股骨干骨折术后钢板螺钉松动折断原因探讨

我科自2001年9月至2006年3月共收治24例股骨干骨折术后钢板螺钉松动折断患者,其中螺钉松动11例,钢板螺钉断裂13例,现分析报告如下。1临床资料本组24例,男16例,女8例;年龄18~54岁,平均32岁。手术后至钢板螺钉松动折断时间2.5~13个月,平均4.5个月。骨折按AO分型,A 3型2例,B 1型4例,B 2型3例,B 3型4例,C 1型6例,C 2型2例,C 3型3例。内固定情况:普通钢板7例,加压钢板12例,角钢板2例,解剖型钢板2例,DCS 1例。钢板螺钉在前侧1例,前外侧8例,外侧15例。本组病例中2例骨折断端对位对线尚好,患者拒绝再次手术,予管型石膏外固定。22例入院后再次行…     

四肢锁定钢板螺钉取出困难的原因分析及对策

目的对我院行四肢锁定钢板螺钉取出术中出现螺钉取出困难的原因进行分析,并提出解决措施。方法自2009年3月至2013年10月,我院所进行的206例四肢锁定钢板螺钉取出术中,有14例螺钉取出困难,发生率为6.8%。其中男性11例,女性3例,年龄20~40岁,平均年龄28.8岁。骨折部位:分别为股骨干、股骨近端、股骨髁上、胫骨多段、肱骨近端。螺钉所在的位置:骨干区13例,干骺段1例。内固定的时间:12~35个月。对于滑丝或无法拧动的螺钉,先使用工业钻头将滑丝的螺钉帽磨掉,取出接骨板后,使用大力钳钳住螺钉的裸露部分慢慢拧出螺钉,如无法拧动,用空心的断钉取出钻作螺钉周围松解,最终套入断钉取出器将螺钉取出。结果 8枚螺钉没有滑丝但不能拧动,采用断钉取出器取出,有10枚螺钉发生滑丝,使用大力钳完成取出术,有1例3枚螺钉放弃取出。在1枚胫骨螺钉取出术中,将包裹钉尖部分的骨皮质一起凿出,检查发现骨质牢固长入螺钉尖部的凹槽,使螺钉无法转动。术后随访6~14个月,平均9个月,无术口感染及再骨折发生。结论对于锁定钢板螺钉取出困难,主要发生在骨皮质区的螺钉,除螺钉滑丝外,部分原因为皮质骨牢固长入螺钉尖部的3个凹槽,使螺钉根本无法转动。因此在初次植入手术时,螺钉尖部应穿透对侧骨皮质两个螺纹,防止骨质长入钉尖的凹槽内。充分的术前阅片评估,完善的术前准备,都有助于四肢锁定钢板螺钉的顺利取出。     

胸腰段钉棒系统内固定术后断钉原因分析

目的分析椎弓根螺钉术后断钉的原因。方法分析45例胸腰段骨折患者术后10例发生断钉的骨折类型、术中操作、产品设计、螺钉负荷、椎弓根螺钉置入情况、术后活动情况以及术后预防措施。结果 10例术后断钉患者中,术后1个月复查时发现断钉2例,术后4~6个月复查时发现断钉7例,术后30个月复查时发现断钉1例。T11断钉1例,T12断钉4例,L1断钉3例,L2断钉2例。未减压24例(其中含Chance骨折3例)中断钉4例,减压未植骨5例中断钉3例;减压植骨16例(其中含骨折脱位型4例)中断钉3例。45例中椎弓根螺钉预留骨界面过长4例中断钉3例。结论骨折类型与植骨、术中操作、撑开后螺钉负荷过大、术后活动不当、内固定取出过迟为螺钉断裂的主要原因。     

钢板上螺钉取出困难的处理策略

目的探讨钢板上螺钉取出困难的处理策略。方法回顾分析2004年1月-2014年5月47例钢板上螺钉取出困难患者临床资料。男30例,女17例;年龄16~58岁,平均34岁。内固定术后至取出手术时间10个月~20年,平均22个月。内固定部位:上肢25例,下肢22例。术中1枚螺钉取出困难18例,2枚15例,3枚9例,4枚5例。钢板类型:普通钢板15例,锁定钢板32例;不锈钢钢板10例,钛合金钢板37例。结合螺钉取出困难原因及螺钉、钢板、切口和骨质等具体情况,按照先简单后复杂原则,选择不同方法取出螺钉和钢板。结果螺钉和钢板均完全取除,术中无医源性骨折、神经血管损伤发生。手术时间65~270 min,平均125 min;手术出血量80~775 m L,平均157 m L;术后引流量20~250 m L,平均92 m L。术后切口Ⅰ期愈合39例,延期愈合8例。患者均获随访,随访时间3~24个月,平均10个月。术后无感染和再骨折发生。结论对于钢板上螺钉取出困难有多种处理方法,每种方法均有适应证。术前充分准备,掌握各种处理方法和熟悉其适应证,术中根据具体情况选择相应方法,可顺利取出螺钉和钢板。     

重建钢板螺钉在枕颈融合中的应用

目的：探讨重建钢板螺钉在枕颈融合中的应用效果。方法：回顾分析应用重建钢板螺钉固定行枕颈融合5例病人的临床资料和手术效果。结果：术中、术后无并发症发生，经5～18个月的随访，全部病例3个月达到骨性融合，未见钢板折断、拔钉、断钉等。JOA骨髓功能评分分别提高2～5分。结论：运用重建钢板行枕颈融合固定是一种较方便、牢固、经济的方法。     

腰椎椎弓根螺钉断钉取出方法探讨

目的探讨腰椎椎弓根螺钉断钉的取出方法。方法回顾性研究安徽医科大学第二附属医院骨科从2009年7月至2015年5月在临床工作中遇到的10位患者11枚断钉的取出情况,其中男7例,女3例;年龄19~62岁,平均47岁;脊柱骨折7例,脊柱退变性疾病3例。术中尝试从简单到复杂的不同取出方法。结果所有患者断钉均完全取出,取出内固定后随访3~24个月,术后未见明显神经损伤、腰椎不稳或脊柱后凸。结论腰椎椎弓根螺钉断裂术中应尝试从简单到复杂的各种方法,尽量完全取出断钉。本文介绍的方法安全且有效。     

弹性髓内钉和钢板螺钉治疗腓骨骨折的临床对比研究

目的探讨采用弹性髓内钉和钢板螺钉治疗腓骨骨折的临床疗效。方法将2012年12月至2018年9月收治的62例胫腓骨骨折手术的患者,按照腓骨内固定手术方式不同分为弹性髓内钉组和钢板螺钉组,弹性髓内钉组31例,男21例,女10例;年龄22～75岁,平均(49.5±15.6)岁。钢板螺钉组31例,男18例,女13例;年龄24～73岁,平均(45.8±13.2)岁。对比两组患者的手术时间、术中出血量、美国足踝外科协会(American orthopaedic foot and ankle society,AOFAS)的踝与后足评分、腓骨骨折临床愈合时间、愈合率和手术后并发症发生率的情况等。结果所有患者均获随访,随访时间4～24个月,平均(15.0±3.8)个月。弹性髓内钉组:手术时间(24.5±4.6)min,术中出血量(18.2±4.5)mL,骨折临床愈合时间(2.9±0.7)个月,术后无感染发生;钢板螺钉组:手术时间(32.2±10.6)min,术中出血量(30.6±9.9)mL,骨折临床愈合时间(2.5±0.6)个月,术后3例切口局部感染;两组比较差异均有统计学意义(P0.05)。两组末次随访时踝关节功能按AOFAS的踝与后足评分标准评价,弹性髓内钉组优17例,良11例,可3例,平均(89.8±5.2)分;钢板螺钉组获优16例,良10例,可5例,平均(89.1±5.6)分;差异无统计学意义(P=0.582)。弹性髓内钉组骨折愈合率为93.5%,钢板螺钉组骨折愈合率为90.3%,两组比较差异无统计学意义(P=0.859)。结论在治疗腓骨骨折方面,弹性髓内钉比钢板螺钉具有手术时间短、手术出血量少、骨折愈合时间短和并发症少等优势,具有良好的临床应用前景。     

胸腰椎椎弓根钉内固定术后螺钉断裂的原因分析

[目的]探讨椎弓根钉棒系统术后出现断裂的原因.[方法]对2006年9月～2011年9月本院收治的胸腰椎椎弓根钉内固定手术获随访263例患者的临床资料进行回顾性分析,按照手术类型、植骨融合方式、取内固定时间等因素对椎弓根螺钉的影响进行系统分析.其中胸腰椎骨折109例,腰椎滑脱或不稳症154例.[结果]术后263例患者中12例发生断钉,断钉率4.56％.12例发生断钉者中胸腰椎骨折9例(8.2％),腰椎滑脱或不稳症3例(2％);椎间植骨3例(1.9％),后外侧植骨2例(4％),未植骨7例(11.7％);内固定术后7 ～12个月断钉2例(2.3％),12 ～18个月断钉2例(2.1％),18 ～30个月断钉8例(9.7％).[结论]胸腰椎骨折比腰椎滑脱或不稳症断钉率高;未植骨者的断钉率高于植骨融合者,椎间植骨融合者最少断钉;取内固定时间超过18个月断钉率高.因此,严格掌握手术适应证和手术时机,提高手术操作技巧,仔细规范操作,充分有效植骨融合,避免早期活动负重,以及及时取出内固定,可有效防止椎弓根螺钉断裂发生.     

重建钢板螺钉在枕颈融合中的应用

目的 探讨重建钢板螺钉在枕颈融合中的应用效果。方法 回顾分析应用重建钢板螺钉固定行枕颈融合5例病人的临床资料和手术效果。结果 术中、术后无并发症发生,经5～18个月的随访,全部病例3个月达到骨性融合,未见钢板折断、拔钉、断钉等。JOA骨髓功能评分分别提高2～5分。结论 运用重建钢板行枕颈融合固定是一种较方便、牢固、经济的方法。     

SF内固定器治疗胸腰椎骨折术后断钉原因分析

自 1 997～ 2 0 0 3年应用SF内固定器治疗胸腰椎骨折 6 8例 ,取得了满意的效果。但出现 1 2例术后断钉现象 ,断钉率为 1 7.7%。本文就其临床资料进行总结 ,探讨断钉的原因。1　临床资料6 8例胸腰椎骨折共发生断钉 1 2例 ,共 1 6枚 ,其中男 9例 ,女 3例。断钉部位 :位于T1 2 处 3枚 ,L1 处 4枚 ,L2 处7枚 ,L3 处 2枚 ,发生断钉时间最早术后 1 4周 ,最晚为术后2年 4个月 ,平均为 1年 5个月 ,大多数患者都是在取内固定物时发现螺钉断裂。本组 1 2例皆未行植骨融合术。断钉点均发生于椎弓根出口处 ,距螺纹终止 1～ 3圈处。取出断钉 1 0例 ,共…     

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.     

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.     

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.