动力髁螺钉在股骨粗隆周围骨折中的应用

目的：探讨动力髁螺钉（DCS）在股骨粗隆周围骨折中的应用及并发症原因，方法：对20例股骨粗隆周围骨折（粗隆间骨折12例，粗隆下骨折8例。其中粗隆间骨折根据Evans分型方法：I型10例，均为不稳定型：II型2例。）采用间接复位DCS内固定治疗，结果：经8个月－3年（平均2年）的随访，骨折全部愈合，尚存1例轻度髋内翻等并发症。结论：动力髁螺钉（DCS）治疗股骨粗隆周围骨折是DCS的一种新用途，是其他内固定的一个补充，适用于不稳定型的粗隆间骨折和特别靠近近端的粗隆下骨折，当术中其他内固定造成大粗隆游离，影响固定效果时，可改用DCS固定补救，应用间接复位技术，不需要固定小粗隆或内侧小粗隆植骨，术中反复穿钉，术后过早负重，可能引起髋内翻的原因。     

高龄股骨粗隆间骨折168例治疗方法及疗效分析

目的探讨不同术式治疗老年股骨粗隆间骨折的临床效果。方法回顾性分析168例高龄股骨粗隆间骨折,分别采用不同手术方法治疗。其中DHS组95例,PFN组38例,DCS组35例。结果术后随访7～23个月,骨折全部愈合。三组在手术时间、术中出血量、下地行走时间及骨折愈合时间、髋关节创伤后的功能恢复方面差异无统计学意义(P0.05)。3种内固定方法在术后并发症方面的差异有统计学意义(P0.05)。结论三种方法有各自的优点和适应证,需要根据骨折分型结合老年患者骨质情况选择个性化的治疗方案。PFN及DCS对于不稳定的股骨粗隆间骨折,在术后并发症及功能恢复方面更有优势。     

AO动力髁螺钉在股骨粗隆下骨折中的应用

目的：研究和评估AO动力髁螺钉（dynamic condylar screw,DCS)在股骨粗隆下骨折治疗的价值和作用。方法：对36例股骨粗隆下骨折患者行切开复位、DCS内固定，结果：36例患者随访≥24个月，所有病例骨折均愈合，无一例发生钢板螺钉松动，断裂，骨不连等并发症，结论：DCS操作简单，可提供有效的固定稳定性，适用于股骨粗隆下骨折的治疗。     

应用95°髁钢板治疗股骨粗隆下骨折28例

为探讨股骨粗隆下骨折治疗难题,作者从1994年6月至1998年7月采用了AO-95°髁钢板内固定治疗28例股骨粗隆下骨折。其中粉碎性骨折21例,获得满意效果随访6～37个月,除1例并发伤口感染外未见其他等并发症发生,故作者认为髁钢板治疗粗隆下骨折具有固定牢、操作简便、创伤小、并发症少等优点。     

滑动加压鹅头钉治疗股骨粗隆问骨折28例

目的观察滑动加压鹅头钉内固定治疗股骨粗隆间骨折疗效。方法自1999~2003年底对28例股骨粗隆间骨折病人行滑动加压鹅头钉内固定治疗。结果28例病人均获得6~20个月的随访,术后有1例死于帕金森氏病;2例髋关节屈伸活动度小于90°;其余25例均恢复原有生活能力,未见骨折不愈合或迟缓愈合现象。结论滑动加压鹅头钉是治疗股骨粗隆间骨折较好的方法,但有严重内科疾病和严重骨质疏松症者不宜行滑动加压鹅头钉固定。     

三种内固定方式治疗老年股骨粗隆间骨折疗效分析

目的 探讨DHS联合拉力螺钉、PFN、空心拉力螺钉三种不同内固定治疗老年股骨粗隆间骨折的临床效果.方法 对76例老年股骨粗隆间骨折采用手术治疗,其中DHS联合拉力螺钉42例,PFN16例,空心拉力螺钉18例.比较手术时间、术中出血量、下地负重时间、骨折愈合时间、Harris评分等指标.结果 随访7～34个月,空心拉力螺钉手术时间、术中出血量明显少,PFN治疗下地时间明显早于其他两组(P<0.05),DHS联合拉力螺钉固定牢固术后并发症少.结论 稳定型、顺股骨粗隆间骨折应选择DHS治疗.粉碎性、不稳定或反股骨粗隆、粗隆下骨折选择PFN治疗.高龄、体质弱的老年股骨粗隆间骨折选用空心拉力螺钉内固定.     

解剖型锁定钢板治疗股骨粗隆间骨折合并粗隆下骨折的体会

目的 探讨解剖型锁定钢板治疗股骨粗隆间骨折合并粗隆下骨折的疗效.方法 采用解剖型锁定钢板治疗18例股骨粗隆间骨折合并粗隆下骨折.结果 本组随访12～24个月,所有骨折均愈合,愈合时间为2～8个月.根据黄公怡临床评定标准:优12例,良5例,差1例.结论 应用解剖型锁定钢板治疗股骨粗隆间骨折合并粗隆下骨折具有简单实用,安全有效,创伤小,内固定牢固,能早期活动和负重的优点,是一种较好的方法.     

运用Gamma钉内固定治疗股骨粗隆间及粗隆下骨折

目的 探讨Gamma钉治疗股骨粗隆间及粗隆下骨折的临床疗效.方法 对87例股骨粗隆间及粗隆下骨折行Gamma钉内固定治疗,并观察其术后疗效.结果 本组随访1～2.5年.复查X线片显示骨折均牢固愈合,无骨不连、内固定松动、脱出或再骨折,无拉力螺钉切出股骨头及主钉远端股骨干骨折.结论 Gamma钉经准确复位和坚强内固定,可...     

N—Ti梯形自动加压钢板内固定治疗股骨粗隆间粗隆下骨折

目的：总结粗隆间，粗隆下骨折应用N-Ti-TACP内固定的经验及体会。方法：对37例股骨粗隆间，粗隆下骨折行切开复位及N-Ti-TACP内固定。结果：34例患者取得随访≥12个月，32例在3-5.5个月内骨折愈合，2例发生延迟愈合及髋内翻。结论；N-Ti-TACP治疗粗隆间，粗隆下骨折不需特殊设备。操作简单，疗效可靠。     

加长型PFNA内固定治疗复杂型股骨粗隆部骨折

目的探讨加长型股骨近端防旋髓内钉(PFNA)内固定治疗复杂型股骨粗隆部骨折(粗隆间伴粗隆下骨折)的临床疗效。方法用加长型PFNA治疗27例老年复杂型股骨粗隆部骨折(粗隆间伴粗隆下骨折)。结果术后随访6~24个月,平均13个月。3例出现肺部感染,1例褥疮,1例骨不愈合。术后Harris评分;优10例,良8例,可8例,差1例。结论 PFNA内固定牢靠,操作简单,手术时间少,并发症少,是治疗老年复杂股骨粗隆部骨折(粗隆间伴粗隆下骨折)的好的方法。     

Histochemical and contractile properties of striated muscles of urethra and levator ani of dogs and sheep

AIMS: To understand their possible importance in long- and short-term control of continence, some properties of the striated muscles of the urethra and pelvic floor (levator ani) of dogs and sheep were investigated, especially fiber types and contractile characteristics. MATERIALS AND METHODS: Striated muscles of urethra and levator ani of 29 male and 6 female dogs and 11 male and 6 female sheep were removed and cut into strips. Some strips were frozen and stained for ATPase at pH 9.4 and 4.3 for fiber typing; others were set up in an organ bath to study contractile responses to nerve stimulation. RESULTS: All muscles contained both type I (slow) and type II fibers, ranging from 97% type II in female greyhound urethra to 60% in female sheep levator ani. For each muscle, there were fewer type II muscles in sheep than in dog. The diameters of the urethral fibers were about 60% of the levator ani in dogs and 34% in sheep. Contraction of the urethral muscle was faster than for levator ani and declined to about 80% of the peak, 500 msec after the beginning of stimulation at 20 Hz. The levator ani contraction rose to a steady level as long as stimulation continued. CONCLUSIONS: Both the levator ani and urethral striated muscles contain slow and fast fiber types. The levator ani muscles are capable of sustained contraction with rapid onset which will produce long-term closure of the urethra. The circular urethral muscle contraction was faster but less well maintained.     

Incorporation and release of85Sr and14C-proline-hydroxyproline in mineral and collagen of bone and incisor teeth of growing rats

The extent to which exchange and reutilization processes of mineral tracers affect skeletal mineral accretion and resorption measurements was evaluated by comparing the rates of appearance and disappearance of⁸⁵Sr and¹⁴C-proline-hydroxyproline in bones and teeth in growing rats for 12 days following simultaneous parenteral injection of these tracers. Expressions for the relative rates of collagen synthesis and breakdown, which unlike mineral metabolism are considered not to be complicated by exchange phenomena, were based on¹⁴C-proline conversion to¹⁴C-hydroxyproline; the specific activity of the latter was determined. Both the mineral and the collagen specific activities reflected the rates and patterns of growth of the samples assayed; rapid growth and a short interval of time between formation and resorption of tissue in themetaphyseal bone which contains the cartilagineous growth plate, slow growth and an interval of time between formation and resorption of tissue indiaphyseal bone and incisor teeth which is longer than the 12 days of the experiment. However, in metaphyseal bone the specific activity collagen/mineral ratio dropped by one half during the 4–12 day interval in contrast to diaphyseal bone and incisor teeth in which no change in this ratio was observed during this period of time. The data indicate that collagen in the metaphyseal growth zone is removed by resorption before it has become fully mineralized, and that exchange is a relatively unimportant factor in the long term kinetics of bone mineral.

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Zusammenfassung Das Ausmaß, bis zu welchem Austausch- und Wiederverwendungsprozesse der mineralen Tracer die Messungen des mineralen Skelett-Auf- und Abbaues beeinflussen können, wurde ausgewertet; zu diesem Zweck wurde die Geschwindigkeit des Auftretens und Verschwindens von⁸⁵Sr und von¹⁴C-Prolin-Hydroxyprolin in Knochen und Zähnen von wachsenden Ratten während der 12 auf die simultane parenterale Injektion dieser Tracer folgenden Tage verglichen.Der Ausdruck für die relative Geschwindigkeit des Kollagen-Auf- und Abbaues, bei welchem im Gegensatz zum Mineralmetabolismus kein Mitwirken des Austauschphänomens vermutet wird, basiert auf der Umwandlung von¹⁴C-Prolin zu¹⁴C-Hydroxyprolin; die spezifische Aktivität des letzteren wurde bestimmt.Aus der spezifischen Aktivität des Minerals sowie jener des Kollagens konnten die Geschwindigkeit und die Art des Wachstums der untersuchten Proben ersehen werden, d.h.schnelles Wachstum und ein kurzes Zeitintervall zwischen Bildung und Resorption des Gewebes imKnochen der Metaphyse, die auch die knorpelige Wachstumsplatte enthält, und andererseitslangsames Wachstum und längeres Zeitintervall (länger als die 12 Tage des Experimentes) zwischen Bildung und Resorption des Gewebes imKnochen der Diaphyse und in den Schneidezähnen. Immerhin fiel die spezifische Aktivität des Kollagen/Mineral-Anteils im Knochen der Metaphyse während dem 4–12tägigen Zeitintervall auf die Hälfte, im Gegensatz zum Knochen der Diaphyse und der Schneidezähne, bei welchen während dieser Zeitspanne kein Unterschied in diesem Verhältnis beobachtet wurde.Diese Ergebnisse zeigen, daß Kollagen in der Wachstumszone der Metaphyse durch Resorption verschwindet, bevor es ganz mineralisiert ist, und daß der Austausch ein relativ unwichtiger Faktor in der Kinetik auf lange Sicht des Knochenminerals ist.

     

Instrumented ligamentotaxis and stabilization of compression and burst fractures of dorsolumbar and mid-lumbar spines

Background:

Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique employing the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra.

Materials and Methods:

The study includes 15 Denis burst and two Denis type D compression fractures between T₁₂ and L₃. The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patients after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in vertebral body height, sagittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated.

Results:

The preoperative and postreduction percentile vertebral heights at, zero (immediate postoperative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at preoperative, and postoperative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively.The preoperative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final followup. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications.

Conclusion:

Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.     

Principles and Practice of Hemofiltration and Hemodiafiltration

There is growing interest in the convective dialysis therapies, hemofiltration (HF) and hemodiafiltration (HDF). Both require dialysis membranes which are highly permeable to solutes as well as fluid, and in both cases large volumes of ultrafiltration are the condition for convective transport. In HDF the convection is combined with diffusion, and as a consequence, maximum clearance over the entire molecular weight spectrum is achieved. Optimal forms of HDF provide urea clearance 10–15% higher than the corresponding diffusive mode. The larger the solute, the greater is the impact of convection, and β₂-microglobulin (β₂m) levels may be up to 70% reduced. Traditional postdilution HF provides high clearance of medium sized and large molecules. Satisfactory clearance of small solutes requires blood flows in excess of 500 ml/min. With access to practically unlimited volumes of substitution solution through on-line ultrafiltration, predilution HF can now be used. This increases the clearance of small solutes to an acceptable range. For HDF as well as HF, large patient populations consistently treated for longer periods of time are needed to make valid outcome comparisons with other therapies.     

骨折不愈合与延迟愈合的成因与治疗

目的探讨骨折不愈合与延迟愈合的成因、报肯治疗的方法与设果。方法对1990年7月～2004年12月间收治的107例骨折不愈台、54例骨折延迟愈合2例先天性胫骨骨不连进行回顾性研究，分析原因，随访治疗结果。18例延迟愈合行保守治疗，本组其他145例行手术治疗，结果除2例先天性胫骨骨不连外，其余161例的成因中均有医源性因素。10例失去随访，153例平均随访17（6-28）个月，骨折均获骨性连接，愈合时间平均10（6-14）个月，肢体功能恢复良好，结论医源性技术缺陷是骨折不愈合与延迟愈合的主要原因，针对各种不同因素进行合理治疗可获得满意效果。     

Recognition and management of phaeochromocytoma and paraganglioma

Phaeochromocytomas and paragangliomas (PPGL) are catecholamine-secreting neuroendocrine tumours arising from the chromaffin cells in the adrenal medulla. These tumours may be identified incidentally, as part of a work-up for multiple endocrine neoplasia or following haemodynamic surges during unrelated procedures. Advances in perioperative management and improved management of intraoperative haemodynamic instability have significantly reduced surgical mortality from around 40% to less than 3%. Surgery is the definitive treatment in most cases and laparoscopic resection where possible is associated with improved outcomes. Anaesthetic management of PPGL cases represents a unique haemodynamic challenge both before and after tumour resection. In this article we describe the physiology of these tumours, their diagnosis, preoperative optimization methods, intraoperative anaesthetic management and management of postoperative complications.     

Physiology and pharmacology of nausea and vomiting

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic antiemetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of antiemetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist and nabilone, a synthetic cannabinoid.     

Physiology and pharmacology of nausea and vomiting

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic antiemetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of antiemetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist, and nabilone, a synthetic cannabinoid.