下胫腓韧带联合分离的治疗进展

<正>踝关节骨折在日常生活中非常常见,据统计,在所有踝关节骨折和需要手术治疗的踝关节骨折的病例中,伴有下胫腓韧带联合损伤的比例分别占10%和20%[1]。临床中由于对踝关节下胫腓韧带联合损伤认识的不足,导致诊疗方面存在很多误区。下胫腓韧带损伤常导致距骨外移和踝关节不稳,尸体研究发现:当距骨向侧方移动1 mm时,胫距关节连接区域减少42%[2]。下胫腓韧带联合损伤会导致踝关节稳定性下降、踝关节疼痛,而治疗不当或漏诊常会导致疼痛、关     

踝关节骨折三角韧带损伤修复与否的文献综述

踝关节三角韧带损伤占踝关节损伤的10%~15%,其中单独三角韧带损伤较为少见,常合并有踝关节骨折及下胫腓联合韧带的损伤[1-3],踝关节也是体育活动中最常受伤的关节之一[4]。预计到2030年踝关节受伤的发生率将增加3倍[5]。在Lauge-Hansen[6]描述的踝关节骨折分型中,三角韧带损伤或内侧踝骨折,是以环形方式围绕踝关节而发生。三角韧带的损伤最常发生在旋前外和旋后外上,旋后外损伤是最常见的骨折类型。三角韧带结构的命名和解剖形态一直存在争议,它是一个坚强的多层复合体,由浅层和深层组成,是踝关节内侧重要稳定结构[7]。浅层的三角韧带包括胫舟韧带、胫跟韧带和胫距后韧带浅层,跨过踝关节和距下关节[8-9]。最近发表的有关于三角韧带组成的解剖学研究显示,弹簧韧带被认为是三角韧带浅层的一个组成部分[10-11]。三角韧带深层包括胫距前韧带深层和胫距后韧带深层,仅与踝关节相连[8-9](见图1~2)。     

手术治疗重度踝关节骨折脱位

踝关节骨折脱位是踝关节损伤中较严重类型,骨折不稳定,常伴有韧带和关节事囊损伤.我们于1987～1994年手术治疗重度踝关节骨折脱位48例,效果满意,报告如下.     

18 例三踝骨折的治疗体会

三踝骨折(cotton骨折)是常见的关节内骨折,常合并下胫腓联合损伤,踝关节完全失去稳定性,踝穴完整性受到严重破坏,踝关节骨折的治疗均应以骨折解剖复位、损伤韧带愈合良好为原则,因此目前多倾向于切开复位内固定治疗。作者自2001年10月至2004年10月采用切开复位内固定三踝骨折18     

中西医结合治疗髁部骨折(附52例分析)

踝部骨折是最常见的关节内骨折。踝关节是屈戍关节,站立时全身重量都落在踝关节上面,负重最大。在人们日常生活中,走路跳跃等活动,主要依靠踝关节的背伸跖屈活动功能。因为外力作用的方向,大小和肢体受伤时所处的位置不同,可以造成各种不同类型的骨折,各种不同程度的韧带损伤和不同方向的关节脱位,因此,在检查踝关节损伤时,必须了解受伤原因及受伤肢体的位置,并详细检查其临床特征,对照X线摄片进行分析,首先确定骨折类型,然后决定整复方法及固定形式,使之早日康复。     

手术治疗三踝骨折的临床新进展

三踝骨折是所有踝关节骨折的类型中较为复杂的一种,其又被称为Cotton骨折[1]。在人的踝关节中,其主要的组成部分包括距骨以上的关节面和胫腓骨以下的关节面一起组成,踝关节是人体全身中最大负重的屈伸性关节。三组主要的韧带围绕在踝关节周围,彼此间紧密连接。三踝骨折发生的时候,其周围的关节韧带经常会损伤,这个时候应该采取正确的处理方法,否则可能会造成骨折的不愈合后果,产     

旋前外旋型踝关节骨折的诊断与治疗体会

踝关节是人体重要的负重关节,其结构复杂、关节活动度大.在人们日常行走、体育锻炼以及工作中,踝关节损伤时有发生.随着对踝关节骨折研究的深入和内固定技术的发展,踝关节损伤的治疗效果得到了显著的提升.但踝关节损伤后遗留慢性疼痛以及创伤性关节炎,并最终出现功能障碍的病例并不少见,除了踝关节本身结构精细、关节灵活和周围韧带结构复杂的原因外,医生对于踝关节损伤机制的认识不够深刻以及忽视病史及体格检查的重要性也是部分病人踝关节骨折术后功能恢复不满意的原因.     

关节镜下踝关节骨折的手术治疗

踝关节是个高度适配的鞍状负重关节，骨折时还可同时伴有软骨、韧带和肌腱的损伤，创伤性关节炎发生率高。作为常见的关节内骨折，踝关节稳定性重建非常重要，但临床上仍发现部分患者虽然影像学资料显示复位固定满意，但并发后期关节炎，影响生活质量。同时部分患者骨折部皮肤条件差，切开手术感染概率高，为此，我们利用关节镜技术，进行微创手术治疗踝部骨折，     

踝关节骨折的诊断和治疗

踝关节骨折是最常见的骨折之一，其良好预后取决于明确诊断和合理治疗。本文探讨踝关节骨折及其伴发的周围韧带损伤的诊断和治疗方法，并加以展望。     

踝关节稳定性因素及损伤修复的相关研究

踝关节扭伤是最常见的运动损伤~([1]),多见于外侧(85%),韧带联合损伤约占10%,因为踝关节骨折或脱位时,单独的内侧三角韧带损伤很少,仅占5%.最近一次流行病学研究发现在急诊和意外伤害患者中,踝关节扭伤占14%~([2]);在美国大学生运动员中踝关节韧带损伤也是最常见的运动损伤~([3]).     

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.