术前白细胞计数预测肝切除治疗超“米兰标准”肝细胞癌病人的预后

目的 探讨术前白细胞计数对超“米兰标准”肝细胞癌病人肝切除预后的预测价值。方法 回顾性分析 2007年6月至2013年12月在天津医科大学肿瘤医院行肝切除的237例超“米兰标准”肝细胞癌病人的临床资料。利用ROC曲线确定白细胞计数分界值,对病人分组。应用Kaplan-Meier法制作生存曲线,Log-Rank法进行分析。应用COX比例风险模型研究影响预后的危险因素。结果 白细胞计数6.0×10⁹/L为分界值。白细胞较低组和白细胞较高组中位生存时间分别为53.4个月和27.6个月（P=0.002）。白细胞较低组和白细胞较高组中位无复发生存时间分别为20.7个月和12.2个月（P=0.029）。匹配分析后两组间生存时间及无复发生存时间仍有统计学差异。结论 术前白细胞计数可预测超“米兰标准”肝细胞癌病人肝切除的预后。     

鸡尾酒疗法对全膝关节置换术后皮温的影响

[目的]探讨人工全膝关节置换术后,鸡尾酒局部镇痛对患者皮温及术后疼痛评分的影响以及膝关节皮温变化曲线的意义。[方法]2015年10月~2016年6月收集78例拟行初次单侧人工全膝关节置换术的膝骨性关节炎患者,随机分为鸡尾酒组与常规组,每组39例。鸡尾酒组患者术中膝关节周围注射鸡尾酒式镇痛药物并采用分段阻滞,即术野显露时及关闭关节囊前分别注射鸡尾酒25 ml,而常规组术中不做任何处理。所有患者术前术后处理方案均一致。比较两组术后4、8、12h静息时及术后24、48、72 h活动时疼痛视觉模拟评分(visual analogue scale,VAS)、双侧膝关节皮温、膝关节最大被动活动度(range of motion,ROM)以及术后追加止痛药的情况。[结果]鸡尾酒组的VAS评分显著低于常规组(P<0.05);术后1周ROM均优于常规组;鸡尾酒组双侧平均皮温在前3 d较常规组有所降低,且术后第5~7 d两组患者膝关节皮温差达到峰值。[结论]鸡尾酒镇痛能够降低全膝关节置换术后膝关节局部皮温和疼痛,显著提高了患者术后活动度。皮温作为一个较VAS评分更加客观的指标可能术后炎症控制方面有着独到的作用。     

人工全膝关节置换治疗膝关节骨关节炎

目的探讨人工全膝关节置换术(TKA)治疗终末期膝关节骨关节炎的临床疗效。方法对行TKA治疗的181例终末期膝关节骨关节炎患者(226膝)分别于手术后40、120、180、360 d进行定期随访观察,对患者HSS膝关节功能评分及膝关节最大活动度进行比较。结果患者均获得随访,时间1~2年。膝关节功能HSS评分:优209膝(92.5%),良13膝(5.8%),可3膝(1.3%),差1膝(0.4%),优良率98.2%。术后各时间段的HSS评分及膝关节最大活动度均较术前显著提高,差异均有统计学意义(P0.05)。结论 TKA是治疗终末期膝关节骨关节炎的有效方法,正确的手术操作和合理的功能锻炼是取得满意临床效果决定性因素。     

按摩疗法对人工全膝关节置换术术后疼痛的影响

目的 探讨按摩疗法对人工全膝关节置换术（total knee arthroplasty,TKA）术后患者疼痛的影响。方法 选取我院拟行单膝 TKA 患者 142 例,分成对照组和观察组,每组 71 例。对照组患者 TKA 术后行常规术后护理,观察组患者 TKA 术后在常规术后护理基础上行按摩疗法。结果 观察组患者术后 6、12、18 和 24 h 疼痛评分和均显著低于对照组患者（P<0.05）;观察组患者术后6、12 和24 h 焦虑率显著低于对照组患者（P<0.05）;观察组患者术后6、12 和24 h 吗啡用量均显著低于对照组患者（P<0.05）;观察组患者术后满意度评分显著高于对照组患者（P<0.05）。结论 按摩疗法可显著降低 TKA 术后患者疼痛和焦虑感,减少患者镇痛药物使用,提高患者术后满意度。     

周围神经阻滞在全膝关节置换镇痛中的应用

人工全膝关节置换术（total kneea rthroplasty,TKA）指使用人工膝关节假体取代已严重损坏而不能行使正常功能的膝关节,常用于治疗各种退变性和炎性膝关节疾病,可达到减轻疼痛、改善功能以及矫正畸形的目的。TKA术后疼痛剧烈,而疼痛影响到患者的满意度和关节功能的恢复,延长住院时间,     

髌股关节置换失败后的人工全膝关节置换翻修术

背景：髌股关节置换术对于仅侵犯膝关节前间室的单发性关节炎是一种有效的治疗方法，但是当其需要行翻修手术时，是否会影响人工全膝关节置换术的结果仍不明确。本研究旨在回顾先期行髌股关节置换术后再进行人工全膝关节置换术的结果。 方法：我们用人工全膝关节置换术对10例患者共12膝失败的髌股关节置换进行了翻修，翻修原因，包括单发的进行性胫股关节炎（6膝）、单发的髌股关节轧住和轨迹不良（3膝）以及两者同时存在（3膝）。这些患者在髌股关节置换术后进行翻修术的平均时间为4年，每个膝关节均使用了后稳定型假体，未使用加长柄、填充垫或结构性骨移植物。术后对这些患者进行了临床及影像学随访，其中包括美国膝关节学会临床及功能评分（KSS）。术前我们就对这些失败的髌股关节置换术进行了评估，并获得了术前KSS评分。 结果：术后平均随访时间为3．1年，平均KSS临床评分和功能评分从术前的57分和51分分别增加至术后的96分和91分。在最近的随访中，没有临床和影像学证据表明这些患者存在髌股关节轨迹不良、松动和磨损。 结论：基于我们对本组患者的小样本短期随访经验，髌股关节置换失败后进行人工全膝关节置换翻修术不会影响其结果。 可信水平：治疗性研究，Ⅳ级。进一步可信度参见作者介绍。     

心理护理在围手术期人工全膝关节置换患者中的应用

目的　探讨人工全膝关节置换术围手术期心理护理的理论和临床疗效。方法　将60例人工全膝关节置换术患者随机分为观察组和对照组各 3 0例。对照组采用常规护理 ,观察组实施围手术期心理护理 ,从患者正性情绪表现、术后活动与饮食的恢复、平均住院天数三方面进行评价。结果　实验组围手术期正性情绪表现为 ( 3 .76± 1.3 9)、术后活动与饮食的恢复为 ( 4 .69±1.86)、平均住院天数为 ( 16.89± 1.77) ,与对照组比较 ,差异有显著性意义 (P <0 .0 1)。结论　心理护理能有效缓解围手术期人工全膝关节置换术患者的心理障碍 ,促进其身心康复。     

人工全膝关节置换术中髌骨置换的临床研究

目的通过与非髌骨置换比较,探讨髌骨置换对人工全膝关节置换术疗效的影响。方法将2010年9月-11月符合选择标准的63例(63膝)拟行人工全膝关节置换术的骨关节炎患者随机分为两组,其中32例关节置换术中行髌骨置换(置换组),31例不作置换(非置换组)。两组患者性别、年龄、病程、骨关节炎分级、美国膝关节协会评分系统(KSS)标准临床评分及关节功能评分、髌骨评分、髌骨倾斜角、胫股角及髌韧带比值等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。术后6周及3、6、12个月对疗效进行临床及影像学评定。结果两组患者术后切口均Ⅰ期愈合,置换组6例、非置换组8例出现下肢深静脉血栓形成。患者均获12个月随访。置换组术后3、6、12个月时膝前疼痛发生率均低于非置换组(P<0.05)。两组术后各时间点KSS临床评分比较,差异无统计学意义(P>0.05);除术后6周及3个月,其余各时间点置换组关节功能评分明显高于非置换组(P<0.05)。两组髌骨评分除术后12个月外,其余各时间点组间比较差异均无统计学意义(P>0.05)。X线片复查示,两组均无髌骨骨折、髌骨脱位、髌骨不稳、假体松动及断裂发生;术后12个月两组股胫角、髌韧带比值、髌骨倾斜角比较,差异均无统计学意义(P>0.05)。结论人工全膝关节置换术中行髌骨置换可以一定程度改善膝关节功能评分、髌骨评分及降低术后膝前疼痛的发生率。     

微创全膝关节置换术的研究现状

微创（minimally invasive surgery，MIS）人工膝关节置换开始于20世纪90年代后期，Repicci和Romanowski在膝关节单髁置换（unicondyhr knee arthroplasty，UKA）中采用了MIS人路，具有术中出血少，术后疼痛轻，离床活动早，术后康复时间短等优点，因而激起了人们对微创手术和膝关节部分置换的极大兴趣。他们的工作为微创全膝关节置换术奠定了基础。本文综合概括微创TKA近几年文献作如下综述。     

髌骨置换在全膝关节置换中的作用

骨关节炎患者全膝关节置换时,是否应进行髌骨置换,一直是争论的焦点。有人反对．有人支持,还有人认为两者并无差别。本文从髌骨置换的两大分歧、临床效果、手术技巧、患者筛选标准和假体设计等方面进行综述,有利于加深对髌骨处理问题的认识。     

Fungal prosthetic joint infection after total knee arthroplasty

Fungal prosthetic joint infection after total knee arthroplasty (TKA) is a rare complication. Lacunae exist in the management of this complication. 62 year old lady presented with pain and swelling in left knee and was diagnosed as Candida tropicalis fungal infection after TKA. She underwent debridement, resection arthroplasty and antifungal plus antibiotic loaded cement spacer insertion, antifungal therapy with fluconazole followed by delayed revision TKA and further fluconazole therapy. Total duration of fluconazole therapy was 30 weeks. At 2 year followup, she has pain less range of motion of 10^°-90^° and there is no evidence of recurrence of infection.     

Restoration of the joint line in total knee arthroplasty

The purpose of the study was to assess the effect of the joint line position in a posterior cruciate ligament–retaining, mobile-bearing total knee arthroplasty (TKA). Seventy-six consecutive TKAs performed by 1 surgeon were prospectively assessed for a minimum of 2.5 years. Posterior cruciate ligament–retaining, mobile-bearing TKA was performed in all cases. The joint line was elevated 1 mm on average (range, −11 to +10). There was no correlation between joint line position and range of motion, knee function scores, knee pain scores, or patellar height. The joint line position in a posterior cruciate–retaining, mobile-bearing (LCS AP Glide; DePuy, Leeds, United Kingdom) TKA did not affect the early clinical results.     

The painful total knee arthroplasty: Keys to diagnosis

As the prevalance of patients living with total knee replacements continues to rise we continue to see a significant portion of patients living with pain following their primary total knee arthroplasty. For some patients, the etiology of their pain following knee replacement is obvious, yet in many cases the cause of pain remains elusive and thus creates a significant burden for the patient and treating physician. In this review article we focus on common sources of pain following knee replacement and discuss keys to diagnosis. We also propose a unique clinical pathway algorithm to guide diagnostic work up and treatment options.     

膝关节表面置换术治疗骨性关节病疗效及并发症预防

目的探讨人工膝关节表面置换术(TKA)治疗膝关节骨性关节病的疗效及并发症的预防措施。方法对22例膝关节骨性关节病患者(26膝)行TKA,术前积极治疗合并症,重视预防感染及静脉血栓栓塞等并发症;术后早期康复训练以促进关节功能恢复。结果患者均获随访,时间14～54个月。关节功能按HSS评分标准评定:优19膝,良6膝,可1膝。结论 TKA对膝关节骨性关节病的疼痛消除、畸形矫正、功能改善等方面疗效优良。充分认识感染及静脉血栓栓塞症形成的高危因素,做好术前准备、熟练的手术技术和完善的术后康复训练可有效预防并发症的发生。     

不同干预措施对全膝关节置换术围手术期出血的影响

目的探讨止血带松开时机和引流管夹闭对全膝关节置换术(TKA)围手术期出血的影响。方法将70例单膝TKA治疗的膝骨关节炎患者分别采用术中关闭伤口前电凝止血后松开止血带、术后夹闭引流管6h(观察组,40例)和术中全程使用止血带、术后引流管处于自然开放引流状态(对照组,30例),观察两者的出血量及下肢静脉血栓形成情况。结果观察组术中出血量明显多于对照组(P0.05),但术后引流量、隐性失血量及总失血量均明显小于对照组(P0.05)。输血例数及输血量:观察组11例(27.5%),平均输血量2.7 U;对照组24例(80.0%),平均输血量3.4 U;两组比较差异有统计学意义(P0.01)。术后深、浅静脉血栓形成例数:观察组5例(12.5%),对照组1例(3.3%),但差异无统计学意义(P0.05)。结论术中闭合伤口前电凝止血后松开止血带、术后夹闭引流管6 h能够明显减少TKA围手术期的总出血量,但能增加下肢静脉血栓形成。     

Patellar resurfacing in total knee arthroplasty

Routine patella resurfacing in total knee arthroplasty has been debated for decades. The early total knee designs and surgical techniques lead to a high complication rate following patellar resurfacing. This lead to many surgeons abandoning this practice and either leaving the patella unresurfaced routinely or selectively resurfacing. Modern day randomized control trials and meta-analyses of these trials reveal a higher incidience of anterior knee pain and a resultant higher reoperation rate in nonresurfaced patellae. We argue that with modern day designs and surgical techniques, there is a low complication rate to resurfacing and little downside to resurfacing.     

The natural history of anterior knee pain in 2 posterior-stabilized, modular total knee arthroplasty designs

Anterior knee pain (AKP) has been a persistent complaint after total knee arthroplasty; however, the natural course of this complaint has not been fully investigated. This is a 10-year follow-up report of a prospective, randomized study between the Insall-Burstein II (Zimmer, Warsaw, IN) and the Press Fit Condylar Modular (Johnson & Johnson, Raynham, MA) knees. Up to one third of total knee arthroplasties will experience mild to moderate AKP at 1-year follow-up, which will persist in approximately 30% of these previously symptomatic knees at 10-year follow-up. New-onset AKP will develop in approximately 10% of previously asymptomatic knees.     

Recurrent hemarthrosis after total knee arthroplasty

Seven patients developed recurrent hemarthroses following total knee arthroplasty. The average interval between arthroplasty and the first bleed was more than 20 months (range, 1–30 months). All seven required open synovectomy an average of 21 months (6–31 months) after arthroplasty. Follow-up evaluation averaged 44 months (19–60 months) and all had an excellent result without further bleeds. A prolific synovitis was seen in all cases, with histologic features revealing a chronic synovitis with fibrosis and hemosiderin staining. Entrapment of the proliferative synovial tissue between the components is postulated to be the etiology for these recurrent bleeds which averaged four per patient prior to synovectomy.     

Dislocation following primary posterior-stabilized total knee arthroplasty

From 1981 through 1991, 3, 032 primary total knee arthroplasties were performed using the Insall-Burstein Posterior Stabilized Condylar Prosthesis (IB-I, IB-II, and IB-II modified) (Zimmer, Warsaw, IN). Fifteen posterior dislocations occurred: 4 with the IB-I system occurring 2 or more years after surgery, 10 with the IB-II system (8 occurring 6 months after surgery and 2 occurring 2–3 years after surgery), and 1 with the IB-II modified system occurring 9 months after surgery. Statistically significant differences for the rate of dislocation between both the IB-I and IB-II modified arthroplasties versus the IB-II arthroplasties were found (P < .001). In an attempt to identify a cause for these dislocations, the authors retrospectively assessed the 15 dislocated cases with respect to sex, age, weight, height, preoperative and postoperative Hospital for Special Surgery scores, preoperative and postoperative alignment, preoperative versus postoperative reconstruction dimensions, patellar thickness and height, and postoperative flexion and compared the results with those patients who did not experience dislocation. Possible etiologies and mechanisms of dislocation were sought. There were no significant differences between the control and study groups for any variable assessed, with the exception of postoperative flexion, which averaged 118° for the study group and 105° for the control group (P < .001). Conservative management was successful in 11 cases. In September 1988 the IB-II system was introduced; modification of the tibial insert was made in January 1990. The 10 IB-II dislocations occurred prior to the modification of the modular tibial polyethylene insert, and the 3 recurrent dislocations in this group were successfully treated with revision to this modified insert. Since this modification, 656 IB-II modified systems have been implanted with one dislocation (0.15%).