为豁达临床医师视线，提供表面水仁和鉴戒临床陶冶，今后将不时推出在读战友和临床感酷好的战友诓骗业余时期创作的JBJS、spine等杂志的中英文对照稿供专家参阅抚玩。感谢忘我奉献的战友！战友的成长离不开您劳苦的汗水向忘我奉献的战友致意！！期待更多的战友参与行为一、法则：1、 欢快参与翻译使命的战友，请以回帖步地央求具体翻译的部分 ，为幸免类似翻译，以每个主题加予序号（1、2、3....）为单元的步地认领 a、（每位战友每月限领1－2个专题，以收缩使命量，也给其他战友积极参与的契机）b、类似翻译者（未跟贴认领，导致其他战友类似翻译）未跟贴者无积分奖励。c、已经认领的炫夸为 红色尚未认领的炫夸为 玄色 认领翻译文件请到这里：2、 如对文中翻译不明处，请用蓝色字体标出，并接待其他战友校验、解答。3、译文发贴口头：主题：主题执行红色原文玄色译文蓝色4 、版权声明：本译文翰墨执行归网站（>3、翻译小组成员：感酷好说到作念到者即可参与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实时完成使命，请提前pm版主，以便作出相应安排。三、积分奖励机制：（试行）1、选录一篇，奖励1分；全文一篇奖励3分2、校验使命，选录每1贴次1分，全文每1贴次3分。17 A Comparison of the Results of Total Hip　and Knee Arthroplasty Performed on a　Teaching Service or a Private Practice Service有无教学参与的全髋、膝要害置换放手的比较Background: Active participation of residents and fellows in the performance of total hip and total knee arthroplastiesmay affect the outcomes of these procedures. We evaluated the early clinical results and complications associatedwith primary total hip and knee arthroplasties at a hospital that had both university teaching and private practiceorthopaedic services. 布景：入院医师过多的参与全髋、膝东谈主工要害置换可能会影响疗效。本酌量对兼并病院中有无教学参与的初度全髋、膝要害置换的早期临床放手和并发症进行比较。Methods: We performed a retrospective study on a consecutive series of 347 patients who had undergone 230 totalhip and 171 total knee procedures performed by one attending surgeon. One hundred and sixty-nine patients underwentan arthroplasty during which a resident or fellow on a teaching service assisted the attending surgeon; duringthese procedures， the resident or fellow performed part of the arthroplasty under the direct supervision of the attendingsurgeon. Subsequently， 178 patients underwent an arthroplasty performed by the same surgeon without residentor fellow participation. 要领：对通达347名东谈主工要害置换病东谈主进行了记忆性酌量，其中包括230例全髋要害和171例全膝要害，王人由兼并名主治医师完成。有169例要害在置换经由中，部分操作在该主治医师的指导下由入院医师完成。随后的178例病东谈主要害置换沿途由兼并名主治医师完成，莫得入院医师参与。Results: Significantly longer operative times were recorded for both total hip arthroplasty (average， seventy-threecompared with sixty-one minutes; p < 0.0001) and total knee arthroplasty (average， eighty compared with seventythreeminutes; p = 0.0028) when the procedures were performed with the participation of residents or fellows. For totalhip arthroplasty the complication rates were 8% for the teaching service and 10% for the private practice service，and for total knee arthroplasty they were 3% for each service. With the numbers studied， there were no differences inany clinical outcomes between the groups. 放手：当有入院医师参与时，手术时期有昭着增多，全髋要害置换平均由61分钟增多到73分钟（ｐ<0.0001），全膝要害置换时期由73分钟增多到80分钟（ｐ＝0.0028）。有入院医师参与时91porn app，全髋要害置换并发症发生率为8％91porn app，莫得者发病率为10％。而全膝要害置换的并发症发病率王人为3％。凭证数据的分析91porn app，两者的临床放手莫得各别。Conclusions: Teaching and active participation from residents and fellows during total hip and total knee arthroplastydid not have a detrimental effect on the early clinical results， except for a longer surgical time.论断：教学和入院医师的参与，除了手术时期增多外，对全髋要害和全膝要害置换的早期临床放手并莫得不良影响。19 Results of Polyaxial Locked-Plate　Fixation of Periarticular Fractures of the Knee多轴锁定钢板调治膝要害周围骨折的放手Background: Locked-plate fracture-fixation techniques and designs continue to evolve. Polyaxial locking plates thatallow screw angulation and end-point locking have become available; however， there are no clinical data documentingtheir strength and efficacy， to our knowledge. The purpose of this study was to evaluate the clinical performance of avariable-axis locking plate in a multicenter series of periarticular fractures about the knee.布景：锁定钢板固定本事和想象在不断完善。多轴锁定钢板允许螺钉成角和结尾锁定，然则据咱们所知尚无临床数据阐述它们的强度和作用。本酌量通过多中心对使用可调轴向锁定钢板调治膝要害周围骨折的放手进行酌量，来评估其临床服从。Methods: Between 2003 and 2005， fifty-four patients with a total of fifty-six fractures were treated with a polyaxiallocked-plate fixation system (DePuy， Warsaw， Indiana). There were twenty male patients and thirty-four female patientswith a mean age of fifty-seven years. There were twenty-five distal femoral fractures and thirty-one proximal tibial fractures.Twelve of the fractures were open. Clinical and radiographic data， including changes in alignment， hardware breakage，or other mechanical complications of the device， were retrospectively reviewed. Function was assessed with use ofthe Knee Society scores. One patient with a bilateral fracture died less than three months postoperatively， and two patientswere lost to follow-up prior to union. Fifty-two fractures in fifty-one patients were followed to union or for a minimumof six months; the mean duration of follow-up was nine months (range， six to twenty-five months).要领：在2003到2005年间，有54个病东谈主系数56例骨折使用多轴锁定钢板固定系统进行固定（Depuy，Warsaw，Indiana）。其中包括男性20名，女性34名，平均年事57岁。25例为股骨远端骨折，31例为胫骨近端骨折。有12例为怒放性骨折。对这些病例的临床和影像学府上，包括力线改变，内固定断裂和其他的内固定力学并发症等，进行记忆性分析。功能评分汲取膝要害学会评分。其中一例双侧骨折病东谈主在术后三月内去世，另有两例病东谈主在骨折愈合前失访。51名病东谈主（52例骨折）随访至骨折愈合，或者至少6个月。平均随访时期为9个月（6-25月）。Results: Forty-nine (94%) of the fifty-two fractures united. There were no mechanical complications. Most importantly，there was no evidence of varus collapse as a result of polyaxial screw failure. There were three deep infections andone aseptic nonunion. No plate fractured， and no screw cut out.放手：52例骨折中有49例（94%）愈合，莫得机械性并发症。最紧迫的是，莫得1例有预示多轴固定系统失败的内翻塌陷出现。有3例出现深部感染，1例无菌性不愈合。莫得钢板断裂和螺钉切割。Conclusions: The variable-axis locking plates performed well， with a high rate of fracture union and no evidence ofvarus collapse due to failure of the polyaxial screw fixation， in a series of complex fractures about the knee. Complicationrates were similar to those for historical controls treated with fixed-trajectory locking plates. Polyaxial lockingplates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction.论断：可调轴向锁定钢板固定服从纯粹，在调治一系列膝要害复杂骨折中，骨折愈合率高，莫得出现钢板失败所出现的内翻塌陷。并发症发生率类似于使用固定轨谈锁定钢板的病例对照。多轴锁定钢板不错提供更多的固定聘用，而没增多机械性并发症或者出现复位丢失。Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation股骨粗隆间髋部骨折股骨外侧壁完好性：二次手术紧迫的展望因子 Abstract Background: Reoperations after intertrochanteric fractures are often necessitated by fracture displacement following mobilization of the patient. The biomechanical complexity of the fracture， the position of the implant， and the patient's characteristics are known to influence postoperative outcome. We investigated the importance of an intact lateral femoral wall as a factor in postoperative fracture displacement after fixation with a sliding compression hip screw. 酌量布景：股骨粗隆间骨折的患者，行为后骨折移位往往不得不进行二次手术。咱们知谈，该骨折生物力学上的复杂性、内植物的位置以及患者的特征影响入辖下手术后的放手。咱们访谒了滑动加压髋螺钉固定后，完好的股骨外侧壁作为术后骨折移位的一个（影响）要素的紧迫性。Methods: Two hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135° sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters， the integrity of the lateral femoral wall， and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively. 要领：2002年至2004年间，214例通达的股骨粗隆间骨折患者都用4孔（侧面钢板）135°滑动加压髋螺钉进行处理。参考AO/OTA分类系统按术前X线片对骨折进行分类。手术后对大小粗隆的现象、股骨外侧壁的完好性和内固定物的位置进行评价。术后6个月内对由于本事失败而进行的再次手术进行纪录。Results: Only 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months， whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1， A1.2， A1.3， or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001). 放手：股骨外侧壁完好的168例患者中仅有3%（5例）术后6个月内进行了再次手术，而46例波及股骨外侧壁骨折的患者中有22%（10例）进行了再次手术(p < 0.001)。多元Logistic记忆分析招引东谈主口统计和生物力学参数炫夸：股骨外侧壁受累对于再次手术是一个紧迫的展望因子(p = 0.010)。46例中的74%（34例）是在手术经由中股骨外侧壁自身发生了骨折。在103例AO/OTA分型31-A1.1、A1.2、A1.3或 A2.1的股骨粗隆间骨折中仅有3%存在股骨外侧壁骨折，与之比较，99例AO/OTA分型31-A2.2或 A2.3骨折中31%（31例）存在这一骨折 (p < 0.001)。Conclusions: A postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently， we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device， and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall， especially in randomized trials comparing fracture implants. 论断：股骨粗隆间骨折后，咱们发现手术后存在股骨外侧壁骨折是再次手术的一个主要的展望因子，咱们推测，手术前或手术中股骨外侧壁骨折的患者应用滑动加压髋螺钉安装进行处理是不允洽的，何况，股骨粗隆间骨折的分类因此也应该凭证其股骨外侧壁的完好性，尤其是对骨折内固定物进行比较酌量的当场化历练。Level of Evidence: Prognostic LevelⅡ. See Instructions to Authors for a complete description of levels of evidence. 真正度水平：展望类Ⅱ级。对于真正度水平的完好叙述可参考投稿应知。Heterotopic Ossification Following Traumatic and Combat-Related Amputations创伤及战伤相关截肢所致异位骨化________________________________________Background: Although infrequently reported in amputees previously， heterotopic ossification has proven to be a common and problematic clinical entity in our recent experience in the treatment of traumatic and combat-related amputations related to Operation Enduring Freedom and Operation Iraqi Freedom. The purpose of the present study was to report the prevalence of and risk factors for heterotopic ossification following trauma-related amputation as well as the preliminary results of operative excision.布景：天然先前并莫得往往报导，咱们最近在处理peration Enduring Freedom和Operation Iraqi Freedom创伤及战伤相关截肢病例的陶冶标明，异位骨化是一个常见何况辱骂常贫困的一个事件。本次酌量的缱绻，就是报到创伤相关限度所致异位骨化的发生率和危急要素，以及手术取出后的预后。 Methods: We identified 330 patients with a total of 373 traumatic and combat-related amputations who had been managed at our centers between September 11， 2001 and November 30， 2005. We reviewed the medical records and radiographs of 187 patients with 213 amputations who had adequate radiographic follow-up. Additional analysis was performed for twenty-four patients with twenty-five limbs that required excision of symptomatic lesions. The mechanism and zone of injury， amputation level， timing of excision， use of prophylaxis against recurrence， and other confounding variables were examined. Outcomes were assessed by determining clinical and radiographic recurrence rates， perioperative complications， preoperative and follow-up pain medication requirements， and the ability to be fit with a functional prosthesis.要领：咱们在373名在2001年9月11日至2005年11月30日之间曾于我中心就诊的创伤和战伤所致截肢患者中找出了330个合适的案例。咱们温习记忆了187名接受了足够的反射影像随访的患者的213例截肢案例的临床纪录以及影像学府上。何况对其中的需要典型病灶切除的24名患者的25个肢体进行了额外的分析。同期咱们对于其发祈望制、毁伤范围、截肢进度、取出术的时期、防御复发的留神措施以颠倒他的变量要素都进行了测定。通过详情临床和影像学复发率、围手术期并发症、术前和随访时间麻醉剂使用以及患者对假肢的适当才调，咱们得到了酌量的放手。 Results: Heterotopic ossification was present in 134 (63%) of 213 residual limbs， with twenty-five lesions requiring excision. A final amputation level within the zone of injury was a risk factor for both the development and the grade of heterotopic ossification (p < 0.05). A blast mechanism was predictive of occurrence (p < 0.05) but did not correlate with grade. All patients who had been managed with excision were tolerating the prosthetic limb at an average of twelve months of follow-up. Twenty-three limbs demonstrated no evidence of recurrence， and two limbs had development of clinically asymptomatic， radiographically minimal recurrences. Six patients experienced wound-related complications that required reoperation， and two patients required subsequent minor revision surgery. There was a significant decrease in the use of pain medication following surgery (p < 0.05).放手：在136个患者(63%)的213个残肢中出现了异位骨化，其中有25个病灶需要摘除。对异位骨化的进度和发展情况而言，在受损区域的最终截肢进度是一个紧迫的危急要素(p < 0.05)。发祈望制不错展望发生(p < 0.05)，然则和品级没接洽联。系数接受摘除术的病东谈主在平均随访12个月后都对假肢耐受了。23个肢体少量也莫得复发的局面，而另外2个肢体出现了临床不典型、影像学性的小复发。6个病东谈主出现了创伤相关并发症何况需要再次手术，而另外2个病东谈主需要小的改进手术。手术后麻醉剂的使用也有了权臣的减少(p < 0.05)。 Conclusions: Heterotopic ossification following trauma-related amputation is more common than the literature would suggest， particularly following amputations that are performed within the initial zone of injury and those that are due to blast injuries. Many patients are asymptomatic or can be successfully managed with modification of the prosthesis. For patients with refractory symptoms， surgical excision is associated with low recurrence rates and decreased medication requirements， with acceptable complication rates.论断：创伤相关截肢导致的异位骨化比文件报谈要常见得多，迥殊对那些在原发毁伤部位截肢以及冲击波毁伤而言。许多病东谈主都阐扬不典型，或者不错通过假肢的调整来告捷地限度。对于出现矍铄性症状的病东谈主而言，手术摘除不错带来低复发率、权臣减少的麻醉剂用量以及不错接受的并发症发生率。 Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand Population新西兰东谈主群使用Ponseti要领后早期乖谬足复发情况 ________________________________________Background: Nonoperative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. The purpose of the current study was to examine the early rate of clubfoot recurrence following the use of the Ponseti treatment method in a New Zealand population and to analyze patient characteristics to identify factors predictive of recurrence.布景：作为一种基本的调治要领圭臬，非手术调治典型乖谬足已经谢天下范围内越来被专家所接受。在北好意思，尤其是Ponseti要领被报谈以为无论在短期如故恒久疗效方面都取得了很大的告捷。当前咱们的酌量的缱绻就在于在新西兰东谈主群中测定使用Ponseti处理后乖谬足的复发率，何况同期分析病东谈主的本性从而找出不错展望复发的象征因子。 Methods: Fifty-one consecutive babies with a total of seventy-three clubfeet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence， defined as the need for any subsequent operative treatment， was analyzed with respect to the severity at presentation， the time of presentation， the number of casts needed to obtain the initial correction， any family history of clubfoot， ethnicity， and the compliance with postcorrection abduction bracing. Recurrence was classified as minor， defined as requiring a tendon transfer or an Achilles tendon lengthening， or major， defined as requiring a full posterior or posteromedial surgical release to achieve a corrected plantigrade foot.要领：咱们前瞻性地随访了51个患有73例乖谬足何况同期接受了Ponseti要领调治的通达的婴儿患者，每个患儿在脱手调治后，至少随访了2年。咱们仔细分析了作为需要接受另外手术处理的象征的复发情况，主要包括症状出现的严重情况、症状出现的时期、达到运转矫正疗效的处理的次数、乖谬足的家眷史、种族倾向以及矫正后的伸展器械使用情况等几个方面。在复发的分型上，若是患者需要肌腱移植或者是Achilles肌腱强化，则界说为小复发；若是需要透顶的后路或者后中路手术减压才调达到透顶矫正，则称为大复发。 Results: Twenty-one (41%) of the fifty-one patients had a recurrence， which was major in twelve of them and minor in nine. The parents of twenty-six babies (51%) complied with the abduction bracing protocol， and only three of these children had a major recurrence. Compliance with abduction bracing was associated with the greatest risk reduction for recurrence (odds ratio， 0.2; p = 0.009). When the parents had not complied with the bracing protocol， the patient had a five times greater chance of having a recurrence. With the numbers studied， no significant relationships were found between recurrence and the severity at presentation， the time of presentation， the number of casts needed to obtain correction， ethnicity， or a family history of clubfoot.放手：在51例患者中，有21例（41％）出现了复发，其中有12例是大复发，有9例为小复发。在26例父母使用了伸掌器械的患儿中，唯一3例出现了大复发。对伸展器械的顺应性是导致复发的最紧迫的危急因子（上风比：0。2，p＝0.009）。而对于父母莫得使用伸展器械的患儿，出现复发的比例是前者的5倍。通过酌量所得的数据，咱们莫得发现复发与症状的严重进度、症状的握续时期、需要矫正所作念处理的次数、种族以及乖谬足的家眷史有昭着的关联。 Conclusions: Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. When the parents comply with the bracing protocol， the Ponseti method is very effective at maintaining a correction， although minor recurrences are still common. When the parents do not comply with the bracing protocol， many major and minor recurrences should be expected. 论断：对于接受Ponseti要领处理的乖谬足患儿，其对于矫正后伸展器械的顺应性是最紧迫的要素。当使用伸展器械时，天然还会有小的复发，但Ponseti要领如故被解说辱骂常灵验的。若是父母不使用伸展器械，则会使患儿出现如此这般的许多小复发和大复发。 Bone Graft Substitutes: Separating Fact from Fiction骨移植替代物：让事实隔离思象Although great advances have been made in fracture care， treatment failures are not uncommon. Highenergy injuries that result in bone devitalization， or open fractures that are associated with bone loss， can be followed by postoperative infection or， if treated with inadequate methods， may result in the development of a pseudarthrosis.These complex problems require much care before healing can occur. Since the development and use of stainless steel in orthopaedics in the 1920s， surgeons have tried to use advances in metallurgy and implant design to assist fracture-healing. Nails were improved with locking technology， while simple plates were transformed into blade plates， compression plates， and now locking plates. External fixation was revolutionized by G. Ilizarov with the development of distraction osteogenesis. Stainless steel itself was altered to create vanadium， Vitallium， and now titanium alloys. While all of these techniques have decreased the rate of nonunion， they have not completely solved the problem because there are limits to what metal can do to affect the biology of fracture-healing.尽管骨折的调治已经取得了伟大的卓绝，但调治的失败却并不生僻。高能量毁伤导致骨失活，以及怒放性骨折合并骨丢失，不错继发术后感染，或者若是汲取不稳健的要领调治，会导致假要害酿成。这些复杂的问题在愈合之前需要更多的热心。自从1920年代不锈钢开发并用于骨科，医师们脱手尝试诓骗冶真金不怕火本事和内固定想象方面的卓绝来促进骨折愈合。钢钉被改进成为带有锁钉本事的，而肤浅的钢板也被改进为接骨板、加压接骨板以及当前的锁定钢板。外固定架被G. Ilizarov调动为具有牵张成骨功能的。不锈钢自己也被调整为钒、铝以及当前的钛合金。尽管系数这些本事已经减少了骨不联，但并莫得透顶处分问题，因为金属对于骨折愈合的生物学的影响有限。Although the biologic approach to fracture-healing seems intuitive， surgeons have had limited options for decades. An ideal bone-graft substitute must provide scaffolding for osteoconduction， growth factors for osteoinduction， and progenitor cells for osteogenesis. Autologous bone-grafting was described by Fred Albee in 19151. Bone-grafting requires additional surgery， can be painful， and is not without complications. Although Albee also described the use of calcium phosphates as an alternative to bone in the 1920s， it was not until 1965， when Marshall Urist identified “bone formation by autoinduction”2， that new options unfolded. Twenty-three years later， Wozney et al.3 and Luyten et al.4 discovered the proteins responsible for this phenomenon， BMPs-2， 3， and 4. Today these proteins can be harvested from a variety of bonesources or synthesized through recombinant gene therapy， and they are available to the practicing orthopaedist.尽管骨折愈合的生物学措施似乎是直观上的，但几十年来医师们尚有一些有限的聘用。一个理思的骨移植替代材料必须提供骨传导支架、骨引导性滋长因子及具有成骨活性的祖细胞。自体骨移植曾被Fred Albee于1915年说明过。但骨移植需要额外的手术，可能会增多祸殃，而且不成排斥并发症。尽管Albee曾经在1920年代提议过使用硫酸钙作为骨的替代品，但直到1965年Marshall Urist详情了“自身引导的成骨”，新的聘用展当前了咱们的眼前。23年后Wozney小组及Luyten小组发现了引起这一繁荣的卵白BMPs-2、 3和4。当前这些卵白不错通过不同的骨资源获取，或者通过重组基因的要领来合成，当前已应用于骨科临床。There has been an explosion of commercial products for the orthopaedic surgeon to choose from. Calcium phosphate ceramics， calcium sulfate， bioactive glass， biodegradable polymers， and recombinant human BMPs (OP-1 and BMP-2) areall offered as solutions to the problem of bone-healing. While the actions of each product can be confusing， suggested combination therapy can be simply baffling， especially when there are few objective scientific data. Hospital administrators are equally perplexed， particularly by the costs of these products， and in many cases they refuse to allow the surgeon to use them even though they are thought to be useful.对于骨科医师来说，当前可选的商用产物已经有了大限制的激增。磷酸钙陶瓷、硫酸钙、生物活性玻璃、可生物降解团聚物以及重组东谈主BMP(OP-1和BMP-2)都被用作骨愈合问题的处分决策。然则每一种产物的作用可能会令东谈主狐疑，这标明招引调治可能会是种肤浅的防碍，迥殊是当穷乏客不雅的科学数据时。医学行政管理东谈主员也一样感到困惑，迥殊是对于这些产物的价钱，在许厚情况下他们会断绝医师使用这些产物即即是这些产物被以为是有用的。This issue is of critical importance to the orthopaedic surgeon involved in fracture care and treatment of nonunions. As the leaders in fracture care in North America， the Orthopaedic Trauma Association has responded by charging a committee under the leadership of Dr. William De Long to generate a white paper to more clearly identify the issues surrounding these products and their use. This initial report was expanded into the Current Concepts Review5 in this issue of The Journal to offer the information to the general orthopaedic community. It is hoped that， after reading this review， surgeons will be better able to make decisions based on sound scientific principles and to understand the limitations as well as the benefits of these commercially available bone-graft substitutes. In the end， it is the responsibility of the physician to prescribe the correct treatment for the patient， and that decision must be made on the basis of fact， not fiction.这一问题对于从事骨折调治和骨不联处理的骨科医师具接洽键性的紧迫道理。作为北好意思骨折调治方面的带领者，骨科创伤协会已经任命了一个以Dr. William De Long带领的委员会以产生一个白皮书，从而梗概清醒的差别对于这些产物及它们的使用中产生的问题。这一初期的答复在本期杂志的Current Concepts Review部分进一步得到拓展从而为通盘骨科界提供信息。但愿通过阅读这篇综述，医师们梗概以可靠的科学原则作为依据更好的作念出决定，同期梗概更好的会互市用骨移植替代产物的局限及上风。临了，为患者提供正确的调治是医师的包袱，而所作念出的决定必须是以事实为依据的，而不是思象。作家：Roy Sanders， MDPast President， Orthopaedic Trauma AssociationTampa， FloridaFresh Stored Allografts for the Treatment of Osteochondral Defects of the Knee簇新冻存同种异体骨调治膝要害骨软骨缺损Background: Osteochondral allograft reconstruction of articular cartilage defects is a well-established cartilage repair strategy. Currently， fresh osteochondral allograft tissue is commercially available to clinicians approximately thirty days following graft harvest. Little clinical information is available on the outcome of patients who have been treated with fresh allografts stored for several weeks or more. The purpose of this study was to prospectively analyze the clinical outcome and graft morphology of patients who received fresh， hypothermically stored， allograft tissue for the treatment of symptomatic chondral and osteochondral defects of the knee. 酌量布景：骨软骨同种异体骨重建要害软骨缺损是一个建树要害面软骨很好的要领。当前，不错通过交易道路得回的簇新骨软骨同种异体骨组织从采选标本到应用到临床约30天时期。但当前得回的对于接受冻存几个星期或更永劫期的簇新同种异体骨调治的病东谈主的疗效方面的临床府上还很少。这项酌量的缱绻就是前瞻性分析接受用簇新低温冻存的同种异体骨组织调治有症状的膝要害软骨和骨软骨缺损的病东谈主的临床疗效和移植物的形态学变化。Methods: Nineteen patients with symptomatic chondral and osteochondral lesions of the knee who were treated with fresh osteochondral allografts between 1999 and 2002 were prospectively followed. The mean age at the time of surgery was thirty-four years. Validated outcomes instruments (the Activities of Daily Living Scale and the Short Form-36) were used; all patients must have had a baseline functional score prior to surgery and a minimum two-year follow-up evaluation. All grafts were obtained from commercial vendors; the mean preimplantation storage time of the graft was thirty days (range， seventeen to forty-two days). The mean lesion size was 602 mm2. Magnetic resonance imaging was used to evaluate the morphologic characteristics of the implanted grafts. 要领：从1999到2002年随访了19位接受簇新骨软骨同种异体骨调治有症状的膝要害软骨和骨软骨病变的病东谈主，手术时的平均年事为34岁。汲取灵验的临床疗效评分要领（日常生活行为评分和简表36），系数的病东谈主都必须进行术前基本功能评分和最少随访两年的功能评估。系数的移植物都从厂商得回，移植前平均储存时期为30天（从17天到42天不等）。病灶平均大小为602 mm2。汲取磁共振评估移植物的形态学特征。Results: The mean duration of clinical follow-up was forty-eight months (range， twenty-one to sixty-eight months). The mean score (and standard deviation) on the Activities of Daily Living Scale increased from a baseline of 56 ± 24 to 70 ± 22 at the time of the final follow-up (p < 0.05). The mean Short Form-36 score increased from a baseline of 51 ± 23 to 66 ± 24 at the time of final follow-up (p < 0.005). With the numbers studied， we could not correlate graft storage time， body mass index， lesion size， lesion location， or patient age with the functional outcome scores. At a mean follow-up interval of twenty-five months， cartilage-sensitive magnetic resonance imaging demonstrated that the normal articular cartilage thickness was preserved in eighteen implanted grafts， and allograft cartilage signal properties were isointense relative to normal articular cartilage in eight of the eighteen grafts. Osseous trabecular incorporation of the allograft was complete or partial in fourteen patients and poor in four patients. Complete or partial trabecular incorporation positively correlated with Short Form-36 scores at the time of follow-up (r = 0.487， p < 0.05). 放手：平均临床随访时期为48个月（从21到68个月不等）。日常生活行为的平均评分（和圭臬差）从术前的56 ± 24增多到随访终了时的70 ± 22 (p < 0.05)。平均简表36评分从术前的51 ± 23增多到到随访终了时的66 ± 24(p < 0.05)。因为酌量数目的关系，咱们没主义将移植物的储存时期、病东谈主的体重指数、病变的大小、病变的部位、病东谈主的年事与功能评分的放手接洽起来。在平均绝交随访25个月的时候，对软骨很敏锐的磁共振炫夸18位病东谈主移植的软骨还保握正常的要害软骨厚度，其中8个病东谈主移植的同种异体软骨与正常的要害软骨保握迥殊的信号强度。14个病东谈主移植的同种异体骨中沿途或部分骨小梁已融合，4个病东谈主移植的同种异体骨中骨小梁融合情况较差。沿途或部分骨小梁已融合的病东谈主与随访时简表36评分之间的相关性有统计学道理(r = 0.487， p < 0.05)。Conclusions: Fresh osteochondral allografts that were hypothermically stored between seventeen and forty-two days were effective in the short term both structurally and functionally in reconstructing symptomatic chondral and osteochondral lesions of the knee. 论断：储存17－42天簇新低温冻存的骨软骨同种异体骨短期内在结构和功能上能灵验重建有症状的膝要害软骨和骨软骨病变。Pelvic Reconstruction with a Structural Pelvic Allograft After Resection of a Malignant Bone Tumor恶性骨肿瘤切除术后诓骗同种异体骨盆结构移植物行骨盆重建Background: Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis.布景:由于相关并发症太多，骨盆恶性肿瘤切除后骨盆弓的重建仍然是外科中的弘大挑战. 本酌量的缱绻在于评价诓骗同种异体骨移植重建骨盆手术的功能后果和并发症的发生率Methods: Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors， sixteen of which were high-grade sarcomas， and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score.要领:对24名病东谈主进行骨盆恶性骨肿瘤切除后同种异体骨移植盆腔重建手术. 对生涯下来的病东谈主进行最少24个月的随访. 其中19个为原发恶性骨肿瘤， 在这19个病东谈主中16个高度恶性的赘瘤，，另外5东谈主为孑然的转换灶.诓骗临床和发射技巧对病东谈主进行评估， 同期诓骗肌肉骨骼肿瘤协会评分进行功能评估.Results: The mean age of the patients at the time of the index surgery was thirty-four years， and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation， eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients， and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision， with nine of these revisions related to the reconstruction.The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device， and five of them had normal function with no or only a slight limp.放手: 进行该手术时病东谈主的平均年事为34岁， 平均随访时期为41个月. 转子周区有累及的18个病东谈主诓骗东谈主工髋要害(13)或骨软骨同种异体移植物(5)进行了重建. 另外6个病东谈主切除范围累及了髂骨.系数的病东谈主都接受了经消毒而未进行二次辐射的大块同种异体骨.在咱们临了一次进行评估时，8名病东谈主正处于无病生涯期， 7名病东谈主局部复发.6名病东谈主存在神经学的不及，三名病东谈主发生深部感染. 16名骨移植病东谈主中3名发生了骨不连. 系数病例均未发生移植物融化或骨折.11名病东谈主进行了手术修正， 其中9名病东谈主的修正波及到了手术重建区. 最近一次随访时，平均肌肉骨骼肿瘤协会评分的最大可能得分为73%. 11个年事小于20岁的病东谈主的平均得分为83%， 另外13个年事稍大的病东谈主的得分为65%. 10名病东谈主不错在无任何赞助诱导的情况下行走， 另有5名病东谈主稍有跛行或莫得，功能正常Conclusions: Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results， especially in young patients. Nonunion was the most common allograftrelated complication. 论断:肢体裁减手术后行骨盆重建手术相关并发症相等多，因此对患原发骨赘瘤的病东谈主进行这类手术一定要稳健洽商. 骨盆同种异体移植物不错重建骨盆的剖解结构并梗概产生很好的功能放手， 尤其是在年轻的病东谈主.但骨不连是移植物发生率最高的并发症Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.置信水平:调治水平Ⅳ级. 不错阅读对作家的指导来得回对置信水平的全面描摹全文翻译Developmental Biology in Orthopaedics. Summary of the 2006 AAOS Research Symposium[b]矫形外科中的发育生物学.2006年AAOS酌量征询会选录在胎儿正常发育经由中， 各式不同的细胞通路互相谐和作用， 保证细胞有步骤的增殖，认知，以致去世， 从而发育成为器官.在昔时的10年里， 对于肌肉骨骼系统的发育问题取得了大宗的进展. 对于这些道路以及它们如何调控细胞行为的常识不错应用于肌肉骨骼系统病理状态和建树经由. 这些紧迫的通路中许多都不错作为调治的靶点. 道理道理的是， 这种要领匡助咱们发现了许多具有致畸作用的因子.识别这些紧迫因子在肌肉骨骼系统中的紧迫作用不错匡助咱们快速找到新的调治要领. 基因修饰的生物，举例转基因小鼠，在这种使命中具有紧迫的作用.由于这种生物在脱手发育的时候就具有遗传劣势，是以它们即不错用来酌量发生在熟识经由中信号转导的紧迫所用，也不错用来酌量病理和建树经由. 因此， 由好意思国矫形外科医师学会， 矫形外科酌量和教学基金会，矫形外科酌量协会，NIH， 加拿大健康酌量院，shriners儿童病院， kyphon，stryker等发起，在多伦多召开了本次矫形外科中的发育生物学会议，记忆矫形外科中的发育生物学的相关常识水平. 探讨如何将这种信息应用到矫形外科疾病中， 并鼓励矫形外科酌量者和发育生物学酌量者之间的谐和. 与会者还就值得酌量的领域达成了共鸣.发育脱手与卵子受精. 受精后的细胞称为合子.合子进行快速的有丝分裂和细胞分化， 酿成一个大要包括100个细胞的球状体---囊胚. 随后，囊胚履历原肠胚酿成， 在此时间，细胞移行酿成三个胚层， 内胚层，中胚层和外胚层. 胚层详情后， 器官发生脱手. 在此时间， 神经板皱褶酿成神管制， 然后体节脱手酿成.每个体节最终发育成一个椎骨以及相邻神经根相关组织. 体节酿成是在一种分节时钟的鼓励下完成的， 这种时钟调遣基因使其以周期的模式抒发从而产生每一个体节的界限.由于体节酿成单个的椎体， 这就很容易会通体节的发生不错导致先天性的脊柱问题， 举例先天性脊柱侧凸. 几个酌量者正在试图通过酌量体节的发育来会通脊柱记性.举例， 酌量标明一种调控分节时钟的基因deta-like3突变将会导致分节时钟芜乱， 并最终导致脊柱肋骨发育不全. 随之而来的，各式无谓严重进度的脊柱侧凸脱手产生. 会通调控体节时钟的基因不错匡助咱们深刻会通先天性脊柱侧凸的成因.另外， 体节和椎体发生的常识不错匡助咱们全方向的会通先天性和得回性脊柱疾病. 从转基因小鼠的酌量中得回的接洽体节时钟调控基因的常识对脊柱侧凸病东谈主具有极大的应用后劲. 不错用来辨认这种基因的一种要领是看其在体节发育经由中是否是被周期性调控的. 另外一种可行的要领是筛选泄漏于化学致畸物的小鼠，从而得回突变的基因. 通过比较小鼠和东谈主的表型不错使咱们把有限的元气心灵围聚在最有可能导致特定东谈主类疾病的基因上. 何况已经解说这种要领是正确的. 这些使命在发现椎体酿成中的紧迫信号通路和提供会诊以及预后信息方面具有极大的应用出息. 最终， 咱们还不错将这些要领应用于发现其他通路，并针对这些通路想象脊柱疾病的调治要领.在当作发育经由中，多潜能细胞分化成不同的类型， 何况每一种都精准的定位在特定的位置上从而匡助肢体发育成合适的形态. 间充质细胞在肌肉骨骼系统发生和生后的发育中的紧迫作用引起了酌量者们的平淡热心，因为在它们分化成肌肉骨骼系统的主要结构细胞， 骨细胞，软骨细胞和成纤维细胞. 长骨源头就是由这些多能间充质细胞的千里积酿成的， 随后这些间充质细胞分化成软骨细胞组成畴昔长骨的软骨板. 要害的酿成是前体组织中细胞去世的经由. 连年来，酌量者们诓骗遗传修饰的小鼠来飞舞选中的不同类型的发育中的细胞群最终分化成了何种熟识细胞. 经过修饰，这些小鼠的某些调遣基因单元一朝脱手抒发，它酒会产生一种容易检测的卵白. 有酌量标明软骨细胞分化成两种熟识细胞，一种是要害衬套软骨，另一种为滋长板. 多能细胞分化成熟识的细胞这如故由是由许多信号通路和基因调遣的， 本次会议中征询到的有sex-determining region Y-box family(SOX)， runt-related transcription factor (RUNX)， bone morphogenetic protein(BMP)， transforming growth factor-(TGF-， fibroblast growth factor (FGF)，and wingless-type MMTV (mouse mammary tumor virus) integration sitefamily (WNT)..在每一步的分化经由中， 都需要对这些信号通路进行近缜密的调遣以保证正确的细胞分化. 这一领域内的深刻使命将使咱们愈加深刻的会通这些分化经由中的调遣经由， 而这些常识不错被应用到肌肉骨骼系统的建树领域.熟识的要害软骨细胞建树功能优有限， 对于这些细胞是如何从未分化的前体细胞分化而来的常识将会匡助咱们揭开调整要害软骨的生物学行为的机制来使熟识的软骨细胞以一种合适的神气增殖从而建树组织缺损. 当前， 对于这如故由的会通仍然处在低级阶段. 这个领域需要咱们干涉更多的元气心灵;这些使命不错很快被应用于软骨建树，组织工程软骨替代和要害炎等领域. 基于这种洽商， 遗传工程小鼠将被应用的愈加平淡， 因为基于这种本事咱们不错很快很灵验的发现特定的基因和信号通路. 一些酌量这正在致力于于小鼠要害炎模子的构建. 通过手术不错引导骨要害炎， 还有许多要领，包括注入抗原等，不错用于诱发炎症性要害炎.跟着长骨的发育， 软骨滋长板逐步被骨细胞所代替------源头是位于骨中间的低级骨化中心， 然后是位于骨端的次级骨化中心. 位于低级骨化中心的软骨称为滋长板， 在骨胎儿期和诞生后的发育中提供长度的增多. 昔时的10年中在胎儿期滋长板发育中取得了弘大的进展. hedgehog signaling， parathyroid hormone-related protein (PTHrP)， FGF，SOX9， TGF-， BMPs， WNTs， and matrix metalloproteinases (MMPs)的作用已经基本阐述. 不错自便进行基因敲除或定点在软骨内进行基因抒发的遗传修饰小鼠在这方面应用起来相等灵验. 解读来自遗传修饰的小鼠的数据当前还存在一定的困难，因为它们不仅导致靶基因的改变， 而且还会对细胞群的发育产生影像. 分析滋长板的新要领， 举例对血流的详备酌量， 给酌量这些基因如何调控滋长板的功能提供了新的视点， 其中一些酌量放手以致对传统的不雅点提议了挑战. 举例， 有酌量标明滋长板的血管化进度比以前以为的要高许多， 恰是因为这种结构本性，才使局部的滋长板调遣因子不错资料奔袭至该处， 同期这在滋长板对毁伤的反馈中也有紧迫的作用. 由缺氧引导因子等基因介导的滋长板软骨细胞缺氧状态在调控软骨细胞分化中起着紧迫的作用. 不错在东谈主类或小鼠身上应用影像学本事将基因修饰的小鼠和东谈主类关联起来.在这方面， 新的磁共振本事具有平淡的应用出息. 尽管咱们已经得回了许多胎儿期滋长板的常识，然则咱们却儿童期的情况知之甚少;一样这亦然一个值得热心的领域. 这些使命不错应用于肢体不等长以及躯壳短小症等领域. 事实上， 躯壳短小症被以为与突变对滋长板功能的影像接洽. 举例， FGF-突变导致将导致软骨发育沿途不全. 以滋长板中滋长因子信号通路为靶点的药理学要领对这些疾患的药物调治具有极大的应用后劲.在发育经由中， 骨在软骨性骨板中的酿成是一个基质降解和血管融合的经由.多能间充质细胞经过多个基因和多种调遣通路的作用分化酿成成骨细胞，这些基因和通路平方包括RUNX2， BMP， and WNT等. 这些细胞的来源尚不是透顶清醒，但近来的酌量标明骨膜细胞在这如故由中起着紧迫的作用. 调控基质降解和血管酿成的调遣因子，举例vascular endothelial growth factor [VEGF] and select MMPs 在这如故由中阐扬中枢作用. 在生后骨建树和再生经由中(举例骨骼愈合和牵拉骨酿成本事)也需要这些因子的参与. 举例， 对小鼠进行酌量发现，在骨酿成经由中调控血管生成和缺氧状态的调遣因子(HIF或VEGF)在骨坏死和牵拉成骨术中也一样起作用. 也恰是因为这么， 对成骨细胞发育的调控道路及如安在再生经由中应用它们不错用作改善骨折愈合， 加快骨酿成的速度，改善交融速度以及要害成型术中骨的融合.干细胞亦然一种多能细胞， 在其分裂产生的两种子细胞中， 一个保留干细胞的多能本性， 另一个不错分化成不同的细胞系. 在熟识动物的许多组织中有小量具有干细胞本性的细胞.， 何况以为这些细胞在改种生物的一世中看守该组织的形态和功能. 然则早期干细胞与 这些熟识干细胞的发育模式有所不同. 最近对间充质干细胞的酌量标明在毁伤后的愈合经由中， 干细胞也不错分泌多种调剂因子， 使周围的熟识细胞匡助组织的愈合. 研发诓骗这些多颖慧细胞匡助骨和软骨建树的要领需要咱们更多的努力. 这些细胞的来源各式万般， 一个来源是肌肉， 其内存在的干细胞称为卫星细胞; 经过某种步地的基因疗法，这些细胞不仅不错改变肌肉的行为， 它们还不错聘用组织. 不同的年事和性别不错通过影像肌肉强度和骨密度等要素来对多颖慧细胞的行为产生影像. 这一领域的酌量在许多矫步地态有平淡的应用，尤其是与老龄相关的.肌肉骨骼系统的肿瘤一样诓骗发育经由中的许多因子和通路来进行调遣. 滋长板发育经由中起紧迫作用的细胞通路， 不如缺氧状态激活的细胞通路，在软骨肿瘤中也起很紧迫的作用. 癌症也可能是由一定数目的干细胞来看守的， 就向正常组织那样. 针对这些干细胞酌量调治要领不错得回调治赘瘤的更灵验的要领.对赘瘤中肿瘤干细胞的进一步酌量不错辨认这些细胞和通路，并将其作为调治的靶点来撤废这些病变.天然在骨和要害发育领域咱们已经取得了许多的进展，然则咱们对肌腱和韧带的发育却知之甚少.近来的酌量标明韧带来清静发育经由中要害周围细胞抒发的特殊转录因子.它们运转是基本上是属于细胞外结构， 其最终的基质组成和强度受许多基因的调遣. 这些肌腱中基因的转录调遣， 机械环境以及调控基质组成的调遣因子的抒发速度都在建树和恒久肌腱和韧带功能中具有紧迫的作用.在这一领域的酌量不错发现一些有肌腱建树或保证组织工程肌腱替代最优化的通路.本次论坛中的答复展示了昔时几十年中肌肉骨骼系统发生酌量中所取得的巨猛进展.在接下来的这个年代， 在更深刻酌量发育的基础限度的基础上，咱们还应该诓骗基因修饰生物，举例小鼠或鱼等， 对肌肉骨骼系统的病理改变和建树与再生领域进行平淡的酌量. 发展靶向病毒载体和基于细胞的调治计策将卵白导入到特定的细胞群中将有助于咱们将当前的酌量放手应用在病东谈主身上. 应器具有药效作用的物资针对发育中的紧迫调遣通路---其中一些源头被以为具有致畸作用--进行调治将很快被应用于临床. 肌肉骨骼系统发育生物学的酌量当前正处在改良调治要领转换的源头时期， 本次会议的与会者提议了畴昔使命的新领域， 在这些领域里咱们有信心将当前的酌量放手应用到病东谈主调治的新王国.谢谢众位古道朴妮唛吧