切开复位有限内固定外固定支架治疗胫骨远端骨折

目的探讨切开复位克氏针有限内固定加外固定支架治疗C3型胫骨下端骨折的临床效果。方法AO分型胫骨远端C3型骨折共23例患者,采用一期或延期切开复位有限内固定加外固定支架治疗,随访观察伤口情况、关节面恢复情况及踝关节的活动度。结果本组病例随访时间2-23个月,平均随访时间18个月。未出现钉道感染、螺钉松动及切口感染、裂开病例,依据Marsh踝关节关节面骨折复位评分法,术后关节面恢复优良者15例,中等7例,一般1例。踝关节活动范围在20。之内者13例,在40°之内9例,活动良好1例。结论切开复位克氏针有限内固定加外固定支架能有效重建及恢复胫骨远端C3型骨折胫骨关节面和骨折的稳定性,是一种可选择的治疗方法。     

Hybrid外固定支架治疗胫骨远近端重度开放性骨折的初步报告

目的 探讨应用Hybrid外固定支架治疗胫骨远、近端严重粉碎性、开放性骨折的疗效.方法 自2004年3月至2008年12月采用Hybrid外固定支架治疗27例严重粉碎性、开放性胫骨远、近端骨折患者,男16例,女11例;年龄13～80岁,平均56.2岁;胫骨近端骨折19例,远端骨折8例.按GustiloAnderson分型:Ⅱ型10例,ⅢA型12例,ⅢB型5例.22例患者采用Hybrid外固定支架同定,5例患者采用SheffieldHybrid外同定支架同定.必要时结合有限内固定:6例采用骨片钉固定,4例采用可吸收螺钉固定,3例采用钢丝固定.结果 27例患者术后获7～58个月(平均27个月)随访.外固定支架使用时间平均为6.0个月(4～8个月),骨折愈合时间平均为6.7个月(4～12个月).无伤口感染、神经及血管损伤等并发症发生.仅5例发生针道局部感染,经换药后治愈.患肢功能按JohnerWruhs方法评价:优17例,良8例,中2例,优良率为92.6%.结论 应用Hybrid外固定支架治疗严萝粉碎性、开放件胫骨远、近端骨折具有手术创伤小、固定可靠、可避免伤口并发症和骨小连的发生、能更好地恢复关节面的解剖关系、有利于关节早期活动及避免关节僵硬等优点,是一种较好的治疗方法.     

Hybrid外固定支架治疗开放性胫骨干骺端骨折

目的探讨Hybrid外固定支架治疗开放性胫骨干骺端骨折的疗效。方法2000年3月～2004年7月采用Hybrid外固定支架治疗开放性胫骨近端骨折19例,Pilon骨折6例。软组织损伤程度按Gustilo分类：Ⅱ型8例；ⅢA型10例,ⅢB型5例,ⅢC型2例。伤口彻底清创后直接缝合21例,4例通过皮瓣转移或游离皮瓣移植关闭,3例行深筋膜切开减压。11例骨折行闭合间接复位,14例通过延长伤口或有限切开复位,关节骨折尽可能解剖复位,并予有限内固定。所有患者骨折均用Hybrid外固定支架固定。结果所有患者获平均15．7个月(9～26个月)随访。外固定支架使用时间平均9．4个月(2．9～21．0个月)。骨折愈合时间平均8．8个月,其中2例二期改用钢板内固定加自体髂骨植骨后愈合。除2例创面延期愈合外,创口均一期愈合,未发生深部感染等严重并发症。19例胫骨近端骨折患者末次随访时膝关节活动超过90°者15例；未达70°者4例,但在膝关节松解术后活动超过90°。6例Pilon骨折患者踝关节活动范围均正常,其中2例术后11个月发生创伤性关节炎。按照Rasmussen临床与放射评分,本组中膝关节功能优13例,良3例,可2例,差1例,优良率为84．2%；踝关节功能优3例,良2例,差1例,优良率为83．3%。结论Hybrid外固定支架治疗开放性胫骨干骺端骨折能有效维持骨折稳定性,组织感染坏死率低,对关节活动影响小,但骨折愈合时间长,且有一定的不愈合率。     

Hybrid外固定支架治疗高能量损伤胫骨远端骨折

目的探讨Hybrid外固定支架治疗高能量损伤胫骨远端骨折的疗效。方法采用Hybrid外固定支架治疗15例高能量损伤致胫骨远端骨折患者。结果 15例均获随访,时间12-30个月。骨折愈合时间4-22（5.7±2.1）个月。其中1例因骨不连二期改用钢板内固定加自体髂骨植骨后愈合。根据AOFAS踝关节和后足评分为52-100（88±14）分。结论 Hybrid外固定支架治疗高能量损伤的胫骨远端骨折能有效维持骨折稳定性,软组织愈合佳。     

有限内固定结合外固定支架治疗Pilon骨折

目的　探讨有限内固定结合外固定支架治疗胫骨Pilon骨折的临床疗效。方法　采用有限内固定结合外固定支架治疗Pilon骨折 14例。根据Ruedi Allgower骨折分型:Ⅰ型 3例,Ⅱ型 5例,Ⅲ型 6例。按Teeny踝关节功能评分标准进行疗效评价。结果　全部病例获得随访,随访时间 6个月 ~5年,平均 4 1年;骨折愈合时间 6~24周(平均 10 5周)。踝关节功能评分,优 9例、良 2例、可 2例、差 1例。结论　采用有限内固定结合外固定支架治疗Pilon骨折,能减少并发症并获得较好疗效。     

外支架辅助微创经皮LCP固定治疗A_1～B_1型胫骨远端骨折

目的探讨采用单边外固定支架结合微创经皮锁定加压钢板内固定治疗胫骨远端A1～B1型骨折的临床效果。方法自2006年10月至2009年3月26例胫骨远端A1～B1型骨折,Ⅰ期急诊C臂机引导下闭合复位,行单边外支架超踝关节固定术,Ⅱ期行微创经皮LCP内固定术,解除外支架固定。结果本组26例平均随访12月,均顺利骨性愈合,无1例发生小腿皮肤坏死。术后2例外支架钉孔愈合不良,经换药后愈合。本组术后踝关节功能IOWA评分,平均89分。结论单边外固定支架结合微创经皮锁定加压钢板（MIPO）治疗胫骨远端骨折,具有创伤小,操作简便,骨折愈合率高,踝关节功能恢复良好等优势。     

外固定器结合有限内固定治疗胫骨远端骨折

目的观察外固定器结合有限内固定治疗胫骨远端骨折的临床效果及探讨该方法在胫骨远端骨折治疗中的价值。方法采用Orthofix外固定器结合有限内固定治疗胫骨远端骨折48例,首先将腓骨骨折复位固定,恢复下肢的长度及力线,然后对胫骨远端骨关节面骨折通过有限的切开复位,空心钉或克氏针固定,最后采用Hybrid环形或铰链式外固定器固定。对其临床资料进行回顾性分析。结果随访46例,随访时间6～47个月,所有骨折均愈合,踝活动范围平均背伸20°,跖屈40°。并发症包括针道感染12例,创伤性关节炎4例。根据Helfer踝关节功能评定标准:优20例,良16例,差10例,优良率为78.3%。结论外固定器结合有限内固定治疗胫骨远端骨折可有效地减少感染等并发症,提高治疗效果,是一种比较安全、可靠的治疗方法。     

带关节的超关节外固定架结合有限内固定治疗Pilon骨折

目的应用带关节的超关节外固定架结合有限内固定治疗Pilon骨折，并评估其疗效。方法2002年2月～2004年6月采用单边带关节的超踝关节T型外固定架结合有限内固定治疗19例（21侧）Pilon骨折患者。支架远端螺钉固定于距骨或跟骨，近端螺钉固定于胫骨骨折近端，使踝关节可以距下关节为中心在一定范围内活动。依据伤口软组织情况在术后2～3周松动外固定支架关节开始踝关节功能锻炼。结果19例患者全部获得随访10～18个月，平均13个月。临床效果满意，无切口、伤口及钉道感染，无神经、血管损伤，无骨不连等并发症。踝关节骨折复位情况（Burwell＆charnley踝关节骨折复位评分法）为C1型5例全部达解剖复位；C2型达解剖复位7例，一般2例，C3型达解剖复位4例，一般1例，复位差2例。踝关节症状和功能评分（Baird＆Jackson评分法）为72～98分，平均92分；优4侧，良12侧，可3侧，差2侧，优良率为84．2％。结论带关节的超关节外固定支架结合有限内固定治疗Pilon骨折可避免伤口并发症和骨不连的发生，能更好地恢复关节面的解剖关系，有利于踝关节早期活动，避免关节僵硬，是治疗Pilon骨折的理想方法之一。     

有限固定结合外固定支架治疗Ⅲ型Pilon骨折的病例对照研究

目的：通过对33例Rüedi-Allgower Ⅲ型Pilon骨折的不同治疗方法进行疗效分析,探讨最佳治疗方案。方法：对2009年10月至2012年1月对采用3种治疗方法（单纯石膏外固定术10例,胫骨远端解剖钢板内固定术11例及有限固定结合外固定支架12例）治疗的Ⅲ型Pilon骨折患者进行回顾性分析,对其治疗效果进行综合评定和分析。单纯石膏外固定组男5例,女5例;年龄24～61岁;受伤至治疗时间4 h～15 d;高处坠落伤3例,车祸伤4例,2例摔伤,其他伤1例。胫骨远端解剖钢板内固定组男7例,女4例;年龄21～64岁;受伤至治疗时间为3 h～12 d;高处坠落伤4例,车祸伤5例,摔伤1例,其他伤1例。有限固定结合外固定支架组男7例,女5例;年龄23～67岁;受伤至治疗时间5 h～11 d;高处坠落伤4例,车祸伤6例,摔伤1例,其他伤1例。主要观察和分析指标包括：①骨折复位的影像学表现,观察骨折对位对线情况及关节面是否平整等;②根据Bourne踝关节功能评定标准对最近一次随访的病例进行踝关节功能评分;③患者早期并发症（皮肤坏死、感染、骨折再移位及行走痛）和晚期并发症（骨折延迟愈合、畸形愈合、创伤性关节炎、关节僵硬及肌肉萎缩）的发生率。结果：所有患者获随访,时间8个月～3年,有限固定结合外固定支架组及胫骨远端解剖钢板内固定组解剖复位分别为7例和8例,多于单纯石膏外固定组（2例）.术后随访踝关节功能评分：有限固定结合外固定支架组优8例,良3例,差1例;单纯石膏外固定组优3例,良4例,差3例;胫骨远端解剖钢板内固定组优5例,良4例,差2例;有限固定结合外固定支架治疗组疗效最佳。有限固定结合外固定支架组骨折早期并发症和晚期并发症的发生率低于其他两组。结论：有限固定结合外固定支架治疗Ⅲ型Pilon骨折能较好地恢复踝关节功能,减少并发症的发生,可作为首选治疗方法。     

胫骨远端外侧型解剖钢板固定治疗胫骨远端骨折

目的探讨胫骨远端外侧型解剖钢板固定治疗胫骨远端骨折及评价疗效。方法 31例胫骨远端骨折采用切开复位胫骨远端外侧型解剖钢板内固定治疗。骨折按照AO分型：A1型14例,A2型8例,A3型2例;B1型2例,B2型1例,B3型2例;C1型1例,C2型1例。结果随访8～24个月,平均16个月,骨折均临床愈合。参照Mazur等的踝关节症状和功能评价标准,优16例,良11例,可3例,差1例,优良率87%。结论对于胫骨远端骨折采用外侧型解剖钢板内固定,具有操作方便、固定可靠、并发症少的优点,疗效满意。     

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.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

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.     

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.     

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.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.