JBJS：牵引投照X线图像分析显著影响桡骨远端骨折的诊断和治疗选择

最近，美国马里兰大学医学院骨科及R Adams Cowley创伤急救中心的Elan Goldwyn, MD等对该中心所有桡骨远端骨折石膏固定前牵引下投照的X线图像资料进行了回顾分析，他们的研究论文被发表在近期出版的J Bone Joint Surg Am上。经研究发现，在牵引下投照的桡骨远端骨折标准X线片可以提高损伤分析的可靠性和可重复性，且会对患者的治疗计划产生影响，一定程度上还可以减少患者接受进一步CT检查的需要。研究者认为，之前尽管有较多的研究对桡骨远端骨折的X线投照方式，但涉及牵引下X线图像分析的研究尚未见相关报道，因此，该研究结果可为临床医生诊断和处理相关病例提供一种新思路。

在该研究中，共有50例桡骨远端骨折患者的X线图像资料符合纳入条件，纳入研究的患者均在患者所在的创伤中心接受治疗。通过整理、分析患者的X线图像资料，建立2个图像文件集，一个文件集为损伤时和石膏固定后的X线图像，在该文件集的基础之上附加牵引下投照的X线图像，进而建立第二个文件集。文件集中删除了患者的所有人口统计学相关数据，然后随机由7位经过专业培训的骨科医生对X线片图像进行分析。每位医生均独立地对100个文件集中每一图像分析完成后，回答与损伤特点及其治疗相关的10个问题。采用kappa值统计分析图像分析的可重复性，采用McNemar检验评估观察者分析结果的可靠性。

研究结果显示，牵引投照X线片可显着改善10项问题中4项问题的可重复性。对于观察者分析结果的可靠性，2项问题的分析结果会发生显着改变。附加牵引下X线片图像后，关节内骨折认为需要复位的病例由38.3%增加到53.1% (p < 0.05)，认为需要进一步实施CT评估的病例由21.7%减少到5.1%(p < 0.001)。在其他评估指标方面，附加牵引投照X线图像未见显着影响。

该研究的数据分析结果表明，在桡骨远端骨折的损伤评估中，附加牵引投照X线图像会影响临床医生图像分析的可重复性。另外，牵引投照X线图像会使需要复位的关节内骨折和实施CT检查的检测率发生变化。作者认为，在桡骨远端骨折的损伤评估中，附加牵引投照X线图像在某种程度上可提供与CT扫描检查一致的信息，但患者的花费更低；进一步研究需要比较牵引投照X线图像与CT扫描图像在桡骨远端骨折损伤分析中作用。

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Outcomes of operative treatment of unstable ankle fractures: a comparison of metallic and biodegradable implants.
BACKGROUND
Biodegradable implants for internal fixation of ankle fractures may overcome some disadvantages of metallic implants, such as imaging interference and the potential need for additional surgery to remove the implants. The purpose of this study was to evaluate the outcomes after fixation of ankle fractures with biodegradable implants compared with metallic implants.
METHODS
In this prospectively randomized study, 109 subjects with an ankle fracture underwent surgery with metallic (Group I) or biodegradable implants (Group II). Radiographic results were assessed by the criteria of the Klossner classification system and time to bone union. Clinical results were assessed with use of the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, Short Musculoskeletal Function Assessment (SMFA) dysfunction index, and the SMFA bother index at three, six, and twelve months after surgery.
RESULTS
One hundred and two subjects completed the study. At a mean of 19.7 months, there were no differences in reduction quality between the groups. The mean operative time was 30.2 minutes in Group I and 56.4 minutes in Group II (p < 0.001). The mean time to bone union was 15.8 weeks in Group I and 17.6 weeks in Group II (p = 0.002). The mean AOFAS score was 87.5 points in Group I and 84.3 points in Group II at twelve months after surgery (p = 0.004). The mean SMFA dysfunction index was 8.7 points in Group I and 10.5 points in Group II at twelve months after surgery (p = 0.060). The mean SMFA bother index averaged 3.3 points in Group I and 4.6 points in Group II at twelve months after surgery (p = 0.052). No difference existed between the groups with regard to clinical outcomes for the subjects with an isolated lateral malleolar fracture.
CONCLUSIONS
The outcomes after fixation of bimalleolar ankle fractures with biodegradable implants were inferior to those after fixation with metallic implants in terms of the score on the AOFAS scale and time to bone union. However, the difference in the final AOFAS score between the groups may not be clinically important. The outcomes associated with the use of biodegradable implants for the fixation of isolated lateral malleolar fractures were comparable with those for metallic implants.