关节镜下膝关节内骨折的微创治疗

目的探讨在关节镜下行髌骨、股骨髁、胫骨平台、前后交叉韧带胫骨止点复位、内固定术的临床效果及手术适应证。方法对13例髌骨骨折、8例胫骨平台骨折、6例股骨髁骨折患者在关节镜观察下,皮外钳夹复位、螺钉皮下内固定;前后交叉韧带胫骨止点11例,关节镜监视下行骨折复位,导向器准确钻孔,6号聚乙烯缝线捆绑固定。结果全部患者随访9～22个月,平均16个月。41例患者术后3d肿胀消退,1例因关节内液体渗漏,术后肿胀严重,7d肿胀消退,42例术后6周伸屈功能正常,术后2个月骨折线模糊,6个月均已骨性愈合。结论该术式伤口小、血运损伤少、骨折愈合快、关节功能恢复快,可以同时治疗关节内附属结构损伤,适合于部分B型和部分C型胫骨平台、髌骨骨折,部份B型股骨髁骨折,所有前后交叉韧带胫骨止点撕脱骨折和膝关节内软骨骨折。     

膝关节创伤的微创处理

关节镜技术最早应用于膝关节内创伤微创性诊断与治疗．提高了急性膝关节损伤时关节内软骨损伤的诊断率；可以正确评估半月板损伤的部位、类型和范围，合理选择损伤半月板缝合、部分切除等术式，最大限度保留了半月板；可以进行前、后交叉韧带损伤的修复与重建。关节镜技术结合做创内固定技术可以治疗胫骨平台、髌骨、股骨髁骨折，辅助完成逆行交锁钉治疗股骨远端骨折。经皮微创解剖钢板内固定(如LISS)治疗膝关节邻近股、胫骨干骺端骨折，均提供了临床疗效。     

伴软骨损伤的Hoffa骨折1例

患者,男,31岁,2019年11月29日因扭伤致右膝部疼痛肿胀、膝关节活动受限,于当地医院诊断为右股骨外侧髁骨折。为进一步治疗,于2019年12月3日至山东省中医院就诊,诊断为右Hoffa骨折。CT检查显示:右股骨外侧髁骨折,右膝关节积液。MRI显示:①右膝关节积液;②右股骨远端外髁骨折,右胫骨近段及髌骨有骨挫伤表现;③右髌骨轻度脱位表现,髌内外侧支持带损伤;④右膝前交叉韧带断裂,胫腓侧副韧带、后交叉韧带损伤;⑤右膝内侧半月板后角、外侧半月板前角损伤,外侧前角部分撕裂可能。2019年12月10日在腰硬联合麻醉下行关节镜下右膝探查清理术+半月板损伤修补缝合术+股骨外侧髁骨折切开复位内固定术。患者仰卧位,取膝关节前内、前外侧切口,建立关节镜观察及工作通道。置入关节镜观察关节腔内髌上囊、髁间窝、内外侧间室等结构,见髌骨内侧支持带损伤,髌骨轻度脱位,刨刀清理髌骨内侧支持带游离缘,内侧间室股骨髁边缘骨赘未予特殊处理。     

膝关节多发骨折AO分型构成特点及与临床治疗关系的研究

[目的]通过对膝关节多发骨折患者影像学观察,分析该类骨折AO分型构成特点,探讨AO分型对手术治疗的指导意义。[方法]统计2003～2007年间膝关节多发骨折患者的发病例数,并且按年龄段、发病年份、受伤机制和治疗方法进行分组。每例患者术前X线片进行AO/OTA分型,记录接受手术情况,术后1年进行Lyshlom评分,拍摄X线片评估骨折愈合情况。[结果]共统计膝关节多发骨折167例,占下肢多发骨折的23.69%,其中由交通伤导致占53.29%,30～40岁年龄段所占比例为29.34%。股骨远端+胫骨近端骨折占44.3%,髌骨+股骨远端占31.1%,胫骨近端+髌骨占19.8%例,股骨远端+胫骨近端+髌骨占4.8%。股骨远端骨折A3型最多(25.4%),胫骨近端骨折B1型最多(21.7%),髌骨骨折C3型最多(31.2%)。[结论]膝关节多发骨折多由交通伤导致,多见于青壮年男性,呈逐年升高趋势。以股骨远端合并胫骨近端骨折多见,骨折类型以关节外股骨髁上,胫骨平台合并干骺端和涉及关节面髌骨横行骨折为主,骨折程度主要以粉碎型为主。     

全膝关节置换术后低位髌骨

全膝关节置换术后低位髌骨可导致撞击、疼痛、活动度减少等并发症。形成原因包括以前膝关节手术史,例如前交叉韧带重建术、逆行髓内钉固定术、髌下脂肪垫切除术和膝关节置换术史。诊断包括Insall-Salvati和Blackburne-Peel等方法。需要区分真正的低位髌骨和假性低位髌骨。治疗方法包括胫骨结节截骨、股骨远端垫块、翻修、髌骨上移、胫骨假体改良、髌韧带“Z”字成形等。     

髌骨鹰嘴化固定在治疗膝后交叉韧带损伤中的初步应用

目的 探讨髌骨鹰嘴化固定在治疗胫骨止点撕脱骨折型后交叉韧带损伤中的临床作用.方法 对3例膝后交叉韧带损伤患者,行髌骨鹰嘴化固定,斯氏针固定6周,维持膝关节活动度.结果 术后3个月骨折愈合良好,膝关节后抽屉试验阴性,膝关节活动范围与术前无差别.结论 髌骨鹰嘴化固定治疗胫骨止点撕脱骨折型后交叉韧带损伤,操作简单、创伤微小、...     

胫骨假体旋转参考轴的MR测量研究

目的在磁共振图像上研究胫骨假体旋转排列的骨性标志。方法对68例正常膝关节行磁共振横断面扫描,在胫骨近端横断面上测量胫骨前后轴与髌腱交点内侧宽度比例（AB％）,与股骨外科上髁轴中点与髌腱中内1／3连线的夹角（角α）及后交叉韧带中点与膑腱内侧缘连线夹角（角β）。测量髌骨轴、股骨外科上髁轴、胫骨后髁轴之间的旋转关系。结果AB％为（18．12％±6．17％）,角d为（5．41°±2．52°）,角B为（3．05°±1．38°）。胫骨后髁轴相对股骨外科上髁轴内旋（9．59°±2．73°）、髌骨轴内旋（11．47°±3．27°）。结论将股骨外科上髁轴作为股骨假体旋转参考轴,使用胫骨后髁轴作为胫骨假体参考轴会引起胫骨假体相对股骨假体内旋放置。后交叉韧带中点与髌腱内侧缘连线与胫骨前后轴变异较髌腱中内1／3小,作为术中参考标志相对可靠。     

复杂胫骨平台骨折治疗的挑战

<正>胫骨上端膨大而形成两个髁,称为胫骨平台。与股骨髁对应,在半月板、内外侧副韧带、前后交叉韧带、髌骨及其周围附属结构的支持下,构成膝关节。胫骨平台是重要的负荷结构,周围解剖结构复杂,传导躯体重量,完成各种活动。遭受外伤后,常会发生骨折及其附属结构的损伤,骨折线     

胫骨平台后内髁劈裂骨折的手术治疗

目的:探讨膝关节后内侧入路手术复位内固定治疗胫骨平台后内髁劈裂骨折的临床疗效。方法:2006年1月至2009年7月,采用后侧入路手术治疗胫骨平台后内髁劈裂骨折获得随访的患者21例,男14例,女7例;年龄28～68岁,平均36.9岁。致伤原因:车祸伤14例,高处坠落伤7例。合并伤:合并前交叉韧带损伤15例,均为胫骨平台止点撕脱;合并胫骨平台后外侧塌陷骨折14例。采用膝关节后内侧入路手术复位内固定治疗,术后据Rasmussen膝关节功能评定方法评定疗效。结果:21例均获随访,时间12～30个月,平均17.3个月。无切口感染,无内固定松动及断裂,无骨不愈合,无膝关节内、外翻畸形和骨折再移位。术后后内髁骨折均达解剖复位,1例术后小腿内下方感觉麻木。术后根据Rasmussen膝关节功能评定标准:优12例,良7例,可2例。结论:膝关节后内侧手术治疗胫骨平台后内髁劈裂骨折,有利于平台后内髁骨折的复位和固定,具有暴露清楚、内固定安放方便、创伤小及临床疗效好等优点。     

2例髌韧带断裂手术失败原因分析和对策

1　临床资料例 1,女性 ,42岁 ,因车祸外伤致左股骨髁上粉碎性骨折和左髌韧带断裂 ,术中见髌韧带撕断粉碎 ,予以左股骨髁上骨折复位、髁钢板内固定和髌韧带两断端直接缝合。术后长腿管形石膏固定 12周。术后 8个月再因并发左膝关节内外粘连而入院 ,术中关节外粘连松解后 ,屈左膝关节 60°时 ,髌韧带在原断端断裂 ,且术中发现原本两断端间已瘢痕化。例 2 ,男性 ,3 5岁 ,因车祸外伤致左髌韧带断裂 ,术中见髌韧带两断端整齐 ,予以两断端直接缝合。术后长腿管形石膏固定 8周 ,拆除石膏后第 1次主动伸膝过程中 ,髌韧带再次断裂。术中发现髌韧带在…     

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.