Segond骨折并髌韧带断裂一例

笔者于2008年7月,收治1例Segond骨折并髌韧带断裂.现报告如下. 1 病例报告 患者男性,17岁,因车祸致左膝肿痛、功能障碍3 h入院.查体:左膝肿胀明显,浮髌试验阳性,左膝广泛压痛,因疼痛剧烈前抽屉试验、Lachman试验检查不合作,左膝关节活动受限明显.X线片、CT示:左胫骨外侧髁撕脱骨折,骨折块移位不明显;左胫骨髁间棘骨折,骨折块粉碎,移位明显;左胫骨结节撕脱骨折,骨折移位不明显.左髌韧带连续性失常.入院诊断:①左膝Segond骨折;②左胫骨髁间棘骨折;③左胫骨结节撕脱骨折.     

关节镜监视下丝线三角形缝合法治疗儿童胫骨髁间嵴撕脱骨折

目的探讨儿童胫骨髁间嵴撕脱骨折的治疗方法及疗效。方法对38例儿童胫骨髁间嵴撕脱骨折应用关节镜监视下丝线三角形缝合法治疗。结果本组获随访4-30个月,所有骨折复位、愈合良好,MRI示前交叉韧带走行良好、无松弛,膝关节前抽屉试验、Lanchman试验和轴移试验均为阴性,膝关节活动度正常,Lysholm评分96.5-99.8分,未发现伤肢长短发育异常。结论关节镜监视下丝线三角形缝合法治疗儿童胫骨髁间嵴撕脱骨折具有创伤小、固定牢固、对骨骺影响小、并发症少、康复快等优点。     

胫骨髁间嵴骨折的治疗进展

胫骨髁间嵴撕脱骨折是一种较少见的关节内骨折.胫骨髁间嵴是膝关节前交叉韧带的附着点.当胫骨髁间嵴撕脱骨折后,将导致膝关节明显不稳.目前对其治疗方法上存在不同意见,主要有闭合复位、切开复位加内固定、关节镜下复位内固定等几种治疗方法.     

关节镜下空心钉固定治疗陈旧性胫骨髁间棘撕脱骨折

前交叉韧带的前内侧束及后外侧束止于胫骨髁间棘上,陈旧性胫骨髁间棘撕脱骨折由于前交叉韧带松弛,导致膝关节前方不稳,会继发出现膝关节半月板损伤,以及因骨折块与股骨髁间顶部的撞击引起的伸膝功能受限,故仍需尽早手术治疗.自2003年1月～2006年9月,笔者使用关节镜下空心钉固定治疗9例,疗效满意,报告如下.     

四肢关节专用MRI对膝关节半月板桶柄样撕裂的诊断价值

目的探讨膝关节半月板桶柄样撕裂的MRI征象及其诊断价值。方法回顾分析膝关节半月板桶柄样撕裂23例,所有病例均经过四肢关节专用MRI检查并经关节镜证实。由2名有经验的放射科医师进行盲法阅片,记录并评价各征象的诊断价值。结果23例共见半月板桶柄样撕裂23个,其中发生于内侧半月板者16例(69.6%),外侧半月板者7例(30.4%)。出现领结消失征15例(65.2%),双前角征9例(39.1%),半月板翻转征3例(13.0%),髁间碎片征19例(82.6%),双后交叉韧带征7例(30.4%),后角比例失调征8例(34.8%)。序列试验显示各征象联合诊断时特异性明显提高,其中髁间碎片征和双后交叉韧带征联合的特异度达100%。结论MRI是半月板桶柄样撕裂理想的无创检查方法,有利于该疾病的术前诊断和手术计划制定。     

应用可吸收螺钉治疗前(后)交叉韧带胫骨附着区撕脱骨折

目的：探讨应用可吸收螺钉治疗前（后）交叉韧带胫骨附着区撕脱骨折疗效。方法：对11例应用可吸收螺钉治疗前（后）交叉韧带胫骨附着区撕脱骨折进行6个月－2年随访，平均随访时间为15个月。根据主观标准（病人的主观症状，关节稳定程序与关节功能等）与客观标准（抽屈试验，Lachman试验，X线检查结果等）进行评价。结果：膝关节功能主观标准评价满意率为90％。术前前交叉韧带胫骨附着区撕脱骨折前抽屉试验阳性3例，Lachman试验阳性4例，术前后交叉韧带胫骨附着区撕脱骨折后抽屉试验阳性100％。结论：应用可吸收螺钉治疗前（后）交叉韧带胫骨附着区撕脱骨折疗效满意，无需二次手术将其取出，值得推广应用。     

半月板撕裂和切除对前交叉韧带断裂力学稳定性的影响

目的探讨半月板对前交叉韧带断裂及重建术后胫骨前向稳定性的影响。 方法收集2017年1月至2018年10月期间前交叉韧带重建患者,排除前交叉韧带部分断裂和多发韧带损伤病例。所有不稳定半月板撕裂均行半月板部分切除术,根据半月板损伤部位及程度进行分组。采用KT-1000测量术前、术后3个月和6个月的胫骨前平移量(ATT)。组间对照采用独立样本t检验。 结果共纳入158例前交叉韧带断裂患者,其中半月板正常组61例,内侧半月板后角撕裂组49例(19例为撕脱<总宽度40%;30例为撕脱≥总宽度40%);外侧半月板撕裂组35例(12例为撕脱<总宽度40%;23例为撕脱≥总宽度40%);内侧半月板前角或体部撕裂组13例(6例为撕脱<总宽度40%;7例为撕脱≥总宽度40%)。术前内侧半月板后角撕裂≥总宽度40%患者的胫骨前平移量较半月板正常患者明显增加,差异有统计学意义(t＝12.141,P<0.01)。术后3个月及6个月,各个半月板撕裂组的ATT值与半月板正常患者相比均无差异(P >0.05)。 结论内侧半月板后角撕裂与前交叉韧带断裂可增加膝关节的不稳定性,半月板部分切除术对前交叉韧带重建术后患者的膝关节稳定性无影响。     

关节镜下胫骨髁间棘骨折的治疗进展

髁间棘是胫骨平台中间的一条不规则的隆起,是前交叉韧带(ACL)下止点的附着部.髁间棘撕脱骨折上移明显时,顶挤髁间出现顶部撞击,除影响膝关节伸直外,由于前交叉韧带松驰,会出现前交叉韧带缺失的症状,表现为膝关节前向不稳[1].因此,对有移位的髁间棘撕脱骨折应采取手术治疗,复位骨折并要进行很好的固定.     

胫骨髁间嵴撕脱骨折关节镜下内固定治疗

目的 :探索在关节镜下对胫骨髁间嵴撕脱骨折进行内固定的微创手术方法。方法 :从 1993年 1月～1998年 12月 ,共 9例胫骨髁间嵴撕脱骨折患者在关节镜下进行复位和钢丝内固定治疗 ,其中 3例合并有内侧半月板损伤 ,1例行半月板缝合 ,2例行半月板部分切除。 1例合并有胫骨外侧平台骨折行撬拨复位 ,螺丝钉内固定术。受伤至手术时间平均 6 5d。结果 :9例中有 7例得到了 3 6个月以上的随访 ,平均 43 2个月。采用Lysholm评分法评估患者手术后的功能 ,平均 88 3分 ,优良率 85 7%。客观检查 :前抽屉试验阳性 ,术前 7例 ,术后均阴性 ;Lachman征阳性 ,术前 7例 ,术后 1例弱阳性。术后遗留膝关节活动后疼痛 1例 ;膝关节活动部分受限 2例。结论 :关节镜下对胫骨髁间嵴撕脱骨折进行内固定治疗具有手术创伤小、功能恢复快的优点 ,值得推广。     

前交叉韧带合并不同类型半月板损伤的治疗策略

背景:前交叉韧带合并半月板损伤临床常见,针对不同的损伤类型,采取不同的治疗策略,对术后膝关节功能恢复至关重要。目的目的:研究前交叉韧带合并半月板不同损伤类型的特点,探讨相应的治疗策略。方法方法:选取2005年10月至2013年12月期间收治的前交叉韧带合并半月板损伤患者139例,男98例,女41例;年龄13~71岁,平均31.2岁;左膝62例,右膝77例,病程5 d至1.6年,陈旧性损伤(病程>3周)32例,新鲜性损伤(病程≤3周)107例。患者均有外伤史。临床主要表现为膝关节不稳、疼痛、弹响、绞锁。将术中镜下影像资料进行分析,统计前交叉韧带合并半月板损伤的类型特征及手术方式。结果结果:所有病例均采用关节镜微创手术治疗,前交叉韧带完全断裂113例,部分断裂26例。外侧半月板损伤46例(盘状半月板损伤8例,胫骨髁间棘撕脱2例)占33.1%,内侧半月板损伤65例(46.7%),内外侧半月板同期损伤28例(20.2%)。半月板纵行撕裂42例(桶柄状撕裂24例),水平状撕裂8例,斜行撕裂36例,瓣状撕裂13例,横断性撕裂12例,复合性撕裂28例。前交叉韧带重建139例,半月板部分切除36例,半月板缝合103例。结论结论:陈旧性前交叉韧带合并半月板损伤以外侧半月板多见,急性损伤以内侧半月板损伤为主。内外侧半月板同期损伤多见于陈旧性损伤。陈旧性损伤多数需要半月板部分切除,急性损伤多数可以缝合。前交叉韧带合并半月板损伤应早期手术。     

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.     

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.