高选择性血管造影预测青壮年股骨颈骨折预后的临床研究

目的探讨合适的股骨颈骨折分型方法,准确预测预后。方法对45例青壮年单侧股骨颈骨折采用高选择性血管造影技术(DSA),根据DSA结果进行分型:造影显示越过骨折线3～6支支持带血管影为Ⅰ型;显示1～2支血管影为Ⅱ型;没有越过骨折线血管支显影为Ⅲ型。均在C型臂X线机指导下行闭合空心钉内固定。术后根据症状及影像学,如X线、CT、MRI或DSA来判断股骨头坏死和骨折愈合情况。结果 DSAⅠ型股骨头坏死率为0,骨折不愈合率为13.33%,Ⅱ型股骨头坏死率为7.14%,骨折不愈合率为7.15%,Ⅲ型股骨头坏死率为100%,骨折不愈合率为0。结论①术后并发股骨头坏死的发生率和DSA显示的血管数量成负相关,与年龄成反比;②骨折不愈合的发生与年龄成正比,与DSA显示的血管数量无关联;③DSA对预测股骨颈骨折的预后有一定的指导价值。     

高选择性旋股动脉造影观察股骨颈骨折术后愈合的临床研究

[目的]探讨应用高选择性血管造影技术(DSA)观察不同类型股骨颈骨折对股骨头血供的影响,以指导临床治疗方案的选择。[方法]对入组的46例65岁以下单侧成人股骨颈骨折患者,应用高选择性血管造影技术(DSA)观察越过骨折线动脉数目,并予以分型。[结果]骨折不愈合发生率与越过骨折线支持带动脉血管显影数目无关联(P>0.05),股骨头坏死的发生率与越过骨折线支持带动脉血管显影数目成反比(P<0.05)。DSA支持带动脉显影与Garden分型成反比(P<0.05)。[结论]高选择性血管造影技术为临床股骨颈骨折患者治疗方案的选择,提供了循证医学证据,具有一定临床意义。     

高选择血管造影拟定股骨颈骨折分型标准的初步探讨

目的采用高选择血管造影拟定股骨颈骨折分型标准。方法2004年3月至2008年6月,采用高选择血管造影（digital subtraction angiography,DSA）技术对70例不同年龄组单侧股骨颈骨折患者进行数字减影,男32例,女38例;年龄26～44岁15例,45～55岁11例,56～70岁44例,平均年龄62岁;左侧40例,右侧30例;摔伤34例,高处坠落及交通伤36例。读取DSA显示越过股骨颈骨折线支持带动脉的数目,根据DSA结果拟定骨折分型标准。结果 DSAⅠ型：造影显示越过骨折线3～6支支持带血管影。DSAⅡ型：造影显示越过骨折线1～2支支持带血管影。DSAⅢ型：造影显示无支持带血管影越过骨折线。结论 DSA对股骨颈骨折分型、治疗及预后的判断有一定的指导作用。     

空心螺钉内固定治疗股骨颈骨折诊疗分析

[目的]评价空心螺钉内固定治疗股骨颈骨折的疗效.[方法]本组患者67例,年龄19 ～ 65岁,平均54.7岁.骨折无移位型20例,移位型47例.全部采用空心螺钉内固定手术治疗,随访观察18 ～ 36个月,平均25.8个月.[结果]骨折愈合时间为3～6个月,平均5.3个月.无移位型骨折愈合率为100％,股骨头坏死率为15％.移位型骨折愈合率为89.4％,股骨头坏死率为34.0％.Harris髋关节功能评分,优良率为79.1％.[结论]空心螺钉内固定治疗股骨颈骨折是一种有效的方法.移位型股骨颈骨折股骨头坏死率是无移位型的2倍余,其临床诊疗仍需进一步探讨.     

带血管蒂髂骨瓣移植的临床应用

目的总结带血管蒂髂骨瓣治疗股骨颈骨折及小儿股骨头缺血坏死的临床疗效. 方法本组股骨颈头下型骨折123例,采用带旋髂深血管支髂骨瓣治疗43例(股骨颈陈旧性骨折、股骨头早期坏死15例,股骨颈头下型骨折28例);带旋股外侧动脉升支血管髂骨瓣治疗80例(股骨颈骨折并股骨头早期坏死9例,股骨颈头下型骨折71例),其中小儿股骨头缺血坏死10例.切取的骨瓣最小为2 cm×2 cm×1.5 cm,最大为5 cm×1.5 cm×8 cm. 结果术后2个月出现骨痂,3～5个月后骨折基本愈合,股骨头缺血坏死一般在3个月以后恢复正常.123例股骨颈骨折119例治愈,股骨头坏死4例;小儿股骨头缺血坏死10例均获成功. 结论两种带血管的髂骨瓣血运都极其丰富.带旋股外侧动脉升支血管髂骨瓣由于解剖上的特点则更适合用于股骨颈、粗隆部及股骨中上段疾患.     

髋臼合并同侧股骨颈骨折的手术治疗与预后

目的 探讨髋臼合并同侧股骨颈骨折的手术方法与预后.方法 1990年10月至2008年1月共收治7例髋臼合并同侧股骨颈骨折患者,其中男5例,女2例;年龄22～55岁(平均38.6岁).髋臼骨折按Letournel分类:后壁骨折2例,后柱伴后壁骨折1例,横行伴后壁骨折2例,双柱骨折2例.股骨颈骨折按Garden分型:Ⅲ型2例,Ⅳ型5例.其中X线片和CT片示股骨颈骨折合并股骨头游离脱位于髋臼后上方者5例,仅显示股骨颈骨折而无脱位者2例.结果切开复位内固定术后X线片示5例移位髋臼骨折患者获解剖复位,2例获满意复位.股骨颈骨折均获满意复位和固定.7例患者术后获1～18年(平均8.6年)随访,X线片示5例合并股骨头脱位者日后均出现股骨头缺血性坏死,坏死率高达100%(5/5),髋关节功能恢复均为差,于内固定术后2～4年改行全髋关节置换术.而2例股骨头未脱位者至今X线片上仍未显示任何股骨头坏死迹象,也无创伤后关节炎表现,髋关节功能恢复均为优.结论 髋臼合并同侧股骨颈骨折患者,如同时合并股骨头脱位,因股骨头坏死率高,应首选全髋关节置换术治疗.如未合并股骨头脱位,可以考虑首选切开复位内固定.     

带蒂肌骨瓣治疗青壮年股骨颈骨折

目的探讨青壮年错位型股骨颈骨折治疗方法。方法回顾分析42例确诊病例的临床资料。结果42例随访患者，随访时间8个月～9年，平均3年1个月。1例骨折延迟愈合，2例骨折不愈合。骨折愈合率为95．2％。骨折愈合时间3～11个月，平均6个月。股骨头缺血坏死5例，2例是骨折不愈合者，股骨头亦发生坏死。3例股骨颈骨折愈合后1a以上发生股骨头缺血坏死。股骨头缺血坏死率为11．9％。结论带蒂肌骨瓣移植加多根松质骨加压螺钉内固定治疗青壮年GardenⅢ、Ⅳ型股骨颈骨折对提高青壮年错位型股骨颈骨折愈合率和降低股骨头缺血坏死率是肯定的。前方手术入路带蒂肌骨瓣移植优于后方手术入路。     

青壮年移位型股骨颈骨折（Garden Ⅲ、Ⅳ）的手术治疗

目的：评价空心加压螺钉联合臀中肌骨瓣移植治疗青壮年移位型股骨颈骨折的疗效。方法2008年6月～2012年6月我院对27例移位型青壮年股骨颈骨折（Garden Ⅲ、Ⅳ）患者采用改良Smith-Peterson入路（S-P）空心加压螺钉联合臀中肌骨瓣移植治疗。结果27例患者均获随访,随访时间18～60个月,平均36个月。骨性愈合时间4～8个月、平均6.5个月,骨折愈合25例,愈合率93.3％,股骨头坏死3例、其中2例骨折不愈合后期发展为股骨头缺血坏死、另1例为内固定取出术后出现股骨头坏死。股骨头坏死率为10.0％。结论采用改良S-P入路对股骨头周围血供破坏小,臀中肌骨瓣移植联合空心加压螺钉治疗青壮年移位型股骨颈骨折,对提高青壮年移位型股骨颈骨折愈合率和降低股骨头缺血坏死率疗效肯定,值得临床使用。     

早期闭合复位空心螺钉固定治疗青壮年股骨颈骨折

目的 总结早期闭合复位空心螺钉内固定治疗股骨颈骨折的临床体会。方法 本组32例患者，全部采用闭合复位空心螺钉内固定技术。结果 术后随访1.5～5年，32例患者有6例出现股骨头坏死。5例出现股骨颈骨折不愈合，骨折不愈合率为15.6％。其他21例患者全部愈合。结论 采用闭合复位空心螺纹钉固定治疗青壮年股骨颈骨折，能减少股骨头坏死的发生率，是一种较好的治疗方法。     

应用选择性血管造影技术评价股骨颈骨折后股骨头血供情况及其对临床治疗的指导作用

目的探讨应用选择性血管造影（digital subtraction angiography,DSA）评价股骨颈骨折后早期股骨头血液循环损伤情况,以指导临床治疗。方法采用DSA对25例单侧股骨颈骨折的髋部进行旋股动脉及支持带动脉造影,按DSA结果分型,分别为Ⅰ、Ⅱ、Ⅲ型,以了解各型病例术前、术后的股骨头血供。结果 DSAⅠ、Ⅱ型病例无股骨头坏死,DSAⅢ型病例均出现股骨头坏死。结论 DSA可为股骨颈骨折的治疗提供更多、更有力的临床依据。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.