髌股关节退变对Oxford内侧单髁置换疗效的影响

目的本研究对因膝关节前内侧关节炎进行Oxford单髁置换的中国患者前瞻性收集数据和术中观察髌股关节情况,并探讨这一结论的正确性。方法研究包括本单位从2009年8月至2011年5月连续进行的50例（45例患者）单髁置换病例。术前记录膝关节疼痛的部位,放射学检查发现的髌股关节退变用Ahlback系统分级。对于术中观察到的股骨滑车软骨磨损情况用Weidow5级分级系统记录,其将软骨状况从无磨损到全层磨损分为0至Ⅳ级。在术后1年随访是用Hospitalfor Special Surgery膝关节评分系统和自我满意度评分对临床疗效进行评定。结果术前放射学检查发现17膝（34％）存在髌股关节退变。术中观察发现27膝（54％）存在股骨滑车软骨面磨损,其中19例（38％）位于滑车沟偏内侧,6例（12％）位于滑车沟中央,1例（2％）位于滑车沟偏外侧,共有3例（6％）全层软骨磨损,2例（4％）位于滑车沟偏内侧,1例（2％）位于滑车沟偏外侧。不论是放射学发现的髌股关节退变还是术中发现软骨磨损病例与髌股关节相对正常病例相比,临床疗效没有显著性差异。结论术前放射学发现的髌股关节退变和术中发现髌股关节软骨磨损均不能作为Oxford内侧单髁置换的反指征。因外侧髌股关节退变的相关数据较少,对这类患者选择单髁置换时应慎重。     

髌股关节软骨与软骨下骨的几何学匹配性及临床意义

目的 测量并比较髌股关节软骨覆盖和软骨下骨的几何形状.方法 2009年1月至2010年3月,选取髌股关节正常的膝关节标本9例,在膝关节屈曲20°～30°位,沿髌骨中心垂直于髌股关节面横行切开,暴露髌股关节,测量骨性髌骨适合角、软骨性髌骨适合角、髌骨软骨顶点参数、髌骨软骨下骨顶点参数、滑车骨性凹点参数和滑车软骨凹点参数.然后在临床中随机选取11例髌股关节软骨覆盖及力线正常患者的髌股关节轴位MRI,测量上述指标,与解剖学研究进行比较.结果 解剖学样本数据:骨性髌骨适合角为(-4.5±1.1)°,软骨性髌骨适合角为(0.5±0.8)°,均为右膝;髌骨软骨顶点参数为1.13±0.11,髌骨软骨下骨顶点参数为1.67±0.14,滑车骨性凹点参数为1.35±0.28,滑车软骨凹点参数为1.38±0.33.骨性髌骨适合角与软骨性髌骨适合角差异有统计学意义(P＜0.05),髌骨软骨顶点参数与髌骨软骨下骨顶点参数差异有统计学意义(P＜0.05).滑车骨性凹点参数与滑车软骨凹点参数差异无统计学意义(P＞0.05).临床影像学样本数据和解剖学数据相近,差异无统计学意义(P＞0.05).结论 覆盖髌骨软骨的几何形状与软骨下骨的几何形状存在着明显的差异,而股骨滑车软骨与软骨下骨的几何形状基本相似.     

髌股关节发育不良对髌骨脱位磁共振成像表现的影响

背景：当存在髌股关节发育不良时,髌骨脱位的损伤程度较轻,因此更加依赖影像学诊断。 目的：比较髌股关节发育不良患者和髌股关节发育正常患者髌骨脱位时磁共振成像（MRI）表现的异同。 方法：回顾性分析54例经临床证实的髌骨脱位患者的MRI影像学资料。髌股关节发育不良患者32例,髌股关节发育正常患者22例。记录患者MRI中髌骨内侧骨挫伤或撕脱骨折、髌骨关节面骨软骨骨折、股骨外侧髁外侧部骨挫伤、髌股内侧支持带撕裂等情况。 结果：髌股关节发育不良组的32例患者中,髌骨内缘骨折12例,内侧支持带损伤10例,髌骨软骨损伤7例,股骨外髁骨挫伤18例;髌股关节发育正常组的22例患者中,髌骨内缘骨折8例,内侧支持带损伤14例,髌骨软骨损伤14例,股骨外髁骨挫伤14例。两组在内侧支持带损伤和髌骨内缘骨折上有显著统计学差异（P＜0.05）。 结论：MRI可以较好地诊断髌骨脱位。当髌股关节发育不良时,内侧支持带损伤和髌骨内缘骨折的发生率降低。     

比较前交叉韧带撕裂与髌骨外侧脱位患者髌股关节解剖学参数异常检出率

目的 对比前交叉韧带（ACL）撕裂与髌骨外侧脱位（LPD）患者之间，股骨滑车发育不良、髌骨高位、胫骨结节-股骨滑车沟（TT-TG）间距过宽检出率的差异。方法 回顾性分析79例ACL撕裂患者（ACL撕裂组）、46例LPD患者（LPD组）及100例膝关节未见明显异常者（对照组）的膝关节MRI，对比3组间股骨滑车发育不良、髌骨高位（Insall-Salvati指数>1.2）及TT-TG间距过宽（TT-TG间距>15 mm为过宽）检出率的差异。结果 ACL撕裂组中，股骨滑车发育不良18例（18/79，22.78%），髌骨高位12例（12/79，15.19%），TT-TG间距过宽10例（10/79，12.66%）；LPD组中，股骨滑车发育不良26例（26/46，56.52%），髌骨高位21例（21/46，45.65%），TT-TG间距过宽13例（13/46，28.26%）；对照组股骨滑车发育不良9例（9/100，9.00%），髌骨高位6例（6/100，6.00%），TT-TG间距过宽5例（5/100，5.00%）。3组间股骨滑车发育不良、髌骨高位和TT-TG间距过宽检出率差异均有统计学意义（P均<0.01）；LPD组股骨滑车发育不良、髌骨高位检出率均高于对照组及ACL撕裂组（P均<0.05），TT-TG间距过宽检出率高于对照组（P<0.05）；ACL撕裂组TT-TG间距过宽检出率与LPD组及对照组差异均无统计学意义（P均>0.05）。结论 股骨滑车发育不良、髌骨高位及TT-TG间距过宽在ACL撕裂与LPD患者中的检出率均较高；前二者在LPD中尤为显著。     

手法治疗髌股关节紊乱

髌股关节紊乱（髌骨倾斜、髌骨半脱位）是髌骨不稳定的常见原因，而髌骨排列和运动轨迹异常及由此形成的应力分布异常所造成的关节软骨损伤，是髌股关节疼痛的主要原因，是髌股关节常见病。表现为膝前疼痛、髌骨轨迹异常和髌股关节软骨损伤。随着人们对以软骨退变为主要特征的膝关节骨关节病研究的不断深入，发现髌股关节紊乱在膝关节骨关节病中占有很高比例，其治疗的成功与否直接关系着膝关节骨关节病的疗效：2005年12月至2007年4月完成病例治疗观察，报告如下。     

髌骨倾斜对兔髌骨关节软骨损害的实验研究

目的建立兔髌骨倾斜的模型并观察髌股关节软骨损害的变化,为临床治疗髌股关节疾病提供实验依据。方法新西兰大白兔24只,随机分3组,每组8只,行右膝髌骨内侧支持带松解和外侧支持带紧缩术,术后不固定右膝关节。左膝髌骨为对照组。分别于术后第2周、4周、8周处死取材,分别进行髌骨倾斜角CT测量、髌骨关节面软骨大体观察、软骨组织Mankin评分。结果（1）实验侧髌骨倾斜角明显大于对照侧;（2）术后4周可见关节软骨软化,色泽晦暗,裂隙形成;术后8周关节软骨粗糙,有大的裂隙且色泽晦暗;对照组无软骨退变;（3）HE染色光镜下观察关节软骨,术后4周时,关节软骨轻度变性,可见软骨细胞变扁,表面不规则,术后8周时,软骨明显变性,可见软骨细胞增殖,排列紊乱,基质减少,潮线不完整。根据软骨Mankin评分,术后4、8周时右膝实验组得分明显高于左膝空白对照组,相比较有显著的统计学意义（P〈0.05）。结论兔髌骨倾斜后4周,髌骨外侧关节面软骨出现软骨软化,随着时间的延长软骨退变进一步加重,为治疗髌股关节软骨疾病提供实验依据。     

复发性髌骨脱位的临床治疗分析

目的 通过关节镜下行膝关节外侧支持带松解、内侧髌股韧带重建联合胫骨结节内移治疗复发性髌骨脱位,观察其临床效果。方法 分析中国人民解放军联勤保障部队第九四〇医院2019年4月至2020年4月治疗的20例复发性髌骨脱位患者,其中男5例,女15例;年龄13～34岁,平均25岁。股骨滑车发育不良分型,A型3例,B型5例,C型8例,D型4例。先行膝关节腔内探查术,探查完毕后行关节镜下髌股外侧支持带松解术,取同侧半腱肌肌腱移植髌股内侧韧带重建术,术前测量胫骨结节-股骨滑车间距(tibial tuberosity-trochlear groove distance, TT-TG)>20 mm者同时行胫骨结节内移截骨术,对于合并股骨或髌骨关节面骨折和软骨损伤患者,尽最大可能复位骨折,修复关节软骨。结果 术后随访6～12个月,均未出现再次脱位,患侧膝关节恐惧试验阴性,无膝关节打软。末次随访平均髌股关节功能评分(60.8±7.2)分,与术前比较差异有统计学意义(P<0.05)。结论 关节镜下髌外侧支持带松解、取同侧半腱肌肌腱移植重建髌股内侧韧带重建术,联合胫骨结节内移术治疗复发性髌骨脱位,临床...     

髌股关节不稳定症的影像学诊断与治疗

髌股关节是伸膝装置中的重要组成部分，髌骨在股骨滑车凹中正常运动轨迹依赖于髌骨与股骨髁间凹的骨性关节和关节囊、支持带提供的静态稳定作用，以及股四头肌的动态稳定作用。如果髌股关节不稳定，就会发生髌股关节运动轨迹的改变、髌骨向外侧倾斜和／或半脱位，使外侧髌股关节面产生过高压力，软骨被磨损，最终导致软骨软化和骨关节炎。     

髌股关节疾患及其治疗(文献综述)

髌股关节疾患是常见病,多因髌骨畸形、高位、偏斜、髌股关节负荷加重和外伤等所致。现就髌股关节常见的几种疾患及其治疗分别加以叙述。髌股关节疾患的病因和种类【病因】髌股关节疾患主要有髌骨脱位、半脱位、髌骨软化症和髌股关节退变。根据病因可分类为:(1)关节软骨的变性软化;(2)关节位置异常;(3)关节间隙狭窄。这三种原因可单独存在,也可重叠出现。髌骨软化症以软骨肿大软化为特征,多发于青少年,中老年多为关节软骨退变。髌骨的位置异常有髌骨的外方偏移和倾斜,也是髌骨半脱位的原因。     

双极射频治疗山羊髌骨软骨退变的实验研究

目的探讨双极射频在治疗髌骨软骨退变中价值。方法采用髌骨外侧支持带紧缩和内侧支持带松解的方法制造16只山羊髌骨软骨退变的动物模型。3个月后对右髌骨退变的软骨进行双极射频成形手术,左膝为对照侧,两侧同时进行恢复髌股关节对合的手术。观察双极射频对退变软骨的即刻效应和后期效应。结果造模方法可以造成山羊髌股关节倾斜,3个月后发生以髌骨内侧面OuterbridgeⅠ级和Ⅱ级为主的病变。即刻观察发现射频处理后的软骨表面光整,小的裂隙被融合。浅层的少量软骨细胞死亡,深层细胞受到的影响比较小。3个月后发现治疗侧髌骨软骨表面仍光滑,改良Mankin’8软骨评分结果显示治疗侧（8．50±2．51）分,对照组（11．00±4．15）分（t=2．57,P〈0．05）,治疗侧软骨损伤比对照侧轻。流式细胞学检测发现治疗侧软骨细胞死亡率（18．69±7．26）％,和对照侧（25．66±13．04）％相比,差异无统计学意义（t：1．94,P〉0．05）。结论一个能级的双极射频不会对软骨细胞造成明显的损害,软骨成形术是治疗髌骨软骨退变的有效方法之一。     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Differences in Osteocyte Density and Bone Histomorphometry Between Men and Women and Between Healthy and Osteoporotic Subjects

Bone defects related to osteoporosis develop with increasing age and differ between males and females. It is currently thought that the bone remodeling process is supervised by osteocytes in a strain-dependent manner. We have shown an altered response of osteocytes from osteoporotic patients to mechanical loading, and osteocyte density is reduced in osteoporotic patients, which might relate to imperfect bone remodeling, leading to lack of bone mass and strength. Hence, information on osteocyte density will contribute to a better understanding of bone biology in males and females and to the assessment of osteoporosis. Osteocyte density as well as conventional histomorphometric parameters of trabecular bone were determined in cancellous iliac crest bone of healthy postmenopausal women and men and of osteoporotic women and men. Osteocyte density was higher in healthy females than in healthy males and lower in osteoporotic females than in healthy females. Bone mass was reduced in osteoporotic patients, both male and female. In females, trabecular number was reduced, whereas in males, trabecular thickness was reduced and eroded surface was increased. There were no correlations between the parameter groups bone architecture, bone formation, bone resorption, and osteocyte density. These results are consistent with impaired osteoblast function in osteoporotic patients and with a different mechanism of bone loss between men and women, in which osteocyte density might play a role. The reduced osteocyte numbers in female osteoporotic patients might relate to imperfect bone remodeling leading to lack of bone mass and strength. M. G. Mullender and S. D. Tan contributed equally to this work.     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。