcutaneous ulnar nerve transposition had been performed. If these ulnar nerve palsies were a result of the complete anterior transposition (i.e., caused by handling, retraction, or devascularization of the nerve), this would be a substantial disadvantage of that procedure, but our data are provisional and it is unclear if the rate of palsy is lower after protection of the nerve without transposition. On the other hand, it is not clear that complex fractures of the distal part of the humerus can be treated without moving the ulnar nerve out of the cubital tunnel。由于前面提到的原因，手术后尺神经麻痹的确切发生率无法准确说明，但是它可能高达13%。我们开始分析我们的经验，我们有32例肱骨远端双柱骨折病人进行了完全的皮下尺神经转位术，其中有7例（22%）发生了新的医源性术后尺神经麻痹。如果这些尺神经麻痹是完全前置转位的后果的话，这将是这个操作的本质性缺点，但是我们的数据是临时的，我们还不清楚没有进行神经转位的保护时麻痹的发生率是否较低。另一方面，还不清楚肱骨远端复杂性骨折是否可以进行治疗而不将尺神经移出到肘管外。A few authors reporting on retrospective case series of patients who had undergone internal fixation of a bicolumnar fracture of the distal part of the humerus have commented on the handling of the ulnar nerve5-7,72,73,77,79,80. The occurrence of postoperative nerve palsy is inconsistent, and no definitive treatment recommendations can be made. Kundel et al.7 reviewed the cases of seventy-seven patients in whom transposition was performed only when implants were placed in the groove below the medial epicondyle (in thirteen cases). They reported a 27% prevalence of injury or surgery-related ulnar neuropathy with this technique. In a study of fifty-five patients in whom transposition was performed only when there were preexisting ulnar nerve symptoms, Gupta and Khanchandani6 reported that 5% had an acute postoperative ulnar nerve palsy. Wang et al.5 advocated routine subcutaneous transposition, reporting no ulnar nerve complications in twenty patients who had been so treated。一些报道进行肱骨远端双柱骨折的内固定病人的回顾性病例系列的作者对尺神经的处理进行了评论。手术后神经麻痹的发生是不合理的，无明确治疗措施可以推荐进行。Kundel等回顾分析了77例病人，该组病人中仅当植入物置于内上髁以下的沟内时才进行尺神经的转位（30例）。他们报道这种技术的损伤或手术相关性尺神经病变发生率为27%。在一个仅当尺神经症状已经存在的55例病人进行转位术的研究中，Gupta和Khanchandani报道5%发生了急性的术后尺神经麻痹。Wang等提倡常规进行皮下转位术，报道了这样处理的20例病人中无尺神经并发症发生。The ulnar nerve is routinely transposed when bicolumnar fractures of the distal part of the humerus are treated with linked total elbow arthroplasty. Acute postoperative ulnar nerve dysfunction has been reported in 0% to 26% of patients64-66,68,69。当肱骨远端双柱骨折采用连锁的全肘关节成形术治疗时尺神经被常规转位。报道称急性术后尺神经功能障碍可以发生于0%到26%的病人。Capitellar and/or Trochlear Fractures and Elbow Fracture-Dislocations细头和/（或）滑车骨折和肘骨折-脱臼Complex articular fractures of the distal part of the humerus that do not involve the medial column (capitellar/trochlear fractures and lateral column fractures) and most elbow fracture-dislocations can be treated without the need to identify or protect the ulnar nerve. Acute postoperative ulnar nerve palsy is very uncommon with these injuries, but patients are at risk for delayed-onset ulnar neuropathy. One of us (D.R.) and colleagues described twenty-one patients with a complex articular fracture of the distal part of the humerus (complex capitellar and trochlear fractures), two of whom had a subacute ulnar neuropathy after an initial uneventful recovery80. Both patients had resolution of symptoms subsequent to an ulnar nerve release, performed at six weeks postoperatively in one patient and at eight weeks in the other。不涉及内侧柱的肱骨远端部分的复杂性关节骨折（细头/滑车骨折和外侧柱骨折）和大多数肘骨折-脱臼可以进行治疗而不需要识别和保护尺神经。急性术后尺神经麻痹在这些损伤中非常不常见，但是病人有发生延迟性尺神经病变的风险。我们中有一位和同事描述了21例肱骨远端复杂性关节骨折（复杂性细头和滑车骨折）的病人，其中2例在最初的不平静恢复后发生了亚急性尺神经病变。2例病人在尺神经释放后症状均消退，1例病人是在术后6周进行，另外1例是在术后8周。Fracture of the olecranon has been associated with a prevalence of postoperative ulnar neuropathy of 6% (two of thirty-one)85 and prevalences of delayed-onset ulnar neuropathy of 2% (one of fifty-two86) to 22% (four of eighteen32). We are in the process of reviewing the results of our treatment of dislocations of the elbow with associated intra-articular fractures and have noted a rate of delayed ulnar neuropathy of approximately 11% within two to five years postoperatively; the rate has been 15% after treatment of so-called terrible triad injuries (dislocation with fractures of the radial head and coronoid process). Because patients with these fracture types are at risk for delayed ulnar neuropathy, we have started to consider identification, prophylactic in situ decompression, and protection of the ulnar nerve during operative treatment of these injuries. More data are needed regarding the relative advantages and disadvantages of routine in situ release of the ulnar nerve, but we have encountered few sequelae in the short term. This situation may be analogous to that of unlinked total elbow arthroplasty, which was associated with a substantial rate of ulnar neuropathy87-95 before routine ulnar nerve decompression was added to the operative protocol。鹰嘴的骨折与6%（2/31）的术后尺神经病变的发生率和2%（1/32）到22%（4/18）的延迟性尺神经病变的发生率相关。我们正在回顾我们所治疗的肘关节错位联合关节内骨折的结果，发现术后2-5年内延迟性尺神经病变的发生率达约为11%；在所谓恐怖的三联损伤（错位联合桡骨头和冠突骨折）的治疗后其发病率为15%。因为这种类型骨折的病人有发生延迟性尺神经病变的风险，我们开始考虑在这些损伤的手术治疗期间进行尺神经的识别、预防性原位减压和保护。还需要更多的关于常规尺神经原位释放的相对优点和缺点的数据，但是我们已经在短期内已经遇到了少数后遗症。这种情况可能类似于分离的全肘关节成形术，和手术治疗时没有额外进行常规的尺神经减压术前的尺神经病变的实际发生率相关。Management of Ulnar Nerve Dysfunction尺神经功能障碍的处理Postinjury or Postoperative Nerve Palsy损伤后或术后的神经麻痹Nerve palsies identified within the first two weeks after an injury or operation are most likely related to traumatic or operative injury to the nerve. Sometimes it appears that a nerve that was intact at the initial postoperative examination becomes dysfunctional within the next few days, but in our opinion this is unlikely. It seems more likely that the initial postoperative examination was incomplete or inaccurate than that the status of the ulnar nerve changed over a few days. Consequently, if the surgeon is confident that the nerve is not lacerated or entrapped by an implant or injury, then a postoperative palsy should be managed with observation; otherwise the nerve should be explored。损伤或手术后最初两周内发现的神经麻痹最可能和创伤或手术对神经的损伤有关。最初的术后检查时尚完整的神经有时似乎会在随后的数天内发生功能障碍，但是我们认为这是不可能的。最初的术后检查要比数天后尺神经状态改变的检查不完全或不准确似乎更有可能。结果，如果手术医生非常自信神经没有被植入物或损伤弄伤或受困，然后对术后麻痹的处理就应该是观察，要不然就应当进行神经的探查。Subacute Ulnar Neuropathy亚急性尺神经病变Subacute ulnar nerve dysfunction96 can present as a sudden deterioration of function after an initial period of good recovery. It was described as secondary ulnar nerve palsy by Broca and Mouchet in 189957, and its occurrence was recently reemphasized by Faierman et al.96. Suggestive symptoms and signs can be confirmed with electrophysiological testing. The clinical presentation can be similar to that of complex regional pain syndrome, with pain out of proportion to what is expected and pain with light touch or even small movements. This is an uncommon condition, and it improves after ulnar nerve transposition96。亚急性尺神经功能障碍可以表现为在最初的良好恢复期后功能突然恶化。Broca和Mouchet于1899年将其描述为继发性尺神经麻痹，最近Faierman等再次强调它的发生率。暗示性症状和体征可以通过电生理测试证实。临床表现可以和复杂性区域性疼痛综合征类似，疼痛与期望的不成比例，轻微触摸或甚至小的移动时产生疼痛。这是一种不常见的情况，在尺神经转位后改善。Chronic Ulnar Neuropathy慢性尺神经病Chronic ulnar nerve dysfunction after trauma is often not recognized until advanced changes such as static numbness, weakness, and atrophy are present. Operative treatment is warranted after the lesion is confirmed and documented with electrodiagnostic testing. The variety of operative techniques described for the treatment of idiopathic ulnar neuropathy can usually be considered for posttraumatic ulnar neuropathy as well. No clear superiority of one technique over another has been demonstrated. In the unusual situation in which chronic ulnar neuropathy develops even though the nerve had been transposed anteriorly in the subcutaneous tissues at the time of the operation, one can consider repeat decompression with or without submuscular placement of the nerve97。创伤后的慢性尺神经功能障碍经常直到晚期改变如静止性麻木、无力和萎缩存在之后才会被识别。手术治疗在病变确诊后是合理的，需采用电诊断法测试说明。描述的治疗自发性尺神经病的手术技术的多样通常也可以考虑用于创伤后尺神经病。不常见情况下即使手术时尺神经已经被前置转位于皮下组织，仍有可能发生慢性尺神经病，你就可以考虑重复进行减压术，可以将神经置于肌下或否。McKee et al. reviewed the cases of twenty patients (twenty-one elbows) in whom chronic ulnar neuropathy had been treated with ulnar nerve decompression as part of an elbow reconstruction98,99. At an average of thirty-two months after the operation, the patients frequently had a return of intrinsic muscle function and had a high rate of satisfaction. There were seventeen good-to-excellent results, two fair results, and two poor results. Ten patients had a McGowan grade-3 lesion preoperatively, and none had one postoperatively. The average Gabel and Amadio score increased from 3.2 to 6.5 points. There was no worsening of intrinsic strength. Of seventeen patients with preoperative weakness, twelve recovered grade-5 power, four recovered grade-4 power, and one still had grade-3 power. The average satisfaction score was 8.0 of 10 points。McKee等回顾了尺神经减压作为肘重建术一部分的20例慢性尺神经病病人（21例肘）。术后平均32个月时，病人经常有内在肌肉功能的恢复，满足感病人比例高。17例病人结果好-优，2例中等结果，2例结果差。10例病人病变为术前McGowan 3级，术后均无。平均Gabel和Amadio评分从3.2增加到6.5分。没有内在力量的恶化。17例术前无力的病人中，12例恢复为5级，4例恢复为4级，1例仍然为3级。平均满意评分为8.0分，满分为10分。Barrios et al. directly compared the results of neurolysis and transposition of the ulnar nerve in patients with either idiopathic or posttraumatic cubital tunnel syndrome100. The results were slightly better (as measured with a scoring system and categorical ratings based on the Nerve Committee of the British Medical Research Council101) in the patients with idiopathic ulnar neuropathy. A greater number of patients with idiopathic ulnar neuropathy had complete recovery. The duration of symptoms did not affect the outcome100。Barrios等直接比较了自发性或创伤后肘管综合征病人的神经松解术同尺神经转位术的结果。自发性尺神经病病人的结果要稍微好一些（采用基于英国医学试验局神经委员会的评分系统和分类分级来测量）。自发性尺神经病病人有更多数量的完全恢复。症状持续时间不影响结果。Ulnar Neuropathy Associated with Elbow Contracture肘挛缩相关的尺神经病Chronic ulnar nerve dysfunction is often seen in conjunction with elbow stiffness, with or without arthrosis. In fact, ulnar nerve dysfunction can be considered part of the disease process of primary osteoarthritis of the elbow, with a prevalence as high as 54% (twenty-seven of fifty patients) in one study102. Antuna et al. reported ulnar nerve dysfunction in 15% (seven) of forty-six patients prior to an ulnohumeral arthroplasty for primary elbow arthritis and 28% (thirteen) of the forty-six postoperatively and recommended routine transposition of the ulnar nerve in elbows with <100° of preoperative flexion as well as in patients with preoperative ulnar nerve symptoms103. While it is appropriate to consider stiff or arthritic elbows as being at risk for the development of ulnar nerve dysfunction after an operation that restores greater flexion to the elbow, postrelease ulnar neuropathy can also occur in patients with good preoperative flexion; therefore, definitive criteria for decompressing the ulnar nerve at the time of an elbow contracture release cannot be made at this time。慢性尺神经功能障碍经常可以联合见于肘僵硬病人中，伴或不伴关节病。事实上，尺神经功能障碍可以看作是肘原发性骨关节炎疾病过程的一部分，一项研究中其发生率高到54%（27/50例）。Antuna等报道尺神经功能障碍在没有进行尺肱关节成形术之前的46例原发性肘关节炎病人中发生率为15%（7例），术后为28%，并推荐对肘关节术前屈曲<100度和术前即存在尺神经症状的病人常规进行尺神经转位术。将僵硬或关节炎性肘关节作为重建较大屈曲的肘关节手术后发生尺神经功能障碍的风险是合理的，然而释放术后尺神经病也可以发生于术前屈曲良好的病人中，因此，现在还没有制定肘挛缩解除术时尺神经减压的明确标准。Ulnar Neuropathy Associated with an Ununited Fracture of the Distal Part of the Humerus肱骨远端不连接性骨折相关的尺神经病Decompression and anterior subcutaneous transposition of the ulnar nerve has become an integral part of the operative treatment of an ununited fracture of the distal part of the humerus100,104,105. Helfet et al. reported preoperative ulnar nerve dysfunction in 30% of fifty-two patients104. McKee et al. reviewed the cases of thirteen patients with distal humeral malunion or nonunion, nine of whom had ulnar neuropathy before operative treatment of the malunion or nonunion99. External neurolysis and subcutaneous transposition of the ulnar nerve was performed in all nine patients, and all had a decrease in the ulnar nerve symptoms. Ulnar nerve transposition addresses preoperative nerve dysfunction, diminishes the potential for new ulnar neuropathy due to increased motion, and increases the safety of the procedure in most patients。尺神经的减压和皮下前置转位已经成为肱骨远端不连接性骨折手术治疗的一个完整部分。Helfet等报道52例病人中30%存在术前尺神经功能障碍。McKee等回顾了30例远端肱骨连结不正或不连结的病人，其中有9例在连结不正或不连结的手术治疗前即存在尺神经病。所有9例病人都进行了表面性神经松解术和尺神经皮下转位术，所有病人尺神经症状减少。尺神经转位论述了术前神经功能障碍，由于活动度增加因此减小了新的尺神经病的发生可能，并增加了大多数病人中操作的安全性。Recalcitrant Ulnar Neuropathy顽固性尺神经病Persistent ulnar nerve dysfunction after traumatic or operative injury or after treatment of a subacute or chronic ulnar neuropathy is commonplace and may not respond well to treatment. Entrapment of the ulnar nerve in substantial scar tissue after trauma and several operations can make repeat decompression or transposition difficult. It is reasonable to consider whether the nerve was incompletely released, but objective support for this etiology in the form of a very focal problem or progressive worsening demonstrated by electrophysiological testing may be necessary to distinguish treatable from untreatable nerve dysfunction. In the absence of a clear point of residual compression, nerve release surgery alone may not decrease symptoms or improve nerve function39。创伤或手术损伤后或亚急性或慢性尺神经病治疗后发生的持久性尺神经功能障碍很常见，对治疗反应不好。创伤或多次手术后尺神经包埋于皮下疤痕组织会使得重复减压或转位变得困难。考虑神经是否被完全释放是合理的，但是非常局灶性的问题或进展性的恶化可以通过电生理测试说明，这些病因学的客观支持可能对区别可治性和非可治性神经功能障碍很有必要。在没有澄清是否存在残余压迫的情况下，单纯进行神经释放手术可能并不能减轻症状或改善神经功能。Salvage techniques such as use of silicone sheaths or vein-wrapping39,106-108 to address scarring around the nerve have been described primarily for the treatment of pain and paresthesias, but two-point discrimination and electromyographic findings may also improve. These techniques are challenging and remain controversial. In theory, they minimize adhesions between the surrounding tissues and the nerve107. Promising early results have been reported39,106-108 by the advocates of these techniques, but additional research is needed to fully assess their value. Implantable peripheral nerve stimulators have also been used for chronic pain believed to be due to recalcitrant ulnar neuropathy, but these devices should be considered experimental109-111。补救技术如硅树脂鞘或静脉包绕使得斑痕位于神经周围已经首先被描述用于治疗疼痛和感觉错乱，但是两点辨别力和肌电图发现可能也会有改善。这些技术具有挑战性，还存在争议。理论上讲，他们极大的降低了周围组织同神经之间的黏附。令人鼓舞的zoaqi结果也已经被这些技术的倡导者报道，但是还需要额外的试验来完全评估它们的价值。可植入外周神经刺激器也已经用于治疗顽固性尺神经病导致的慢性疼痛，但是这些器具应该看作是试验性的。Overview概述Although definitive data are not available, current expert opinion supports identification and protection of the ulnar nerve during the treatment of a bicolumnar fracture of the distal part of the humerus and other types of complex elbow injury. The decision to transpose the ulnar nerve may be based in part on the injury type and be done when implants are applied to the medial epicondyle and medial side of the trochlea. Authors of future studies should systematically document nerve status and differentiate among injury-related, postoperative, subacute, and chronic ulnar nerve dysfunction. Ulnar nerve decompression is an important aspect of posttraumatic elbow reconstruction and can improve both elbow and hand function.尽管还没有确定性的可用数据，但是现在的专家观点支持在肱骨远端双柱骨折和其他类型的复杂性肘外伤的治疗期间进行尺神经的识别和保护。转位尺神经的决定在一定程度上可以基于损伤类型，当有植入物用于内上髁和滑车的内侧边时应当进行。以后的研究的作者应当系统阐述神经状态，区别损伤相关性、术后、亚急性和慢性尺神经功能障碍。尺神经减压术是创伤后肘重建的一个重要部分，可以改善肘和手的功能。Locally Administered Antibiotics for Prophylaxis Against Surgical Wound Infection预防手术创伤感染的局部抗生素使用Background: Currently, the standard for prophylaxis against surgical infection consists of perioperative systemic antibiotics. In this study, we investigated the relative efficacy of various methods of antibiotic delivery for the prevention of surgical wound infections. We hypothesized that sustained release of local antibiotics inside the wound cavity by a drug delivery system would be more effective than systemically administered antibiotics. 背景：目前，手术感染预防的标准主要包括术周系统地使用抗生素。在本研究中，我们调查了各种用来防治手术创伤感染的各种不同抗生素使用的有效性。我们猜想，在创腔中通过药物释放系统持久地释放局部抗生素比系统地使用抗生素要更为有效。Methods: Using a rat model, we inoculated a surgical wound in the quadriceps muscle with 8.0 x 105 colony-forming units of Staphylococcus aureus and then administered one of seven types of treatment: no treatment (control), bacitracin irrigation, calcium sulfate flakes, systemic gentamicin, local aqueous gentamicin, local gentamicin-loaded calcium sulfate flakes, and a combination of local gentamicin-loaded calcium sulfate and systemic gentamicin. The seven treatment groups consisted of ten rats each. To further evaluate a trend, the group treated with systemic gentamicin and the one treated with local gentamicin solution were extended to include twenty-five and twenty-seven rats, respectively. At forty-eight hours postoperatively, specimens from the wounds were obtained for quantitative culture. 方法：通过一个大鼠模型，我们在四头肌中移植了8.0 x 105 集落单位的金黄色葡萄球菌，然后使用了一下7种处理方法中的一种：没有处理（对照），枯草杆菌素冲洗，硫酸钙粉，系统使用庆大霉素，局部庆大霉素注射，局部庆大霉素合并硫酸钙粉，以及布局庆大霉素合并硫酸钙粉再加系统使用庆大霉素。在7个治疗组中，每组都由10只老鼠组成。相对地，为了进一步评估研究趋势，系统性使用庆大霉素的组与局部使用庆大霉素的组分别扩展为25只老鼠与27只老鼠。在术后的48个小时后，我们取下了创伤处的样本用来定量培养。Results: The control group, the group treated with bacitracin irrigation, and the one treated with plain calcium sulfate had very high bacterial counts and high mortality rates while the groups treated with gentamicin had low bacterial counts and a 100% survival rate. Local gentamicin was significantly more effective than systemic gentamicin in reducing bacterial counts. 结果：对照组、使用枯草杆菌素和使用硫酸钙粉组有很高的细菌计数和死亡率，而使用庆大霉素组则细菌计数较低并且100％成活。局部使用庆大霉素比系统性使用庆大霉素在减少细菌计数方面要有效得多。Conclusions: The gentamicin-loaded calcium sulfate flakes did not result in bacterial counts that were significantly lower than those following systemic administration of gentamicin, which refuted our hypothesis. However, gentamicin solution injected directly into the closed wound did result in levels of bacteria that were significantly lower than those following treatment with the systemic gentamicin. 结论：使用庆大霉素合并硫酸钙粉组并没有使得细菌计数比系统性使用庆大霉素组要低很多，这和我们的假设是矛盾的。但是，较之系统性使用庆大霉素组，局部注射庆大霉素使得细菌的水平明显下降了。Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures危及肢体的III型开放型胫骨骨干骨折处理的非术者变量的分析Background: The open tibial diaphyseal fracture remains a treatment challenge. The purpose of the present analysis of the long-term follow-up data on a previously reported cohort of patients was to identify surgeon-controlled variables that affected fracture union, complications, and final outcome in patients who had sustained a severe open tibial shaft fracture. 背景：开放性胫骨骨干骨折的处理，目前仍然很具有挑战性。目前的研究对一先前已经报导过的病人队列进行了长期随访分析，从而来区别可能影响骨折愈合、并发症和患者预后的非术者变量。所有这些病人都曾经经受过开放性胫骨骨干骨折。Methods: A cohort of 156 patients with a limb-threatening open tibial diaphyseal fracture was identified from the Lower Extremity Assessment Project (LEAP) study group. The patients were prospectively followed for two to seven years. In addition to the Sickness Impact Profile, other outcome metrics included the time to fracture union as well as the occurrence of infection and other complications that required rehospitalization. Statistical differences between groups were calculated. 方法：我们在下肢末梢测定项目研究小组(LEAP)中区分出了危及肢体的胫骨骨干骨折的156例病人队列。这些病人都术后随访了2到7年。除了疾病所影响的外形改变外，其他预后的测定还包括骨折愈合的时间和感染发生的情况以及需要再次住院的并发症情况。另外，我们还计算了组间的统计学差异。Results: Within the parameters of the present study, the timing of débridement, the timing of soft-tissue coverage, and the timing of bone-graft placement had no effect on outcome. Patients in whom the fracture was definitively treated with an external fixator had more surgical procedures, took longer to achieve full weight-bearing status, and had more readmissions to the hospital for the treatment of infection and nonunion than did those in whom the fracture was treated with an intramedullary nail. Patients undergoing external fixation who also had a muscle flap for wound coverage had more physical impairment and a worse functional outcome than did patients who had an amputation. 结果：本研究的数据显示，清创术的时间、软组织覆盖的时间以及骨移植片安放的时间对于结果都没有影响。与使用髓内钉的病人相比，使用外固定的病人需要更多的手术处理，要更长的时间才能达到负重状态，也需要更多的非工会的住院来处理感染情况。在使用外固定的病人中，使用肌瓣处理创口比截肢的病人有更多的物理损伤，也有更差的功能预后。Conclusions: Surgeons should carefully consider alternative treatment options for patients who have a severe open tibial fracture when limb salvage is perceived to require the combination of external fixation for fracture fixation and a muscle flap for wound coverage. 结论：对于严重开放性胫骨骨折的病人，为了保存肢体，当需要合并外固定来固定骨折或需要肌瓣移植来促进创口愈合时，外科医生需要仔细为它们选择一种可行的处理方法。 7、Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique复杂肱骨远端骨折：采用平行钢板技术原理固定Background: Severe comminution, bone loss, and osteopenia at the site of a distal humeral fracture increase the risk of an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the outcome of treating these fractures with a principle-based technique that maximizes fixation in the articular fragments and stability at the supracondylar level.背景：肱骨远端骨折部位的严重粉碎、骨丢失、骨量减少增加了疗效欠佳的风险，常见于不合适的内固定。本研究的目的在于确定采用标准技术治疗这些骨折的效果，这一标准包括尽可能固定关节碎片及肱骨髁上水平的稳定。Methods: Thirty-four consecutive complex distal humeral fractures were fixed with two parallel plates applied (medially and laterally) in approximately the sagittal plane. The technique was specifically designed to satisfy two principles: (1) fixation in the distal fragments should be maximized and (2) screw fixation in the distal segment should contribute to stability at the supracondylar level. Twenty-six fractures were AO type C3, and fourteen were open. Thirty-two fractures were followed for a mean of two years. The patients were assessed clinically with use of the Mayo Elbow Performance Score (MEPS) and radiographically.方法：34例复杂肱骨远端骨折采用近乎矢状面平行两块钢板固定（内侧和外侧），这一技术需满足两个原则：（1）尽可能固定远端折块，（2）远端骨块的固定螺钉必须有利于肱骨髁上水平的稳定。26例骨折属AO分型的C3型，14例为开放性骨折。31例骨折平均随访2年。所有患者采用Mayo肘关节功能指数（MEPS）及X线进行评估。Results: Neither hardware failure nor fracture displacement occurred in any patient. Union of thirty-one of the thirtytwo fractures was achieved primarily. Five patients underwent additional surgery to treat elbow stiffness. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, twenty-eight elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99°. The mean MEPS was 85 points. The result was graded as excellent for eleven elbows, good for sixteen, fair for two, and poor for three.结果：没有患者出现内固定失效或骨折移位。随访的32例患者中的31例骨折达到愈合。5例患者因肘关节僵直接受再次手术。有1例出现深部感染，在没有取出内固定的情况下得到控制，骨折愈合未受到影响。在最近的随访中，28例患者肘关节无疼痛或仅轻微疼痛，其平均屈伸弧度为99°。平均MEPS为85分。疗效：11例优，16例良，2例中，3例差。Conclusions: Stable fixation and a high rate of union of complex distal humeral fractures can be achieved when a principle-based surgical technique that maximizes fixation in the distal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilitation to restore elbow motion.结论：在复杂肱骨远端骨折治疗时，尽可能固定远端折块及肱骨髁上水平的稳定，可以取得稳固的内固定，并能获得很高的愈合率。采用这一技术取得的早期稳定允许患者加强功能锻炼以恢复肘关节活动度。 10、Dedifferentiated Chondrosarcomas Arising in Preexisting Osteochondromas骨软骨瘤形成的去分化型软骨肉瘤Background: Dedifferentiated chondrosarcomas that arise in osteochondromas are extremely rare lesions for which very little information on treatment and outcome is available in the literature. The purpose of the present study was to describe the specific clinical, radiographic, and histologic features of this lesion and to evaluate the oncologic outcome after different treatment strategies.背景：由骨软骨瘤形成的去分化型软骨肉瘤非常少见，其治疗及预后，文献少有报道。本研究旨在描述其特定的临床表现、放射学及组织学特征，并从肿瘤学评估不同治疗方案的疗效。Methods: We reviewed the files of the Rizzoli Institute between 1970 and 2002 and identified eighteen patients for whom adequate records and histologic images were available and in whom a high-grade sarcoma had been diagnosed at the same location as a preexisting osteochondroma. Radiographic studies, histologic slides, and clinical records were reviewed, the features of those studies were tabulated, and prognostic features and the results of treatment were identified.方法：研究回顾了Rizzoli学院1970-2002年的病历文件，确认有18例患者的资料及组织学影像符合标准，这些患者在先前存在骨软骨瘤的部位形成了高分化的肉瘤。文章对放射学研究、组织学涂片和临床记录进行回顾，将其特征列表，并确认预后信息和治疗结果。Results: The patients included twelve men and six women with an average age of forty-six years (range, twenty-two to seventy-four years). Eight lesions occurred in patients with multiple osteochondromas, and ten occurred in patients with solitary lesions. The most common locations were the pelvis (six lesions) and the femur (five lesions). Symptoms included pain, swelling, and a growing mass; the average duration of symptoms was eighteen months. Radiographically, ten lesions appeared as a conventional secondary chondrosarcoma arising in an exostosis, whereas eight showed typical signs of dedifferentiation. Histologic evaluation of the cartilage component demonstrated thirteen grade-1 and two grade-2 chondrosarcomas. In three cases, no cartilage component was recognized. The dedifferentiated component was considered to be an osteosarcoma in nine cases (including six cases in which it was osteoblastic and three in which it was fibroblastic), a malignant fibrous histiocytoma in eight, and a fibrosarcoma in one. The dedifferentiated component represented an average of 59% (range, 20% to 100%) of the lesion. For the fifteen patients who were managed at the authors’ institution, the two and five-year survival rates were 47% and 29%, respectively; the median survival time was fourteen months. Patients who were managed with a combination of surgery and chemotherapy had a better overall survival rate than did those who were managed with surgery alone (p = 0.03).结果：患者中包括12例男性和6例女性，平均年龄为46岁（22-74岁）。8例患者骨软骨瘤为多发性，10例单发。最常见的部位为骨盆（6例）和股骨（5例）。临床症状包括疼痛、肿胀和不断长大的肿块，平均持续18个月。影像学表明，10例病损软骨肉瘤常规由外生骨疣转化而来，另外8例则表现为典型去分化特征。对软骨成分的组织学研究表明13例软骨肉瘤分级为1级，2例为2级，3例患者未发现软骨成分。9例患者的去分化成分被认为是骨肉瘤，包括6例成骨细胞性和3例成纤维性。8例为恶性纤维组织细胞瘤和1例纤维肉瘤。去分化成分平均占据了59％病损部位（20％-100％）。15例在作者所属学院中治疗的患者，2年及5年生存率分别为47％和29％，平均生存时间为14个月。相比于仅采取手术治疗的患者，手术、化疗联合治疗的患者总体生存率更高（p＝0.03）。Conclusions: Dedifferentiated chondrosarcoma arising in a preexisting osteochondroma is an extremely rare lesion with a poor prognosis. In the present small series, overall survival was better when wide surgical resection was combined with adjuvant chemotherapy.结论：由骨软骨瘤转化的去分化软骨肉瘤非常少见，预后较差。在现有病例中，采用广泛手术切除与辅助性化疗相结合的治疗方法，总体生存率更高。Controversies inLower-Extremity Amputation下肢截肢术中存在的争议By Michael S. Pinzur, MD, Frank A. Gottschalk, MD, Marco Antonio Guedes de S. Pinto, MD, and Douglas G. Smith, MDAn Instructional Course Lecture, American Academy of Orthopaedic SurgeonsUsing the experience gained from taking care of World War II veterans with amputations, Ernest Burgess taught us that amputation surgery is reconstruc-tive surgery. It is the first step in the re-habilitation process for patients with an amputation and should be thought of in this way. An amputation is often a more appropriate option than limb salvage, irrespective of the underlying cause. The decision-making and selection of the amputation level must be based on realistic expectations with regard to functional outcome and must be adapted to both the disease process being treated and the unique needs of the patient. Sometimes the amputation is done as a life-saving procedure in a patient who is not expected to walk, but more often it is done for a patient who should be able to return to a full active life. This lecture addresses amputations done to return the patient to full activity. Our purposes are to assist the reader in (1) establishing reasonable goals when confronted with the question of limb salvage versus amputation,(2) understanding the roles of the soft- tissue envelope and osseous platform in the creation of a residual limb, (3) un- derstanding the method of weight-bearing within a prosthetic socket, and(4) determining whether a bone bridge is a positive addition to a transtibial amputation.Ernest Burgess利用照顾II次世界大战中截肢的退伍军人所得的经验，教导我们截肢手术是重建性手术。它是截肢病人恢复过程中的第一步，而且应该这么认为。截肢经常是比救肢更恰当的选择，而不论其根本原因是什么。决策的制定和截肢平面的选择必须基于功能结果的现实期望值，且必须适合所要治疗的疾病过程和病人的独特需要。有时候截肢是用于无行走期望的病人的救命性措施，但是它更经常情况下是用于应该能够恢复完全独立生活的病人的。我们的目的是帮助读者：1）在面对救肢VS截肢的问题时建立合理的目标；2）理解残余肢体建立时软组织包埋和骨质平台的作用；3）理解假肢接受腔内承重的方法；4）决定骨桥是否是经胫骨截肢术的一个积极条件。The Lower Extremity Assessment Project (LEAP) has provided objective outcome data on patients with mutilating limb injuries1. Five hundred and sixty-nine consecutive patients with mutilating limb injuries treated at eight academic trauma centers provided objective observational outcome data relative to limb salvage and amputation.One hundred and forty-nine under- went lower-extremity amputation dur- ing the course of their care. This ongoing study is providing a realistic understanding of the less-than-favorable results associated with both limb salvage and amputation. Much of what has been learned from LEAP can be applied to the care of patients with a non- traumatic amputation.下肢评估工程（LEAP）提供了肢体残废损伤病人的客观结果资料。8个研究院的创伤中心的569例肢体残废损伤病人提供了有关肢体救治和截肢的客观观察结果数据。149例病人在治疗期间进行了下肢截肢术。这个正在进行的研究提供了与肢体救治和截肢相关的良好以下结果的现实性理解。从LEAP中获悉的许多东西可以应用于治疗非创伤性截肢病人。A reasonable functional goal should be established before an extremity amputation is performed. The goals for a young individual who is going to reenter the workforce after a traumatic amputation are very different from those for an elderly debilitated patient with diabetes who has a limited life expectancy. Before surgery is performed, four issues need to be addressed, in order to create a needs assessment:1. If the limb is salvaged, will the functional outcome be better than it would be after an amputation and fitting of a prosthetic limb? This question needs to be addressed regardless of whether the patient has a mutilating limb injury, a diabetic foot infection, a tumor, or a congenital anomaly.2. What is a realistic expectation following treatment? The realistic expected functional outcome is the average functional outcome for patients with the same comorbidities and level of amputation; it is not the best possible outcome.3. What is the cost of care? This cost goes beyond resource consumption. Can the patient and his or her family afford the multiple operations and the time off from work necessary to accomplish limb salvage, or are they best served by amputation and fitting of a prosthetic limb?4. What are the risks? Limb- salvage surgery for any diagnosis is riskier than an amputation. When a patient has had an infection in an ischemic limb, the risk of recurrent infection and sepsis is far lower when the limb is removed than when it is retained.应该在截肢进行前确立合理的功能性目标。对于一个在创伤截肢术后要重新回到工作岗位的年轻人来说，其目标和寿命有限的年老体衰的糖尿病病人非常不同。在手术进行前，须列出四点来建立一个需要评估。1． 如果肢体被救下了，其功能性结果是否会比截肢和安装假肢更好？这个问题需要列出，无论病人是否存在肢体残废损伤、糖尿病组感染、肿瘤或先天性畸形。2． 治疗的现实期望是什么？期望的现实性功能结果是有着同样并存病和截肢水平的病人能够达到平均功能性结果；这不是最好的可能结果。3． 治疗的费用是多少？这个费用超出资源消耗。病人和他（或她）的家庭能否负担得起完成截肢所必需的多重手术的费用和需要脱离工作的时间，或者他们能否通过截肢和安装假肢而得到最好的治疗？4． 风险有什么？任何诊断的救治手术都要比截肢术风险大。当病人缺血性肢体存在感染时，移除肢体时感染复发和败血症的风险要远比保肢时高。Once these issues have been addressed, the patient and the surgical team generally have sufficient data to support the decision-making process.When performing an amputation as a reconstructive effort after trauma, infection, tumor, or vascular insufficiency, one should strive to create:1. Optimal residual limb length without osseous prominences.2. Reasonable function in the joint proximal to the level of the ampu- tation to enhance prosthetic function.3. A durable soft-tissue envelope. Although new prosthetic technology allows compensation for a suboptimal soft-tissue envelope, it is well accepted that amputees fare better with a durable soft-tissue envelope and fare worse when the skin is adherent to bone or there is a split-thickness skin graft in areas of high pressure or shear. Therefore, muscles should be secured to bone to prevent retraction. When possible, full- thickness myocutaneous flaps should be used, with muscle cushioning in areas of high pressure and shear (Figs. 1-A through 1-D).一旦这些条目列出，病人和手术组通常有充分数据来支持决策制定过程。当把截肢作为创伤、感染或血管功能不全后的重建性努力时，应当努力争取以下几点：1． 无骨质突起情况下的最佳残余肢体长度。2． 截肢平面近端关节的合理功能来加强假肢功能。3． 耐久的软组织包封。尽管新的假肢技术可以代偿欠佳的软组织包封，但是一般认为截肢者在有耐久的软组织包封时行走更好一些，当皮肤附着于骨或高压力或剪应力区域有中厚皮片时行走较差。因此，肌肉应当固定于骨来防止其回缩。可能情况下应当采用全厚肌皮瓣，使肌肉在高压力和剪应力区域起缓冲作用。Disarticulation Compared with Transosseous Amputation关节离断术同经骨截肢术的比较The more distal the level of lower- extremity amputation, the better the walking independence and functional outcome, unless the quality of the residual limb creates so much discomfort that it negates the potential benefits of limb-length retention. Therefore, the amputation should be done at the most distal level that will result in a functional residual limb. Efforts to create a functional residual limb should take into account the method of weight-bearing (load transfer) and the tissues available to create a soft-tissue envelope.下肢截肢术平面越靠近远端，行走的独立性和功能性结果就越好，除非残余肢体的质量产生了许多不舒服以至于抵消了肢体长度保留的可能益处。因此，截肢应当在可以获得功能性残余肢体的最远端水平进行。尝试创造功能性残余肢体时应当考虑承重（荷重转移）的方法和可用于创造软组织包封的组织。The best residual limb cannot duplicate the unique weight-bearing properties of a normal foot. The foot has multiple bones and articulations that function as a shock absorber at heel strike, a stable platform during stance phase, and a “starting block” for stability at push-off. The multiple bones and joints allow positioning of the durable plantar soft-tissue envelope in an optimal orientation for accepting load. An amputee has, in place of a foot, a residual limb that must tolerate weight- bearing (load transfer) with the socket of a prosthesis.最佳的残余肢体不可以复制正常足的独特承重特性。足有多块骨头和关节，它们在脚后跟撞击地面时像减震器一样起作用，是蹋脚位的一个稳定平台，在推开时是维持稳定性的一个起始块。多个骨头和关节允许耐久的跖软组织包封在接受荷重的理想定位时的体位保持。截肢者的残余肢体必须通过假肢来承重（荷重转移）以代替正常足。When the amputation is through a joint (disarticulation), the load transfer can be accomplished directly; i.e., there is end-bearing. When the amputation is done through the bone (trans-osseous), the load transfer must be accomplished indirectly by the entire residual limb, through a total-contact socket of the prosthesis, as weight-bearing on the end of the residual limb is too painful. Disarticulation allows dissipation of the load over a large surface area of less stiff metaphyseal bone. With a well-constructed soft-tissue envelope to cushion the residual osseous platform, the direct-transfer prosthetic socket need only suspend the prosthesis. This differs from transosseous amputation at the transtibial or trans- femoral level, where the surface area of the end of the bone is small and the diaphyseal bone is less resilient. The end of the bone must be “unweighted” by dissipating the load over the entire surface of the residual limb. This indirect load transfer requires a durable and mobile soft-tissue envelope that can tolerate the shearing forces associated with weight-bearing. The socket fit becomes crucial. When a patient loses weight the residual limb tends to bottom out, and painful end-bearing or tissue breakdown develops. Patients who gain weight are not able to fit the limb into the prosthesis. The choice of disarticulation or transosseous ampu- tation must be individualized for each patient.当截肢是通过关节时（关节离断术），荷重转移可以直接完成，即末端承重。当截肢是通过骨头时（经骨的），荷重转移必须通过整个残余肢体的假肢的全接触式接受腔间接完成，因为残余肢体末端承重很痛苦。关节离断术允许荷重耗散于比较不僵硬的干骺端骨头的巨大表面区域。有着结构良好的软组织包封来垫残余骨质平台时，直接转移的假肢接受腔仅需要使假肢悬挂。这不同于胫骨或股骨平面的经骨截肢术，因为这些骨头末端的表面区域小和骨干无弹力。骨末端必须通过将荷重消散在残余肢体的整个表面来减重。这种间接荷重转移需要耐久性的合可移动的软组织暴风，可以耐受承重相关的剪应力。接受腔的安装成为关键。当病人体重减轻时，残肢倾向于降至最低点，会发生痛苦的末端承重或组织破坏。体重增加的病人不能够使肢体适应假肢。每个病人的关节离断术或经骨截肢术的选择必须个体化。Transtibial (Below-the-Knee) Amputation经胫（膝下）截肢术The standard transtibial prosthetic socket is fabricated with the knee in approximately 10° of flexion, in order to unload the distal part of the tibia and optimally distribute the load. Load transfer is accomplished by distributing the load over the entire surface area of the residual limb, with a concentration over the anterior-medial and anterior-lateral areas of the tibial metaphysis.标准的经胫假肢接受腔以大约10度的屈曲与膝焊接，目的是解除胫骨远端部分的负担和最佳分配荷重。荷重转移通过将荷重分配到残肢的整个表面区域来完成，集中于胫骨干骺端的前内侧和前外侧区域。Mutilating limb injuries frequently disrupt the interosseous membrane, disengaging the relationship between the tibia and fibula. This loss of integrity of the interosseous mem- brane prevents the fibula from participating in normal load transfer. In other situations, the residual fibula may become unstable following transtibial amputation because of loss of the integrity of the interosseous membrane or as a result of loss of the integrity of the proximal tibiofibular joint even without an obvious traumatic disruption.肢体残废损伤经常使得骨间膜断裂，打乱了胫骨和腓骨之间的关系。骨间膜完整性的丢失妨碍了腓骨参与正常的荷重转移。其它情况下，残余腓骨可能会在经胫截肢术后变得不稳定，原因是骨间膜完整性的丢失，或由于近端胫腓关节完整性的丢失，甚至实在没有明显的外伤性断裂的情况下。Individuals with instability of the residual fibula following transtibial amputation can have pain due to several causes. When the residual limb is compressed within the prosthetic socket, the residual fibula may angulate toward the tibia with prolonged weight-bearing. The result is a conical, pointed residual limb, which tends to bottom-out during prolonged weight-bearing. The conical residual limb acts as a wedge, leading to painful end-bearing and soft- tissue breakdown over the terminal tibia. When the residual limb is short, or the interosseous membrane has been disrupted, the residual fibula can be abducted as a result of unopposed action of the biceps femoris muscle (Fig. 2)4,5.These alterations of the load-bearing platform become accentuated in younger, more active amputees, with higher demand, or with prolonged activities.经胫截肢术后残余腓骨不稳定的个体的疼痛可能有几个原因。当残余肢体在假肢接受腔内受压时，残余腓骨可能会朝向持续承重的胫骨成角。结果是圆锥形的尖的残存肢体，在持续承重时易于降至最低点。圆锥形的残存肢体像一个楔子一样，导致终末胫骨的疼痛性的末端承重和软组织破坏。当残存肢体短，或骨间膜断裂时，残存肢体会由于无对抗的股二头肌的作用而外展。承重平台的这些改变在年轻的更活泼的活动需求更高或活动更长的截肢者中变得明显。During World War I, Ertl proposed the creation of an osteoperiosteal tube, derived mostly from tibial periosteum, and affixing it to the fibula to create a stable residual limb8. Following World War II, his concept was success- fully introduced in the United States by Loon4, Deffer9, and others10. Arthrodesis, or bone-bridging, of the distal parts of the tibia and fibula has recently become a controversial topic, with both ardent supporters and strong detractors. Recent investigations suggest that the technique may provide a potential benefit for an active amputee by creating a stable platform with an enhanced surface area for load transfer5,11,12 (Figs.3-A and 3-. Most supporters suggest that the technique should be reserved for younger, more active amputees who will benefit from the potentially enhanced functional residual limb and are more able to tolerate the increased morbidity risk associated with the additional surgery necessary to obtain the bone bridge.I次世界大战期间，Ertl提出骨与骨膜管的建立，大部分从胫骨骨膜而来，并将它固定于腓骨以创建稳定的残肢。II次世界大战后，他的概念被Loon、Deffer和其它人成功引入美国。胫骨和腓骨远端部分的关节融合术或骨桥最近成为有争议的主题，有热忱的支持者，也有强烈的排斥者。最近的调查表明该技术可能会通过创建稳定的荷重转移表面积增加的平台而给活泼的截肢者带来益处。多数支持者建议该技术应该保留用于年轻的活泼的截肢者，这些人将会从可能增强的功能性残肢中获益，并更能够耐受获得骨桥所必须的额外手术相关的并发症风险增加。The surgery can also be performed as a late reconstruction for active amputees with residual limb pain that appears to be associated with an unstable or disengaged residual fibula. These patients may have a conical end- bearing residual limb, usually with pain at the end of the residual limb and occasionally with tissue breakdown. Others may have pain along a prominent or unstable fibula. On examination, the fibula usually can be felt to be unstable.手术也可用于残肢疼痛可能与不稳定或自由的残存腓骨有关的活泼截肢者的晚期重建。这些病人可能会有一个圆锥形的末端承重残肢，残肢末端通常会有疼痛，偶尔会有组织破坏。其他患者可能会有沿突出的或不稳定的腓骨的疼痛。体检时，通常会感觉到腓骨的不稳定。The operation involves use of a long posterior myocutaneous flap. For the average 6-ft (1.8-m)-tall patient, the optimal residual tibial length should be a minimum of 10 to 12 cm in order to create an adequate weight-bearing platform, but it should not be longer than 15 to 18 cm. (An excessively long residual limb requires the prosthetic socket to be put into full extension. This leads to increased distal pressure, increased end-bearing, and more stump failures.) The fibula is divided 4 cm distal to the tibia to allow the creation of the bone bridge. Care is taken to maintain as many muscular attachments to the distal aspect of the fibula as possible. One centimeter of the fibula is removed at the level of the distal tibial cut to allow rotation of the vascularized bone. A notch is made in the lateral cortex of the residual tibia to accept the rotated fibular segment. Stability can be obtained by suturing the fibular segment through drill-holes, or with screw fixation (Fig. 3-.手术时涉及长的后面的肌皮瓣的使用。对于平均6-ft（1.8m）高的病人来说，最佳残存胫骨长度应该是最小10-12cm，以便创建足够的承重平台，但是不应该长于15-18cm。（过长的残肢需要残肢延伸入整个假肢接受腔。这导致远端压力增加、末端承重增加和更多的残肢失败。）腓骨在胫骨远端4cm处截断，从而允许骨桥的建立。要注意使腓骨远端部分保留尽可能多的肌肉附件。在远端胫骨截断水平应该移除1cm腓骨从而使得血管化的骨头能够旋转。在残存胫骨的外侧皮质作一凹槽来接受旋转的腓骨节段。通过钻孔或螺钉固定缝合腓骨节段可以获得稳定性。The transferred fibular segment used between the distal parts of the fibula and tibia can be supplemented with a vascularized periosteal sleeve taken from the tibia, as described by Ertl. The periosteum on the anterior surface of the tibia, which is quite thick, is raised from the tibia distal to the level of the tibial transection. When the periosteum is raised, it is important to keep it attached proximally and to take a thin slice of cortical bone with it. This almost guarantees that the periosteum obtained has maintained its vascular supply. A 1-in (2.5-cm) osteotome is used to raise the periosteum and the thin slice of cortical bone. The periosteal sleeve is sutured over the rotated fibular segment. The periosteal graft alone has also been used in place of the fibula, but we have no experience with that technique and do not recommend it.用在腓骨和胫骨远端部分之间的转移的腓骨节段可以用从胫骨上取下的血管化骨膜套来增补，如Erel所描述的。胫骨前表面上的骨膜非常厚，从胫骨横断水平以远取下。骨膜取下时，保持其近端附着和一同取下薄层皮质骨很重要。这几乎保证了所得骨膜血供的维持。采用1-英寸（2.5cm）骨刀来取骨膜和薄层皮质骨。骨膜套缝合于旋转的腓骨节段上。单单骨膜移植物可以用来代替腓骨，但是我们没有该技术的经验，因此不推荐它。The anterior aspect of the distal surface of the tibia is beveled, and a durable full-thickness myocutaneous flap is repaired to the anterior aspect of the tibia through drill holes or by suturing the posterior gastrocnemius fascia to the anterior periosteum of the residual tibia and the anterior compartment fascia.胫骨远端表面的前面部分斜削，将耐久性的全厚肌皮瓣修补于胫骨的前表面，通过钻孔的方法，或将后面的腓肠肌筋膜缝合于残存胫骨的前骨膜和前室筋膜。When the surgery is performed as a late reconstruction or if there is no distal part of the fibula with which to create the bone bridge, a tricortical iliac crest bone graft is wedged between the terminal residual tibia and fibula after the inner surfaces of both have been prepared with a burr (Figs. 4-A, 4-B, and 4-C).当手术是作为晚期重建时或在没有创建骨桥所需的腓骨远端部分时，可以在末端的残存胫骨和腓骨内表面用锉修补后，以髂嵴骨皮质移植物来桥接它们。Postoperative Care术后监护A rigid plaster dressing is applied to protect the residual limb and to control postoperative swelling. Another option is to use elastic bandages for a compressive dressing, but these need to be put on carefully so as not to pro- duce a pressure sore. This is especially important when a patient has a peripheral neuropathy. Our experience has been that if the patient has pain at the end of the stump or in the stump shortly after surgery it is due to a local problem and the dressing needs to be changed, but pain that seems to be in the distal, amputated part of the limbis the so-called phantom-limb phenomenon. Phantom sensation is a normal response after an amputation that usually resolves. Telling the patient before the surgery that they will have phantom sensations tends to decrease anxiety about this phenomenon.用坚硬的石膏包扎来保护残肢和控制术后肿胀。另一个选择是用弹力绷带加压包扎，但是这需要仔细使用以免产生褥疮。病人有外周神经病时这尤其重要。我们的经验是如果病人术后残肢末端或内部存在疼痛，那是由于局部问题，需要更换包扎，但是如果疼痛在远端的已截掉的肢体，就是所谓的幻肢现象。幻觉是截肢术后的正常反应，通常可以消退。在术前告知病人他们将会有幻觉易于减轻关于这种现象的忧虑。Weight-bearing with a temporary prosthesis is initiated when the residual limb appears capable of tolerating weight-bearing. Pain with weight-bearing lasts longer for patients who have had a bone-bridge reconstruction than it does for those without a bone bridge. The pain may last for six to nine months and seems to resolve as the bone bridge heals. It is assumed that the site of healing between the fibula and tibia remains tender until the bone becomes solid. The pain should be treated nonoperatively unless there is a sign of inadequate placement of thegraft or sutures. Usually, the patient can be fitted for a prosthesis, but he or she may not be able to bear full weight until the tenderness resolves.当残肢能够耐受承重时，临时性假肢的承重即开始了。骨桥重建病人的承重性疼痛要比无骨桥患者持续时间长。疼痛可持续6-9个月，骨桥愈合后消退。可设想腓骨和胫骨之间的愈合部位直到骨变得坚硬前会一直保持疼痛。除非有移植物或缝合的不适当固定的迹象，否则疼痛都应非手术治疗。通常，病人可以适应假肢，但是他或她可能会直到触痛消退后才能够承受完全的重量。Skin Flap for Transtibial (Below-the-Knee) Amputation经胫骨（膝下）截肢术的皮瓣Load transfer following transtibial amputation appears to be enhanced when the residual limb has a large osseous surface area covered with a durable soft-tissue envelope composed of a well-cushioned mobile muscle mass and full-thickness skin. This desired result is best achieved through use of a long posterior myofasciocutaneous flap. Despite the fact that the standard posterior flap for transtibial amputation is satisfactory for most patients, retraction of the flap over time can lead to a troublesome pressure point overlying the anterior aspect of the distal part of the residual tibia. The standard transtibial amputation technique, popularized by Burgess et al., often places the surgical incision directly over that portion of the residual tibia. This raises the potential for adherent scarring of the skin to that part of the tibia or for inadequate cushioning of this region during weight-bearing. When the anterior aspect of the distal part of the residual tibia is not sufficiently padded, there is an increased likelihood of localized discomfort, blistering, or tissue breakdown associated with the normal pistoning that occurs between the residual limb and the prosthetic socket during normal walking. An extended posterior flap appears to prevent these potential morbidities by providing improved cushioning and comfort even for individuals who are capable of only limited activity. The encouraging results of this relatively simple modification support the well-accepted notion that an optimal residual limb should be composed of a sufficient osseous plat- form and a durable and cushioned soft- tissue envelope.当残肢大的骨表面区域覆盖有缓冲作用好的可移动肌肉团和全厚皮肤组成的耐久软组织包封时，经胫骨截肢术后荷重转移似乎增强了。通过长的后面的肌皮瓣的使用可以很好地实现这个渴望的结果。尽管事实是经胫骨截肢术中的标准的后面的皮瓣令大多数病人感到满意，但是皮瓣随时间的回缩可以导致残余胫骨远端部分的前面部分产生麻烦的压觉点。标准的经胫骨截肢技术，被Burges等推广，其手术切口经常直接位于残余胫骨以上。这增加了那部分胫骨皮肤产生粘连性疤痕的可能，或增加了承重期间该区域的不适当缓冲。当残余胫骨远端部分的前面没有被充分填补的时候，正常行走时残余肢体和假肢接受腔之间的正常活塞相关的局部不适感、起泡或组织破坏的可能性会增加。延伸的后面皮瓣似乎可以通过提供改善的缓冲来防止这些可能并发症和增加仅有有限活动病人的舒适感。这个相对简单的修改的令人鼓舞的结果支持了公认结果：理想假肢应当由一个有效的骨质平台和耐久的缓冲性软组织包封组成。The extended posterior flap is created by increasing the length of the standard posterior flap by several centi-meters (Figs. 5-A and 5-. The posterior myocutaneous flap is created and the osseous cuts are performed in the traditional manner. The myocutaneous flap is generally created from the gastrocnemius muscle and overlying skin, with removal of the soleus muscle belly in all but very thin patients. Care is taken in the handling of the transectednerves to avoid the development of sensitive, painful neuromas. It is advised to avoid clamping of the nerves prior to transection in order to avoid the pain so frequently encountered following crushing injuries. The nerves should be dissected proximal to the level of the bone transection, with use of gentle traction with a sponge, and then theyare transected with a fresh scalpel blade. This allows the inevitable terminal neuroma to be cushioned within bulky muscle. To avoid a bulbous stump, the posterior and lateral compartment muscles (except the gastrocnemius) should be transected at the level of the transected tibia. Anterior skin is re- moved to allow proximal attachment of the muscle flap and proximal placement of the wound scar. A myodesis of the posterior muscle flap to the tibia can be performed through drill holes. The posterior gastrocnemius fascia is secured to the transected anterior compartment fascia and tibial periosteum with horizontal mattress sutures (Figs. 6-A and6-. A rigid plaster dressing is applied, and prosthetic fitting is initiated when the residual limb appears capable of weight-bearing.延伸的后面皮瓣通过将标准后面皮瓣的长度增加几公分得到。后面的肌皮瓣和骨截断采用传统方式操作。肌皮瓣一般从腓肠肌和上面的皮肤来构建，除了非常瘦的病人外要移除比目鱼肌。谨慎处理切断的神经以避免敏感性的疼痛性神经瘤的发生。建议避免在横断神经前钳夹神经以避免压碎性损伤后如此常见的疼痛。神经应该在骨截断水平的近端横断，用海绵轻柔牵引，然后用新的手术刀片切断。这允许不可避免的末端神经瘤的产生，可在肌肉内缓冲。为了避免球根状残端，后面的和侧面的肌肉（除了腓肠肌）应该在胫骨横断水平横断。移除前面的皮肤从而允许肌肉瓣的近端附着和伤口疤痕的近端固定。后面的肌肉瓣的肌肉固可通过钻孔固定于胫骨。后面的腓肠肌筋膜水平褥式缝合于横断的前隔膜和胫骨骨外膜上。应用坚硬的石膏包扎，当残肢看起来能够承受重量时开始假肢的装配。Transfemoral (Above-the-Knee) Amputation经股（膝上）截肢术Transfemoral amputation is performed less frequently than in the past, but it is still necessary in some patients with severe vascular disease, a neoplasm, infection, or trauma in whom reconstruction at a more distal level is not feasible15,16. The energy expenditure for walking, even on a level surface, by an individual with a transfemoral amputation has been shown to be as much as 65% greater than that for similar, able-bodied individuals17,18. Energy expenditure can be minimized by a properly performed above-the-knee amputation.经股截肢术不如过去进行得频繁，但是它在一些患严重血管疾病、新生物、感染或创伤的病人中远端水平的重建不可行时仍是必需的。经股截肢术病人的行走甚至水准面的能量消耗已表明要比类似的健壮病人高65%之多。能量消耗可通过恰当的膝上截肢术最小化。The anatomical alignment of the lower limb has been well defined. The mechanical axis lies on a line from thecenter of the femoral head through the center of the knee to the center of the ankle. In normal two-limbed stance,this axis measures 3° from the vertical axis and the femoral shaft axis measures 9° from the vertical axis19. The femur is normally oriented in relative adduction, which allows the hip stabilizers (the gluteus medius and minimus) and abductors (the gluteus medius and the tensor fasciae latae) to act on it to reduce the lateral motion of the center of mass of the body, producing an energy- efficient gait (Fig. 7).下肢的解剖学排列已经被很好的确定。力轴位于从股骨头中心通过膝中心再到踝中心的线上。正常两腿姿态情况下，这个轴与垂直轴成3度角，股骨颈轴与垂直轴成9度角。股骨正常情况下定位于相对内收状态，这允许髋的稳定（臀中肌和臀小肌）和此基础之上的外展以减少身体质心的外侧移动，产生节能姿态。In most individuals who have undergone a transfemoral amputation, the mechanical and anatomical alignment is altered as a result of disruption of the adductor magnus insertion at the adductor tubercle and the distal part of the linea aspera. This allows the residual femur to drift into abduction as a result of the unopposed action of the hip abductors. Many patients who have undergone a transfemoral amputation encounter difficulties with prosthetic fitting due to inadequate muscle stabilization at the time of the amputation21. The unstable femur disrupts the relationship between the anatomical and mechanical axes of the limb. The abductor lurch, so common after transfemoral amputation, is a consequence of the unopposed action of the intact hip abductors. This dynamic deformity overcomes the capacity of even modern prostheses to compensate.大多进行经股截肢术的个体，由于收肌结节和粗线远端大收肌插入的中断导致了力学和解剖学排列的改变。这允许残余的股骨由于髋展肌的无抵抗作用而漂移外展。许多进行经股截肢术的病人由于截肢时没有足够的肌肉稳定导致在假肢安装时遇到了困难。不稳定的股骨使肢体的解剖学和力学轴间的关系被打破。外展肌倾斜在经股截肢术后如此常见，这是完整的髋外展肌的无抵抗作用的后果。这种动态畸形甚至超过了现代假肢所能代偿的能力。Traditional transfemoral amputation is done by suturing the femur flexors to the extensors—i.e., creating a myoplasty—while ignoring the adductors that contribute to stability of the residual femur22. When the adductors are not anchored to bone, the hip abductors are able to act unopposed, producing a dynamic flexion-abduction deformity. This deformity prepositions the femur in an orientation that is not conducive to efficient walking. The retracted adductor muscles lead to a poorly cushioning soft-tissue envelope, further complicating prosthetic fitting.传统的经股截肢术中是将股骨屈肌缝合到伸肌上-即构建肌成形术-而忽略对有助于残存股骨稳定性的内收肌。当内收肌没有锚定于骨时，髋外展肌能够无对抗地作用，产生动态的弯曲-外展畸形。这种畸形使得股骨向一种不利于有效行走的方向发展。内收肌群导致了缓冲作用差的软组织包封，进一步使得假肢的安装复杂化。The cross-sectional area of the adductor magnus is three to four times larger than that of the adductor longus and brevis combined. It has a moment arm with the best mechanical advantage. Transection of the adductor magnus at the time of amputation leads to substantial loss of cross-sectional area, a reduction in the effective moment arm, and loss of up to 70% of the adductor pull20,25. This results in overall weakness of the adductor force of the thigh and subsequent abduction of the residual femur (Fig. 7). The decrease in overall limb strength is due to (1) a reduction in muscle mass at the time of the amputation, (2) inadequate mechanical fixation of the remaining muscles, and (3) and atrophy of the remaining muscles. 大收肌的横断面积比长收肌和短收肌联合起来还要大3-4倍。它有着最好机械效益的力臂。截肢术时大收肌的横断导致了横断面积丢失，有效力臂减小，内收肌拉力丢失高达70%。这导致了大腿内收肌力量的总体减弱和随后的残存股骨的外展。总的肢体力量的降低是由于：1）截肢时肌肉块的减少；2）剩余肌肉的不充分机械固定；3）剩余肌肉的萎缩。Magnetic resonance imaging has demonstrated a 40% to 60% decrease in muscle bulk after a traumatic transfemoral amputation. Most of the atrophy is in the adductor and hamstring muscles, whereas the intact hip abductors and flexors show smaller changes, ranging from 0% to 30(,29. As much as 70% atrophy of the adductor magnus has been found. The amount of atrophy correlates with the length of the residual limb, and this atrophy is most likely due to loss of the muscle insertion.磁共振成像发现在创伤性经股截肢术后肌肉容量下降了40%-60%。大部分萎缩是在内收肌和腿后肌，而完整的髋外展肌和屈肌显示出改变较小，变化范围从0%-30%不等。大收肌被发现有高达70%的萎缩。萎缩的数量和残肢的长度相关，这种萎缩很大可能是由于肌肉插入的丢失。Electromyographic studies of residual limbs following transfemoral amputation have revealed normal muscle phasic activity; however, the active period of the retained muscles appears to be prolonged29. The electrical activity of sectioned muscles varies, depending on whether the muscles have been reanchored and on the length of the residual femur. Furthermore, asymmetric gait has been related to residual limb length, and lateral bending of the trunk has been correlated directly with atrophy of the hip stabilizing muscles.经股截肢术后残肢的肌电图描记研究揭示了正常肌肉形势活性；然而，保留的肌肉的活跃周期似乎延长了。切开的肌肉的电活性不同，取决于肌肉是否被重新锚定和残存股骨的长度。此外，不对称步态也和残肢长度相关，躯体的侧弯和髋的稳定性肌肉直接相关。All of these findings indicate the need to preserve the hip adductors and hamstrings. Preservation of a functional adductor magnus helps to maintain the muscle balance between the adductors and abductors by allowing the adductor magnus to maintain its power and retain the mechanical advantage for positioning the femur. Preservation is best accomplished with a myodesis. The patient is positioned supine with a sandbag under the buttocks to avoid performing the myodesis with the hip in a flexed position thus producing an iatrogenic hip flexion contracture. A tourniquet is generally not necessary for patients with peripheral vascular disease. Depending on the size of the patient, a standard, or a sterile, tourniquet can be used when the transfemoral amputation is being performed because of a traumatic injury or a tumor and normal femoral vessels can be expected.所有这些发现都表明了需要保留髋内收肌和腘绳肌腱。功能性大收肌的保留可通过允许大收肌维持它的力量和保持定位股骨的机械效益来帮助维持内收肌和外展肌之间的肌肉平衡。通过肌固定术可很好的实现保留。病人仰卧，臀下垫沙袋，这样可以避免在髋屈曲位时进行肌固定术并进而产生医源性髋屈曲性挛缩。对外周血管基本能够的病人来说止血带通常是必须的。进行经股截肢术时需根据病人的大小使用标准的无菌止血带，因为可能会碰到创伤性损伤或肿瘤和正常股血管。Equal anterior and posterior flaps should be avoided, as such flaps place the suture line under the end of the residual limb, making prosthetic fitting more difficult and adequate muscular padding less likely. A long medial-based myofasciocutaneous flap is dependent on the vascular supply from the obturator artery, which generally has less severe vascular disease and is thus preferred (Figs. 8-A and 8-31. The flap configuration may need to be modified, in order to preserve residual limb length, when an amputation is done after trauma or because of neoplastic disease. The tendon of the adductor magnus is detached. The femoral vessels are identified in Hunter’s canal and are ligated. The major nerves should be dissected 2 to 4 cm proximal to the proposed bone cut, gently retracted, and sectioned with a new sharp blade. The quadriceps is detached just proximal to the patella, with retention of some of its tendinous portion. The smaller muscles, including the sartorius and gracilis and the more posterior group of hamstrings (biceps femoris, semitendinosus, and semimembranosus) should be transected 2 to 2.5 cm longer than the proposed bone cut to facilitate the anchoring of those muscles in bone.应该避免前后皮瓣相等，因为这样的皮瓣将缝线固定在残肢末端下面，会使得假肢的安装更困难，并使足够的肌肉填充的可能性更小。长的内侧为基础的肌筋膜皮瓣，其血供依赖于闭孔动脉，通常有不严重的血管疾病，因此可更愿选择。当创伤后进行截肢或因为肿瘤性疾病时，皮瓣的形态可能需要修整，以便维持残肢长度。大收肌肌腱被离断。识别出Hunter’s管里的股血管并结扎。主要的神经应该在计划的骨切口近端2-4cm处切断，轻柔的牵引并用新的锋利刀片切断。在髌骨近端切断四头肌，保留一些肌腱部分。较小的肌肉包括缝匠肌和股薄肌和更后面的腘绳肌腱群（股二头肌，半腱肌和半膜肌）应该比计划的骨切口长2-2.5cm，以使这些肌肉易于锚定于骨头上。The femur is then transected with an oscillating power saw 12 to 14 cm proximal to the knee joint to allow sufficient space for the prosthetic knee joint. Drill-holes are made in the distal end of the femur to anchor the transected muscles. The adductor magnus is attached to the lateral cortex of the femur while the femur is held in maximum adduction. This allows appropriate tensioning of the anchored muscle. The hip is positioned in extension for reattachment of the quadriceps to the posterior part of the femur, and the remaining hamstrings are anchored to the posterior area of the adductor magnus or the quadriceps.然后用震荡的动力锯在膝关节近端12-14cm处横断股骨，以使得假膝关节有足够的空间。在股骨远端钻孔以锚定横断的肌肉。在股骨处于最大内收情况下将大收肌附着于股骨的外侧皮质。这是的锚定的肌肉能够进行适当的张力调整。髋置于伸展位，将四头肌附着于股骨后面部分，剩余的腘绳肌腱锚定于大收肌或四头肌的后面区域。Postoperative Care术后护理A soft compression dressing with a “mini-spica” wrap above the pelvis is used in the early postoperative period. Because the residual limb is relatively short, it is difficult to maintain a rigid plaster dressing. Range-of-motion exercises and early walking are encouraged. Preparatory prosthetic fitting can be initiated as soon as the residuallimb appears capable of accepting the load associated with weight-bearing.This varies with individual patients and the experience of the rehabilitation team.术后早期采用迷你人字形围巾软加压包扎骨盆以上。因为残肢相对较短，很难维持住坚硬的石膏包扎。鼓励活动锻炼和早期行走。当残肢能够接受承重相关的荷重时即可开始准备安装假肢。这随不同的个体病人和康复综合小组的经验而不同。Overview概述In conclusion, an amputation should be considered the first step in the rehabilitation of a patient for whom reconstruction of a functional limb is not possible. Care should be taken to create a residual limb that can optimally interact with a prosthetic socket to create a residual limb-prosthetic socket relationship capable of substituting for the highly adaptive end organ of weight-bearing. A well-motivated patient in whom the amputation is done well and who is taught how to use the prosthesis will be able to return to most activities.总之，对于功能性肢体重建不可能的病人进行康复治疗，应当首先考虑截肢术。应当注意创建能够和假肢接受腔理想地作用的残肢，来创建能够替代承重终末器官的高度适合的残肢-假肢接受腔关系。对于很好的诱导的病人，如果截肢术做的漂亮，并教会其如何使用假肢，那么病人将能够回到大多数活动中来。