帕米磷酸钠和降钙素对人工关节磨损微粒引起单核细胞分泌溶骨性因子的影响

目的　探讨帕米磷酸钠和降钙素防治人工关节松动的可能性。方法　采集人体外周血 ,分离单核细胞 ,分组培养。实验分 4组 ,第 1组 :仅单核细胞 ,为对照组 ;第 2组 :单核细胞及微粒 ,为微粒组 ;第 3组 :单核细胞、微粒及帕米磷酸钠 (阿可达 ) ,为阿可达组 ;第 4组 :单核细胞、微粒及降钙素 (密钙息 ) ,为密钙息组。培养 48h后 ,检测细胞上清液中肿瘤坏死因子 (TNF) α、白细胞介素 (IL) 1和IL 6的含量。结果　微粒组的细胞上清液中溶骨性因子含量明显高于对照组 (P <0 .0 1) ;而阿可达组和密钙息组的溶骨性因子含量明显低于微粒组 (P <0 .0 1)。结论　阿可达和密钙息能有效地抑制微粒刺激单核巨噬细胞分泌溶骨性因子 ,从而间接抑制破骨细胞的活性。     

人工全髋置换术中拉钩对下肢深静脉血栓影响的研究

目的：通过对髂外动静脉及股动静脉与髋臼解剖学与临床的研究，探讨在全髋臼置换术中拉钩在髋放置位置对下肢深静脉血栓的影响。方法：通过解剖学研究56具成年骨盆标本中髂外动静脉及股动静脉来源及走行、与髋臼的关系进行测量分析；并通过临床观察22例（股骨颈骨折12例、股骨头缺血性坏死6例、类风湿性关节炎4例）在人工全髋置换术（THR）中拉钩放置安全区，经下肢静脉超声多普勒检查观察下肢深静脉血栓发病率。结果：在左侧3-5点间、右侧7-9点、左侧9点、右侧3点使用拉钩用力要适度，牵拉时间过长，会造成臀下血管、股动脉的牵拉过度或时间过长，易引起下肢深静脉血栓；通过临床22例THR拉钩放置安全区的观察，无一例下肢深静脉血栓，仅有2例轻度深静脉血流缓慢、但无明显的症状体征，经过口服活血通络中药后消失。结论：通过解剖学与临床观察研究，确定在THR中拉钩放置位置、深度是避免下肢深静脉血栓的重要因素。     

改良Richard钉在髋部骨折中的应用

髋部骨折是常见骨折之一，且逐年增多。多发生于老年人，并发症多，死亡率高。应用Ｒｉｃｈａｒｄ钉治疗是目前最佳方法之一。我们将Ｒｉｃｈａｒｄ钉进行了改进，一是增加了松质骨螺钉粗螺纹长度；二是根据不同类型的粗隆下骨折，增加了套筒钢板的长度。经５２例粗隆间骨折和２１例粗隆下骨折患者的临床应用，无死亡，无髋内翻及机械装置并发症的发生。术后病人无需外固定，可早期床上及下地活动。经随访８～３８个月，平均随访时间１５．６个月，骨折全部愈合。我们认为改良Ｒｉｃｈａｒｄ钉是治疗髋部粗隆间和粗隆下骨折更为理想的内固定装置。     

高效液相法测定金樱子中三萜酸类成分的含量

定量测定不同产地金樱子中2α,3α,19α,23-四羟基乌苏-12-烯-28-羧酸的含量.采用高效液相法,色谱柱:Kromasil-C18(4.6 mm×250 mm,5 μm)柱,大连依利特公司;检测波长203 nm,柱温:35 ℃;流动相:乙腈-水(35:65),流速1 mL/min.结果表示所测成分与其他组分具有良好的分离度,线性范围为0.4～10 μg, 加样回收率为102.5%,RSD=2.66%.说明不同产地的三萜类有机酸的含量差别很大.本方法操作简单,结果准确,可用于含2α,3α,19α,23-四羟基乌苏-12-烯-28-羧酸的药物的含量测定.     

Acoustic transmission in normal human hips: structural testing of joint symmetry

An acoustical technique has been developed for the measurement of structural symmetry of the hip joints. A mild vibratory force was applied to the sacrum and sound signals were picked up at both hips by a pair of microphones installed in two stethoscopes. These stethoscope–microphone assembles were calibrated to achieve a difference in relative sensitivity of less than 0.2 dB. The relative transmission of sound signals was analysed and compared between both hips by a dual-channel signal analyser. Twenty-seven healthy adults, 20 healthy pre-school children and 19 normal neonates were tested. Results from these three groups showed high coherence of the sound signals and that the discrepancy between both hips was smallest in the frequency range of 200–315 Hz. For normal neonates, the sound signals maintained a high coherence (γ²>0.97) and small discrepancy (D<1.25 dB) between both hips. This study has shown that the acoustical technique provides a practical structural testing for bony symmetry of the hips and the results offer a baseline for further investigation into developmental dysplasia of the hip (DDH) in neonates. Clinical screening for DDH is still problematic in developing countries.     

全髋关节置换术均衡双下肢长度的探讨

目的探讨全髋关节置换术均衡双下肢长度的临床意义和手术设计。方法回顾分析2000-2004年获得随访的单侧全髋关节置换手术病例48例,采用骨水泥型假体12髋,混合型假体36髋,术前双下肢等长30例(含股骨颈骨折患者),10例患肢长度短缩1.0-2.0cm,6例短缩2.0-4.0cm,2例短缩4.0-6.0cm。通过术前肢体长度测量及X片测量制定手术方案,选择假体、预估颈长和截骨平面;术中正确磨削髋臼,寻找最佳旋转中心,结合透视及特殊试验修正截骨平面,调节假体颈长,达到均衡双下肢长度的目的。结果全部病例采用Harris评分,优30例,良12例,中4例,差2例。术前等长30例巾术后出现5例手术侧延长1.0-2.0cm,1例延长2.5cm。术前不等长的18例中,术后恢复等长10例,6例手术侧延长1.0-2.0cm,2例术前重度短缩的先天性髋关节发育不良病人术后仍然短缩2.0-3.0cm。术后肢体等长35例Harris评分平均92.3分,术后肢体不等长13例Harris评分平均88.6分。结论全髋关节置换术的手术设计。手术技巧以及假体设计等诸多因素影响下肢长度,术后肢体不等长降低了患者的满意度。应重视术前测量及术中综合评价方法的运用,重视软组织平衡技术和肢长调节,掌握全髋置换术中均衡下肢长度的手术技术,进一步改善手术效果。     

Anatomic basis of the transgluteal approach to the hip-joint by anterior hemimyotomy of the gluteus medius

The authors present a study of the intrinsic anatomy of the gluteus medius m. and of its innervation through the caudal branch of the superior gluteal n. The existence of an intramuscular tendon in the thickness of the gluteus medius was constantly prooved in 40 muscles. The relations of the intrinsic fibrous structure of the muscle and its innervation were studied. The authors deduce from that the topography of a gluteus medius incision, with respect to a safety area towards its innervation, which leads to an exposure of the acetabulum that is satisfying and gives opportunities of a sound repair after the surgery of the hip joint through the transgluteal approach. They propose the anterior hemimyotomy of the gluteus medius m designation.

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Bases anatomiques de l'abord transglutéal de la hanche par hémimyotomie antérieure du muscle moyen fessier

Résumé Les auteurs présentent une étude de l'anatomie intrinsèque du m. moyen fessier (MF) et de son innervation par le rameau caudal du n. glutéal supérieur (NGS). 40 muscles ont été étudiés. L'existence d'une lame tendineuse dans l'épaisseur du MF a été constamment mise en évidence. Les rapports entre les éléments de l'architecture fibreuse intrinsèque du muscle et son innervation ont été étudiés. Les auteurs en déduisent la topographie d'une incision du MF respectant une zone de sécurité vis à vis de son innervation, procurant une exposition acétabulaire satisfaisante et des possibilités de réparation solide après chirurgie de l'articulation coxo-fémorale par voie d'abord transglutéale, et proposent la dénomination hémimyotomie antérieure du MF.

     

一种自动优选标准型股骨柄的方法

髋关节置换手术中采用标准型假体时,术前只能大致选取假体,术中还要预备多个假体,往往手术时间增长。为了解决这一问题,本文提出一种利用计算机优选标准型髋关节假体的方法。从X线片中获取患者股骨解剖数据。利用这些解剖数据和股骨近端截面平均数据库三维重建患者股骨近端,重建出的股骨近端模型使优选标准假体成为可能。理论分析表明,该方法切实可行。     

老年髋部骨折患者围术期“2P-3R”营养管理模式构建

目的构建老年髋部骨折患者围术期营养管理模式,促进患者早手术、早下地、早康复。方法针对老年髋部骨折患者营养管理现状,采用课题研究型品管圈活动进行改进。经过科学循证、专家指导等,从术前、术后及家庭三个环节,骨科、营养科、家庭三个维度,人员、制度、材料设备、方法、信息五个方面,制定三大对策群组并予以实施,包括组建营养支持团队、构建营养管理策略、搭建多维信息交互平台等。结果老年髋部骨折患者首次下地时间缩短为26.7 h,平均住院日缩短为5.6 d,实现了早手术、早下地、早康复的目标。结论对老年髋部骨折患者实施个性化、全流程的序贯性营养干预具有重要意义。后续还需开展大样本多中心研究以进一步验证成效,数据自动采集与智能反馈也是今后研究重点。     

Comorbidity and Quality of In-Hospital Care for Hip Fracture Patients

ObjectivesWe examined whether the comorbidity burden of patients with hip fracture was associated with quality of in-hospital care reflected by fulfillment of process performance measures.DesignPopulation-based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry (DMHFR).Setting and ParticipantsPatients aged 65 years or older with an incident hip fracture from 2014 to 2018 registered in the DMHFR (n = 31,443).MethodsComorbidity was measured using the Charlson Comorbidity Index based on hospital diagnoses. Quality of in-hospital care was defined as fulfillment of eligible process performance measures, including preoperative optimization, early surgery, early mobilization, pain assessment, basic mobility, nutritional risk, need for anti-osteoporotic medication, fall prevention, and a post-discharge rehabilitation program, reflecting guideline-recommended in-hospital care. The outcomes were (1) an all-or-none composite measure defined as fulfillment of all relevant process performance measures, and (2) fulfillment of the individual process performance measures. Using binary regression, we calculated relative risk (RR) for the association between comorbidity level and outcomes.ResultsThe overall proportion of patients with hip fracture who fulfilled the all-or-none measure was 31%. Among patients with no comorbidity, 34% fulfilled the all-or-none measure versus 29% among patients with high comorbidity (Charlson ≥ 3). This corresponds to a 15% lower chance (RR = 0.85, 95% confidence interval 0.81–0.89). Increasing comorbidity was also associated with lower fulfillment of the individual process performance measures. The largest difference was seen for preoperative optimization, early surgery, and early mobilization, where patients with high comorbidity had 6% to 11% lower chance of fulfillment of these process performance measures compared with patients without comorbidity.Conclusion and ImplicationsIncreasing level of comorbidity was associated with lower quality of in-hospital care among patients with hip fracture. Our results highlight the need for tailored clinical initiatives to ensure that comorbid patients also benefit from the positive progress in hip fracture care in recent years.