计算机导航关节镜下前十字韧带重建术

目的介绍计算机导航技术辅助关节镜下前十字韧带重建术的术前规划和手术方法,比较导航技术辅助与单纯关节镜技术中股骨、胫骨隧道位置的优良率。方法根据术前标准正侧位X线片设计股骨、胫骨隧道的理想位置。术中“C”型臂X线机获得正侧位影像后输入计算机,形成虚拟工作界面。膝关节周围分别于股骨、胫骨侧安置“患者追踪器”。前十字韧带胫骨及股骨导向器上分别装配“工具追踪器”。经过注册及校准后,导航系统识别并捕获上述追踪器发射的信号,确定膝关节的位置,实时跟踪手术工具的位置和方向,并将隧道的虚拟路径叠加在工作界面上,供术者实时调整导向器的位置与方向,直至达到术前规划的要求。临床上完成计算机导航关节镜下前十字韧带重建术46例。对其中40例进行术后X线片测量,确定胫骨及股骨隧道的位置,并与同期进行的40例单纯关节镜下重建术隧道位置的测量结果进行比较。结果导航组胫骨隧道位置平均为45.35%±3.827%(37%￣53%),股骨隧道位置平均为62.25%±5.610%(52%￣73%);关节镜组胫骨隧道位置平均为41.05%±6.008%(25%～54%),股骨隧道位置平均为56.62%±7.316%(46%￣77%)。导航组的股骨及胫骨隧道位置较关节镜组偏后,差异有统计学意义(P<0.05),导航组的标准差小于关节镜组。结论计算机导航技术可以使关节镜下前十字韧带重建手术中胫骨及股骨隧道的位置更偏后,提高了手术准确性及可重复性。     

经皮穿刺椎体成形术治疗合并肺气肿的胸椎压缩性骨折

目的 探讨合并严重肺气肿的胸椎压缩性骨折进行经皮穿刺椎体成形术的技术特点和治疗效果。方法 7例(10个椎体)合并严重肺气肿并且透视椎体显示不清的胸椎骨质疏松椎体压缩骨折患，侧卧位在CT结合C型臂透视引导下进行经皮穿刺椎体成形术。术前、术后2d和随访时分别测定疼痛强度评分、止痛药使用和活动能力评分。随访2-8个月，平均5个月。结果 7例皆顺利完成手术，注射骨水泥的量平均2．2ml／椎体(1．0～4．0m1)，无临床并发症，手术时间2—3．5h／例。疼痛强度评分值术后2d比术前平均减低3．9，随访时进一步下降0．2—2．9，活动能力和止痛药使用术后均明显改善。结论 合并肺气肿的胸椎压缩性骨折患行经皮穿刺椎体成形术治疗前应进行骨折椎体透视检查，显示不清选择侧卧位在CT结合C型臂透视引导下穿刺注射可获得良好疗效。     

脑卒中患者吞咽障碍及康复效果影像学研究

目的探讨电视X线透视吞咽功能检查（videofluoroscopic swallowing study,VFSS）在脑卒中患者吞咽功能评估中的应用价值,观察脑卒中后吞咽障碍发生情况,康复前后患者吞咽功能变化.方法脑卒中患者70例及健康成人80名分别作为研究组与对照组均进行VFSS,比较两组误吸等VFSS异常征象的发生情况.对发现误吸患者进行吞咽功能康复训练4周,训练后复查VFSS,比较训练前后吞咽异常的发生情况变化.结果对照组渗透或误吸、口腔滞留、咽腔滞留的发生率为5.0%,13.4%,25.3%.主要为轻度渗透及口咽腔滞留.研究组渗透或误吸、口腔滞留、咽腔滞留发生率为45.0%,46.5%,48.9%,主要为重度渗透或误吸,中重度口咽腔滞留.其中隐匿性误吸为10次（占总误吸的24.4%）.误吸患者康复治疗后渗透或误吸发生率较康复治疗前减少（P＜0.05）.结论脑卒中后吞咽障碍在康复期仍较为常见,可表现为多种影像学异常.VFSS可确切诊断吞咽异常,进行针对性康复训练,使患者吞咽功能提高.     

Vaginal topography does not correlate well with visceral position in women with pelvic organ prolapse

The objective was to determine whether vaginal topography accurately predicts the location of the pelvic viscera on fluoroscopy in women with pelvic organ prolapse. Eighty-nine women undergoing preoperative evaluation for reconstructive pelvic surgery at a tertiary care referral practice formed the study population. Each woman completed a comprehensive urogynecologic history and physical examination, which included a quantified (POP-Q) assessment of her vaginal topography, as described by Bump et al. In addition each woman underwent pelvic floor fluoroscopy (PFF). Visceral sites were selected which corresponded clinically to the vaginal sites measured by the POP-Q. The most dependent portion of the bladder, small intestine, rectum and urethrovesical junction was measured. Twenty-five (28%) women had stage II prolapse, 34 (38%) had stage III prolapse, and 28 (32%) had stage IV prolapse. The remaining 2 women were symptomatic, with stage I prolapse. For the entire study population there was no correlation between the fluoroscopic position of the small bowel and/or rectum and any apical or posterior wall POP-Q site (C, Ap or Bp). There was no correlation with the fluoroscopic position of the UVJ at rest or with straining and the corresponding POP-Q site (Aa). The fluoroscopic position of the most dependent portion of the bladder correlated only modestly with the upper (Ba,ρ=0.51) and lower Aa,ρ=0.68) anterior vaginal wall POP-Q sites. In women without prior surgery (n=33) there was only modest correlation between the fluoroscopic position of the bladder and the corresponding POP-Q site (Aa,ρ=0.71). In this unoperated subpopulation there was no correlation with PFF and any other POP-Q site. In women who had undergone prior hysterectomy (n=25) or hysterectomy with anterior and/or posterior colporrhaphy (n=17), there was only a modest correlation of the most dependent portion of the bladder and the upper anterior vaginal wall site (Bb,ρ=0.67 andρ=0.55, respectively). It was concluded that vaginal topography does not reliably predict the position of the associated viscera on PFF in women with primary or recurrent pelvic organ prolapse. EDITORIAL COMMENT: The authors seek to evaluate whether physical examination of vaginal prolapse using the POP-Q test correlates with fluoroscopic findings of visceral position. Surprisingly, little correlation is found, even in previously unoperated patients. One reason for this lack of correlation between the two modalities of evaluation may lie in the use of two different fixed points of reference: the POP-Q examination uses the hymen as the fixed point of reference, whereas the investigators chose to use the posterior edge of the femur as a fixed bony point of reference when evaluating pelvic floor fluoroscopy in the same patient. The lack of correlation between visual inspection of vaginal wall prolapse and what lies deep to that prolapse should not be used to invalidate the use of the POP-Q as a means to evaluate pelvic prolapse. Rather, the findings support the premise behind the ICS/AUGS/SGS committee on pelvic organ prolapse, specifically that clinical pelvic examination of the vaginal walls looks at surfaces only, and as such cannot determine what, if any, organ lies deep to that surface.     

脑卒中后吞咽困难的影像学分析

目的明确脑卒中后吞咽困难在X线透视影像学上的表现及特点.方法对56例脑卒中后吞咽困难患者及30名健康志愿者进行X线电视透视检查,记录异常表现,测量定量参数.统计方法采用秩和检验、t检验、卡方检验及Logistic回归分析.结果脑卒中后所有吞咽器官都表现功能异常,口期吞咽异常者46例,咽期异常者56例.与正常组对照,误吸组喉上抬幅度、速度降低,环咽肌打开宽度减少,吞咽潜伏期延长.34例存在误吸.误吸与舌运动减弱（P=0.021）、舌与硬腭接触不良（P=0.021）、声门关闭不全（P=0.011）、喉上抬慢且幅度降低（P=0.003）、吞咽延迟（P=0.001）及穿透（P=0.000）有关.结论脑卒中可损伤所有参与吞咽的器官,咽期吞咽更易受损,舌肌无力、声门关闭不全、喉结构上抬差及吞咽延迟可造成误吸.     

Linkage guide for rotational alignment during total knee arthroplasty

A linkage guide was devised for use in conjunction with knee arthroplasty instruments to achieve proper component rotation. The femoral component was rotationally aligned to the surgical epicondylar axis using one guide. The other guides were used after all bone surfaces were cut and soft tissue balancing was completed. A Kirschner wire was guided into the proximal tibial aspect parallel to the sagittal plane of the femoral component with the patella in its normal position and the knee in full extension. The wire was used as a reference to determine tibial component rotation. The relative rotational alignment of 21 knees in 19 patients who had undergone cruciate-retaining total knee arthroplasty utilizing this guide was assessed using the modified Eckhoff method. The results of radiographic analysis were compared with those in a control group of 25 knees where the guide was not employed. The external rotation of the femoral component relative to the tibial component was 1.3° ± 2.0° (mean ± SD) in the guided group and 1.1° ± 4.4° in the control group. The relative rotational angle was significantly more consistent using the guide. Implant malrotation can be reduced using our technique.     

Accuracy analysis of computer-assisted surgery for femoral trochanteric fracture using a fluoroscopic navigation system: Stryker ADAPT®system

PurposeADAPT is a fluoroscopic computer-assisted surgery system which intraoperatively shows the distance from the tip of the screw to the surface of the femoral head, tip-to-head-surface distance (TSD), and the tip-apex distance (TAD) advocated by Baumgaertner et al. The study evaluated the accuracy of ADAPT.Patients and methodsA total of 55 patients operated with ADAPT between August 2016 and March 2017 were included as subjects. TSD and TAD were measured postoperatively using computed tomography (CT) and X-rays. The intraclass correlation coefficient (ICC) was checked in advance. The error was defined as the difference between postoperative and intraoperative measurement values of ADAPT. Summary statistics, root mean square errors (RMSEs), and correlations were evaluated.ResultsICC was 0.94 [95% CI: 0.90–0.96] in TSD and 0.99 [95% CI: 0.98–0.99] in TAD. The error was −0.35 mm (−1.83 mm to 1.12 mm) in TSD and +0.63 mm (−5.65 mm to 4.59 mm) in TAD. RMSE was 0.63 mm in TSD and 1.53 mm in TAD. Pearson’s correlation coefficient was 0.79 [95% CI: 0.66–0.87] in TSD and 0.83 [95% CI: 0.72–0.89] in TAD. There were no adverse events with ADAPT use.ConclusionADAPT is highly accurate and useful in guiding surgeons in properly positioning the screws.