儿童骶臼发育不良的手术治疗

髋臼发育不良是儿童髋关节的常见病，也是发生退行性骨关节炎的主要原因之一犤１－３犦。Stulberg等犤４犦报告１３０例成人骨关节炎患者中，有４８％继发于婴幼儿时期的髋臼发育不良。正常髋关节的股骨头和髋臼呈同心圆关系。儿童髋臼的正常发育主要依赖于股骨头对“Y”形软骨中心的刺激。在髋臼发育不良状态下，头臼失去同心圆关系，股骨头不能刺激“Y”形软骨中心，髋臼软骨骨化迟缓、停滞，髋臼的深度逐渐变浅、坡度增加，使髋关节受力面积减小，应力增大，负重力线移向髋臼外侧缘。随患儿步行和负重的增加，髋关节可出现进行性半脱位…     

髋臼周围损伤对髋关节发育影响的实验研究

目的：探讨髋臼软骨及周围骨膜损伤对髋关节发育的影响。方法：4-5周龄白兔20只，切除其右饲髋关节部分髋臼软骨(A组)及臼缘上方骨膜(B组)，左侧作为对照。用X线、形态学及组织学方法观察髋关节发育状况。结果：右侧全部出现髋关节发育不良，半脱位发生率：A组80％，B组40％。对照侧发育正常。结论：髋臼软骨及臼缘上方骨膜破坏可导致髋关节发育不良和半脱位。     

髋臼发育不良动物模型的建立及其临床意义

目的探讨髋臼发育不良在先天性髋关节脱位发病过程中的意义。方法将１２只幼犬通过外科手术造成单侧髋关节脱位,术后３、４周通过大体标本、组织学及Ｘ线摄片,观察髋臼变化。结果术后３周幼犬实验性髋关节脱位侧即出现髋臼发育不良,髋臼上部呈斜坡状,髋臼浅,Ｘ线片上可见髋臼指数增大,由实验前平均１３２±１３度增大为平均２７８±１５度,组织学观察见髋臼软骨退行变化。结论髋臼发育不良为髋关节脱位的继发病变,不是髋关节脱位的原因;如果髋关节脱位或髋关节松驰得到及时治疗,髋臼发育不良可以恢复正常     

髂臼成形骨盆截骨术治疗幼儿发育性髋脱位的疗效

目的探讨髂臼成形(Pemberton)骨盆截骨术治疗幼儿发育性髋脱位(DDH)的疗效。方法对54例DDH患儿采用Pemberton骨盆截骨术治疗。记录临床随访结果和髋关节解剖结构参数。末次随访时,采用Mckay评估标准评价髋关节功能,采用Severin标准评价髋关节形态和复位情况。结果单侧DDH患儿均获得9个月随访;双侧DDH患儿先手术侧获15~18个月随访,后手术侧获9个月随访。术后3个月,患儿股骨、髋臼截骨处均愈合,无重要血管神经损伤、截骨处明显感染等并发症发生。术后6个月、末次随访时髋关节各解剖结构参数均较术前改善明显(P<0.05);与术后6个月相比,末次随访时,骨性髋臼指数(AI)和髋臼深度逐渐增大(P<0.05),中心边缘角(CE角)、髋臼顶宽度和Reimers不稳定指数逐渐减小(P<0.05),髋关节各解剖结构参数已逐步接近同龄正常儿童。末次随访时,单侧DDH患儿患侧的髋臼顶宽度、臼头指数均明显高于健侧(P<0.05),AI、CE角、髋臼深度患侧与健侧比较差异均无统计学意义(P>0.05)。末次随访时,4例髋臼Y形软骨已闭合,其中1例Y形软骨早闭;采用Mckay评估标准评价髋关节功能的优良率为86.67%;采用Severin标准评价髋关节形态和复位情况的优良率为83.33%。结论Pemberton骨盆截骨术可以有效纠正DDH,修复髋关节功能,促进骨骺生长及患儿康复,效果显著。     

髋臼发育不良（developmental dysplasia of thehip，DDH）

髋臼发育不良属于髋关节发育异常（developmental dysplasia of hip，DDH）的一种，是指由于髋臼发育缺陷造成髋臼对股骨头的覆盖不良，导致长期生物力学的异常而逐渐出现股骨头半脱位、负重区软骨退变及股骨头局灶性坏死、严重骨关节炎的一种疾病，主要病理改变表现为髋臼外上方和前方缺损，髋臼变浅，髋关节中心外移，致使髋臼对股骨头的包容与覆盖不足。髋臼发育不良可以伴有髋关节不同程度的半脱位。由于髋臼对股骨头覆盖率减低，髋臼和股骨关节面对合关系不正常，     

髋臼发育不良的动物模型制作及其临床意义

目的: 该实验借助大体标本、X线片和组织病理切片观察, 阐述髋臼发育不良导致髋关节脱位的发病过程和评价动物模型的可靠性。方法: 将 12只 4个月龄兔通过外科手术造成单侧髋关节半脱位动物模型, 手术后 4、6、8周, 观察兔髋关节脱位和继发性假臼形成的过程。结果: 手术后 4周, X线片未发现髋关节脱位, 大体解剖和组织病理切片观察髋臼缘软骨面基本完好。手术后6、8周, X线片示完全性髋关节脱位, 大体解剖和组织病理切片观察髋臼顶缘软骨不同程度变性脱落坏死, 而且手术后 8周, 髋臼缘上部髂骨外板有假臼形成。结论: 本实验所建立的近似于髋臼发育不良导致先天性髋关节脱位的动物模型, 简单可靠, 为此类疾病的研究提供了必要的实验基础。     

针对髋臼发育不良的假体设计——Plasmacup型臼杯

BiCONTACT全髋假体在欧洲应用于临床已有15年历史,术后效果满意。Ito1978年研究指出,日本髋关节骨性关节炎患者中90.2％由髋关节发育不良引起,主要表现为髋外翻、髓腔过窄、过度前倾、股骨头变小、臼窝变窄变浅和出现假髋臼,后者常伴有股骨头半脱位。严重时患者会出现组件侧方支持的缺乏,增加了假体无菌性松动的危险性。解快上述问题的方法:①髋臼的重建;②植骨和髋臼组件螺钉内固定。该文详细阐述了多螺钉固定臼杯和移植     

小儿发育性髋脱位并关节松弛症术后渐发半脱位的原因分析及对策

目的探讨发育性髋脱位并关节松弛症患儿术后渐发半脱位的原因及对策。方法笔者自2005-02—2015-03对13例小儿发育性髋脱位并关节松弛症采用切开复位、Salter骨盆截骨、股骨近端短缩旋转截骨术治疗,于术后即刻、8周、12周、24周、36周对髋臼指数、CE角沈通氏线、泪滴是否出现、髋臼眉弓是否出现等指标进行比较,确定髋关节是否稳定复位。结果术后12周髋关节出现半脱位,通过外展支具后24周髋关节获得稳定复位。结论由于关节囊松弛,失去髋脱位术后早期对复位股骨头的固定作用,早期头臼尚不匹配,故出现半脱位;此类患儿术后髋关节的稳定复位主要依靠头臼骨性匹配,外展支具能有效矫正半脱位,促进髋关节同心骨性重塑。     

髋臼内壁截骨术在发育不良髋关节全髋置换髋臼重建中的应用

目的探讨髋臼内壁截骨术在发育不良髋关节髋臼重建中的应用。方法2001年5月至2002年12月,采用结合髋臼内壁截骨术的全髋关节置换术治疗髋关节发育不良患者17例18髋,男1例1髋,女16例17髋,年龄35～70岁,平均51.4岁。其中CroweⅠ期4髋,Ⅱ期7髋,Ⅲ期4髋,Ⅳ期3髋。通过在手术前、后X线片上绘制Ranawat三角,对照手术前、后髋关节旋转中心与理想旋转中心的距离,测量术后臼杯穹顶与Kohler线的距离、臼杯直径等研究髋关节旋转中心重建与臼杯固定的效果。结果所有人工臼杯均安置于真臼位置,臼杯直径44～56mm,平均50.78mm。术前股骨头中心距理想旋转中心水平距离为12～40mm,平均21.09mm;术后股骨头中心距理想旋转中心水平距离为-3～10.1mm,平均3.73mm;手术前、后比较差异有统计学意义(t=7.95,P<0.01)。术前股骨头中心距理想旋转中心垂直距离为5～32mm,平均15.39mm;术后股骨头中心距理想旋转中心垂直距离为-18～26.3m m,平均4.98mm;手术前、后比较差异有统计学意义(t=3.42,P<0.01)。随访3个月以上者,截骨部位均骨性愈合。结论内壁截骨术有助于将发育不良髋关节的髋臼安置于真臼位置,保留髋臼底部的骨量,避免髋臼外上方植骨的并发症。     

髋关节发育不良的病理演变

髋关节发育不良是指髋臼或股骨头的形状、大小以及他们之间的关系发育异常 ,常见类型是髋臼发育不良及头臼包容异常。其病因尚不清楚 ,临床上缺乏统一的诊断和分型标准 ,治疗方法的选择也有较多分歧。本文就髋关节发育不良的病理特征、病理演变规律及治疗后病变转归等情况做一综述。1　髋关节的正常发育髋关节的正常发育依赖于股骨近端、髋臼软骨、“Ｙ”形软骨和周围骨的平衡生长 ,受基因调控。胚胎 8周时 ,髋关节的轮廓形成 ,1 1周时髋关节已完全形成。胎儿期髋关节全部由软骨组成 ,髋臼顶由髂骨干骺部组成 ,向后方呈偏心性生长 ,由于髋臼…     

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.