髌骨旁外侧切口双钢板内固定治疗复杂胫骨平台骨折

目的研究髌骨旁外侧切口结合双钢板内固定治疗复杂胫骨平台骨折(SchatzkerⅤ、Ⅵ型)的效果。方法采用髌骨旁外侧切口结合双钢板固定治疗复杂胫骨平台骨折16例,对膝关节功能进行评价。结果 16例均获得随访,时间6～18个月,膝关节功能按Rasmussen标准:优10例,良4例,可2例。结论髌骨旁外侧切口结合双钢板内固定治疗复杂胫骨平台骨折手术视野好、固定确切、软组织损伤小、并发症少,值临床推广应用。     

胫骨外髁截骨联合内外侧双钢板固定治疗胫骨平台外后髁骨折

目的 探讨胫骨外髁截骨联合内外侧双钢板固定治疗胫骨平台外后髁骨折的临床疗效. 方法 2008年1月至2010年5月共收治17例胫骨平台外后髁骨折患者,男13例,女4例;年龄24 ～ 59岁,平均40.8岁.骨折按Schatzker分型:V型10例,Ⅵ型7例.均采用胫骨外髁截骨、前外侧联合后内侧切口双钢板内固定.术后12周内患肢不负重. 结果 17例患者术后获12 ～ 17个月(平均14.3个月)随访.17例患者骨折均获愈合,愈合时间平均为14周(12～18周).术后1年膝关节功能Rasmussen 评分为18 ～ 26分,平均23.6分,其中优13例,良3例,差1例,优良率为94.1％.结论 胫骨外髁截骨显露胫骨平台外后髁骨折联合内外侧双钢板固定是治疗胫骨平台外后髁骨折的一种有效方法.     

复杂胫骨平台骨折2种手术治疗方法的比较分析

目的比较双切口双钢板内固定术与膝前正中切口锁定钢板内固定术治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折的手术效果。方法 76例SchatzkerⅤ、Ⅵ型胫骨平台骨折采用膝前正中切口锁定钢板内固定术治疗38例（A组）,采用双切口双钢板内固定术治疗38例（B组）。比较2组手术时间、术中出血量、住院时间、术后至开始负重时间、骨折愈合时间、胫骨平台内翻角（TPA）、胫骨平台内侧后倾角（PSA）、并发症及末次随访时Rasmussen膝关节功能评分。结果 B组手术时间、术中出血量、住院时间、术后至开始负重时间少于A组,B组术后TPA、PSA小于A组,差异均有统计学意义（P〈0.05）;但2组骨折愈合时间比较差异无统计学意义（P〉0.05）。B组出现钉道感染、关节强直、膝内翻畸形、骨折延迟愈合的患者较A组少,差异有统计学意义（P〈0.05）;2组切口感染、皮肤坏死、内固定松动断裂、膝关节不稳、骨坏死及骨折不愈合并发症比较差异无统计学意义（P〉0.05）。末次随访时Rasmussen膝关节功能评分：A组优5例,良16例,可10例,差7例,优良率55.3%;B组优14例,良15例,可6例,差3例,优良率76.3%;B组Rasmussen膝关节功能评分优于A组,差异有统计学意义（P〈0.05）。结论对于SchatzkerⅤ、Ⅵ型胫骨平台骨折,双切口双钢板内固定术手术时间短,治疗效果较好,并发症较少。     

双钢板法治疗胫骨平台双髁骨折

目的探讨双钢板法治疗胫骨平台双髁骨折的临床疗效。方法从2002年3月～2004年6月在我院采用双钢板法治疗胫骨平台双髁骨折19例,其中男14例,女5例;平均39.4岁(28～52岁);左膝12例,右膝7例。按Schatzker分型:Ⅴ型8例,Ⅵ型11例。按AO分型:C1.3型11例,C2.3型6例,C2.4型2例。采用内、外侧两个切口,外侧为胫骨平台标准入路———外侧髌骨旁入路,内侧为胫骨后内侧入路;行双钢板固定:内侧用一块四孔1/3半管型接骨板或前臂小钢板固定,外侧异形钢板固定。结果术后16例获得随访,随访4～31个月,平均15个月。按照Rasmussen[1犦的标准评价膝关节功能:优11例,良5例,差3例,优良率为84.2%。结论双切口双钢板技术具有手术创伤小,切口及软组织并发症明显减少,骨折固定长期的稳定性良好,可以早期行CPM机锻炼,关节功能恢复满意等优点,是治疗胫骨平台双髁骨折安全、有效的方法。     

有限内固定联合外固定支架治疗Schatzker Ⅴ、Ⅵ型胫骨平台骨折

目的探讨有限内固定联合外固定支架治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折的临床疗效。方法手术治疗55例SchatzkerⅤ型(31例)和Ⅵ型(24例)胫骨平台骨折患者。术中先透视下闭合复位或辅以小切口复位胫骨平台内外侧髁,并给予螺钉固定,再应用外固定支架固定,对塌陷骨折撬拨复位人工骨填充。结果骨折解剖复位39例,近解剖复位16例。患者均获得随访,时间12~54个月。骨折愈合时间4~7个月。末次随访膝关节功能按Rasmussen评分标准:优32例,良15例,可7例,差1例,优良率85.5%。切口并发症7例(12.7%):其中切口浅表感染2例,钉道感染5例,未发生深部感染,骨髓炎及骨不连。结论有限内固定联合外固定支架治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折可获得满意临床疗效,具有创伤小、并发症发生率低、骨折愈合快等优点。     

经双切口入路手术治疗胫骨平台双髁骨折

[目的]评价经膝关节前外侧和后内侧双切口人路手术治疗胫骨平台双髁骨折的临床疗效.[方法]自2003年6月～2010年5月对42例胫骨平台双髁骨折采用膝关节前外侧和后内侧双切口入路进行手术治疗,其中Schatzker V型骨折29例,Schatzker VI型骨折13例.随访时间16～27个月.观察切口感染和骨折愈合时间.配对t检验比较术后初次和末次随访骨折复位及复位丢失放射学Rasmussen评分.随访末HSS评分评价膝关节功能.[结果]切口感染7例,其中浅部感染2例,深部感染5例,感染率16.67%.骨折平均愈合时间(4.60±1.27)个月.术后初次放射学Rasmussen平均评分(13.86 ± 3.23 )分,随访末期(13.71±3.26)分,二者比较差异无统计学意义(P=0.08 >0.05).随访末膝关节功能HSS评分平均为(74.33±12.34)分,优10例,良22例,可9例,差1例,优良率76%.[结论I采用膝关节前外侧和后内侧双切口手术人路可充分暴露膝关节内结构及胫骨平台双裸骨折端,为骨折直视下精确复位和植骨内固定提供了良好的操作空间,关节面复位满意,内固定牢固,术后骨折复位丢失率低、骨折愈合率高,有效减少软组织并发症,利于膝关节功能恢复,适合胫骨平台双髁骨折的手术入路.     

经皮鱼嘴钳固定治疗胫骨平台骨折

目的:分析微创技术治疗胫骨平台骨折的疗效。方法:胫骨平台骨折83例,男59例,女24例;年龄18~58岁,平均37岁。交通事故伤36例,坠落伤21例,砸伤10例,摔伤16例。外翻应力伤31例,内翻应力伤9例,垂直压迫或合并旋转应力伤43例。按Schatzker分类:Ⅰ型15例,Ⅱ型26例,Ⅳ型17例,Ⅴ型25例。均行经皮撬拨复位、鱼嘴钳固定治疗。结果:随访81例,时间2~7年,骨折均于3个月内愈合,膝关节完全伸直,屈膝平均127°(95°~145°)。参照Rasmussen胫骨髁部骨折膝关节功能进行评分:优49例,良27例,可4例,差1例。结论:经皮鱼嘴钳固定手术创伤小,固定可靠,能早期进行功能锻炼,避免二次手术取内固定物,是治疗胫骨平台骨折的有效方法。     

前后联合小切口入路治疗SchatzkerⅣ胫骨平台骨折型效果观察

目的探讨SchatzkerⅣ型胫骨平台骨折的临床特点与前后联合小切口手术入路方法和效果。方法对76例SchatzkerⅣ型胫骨平台骨折患者实施前后联合小切口入路治疗,分析其治疗效果。结果术后均获得随访12~24个月,骨折平均愈合时间8个月。依据Rasmussen膝关节功能评分,优良率82.89%(63/76)。结论对SchatzkerⅣ型胫骨平台骨折患者实施前后联合小切口入路,软组织剥离少,手术野暴露清晰,膝关节功能恢复良好。     

单切口双钢板支撑技术治疗复杂胫骨平台骨折

目的探讨单切口双钢板支撑技术治疗复杂胫骨平台骨折临床疗效。方法本组共30例复杂胫骨平台骨折的患者,按Schatzker分类,Ⅴ型18例,Ⅵ型12例,均采用单切口双钢板支撑技术治疗。结果随访7～24个月,平均15个月,骨折均愈合,切口均一期愈合,按Rasmussen评分标准评定:优13例,良15例,可2例。结论单切口双钢板支撑技术治疗复杂胫骨平台骨折,固定稳固、并发症少,关节功能恢复满意。     

复杂胫骨平台伴后髁骨折的手术治疗

目的探讨后内侧联合前外侧入路手术治疗复杂胫骨平台伴后髁骨折的近期疗效。方法笔者自2010-10—2015-03采用后内侧联合前外侧入路手术治疗41例复杂胫骨平台伴后髁骨折。术后采用Rasmussen放射学评分标准评价手术复位效果,骨折完全愈合后按照美国特种外科医院(HSS)膝关节功能评分评定膝关节功能。结果 41例均获得随访14~31个月,平均17.4个月。术后Rasmussen放射学评分平均15.4(11~18)分;优17例,良20例,可4例,优良率90.2%。术后HSS膝关节功能评分平均91.5(57~95)分;优16例,良20例,可4例,差1例,优良率87.8%。所有患者术后切口及骨折均顺利愈合。结论后内侧联合前外侧入路手术治疗复杂胫骨平台伴后髁骨折近期疗效满意,值得推广。     

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.