X线引导下经皮通用脊柱系统内固定治疗胸腰椎骨折

目的探讨X线引导下经皮通用脊柱系统(USS)内固定治疗胸腰椎骨折的可行性.方法 2002年10月～2004年5月对无须减压胸腰椎骨折8例采用后路经皮USS椎弓根螺钉植入,在椎旁肌深层置入固定棒行伤椎复位固定.结果手术时间120～240 min,平均140 min.术中出血量20～90 ml,平均40 ml.后凸Cobb's角术前(21.5±4.3)°、术后(2.7±1.5)°(t=17.541,P=0.001),椎体塌陷术前18.5%±4.1%、术后2.4%±1.0%(t=16.504,P=0.001).术后3周佩戴腰围支具下床,复查Frankel分级,C级恢复至D级2例,D级恢复至E级1例,保持D级1例,保持E级4例.结论经皮USS内固定治疗无须减压的胸腰椎骨折创伤小,恢复快,但技术难度高,X线暴露时间长.     

Robotic surgery in gynecologic oncology: evolution of a new surgical paradigm

Robotic surgical platforms were first developed with telesurgery in mind. Conceptualized by NASA and the military to provide surgical expertise to remote locations, some telesurgical success has been documented, but progress has been held back by communication bandwidth limitations. Telepresence surgery, where the surgeon is in proximity to the patient but is provided with an ergonomic console equipped with three-dimensional vision and autonomous control of wristed laparoscopic surgical instruments and energy sources, has shown efficacy first in cardiac and then urologic cancer surgery. Interest is currently focused on the application of this technology in the field of gynecology, with techniques being described to perform simple hysterectomy, myomectomy, tubal anastomosis, and pelvic reconstruction procedures. This article will review the application of robotic- and computer-assisted surgery in the specialty of gynecologic oncology.     

X线透视导航技术在创伤骨科的应用

X线透视导航技术对创伤骨科尤为重要。因为术前骨折块及骨折移位的方向可发生改变,所以需在术中将骨折块整复对位后,才能进行透视图像的获取和导航手术操作。X线透视导航技术的优点包括减少X线暴露的时间、准确放置植入物、术中适时测量评估及改善创伤骨科的微创操作。随着软件和硬件的不断改进及发展,许多需要术中X线透视监控的手术操作现在都可以借助X线透视导航技术完成。我们过去四年的临床经验已证实X线透视导航技术的优点及不断扩大的应用领域。X线透视导航技术在不断进展,因此需要更多的临床实践来评价此技术的使用价值。另外,X线透视导航系统在虚拟外科环境的外科培训和评价中发挥重要作用。这一技术将不仅为年轻外科医生提供实践机会,而且也将产生设计外科技术资格客观评价系统的新领域。     

计算机辅助导航骨科手术及医用机器人技术在创伤骨科的应用

本文介绍了计算机辅助导航骨科手术(CAOS)及医用机器人技术在创伤骨科应用中的主要进展、当前在临床应用中存在的主要问题和相关对策,并对其未来的发展趋势进行了预测,同时简要介绍了北京积水潭医院创伤骨科在计算机辅助导航骨科手术及医用机器人技术方面的研究进展。当前骨科手术导航定位所应用的医学图象导引系统已经由使用单一的C型臂、CT等传统影像设备向应用三维C型臂、多模态图像处理系统等新型影像设备转变,基于多模态图像的导航系统将有可能成为导航手术的主流。医用机器人已经在自动化程度和人机交互模式方面,有了长足进展,摆脱了原有工业机器人的结构模式。医学图像后处理技术及其它相关信息技术极大地丰富了导航和机器人外科,只有在不断完善光学定位技术的同时,加大对其它定位方法的研究,才能够提高定位精度;要对相关设备进行开放式结构设计,使不同导航系统的注册软件能够互相兼容,手术器械能够通用,降低设备成本。骨科医生要正确认识计算机辅助导航骨科手术及医用机器人技术,在充分了解CAOS的技术特点、基本原理、操作程序的基础上,对要实施的手术具有深刻的理解,才能开展CAOS手术。目前,迫切需要建立CAOS技术标准、临床适应证和手术操作规范,进行CAOS产品之间的技术比较和评估,便于医生选择合适的CAOS产品。伴随快速发展的信息技术,数字化手术室、智能化微创导航手术系统、医用机器人辅助的远程医疗将有可能成为未来CAOS技术的主要组成部分。     

Minimally invasive hemiarthroplasty in femoral neck fractures. Randomized comparison between a mini-incision and an ordinary incision: preliminary results

Minimally invasive osteosynthesis is a well-recognized treatment; however, those of arthroplasty or hemiarthroplasty may rarely be performed. We reviewed the comparison of a mini-incision approach in hemiarthroplasty versus that of an ordinary approach in patients with femoral neck fractures. Two different operative procedures were compared. Thirty-two patients (group 1) had a mini-incision in hemiarthroplasty. Thirty-two patients (group 2) were treated with the conventional approach. The postoperative treatment course was the same for both groups. The mean length of follow-up was 25 months. The results were excellent or good in 86% of the patients (50 of 64) and were equally good for both procedures. However, the full weight bearing term was significantly shortened for patients treated by the mini-incision procedure. Good and excellent results can be expected from either the mini-incision or the ordinary approach in hemiarthroplasty. Only full weight bearing term was significantly short following the mini-incision. This approach results in less dissection and facilitates rapid patient recovery and possibility earlier discharge from the hospital.     

Pilon骨折的微创治疗

目的探讨微创技术治疗Pilon骨折的手术方法、手术指征及其手术疗效。方法采用微创手术治疗的26例Pilon骨折患，平均年龄46．2岁；骨折类型：Rtiedi—Allgower-Pilon骨折分型Ⅰ型12例、Ⅱ型10例、Ⅲ型4例。3例行空心螺钉固定，14例行MIPPO技术钢板固定，9例应用外固定支架，其中4例使用外固定支架结合有限内固定。术后平均随访18．2个月。结果采用Mazur方法评估手术疗效，26例患，优18例、良7例、可1例，优良率92．3％。术后并发症包括创面不愈合1例、复位不良1例、关节退行性变2例。结论正确选择手术时机，术中良好复位，根据骨折类型选择微创固定方式是治疗Pilon骨折有效方法。     

Neurosurgical robotics: a review of brain and spine applications

Neurosurgery has traditionally been at the forefront of advancing technologies, adapting new techniques and devices successfully in an effort to increase the safety and efficacy of brain and spine surgery. Among these adaptations are surgical robotics. This paper reviews some of the more promising systems in neurosurgical robotics, including brain and spine applications in use and in development. The purpose of the discussion is twofold—to discuss the most promising models for neurosurgical applications, and to discuss some of the pitfalls of robotic neurosurgery given the unique anatomy of the brain and spine.     

Experimental Assessment of Right Ventricular Function in Normal Pigs with a Left Ventricular Assist Device

Abstract: Right ventricular (RV) failure during the use of a left ventricular assist device (LVAD) is the leading cause of death in circulatory support patients. Previous work, both experimentally and clinically, has shown the difficulties in predicting the behavior of the right ventricle at the start of LVAD. An experimental study has been designed to evaluate RV functional changes during LVAD and its relation to preload changes. The model used adult mongrel pigs (n = 10). Right ventricular functional parameters were measured with a thermodilution RV ejection fraction catheter. The left ventricle was supported by a Nippon Zeon blood pump. Two groups were studied, the first one was the LVAD–off group (n = 5) and the other was the LVAD–on group (n = 5) which was supported by LVAD at maximum flow. Change of cardiac output, mean pulmonary artery pressure (PAP), RV stroke work, and RV ejection fraction in both groups were not significantly different. However, the relationship between right ventricular end–diastolic pressure (RV–EDP) and right ventricular stroke volume (RVSV) was significantly changed at a high level of RV–EDP. When RV–EDP was over 6. 5 mm Hg in the LVAD–off group, RVSV decreased to 52. 3 ± 11. 5 ml while in the LVAD–on group, RVSV increased to 97. 2 ± 22. 0 ml. The change in PAP in the LVAD–on group was lower than in the LVAD–off group. We conclude that, at the volume overload state, LVAD can reduce the afterload of the right ventricle and maintain Frank–Starling's effect, thus having a beneficial effect on right ventricular performance.     

微创经皮钢板内固定治疗胫腓骨骨折的体会

目的报道以生物学内固定及间接复位技术为基础，微创经皮LC-DCP钢板内固定治疗胫腓骨骨折的临床疗效。方法应用间接复位技术，通过建立胫骨内侧皮下隧道，采用LC-DCP钢板内固定治疗胫腓骨折28例。结果全部病例获得随访，时间为10～18个月(平均15个月)。X线片见骨痂为4～7周(平均4．6周)，骨愈合时间为12～18周(平均12．8周)。全部病例Ⅱ期骨愈合，无骨不愈合或延迟愈合，无钢板松动等并发症，其中15例已拆除钢板，无再骨折现象发生。结论微创经皮LC-DCP钢板内固定治疗胫腓骨骨折符合生物学固定的原则，疗效满意。     

境外医院领导体制概述

介绍了境外部分国家和地区的医院类型、政府在医院管理中的职能和有关医院领导体制的基本情况,侧重介绍了医院最高领导机构和决策者的组成和特征。指出:要转变政府职能,强调医院的自主经营和自主管理,医院的发展需要有一支高效率、高管理水平的医院领导队伍。