头状骨、月骨、三角骨、钩骨测量及四角融合器的设计

目的测量头状骨、月骨、三角骨、钩骨,为研制适于腕骨四角融合术的内固定器械提供解剖学依据,并设计镍钛记忆合金腕骨四角融合器（NiTi shape memory alloy four—comer arthrodesis concentrator,NT—FCAC）。方法解剖45侧成人腕骨标本,保留腕掌、背侧韧带,切除大、小多角骨和手舟骨,游标卡尺测量头状骨、月骨、三角骨、钩骨各骨间距;然后,解剖出上述四腕骨,观察各骨形态,游标卡尺测量各参数;最后,依据测量结果及四腕骨解剖形态特点,结合镍钛记忆合金的特性,设计镍钛记忆合金腕骨四角融合器。结果头月间距最小为（24．75±3．13）mm,钩月间距（29．46±2．85）mm,月三角间距（26．48±2．08）mm;三角骨厚度最小为（8．76±0．91）mm;依据测量结果及镍钛记忆合金的特性,设计出了镍钛记忆合金腕骨四角融合器。结论依据头状骨、月骨、三角骨和钩骨解剖特点及测量结果,结合镍钛记忆合金的特性,能够设计出适于腕骨四角融合术的内固定器械。     

天玑骨科机器人辅助四角融合经皮螺钉内固定技术介绍

<正>四角融合术是治疗舟骨骨折不愈合进行性塌陷性关节炎和舟月分离性腕关节炎2～3期的常用术式^[1]。传统四角融合术需要在腕背部作纵向6～8 cm切口，去除舟骨，打磨月骨及三角骨远端关节面和头状骨及钩骨近端关节面，随后在透视引导下打入2～4枚螺钉固定月骨、三角骨、头状骨及钩骨。由于这4块腕骨体积小、形状各异，合理排布螺钉从而达到腕骨间牢固固定且螺钉之间不产生阻挡是手术难点。为了完成螺钉植入，需要反复尝试置入导针并多次透视明确，即便对于经验丰富的医生也是很大挑战，而且术者及患者往往要接受大量放射性暴露。为了微创而精准地完成四角融合术，我们进行了首例机器人辅助腕关节四角融合经皮螺钉内固定。报告如下。     

镍钛记忆合金舟大小融合器的研制及生物力学测试

目的探讨一种腕舟、大、小多角骨融合术内固定器械的研制和生物力学测试。方法根据国人腕舟状骨、大多角骨及小多角骨的解剖学参数测量和统计分析，采用镍钛记忆合金制作镍钛记忆合金舟大小融合器（NiTi shape memory alloy STT arthrodesis concentrator，NT-STTAC）；取24侧成人上肢标本，分成NT-STTAC固定组和克氏针固定组，体外模拟腕舟状骨和大、小多角骨融合术，用858型双轴液压材料测试系统（858-MTS）测试其固定强度；大、中、小三型号的NT-STTAC各2件施加19．6—196．0N的循环拉伸负荷（1Hz），观察NT-STTAC的形变情况；分析实验结果，评价NT-STTAC的生物力学特性。结果NT-STTAC固定组的固定强度大于克氏针固定组（P〈0．05）；6件三型号NT-STTAC发生形变达6％时，施加的载荷次数分别为3012、3228、3356、3678、3424和3986次。NT-STTAC三固定臂产生的回复力可将舟状骨和大、小多角骨有效地聚合于一体，其体部可遮挡植入上述3处腕骨间关节间隙的松质骨，防止其滑脱。结论NT-STTAC的设计符合国人舟状骨和大、小多角骨的解剖学特点，其固定强度可满足腕舟、大、小多角骨融合术后无需外固定及早期功能锻炼的生物力学要求，疲劳强度可满足腕舟、大、小多角骨融合后达骨性愈合的需要。     

四角融合术在治疗腕部疾患中的应用进展

1984年Watson和Ballet在系统回顾4000多张腕部X线片后，提出了舟月进行性腕塌陷（scapholunate advanced collapse，SLAC）的概念，并系统描述了SLAC的临床表现、诊断和治疗方法，首次进行四角融合术（four—corner arthrodesis），即头状骨、月骨、三角骨和钩骨融合，是一种重建腕关节功能的部分腕骨融合手术方式，目前常常联合舟骨切除用于治疗各种原因引起的SLAC。[第一段]     

舟骨切除并四角融合术在舟月进行性塌陷中的应用进展

舟骨切除并四角融合术是指完整切除舟骨,做头状骨、月骨、三角骨和钩骨的有限腕关节融合术。该术式主要适用于舟月进行性塌陷治疗（ScapholunateAdvancedCollapse,SLAC）。禁忌证包括：Kienbock病（月骨无菌性坏死）、桡月关节退行性改变、腕骨向尺侧移位等。1984年Watson等系统报道了SLAC的临床表现和诊治方法,此后备受手外科医生重视。     

腕头状骨、月骨、三角骨、钩骨的X线测量及意义

目的探求一种腕头状骨、月骨、三角骨、钩骨的大样本数据测量方法．方法在TX-DR1000型DR直接数字成像系统工作站中（北京万东医疗装备股份有限公司）对腕头状骨、月骨、三角骨、钩骨的长度、宽度进行测量,与解剖学标本测量数据比较。结果在DR直接数字成像系统工作站中测量的头状骨、月骨、三角骨、钩骨各参数（长度、宽度）,经统计学分析,与解剖学标本测量数据比较．差异无统计学意义。结论通过在TX—DR1000型DR直接数字成像系统工作站中对腕头状骨、月骨、三角骨、钩骨的长度、宽度进行测鼍,是一种对活体腕骨进行参数测量的可靠方法,该测量方法简单、快捷,成本低廉．可进行大样本数据测量,适宜推广。     

四角融合术治疗舟骨骨不连腕进行性塌陷

[目的]介绍腕骨四角融合术微型锁定钛板内固定治疗舟骨骨不连腕进行性塌陷(scaphoid nonunion advanced collapse,SNAC)的手术技术和初步疗效。[方法] 2012年6月～2016年9月,5例SNAC患者接受手术治疗。术中彻底切除舟骨,显露月骨、头骨、三角骨及钩骨,保护月桡关节软骨,去除上述4块腕骨间关节软骨面至松质骨面,调整头骨及月骨对位关系,将自体骨粒充填至头骨、月骨、三角骨及钩骨之间,将微型钛板置入上述4块腕骨背侧,4枚螺钉固定。[结果]术后切口均I期愈合,均无骨不连、伤口感染、皮肤坏死等并发症。术后平均随访(26.81±2.28)个月,5例患者腕关节静息时疼痛均完全缓解,1例长时间重体力劳动偶有疼痛;所有患者握力均有明显好转;关节活动度达到健侧的50%以上。[结论]应用四角融合术微型锁定钛板内固定治疗SNAC安全有效,融合率高,能够明显缓解疼痛,保存部分腕关节功能。     

闭合性腕骨尺侧轴向脱位一例

创伤性腕骨的轴向脱位比较少见[1],笔者收治闭合性经钩骨、豌豆骨周围尺侧轴向脱位1例,报告如下. 1 病例报告 患者,男,35岁.工作中损伤右腕部.查体:右腕明显肿胀,手及腕部压痛阳性.因疼痛剧烈不能主动活动右腕及右手各指,无血管危象.X线片显示:腕关节的尺侧向近侧和尺侧方向移位,腕关节的桡侧与桡骨保持正常的解剖关系,第四、五掌骨随钩骨一起向近端移位(图1),钩骨较大的骨折块向背侧移位;CT检查显示:钩骨骨折.在臂丛阻滞麻醉下行切开复位内固定治疗,在第三、四掌骨间背侧纵行切开,显露第三、四伸肌腱鞘间的伸肌支持带."T"形切开腕背侧韧带和关节囊,牵引腕部,将钩骨复位后,用1枚克氏针固定钩骨和头状骨,以稳定骨折及钩头关节,另1枚克氏针固定第四掌骨基底和钩骨,以稳定第四腕掌关节,修复撕裂的韧带.术后X线片显示:钩骨骨折和腕尺侧脱位复位,克氏针内固定良好(图2).术后管形石膏外固定12周.     

经舟骨月骨周围脱位的诊断与治疗

1 应用解剖 腕骨的结构复杂，八块腕骨分为近、远两排，从桡侧向尺侧远排为大多角骨、小多角骨、头状骨和钩骨，远端与掌骨基底部形成腕掌关节，其近端与近排腕骨形成腕骨间关节。近排依次为舟骨、月骨、三角骨和豌豆骨，前三块腕骨与桡骨远端形成桡腕关节。桡腕关节是典型的椭圆关节，由桡骨腕关节面和关节盘的下面构成关节窝，舟、月、三角骨构成关节头，关节囊松弛，关节腔较宽，其外有韧带增强。     

月骨摘除及豆状骨植入腕骨的应力研究

目的：为腕月骨摘除后，应用带蒂豆状骨植入与腕骨间融合术联合治疗腕月骨缺血性坏死，提供生物力学依据。方法：选用１０只离体上肢标本，在摘除月骨前、后及植入豆状骨以后，行舟骨－头状骨（ｓｃａｐｈｏｉｄ－ｃａｐｉｔａｔｅ Ｓ－Ｃ）融合及舟骨－大多角骨－小多角骨 （ｓｃａｐｈｏｉｄ－ｔｒａｐｚｏｉｄ－ｔｒａｐｅｚｉｕｍ Ｓ－Ｔ－Ｔ）融合，在持续缓慢加载下，采用电阻应变片测定各腕骨的应力。结果：（１）腕骨完整时，头状骨及月骨的应力最大；（２）月骨摘除后，腕骨的应力变化无一定规律性；（３）豆状骨植入后，豆状骨的应力最大；（４）行Ｓ－Ｃ或Ｓ－Ｔ－Ｔ融合后，豆状骨的应力减小。结论：实验结果证实，为了减少豆状骨植入后承受的应力，行局限性腕骨间融合是有效的。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.