股骨转子间骨折围手术期隐性失血的比较研究

 目的 探讨围手术期不同内固定方式、不同时段隐性失血量的差异。方法 回顾性分析2008 年1 月至2012 年1 月应用动力髋螺钉(DHS)、股骨近端短重建钉(IMHS)和经皮加压钢板(PCCP)治疗AO/OTA 31-A1、31-A2 型股骨转子间骨折患者的围手术期临床资料, 其中DHS 组35 例, IMHS 组55 例, PCCP组38 例。比较不同内固定方式及不同时间段(术后第1 天、第2~3 天、第4~5天)的隐性失血量。结果 三种手术方式治疗股骨转子间骨折术后平均总隐性失血量是平均显性失血量的7 倍以上。PCCP、IMHS、DHS 组组间总隐性失血量比较, 差异均有统计学意义;而IMHS 组与DHS 组比较, 差异无统计学意义。对于阶段性隐性失血量, 在DHS 组三个时间段比较, 差异无统计学意义;在IMHS 组及PCCP 组, 术后第4~5 天与第1 天、第2~3 天比较差异均有统计学意义;而术后第1 天与第2~3 天比较差异无统计学意义。对于各组三个时间段阶段性隐性失血量/总隐性失血量比例, 术后第4~5 天与术后第1天、第2~3天比较, 差异均有统计学意义, 而术后第1 天与第2~3 天比较差异无统计学意义。结论 股骨转子间骨折围手术期隐性失血量远大于术中显性失血量。PCCP 组的总隐性失血量明显少于IMHS 组和DHS 组, 而IMHS 组与DHS 组的总隐性失血量相似。隐性失血主要发生在手术后的前3 d, 故术后前3 d应密切监测患者的血红蛋白变化, 及时评估患者的失血情况。     

Mechanical and hypoxia stress can cause chondrocytes apoptosis through over-activation of endoplasmic reticulum stress

ObjectiveTo examine the role of mechanical force and hypoxia on chondrocytes apoptosis and osteoarthritis (OA)-liked pathological change on mandibular cartilage through over-activation of endoplasmic reticulum stress (ERS).MethodsWe used two in vitro models to examine the effect of mechanical force and hypoxia on chondrocytes apoptosis separately. The mandibular condylar chondrocytes were obtained from three-week-old male Sprague–Dawley rats. Flexcell 5000T apparatus was used to produce mechanical forces (12%, 0.5 Hz, 24 h vs 20%, 0.5 Hz, 24 h) on chondrocytes. For hypoxia experiment, the concentration of O₂ was down regulated to 5% or 1%. Cell apoptosis rates were quantified by annexin V and propidium iodide (PI) double staining and FACS analysis. Quantitative real-time PCR and western blot were performed to evaluate the activation of ERS and cellular hypoxia. Then we used a mechanical stress loading rat model to verify the involvement of ERS in OA-liked mandibular cartilage pathological change. Histological changes in mandibular condylar cartilage were assessed via hematoxylin & eosin (HE) staining. Immunohistochemistry of GRP78, GRP94, HIF-1α, and HIF-2α were performed to evaluate activation of the ERS and existence of hypoxia. Apoptotic cells were detected by the TUNEL method.ResultsTunicamycin, 20% mechanical forces and hypoxia (1% O₂) all significantly increased chondrocytes apoptosis rates and expression of ERS markers (GRP78, GRP94 and Caspase 12). However, 12% mechanical forces can only increase the apoptotic sensitivity of chondrocytes. Mechanical stress resulted in OA-liked pathological change on rat mandibular condylar cartilage which included thinning cartilage and bone erosion. The number of apoptotic cells increased. ERS and hypoxia markers expressions were also enhanced. Salubrinal, an ERS inhibitor, can reverse these effects in vitro and in vivo through the down-regulation of ERS markers and hypoxia markers.ConclusionWe confirmed that mechanical stress and local hypoxia both contributed to the chondrocytes apoptosis. Mechanical stress can cause OA-like pathological change in rat mandibular condylar cartilage via ERS activation and hypoxia existed in the meantime. Both mechanical forces and hypoxia can induce ERS and cause chondrocytes apoptosis only if the stimulate was in higher level. Salubrinal can protect chondrocytes from apoptosis, and relieve OA-liked pathological change on mandibular condylar cartilage under mechanical stress stimulation.     

肿瘤型假体重建膝关节周围原发性肿瘤切除后骨缺损

目的总结膝关节周围原发性骨肿瘤保肢手术中人工关节重建的疗效和并发症。方法回顾性分析我院1995年12月至2005年12月83例应用肿瘤型假体重建膝关节周围骨肿瘤切除后骨缺损的临床资料。其中骨肉瘤58例,多中心骨肉瘤2例,皮质旁骨肉瘤1例,恶性纤维组织细胞瘤4例,骨巨细胞瘤13例,平滑肌肉瘤1例,尤文肉瘤2例,软骨肉瘤2例。根据骨缺损重建部位分组：股骨下端组44例,胫骨上端组34例,全股骨置换组5例。结果所有患者均获得随访,随访时间12～130个月,平均41个月。局部复发6例,2例晚期感染,假体松动2例,无假体断裂;假体3、5年生存率分别为88．2％、82．1％。41例植骨患者形成皮质外骨桥。肢体肌肉骨骼肿瘤外科治疗重建术后功能评分：股骨下端组19．0—29．0分,平均25．0分;胫骨上端组17．0—28．0分,平均24．4分;全股骨置换组16．0—21．0分,平均19．0分。股骨下端组和胫骨上端组功能优于全股骨置换。结论肿瘤型人工关节重建膝关节周围骨肿瘤并发症发生率低,关节功能良好。     

Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery

Spinal stenosis refers to narrowing of the spinal canal with encroachment of the neural structures by adjacent bone and soft tissue. Surgical treatment usually offers greater pain relief and functional recovery than non-surgical treatment. Nevertheless, neurological complications from decompressive laminectomy have been reported to range between 1% and 33%. Therefore, the purpose of this prospective study was to evaluate the efficacy of transcranial motor evoked potentials (TcMEP) and continuous electromyography (EMG) to prevent irreversible pyramidal tract damage during decompressive laminectomy. We prospectively evaluated 25 patients (11 males and 14 females) who underwent decompressive laminectomy for lumbar spinal stenosis. TcMEP and EMG were monitored intraoperatively. Postoperatively all patients had regular follow-up examinations. Electrophysiological monitoring was not performed in two patients because of the use of incompatible anaesthetic regimens. In 17/25 patients there was an increase in TcMEP amplitudes of more than 50%, whereas in six patients the amplitudes only slightly increased or remained unchanged. The 17 patients with the increased TcMEP amplitudes had the greatest improvement 3 and 12 months postoperatively, based on neurological examination and the visual analog scale pain ratings (p < 0.001). Intraoperative monitoring may allow rapid identification of potential damage of the neural structures and avoidance through corrective action. TcMEP and continuous EMG monitoring is an effective method for monitoring neural function cord during surgical decompression of the lumbar spine and may additionally give prognostic information for the assessment of patient outcome.     

胫骨后外侧平台骨折的CT形态学研究

 目的 探讨胫骨后外侧平台关节面骨折在胫骨平台骨折中的发生率及其形态学特点。方法 回顾性分析2008年 5月至 2013年 1月 309例胫骨平台骨折患者的 CT图像及临床资料,其中 45例 CT图像缺失或不兼容医学影像存储和传输（PACS）系统予排除,共纳入 264 例患者资料。确定胫骨平台后外侧象限关节面骨折块在胫骨平台骨折中的发生率并测量其骨折线的轴向角度、受累面积、矢状位角度、骨折块高度及移位程度等形态学参数。结果 在 264例胫骨平台骨折中,共检测到 39例胫骨平台骨折存在后外侧象限关节面骨折块,在胫骨平台骨折中的发生率为 14.8%（39/264）。其中男 18例,女 21例;年龄 31~70岁,平均 52岁;左侧 17例,右侧 22例。致伤原因：交通伤 22例,重物砸伤 2例,摔伤 11例,受伤原因不明 4例。后外侧象限关节面骨折块的骨折线偏于冠状位,骨折线轴向角度为-43°~62°,平均 22°;受累的后外侧骨折块面积占整个胫骨平台面积的 8%~32%,平均 14.1%;后外侧平台骨折块的矢状位角度为 58°~97°,平均 76°,提示该骨折块在垂直剪切应力下易发生移位;后外侧骨折块的高度为 18~42 mm,平均 28 mm;后外侧髁骨折块平均移位 2~19 mm,平均 10.48 mm。结论 胫骨平台骨折累及后外侧平台关节面的发生率为 14.8%;胫骨后外侧平台关节面的骨折线偏于冠状位且矢状位角度较大,骨折块所累及的关节面面积较小。     

Specific Decrease in B-Cell-Derived Extracellular Vesicles Enhances Post-Chemotherapeutic CD8+ T Cell Responses

1. Download high-res image (197KB)
2. Download full-size image

     

低频超声对万古霉素骨水泥药物释放的影响

目的在体外和动物体内条件下研究低频超声对抗生素骨水泥（antibiotic-loaded bone cement,ALBC）的促释放作用及其规律.方法制作载万古霉素ALBC的体外试件和体内试件.分别将质量分数为5%和10%的ALBC体外试件随机分为对照组、100mW/cm^2超声组和300mW/cm^2超声组.所有试件于40 ml PBS中浸泡8 h后,超声组接受超声干预30 min,观察浸泡24 h内药物累积浓度的变化.另取健康新西兰大白兔16只,将质量分数为7.5%的ALBC植入髋关节后随机分为对照组和超声组,每组8只.超声组于术后不同时间接受超声干预30min（300mW/cm^2）,术后5 d内定时检测引流液和尿液中万古霉素浓度,术后4周检测ALBC残余药量.结果体外条件下100mW/cm^2超声组和1000 mW/cm^2超声组在浸泡24 h后的药物释放分别较10%对照组增加71.77%、73.62%,50mW/cm^2超声组和500 mW/cm^2超声组分别较5%对照组增加13.03%、23.78%.超声强度和药物载荷均显著增加ALBC的药物释放.体内条件下超声组药物释放量在术后1 d和5 d分别较对照组高148.18%（t=3.510,P＜0.01）和82.39%（t=2.345,P＜0.05）,术后4周超声组ALBC药物溶出低于对照组（t=3.697,P＜0.01）.结论低频连续型超声能促进和加快ALBC的药物释放.     

Locally applied simvastatin promotes fracture healing in ovariectomized rat

Summary Simvastatin solution was injected subcutaneously to the site of fractured tibiae of ovariectomized rats. Afterwards healing quality was evaluated by morphologic, radiographic, biomechanical, histological and histomorphometric methods at 1, 2 and 4 weeks after fracture. Results showed that locally applied simvastatin improved fracture healing. Introduction Many studies have documented an anabolic effect of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, statins, on undisturbed bone. Reports of their effects, however, on fractured skeletal sytems have been limited. A study was, therefore, conducted to check the effects of statins on fracture healing. Methods Simvastatin (10 mg/kg/day) was injected subcutaneously to tissue overlying the site of fractured tibiae of ovariectomized rats for a treatment period of 5 days. Vehicle reagent was used as a control. Healing quality was evaluated at 1, 2 and 4 weeks after fracture. Results Compared with that in the vehicle group, the callus cross-section area in simvastatin-treated rats was significantly enlarged by 21.3% (p < 0.05) at 1 week and by 21.5% (p < 0.05) at 2 weeks; new woven bone was relatively substantive and arranged more tightly and regularly at 2 and 4 weeks; and maximal load was increased by 57.5% (p < 0.05) at 2 weeks and by 31.4% (p < 0.05) at 4 weeks. Histomorphometrically, simvastatin was associated with a significant (p < 0.05) increase of mineralization width (MLW), mineralization volume (MLV) and mineral apposition rate (MAR). Conclusion The current study suggests that local application of simvastatin could promote fracture healing in ovariectomized rats.     

计算机辅助经髋臼长螺钉固定进钉安全区的解剖研究

目的探讨经髋臼长螺钉固定骨性钉道的安全进钉区。方法选取10具成年男性半骨盆,每个半骨盆分成髂前区、髂后区、耻骨区和坐骨区并断层。通过断层的边界参数建立三维模型,利用计算机C语言辅助程序计算全钉道在骨性区域内的钉道参数,形成钉道线的集合,钉道线在髋臼上的交点形成点阵,这些点阵的集合代表了髋臼区进钉的位置。在髋臼球中心建立三维坐标系,建立间隔15°的经纬线以定义和描述点阵所分布的区域。结果所构建的骨盆四个分区三维模型逼真反映髋臼的真实几何形态。髂前区、髂后区、耻骨区和坐骨区各自允许长达60 mm、100mm、50 mm及40 mm的螺钉安全固定,进钉区分别位于经线方向60°到150°、纬线0°到30°的区域,经线60°到150、纬线0°到75°的区域,经线-15°到45°、纬线0°到45°的区域及经线-75°到-150°、纬线0°到30°的区域。结论髋臼四个分区均能获得临床满意的长螺钉钉道安全区域,有助于指导全髋翻修术的长螺钉固定以及假体改良设计。     

混合式单臂外固定架骨延长术治疗感染性骨不连

目的评价混合式单臂外固定架骨延长术治疗长骨干骺端感染性骨不连的初步临床结果。方法2003年1月至2006年2月采用混合式单臂外固定架固定、局部清创和截骨延长法治疗感染性骨不连21例,男17例,女4例;年龄18～48岁,平均31.5岁。16例为开放骨折内固定术后感染,5例为闭合骨折内固定术后感染。胫骨近端12例,胫骨远端6例,股骨远端3例。12例行骨折端植骨,其中2例二次植骨。结果21例术后随访10～36个月,平均18个月。18例骨折获得初期愈合,3例骨折愈合时仍有局部窦道和渗液,2例骨折尚未完全愈合,1例行截肢术,20例感染得到控制。改良ASAMI骨评定结果为优良13例,中4例,差4例;功能评定结果为优良11例,中6例,差4例。平均骨延长5.6cm,平均愈合时间为11个月。15例发生钉道感染。结论对长骨干骺端感染性骨不连可使用混合式单臂外固定架骨延长术、骨折端开放换药的方法。该方法控制感染好,可自体修复骨缺损,供区畸形发生率低。但固定需采用HA涂层螺钉,严格控制延长速度,一般在1mm/d以内,分次进行延长,手术风险小。