Moral decisions regarding innovation. The case method

Little consideration has been given to the ethics of innovation in surgery despite the major role of innovation in orthopaedic practice. We propose that a series of cases of increasing ethical complexity may serve as a classification system and assist orthopaedists in thinking about the ethical dimensions of other cases.     

膝关节损伤的MRI诊断及其临床价值

目的：探讨MRI对膝关节损伤的诊断及临床应用价值。方法：回顾性分析266例膝关节损伤的MRI资料，男182例，女84例，年龄16～56岁，平均38岁。其中车祸损伤144例，运动损伤68例，其他54例。损伤类型，骨折31例，骨挫伤106例，软骨骨折11例，半月板损伤224例，韧带损伤198例，关节积液212例。结果：31例骨折表现为线状长T1长T2信号影；106例骨挫伤表现为斑片状等或长T1WI、等或长，T2WI信号，STIR序列呈高信号，边界不清；11例软骨骨折表现为软骨信号连续中断或凹陷，出现异常信号；224例半月板损伤表现为半月板低信号影内出现不同形状高信号灶；198例韧带损伤表现为韧带增厚、扭曲，韧带移行区有长T2信号和(或)短T1信号；212例关节积液表现为长T1长T2信号，血肿可见短T1高信号。结论：MRI对膝关节损伤的诊断具有重要的临床价值。     

Mechanism of traumatic knee injuries and MRI findings

Bone bruises are focal abnormalities in subchondral bone marrow due to trabecular microfractures as a result of traumatic force. These trauma-induced lesions are better detected with magnetic resonance (MR) imaging using water-sensitive sequences. Moreover, the pattern of bone bruise is distinctive and allows us to understand the dynamics of trauma and to predict associated soft injuries. This article discusses the mechanism of traumatic injury and MR findings.     

Effect of an algorithm on the treatment of knee injuries.

An audit was performed of the treatment of patients presenting with acute knee injuries to the accident and emergency department of a district general hospital. This showed that for patients requiring follow-up the majority were reviewed by the casualty officers themselves in the accident department, with the result that definitive diagnosis and treatment for patients with continuing symptoms was often delayed. Once the current treatment had been discussed at an audit meeting, a protocol (in the form of an algorithm) of the treatment of knee injuries was produced. A further audit was performed after the protocol had been in use. This demonstrated that the protocol was effective in encouraging the casualty officers to seek the help of more senior members of staff and also reduced the time taken to definitive diagnosis and treatment.     

膝关节韧带损伤的MRI诊断价值

目的:探讨膝关节韧带损伤的MRI特点与诊断价值。方法:收集2008年6月至2010年2月经MRI检查的74例膝关节损伤患者,男47例,女27例;年龄12～76岁,平均37.3岁;病程2h～10d。临床表现为膝关节肿胀、疼痛,关节不稳、伸屈活动障碍,外翻试验、抽屉试验阳性,膝内侧明显压痛。对其MRI表现进行回顾性分析。结果:74例韧带损伤,其中前交叉韧带19例,后交叉韧带18例,外侧副韧带13例,内侧副韧带24例。韧带完全断裂12例,其中8例交叉韧带MR表现为韧带的连续性中断、断端回缩,局部或弥漫性肿胀,PDWI上呈中等信号,T2WI和脂肪抑制序列呈高信号;4例侧副韧带MR表现为韧带连续性中断或韧带肿胀增粗,PDWI上呈中等信号,T2WI和脂肪抑制序列呈高信号。部分纵形撕裂62例,MR表现为韧带连续性完整,韧带增粗,PDWI上呈中等信号,T2WI和脂肪抑制序列呈高信号。经手术、关节镜检查确诊44例,与MRI诊断相符41例。结论:MRI能诊断膝关节韧带损伤,是一种理想的诊断膝关节外伤的检查方法,宜作为常规检查。     

膝关节半月板损伤的MR检查技术

MRI已成为诊断膝关节半月板损伤的首选方法。目前有多种脉冲序列及技术应用于膝关节损伤检查。本文就膝关节半月板损伤MR多种脉冲序列及检查技术的特点与应用情况进行综述。     

Two-phase surgical treatment of anteromedial knee injuries

The treatment of severe anteromedial knee injuries over the years has undergone various types of approach, changing from proposals, such as combined surgical repair of the anterior cruciate ligament and medial compartment, to the more current protocol which involves conservative treatment of the peripheral injury and later reconstruction of the anterior cruciate ligament. However, in serious ruptures of the medial ligament compartment, conservative treatment does not make it possible to recover peripheral stability, thus transferring abnormal forces onto the anterior cruciate pro-ligament graft which can gradually deteriorate the transplant itself. Thus in severe anteromedial injuries a treatment with two distinct surgical phases is proposed, using direct immediate suture of the peripheral compartment and, after a period of rehabilitation, later replacement of the anterior cruciate ligament by arthroscope graft. Given the obtained results and the few complications observed in 25 cases, it is probable that this therapeutic scheme can be proposed in selected cases of severe ligament laxity of the medial compartment associated with rupture of the anterior cruciate ligament.     

Diagnosis and treatment of posterolateral knee injuries

Posterolateral knee injuries can be very debilitating. It is important to understand the complex anatomy and pertinent diagnostic tests to properly treat posterolateral knee injuries. The fibular collateral ligament, popliteus tendon, and the popliteofibular ligament are the main static stabilizers against abnormal varus and posterolateral translational moments. Important radiographic imaging studies for the posterolateral knee include full length anteroposterior radiographs, taken with the patient standing, to assess for varus alignment in patients with chronic injuries and high field (1.5 tesla or higher) magnetic resonance imaging with specific posterolateral knee sectioning. A physical examination that includes the external rotation recurvation test, varus stress test at 30 degrees, dial test at 30 degrees and 90 degrees, posterolateral drawer test, reverse pivot shift, and an assessment for a varus thrust gait are essential to properly diagnose a posterolateral knee injury. Patients with acute (< 3 weeks) anatomic repairs of Grade III posterolateral knee injuries have the best functional outcome. Although various surgical reconstruction techniques have been developed to treat chronic or irreparable acute posterolateral knee injuries, these techniques have not achieved outcomes comparable with the treatment of other ligament injuries of the knee. Techniques for anatomic reconstructions of these structures are just being developed. Improved education of clinicians as to the proper diagnosis of posterolateral knee injuries is necessary because a large number of these injuries still are missed on initial examinations. In addition, additional research into the most optimal posterolateral knee reconstruction techniques and outcome studies are needed to improve the treatment of this debilitating knee injury.     

The preoperative thoracic X-ray for tactical decisions for the thoracic injuries treatment

Data of 379 patients with penetrating thoracic wounds were analyzed. The pathologic changes on X-ray of the thoracic cavity were registered 239 (63,1%) patients: the hemothorax was diagnosed in 44,3%, pneumothorax - in 26,8% and hemopneumothorax - in 28,9%. 154 patients had videothoracoscopic surgery and 225 patients were operated on using traditional open methods. Operative findings were compared with X-ray data. The sensitivity of plain chest radiography in diagnostics of hemothorax was 52,1%, the specificity - 92,1%. Mistakes of interpreting X-ray data in diagnosing of low-volume hemo- or pneumothorax were defined. The computed tomography of the thorax proved to be the most precise means of intrapleural injuries diagnostics. The optimal algorithm of preoperative thoracic X-ray was suggested.     

The influence of multidisciplinary team meetings on treatment decisions in advanced bladder cancer

Objectives

To investigate the role of specialised genitourinary multidisciplinary team meetings (MDTMs) in decision-making and identify factors that influence the probability of receiving a treatment plan with curative intent for patients with muscle invasive bladder cancer (MIBC).

Patients and methods

Data relating to patients with cT2-4aN0/X-1 M0 urothelial cell carcinoma, diagnosed between November 2017 and October 2019, were selected from the nationwide, population-based Netherlands Cancer Registry (‘BlaZIB study’). Curative treatment options were defined as radical cystectomy (RC) with or without neoadjuvant chemotherapy, chemoradiation or brachytherapy. Multilevel logistic regression analyses were used to examine the association between MDTM factors and curative treatment advice and how this advice was followed.

Results

Of the 2321 patients, 2048 (88.2%) were discussed in a genitourinary MDTM. Advanced age (>80 years) and poorer World Health Organization performance status (score 1–2 vs 0) were associated with no discussion (P < 0.001). Being discussed was associated with undergoing treatment with curative intent (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.9–4.9), as was the involvement of a RC hospital (OR 1.70, 95% CI 1.09–2.65). Involvement of an academic centre was associated with higher rates of bladder-sparing treatment (OR 2.05, 95% CI 1.31–3.21). Patient preference was the main reason for non-adherence to treatment advice.

Conclusions

For patients with MIBC, the probability of being discussed in a MDTM was associated with age, performance status and receiving treatment with curative intent, especially if a representative of a RC hospital was present. Future studies should focus on the impact of MDTM advice on survival data.     

关节镜对膝关节训练伤的诊断与治疗

[目的]探讨关节镜对急慢性膝关节损伤的诊断与治疗效果.[方法]对132例急慢性膝关节损伤患者通过关节镜诊断并治疗,分析急慢性膝关节损伤的临床诊断误诊率和治疗效果的差异程度.[结果]急性损伤(受伤3周以内)83例,临床诊断误诊率:ACL 10.8%,PCL 6.0%,半月板损伤15.7%,二联征3.6%,三联征2.4%.慢性损伤49例,临床诊断误诊率:ACL 41%,PCL 2.0%,半月板损伤8.2%,二联征2.0%,三联征2.0%.急性膝关节损伤合并关节软骨损伤7例,损伤软骨面积均在2 cm2以内,程度为Ⅰ～Ⅱ度,占8.4%,慢性损伤合并软骨退变损伤31例,损伤软骨面积从1 cm2到全髁软骨剥脱不等,Ⅰ～Ⅲ度,占63.3%.[结论]急性膝关节损伤应早期行关节镜的检查和治疗,提高诊断正确率,若诊治不及时,演变为慢性关节损伤.对关节不稳定的患者应尽早手术使关节稳定,以减少继发性软骨损伤.     

膝关节外伤并发血管损伤临床治疗

我院近4年所遇到的膝关节外伤合并血管损伤12例13膝,现将其诊断治疗情况介绍如下:1 临床资料本组12例,男10例,女2例;年龄20～52岁,平均36.7岁;左膝5例,右膝6例,双膝1例;开放性损伤9例,闭合性损伤3例(4膝);其中股骨髁骨折4例,胫骨髁骨折9例;其中1例并发腓骨上段骨折,上胫腓关节分离1例.膝关节后脱位1例(2膝),关节前脱位1例,侧方脱位2例.受伤至就诊时间1.5～8小时.就诊时患肢末梢血运差11例,1例患肢末梢血运好,足背动脉及胫后动脉均可触及搏动而误诊,余皆立即确诊.除1例为重物砸伤外,其余为车祸致伤,入院时均未做造影检查及多普勒检查.     

膝关节软骨损伤的外科治疗进展

关节软骨损伤后,软骨缺损通常缺乏自行修复能力,要求外科修复。传统外科治疗软骨损伤包括关节镜下冲洗清理术、微骨折术、自体骨软骨移植术、异体骨软骨移植术和自体软骨细胞移植等方法。关节冲洗清理术去除了关节内致痛因素,操作简单,应用广泛,早期疗效确切。微骨折术及自体骨软骨移植对小面积的软骨缺损修复较为理想,然而远期临床观察发现钻孔渗透修复的纤维软骨会降低微骨折术后疗效,相对于重建负重区关节面完整性自体骨软骨移植更具有优势。自体软骨细胞移植及异体骨软骨移植适用于更大面积的软骨缺损,异体骨软骨移植术后存活率受到局部排斥反应影响,从而降低了远期疗效。软骨组织工程技术可最大限度地提高自体软骨细胞移植的修复质量,实现修复组织接近透明软骨,但对于累及软骨下骨板、反应性骨水肿、严重骨量丢失或下肢轴线不良具有局限性。近年来许多新技术陆续应用于软骨损伤治疗领域,创伤小、操作简便、恢复快、疗效好、花费低、多技术联合应用的外科修复技术将会成为未来的治疗软骨损伤的重要手段。目前如何提高软骨修复质量,更具抗压、耐磨性,仍亟待解决。     

Running injuries about the knee.

Evaluation and treatment recommendations for a painful knee in a runner can be accomplished with a good knowledge of knee pathology, careful physical exam, and appropriate use of imaging tests. Most knee problems in a runner fall into one of the entities listed above. Fortunately, almost all can expect significant improvement with appropriate treatment.     

Two-year follow-up of conservative treatment of knee ligament injuries

Sixteen patients with old knee ligament injuries and symptoms of instability or pain were treated with a 3-month thigh muscle strength training program. Nine patients had a tear of the anterior and six patients a tear of the posterior cruciate ligament. One patient had a tear of both cruciates. Knee function was determined with a knee scoring scale, and thigh muscle strength with a Cybex-II dynamometer before training, after 1 and 3 months of training, and at a late follow-up after 2 years. Ten patients who increased their quadriceps strength by more than 15 per cent increased their score over 30 per cent. Three patients who showed a minor increase in strength did not increase their score significantly. Three patients did not increase their strength at all. All of these admitted a reluctance to train. Four patients, all with anterior cruciate ligament tears, were operated on after the 3-month training period. All four patients increased their strength. Two of them increased their functional score also, but they strove for a very high activity level and were therefore operated on. The other two patients had no symptomatic relief and were therefore also operated on. Improvements in muscle strength and knee function were unchanged at the 2-year follow up.

Before planning a knee ligament reconstruction, a period of strength training is recommended.     

膝关节多韧带损伤的手术治疗体会

目的 :介绍膝关节多韧带损伤的手术治疗方法和结果 ,总结治疗的经验与教训。方法 :随访自2008年至2013年经治的26例膝关节多韧带损伤患者,其中男17例,女9例;年龄29~55岁,平均40.7岁。所有患者在关节镜下采用自体或异体肌腱重建交叉韧带,并同时修补内侧副韧带、外侧副韧带及处理内外侧复合体损伤。9例分期手术,其余均采取Ⅰ期手术处理所有损伤。用Lysholm膝关节评分评价手术前后膝关节功能。结果:26例均获随访,时间为0.8~3.2年,平均1.6年,手术平均等待时间为1.2个月。术前膝关节Lysholm评分42.5±4.5(33~48分),终末随访时78.1±3.9(57~95分),随访时评分提高。术后关节活动度均超过90°,内外翻试验正常或接近正常,所有患者在屈70°时Lachman试验阴性。结论 :膝关节韧带多发损伤应首选关节镜下Ⅰ期重建;如无法Ⅰ期同时重建前后交叉韧带,则Ⅰ期先重建后交叉韧带,Ⅱ期重建前交叉韧带;后交叉韧带因多种原因易漏诊,避免因术前准备不充分而分期手术。     

膝关节运动损伤的诊治要点

<正>膝关节损伤,根据病因可分为运动损伤和车祸伤;根据解剖,可分为骨性损伤和软组织损伤,以及混合损伤[1-6]。单纯骨性损伤主要包括股骨髁骨折、胫骨平台骨折和髌骨骨折,借助X线片