开放性跖跗关节损伤的手术治疗

目的:探讨开放性跖跗关节损伤手术治疗方法及临床疗效。方法 :选择2011年3月至2015年1月手术治疗的21例开放性跖跗关节损伤患者,男14例,女7例;年龄20~75岁,平均45.6岁;左足13例,右足8例;交通伤5例,碾压伤6例,重物压伤10例。跖跗关节损伤根据Myerson分型:B2型5例,C1型9例,C2型7例。软组织损伤按照Gustilo分型:ⅡB型5例,ⅢA型10例,ⅢB型6例。采用分期手术治疗。术后观察骨折愈合及其并发症情况,并采用美国足踝外科协会(AOFAS)中足评分评价手术疗效。结果:21例患者术后均获随访,时间11~40个月,平均16.2个月。骨性愈合时间10~16周,平均12.3周。未并发深部感染、骨不连及骨髓炎等并发症。末次随访AOFAS中足评分为83.0±14.9;优9例,良8例,中2例,差2例。2例患者因并发严重创伤性关节炎再次行跖跗关节融合术。结论:对于开放性跖跗关节损伤的治疗,急诊合理清创,全面评估软组织损伤情况,正确把握内固定的手术指征及时机,可以降低深部感染及骨髓炎的发生率。     

Lisfranc损伤诊疗研究进展

正Lisfranc损伤是一种广义的跖跗关节损伤,后来随着研究深入,提出跖跗关节复合体概念,包括组成跖跗关节关节的骨、关节与韧带等全部结构~([1-2])。Lisfranc损伤临床相对较少见,解剖结构复杂,损伤机制多样,且X线片不易发现而导致漏诊,首诊的漏诊率可高达1/3~([3]),从而导致后期并发症,如跖跗关节慢性疼痛、足弓塌陷、退化性关节疾病等,严重影响患者工作     

跖跗关节复合体损伤的手术治疗

目的 评价跖跗关节复合体损伤的手术治疗效果.方法 2003年1月至2008年12月,共收治167例闭合性跖跗关节损伤患者,其中跖跗关节复合体损伤35例.通过X线及CT检查明确诊断,闭合或切开复位螺钉或钢板内固定,术后定期放射学检查随访,以美国足踝外科协会(AOFAS)中足评分系统进行功能评估.结果 本组有135例获得12～78个月随访,平均随访时间48个月.其中跖跗关节复合体损伤26例,术后AOFAS评分48～75分,平均67分;其中16例继发创伤性关节炎,12例因疼痛明显、行走受限二期行关节融合术;单纯跖跗关节损伤109例,术后AOFAS评分70～95分,平均82分,继发创伤性关节炎的17例中5例二期行关节融合术.单纯跖跗关节损伤闭合复位经皮螺钉内固定者术后AOFAS中足评分82～95分,平均87分,与跖跗关节复合体损伤者比较差异具有统计学意义(t=2.651,P<0.05).结论 跖跗关节复合体损伤的预后比单纯跖跗关节损伤的差,而准确诊断、实现复合体各个部分的解剖复位和可靠固定是取得良好治疗效果的关键.     

外固定架在跗跖关节损伤复位与固定中的应用

目的探讨外固定架在跗跖关节损伤复位与固定中应用的效果。方法外固定架复位固定治疗跗跖关节损伤31例。用外固定架固定针帮助复位,并以外固定架的加压作用纠正残余分离移位。结果获解剖复位27例,功能复位4例。经4~23个月随访,无一例发生再移位,骨折全部骨性愈合。结论应用外固定架进行复位固定是治疗跗跖关节损伤的较好选择。     

跗跖关节损伤的机理及并发伤

1980年1月到1989年12月芬兰Turku大学外科曾治疗了750例跗跖关节损伤或跖骨骨折,其中66例(9％)为跗跖关节损伤,684例(91％)为末累及跗跖关节的单纯跖骨骨折。损伤机理为:1)低能量损伤,2)高处坠落伤,3)直接挤压伤,4)高能量车祸伤。     

Herbert螺钉治疗跖跗关节损伤的疗效

目的探讨Herbert螺钉内固定治疗跖跗关节损伤的疗效。方法对24例跖跗关节闭合损伤患者采用切开复位内固定治疗。根据跖跗关节三柱解剖,外侧柱采用克氏针弹性固定,内侧柱及中间柱采用Herbert螺钉坚强固定。结果患者均获得随访,时间12～19个月。所有患者无感染及内固定断裂发生。末次随访时按照AOFAS中部足功能评分标准评价疗效:优15例,良6例,可2例,差1例,优良率为21/24。结论 Herbert螺钉治疗跖跗关节损伤,能达到坚强固定、早期功能锻炼的目的,疗效满意。     

跖跗关节骨折脱位的诊治体会

跖跗关节又称为Lisfranc关节,在治疗上,由于以往非手术治疗常难以取得良好的疗效,故解剖复位和坚强内固定正被临床所接受。现将笔者2000年9月~2007年4月所收治的跖跗关节骨折脱位32例报告如下。1临床资料1.1一般资料本组32例36足,左侧27足,右侧9足;男性21例,女性11例;年龄19~63     

跗跖关节复合损伤的诊断和治疗

跗跖关节是中足的复杂结构，在步行时完成重力由中足向前足的传导，并在步态各期支持体重。跗跖关节损伤会严重影响患者的步态和行走。跗跖关节骨折脱位又称为中足损伤，其中包括楔骨、舟骨的损伤。跗跖关节的高能量损伤常见于交通事故和工业伤，低能量损伤常见于运动员和老年人，一般由扭曲力造成[1]。过去10年中，对跗跖关节损伤的治疗有了很大进展。Mittlmeier等[2]指出，对高能量损伤所致的跗跖关节骨折脱位，解剖复位内固定是获得优良结果的必要条件。他对25例患者应用马里兰评分得出，精确的轴线对线与中部、外侧结构长度的恢复是治…     

微型钢板内固定治疗跖跗关节损伤21例

目的探讨切开复位微型钢板内固定治疗跖跗关节损伤的临床疗效。方法应用国产钛合金微型钢板内固定治疗跖跗关节损伤21例。结果切口均一期愈合,有2例切口边缘部分坏死,经换药后痊愈。患者均获随访,时间9～16（12.2&#177;3.6）个月。术后9～16个月拆除内固定。根据美国足踝外科协会AOFAS评分为73～95（86.5&#177;9.8）分,优10例,良9例,中2例。结论切开复位微型钢板内固定治疗跖跗关节损伤,可达到坚强稳定跖跗关节的效果,可以早期活动踝部诸关节,达到较理想的临床疗效。     

跖跗关节损伤的研究进展

跖跗关节损伤的临床发生率相对较低,但范围较宽,除了构成跖跗关节的跖骨基底、骰骨、楔骨的骨折和相应的韧带损伤之外,还涉及楔骨间关节和舟楔关节的骨折脱位.跖跗关节损伤的诊断比较困难,轻微损伤者犹甚,而一旦漏诊误诊,致残率极高~([1-2]),其诊断及治疗亟需引起临床的重视和应对.     

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.