加压空心螺钉与动力髋螺钉治疗老年性股骨转子间骨折的疗效对比

[目的]分析比较加压空心钉与动力髋螺钉治疗高龄股骨转子间骨折的效果.[方法]回顾性分析2000年7月～2006年12月接受加压空心钉或动力髋螺钉固定治疗且有完整资料的152例老年性股骨转子间骨折患者.采用加压空心钉固定68例,动力髋螺钉固定84例.比较两种固定方法在手术时间、术中出血量、术中及术后并发症、术后1年功能恢复情况等方面的结果.[结果]对于老年性股骨转子间骨折患者,与动力髋螺钉固定相比,加压空心钉固定手术时间短、术中出血量少,两者差异有显著性意义(P<0.05);对于EvansⅠ、Ⅱ型骨折的患者,在骨折愈合时间及术后并发症、术后1年功能恢复情况等方面的差异无显著性意义(P>0.05),而对于Ⅲ、Ⅳ型骨折的患者,两种内固定的差异有显著意义(P<0.05).[结论]对Ⅰ、Ⅱ型骨折和全身情况差的患者宜采用加压空心钉固定;动力髋螺钉适用于全身情况尚可及Ⅰ～Ⅳ型骨折的患者.     

DHS与Intertan髓内钉治疗股骨粗隆间骨折疗效分析

[目的]探讨DHS与Intertan髓内钉治疗股骨粗隆间骨折的适应证、手术技巧及临床疗效.[方法]2008年2月～2010年2月收治52例股骨粗隆间骨折患者,男24例,女28例;年龄38～ 89岁(平均68.1岁),骨折按Evans分型,均为顺粗隆间骨折,其中Ⅰ型8例,Ⅱ型10例,Ⅲ型18例,Ⅳ型16例.行DHS内固定37例,行Intertan髓内钉内固定15例;从手术情况、骨折愈合时间、术后Harris髋关节评分及术后并发症等方面分析比较.[结果]所有患者术后获平均24个月(17 ～38个月)随访,在手术时间、术中失血量、平均骨折愈合时间、术后Harris髋关节评分及术后并发症的发生上两组有明显差异(P＜0.05).[结论]对于Evans Ⅰ型股骨粗隆间骨折应用DHS内固定可取得良好的效果,对于EvansⅡ型适用Intertan髓内钉,也可用DHS;对于EvansⅢ、Ⅳ型最适用Intertan髓内钉;Intertan髓内钉设计更符合股骨近端生物力学特点,有效恢复股骨近端稳定性,适用于粉碎性、复杂及合并骨质疏松的股骨粗隆间骨折,可缩短卧床时间,提高生活质量,减少并发症.     

Gamma钉在治疗股骨转子间骨折中的应用

目的总结Gamma钉治疗股骨转子间骨折的经验。方法24例股骨转于间骨折采用Gamma钉内固定手术治疗(EvansⅠ型1例，Ⅱ型2例，Ⅲ型12例，Ⅳ型9例)。结果经4～15个月随访，平均8个月，疗效满意。结论术中尽可能恢复股骨转子后内侧皮质的完整性；正确的操作、固定钉恰当固定位置及加强术后功能锻炼是取得良好疗效的关键。     

股骨近端锁定钢板和股骨近端髓内钉治疗老年股骨转子间骨折比较

目的 探讨股骨近端锁定钢板和股骨近端髓内钉(PFN)治疗老年股骨转子间骨折中的临床疗效.方法 手术治疗80例老年股骨转子间骨折患者,其中股骨近端锁定钢板固定41例,PFN固定39例.比较两组手术时间、出血量、术前及术后Harris评分.结果 80例均获随访,时间1～2年.术后3～5个月骨折均愈合,髋关节无疼痛且功能恢复良好.两组手术时间、术中出血量、术前及术后Harris评分比较差异无统计学意义(P＞0.05).结论 根据骨折类型及解剖结构合理选择内固定,股骨近端锁定钢板和PFN治疗老年股骨转子间骨折Evans Ⅰ～Ⅲ型可以获得相同的临床效果,但股骨近端锁定钢板更适用于Evans Ⅳ型骨折.     

髓内外固定治疗股骨转子间骨折治疗体会

目的探讨老年股骨转子间骨折内固定手术方法。方法回顾性分析78例股骨转子间骨折,男43例,女35例;年龄64～93岁。按照Evans分型,Ⅰ型13例,Ⅱ型18例,Ⅲ型23例,Ⅳ型14例,Ⅴ型10例。其中采用动力髋螺钉（dynamic hip screw,DHS）内固定31例,防旋型股骨近端髓内钉（proximal femoral nail antirotation,PFNA）固定40例,股骨近端锁定板固定7例。结果术后随访78例,其中76例骨折愈合,愈合时间4～6个月。术后并发症包括退钉1例,股骨头切割1例,钢板断裂1例。结论根据骨折分型及骨质疏松情况选择适当的固定术式可以提高股骨转子间骨折疗效,减少术后并发症。EvansⅠ、Ⅱ骨折首选DHS内固定,EvansⅢ型以上不稳定性骨折可选择髓内固定系统,对于严重骨质疏松、粉碎不稳定骨折可选用解剖锁定钢板,术后适当延长下地负重时间。     

同侧股骨颈、股骨干骨折的手术治疗

目的观察两种手术方法治疗同侧股骨颈和股骨干骨折的疗效。方法对1999年10月～2002年2月收治的16例同侧股骨颈和干骨折进行手术治疗。年龄29～71岁,平均40岁。4例开放性骨折为GustiloⅡ型。16例患者有合并损伤,5例患者累及同侧髌骨。股骨颈骨折按照Garden分型Ⅱ型8例,Ⅲ型7例,Ⅳ型1例。股骨干骨折按照Winquist分类Ⅰ°4例,Ⅱ°5例,Ⅲ°2例,Ⅳ°5例。9例患者使用AOⅡ型顺行股骨交锁髓内钉固定股骨颈和股骨干骨折,7例患者使用空心螺纹钉联合逆行股骨交锁髓内钉治疗。结果全部病例随访12～40个月,平均22个月。1例患者术中X线透视检查发现股骨颈骨折予空心螺纹钉固定。2例患者漏诊,术后随访时发现股骨颈骨折形成骨不连,除1例骨不连患者外,其余患者骨折均顺利愈合,股骨颈与股骨干骨折平均愈合时间分别为14周(12～17周)、12周(10～14周)。结论空心螺纹钉和股骨逆形交锁髓内钉以及AOⅡ型顺行股骨交锁髓内钉固定股骨颈和股骨干骨折均可获得满意结果,但后者疗效仍需进一步观察。     

三种内固定方式治疗股骨远端骨折的疗效比较

目的 比较顺行髓内钉、逆行髓内钉及锁定加压钢板内固定治疗股骨远端骨折的疗效.方法 对2005年1月至2009年12月期间采用内固定治疗且获得随访的85例股骨远端骨折患者资料进行回顾性分析,男46例,女39例;年龄15 ～58岁,平均38.8岁.根据内固定方式不同分为3组:顺行髓内钉组(n=17)、逆行髓内钉组(n=42)及锁定加压钢板组(n=26).比较3组患者的手术时间、术中出血量、膝关节功能优良率及并发症发生率. 结果 85例患者术后获12 ～ 24个月(平均18个月)随访.除1例患者出现骨折不愈合外,其余患者骨折均在6个月内获愈合.在手术时间和术中出血量方面,顺行髓内钉组、逆行髓内钉组均优于锁定加压钢板组,顺行髓内钉组优于逆行髓内钉组,差异均有统计学意义(P＜0.05).顺行髓内钉组、逆行髓内钉组及锁定加压钢板组患者膝关节Kolment 标准评定结果优良率分别为58.8％ (10/17)、88.1％ (37/42)、69.2％ (18/26),逆行髓内钉组与顺行髓内钉组比较差异有统计学意义(P＜0.05).顺行髓内钉组、逆行髓内钉组及锁定加压钢板组患者术后并发症发生率分别为11.8％ (2/17)、9.5％ (4/42)、7.7％(2/26),差异无统计学意义(P=1.000).所有患者均未出现关节感染. 结论 逆行髓内钉治疗股骨远端骨折具有定位准确、固定牢靠、手术时间短及术中出血量少等优点,术后疗效较顺行髓内钉和锁定加压钢板更满意.     

股骨近端防旋髓内钉治疗老年股骨转子间骨折

2010年8月～2011年9月,我院对20例股骨转子间骨折患者采用闭合复位股骨近端防旋髓内钉(PFNA)内固定,取得了良好的效果。1材料与方法1.1病例资料本组20例,男8例,女12例,年龄65～92岁。均为股骨转子间骨折。骨折按Evans分型:Ⅰ型17例,Ⅱ型2例,Ⅲb型1例。受伤至手术的时间6 h～3 d。     

加长型股骨近端髓内钉内固定治疗股骨转子间合并股骨干中段骨折

目的总结加长型股骨近端髓内钉(PFN)内固定治疗股骨转子间骨折合并股骨干中段骨折的经验。方法对10例股骨转子间骨折合并股骨干中段骨折采用此种加长型PFN内固定手术治疗(股骨转子间骨折Evans分型：Ⅰ型1例,Ⅱ型3例,Ⅲ型5例,Ⅳ型1例)：结果随访3～15个月,平均9个月,髋关节Harris评分：优6例,良3例,可1例;股骨干按马元璋评分：优6例,良4例。结论术中保持下肢力线正常,尽可能恢复股骨转子后内侧皮质的完整性;正确的操作、固定钉固定于恰当位置及术后正确功能锻炼是取得良好疗效的关键。     

股骨近端抗旋髓内钉治疗老年股骨转子间骨折

目的探讨防旋型股骨近端髓内钉（proximal femoral nail antirotation,PFNA）及PFNA-Ⅱ亚洲型股骨近端抗旋髓内钉治疗老年股骨转子间骨折的临床疗效。方法对2009年1月至2011年12月应用PFNA及PFNA-Ⅱ亚洲型股骨近端抗旋髓内钉,闭合复位治疗老年股骨转子间骨折39例患者的临床资料进行分析,均为闭合性骨折。其中男19例,女20例;年龄63～89岁,平均年龄（71.3±8.5）岁。Evans分型,Ⅰ型2例,Ⅱ型6例,Ⅲ型9例,Ⅳ型10例,Ⅴ型12例。结果随访3～24个月,平均14.4个月。骨折均已愈合,无髋内翻、内固定松动及股骨头切割现象;按Harris髋关节功能评分,优24例,良9例,中5例,差1例,优良率84.6%。结论 PFNA及PFNA-Ⅱ亚洲型治疗老年股骨转子间骨折固定牢固,操作简单,并发症少,是一种理想的治疗方法。     

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.     

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.