影响髋臼骨折疗效的因素

目的：探讨影响髋臼骨折疗效的相关因素。方法：回顾性总结我院1990年1月－2000年1月收治的髋臼骨折患66例并加以分析。结果：全组66例，63例获得随访，平均随访20个月，根据Matta评分法评分，优26例（41．3％），良18例（28．6％），中10例（15．9％），差9例（14．3％）。结论：影响髋臼骨折疗效的主要因素包括骨折类型、治疗方法，手术时间、手术入路、复位的质量，术后的功能锻炼，并发症的预防。     

髋臼骨折手术并发症及预防

目的探讨髋臼骨折手术后并发症发生的原因及其预防措施，以提高髋臼骨折的手术治疗效果。方法髋臼骨折患54例，简单骨折选择单纯腹股沟人路18例(Ilioiguinal Approach)或单纯后人路20例(Kocher—langenback Approach)；复杂骨折采用前一后联合手术人路16例。结果所有患随访6～32个月，平均15．3个月。并发症发生情况：早期并发症：表浅感染1例占1．9％；坐骨神经损伤2例占3．7％；螺钉穿人髋臼1例占1．9％；腹壁疝1例占1．9％。晚期并发症：移位骨化3例占5．6％；骨性关节炎2例占3．7％。并发症发生率为18．5％。结论①手术治疗是髋臼骨折的首选方法，手术医生应熟练掌握髋臼的解剖特点及骨折类型，选择正确的手术人路；②术中应仔细操作，避免切口周围组织过度牵拉，尽量达到解剖复位或接近解剖复位，同时透视下确定螺钉的位置；③术后早期行患肢功能锻炼。     

经腹直肌旁入路手术治疗髋臼骨折的疗效

目的 探讨经腹直肌旁入路手术治疗髋臼骨折的临床疗效。方法 采用经腹直肌旁入路手术治疗43例髋臼骨折患者。记录术后骨折复位和愈合情况、并发症发生情况，采用Aubigne-Postel评分标准评价髋关节功能。结果 患者均获得随访，时间3～20个月。术后骨盆X线片显示髋臼骨折复位良好、关节面平整、髂坐线和髂耻线连续性良好。术后3个月骨折均基本愈合。术后未出现感染、神经损伤、腹股沟疝、肺栓塞、内固定失效、螺钉穿入关节腔、股骨头坏死等并发症。术后3个月采用Aubigne-Postel评分标准评价髋关节功能：优29例，良11例，中2例，差1例，优良率93.0%。末次随访时，患者均弃拐完全负重行走，步态正常，手术侧髋关节均达屈曲120°、外展40°、内收30°。结论 经腹直肌旁入路手术治疗髋臼骨折，具有切口小、显露满意、损伤小、并发症少、术后患者髋关节功能恢复好的优点。     

移位髋臼骨折的手术治疗

目的：探讨移位髋臼骨折的手术方法。方法：对38例髋臼骨折不同类型不同手术入路分别用加压螺钉、可吸收螺钉，普通钢板及重建钢板等予以内固定治疗。结果：随访平均19个月（6－42个月）。术后未发生伤口感染、坐骨神经或血管损伤及深静脉栓塞。复位情况按Judet方法评估，达到解剖复位者30例，复位满意者5例，不满意3例。按美国矫形外科研究院标准评估疗效：优23例，良8例，可4例，差3例。结论：开放复位内固定是治疗髋臼骨折较为可靠的方法，正确的骨折分型、手术切口的选择是复位成功的关键，内固定材料的选择是手术疗效的保证。     

手术治疗移位髋臼骨折的临床探讨

目的探讨和总结移位髋臼骨折的治疗方法。方法对我院从2010年5月~2015年5月收治的19例移位髋臼骨折患者进行回顾分析,总结其治疗方法及临床效果。结果 19例均获得随访,随访6~24个月(平均18个月),临床效果评价采用改良的d’Aubigne-Postel髋关节评分标准进行评分,优14例,良3例,可1例,差1例,优良率89.5%。1例术后出现严重的创伤性关节炎并股骨头缺血坏死行人工全髋关节置换,1例采用后入路患者发生异位骨化,1例术中牵拉损伤坐骨神经。结论采用合适的手术治疗方法治疗移位髋臼骨折,能重建髋关节的匹配及稳定性,术后患者可早期活动,临床疗效良好。     

经前后联合入路治疗复杂髋臼骨折28例分析

目的探讨经髂腹股沟联合K-L,入路治疗复杂髋臼骨折的疗效。方法自1999年7月至2007年6月，采用前后联合入路手术治疗复杂髋臼骨折28例，统计平均手术时间和出血量，术后X线表现按Matta标准评估，远期髋关节功能和异位骨化分别按d’Aubigne和Brooker标准评估。结果平均手术时间3．5h，平均失血量为1000mL。术后以Matta复位标准评价，优18例，良7例，中3例。术后随访6个月～3年，平均16个月。髋关节功能按d’Aubigne标准评定，优19例．良7例。中2例。异位骨化按Brooker标准评定，髂腹股沟人路无一例异位骨化，K—L入路发生异位骨化6例，无一例感染。结论前后联合手术入路有利于复杂髋臼骨折的显露和复位，临床效果好，并发症少     

髋臼骨折骨不连的治疗

目的 探讨髋臼骨折骨不连的发生原因及治疗方法。方法 1995年5月-2005年8月收治髋臼骨折骨不连患者10例，8例为手术后发生骨不连，第一次手术至第二次手术时间为10～24个月，平均15个月。术前仔细分析髋臼骨折损伤类型及发生骨不连的原因，根据发生骨不连部位分别采取Kocher-Langenbeck切口、髂腹股沟切口或前后联合切口手术，彻底清理骨折端，均行植骨内固定治疗。结果 9例患者获得15～27个月（平均19个月）随访，经二次手术，骨折骨不连均达到骨性愈合。髋关节功能按照Matta的评分标准：优3例，良5例，可1例。结论 髋臼骨折骨不连多由于治疗者缺乏髋臼骨折治疗经验、治疗措施不当引起。准确掌握手术适应证、术前明确骨折分类、把握手术时机、正确选择切口、满意的复位和正确的内固定方式是预防术后骨不连的关键。     

陈旧性髋臼骨折的手术治疗

目的：探讨陈旧性髋臼骨折手术治疗的方法并评价术后疗效。方法：对1993年8月-2001年8月手术治疗的陈旧性髋臼骨折32例的手术入路、手术方法、功能结果及并发症进行回顾性分析。结果：平均随访时间49.6个月。髋关节功能评分优3例,良16例,中10例,差3例,优良率为59.4％。术后出现坐骨神经损伤1例,出现异位骨化6例,股骨头坏死3例。结论：陈旧性髋臼骨折的治疗要慎重选择手术指征,经恰当的手术入路,正确的复位固定方法,可以获得相对满意的结果。     

移位髋臼骨折的手术治疗

目的探讨移位髋臼骨折的手术方法。方法对22例髋臼骨折按不同类型、不同手术入路分别用加压螺钉、重建钢板等予以内固定治疗。结果平均随访14个月(5~30个月)。术后发生1例伤口感染和1例坐骨神经牵拉伤,未发生血管损伤及深静脉栓塞。复位情况按Judet方法评估,达到解剖复位者18例,复位满意者4例。按美国矫形外科研究院标准评估疗效,优14例,良5例,可2例,差1例。结论重建钢板内固定治疗移位髋臼骨折是有效的方法,正确的骨折分型、手术切口的选择是复位成功的关键。     

髋臼骨折手术治疗后髋关节功能恢复的影响因素分析

背景：髋臼骨折多为高能量损伤所致,属于关节内骨折,手术是最佳治疗方式。但骨折类型、手术入路、复位质量、年龄、手术时机等会对治疗效果产生影响。因此,分析影响手术效果的关键因素十分必要。目的：探讨手术治疗髋臼骨折后影响髋关节功能恢复的因素。方法方法：选择2010年1月至2013年10月手术治疗且随访资料完整的髋臼骨折患者42例,18例采用Kocher-Langenbeck入路,14例采用髂腹股沟入路,10例采用前后联合入路。术后采用Matta标准评定骨折复位情况。采用改良的Merled＇Aubigne-Postel评分系统评价患者髋关节功能。对可能影响手术疗效的指标（如性别、年龄、手术时机、骨折类型、手术入路、复位质量等）进行单因素及多因素Logistic回归分析,筛查影响手术疗效的危险因素。结果：术后14例达到解剖复位,20例良好复位,8例一般复位。切口均甲级愈合,未出现感染。全部患者术后随访12-26个月,平均19个月。X线检查示骨折于术后10-18周愈合,平均14周。术后出现坐骨神经损伤4例,创伤性关节炎2例,股骨头缺血坏死2例,异位骨化7例。术后6个月时髋关节功能评定为优13例,良21例,可5例,差3例,优良率为81%。单因素分析结果显示性别、年龄、手术入路、髋关节脱位与手术疗效无明显关系（P〉0.05）,而手术时机、骨折类型、复位质量、异位骨化与手术疗效有关（P〈0.05）。多因素分析显示骨折类型、手术时机、复位质量是影响手术效果的独立因素（P〈0.05）。结论：骨折类型、手术时机和复位质量是影响髋臼骨折手术疗效的独立因素,而后两者是相对可控的因素,治疗时要选择合适时机、尽量达到解剖复位,以期获得良好的临床结局。     

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.     

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.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.