几种不同髋疾病全髋置换术后疗效观察

目的比较不同髋关节疾病行THR后的疗效,为临床上治疗髋关节疾病行THR后的疗效及预后判断提供依据。方法对2000年1月至2007年1月在我科行首次THR的126例患者按诊断分为4组：新鲜股骨颈骨折（fres hfemoral neck fracture,FFNF）、陈旧性股骨颈骨折（old femoral neck fracture,OFNF）,骨性关节炎（osteoarthritis,OA）,股骨头坏死（femoral head necrosis,FHN）。依据诊断进行回顾性分析,使用Harris评分对THR术后疗效评估,初步评价不同髋关节疾病行THR术后的疗效。结果新鲜股骨颈骨折组由术前平均21.6分恢复到术后平均82.5分（平均63.5岁）;陈旧性股骨颈骨折组由37.7分恢复到90.6分（58.9岁）;骨性关节炎组由35.0分恢复到81.6分（59.5岁）;股骨头无菌性坏死组由4.07分恢复到86.3分（56.9岁）;骨性关节炎患者中的原发性骨性关节炎组由29.4分恢复到87.8分（58.7岁）。结论 THR正逐渐成为目前治疗严重髋关节疾病的最有效术式,严格实施术后随访有利于提高和改进THR手术水平、改进假体选择和设计、正确评估手术预后。     

Comparison of total hip and knee joint replacement in patients with rheumatoid arthritis and osteoarthritis: a nationwide,population-based study

INTRODUCTION

Patients with rheumatoid arthritis (RA) and osteoarthritis (OA) may require total hip replacement (THR) or total knee replacement (TKR). The present study aimed to compare the demographic characteristics and medical costs of RA and OA patients from Taiwan who underwent either THR or TKR.

METHODS

The medical records of patients who had undergone THR or TKR from 1 January 1996 to 31 December 2010 were obtained from the Taiwan National Health Insurance Research Database (NHIRD). In all, we found 49 and 146 RA patients who received THR and TKR, respectively, and 1,191 and 6,574 OA patients who received THR and TKR, respectively. The gender, age, Charlson comorbidity index (CCI), hospital grade, age at registration in the catastrophic illness dataset, and medical utilisation costs of the different groups were compared.

RESULTS

There were statistically significant differences in age, CCI score, drug costs and surgery costs between RA and OA patients. Joint replacement incidence was lower in RA patients than in OA patients, and among patients who underwent THR, total medical costs incurred were higher for RA patients than OA patients. RA patients who underwent THR incurred a significantly greater total medical utilisation cost in the outpatient department (3 months before surgery and 12 months after surgery) than OA patients who underwent THR.

CONCLUSION

Analysis of Taiwan NHIRD with regard to patients who had undergone either THR or TKR indicated that RA patients were younger than OA patients, and that significantly more medical resources were used for RA patients before, during and after hospitalisation for these procedures.     

Free radicals and Dupuytren's contracture

The concentration of substrate expressed as hypoxanthine capable of reacting with xanthine oxidase to release superoxide free radicals (O2-) was measured in control and Dupuytren's contracture palmar fascia. In Dupuytren's contracture palmar fascia the concentration of hypoxanthine was six times that of control and was greatest in "nodular" areas. Xanthine oxidase activity was also detected in Dupuytren's contracture palmar fascia. These results suggest a greater potential for hypoxanthine-xanthine oxidase generated oxygen free radical formation in Dupuytren's contracture than in control palmar fascia. Production of free radicals may be an important factor in the pathogenesis of Dupuytren's contracture. The benefit of allopurinol in the management of Dupuytren's contracture and other fibrotic conditions may thus be explained, as allopurinol binds to xanthine oxidase and prevents release of free radicals.     

全髋关节置换术治疗先天性髋关节发育不良

目的:探讨全髋关节置换术治疗先天性髋关节发育不良患者继发骨性关节炎的临床效果。方法:对9例(11个髋)先天性髋关节发育不良继发骨关节炎的患者施行全髋关节置换术。本组随访11个月～9年,平均49个月。结果:根据MerleD'Aubigne评分标准,优7髋,良3髋,中1髋,优良率90.9%。无坐骨神经及股神经损伤患者。结论:全髋关节置换术是治疗先天性髋关节发育不良患者继发骨性关节炎的有效方法,注意肌力平衡,真臼安放生物性假体,细直柄假体应用骨水泥固定,调整前倾角是手术成功的关键。     

Thyroid hormone resistance

Thyroid hormone resistance (THR) is a rare syndrome of reduced end organ sensitivity. Patients with THR have elevated serum free thyroxine (FT4), free triiodothyronine (FT3), but normal or slightly elevated serum thyrotropin values. The characteristic clinical feature is goitre without symptoms and metabolic consequences of thyroid hormone excess. THR can be classified on the basis of tissue resistance into pituitary, peripheral or generalised (both pituitary and peripheral) types. Mutations in the TRbeta gene, cell membrane transporter and genes controlling intracellular metabolism of thyroid hormone have been implicated. THR is differentiated from thyroid stimulating hormone (TSH) secreting pituitary adenoma by history of THR in the family. No specific treatment is often required for THR; patients with features of hypo- or hyperthyroidism are appropriately treated with levo-triiodothyronine (L-T3), levo-thyroxine (L-T4), dextro-thyroxine(D-T4) or 3,3,5 triiodo-thyroacetic acid (TRIAC). The diagnosis helps in appropriate genetic counselling of the family.     

退变颈间盘组织中一氧化氮和超氧化物歧化酶含量的变化及其意义

目的：研究一氧化氮(N0)和超氧化物歧化酶(SOD)在退变颈问盘组织中含量的变化并对其意义进行探讨。方法：用分光光度法测定32例颈间盘突出症(PCID)患者的颈间盘组织及10例正常颈间盘组织中的NO和SOD的含量并进行比较。结果：退变颈间盘组织中NO含量高于正常颈间盘组织，SOD含量低于正常颈间盘组织。结论：颈间盘退变时，颈问盘组织中NO升高SOD降低，氧自由基损伤在颈间盘退变中发挥重要作用。     

局麻对一级传入神经元P物质的影响——免疫细胞化学观察

本文用免疫细胞化学方法研究了局麻下三叉神经半月神经节神经元内P物质的变化。结果表明,局麻侧面部皮肤P物质阳性神经纤维增多,半月神经节内P物质阳性的中小型细胞减少,三叉神经脊束核末梢内P物质阳性反应减弱。对照侧相反。结果提示局麻药阻断了钠离子内流,使神经节细胞轴浆运输减慢,P物质在周围突的储留增多,胞体P物质合成及中枢突释放均减少,痛信息不易传入中枢而镇痛。     

全髋关节置换术后并发症分析及处理

目的探讨髋关节人工假体置换术后并发症产生的原因及防治措施。方法回顾调查1995年1月~2002年12月我院进行人工全髋关节置换术246例(255髋)。股骨颈骨折109例,股骨头缺血坏死78例,骨关节病45例,强直性脊柱炎5例,股骨上段肿瘤9例。结果246例(255髋)患者其中7例已死亡,失访8例,其余231例(235髋)患者随访2.0~9.0年,平均5.5年。发现术后并发症46例,髋关节脱位6例,伤口感染4例,假体松动下沉6例,下肢静脉栓塞3例,股骨骨折1例,疼痛26例。结论合理选择人工假体,术中严格操作,术后加强护理,可降低人工假体置换术后并发症的发生率。     

腰椎退行性病变与原发性膝关节骨关节炎发病的关系

目的 初步研究腰椎退行性病变与原发件单膝骨关节炎发病率之间的关系.方法 回顾分析2008年1至12月北京大学人民医院骨科115例原发性单膝骨关节炎和119例原发性双膝骨关节炎行人工全膝关节置换术的老年患者的临床资料,根据腰椎退变的体征和放射学改变将单膝、双膝患者分为上腰椎退变、下腰椎退变、伞腰椎退变及无腰椎退变组,进行X2榆验,比较单、双膝患者的腰椎退变情况有无差异.结果 原发性单膝骨关节炎患者腰椎间盘突出或神经根管狭窄侧与膝关节病变侧相同.单膝患者的腰椎退变发病率(60%)高于双膝骨关节炎患者的腰椎退变发病率(31.1%),X~2=19.723,P=0.000;单膝患者的上腰椎退变发病率(29.6%)高于双膝患者的上腰椎退变发病率(6.7%),X~2=20.720,P=0.000;单膝患者的下腰椎退变发病率(17.4%)高于双膝患者的下腰椎退变发病率(8.4%),X~2=4.227,P=0.040;全腰椎退变发病率没有差异,X~2=0.402,P=0.526.结论 同一老年患者的原发性单膝骨关节炎发病与腰椎退变相关,特别是上腰椎退变会诱发单膝骨关节炎的发生和加重;原发性膝骨关节炎的屈曲畸形可能会导致下腰椎、甚至上腰椎退变的加重.     

Prevention of deep vein thrombosis in orthopedic surgery

In the absence of thromboprophylaxis, venous thromboembolism (VTE) affects about 50 to 80% of the patients after total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery. Since stratification of patients in those who will become symptomatic and those who will not, is not possible, primary high risk thromboprophylaxis should be provided to all patients undergoing major orthopedic surgery of the lower extremity. Various non-pharmacologic and pharmacologic thromboprophylactic measures have been evaluated. With regard to pharmacologic thromboprophylaxis unfractionated heparin has now almost completely been replaced by low molecular weight heparin (LMWH) for VTE prophylaxis. The use of acetylsalicylic acid for thromboprophylaxis in patients undergoing major orthopedic surgery of the lower extremities is not recommended. The optimal beginning of LMWH thromboprophylaxis is either 2 hours preoperatively or 6 to 8 hours postoperatively. Extended thromboprophylaxis (beyond 7 to 10 days after surgery) is recommended for high-risk patients. New antithrombotics, such as fondaparinux or (xi)melagatran, significantly reduce the risk of asymptomatic but not of symptomatic VTE compared to LMWH. In the light of other potential side effects (e.g., an increased bleeding risk) and high costs the role of these new drugs in the prophylaxis of VTE in patients undergoing major orthopedic surgery of the lower extremities remains to be established.     

髌骨侧向移动值的实验和临床研究

分析５例尸体标本的膝关节支持带在切开松解或缝合紧缩等不同状态以及半月板损伤、骨关节炎两组临床病例。髌骨在伸膝位时的侧向移动值，经统计检验Ｐ＜０．０１，显示了本研究有一定的代表性和可信性。说明１．支持带具有髌股关节的侧副韧带功能，与髌骨侧向活动的稳定性密切相关。２．支持带的异常会引起髌骨错格，是髌前痛的重要因素。３．支持带的切开或紧缩手术可以改善髌股关节的适合性，对治疗髌股关节炎具有一定疗效。提出临床髌骨侧向移动的分级方法。     

全髋关节置换与内固定治疗股骨颈骨折疗效比较

目的比较全髋关节置换术与内固定术治疗股骨颈骨折的疗效.方法回顾性总结35例行内固定术、31例行全髋关节置换术治疗股骨颈骨折病人的临床随访资料,术后平均随访时间3.8年.结果全髋关节置换术后优良率71.0%,27例无病废病人平均Harris评分90.4;内固定治疗术后优良率48.6%,20例无病废病人平均Harris评分91.6,15例严重病废病例中股骨头坏死与骨折不愈合各6例,其他原因3例,股骨头坏死病人年龄均小于65岁.结论全髋关节置换是股骨颈骨折有效的治疗方法.65岁以上股骨颈骨折病人,有时也可行内固定治疗.     

老年人髋关节置换术疗效分析

目的:探讨全髋关节置换术(THR)对老年患者的临床价值。方法:回顾分析我院2002年～2005年38例全髋关节置换术老年患者的手术效果,术后随访1～3年,平均2.4年。对术后髋关节功能进行评分。结果:38例平均随访2.4年,无1例感染,无关节严重疼痛,功能阻碍及DVT发生。无术后关节早期脱位,无假体松动、断裂、下沉等并发症发生。随访表明髋关节置换术的优良率达92.1%,手术效果满意。结论:全髋关节置换术对老年患者可解决患髋的疼痛,改善髋关节功能。是一种治疗老年髋部疾患安全有效的方法,但应严格掌握其手术适应症。     

不同退变程度腰椎间盘组织中一氧化氮和超氧化物歧化酶含量的变化及其意义

目的:研究一氧化氮(NO)和超氧化物歧化酶(SOD)在不同退变程度腰椎间盘组织中含量的变化及其意义.方法:用分光光度法测定46例腰椎间盘突出症患者的腰椎间盘组织中的NO和SOD的含量并进行比较.结果:随腰椎间盘退变程度的加重腰椎间盘组织中NO含量升高,SOD含量减低.结论:腰椎间盘退变时,腰椎间盘组织中NO升高SOD降低,氧自由基损伤在腰椎间盘退变中发挥重要作用.     

Lower limb orthopaedic surgery results in changes to coagulation and non-specific inflammatory biomarkers,including selective clinical outcome measures

Background

With an aging society and raised expectations, joint replacement surgery is likely to increase significantly in the future. The development of postoperative complications following joint replacement surgery (for example, infection, systemic inflammatory response syndrome and deep vein thrombosis) is also likely to increase. Despite considerable progress in orthopaedic surgery, comparing a range of biological markers with the ultimate aim of monitoring or predicting postoperative complications has not yet been extensively researched. The aim of this clinical pilot study was to test the hypothesis that lower limb orthopaedic surgery results in changes to coagulation, non-specific markers of inflammation (primary objective) and selective clinical outcome measures (secondary objective).

Methods

Test subjects were scheduled for elective total hip replacement (THR) or total knee replacement (TKR) orthopaedic surgery due to osteoarthritis (n = 10). Platelet counts and D-dimer concentrations were measured to assess any changes to coagulation function. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured as markers of non-specific inflammation. Patients were monitored regularly to assess for any signs of postoperative complications, including blood transfusions, oedema (knee swelling), wound infection, pain and fever.

Results

THR and TKR orthopaedic surgery resulted in similar changes of coagulation and non-specific inflammatory biomarkers, suggestive of increased coagulation and inflammatory reactions postoperatively. Specifically, THR and TKR surgery resulted in an increase in platelet (P = 0.013, THR) and D-dimer (P = 0.009, TKR) concentrations. Evidence of increased inflammation was demonstrated by an increase in CRP and ESR (P ≤ 0.05, THR and TKR). Four patients received blood transfusions (two THR and two TKR patients), with maximal oedema, pain and aural temperatures peaking between days 1 and 3 postoperatively, for both THR and TKR surgery. None of the patients developed postoperative infections.

Conclusions

The most noticeable changes in biological markers occur during days 1 to 3 postoperatively for both THR and TKR surgery, and these may have an effect on such postoperative clinical outcomes as oedema, pyrexia and pain. This study may assist in understanding the postoperative course following lower limb orthopaedic surgery, and may help clinicians in planning postoperative management and patient care.     

经皮松解髌外侧支持带结合关节镜下清理治疗髌股骨关节炎

目的:探讨经皮松解髌外侧支持带结合关节镜下关节清理术治疗髌股骨关节炎的疗效。方法:对2008年4月~2010年10月该院采用经皮松解髌外侧支持带结合关节镜下关节清理术治疗髌股骨关节炎并获得随访的患者进行门诊随访。采用Lysholm膝关节评分标准和对患者下蹲时膝前痛采用疼痛视觉模拟评分(VAS)法进行评价。结果:术前与术后6个月,术前与术后1年Lysholm评分和VAS评分比较存在显著性差异(P<0.01),术后6个月与术后1年Lysholm评分和VAS评分也存在显著性差异(P<0.01)。结论:经皮松解髌外侧支持带结合关节镜下关节清理术治疗髌股骨关节炎具有操作简单、创伤小、松解充分、疗效可靠等优点。     

全髋关节置换术的疗效评价

目的对人工全髋关节置换的病例进行分析总结,评价人工全髋置换术的疗效.方法回顾调查1995年1月～2001年6月该院进行人工全髋关节置换术152例(157髋).男73例,女89例;平均年龄56.2岁.股骨颈骨折69例,股骨头缺血性坏死47例,骨关节病32例,骨肿瘤6例,强直性脊柱炎3例.患者的情况以Harris评分为标准.对患者术前、术后和随访期间的症状、体征、X线照片进行总结评价.结果152例(157髋)患者其中5例现已死亡,失访5例,其余142例(143髋)患者随访1.5～8.0年,平均4.1年.平均Harris评分由术前的55.8分提高到术后的95.0分,最后一次随访平均Harris评分为87.1分.骨水泥反应3例,下肢深静脉栓塞2例,伤口感染3例,髋关节脱位4例,股骨骨折3例,疼痛24例,下肢不等长2例.结论全髋关节置换术作为髋关节重建的一种有效方法,可为患者解除疼痛,恢复髋关节功能,提高生活质量.     

晚期骨关节炎患者关节软骨细胞中HIF-1α和VEGF的表达

目的 研究低氧诱导因子1α(HIF-1α)和血管内皮生长因子(VEGF)在晚期骨关节炎(OA)患者关节软骨细胞中的表达,初步探讨HIF-1α在OA发病机制中的作用.方法 选取18例晚期膝骨关节炎(KOA)接受全膝关节置换术患者的膝关节软骨组织标本,根据取材部位分为KOA负重区组(磨损较重的股骨内髁)和KOA相对非负重区组(磨损较轻的股骨外髁);另选取5例因股骨近端或股骨干肿瘤而截肢患者的正常膝关节软骨组织标本作为对照.HE和SaFRanin O染色下进行Mankin整体评分比较各组关节软骨组织退变程度;免疫组织化学染色检测关节软骨细胞HIF-1α和VEGF表达,比较各组HIF-1α和VEGF阳性细胞计数.结果 KOA负重区组Mankin整体评分为(12.36±0.84),显著高于KOA相对非负重区组的(7.23±0.32)和对照组的(0.88±0.15)(P＜0.05).免疫组织化学染色显示,KOA负重区组关节软骨细胞HIF-1α和VEGF阳性细胞计数分别为4.81±0.62和5.67±0.32,均显著高于KOA相对非负重区组和对照组(分别为2.37±0.68、4.87±0.33和0.78±0.14、2.02±0.45)(P＜0.05).结论 晚期OA患者关节软骨细胞中HIF-1α和VEGF蛋白表达明显增加.提示上调靶基因VEGF表达是HIF-1α在OA发病中可能的调节机制.     

一氧化氮在突出腰椎间盘中的表达

目的：探讨一氧化氮（NO）在腰椎间盘退变及腰椎间盘突出症引起的坐骨神经痛发生中可能起到的作用。方法：测定25例腰椎间盘突出症患者手术取出的髓核组织中一氧化氮，一氧化氮合酶（NOS）的含量，以5例新鲜尸体的腰椎间盘髓核组织作为正常对照。对患者坐骨神经痛的程度以Dallas疼痛调查表作评分。结果：在腰椎间盘髓核组织中测得NO与NOS的存在，患者组含量明显高于正常对照组（P＜0．01），NO的含量与疼痛程度有相关性。结论：在腰椎间盘退变及腰椎间盘突出症引起的坐骨神经痛的发生中，一氧化氮可能起到某种重要作用。