复杂踝关节骨折中后踝骨折及下胫腓联合分离的手术治疗体会

目的总结复杂踝关节骨折中后踝骨折及下胫腓联合分离的手术治疗方法及临床疗效。方法自2010-03—2013-03共手术治疗三踝骨折38例,其中合并胫腓下联合分离32例,整复固定的顺序是外踝、内踝、后踝和下胫腓联合。结果 38例均获得平均15（6~36）个月随访。1例下胫腓联合固定后轻度背伸受限,6周取出螺钉后经过康复锻炼恢复良好。末次随访时临床疗效按Baird-Jackson踝关节评分评定：优30例,良5例,可2,差1例,优良率达92.1%。疗效差的1例为糖尿病肾病患者。结论固定后踝对于稳定踝关节有重要意义,固定后踝后可正确评估下胫腓联合分离情况并根据情况决定是否固定,可以恢复踝关节的稳定性,取得良好的治疗效果。     

关节镜辅助下手术治疗合并下胫腓联合分离的踝关节骨折

目的探讨关节镜辅助下手术治疗合并下胫腓联合分离的踝关节骨折脱位的疗效。方法自2000年3月～2005年3月在关节镜辅助下手术治疗合并下胫腓联合分离的踝关节骨折脱位患者37例，根据AO-Weber分型：B型11例，C型26例。通过关节镜修整软骨缺损的关节面，取出游离体，1／3管型钢板固定外踝，螺钉固定骨折的内踝和后踝。在关节镜监视下准确复位仍有残存不稳的下胫腓联合，并用螺钉固定。结果所有患者获得14～36个月（平均21．4个月）随访，骨折愈合时间11～15周，平均13周。无感染、断钉及下胫腓联合再分离等并发症，根据AOFAS评分：优23例，良10例，可或差4例，优良率为89.1％。结论通过踝关节镜可更准确判断下胫腓联合的稳定性，并更精确地将其复位、固定，操作简便，疗效可靠。     

无骨折的踝关节外脱位1例报告

患者男 ,34岁。右踝扭伤 3ｄ ,踝部明显肿胀 ,活动受限 ,内侧及前侧局限性压痛 ,踝关节弹性固定。拍片为右踝外脱位 ,距骨与内踝间隙 1 5ｃｍ ,未见骨折。诊断为右踝外脱位并下胫腓分离。腰麻下试行手法复位失败 ,即给手术治疗。术中见内踝三角韧带浅深两层完全断裂 ,胫后肌腱嵌入 ,胫腓下前后韧带断裂 ,骨间韧带断裂 ,下胫腓完全分离 ,三踝未见骨折。修补韧带 ,2枚加压螺丝钉固定下胫腓联合。术后石膏外固定 ,8周后开始主动功能锻炼 ,10周后取出内固定螺丝钉 ,随访 1年 ,右踝关节功能恢复良好。踝关节脱位多合并内、外踝或后踝骨折 ,创伤严…     

三踝骨折的独立分型

目的：探讨并总结与三踝骨折的独特移位规律相对应的独立分型，改进其复位与固定方法。方法：根据42例三踝骨折患者的术前x线片，根据其有无距骨移位和移位方向以及有无下胫腓分离进行分型，并与传统分型进行比较。结果：三踝骨折可分为稳定型（12例）和非稳定型（30例）。非稳定型又分为3型：Ⅰ型（距骨外脱位型）16例，其中，Ⅰa型（无下胫腓分离的距骨外脱位型）5例；Ⅰb型（有下胫腓分离的距骨外脱位型）11例；Ⅱ型（距骨外后脱位型）8例，其中，Ⅱb型（无下胫腓分离的外后脱位型）5例，Ⅱb型（有下胫腓分离的外后脱位型）3例；Ⅲ型（距骨后脱位型）6例，其中，Ⅲa型（无下胫腓分离的后脱位型）2例，Ⅲb型（有下胫腓分离的后脱位型）4例。结论：根据X线片可对三踝骨折进行独立分型。三踝骨折的独立分型突出了距骨脱位和下胫腓分离两个反映踝关节损伤程度的重要因素，深化了对三踝骨折移位规律的认识，并对其手术适应证的选择、预后判断、手术顺序的安排等均有一定指导意义。     

手术治疗踝关节骨折脱位(附22例报告)

作者对22例踝部骨折脱位并下胫腓关节分离病人进行手术治疗。18例下胫腓联合做了加压螺钉或骨栓固定,外踝骨折应用4孔钢板或髓内针固定陈旧性骨折脱位需作下胫腓关节加压融合,同时作纵轴穿针稳定距骨。随访1～6年,优良率达90.9％。认为Laugehansen分类法符合临床实际、实用,手术内固定治疗踝关节骨折脱位对踝关节稳定性、功能恢复具有重要意义,其治疗关键在于处理好下胫腓关节分离和腓骨骨折。     

踝关节骨折并下胫腓联合的手术治疗

目的：探讨踝关节骨折并胫腓联合分离手术治疗特点及关键步骤。方法：回顾下胫腓联合分离并内、外、后踝骨折21例，其中外踝骨折并下胫腓联合分离5例，双踝骨折并下胫腓联合分离10例，三踝骨折并下胫腓联合分离6例；在手术治疗上，根据胫腓联合微动关节的特点，通过一枚螺丝钉在距踝关节平面上1．5cm处，通过三层骨皮质将腓骨和胫骨固定，保证踝关节活动时有一定的微动，使固定更接近踝关节的正常生理功能。结果：术后1～3年随访优良率为85．7％。结论：内踝、外踝与下胫腓联合损伤具有它的特殊性，主张应手术复位内固定，早期治疗优于后期治疗，手术复位应达到解剖对位。     

踝部B型、C型骨折的手术治疗

目的：讨论踝部B型，C型骨折手术治疗的重要性，方法：手术复位，内固定外踝，骨踝或后踝骨折，有胫腓关节分离者用长螺钉或骨栓固定，以维持踝穴的稳定，结果：全部病例随访2年以上，均获得骨性愈合，优良率达96．67％，结论：解剖复位外踝和稳定下胫腓关节对踝关节的稳定和防止发生创伤性关节炎具有重要.意义。     

胫腓下联合分离伴踝部骨折的治疗

目的：探讨踝关节损伤时胫腓下联合分离的机制及胫腓下联合固定的利弊。方法：伴胫腓下联合分离的踝天节损伤共31例,其中19例未行胫腓下联合分离固定,10例用螺钉困定胫腓下联合,2例用下胫腓钩固定。内踝骨折以螺钉或张力带钢丝固定。外踝以螺钉或钢板固定,后踝用松质骨螺钉加压固定。结果：胫腓下联合固定患者中2例松动,2例术后1～2年取出固定螺钉,其余10例均6～12周取出胫腓下联合固定螺钉。未发生胫腓下联合螺钉断裂。内外踝及后踝骨折内固定于6～29个月取出。未行胫腓下联合分离固定的病例均未出现胫腓下联合分离。结论：胫腓下联合的稳定性不仅仅取决于胫腓下联合本身,胫腓下联合韧带损伤时,只有同时伴有踝关节内侧骨韧带复合体损伤,才会出现临床上的胫腓下联合分离,因此踝关节骨折脱位时,只要内外踝或后踝解剖复位,固定,牢固,胫腓下联合分离即可自动复位,一般不必做胫腓下联合的固定。     

踝关节骨折脱位的治疗

目的：总结踝关节骨折脱位治疗的经验。方法：对1987~1997年103例踝关节骨折脱位治疗情况进行分析,随访6个月~5年,平均2年3个月。采用Weber评分标准评定临床疗效。结果：手术治疗38例：优13例（34.2%）,良18例(47.4%),差7例（18.4%）,优良率占81.6%。其中单纯外踝骨折14例仅14.3%(2/14)获得解剖复位,临床疗效优良率达92.8%。手术治疗65例：优34例（52.3％）,良23例（35.4%）,差8例（12.3%）,优良率占87.7%。其中单纯外踝骨折18例,83.3%（15/18）获解剖复位,疗效优良率为94.4%。合并下胫腓关节分离31例。术中没有下胫腓联合固定20例,80%(16/20)未发现有踝穴增宽,4例下胫腓关节有轻中度分离,疗效差。结论：⑴目前广泛应用的分类方法,没有一个可用来判断预后,踝关节损伤的分类还需要进一步完善;⑵单纯外踝骨折,保守治疗可获满意疗效,手术比保守治疗并无优势;⑶合并下胫腓联合损伤时,只要内、外踝及腓骨骨折准确定位,固定牢固,不需要固定下胫腓联合。     

踝关节骨折伴下胫腓关节分离的治疗

目的 探讨踝关了骨折伴下胫腓关节分离的治疗方法。方法 对２０例踝关节骨折伴下胫腓韧带分离患者按Ｂｏｎｎｉｎ分度法,Ⅱ１２例,Ⅲ度８全和加压松质骨螺钉内固定术,使踝穴结构恢复正常。结果 随访８～１８个月,平均１４．５个月病人踝关节功能恢复正常,优良率达８５％。结论 对踝关节骨折伴下胫腓韧还分离的患者在治疗骨折的同时注意修补下胫腓韧带以恢复正常踝穴结构,避兔创伤生骨关节炎发生。     

胸腰椎骨折椎弓根内固定断裂与植骨融合方式的相关性分析

[目的]探讨胸腰椎骨折椎弓根螺钉内固定系统内固定术后,椎弓根螺钉断裂与植骨融合方式之间的关系,以探讨胸腰椎骨折植骨融合的最佳方式。[方法]回顾性研究1995年5月~2005年12月本院脊柱外科收治的胸腰椎骨折病人197例,其中A组单纯内固定(不植骨)患者14例,B组“H”形椎板植骨21例,C组横突间植骨67例,D组椎间、椎内联合横突间植骨95例。[结果]术后随访6~32个月,内固定断裂12例,其中A组4例,B组3例,C组5例,D组0例,4组中D组内固定断裂率显著低于其他3组(P<0.05)。[结论]椎间、椎体内联合横突间植骨重建脊柱三柱的稳定性,符合人体生物力学原理,能有效降低内固定断裂的发生。     

On the measurement of the functional properties of the CFTR

A number of methods are currently employed to assess the functional properties of CFTR channels and their response to pharmacological potentiators, correction of the defective CFTR trafficking, and vectorial introduction of new proteins. Here we review the most common methods used to assess CFTR channel function. The suitability of each technique to various experimental conditions is discussed.     

The Measurement of the Inclination Angle of the Hamate and Analysis of the Inclination Angle for the Rotation Deformity of the Little Finger in the Fixation of the Carpometacarpal Joint

ObjectiveComplex base fractures of the fifth metacarpal bone and dislocation of the fifth carpometacarpal joint are more prone to internal rotation deformity of the little finger sequence after fixation with a transarticular plate. In the past, we have neglected that there is actually a certain angle of external rotation in the hamate surface of transarticular fixation. This study measured the inclination angle of the hamate surface relative to the fifth metacarpal surface for clinical reference.MethodsIn a prospective single‐center study, we investigated the tilt angle of 60 normal hamates. The study included thin‐layer computed tomography (CT) data from 60 patients from the orthopaedic clinic and inpatient unit from January 2017 to March 2020, including 34 men and 26 women who were 15~59 years old, average 35 years old. The CT data of 60 cases in Dicom format of the hand was input into Mimics and 3‐Matics software for three‐dimensional (3D) reconstruction and measuring the angle α between hamate surface and the fifth metacarpal surface. According to the possible placement of the transarticular plate on the fifth metacarpal surface, we measured the angle β between the hamate surface 1 and the fifth metacarpal surface and the angle γ between the hamate surface 2 and the fifth metacarpal surface.ResultsThe average angle between the hamate surface and the fifth metacarpal surface was 11.66°. The hamate surfaces 1 and 2 have an external rotation angle of 7.30° and 7.51° on average with respect to the fifth metacarpal surface, respectively. There is no statistically significant difference in the angles between the two groups (P > 0.05).ConclusionsThe horizontal angle of the dorsal side of the hamate is different from the back of the fifth metacarpal surface, and the hamate has a certain external rotation angle with respect to the fifth metacarpal surface. No matter how the transarticular plate is placed, the plate always has a certain external rotation angle relative to the fifth metacarpal surface. When the fixation is across the fifth carpometacarpal joint, if the plate does not twist and shape, it will inevitably cause internal rotation of the fifth metacarpal, resulting in internal rotation deformity of the little finger sequence.     

静脉输注甘露醇开放血脑屏障对抗生素透过血脑屏障的影响

目的　通过快速静脉输注甘露醇可逆性开放血脑屏障 (BBB) ,探知此方法能否增加抗生素透过BBB的量 ,在何时达到最高峰 ,其通透量增加后临床上有无不良反应。方法　采用自身配伍设计 ,共 6个样本组。对照组仅使用抗生素 ;其余 5组分别在使用甘露醇前 60、3 0min ,同时使用甘露醇后 3 0、60min使用抗生素 ,各组皆取使用抗生素后 1h的脑脊液测其抗生素浓度。抗生素选用头孢三嗪。结果　测量值经过q检验 ,经 2 0 %甘露醇处理前后的CSF中的头孢三嗪浓度差异有非常显著性。全组患者经临床观察未出现神经系统的不良反应。结论　经静脉快速输注2 0 %甘露醇后可以使透过BBB的水溶性抗生素的量增加 ,两者使用的顺序是在抗生素使用 3 0min内即给予甘露醇快速滴注。该方法不会增加低神经毒性抗生素在中枢神经系统的不良反应。     

Preservation of the pylorus and resection of the head of the pancreas

The historical evolution of the pylorus-preservation resection of the head of the pancreas is traced from the first resections early in this century to relative standardization of the operation, to a lowering of the operative mortality, and to an interest in improving nutritional status after resection. There are many theoretical advantages for the function of the upper gastrointestinal tract after pylorus and gastric preservation, such as maintenance of gastric capacitance and equilibration of osmotic pressure in gastric digestants, foodstuff digestion and absorption, and bowel motility. After the pylorus-preserving resection, gastric emptying is normal, pyloric function to prevent duodenal reflux is often normal, and gastric acids and serum levels of duodenal hormones are at normal levels, whereas after standard pancreatoduodenectomy, all of these are often abnormal. No prospective blinded studies have been published comparing nutritional values after the two operative procedures, but evidence is presented of a satisfactory result with regard to gastric capacitance, body weight gain, and lack of postgastrectomy symptoms. An undoubted advantage of the pylorus-preserving feature is a simplification of the operation. These gains are achieved without increase in operative mortality, without increase in the incidence of jejunal ulcer, and without theoretical or actual decrease in value of the procedure as a cancer operation, except in patients with duodenal carcinoma proximal to the ampulla of Vater.     

下颌全牙弓后移量及最后界的测量

目的：研究下颌牙弓的有效后移量及找寻下颌牙弓移动的后界。方法：选取涉及拔除下颌第三磨牙或下颌第三磨牙缺失的病例18例（男6例,女12例）。采用种植支抗牵引下牙弓向远中,治疗完成时所有病例均明确到达下颌牙弓后界,即下颌第二磨牙远中到达下颌升支前缘软组织交界处。应用治疗前后的曲断片测量下颌第二磨牙远中到升支前缘的距离。结果：下颌第二磨牙后移量为（3.49±1.21）mm;治疗后磨牙后间隙的长度为（4.43±0.97）mm。结论：下颌牙弓可确定性地实现整体后移;最大后移量由磨牙后间隙的长度决定;其最后界止于下颌第二磨牙远中与下颌升支前缘软组织交界处。     

Preservation of the pylorus in resection of the head of the pancreas

Whipple's pancreatoduodenectomy was the standard operation for diseases of the head of the pancreas for more than 40 years, but the results were vitiated in part by poor gastrointestinal function and malnutrition. Reintroduced in 1978, pylorus-preserving proximal pancreatoduodenectomy (PPPP) has had an increasing impact on pancreatic surgery as its benefits have been recognized: improved nutritional status, decreased incidence of postgastrectomy syndromes, and a technically easier operation. Postoperative mortality rates and 5-year survival rates are comparable with those of the classic Whipple procedure. PPPP is indicated for most patients with chronic pancreatitis of the pancreatic head. It is also appropriate for patients with periampullary cancer and for those with pancreatic cancer arising from the lower part of ‘the head and the uncinate process. More than 650 patients have now undergone PPPP: 31% for chronic pancreatitis and 66% for periampullary and pancreatic cancers. We assess the indications for PPPP, outline the operation, and review the results.