小切口入路腹膜后手术

传统的腰前路手术常需一长且有痛苦难堪的皮肤切口 ,目前研究的主要目的是探讨腰部不稳前路小切口入路手术的可行性及安全性 ,重点是其适应证、手术技能及最少 2年的随访结果。 1996年 5月～ 1997年 12月 ,作者用此技术共手术患者 2 5例 ,其手术适应证包括下腰手术失败综合征、腰椎间盘突出、结核性或化脓性脊椎炎、脊椎前移和脊椎肿瘤 ,在有良好照明光源的情况下 ,术时作一左侧切口 ,切口平均长约 5cm ,术中对大静脉无损伤且无生理性恶化 ,术后 3～ 6个月即出现骨性融合 ,平均随访 3 9.6个月 ,优9例 ,良 11例 ,2例一般 ,1例效果差 ,作者认…     

寰椎椎动脉沟环所致颈性眩晕患者的手术治疗

寰椎椎动脉沟环是引起颈性眩晕的原因之一。作者经治７例沟环所致颈性眩晕患者，经３－６年随访，优良者６例，疗效满意，文内探讨了沟环引起颈性眩晕的机制、诊断、鉴别诊断及手术适应证。作者认为手术切除沟环是治疗该病的有效手段之一     

二尖瓣直视成形术早期血流动力学测定及远期随访

为探讨二尖瓣直视成形术的手术适应证和手术方式，对５０例风心病二尖瓣狭窄或合并关闭不全病人行二尖瓣直视成形术后，进行早期血液动力学变化观察和远期心功能随访。结果术后早期心输出量及肺楔压有明显改善（Ｐ＜０．０１），晚期随访超声心动图示心功能可达Ｉ～ＩＩ级。作者认为，严格选择二尖瓣直视成形术适应证和手术方法，此术式远期疗效良好。     

腰椎间盘突出症手术效果欠佳原因分析（附340例手术报告）

采用后路手术治疗腰椎间盘突出症３４０例，术后随访一个月至２年，效果欠佳２８例，占８．２％，作者体会到只要术前明确诊断，手术适应证加以控制，做好病灶定位，掌握手术方式和技巧，手术治愈率将大大提高。     

大转子股骨头互换术治疗股骨头骺早闭

作者于1990年10月至1994年10月,利用股骨转子下截骨大转子股骨头互换术,治疗股骨头骨骺早闭、大转子相对过长的髋关节病废患者5例,经随访观察,效果满意.文中讨论了本病的病理特点及其手术治疗原理和适应证.     

胸腔镜肺叶切除术

作者自１９９４年以来，在动物实验的基础上，对２１例患者施行电视胸腔镜肺叶切除术，其中有１６例肺癌患者。手术效果满意，无重大合并症，作者就经胸腔镜肺叶切除术的方法和注意事项以及适应证进行介绍。并认为电视胸腔镜肺叶切除术是可行的，目前在技术尚不成熟的阶段，要严格掌握手术适应证     

慢性酒精性胰腺炎的择期手术

慢性酒精性胰腺炎择期手术的适应证主要是常伴有内或外分泌功能障碍的顽固性疼痛。由于诊断方法的改进手术治疗逐渐增多。作者统计1970～1980年治疗的83例中,前五年仅18例,后五年65例。作者从手术死亡率、饼发症、减轻疼痛、术后内和外分泌功能及患者恢复工作能力方面进行了分析。男:女为68:15,手术时患者年龄25～61岁,平均41岁。53例随访平均3.2年,14例死亡,16例失去随访。所有病例均有严重的、向胸或背部放射的上腹痛。8例疼痛不到1年,47例2～5年,28例超过5年。27例术中     

气管,支气管成形术40例

作者报告了４０例气管、支气管成形术的治疗体会。其中气管成形术３例,隆凸成形术２例,支气管成形肺切除术３４例,肺动脉成形术１例。术后并发症４例（１０％）,手术死亡２例（５％）。恶性肿瘤３０例,随访１～１０年,术后１年、３年、５年、１０年生存率分别为８３．３％、５３．３％、４０％、２３．３％。作者对手术适应证及麻醉的处理、手术方法及结果进行了讨论。这种手术能最大限度地清除病灶和保留健肺,但其手术并发症和死亡率均高于肺癌常规手术。因此要严格掌握手术适应证。     

选择性脊神经后根切断结合矫形手术治疗脑瘫所致肢体痉挛

作者采用选择性脊神经后根切断术(SPR)结合矫形术治疗39例脑瘫所致肢体痉挛患者,通过临床实践和6月～4年随访观察,发现SPR能够有效地解除肌肉痉挛,纠正动力性畸形,不易复发,但对于较明显的固定挛缩畸形,必须同时配合Ⅱ期矫形手术,方能达到预期效果。强调术后肌力强化训练的必要性。对于手术患者年龄选择、手术适应证、手术操作技术、神经根切断比例及疗效判断标准提出了自己的看法。     

再论二尖瓣成形手术适应证及手术技巧

本文研究二尖瓣成形术适应证和手术技巧，以改善远期疗效。作者分析研究210例二尖瓣成形术手术经验和长期随访资料，结果显示，手术死亡12例，其余恢复良好。13例手术后36-144个月接受了二次手术，其中10例因风湿现变复发；另15例于术后21-111个月因二尖瓣再狭窄及关闭不全离不开药物治疗，表明风湿性二尖瓣成形手术适应证必须严格掌握；提高手术技巧可以更好改善心脏功能和治疗效果。     

影响全膝人工关节置换术后疗效的相关因素分析

目的分析后稳定型全膝人工关节置换（total knee replacement，TKR）术后疗效和并发症发生情况，探讨影响TKR术后疗效的相关因素。方法1998年1月～2004年8月，应用后稳定型膝关节假体对60例（74膝）骨性关节炎患者行TKR手术。以术后膝关节HSS（hospitl for special surgery）评分和各单项评分的改善率评定TKR术后疗效；比较有并发症和无并发症患者之间疗效优良率的差异；采用Pearson相关分析对TKR术后HSS评分与术前患者自身的有关因素进行相关性分析。结果60例患者获随访24～94个月，平均42．5个月。术后膝关节HSS评分、疼痛、功能、关节活动度、肌力、屈曲畸形及稳定性评分分别为84．2±14．2、25．7±6．9、17．9±4．3、13．1±2．0、9．2±0．8、8．1±0．4和9．3±0．1，较术前均有不同程度改善，尤以疼痛缓解最为明显，且差异均有统计学意义（P〈0．05）。疗效评定优良率为90．5％。10膝发生局部并发症，其中腓总神经损伤1膝，伤口愈合不良2膝，伤口感染、关节内感染及关节僵硬各1膝，症状性下肢深静脉血栓形成2膝，髌-股关节并发症2膝。有并发症患者膝关节优良率（60．0％）明显低于无并发症患者（95．3％），且差异有统计学意义（P〈0．05）。相关分析显示TKR术后HSS评分与膝关节术前HSS评分、疼痛和功能评分呈正相关，相关系数分别为0．523、0．431和0．418（P〈0．01）；而与患者术前关节活动度、肌力、屈曲畸形、稳定性、年龄、体重和体重指数等无相关（P〉0．05）。结论采用后稳定型TKR是治疗重症膝关节骨性关节炎的有效方法。术后疗效与术前膝关节HSS评分、疼痛和功能评分呈正相关；并发症的发生对术后疗效有明显负面影响。     

Knee endoprosthesis implantation in hemophiliac arthropathy: results, problems and complications

AIM OF STUDY: In the final stages of haemophilic arthropathy of the knee joint, the preservation of walking ability is only possible by joint replacement. Fibrotic ancylosis and severe deformities, being mostly bilaterally, make the joint reconstruction difficult and impair the results. The purpose of this study was to evaluate the results of total knee replacement (TKR) in haemophilia. METHODS: From 1990 to 1998, 14 TKR in 7 patients with severe haemophilia were performed. The mean age at operation was 47.3 years (range, 27-62 years). The mean follow-up period was 3.7 years (range, 1-7 years). The TKR was performed bilaterally at the same time in 6 cases. In 1 case, the bilateral TKR was done one after another with 6 months interval. In 10 knee joints, an unconstrained or semi-constrained surface replacement system was used. In 4 joints, a hinged prosthesis was required. RESULTS: The range of motion (extension-flexion) was improved from 0-23-69 degrees preoperatively to 0-4-88 degrees at follow-up. The mean HSS Score increased from 34.5 points preoperatively to 77.9 points at follow-up. Perioperatively, no haemorrhages or early infections were observed. In 1 case, 6 years postoperatively a late infection of the hinged knee prosthesis occurred. A two-stage-exchange of the prosthesis was performed. Aseptic loosenings of prosthetic components were not observed. CONCLUSION: The TKR in haemophilia is technically demanding and requires a consequent perioperative F-VIII or F-IX substitution. A bilateral simultaneous implantation is useful. The indication for TKR has to be strict because of the higher risks and requires a close cooperation with the haemostaseologist.     

Intramedullary Arthrodesis of the Knee in the Treatment of Sepsis After TKR

Infection is a devastating complication following total knee replacement (TKR). In the majority of cases, single- or two-stage revision has excellent results in eradicating infection and restoring function. Rarely, recurrent infection requires alternative treatments such as resection, amputation, or arthrodesis. A review of infections following TKR treated at two joint replacement centers identified 29 cases of resistant knee sepsis treated with a long intramedullary fusion nail. Clinical outcome and radiographs were reviewed at an average follow-up of 48 months (13–114). After the initial intramedullary arthrodesis union occurred in 24 of 29 patients (83%). The average time to fusion was 6 months (3–18 months). Failures included two cases of nail breakage, one of which subsequently achieved fusion following revision nailing, and three cases of recurrent infection requiring nail removal and permanent resection. At a minimum 2-year follow-up, 28% of the patients that achieved fusion complained of pain in the fused knee, 28% complained of ipsilateral hip pain, and two patients complained of contralateral knee pain. Four of the 25 fused patients (16%) remained nonambulatory after fusion, 17 required walking aids (68%) and only four ambulated unassisted. There was no association between age, number of previous procedures, the use of two-stage versus single stage technique, or infecting organism and failure of arthrodesis. Intramedullary arthrodesis is a viable treatment for refractory infection after TKR. Patients undergoing fusion should be informed of the potential for nonunion, recurrence of infection, pain in the ipsilateral extremity, and the long-term need for walking aids.     

Predictors of periprosthetic fracture after total knee replacement: An analysis of 21,723 cases

Background and purpose Periprosthetic fracture is a devastating complication of total knee replacement (TKR). Most published studies have not comprehensively assessed clinical and demographic predictors. We wanted to determine the incidence and predictors of postoperative periprosthetic fracture after primary and revision TKR.

Patients and methods We used prospectively collected data in the Mayo Clinic Total Joint Registry on all patients who underwent primary or revision TKR at the Mayo Clinic, Rochester, from 1989 through 2008. We assessed incidence of postoperative periprosthetic fractures and modifiable (comorbidity, body mass index) and unmodifiable factors (age, sex, operative diagnosis, ASA class, previous cardiac disease, and previous thromboembolic disease) as predictors of postoperative periprosthetic fractures. We used multivariable-adjusted Cox regression analyses separately for primary and revision TKR.

Results 12,914 patients underwent 17,633 primary TKRs and 3,286 patients underwent 4,090 revision TKRs during the period 1989–2008. 1.1% of patients (188/17,633) after primary TKR and 2.5% of patients (104/4,090) after revision TKR sustained a postoperative periprosthetic fracture on or after postoperative day 1. Older age was associated with lower risk of periprosthetic fractures after primary TKR (p < 0.001). Compared to ≤ 60 years, risk was lower for ages 61–70 years (hazard ratio (HR) = 0.5, 95% confidence interval (CI): 0.3–0.7)) and 71–80 years (HR = 0.6, CI: 0.4–0.8), but not for age > 80 years (HR = 0.9, CI: 0.5–1.6). In revision TKR cohort, a diagnosis of non-union (HR = 4.9, CI: 1.2–20), infection (HR = 2.9, CI: 1.3–6.4) or previous surgery with components removed (HR = 2.1, CI: 1.3–3.4) increased the risk of postoperative periprosthetic fracture, compared to a diagnosis of loosening/wear/osteolysis.

Interpretation We identified significant risk factors for periprosthetic fracture after primary and revision TKR. Patients with these risk factors can be informed by their surgeons of increased risk of this uncommon, but serious complication of TKR.     

Balance is an important predictive factor for quality of life and function after primary total knee replacement

We investigated the extent to which improved balance relative to pain relief correlates with the success of total knee replacement (TKR). A total of 81 patients were recruited to the study: 16 men (19.8%) and 65 women (80.2%). Of these, 62 patients (10 men, 52 women) with a mean age of 73 (57 to 83) underwent static and dynamic assessment of balance pre-operatively and one year post-operatively. The parameters of balance were quantified using commercially available and validated equipment. Motor function and self-reported outcome were also assessed. There was a significant improvement in dynamic balance (p < 0.001) one year after TKR, and better balance correlated with improved mobility, functional balance and increased health-related quality of life. As it seems that balance, and not only pain relief, influences the success of TKR, balance skills should be better addressed during the post-operative rehabilitation of patients who undergo TKR.     

全膝关节置换术后深静脉血栓的预防

目的 探讨全膝关节置换术后深静脉血栓形成的预防措施.方法 回顾苏州大学附属第三医院2004年至2007年87例TKR手术后深静脉血栓形成情况.结果 87例患者中,15例患者术后发生深静脉血栓,38例术后使用低分子肝素,5例患者发生深静脉血栓形成,35例使用阿司匹林患者中,6例深静脉血栓形成,与使用低分子肝素组比较无统计学意义,仅使用机械预防措施10例患者中发生4例深静脉血栓形成.结论 术前使用低分子肝素可以预防深静脉血栓形成的发生,采用硬膜外麻醉,术后采用药物阿司匹林或低分子肝素可以较好地预防深静脉血栓的形成.     

Dutch guideline on total hip prosthesis

Background?A maximum surgical blood ordering schedule may lead to wastage of valuable resources due to over-ordering of blood and/or under-utilisation. We audited the results of a group-and-save (GS) policy for primary hip (THR) and knee (TKR) arthroplasty to evaluate its safety and practicality.Patients and methods?We conducted a retrospective review of consecutive patients attending for THR (177) or TKR (137) over a period of 8 months (phase 1). Following introduction of a limited GS policy, 205 THR and 147 TKR were reviewed prospectively over a corresponding period of 8 months (phase 2). Corresponding THR and TKR groups in each phase were comparable with respect to age, gender, length of stay, operating surgeon, pre- and lowest postoperative hemoglobin, reason for and timing of transfusion. Quantities (units) of blood requested pre- and postoperatively, transfused and returned to the blood bank, were recorded.Results?77 and 62% of all blood requested for THR and TKR, respectively, in phase 1 was not used. 58 and 21% of patients undergoing THR and TKR, respectively, in phase 2 underwent preoperative GS, with 92% and 100% of all blood requested being used for transfusion. Overall, the quantity of blood returned was reduced by 25% for the THR group. Transfusion rates fell by 9% and 5% for the TKR and THR groups, respectively. We found no adverse events associated with blood from a GS sample. Cost savings of 37 800 euros were calculated estimated for the study period (phase 2).Interpretation?For routine primary THR/TKR, GS policy is a safe procedure. Reduction in non-utilisation of blood has economic and cost-saving implications for limited healthcare resources. Having subsequently introduced a group-and-save policy for all patients undergoing routine THR/TKR, considerable savings have been identified after only 2 months.     

风湿病患者人工膝关节置换术后院内感染的风险因素分析

目的 探讨人工膝关节置换（ＴＫＲ）患者院内感染的风险因素,方法 对１９８８年８月～、１９９８年１０月收治的３６３例５０３个人工关节置拘中不同年龄和原发病种类、不同伴发疾病等情况中医院感染的发生情况进行统计分析。结果 类风湿性关节炎与骨性关节炎患者ＴＫＲ术后院内感染发病率差异无显著性意义（Ｐ〉０．０５）;返修术埂、服用激素者及糖尿病患者的院内感染率明显高于一般ＴＫＲ患者（Ｐ〈０．０１）;双膝ＴＫＲ     

Patient expectations of arthroplasty of the hip and knee

Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction.     

Duplex ultrasonography after total hip or knee arthroplasty

We prospectively studied all patients admitted for total hip (THR) or knee (TKR) arthroplasty from July 2000 to February 2001. No pharmacological anticoagulation was given. All patients received a standardized postoperative rehabilitation regimen. Forty-six patients with known risk factors for deep vein thrombosis (DVT) were excluded. Eighty patients were studied (22 THR, 58 TKR; 55 women, 25 men). Mean age was 68 (30-90) years. Duplex ultrasonography on both lower limbs was performed on days 5-7 postoperatively. Location and extent of any thrombus were documented. In patients with distal DVT, a follow-up scan was done on days 10-14. If proximal propagation was observed, patients received full anticoagulation. If no propagation was detected, the distal thrombus was considered stable and clinical observation was continued. In the THR group, 1/22 and in the TKR group 9/58 were found to have distal DVT. All were asymptomatic. On follow-up scanning, none showed proximal propagation. All patients were followed up for at least 18 months, and none showed postthrombotic symptoms. Isolated distal DVT in "low-risk" Chinese patients after THR or TKR is not uncommon. Clinically they are usually "silent." If routine perioperative pharmacologic antithrombotic prophylaxis is not practiced, monitoring with duplex ultrasonography may need to be considered.