腓骨头复合组织瓣修复儿童内踝骨皮肤缺损四例

目的 探讨腓骨头复合组织瓣修复儿童内踝骨皮肤缺损的临床效果.方法 2005年8月至2009年4月,根据腓骨头区域的解剖学特点.设计了以膝下外侧血管束为供血的腓骨头复合组织瓣,修复儿童内踝骨皮肤缺损4例,内踝缺损均累及骨骺,皮肤缺损面积为3～6 cm × 8～10cm.结果 4例腓骨头复合组织瓣血供丰富,全部存活,朱出现血管危象.术后随访4个月至4年,4例骨端全部愈合,重建内踝形态良好,踝关节外形及功能恢复满意.结论 腓骨头复合组织瓣是修复儿童内踝骨皮肤缺损的一种较好方法.

Abstract：

Objective To investigate the therapeutic effect of fibular head composite flap for bone and skin defect at medial malleolus in children. Methods From Aug. 2005 to Apr. 2009, 4 children cases(2 male, 2 famale, from 3 to 11 year) with bone and skin defect at medial malleolus were reconstructed with fibular head composite flaps pedicled with lateral inferior genicular vascular bundle. The skin defect was 3- 6 cm × 8-10 cm in size. Results All the 4 compostie flaps survived completely. The patients were followed up for 4 months to 4 years with good bony healing. Both esthetic and functional results were satisfactory in ankle joint. Conclusions The fibular head composite tissue flap has a good therapeutic effect for bone and skin defect at medial malleolus in children.     

儿童内踝外伤性缺损的修复重建

目的 探讨以带血管蒂腓骨头骨骺复合组织瓣修复重建儿童内踝外伤性缺损的手术方法 及临床效果. 方法 2003年7月-2007年12月,收治8例车轮绞伤导致内踝Peterson Ⅵ型骨骺损伤患儿.男5例,女3例:年龄2～10岁.左侧5例,右侧3例.内踝完全缺如,均伴内踝周围皮肤缺损,范围4.0 cm×2.0 cm～9.5 cm×5.5 cm.受伤至入院时间为6～8 h 2例,24～168 h 6例.术中设计腓骨头骨骺复合组织瓣一期修复内踝及其周围软组织缺损.切取皮瓣4.5 cm×2.5cm～10.0 cm×6.0 cm,截取腓骨头骨骺长度2.5～3.0 cm.供区直接缝合. 结果 术后伤口均I期愈合,复合组织瓣全部成活,无血运障碍;供区愈合良好.患儿均获随访,随访时间1～5年.内踝骨骺6～9周愈合.皮瓣色泽及弹性较好,无瘢痕挛缩.无踝关节内翻畸形发生,负重及行走满意.6例踝关节屈伸正常;2例轻度受限,背屈18～20°,跖屈35.距骨无内移,踝关节无过度外翻.按美国矫形足髁协会足踝功能评判标准,优7例,良1例.内踝骨骺无早闭发生,骨化中心逐渐明显或增大,发育与对侧基本保持同步.供区膝关节屈伸活动度正常,无内翻不稳定. 结论 腓骨头骨骺复合组织瓣可一期修复儿童内踝骨骺及周围软组织缺损,重建的内踝可随儿童的生长同步发育,是重建儿童内踝外伤性缺损的理想方法 之一.     

内踝骨与软组织缺损的显微外科修复与重建

目的 报道创伤致内踝部骨与软组织缺失的显微外科修复重建临床效果.方法 根据内踝部骨与大面积复合组织缺损,设计吻合胫前返血管的腓骨头骨瓣,分别应用腓骨头复合骨瓣重建内踝及三角韧带,吻合血管的背阔肌皮瓣移植修复内踝部软组织缺损6例.结果 术后随访半年至5年,修复内踝部外观好,踝关节稳定,关节活动好,效果满意.按美国AOFAS足踝功能评判标准,结果优5例,良1例.结论 应用腓骨头复合组织瓣及游离皮瓣移植修复内踝部骨与内侧复合组织缺损,更利于患者踝关节功能以及外形美观的恢复.     

游离髂骨复合组织瓣修复内踝骨与皮肤缺损

目的探讨游离髂骨复合组织瓣修复内踝骨与皮肤缺损的手术方法及临床疗效。方法笔者自2013-03—2015-09对7例内踝骨质缺损合并三角韧带以及内踝部位皮肤软组织缺损采用带旋髂浅动脉髂骨复合组织瓣重建内踝和三角韧带,修复内踝部皮肤及皮下组织缺损。结果 7例均获得随访9~31个月,平均25个月。内踝创面皮瓣全部成活,伤口愈合良好,游离移植髂骨瓣未出现骨质吸收,均达到骨性愈合,愈合时间11~17周。重建内踝形态良好,踝穴稳定,踝关节功能恢复满意,皮瓣外观及质地满意。结论游离髂骨复合组织瓣修复内踝骨与皮肤缺损,可获得满意的踝关节外观及功能。     

腓骨头瓣联合小腿皮神经营养血管皮瓣移植修复内踝骨及软组织缺损

目的 探讨膝下外侧血管蒂腓骨头瓣联合小腿皮神经营养血管皮瓣移植修复内踝部骨与复合组织缺损的疗效. 方法 根据内踝部骨与复合组织缺损的大小,设计膝下外侧血管蒂腓骨头肌腱瓣移植重建内踝和三角韧带、切取小腿皮神经营养血管皮瓣修复内踝部软组织缺损刨面.临床应用7例,分别因机器绞伤、重物砸伤、撕脱伤所致的开放性创伤.皮肤缺损5cm×6cm～8cm× 16cm.观察术后患者内踝的影像学及功能恢复情况. 结果 7例患者均顺利完成手术,内踝及软组织缺损Ⅰ期修复,术后随访8个月至6年,移植骨及皮瓣愈合良好,踝关节稳定,关节活动正常,内踝部外形好,效果满意. 结论 以膝下外侧血管蒂腓骨头肌腱瓣联合小腿皮神经营养血管皮瓣移植修复内踝部骨与复合组织缺损具有可行性.     

带血管蒂腓骨头骨骺截骨整形重建内踝的应用解剖与临床应用

目的 为带血管蒂腓骨头骨骺截骨整形重建内踝提供解剖学依据,并探讨其临床应用效果.方法 20侧2～12岁新鲜儿童下肢标本,对腓骨头及内踝进行形态学测量,根据测量数据推导截骨公式.临床急诊或延期手术,移植截骨改良的腓骨头骨骺复合组织瓣一期修复内踝缺损,随访观察临床效果.结果 腓骨头倾斜角(M)为(170±8)°,关节面内倾角(N)为(145±6)°,纵长为(1.5±0.2)cm,横宽为(1.4±0.2)cm;内踝内翻角(L)为(152±8)°,关节面纵长为(1.25±0.2)cm,横宽为(1.25±0.2)cm.设内踝缺损面与胫骨纵轴的夹角为(Q),截骨角度X=L-N-Q,顶点位于腓骨头倒置后的关节面上1/6处.临床应用6例,全部一期愈合,随访1～3年,内踝发育良好,未发生骺早闭,无内翻畸形,踝关节负重、行走功能正常.结论 儿童腓骨头骨骺与内踝形态有一定的差异,通过截骨可获得满意的供体,同时携带皮瓣可一期修复内踝骨骺及周围软组织缺损并同步发育,是重建儿童内踝创伤性缺损的理想方法.     

带血管蒂骨骺瓣移植的基础与临床研究

目的介绍带血管蒂骨骺瓣移植的基础研究及相关临床应用。方法回顾总结笔者近20年来在带血管蒂骨骺瓣移植方面所做的相关应用解剖、动物实验及临床应用研究,探讨其临床应用疗效。结果膝下外侧动脉腓骨头骺瓣和臀上动脉深上支髂骨骺瓣均可作为骨骺游离移植的供区。动物实验表明,带血供的骨骺瓣移植能够成活并保持生长能力。1例膝下外侧动脉腓骨头骺瓣移植重建尺骨远端患者,18年随访示修复的尺骨与对侧几近等长且功能良好。结论带血管蒂骨骺瓣移植是修复儿童长骨骨端缺损的有效方法。     

腓骨头复合瓣重建内踝的临床研究

[目的]探索内踝骨与软组织缺损修复与重建的新方法。[方法]根据内踝部骨与复合软组织的缺损面积，设计以胫前动脉返支为蒂的腓骨头肌腱骨瓣，移植重建内踝和三角韧带，并组合游离移植背阔肌皮瓣修复内踝创面，临床应用7例，均为男性，分别因机器、车祸、猎枪弹伤。骨及软组织缺损，创面最小19cm×12cm，最大24cm×12cm。[结果]6例患者创面Ⅰ期愈合，1例创面感染，经抗感染换药6个月愈合。术后随访6个月～6年，平均3年，移植骨及皮瓣愈合良好，踝关节稳定，关节活动正常，内踝部外形好，效果满意。[结论]腓骨头复合瓣移植重建内踝是修复内踝缺损的好方法。     

儿童腓骨头骨骺移植重建内踝的中长期随访观察

目的对儿童腓骨头骨骺移植重建内踝的中长期疗效进行临床评价。方法自2004-01—2013-10采用腓骨头骨骺移植重建治疗11例内踝缺损的患儿,经中长期随访,观察患儿的症状及膝、踝关节功能、影像学改变。结果本组11例患儿移植组织全部成活,11例获得1~10年,平均6年7个月随访。11例患儿走、跑、跳功能正常,能正常上学、参加体育活动,3例大运动量后感踝关节酸胀,休息缓解。疗效按照膝关节功能按照HSS评分:优9例,良2例;踝关节功能按照AOFAS评分:优5例,良3例,可2例,差1例;影像学资料显示11例患儿腓骨近端骨缺损逐渐延长,内踝逐渐发育,足踝部出现影像学改变。按照踝部X线评分:优4例,良4例,可2例,差1例。并发症处理:3例皮瓣修整,1例骨桥切除、脂肪填塞(10岁),1例骨骺阻滞(13岁),1例截骨矫形(16岁),1例足趾肌腱松解。结论腓骨头骨骺移植重建内踝对于供区(膝、踝)无明显影响,功能恢复满意,在随访中应根据影像学改变做出针对性处理,以获得优良的远期效果。     

组合与复合组织移植治疗手部套脱伤

目的探讨组合与复合组织移植治疗手部套脱伤及重建手功能的疗效。方法应用组合组织瓣和复合组织瓣移植治疗伴有指缺损的全手或手指皮肤套脱伤15例，共移植26块组织瓣。结果15例26块组织瓣，全部成活25块，部分坏死1块。术后随访5．36个月。手功能评定：优12例，良3例。结论组合与复合组织瓣移植是治疗伴有指缺损的手部皮肤套脱伤，重建手功能的良好治疗方法。     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7–12, 2020     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。