胫骨平台骨折手术疗效影响因素分析

目的探讨胫骨平台骨折手术疗效的影响因素。方法根据Rasmussen膝关节功能评分标准将356例手术治疗的胫骨平台患者分为优良组(n=288)与中差组(n=68),对比两组临床资料,探讨其手术疗效的影响因素。结果两组患者在骨折类型、膝关节周围合并伤、骨折复位情况、术后并发症及术后康复等方面比较差异有统计学意义(P0.01);经多因素Logistic回归分析发现,上述因素均为胫骨平台骨折手术疗效的影响因素(P0.05或P0.01)。结论骨折类型、膝关节周围合并伤、复位情况、术后并发症、术后康复情况均为胫骨平台手术效果的独立影响因素,了解这些影响因素对于胫骨平台骨折患者的临床手术治疗具有重要的指导意义。     

Schatzker Ⅳ~Ⅵ型胫骨平台骨折的治疗策略及预后影响因素

目的探讨SchatzkerⅣ~Ⅵ型胫骨平台骨折治疗策略及影响预后的因素。方法对167例SchatzkerⅣ~Ⅵ型胫骨平台骨折患者分别采用双钢板及锁定板加空心螺钉治疗,分析术后疗效及相关的影响因素。结果167例均获得随访,时间13~57个月。采用Rasmussen膝关节功能评分标准评价疗效:优95例,良43例,可22例,差7例,优良率为82.6%。结论术前准确评估骨折类型及移位程度,注重软组织损伤程度的评估,选择合适的手术时机、入路和固定方法,关节面的解剖复位、充分植骨、可靠的固定,术后正确指导功能锻炼、积极预防各种并发症,是提高SchatzkerⅣ~Ⅵ型胫骨平台骨折临床治疗效果的关键。     

SchatzkerⅣ~Ⅵ型胫骨平台骨折的手术疗效

目的探讨SchatzkerⅣ~Ⅵ型胫骨平台骨折的手术疗效。方法对29例SchatzkerⅣ~Ⅵ型胫骨平台骨折患者采用L-Tcp加压钢板及拉力螺钉内固定术治疗。结果患者均获得随访,时间14~27个月。骨折均临床愈合,时间18~29周。并发症:1例术后并发腘静脉血栓,予以抗血栓治疗后治愈;1例未达到解剖复位;2例出现切口感染,经伤口换药二期修复后治愈。末次随访膝关节活动度:伸-5°~5°,屈90°~125°,活动范围85°~130°。按照Rasmussen膝关节功能评分标准评定:优13例,良11例,可3例,差2例。结论手术治疗SchatzkerⅣ~Ⅵ型胫骨平台骨折应处理好膝关节周围合并伤,注重关节面复位质量、坚强内固定及术后功能锻炼。     

自制胫骨关节面塌陷骨折复位器的临床应用

目的探讨应用自制胫骨关节面塌陷骨折复位装置在治疗胫骨关节面塌陷骨折中的疗效。方法应用自制胫骨关节面塌陷骨折复位器治疗38例胫骨关节面塌陷骨折患者。结果 38例均获得随访,时间6～36个月。术后6个月,胫骨近端骨折按Rasmussen膝胫骨关节功能标准评价疗效:优17例,良6例,可2例,优良率为23/25;胫骨远端骨折按Lowa踝胫骨关节功能标准评价疗效:优9例,良3例,可1例,优良率为12/13。结论应用自制胫骨关节面塌陷骨折复位器治疗胫骨关节面塌陷骨折,操作简便,胫骨关节面创伤小,可达到解剖复位,利于膝、踝关节功能的恢复。     

钢板内固定联合磷酸钙骨水泥治疗胫骨平台骨折的疗效

目的探讨钢板内固定联合磷酸钙骨水泥治疗胫骨平台骨折的临床疗效。方法采用钢板内固定联合磷酸钙骨水泥填充关节面塌陷治疗38例胫骨平台骨折患者。结果患者均获得随访,时间15～24个月。术后6个月患者均可完全负重行走。骨折骨性愈合时间为6～8个月。末次随访时,膝关节活动度为115°～145°,无屈曲挛缩畸形;膝关节功能采用Rasmussen胫骨平台骨折评分评定疗效:优21例,良12例,可5例,优良率为86.8%。1例患者在术后3个月时发现关节面塌陷(下沉深度为1.5 mm),其余患者至末次随访时未发现关节面塌陷。结论采用钢板内固定联合磷酸钙骨水泥治疗胫骨平台骨折,能够有效阻止关节面复位再丢失,临床疗效和影像学结果满意,术后并发症发生率较低。     

关节镜辅助下微创治疗胫骨平台骨折

目的探讨关节镜辅助治疗胫骨平台手术效果。方法对63例闭合性胫骨平台骨折在关节镜监控下复位小切口内固定。结果患者均获随访,时间618个月,骨折临床愈合时间4-10个月,无感染、关节强直等并发症发生,X线片显示49例达解剖复位,14例平台关节面有2 mm以下塌陷。按Rasmussen功能评分标准：优35例,良22例,可6例,总优良率90.5%。结论关节镜辅助治疗胫骨平台骨折,疗效可靠,创伤小,术后关节功能恢复快。     

后内侧入路Ⅲ型中T型锁定板内固定治疗胫骨平台后外侧骨折

目的 探讨后内侧入路Ⅲ型中T型锁定板内固定治疗胫骨平台后外侧骨折的疗效。方法 采用后内侧入路Ⅲ型中T型锁定板内固定治疗19例胫骨平台后外侧骨折患者。术后10个月采用Rasmussen骨折复位解剖学评分标准来评价骨折复位质量,末次随访时采用HSS评分评价膝关节功能。结果 患者均获得随访,时间10～24个月。骨折均愈合,时间12～15周。术后均未发生内固定松动、关节面塌陷、力线丢失、切口深部感染及创伤性关节炎等并发症。术后1例由于肥胖原因关节屈伸锻炼不配合,活动度受限,加用CPM机锻炼后明显好转。术后10个月,采用Rasmussen骨折复位解剖学评分标准评价骨折复位质量:优15例,良4例;膝关节屈曲为110°～135°。末次随访时采用HSS评分评价膝关节功能:优11例,良7例,可1例,优良率为18/19。结论 后内侧入路Ⅲ型中T型锁定板内固定治疗胫骨平台后外侧骨折显露充分,有利于骨折解剖复位,疗效良好。     

切开复位内固定并植骨治疗复杂胫骨平台骨折110例

目的探讨切开复位内固定并植骨治疗复杂胫骨平台骨折（SchatzkerIV—VI型）的手术方法及临床疗效。方法对110例采取切开复位内固定并植骨治疗的复杂胫骨平台骨折进行回顾性分析。结果术后110例均获得平均33．6（6-48）个月随访．所有患者均获骨性愈合,疗效采用Rasmussen评分标准评定：优43例,良51例,可10例,差6例,优良率85．5％。结论术中应根据具体骨折类型采用相应手术人路和固定方式,充分植骨并解剖复位关节面,维持下肢正常力线．修复关节周围韧带可取得满意的临床疗效。     

交锁髓内钉内固定治疗累及胫骨平台的复杂胫骨骨折

目的探讨交锁髓内钉内固定治疗累及胫骨平台的胫骨多段多平面骨折的可行性,并总结手术技巧及临床疗效。方法回顾性分析自2013-06—2016-06采用胫骨近端多向锁定交锁髓内钉内固定治疗的21例累及胫骨平台的胫骨多段骨折,术中经皮或有限切开辅助复位胫骨平台关节面骨折块并用拉力螺钉或锁定钢板内固定。术后采用胫骨平台骨折复位Rasmussen放射学评分评定复位质量,末次随访时采用膝关节功能KSS评分标准评定疗效。结果 21例均获得随访,随访时间平均16.3(12~24)个月。术后X线片及CT显示骨折复位固定良好,胫骨平台骨折复位Rasmussen放射学评分平均17.7(17~18)分,优20例,良1例。骨折均顺利愈合,愈合时间平均13.1(10~16)周。末次随访时疗效采用膝关节功能KSS评分标准评定:优19例,良2例。结论对于合并严重软组织损伤、累及胫骨平台但塌陷较轻的多段多平面复杂胫骨骨折采用交锁髓内钉联合钢板螺钉内固定治疗是一种可行的手术方法,而且创伤小、骨折固定良好。     

膝关节镜辅助下微创手术治疗胫骨平台骨折

目的探讨在膝关节镜辅助下微创手术治疗胫骨平台骨折的疗效与体会。方法自2010-01—2013-06对28例胫骨平台骨折在膝关节镜辅助下复位后经皮微创内固定。在关节镜下探查整个关节腔,用探钩或骨膜剥离器将骨折解剖复位,骨缺损处取自体髂骨植骨,经皮微创空心钉、拉力螺钉或锁定钢板固定骨折。如合并半月板或韧带损伤则在镜下作相应的处理。结果术后3~6个月骨折愈合,关节面平整,无膝关节内外翻畸形、膝关节僵硬、关节不稳等并发症。28例术后获得6~24个月随访,末次随访时疗效根据Rasmussen评价标准评定：优25例,良2例,可1例,优良率96.4%。结论膝关节镜辅助下微创手术治疗胫骨平台骨折具有创伤小、骨折复位精确、并发症少、功能恢复快的优点。     

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.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

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.