延期手术治疗Maisonneuve骨折

目的 探讨延期手术治疗Maisonneuve骨折的临床疗效. 方法 对2006年1月至201 1年6月延期手术治疗的21例Maisonneuve骨折患者的病例资料进行回顾性分析,男18例,女3例;年龄17～63岁,平均36.8岁.所有患者均存在下胫腓韧带损伤,合并外踝骨折17例,内踝骨折14例,三角韧带断裂7例,后踝骨折15例.所有患者均由于复合伤、皮肤条件差、漏诊等原因未得到及时手术,其中2周后手术者6例,3周后手术者11例,4周后手术者4例.受伤至手术时间为14 ～ 32 d,平均为21.3d.手术切开复位内固定外踝、内踝、后踝骨折,修复重建断裂的三角韧带和下胫腓前韧带,术后采用美国足踝外科协会(AOFAS)踝-后足评分对踩关节功能进行评价. 结果 所有患者术后获10～18个月(平均12.3个月)随访,骨折均获愈合,愈合时间为10 ～22周,平均12.4周.所有患者无发生感染、内固定松动和断裂.踝关节屈曲活动于术后6个月左右基本恢复至对侧水平,但内外翻幅度受限、疼痛广泛存在,末次随访时仍有10例(47.6％)患者与对侧差别明显.5例患者出现距骨外移,不同程度的踝穴增宽.疗效按照AOFAS踝-后足评分进行评价:优5例,良9例,可4例,差3例,优良率为66.7％. 结论 Maisonneuve骨折延期治疗手术难度大,术后踝关节功能恢复困难.早期诊断和早期手术是治疗的关键.     

Fluoroscopically guided anterior atlantoaxial transarticular screws: a feasibility and trajectory study using CT-based simulation software

Background contextAnterior transarticular screw (ATAS) fixation has been suggested as a viable alternative to posterior stabilization. However, we are not aware of previous reports attempting to establish the usefulness of specific fluoroscopic landmark-guided trajectories in the use of ATAS, and we could find no reference to it in a computerized search using MEDLINE.PurposeTo determine the anatomic feasibility of ATAS placement using defined fluoroscopic landmarks to guide screw trajectory.Study designEvaluation using three-dimensional screw insertion simulation software and 1.0-mm–interval computed tomographic scans.Patient sampleComputed tomographic scans of 100 patients including 50 men and 50 women.Outcome measuresIncidence of violation of the vertebral artery groove of C1 and C2, the spinal canal, and the atlanto-occipital joint and screw lengths and lengths of C1 and C2 purchase.MethodsFour screw trajectories were determined: promontory screw (PS), single central facet (CF) screw, and medial (MF) and lateral (LF) double facet screws. Placement of a 4.0-mm screw was simulated using defined fluoroscopic landmarks for each trajectory. The previously mentioned outcome measures were evaluated and compared for the four trajectories. This study was not supported by any financial sources, and there is no topic-specific potential conflict of interest with this study.ResultsNo violation of the C1 or C2 vertebral artery groove or of the spinal canal was observed for any of the screw types. Screw lengths and the length of C2 purchase were by far the longest for PS (40.4±2.8 and 25.7±2.1 mm, respectively; p<.001 in all post hoc comparisons). The length of C1 purchase was longer for CF (16.4±2.3 mm) and LF (15.8±1.6 mm) than PS (14.7±2.0 mm) and MF (14.6±2.4 mm) (p≤.001, respectively). There was no atlanto-occipital joint violation if the length of C1 purchase was set at 12 mm for CF and LF and at 10 mm for PS and MF.ConclusionsOur results suggest that it may be possible to place ATASs without violating the vertebral artery groove, spinal canal, or the atlanto-occipital joint by using the described entry points, trajectories, and fluoroscopic landmarks.     

Blood Utilization After Primary Total Joint Arthroplasty in a Large Hospital Network

Background

Since a study in orthopedic hip fracture patients demonstrated that a liberal hemoglobin (Hb) threshold does not improve patient morbidity and mortality relative to a restrictive Hb threshold, the standard of care in total joint arthroplasty (TJA) should be examined to understand the variability of red blood cell (RBC) transfusion following TJA.

Questions/purposes

The study aimed to answer the following questions: (1) What is the blood utilization rate after primary TJA for individual surgeons within a large hospital network? (2) What is the comparison of hospital charges, length of stay (LOS), and discharge locations among TJA patients who were and were not transfused?

Methods

A retrospective study was conducted on 3,750 primary total knee arthroplasties (TKAs) and 2,070 primary total hip arthroplasties (THAs), and data was retrospectively collected over a 15-month period on the number of RBCs transfused per patient, along with demographic and cost details. The number of patients who received at least 1 RBC unit and the number of RBCs transfused per patient was calculated and stratified by surgeon.

Results

In the postoperative period, 19.3% TKA patients and 38.5% THA patients received a RBC transfusion. Transfusion rates following TJA varied widely between surgeons (TKA 4.8–63.8%, THA 4.3–86.8%). Transfused TKA patients received an average of 1.65 ± 0.03 RBCs, and THA patients received an average of 1.97 ± 0.14 RBCs. LOS and hospital charges for blood transfusion patients were higher than nontransfused patients.

Conclusion

Blood utilization after primary TJA varies greatly among surgeons, suggesting that resources may be misallocated. These findings highlight the need to standardize RBC transfusion practice following TJA.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9327-y) contains supplementary material, which is available to authorized users.     

Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: a Review of Risk Factors and Current Approaches to Diagnosis and Management

Background

Prevention, early identification, and effective management of periprosthetic joint infection (PJI) in patients with inflammatory joint disease (IJD) present unique challenges for physicians. Discontinuing disease-modifying anti-rheumatoid drugs (DMARDs) perioperatively may reduce immunosuppression and infection risk at the expense of increasing disease flares. Interpreting traditional diagnostic markers of PJI can be difficult due to disease-related inflammation.

Purposes

This review is designed to answer how to (1) manage immunosuppressive/DMARD therapy perioperatively, (2) diagnose PJI in patients with IJD, and (3) treat PJI in this population.

Methods

The PubMed database was searched for relevant articles with subsequent review by independent authors.

Results

While there is evidence to support the use of methotrexate perioperatively in RA patients, it remains unclear whether using anti-tumor necrosis factor medications perioperatively increases the risk of surgical site infections. Serum erythrocyte sedimentation rate and C-reactive protein can be useful for diagnosis of PJI in this population, but only as part of comprehensive workup that ultimately relies upon sampling of joint fluid. Management of PJI depends on several clinical factors including duration of infection and the likelihood of biofilm presence, the infecting organism, sensitivity to antibiotic therapy, and host immune status. The evidence suggests that two-stage revision or resection arthroplasty is more likely to eradicate infection, particularly when MRSA is the pathogen.

Conclusion

Immunosuppression and baseline inflammatory changes in the IJD population can complicate the prevention, diagnosis, and treatment of PJI. Understanding the increase in risk associated with IJD and its treatment is essential for proper management when patients undergo lower extremity arthroplasty.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9338-8) contains supplementary material, which is available to authorized users.     

Oxford单髁置换术的术后影像学评价及分析

目的对Oxford单髁置换术治疗膝关节内侧间室骨关节炎（OA）的患者进行术后x线评价,并对假体位置不良原因分析和改进。方法回顾性分析2010年1月～2011年12月的35例膝OA患者行Oxford单髁置换的资料,男7例,女28例,左膝15例,右膝20例,年龄51～73岁,平均年龄63．8岁,体重48～68kg,均为内侧间室置换。手术后常规拍摄膝关节标准正侧位x线片,对患者术后假体位置进行x线片上测量,并按照Oxford单髁的标准值进行数据对比。结果股骨假体内外翻角（A角）和胫骨假体后倾角（F角）的变异百分比小,分别为0和2．857％,而股骨假体屈伸角（B角）和胫骨平台内外翻角（E角）变异百分比较大,分别为31．429％和17．143％。结论Oxford牛津单髁假体位置不良的好发部位是B角和E角,提高B角和E角的准确性将能够明显改善假体位置。     

第一跖趾关节痛风石的手术治疗

目的探讨和总结跖趾关节巨大痛风石的治疗方法、疗效分析。方法对12例第一跖趾关节巨大痛风石患者,在综合治疗基础上,行手术治疗,术后长期监控血尿酸。结果本组12例,全部得到随访,随访时间6～24个月,平均13．4个月。关节切口Ⅰ期愈合,仅1例切口出现延迟愈合,占8．3％。术后跖趾关节外观和关节功能满意。结论积极的手术治疗是治疗第一跖趾关节巨大痛风石的有效方法,能减少痛风急性发作的次数,改善足的外观、保护足的功能。     

骨水泥固定内衬矫正髋臼外展角的生物力学研究

目的探讨将聚乙烯内衬以骨水泥固定于金属髋臼并矫正髋臼过大的外展角对内衬内表面应变的影响。方法对3具尸体骨盆6个髋关节髋臼行生物型髋臼固定,髋臼假体右侧45°外展,左侧65°外展,前倾均为15°,放置聚乙烯内衬后,在SANS生物力学机上施加一组最大值为500N的垂直载荷,通过电阻应变片测定内衬应变值,再把左侧髋臼的内衬取出,以骨水泥固定外径小4mm的聚乙烯内衬于外展45°,施加同样的垂直载荷,再次测定内衬应变值。结果随着载荷增加,外展65°时的内衬应变明显增加,其上升速度较快,在3个标本均高于右髋外展45°内衬的应变值;骨水泥固定聚乙烯内衬于外展45°后,其应变值接近于正常45°外展的内衬应变值。结论髋臼外展角过大导致内衬应变增加,骨水泥固定内衬矫正外展角可减少内衬的应变。     

基于三维重建和有限元分析的股骨头坏死围塌陷期保髋新技术的临床应用

目的对围塌陷期股骨头坏死进行三维重建和有限元分析定量研究,为确定保髋手术指征和优化保髋方案提供依据。方法首先基于患者的CT和MRI资料,运用Mimics软件进行三维重建和坏死区的形态学定量研究;接着建立股骨头坏死个体化三维有限元模型,运用ABAQUS软件进行量化的有限元分析和保髋手术规划。结果实现了坏死区的形态、位置、体积、体积百分比、负重区投影面积和面积百分比的三维可视化,进而运用正蛙位和失稳分型定性判断疾病的预后和治疗方案;在此基础上,运用个体化三维有限元模型模拟改良髓芯减压、打压植骨、腓骨支撑、空心加压螺钉内稳定的手术操作,通过von Mises Stress冯米斯应力、SSR（stress／strength ratio）应力／强度比值和SED（strain energy density）应变能密度等指标确定保髋手术指征和优化保髋方案。结论三维重建和有限元分析进一步从坏死区形态和生物力学方面进行定量研究,完善了股骨头坏死围塌陷期“微观辨证论治体系”体系,有助于进一步明确保髋手术指征,优化保髋方案,提高保髋疗效。