Study on accuracy and interobserver reliability of the assessment of odontoid fracture union using plain radiographs or CT scans

In odontoid fracture research, outcome can be evaluated based on validated questionnaires, based on functional outcome in terms of atlantoaxial and total neck rotation, and based on the treatment-related union rate. Data on clinical and functional outcome are still sparse. In contrast, there is abundant information on union rates, although, frequently the rates differ widely. Odontoid union is the most frequently assessed outcome parameter and therefore it is imperative to investigate the interobserver reliability of fusion assessment using radiographs compared to CT scans. Our objective was to identify the diagnostic accuracy of plain radiographs in detecting union and non-union after odontoid fractures and compare this to CT scans as the standard of reference. Complete sets of biplanar plain radiographs and CT scans of 21 patients treated for odontoid fractures were subjected to interobserver assessment of fusion. Image sets were presented to 18 international observers with a mean experience in fusion assessment of 10.7 years. Patients selected had complete radiographic follow-up at a mean of 63.3 ± 53 months. Mean age of the patients at follow-up was 68.2 years. We calculated interobserver agreement of the diagnostic assessment using radiographs compared to using CT scans, as well as the sensitivity and specificity of the radiographic assessment. Agreement on the fusion status using radiographs compared to CT scans ranged between 62 and 90% depending on the observer. Concerning the assessment of non-union and fusion, the mean specificity was 62% and mean sensitivity was 77%. Statistical analysis revealed an agreement of 80–100% in 48% of cases only, between the biplanar radiographs and the reconstructed CT scans. In 50% of patients assessed there was an agreement of less than 80%. The mean sensitivity and specificity values indicate that radiographs are not a reliable measure to indicate odontoid fracture union or non-union. Regarding experience in years of all observers taking part in the study, there were no significant differences for specificity (P = 0.88) or sensitivity (P = 0.26). Further analysis revealed that if a non-union was judged present by an observer then, on average, each observer changed decision regarding the presence of a ‘stable’ or ‘unstable non-union’ in 4.2 of all the 21 cases (range 0–8 changes per observer). We investigated the interobserver reliability of the assessment of fusion in odontoid fractures using biplanar radiographs compared to CT scans. A sensitivity of 77% and a specificity of 62% for the radiographs resemble a substantial lack of agreement if different observers evaluate odontoid union. Biplanar radiographs are judged not a reliable measure to detect odontoid fracture union or non-union. The union rates of odontoid fractures have to be revisited and CT scans as the endpoint anchor in outcome studies of treatment related union rates are recommended.     

股骨头旋转中心变异相关指标的影像学测量分析

目的：通过分析不同髋关节疾病的股骨头旋转中心变异情况为髋关节置换提供指导。方法 ：自2016年3月至2021年6月因各种原因拍射双髋关节正位等比例平片患者共5 459例。测量股骨头旋转中心与大转子顶点的相对位置关系,高于大转子顶点2 mm以上为正变异,低于大转子顶点2 mm以上为负变异,共收集831例股骨头旋转中心变异的患者,按照不同疾病分为4组,其中正常组15例,10例为正变异,5例为负变异;股骨头缺血性坏死组145例,25例为正变异,120例为负变异;先天性髋关节发育不良组346例,正变异225例（其中CroweⅠ型25例,Ⅱ型70例,Ⅲ型115例,Ⅳ型15例）,负变异121例（其中CroweⅠ型50例,Ⅱ型60例,Ⅲ型10例,Ⅳ型1例）;髋关节骨性关节炎组325例,正变异45例,负变异280例。结果：各组患者组间比较,股骨头旋转中心变异情况差异有统计学意义（P<0.05）,先天性髋关节发育不良组不同分型之间比较,股骨头旋转中心变异情况差异有统计学意义（P<0.05）。股骨头旋转中心不同变异情况在颈干角、偏心距的差异具有统计学意义（P<0.05）。结论：股骨头旋转...     

股骨转子间骨折的治疗方法选择(附1037例分析)

目的通过比较保守疗法与不同手术方法治疗股骨转子间骨折的疗效及术后并发症，探讨股骨转子间骨折的手术适应证。方法1980年1月～2005年12月共收治1037例股骨转子间骨折患者，其中216例采用保守治疗，行骨牵引、皮肤牵引或髋“人”字石膏固定；手术治疗821例：集柬针固定28例，空心螺钉固定33例，Ender钉固定98例，动力髋螺钉（DHS）固定411例。动力髁螺钉（DCS）固定86例，Gamma钉固定52例，股骨近端螺钉（PFN）固定17例，人工关节置换26例，角钢板固定70例。结果972例获得随访的患者中，保守治疗组176例；集柬针固定组28例，空心螺钉固定组32例，Ender钉固定组93例，DHS固定组392例，DCS固定组86例，Gamma钉固定组52例，PFN固定组17例，人工关节置换组26例，角钢板固定组70例，其优良率分别为52．8％、67．9％、87．5％、77．4％、95．9％、93．O％、90．4％、88．2％、92．3％、84．3％。保守治疗组死亡11人，肺部感染7例，尿路感染4例，髋内翻35例。集柬针固定组髋内翻3例，钉退出4例。Ender钉固定组髋内翻3例，切口感染3例。DHS固定组死亡1例，尿路感染3例，肺部感染3例，螺钉松动2例。DCS固定组内固定断裂1例。Gamma钉固定组螺钉松动1例。人工关节置换组死亡1例。角钢板固定组断裂1例。结论保守治疗髋内翻及内科并发症发生率高。逆股骨转子间骨折采用DCS、Gamma钉或PFN固定，DHS适用于稳定性骨折，四者对股骨转子间骨折的疗效确切，且并发症发生率低。     

Impact of a novel education curriculum on surgical training within an academic training program

BACKGROUND: The training of the 21st century surgeon has become increasingly complex with the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements and work-hour restrictions. Herein we report the two-year results of a novel problem-based learning education module at a large academic surgery program. METHODS: All data were prospectively collected from 2004 to 2006 on all categorical residents in the department of surgery (n = 42). Analysis was performed to identify any correlation between class attendance and American Board of Surgery In-Service Training Exam (ABSITE) score performance (percentile change). All data were reported as a mean with a standard error of the mean. Categorical variables were analyzed using a paired Student's t-test. A bivariate correlation was calculated using Spearman's rho correlation. RESULTS: When comparing the 2004 scores (pre-program) to 2006 scores, there was significant score improvement (P 相似文献   

Cementless hemiarthroplasty in femoral neck fractures: evaluation of clinical results and measurement of migration by EBRA-FCA

Aim of the present study was to evaluate migration rates of cementless primary hemiarthroplasty in acute femoral neck fractures. In a longitudinal, prospective study 46 patients were treated by cementless hemiarthroplasty. Clinical follow up was correlated with the EBRA-FCA method. In 30% of all patients stem migration amounted to more than 2 mm; further, these patients were seen to have a high level of activity. A high degree of migration in more than 30% of all patients requires critical scepticism toward further use of the investigated cementless stem as hemiarthroplasty. According to literature, migration of more than 2 mm suggests a high probability of early aseptic loosening. In patients with a low degree of activity good results could be observed; nevertheless, in patients with a high level of activity the combination of the investigated cementless stem with a solid fracture head cannot be recommended.     

感染性股动脉假性动脉瘤手术治疗及伤口处理：附16例分析

目的:探讨感染性股动脉假性动脉瘤治疗的手术方式,以及评估封闭负压辅助闭合(VAC)装置在治疗感染伤口的作用和应用价值。方法:回顾性分析2015年7月—2018年4月行手术治疗的16例感染性股动脉假性动脉瘤患者的临床资料。结果:16例患者术中破损动脉直接缝合破口5例,自体静脉修补6例,自体静脉置换3例,2例行动脉瘤切除局部旷置。患者手术伤口术后均经VAC装置引流治疗;伤口二期直接缝合12例,行皮瓣移植4例,伤口愈合时间平均34.2 d。术后13例患者获随访6个月,除1例伤口再次破溃接受清创治疗之外,其余12例患者伤口均无再次感染或破溃,所有随访患者动脉瘤均未复发。结论:感染性股动脉假性动脉瘤应尽早手术清创治疗;VAC装置治疗感染性伤口安全、有效。     

兔股动脉和静脉预构轴型扩张皮瓣的实验观察

目的 通过兔股动脉、静脉预构轴型扩张皮瓣的微循环血流晕动态变化、光镜下结构的改变及其成活面积,为预构轴型扩张皮瓣的临床应用提供依据.方法 选择新西兰白兔40只,随机分为4组:预构轴型扩张皮瓣组、预构轴型不扩张皮瓣组、单纯预构轴型皮瓣组及无蒂游离皮瓣组,每组4只,前2组股动脉、静脉移位后,预构轴型扩张皮瓣组、预构轴型不扩张皮瓣组分别在肉膜深面置入容量为50 ml长方形皮肤软组织扩张器,预构轴型扩张皮瓣组7 d后开始注水;无蒂游离皮瓣组为对照组,未采取预构及扩张处理.定期对4组皮肤进行微循环血流量检测,并取样进行光镜观察.预构术后52 d,前3组形成以预构股动静脉血管束为蒂的岛状皮瓣,游离皮瓣组则形成无蒂游离皮瓣后均原位缝合,观察其成活面积.结果 预构轴型扩张皮瓣组较其他组微循环血流量增加,成活面积大[(97.54±2.73)%],光镜下改变显著(P<0.05).结论 扩张术能促进预构轴型皮瓣的血管化进程,明显增大预构轴型皮瓣成活面积,增加其移植的安全性.     

股神经损伤1例漏诊原因分析

患者，男，32岁，主因：左髂部刀刺伤后出血半小时就诊。查体：BP120／80mmHg，心肺无异常，腹平坦，软，无压痛、反跳痛及肌紧张，无移动性浊音，肠鸣音存在。左髂前上棘外下后3cm处有一2．5cm的伤口，无活动性出血，足背动脉搏动有力，足趾活动及感觉均无异常。给予伤口清创缝合术。4h后逐渐出现腹胀、肠鸣音减弱，B超检查因肠管胀气明显不能     

基于股骨近端外侧壁完整性的股骨近端骨折分型方法:附888例病例分析

背景:目前股骨转子部骨折的分型系统均存在一定局限性,反转子间骨折和转子下骨折存在分型交叉,而且目前的分型系统均未将转子部外侧壁包含在内。目的:提出股骨转子部骨折的区域分型法,分析新分型系统中各型临床特点。方法:根据股骨转子部外侧壁是否完整以及后内侧是否存在蝶形骨折块建立区域分型法。回顾性分析2005年4月至2016年12月收治的行内固定治疗的股骨转子部骨折患者共888例,分析区域分型系统中各分型患者基础资料以及骨折愈合时间、最终随访时Harris评分等。结果:Ⅰ~Ⅳ型骨折分别占79.8%(709例)、12.7%(113例)、3.2%(28例)和4.3%(38例)。各型患者间年龄、性别、受伤原因、复位方法、手术时间和术中出血量差异均有统计学意义(P均<0.01)。ⅠA型骨折髓内固定与动力髋螺钉(DHS)相比,最终随访时Harris评分、内固定物相关并发症发生率差异均无统计学意义。ⅠB型骨折髓内固定与微创内固定系统(R-LISS)相比,内固定相关并发症发生率差异有统计学意义(P<0.05)。Ⅱ型骨折采用转子间顺行髓内钉(InterTan)和股骨近端锁定接骨板(PFP)固定的患者,最终随访时Harris评分优良率分别为81.8%、62.5%,高于其他内固定物。Ⅲ型骨折髓内固定与R-LISS固定最终随访时Harris评分优良率分别为58.8%、50.0%。Ⅳ型骨折髓内固定与R-LISS固定最终随访时Harris评分优良率分别为76.9%、45.5%。结论:区域分型法可以较好的反映各型转子部骨折的特点,并指导内固定物的选择和提示预后。对于ⅠA型骨折,推荐采用DHS或髓内固定治疗;ⅠB型骨折推荐使用髓内固定治疗;Ⅱ型骨折因外侧壁不完整,推荐使用PFP或者InterTan治疗;Ⅲ型及Ⅳ型骨折推荐使用髓内固定治疗。     

The impact of intensivists' base specialty of training on care process and outcomes of critically ill trauma patients

Background

The care of the critically ill trauma patients is provided by intensivists with various base specialties of training. The purpose of this study was to investigate the impact of intensivists’ base specialty of training on the disparity of care process and patient outcome.

Methods

We performed a retrospective review of an institutional trauma registry at an academic level 1 trauma center. Two intensive care unit teams staffed by either board-certified surgery or anesthesiology intensivists were assigned to manage critically ill trauma patients. Both teams provided care, collaborating with a trauma surgeon in house. We compared patient characteristics, care processes, and outcomes between surgery and anesthesiology groups using Wilcoxon tests or chi-square tests, as appropriate.

Results

We identified a total of 620 patients. Patient baseline characteristics including age, sex, transfer status, injury type, injury severity score, and Glasgow coma scale were similar between groups. We found no significant difference in care processes and outcomes between groups. In a logistic regression model, intensivists’ base specialty of training was not a significant factor for mortality (odds ratio, 1.46; 95% confidence interval; 0.79–2.80; P = 0.22) and major complication (odds ratio, 1.11; 95% confidence interval, 0.73–1.67; P = 0.63).

Conclusions

Intensive care unit teams collaborating with trauma surgeons had minimal disparity of care processes and similar patient outcomes regardless of intensivists’ base specialty of training.     

液氮冷冻建立犬股骨头缺血坏死模型的实验研究

[目的]为股骨头缺血性坏死的治疗研究建立动物模型.[方法]建立犬双侧股骨头骨缺血模型,并用液氮从缺损内将股骨头冷冻坏死,术后定期拍X线片,并取股骨头行组织切片了解股骨头坏死及修复情况.[结果]术后3d组织切片见股骨头坏死,术后3、6周见股骨头骨坏死和骨修复同时存在,术后12周X线片及大体标本观察见股骨头骨缺损仍然明显.[结论]液氮冷冻建立的犬股骨头缺血坏死可作为模拟临床手术刮除死骨、植骨治疗研究的动物模型.     

Central fracture dislocation of the hip associated with fracture of femoral neck treated by femoral head autograft and total hip arthroplasty: A rare case report

Central Fracture Dislocation of the Hip is a rare condition requiring more attention in its management, caused by high-energy trauma and is often associated with other injuries. This case report presents a 57-years old female who was injured in a traffic accident and diagnosed with polytrauma, abdominal blunt trauma with 7th zone liver laceration, central fracture dislocation of the left hip associated with closed fracture left acetabulum anterior column and closed fracture left neck femur. Until now, there is no mandatory management to treat this kind of injury. Several surgical techniques were explained in previous literatures to treat this condition such as Open Reduction and Internal Fixation (ORIF) procedure and Total Hip Arthroplasty (THA). Some studies chose THA as a treatment for similar condition in older population due to high risk of nonunion and avascular necrosis of the femoral head, especially in cases of significant displacement and devitalization of the femoral head. In this case, we performed femoral head autograft and total hip arthroplasty as a definitive treatment.     

两种手术方法治疗股骨干合并同侧股骨颈骨折的疗效比较

目的 比较股骨重建钉与逆行髓内钉加空心钉治疗股骨于合并同侧股骨颈骨折的疗效,探讨各自的手术适应证.方法 回顾性分析2001年1月至2010年5月收治的21例股骨干合并同侧股骨颈骨折患者资料,采用股骨重建钉固定10例(股骨重建钉组),逆行髓内钉加空心钉固定11例(逆行髓内钉加空心钉组).两组患者术前一般资料差异均无统计学意义(P＞0.05),具有可比性.术后1、3、6、9、12个月及以后每年随访1次,通过临床和影像学评估骨折愈合情况和并发症的发生情况.结果 21例患者术后获12 ～48个月(平均27.1个月)随访.两组患者在手术时间、术中出血量、术后引流量、住院时间、股骨干骨折愈合时间、股骨颈骨折愈合时间及Friedman-Wyman功能评定结果等方面差异均无统计学意义(P＞0.05).股骨重建钉组住院费用高于逆行髓内钉加空心钉组,差异有统计学意义(t=16.710,P=0.016).两组股骨干骨折愈合率(9/10 vs.10/11)、股骨颈骨折愈合率(9/10 vs.11/11)差异均无统计学意义(P＞0.05).股骨重建钉组4例发生并发症,逆行髓内钉组7例发生并发症.结论 股骨干合并同侧股骨颈骨折的治疗应采取个体化原则.股骨重建钉更适用于股骨颈基底部骨折合并狭部及狭部以近的股骨干骨折;对于头下型、难复位的股骨颈骨折合并同侧股骨干远端骨折或需要同时处理的膝关节内损伤、关节周围骨折的患者,逆行髓内钉加空心钉更为理想.     

双源CT三维重建前交叉韧带股骨止点及隧道面积的临床研究

目的通过双源CT（DSCT）三维重建前交叉韧带（ACL）股骨止点印迹及骨隧道面积,为临床实现解剖重建提供依据。方法分别对55例志愿者110膝,30例双束重建60膝及30例单束重建患者60膝进行DSCT扫描。64排工作站（GE,Volume Share 2-AW4．4软件）三维重建膝关节股骨外髁三维模型,再现股骨外髁内侧壁ACL印迹,圈画、测量印迹及骨隧道面积,计算单、双束骨道面积覆盖率。结果ACL股骨自然印迹面积双膝之间：左（146．35±29．0）mm2,右（144．51±33．71）mm^2,两者间无统计学差异（t=0．52,P〉0．05）。性别间自然印迹面积比较：AMB：男（87．08±19．29）mm。,女（77．09±15．17）mm^2,两者间有统计学差异（t=2．04,P〈0．05）;PLB：男（62．82±15．19）mm^2,女（61．64±16．55）mm^2,两者间无统计学差异（t=0．27,P〉0．05）。术后隧道面积覆盖率比较：单束（53±18）％,双束（70±16）％,两者间有统计学差异（t=2．44,P〈0．05）。结论ACL股骨止点自然印迹面积存在性别间及个体化差异,双束重建止点面积覆盖率显著大于单束重建,要实现ACL解剖重建需采用个体化重建技术。     

网络数据来源的股骨干合并同侧股骨颈骨折的诊断与治疗

目的 以网络开放数据库为基础,探讨股骨干合并同侧股骨颈骨折的诊断与治疗策略.方法 筛选2005年11月1日至2008年12月31日中华骨科网(htpp://www.orthochina.org)骨科创伤版数据库中128例股骨颈骨折患者资料,均由通过"骨科医生"身份验证的专业骨科医生提交,提取18例股骨干合并同侧股骨颈骨折患者资料.利用网络开放数据库的特点,综合分析此18例患者的医院分布、漏诊时间和漏诊原因,总结及汇总论坛讨论意见,分析骨科医生对股骨干合并同侧股骨颈骨折的认识,汇总治疗策略.结果 股骨干合并同侧股骨颈骨折占股骨颈骨折的14.1%(18/128).38.9%(7/18)的患者漏诊股骨颈骨折,1例为术巾漏诊,6例为术后漏诊.18例患者中,来自基层一级医疗机构者3例,地区二级医院12例,三级甲等医院3例.7例漏诊患者中,基层一级医疗机构3例,地区二级医院1例,三级甲等医院3例.早期确诊的11例患者多采用钢板加空心加压螺纹钉固定或股骨近端髓内钉固定,疗效可靠.1例术中漏诊患者术中补救后复位固定满意.6例术后漏诊患者中,3例采用空心加压螺纹钉同定,骨折复位较好;3例未对股骨颈骨折固定,预后较差.医生查体不完全、尤摄髋CT和术中透视及复查X线没有包括同侧髋关节是漏诊的主要原因.结论 网络数据库客观反映目前临床诊疗中股骨干合并同侧股骨颈骨折的重要性和风险,漏诊患者中顺行髓内钉的翻修最为困难,早期诊治及避免漏诊十分必要,应强调规范化查体和诊治.     

Management of proximal femoral fractures in the presence of hip resurfacing arthroplasty: peri-operative considerations and a meta analysis

Periprosthetic fractures which occur in close proximity to an in situ hip resurfacing prosthesis can pose a technically demanding challenge to orthopaedic surgeons. While this is currently an uncommon problem, it is logical to assume that as the numbers of hip resurfacing arthroplasties increase, we are likely to see larger numbers of patients with this presentation. In these cases, if the resurfacing prosthesis in not functioning well, the choice to replace it is easy. If it is well functioning, this decision becomes more difficult however. We present a case illustrating our experience with this unusual problem. We discuss our treatment strategy, the issues and options which need to be considered before treating these patients and review the current literature addressing this topic.     

右美托咪定对老年患者股骨头置换术后炎症因子及认知功能的影响

目的:分析右美托咪定对老年股骨头置换术患者术后炎症因子及认知功能的影响。方法:将2016年1月至2017年12月行股骨头置换术的老年患者(年龄≥60岁,ASA分级Ⅰ-Ⅱ级)60例分为3组,每组20例。所有患者接受注射咪达唑仑、芬太尼、依托咪酯、顺阿曲库铵麻醉诱导及吸入七氟醚麻醉维持。术中静吸复合维持先给予1.0μg/kg右美托咪定的负荷量10 min,维持量根据分组分别为右美托咪定0.3μg·kg~(-1)·h~(-1)(B组)和0.6μg·kg~(-1)·h~(-1)(C组)泵注,A组以相同方式给予等量生理盐水。比较3组拔管、清醒、恢复时间,简易智能精神状态评分(MMSE)及术后认知功能障碍发生率,白细胞介素-6(IL-6)、白细胞介素-10(IL-10)及S100β蛋白水平等。结果:3组患者自主呼吸恢复时间、睁眼时间及气管拔管时间、丙泊酚用量比较差异有统计学意义(P0.05)。术后第1、3、7天,B、C组MMSE评分与A组比较,差异有统计学意义(P0.05),且C组高于B组(P0.05)。C组术后认知功能障碍发生率为0.0%(0/20),不良反应发生率为30.0%(6/20),A组分别为25.0%(5/20)、0.0%(0/20),B组分别为5.0%(1/20)、10.0%(2/20),差异均有统计学意义(P0.05)。麻醉诱导前,3组IL-6、IL-10及S100β蛋白水平比较差异无统计学意义(P0.05);术后1 h,B、C组IL-6、IL-10及S100β蛋白水平与A组比较,差异有统计学意义(P0.05),且C组IL-6、S100β蛋白显著低于B组(P0.05),IL-10显著高于B组(P0.05)。结论:对于股骨头置换术老年患者,右美托咪定能够降低炎症因子水平及丙泊酚使用量,术后认知功能障碍发生率低,且呈现剂量依赖性,但是需根据患者情况选择合适剂量。     

PICC技术规范化培训后迁移行为及其影响因素的纵向研究

目的 调查PICC技术规范化培训后培训迁移行为及其影响因素纵向变化,为促进PICC技术持续推广应用提供依据.方法 采用便利抽样法选取参加PICC技术规范化培训学员30名,应用一般人口学资料调查表、护理人员培训迁移行为问卷、护理人员培训迁移影响因素量表于培训结束后1个月、3个月、6个月进行调查.结果 PICC技术规范化培...