分步复位与有限切开复位髓内钉固定治疗股骨转子下骨折的疗效比较

目的:比较分步闭合复位髓内钉固定与有限切开复位髓内钉固定治疗股骨转子下骨折的临床疗效。方法:回顾性分析2014年1月至2020年4月符合纳入标准的46例股骨转子下骨折患者,采用仰卧位分二步闭合复位髓内钉固定24例(闭合复位组),男16例,女8例,年龄34～91(55.42±18.25)岁。采用有限切开复位髓内钉固定22例(有限切开组),其中男15例,女7例,年龄33～87(56.31±14.77)岁。记录两组患者的手术时间,术中出血量,并发症,骨折愈合时间。术后8个月随访时采用髋关节Harris评分系统评估关节功能。结果:所有患者顺利完成手术,无切口感染发生。所有患者获得随访,时间8～36(18.2±6.1)个月。闭合复位组术中出血量、手术时间分别为(157.92±51.07) ml、(82.08±13.43) min,有限切开组分别为(230.91±87.88) ml、(92.73±12.79) min,两组比较差异有统计学意义(P0.05);两组骨折愈合时间比较差异无统计学意义(P0.05)。两组术后并发肺部感染各2例,经内科治疗后痊愈。术后8个月闭合复位组Harris评分(88.42±6.85)分与有限切开组(88.55±6.31)分比较差异无统计学意义(P0.05)。结论:分步闭合复位髓内钉固定及有限切开复位髓内钉固定治疗股骨转子下骨折均可获得满意效果,但分步复位髓内钉固定手术创伤小,手术时间短,术中出血少。     

有限切开辅助复位防旋股骨近端髓内钉治疗不稳定股骨转子间骨折

目的探讨有限切开辅助复位防旋股骨近端髓内钉(PFNA)治疗不稳定股骨转子间骨折的疗效。方法采用有限切开辅助复位PFNA内固定技术治疗23例不稳定股骨转子间骨折患者。根据影响复位的不同情况采用有限切开器械撬拨或钢丝环扎辅助复位治疗。结果骨折复位情况:优17例,良4例,差2例。术后1例死于肺栓塞,1例失联,21例获得随访,时间9～21个月。21例骨折愈合,愈合时间为10～22周。末次随访根据髋关节Harris评分标准评定疗效:优14例,良4例,可2例,差1例,优良率为18/21。结论采用有限切开器械辅助复位PFNA治疗不稳定股骨转子间骨折能保护骨折端血运,减少软组织剥离,骨折复位相对满意,可提高手术治疗的成功率。     

有限切开InterTan髓内钉治疗股骨转子下骨折

目的 探讨有限切开InterTan髓内钉治疗股骨转子下骨折的疗效.方法 采用有限切开InterTan髓内钉治疗33例股骨转子下骨折患者.记录手术时间、术中出血量、并发症发生情况、骨折复位情况、骨折愈合情况、疼痛VAS评分、膝关节活动度.采用Harris评分评价髋关节功能.结果 患者均获得随访,时间1～2(1.2±0.4...     

钛缆捆扎结合髓内钉治疗难复性股骨近端骨折

目的探讨钛缆捆扎结合髓内钉治疗难复性股骨近端骨折。方法采用钛缆捆扎结合股骨髓内钉内固定技术治疗23例难复性股骨近端骨折。根据术中骨折牵引移位特点予有限切开钛缆捆扎复位治疗。结果术中透视骨折复位:优19例,良4例术后1例死于误吸,22例获得随访,时间6～12个月,22例骨折愈合,愈合时间为6～12周。髋关节Harris评分标准评分85～97分,平均92.3分:优17例,良4例,可1例,优良率为95.4%(21/22)。结论钛缆捆扎结合髓内钉治疗难复性股骨近端骨折可以尽最大可能保留骨折端血供,降低骨周组织的破坏,达到良好的骨折复位,明显提高手术治疗的效果。     

股骨转子部骨折髓内钉内固定手术失败的原因分析及预防

目的 探讨股骨转子部骨折髓内钉内固定手术失败的原因及其预防.方法 回顾性分析2008年5月至2011年12月采用髓内钉固定且出现医源性手术失败的4例股骨转子部骨折患者资料,均为女性;年龄65～81岁,平均72.0岁.股骨转子间骨折3例,按改良Evans分型:ⅡB2例,Ⅲ型1例;股骨转子下骨折1例,根据Russell-Taylor分型为IA型.入院至手术时间为3～5d,平均3.8d.结果 手术失败原因:骨折复位错误2例,髓内钉置入错误2例.4例患者术后获10～14个月(平均11.6个月)随访.1例股骨转子间骨折患者术中并发股骨干骨折,卧床4个月后开始部分负重,术后9个月X线片示骨折基本获愈合.1例股骨转子下骨折患者术中并发股骨近端骨折,卧床4个月后行全髋关节置换术治疗.2例股骨转子间骨折患者术后较术前骨折断端明显移位,卧床3个月后部分负重,术后6个月X线片示骨折基本获愈合,患者生活自理,但存在髋关节内翻畸形.结论 骨折复位错误和髓内钉置入错误是股骨转子部骨折手术失败的主要原因.手术失败严重影响患者的康复,术中良好的复位、内固定物正确的放置是手术成功的关键.     

闭合或有限切开复位髓内钉固定治疗Seinsheimer Ⅴ型股骨转子下骨折疗效分析

目的探讨闭合或有限切开复位髓内钉固定治疗Seinsheimer Ⅴ型股骨转子下骨折的疗效。方法 2014年5月—2018年7月,采用闭合或有限切开复位髓内钉固定治疗36例Seinsheimer Ⅴ型股骨转子下骨折患者。男25例,女11例;年龄23～86岁,平均55.8岁。致伤原因:摔伤19例,交通事故伤9例,高处坠落伤7例,重物砸伤1例;均为新鲜闭合性损伤。受伤至手术时间1～14 d,平均6.8 d。术中闭合复位18例,有限切开复位18例;采用股骨重建髓内钉固定17例,InterTan长钉固定5例,加长型股骨近端防旋髓内钉固定14例,辅助钢丝捆扎7例。术后通过X线片和临床随访,判断骨折复位维持情况、内固定物位置、骨折愈合情况;观察髋关节活动范围、行走能力及并发症发生情况,根据Merle d’Aubigne-Postel髋关节评分标准评价髋关节功能。结果术后患者髋部手术切口均Ⅰ期愈合,无血管、神经损伤及感染等并发症发生。患者均获随访,随访时间12～24个月,平均14.2个月。1例患者闭合复位术后2个月出现股骨头内翻移位、螺钉穿出现象,给予翻修手术,髋关节功能恢复稍差。其余患者术后X线片示骨折均愈合,愈合时间9～15个月,平均11.5个月;随访期间未出现内固定失效、骨折再移位、骨不连、畸形愈合、下肢深静脉血栓形成等并发症;髋关节功能恢复良好,能够正常行走、下蹲,不影响日常生活或工作。末次随访时,根据Merle d’Aubigne-Postel髋关节评分标准评价,获优28例,良4例,中3例,差1例,优良率88.9%。结论 C臂X线机透视下闭合或有限切开复位髓内钉固定治疗Seinsheimer Ⅴ型股骨转子下骨折,必要时辅助钢丝捆扎,具有骨折端血供破坏少、复位满意、固定牢靠及利于早期康复训练等优点,疗效确切。     

股骨近端锁定钢板内固定治疗股骨转子下骨折

目的分析应用股骨近端锁定钢板内固定治疗股骨转子下骨折的疗效。方法对22例闭合复位不满意的股骨转子下骨折患者采用有限切开骨折复位结合股骨近端锁定钢板内固定治疗。结果患者均获得随访,时间8～22个月。骨折愈合时间为3～10个月。术后6个月按髋关节Harris评分评定疗效:优13例,良5例,可3例,差l例。结论对于闭合复位不满意的股骨转子下骨折,有限切开复位股骨近端锁定钢板内固定治疗,能够较好地恢复肢体功能,是一种可行的治疗方法。     

半卧位牵引床闭合复位PFNA内固定治疗股骨粗隆下骨折的疗效分析

目的探讨半卧位牵引床闭合复位股骨近端防旋髓内钉(PFNA)内固定治疗股骨粗隆下骨折的手术技巧及疗效。方法回顾性分析自2016-02—2018-05采用半卧位牵引床闭合复位PFNA内固定手术治疗的18例股骨粗隆下骨折,术后6个月采用髋关节功能Harris评分评估疗效。结果本组手术时间平均58(50～65)min,术中出血量平均75(50～100)mL,住院时间平均18(16～22)d。16例通过闭合牵引复位获得骨折功能复位并顺利置入PFNA主钉,2例经过骨折线处作小切口复位钳辅助复位置入PFNA主钉,术后均无髋内翻、旋转畸形。18例均获得随访,随访时间平均7.5(3～12)个月,术后6个月髋关节功能Harris评分:优16例,良2例。末次随访时骨折均达到临床愈合标准,无骨折延迟愈合或骨折不愈合。结论半卧位牵引床闭合复位PFNA内固定治疗股骨粗隆下骨折可获得骨折功能复位,便于主钉准确置入,疗效满意,值得临床推广应用。     

有限切开复位髓内钉结合钢丝捆扎内固定治疗股骨转子下骨折

目的 探讨有限切开复位髓内钉结合钢丝捆扎内固定治疗股骨转子下骨折的临床效果及手术技巧。方法采用有限切开复位髓内钉结合钢丝捆扎内固定治疗26例股骨转子下骨折患者。记录手术情况,末次随访时采用Harris功能评分标准评价疗效。结果 手术时间70～110 min。术中出血量150～350 ml。患者均获得随访,时间4～20个月。术后无切口感染、骨折不愈合、内固定断裂失效等并发症发生。骨折愈合时间为4～6个月。末次随访时,采用Harris功能评分标准评价疗效:优19例,良6例,可1例,优良率25/26。结论有限切开复位髓内钉结合钢丝捆扎内固定治疗股骨转子下骨折具有创伤小、复位简单、固定可靠、骨折愈合率高等优点。     

微创钢丝导入器引导下的钢丝复位技术在难复性股骨转子间骨折治疗中的应用

目的探讨利用微创钢丝导入器引导下的钢丝复位技术在难复性股骨转子间骨折治疗中的应用。方法 2016年4月—2018年4月,收治30例术中牵引床下闭合复位困难的股骨转子间骨折患者。其中男17例,女13例;年龄60～93岁,平均72岁。致伤原因:跌伤22例,交通事故伤8例。骨折根据国际内固定研究协会/美国骨创伤协会(AO/OTA)分型:A1型12例,A2型12例,A3型6例。受伤至入院时间3～40 h,平均6.5 h。术中利用髓内钉头颈钉切口,配合自制微创钢丝导入器置入钢丝捆扎辅助复位股骨转子间骨折,再行髓内钉内固定治疗。结果患者手术时间30～70 min,平均45 min;术中显性出血量100～210 mL,平均160 mL。术后3个月因脑血管疾病意外死亡1例;余29例患者均获随访,随访时间6～18个月,平均8.3个月。术后DR复查示所有患者骨折端均获得良好复位,未出现退钉、骨折移位、髋内外翻畸形等严重并发症;骨折完全愈合,愈合时间3～8个月,平均6个月。术后3个月疼痛视觉模拟评分(VAS)为1～3分,平均1.7分;根据髋关节Harris功能评分评价为优26例,良3例。结论对于难复性股骨转子间骨折,利用头颈钉切口使用微创钢丝导入器置入钢丝辅助复位,可达到满意复位,提高股骨转子间骨折治疗效果。     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

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.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

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.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.