高能量Pilon骨折的手术治疗

目的探讨Pilon骨折的适宜手术方法、最佳手术时机及其手术疗效。方法回顾性分析1998至2004年进行手术治疗的38例单侧胫骨Pilon骨折病例，38例中9例行切开复位三叶型钢板内固定，26例行有限切开内固定并辅以外固定，其中应用外固定支架者24例、辅以石膏托者2例。术后平均随访30．2个月。结果采用Mazur评分系统评估手术疗效，38例患者中，优28例，良8例，可2例。术后3例出现创面不愈合，4例发生感染，1例骨折延迟愈合，4例发生关节退行性变。结论正确选择手术时机，根据骨折类型和条件灵活选择固定方式是取得良好手术效果的关键。     

Pilon骨折手术治疗方法选择

目的 探讨几种Pilon骨折手术方法的适应证及效果.方法 1994年1月至2006年1月期间共手术治疗Pilon骨折54例(男36例,女18例);年龄17～69岁(平均36岁);开放性骨折15例、闭合性骨折39例;Ruedi-AllgowerⅠ型9例、Ⅱ型15例、Ⅲ型30例;AO分型B3/C1型8例,C2型17例,C3型29例.采用闭合复位或有限切开复位加外固定架治疗37例,切开复位、钢板螺钉内固定17例.结果 16例失去随访,38例获1年以内随访,17例获1年以上随访,平均随访时间36个月(6～60个月);骨折全部愈合,平均愈合时间21周,5例出现内翻畸形愈合.3例伤口皮缘浅表坏死(经局部换药后痊愈),5例出现骨性关节炎表现(其中1例行踝关节置换术).Mazur评分结果,优12例,良13例,可7例,差6例.结论 Pilon骨折的治疗应根据骨折类型、软组织损伤程度选择手术方法,才能提高疗效,减少并发症.     

Pilon骨折的手术治疗体会

目的回顾性分析了治疗Pilon骨折的适宜手术方法、最佳手术时机及其手术疗效。方法对1997年至2002年接受手术治疗的52例单侧Pilon骨折患进行随访，平均年龄37．8岁，伤后至手术时间平均6．8d。骨折类型：Ⅰ型4例、Ⅱ型36例、Ⅲ型12例。40例行切开复位三叶型(或T型)钢板内固定；12例行有限切开内固定并辅以外固定，其中应用外固定支架2例，辅以石膏托10例。术后平均随访28．4个月。结果采用Mazur评分系统评估手术疗效，52例患，优43例，良6例，可3例。术后并发症包括创面不愈合4例，感染2例，延迟愈合1例和关节退行性变7例。结论正确选择手术时机，根据骨折类型和条件灵活选择固定方式是取得良好手术效果的关键。     

Pilon骨折手术治疗38例

目的探讨Pilon骨折的手术治疗时机、复位固定方法及临床疗效。方法自2008-09—2013-12共诊治闭合性Pilon骨折38例,均采用切开复位钢板内固定治疗。结果本组38例均获得随访8~24个月,平均15个月。骨折均获得愈合,骨折愈合时间8~16个月,平均10.5个月。术后浅部切口感染1例,经换药后愈合。1例皮肤坏死经换药及行皮瓣转移术后治愈。末次随访时疗效采用Johner-Wruhs评分评定：优20例,良12例,可4例,差2例。结论对于Pilon骨折,通过选择恰当手术时机、合理手术入路及骨折复位固定方法、良好的切口闭合方法可以收到较好的治疗效果。     

后Pilon骨折应用后外侧入路治疗体会

目的 :探讨后外侧入路切开复位内固定(ORIF)治疗后Pilon骨折的临床疗效。方法:自2010年2月至2013年4月,采用后外侧入路治疗17例后Pilon骨折患者,均涉及胫骨远端关节面超过20%,其中男11例,女6例;年龄29~59岁,平均43.4岁。致伤原因:11例坠落伤,4例车祸伤,2例运动损伤。根据俞光荣后方Pilon骨折的分型,Ⅰ型6例,Ⅱ型5例,Ⅲ型6例。观察骨折愈合时间、骨折复位情况及术后并发症情况,并采用AOFAS评分对其临床疗效进行评估。结果:17例患者均获得随访,时间13~24个月,平均20.5个月。后外侧切口均Ⅰ期愈合。所有病例获得骨性愈合,骨折愈合时间12~21周,平均15.2周。术后未出现切口感染、神经血管损伤、骨不连及骨折畸形等并发症。根据AOFAS评分标准,总分92.0±10.1,优14例,良2例,一般1例。结论:后外侧入路能在直视下对后Pilon骨折块进行有效复位及可靠固定,操作安全、简单,是治疗后方Pilon骨折的有效方法,值得推广。     

有限内固定结合外固定支架治疗Ⅲ型Pilon骨折疗效观察

目的回顾性分析有限内固定结合外固定支架治疗Ⅲ型Pilon骨折的临床疗效。方法本院自2007年5月到2011年2月共对42例Ⅲ型（Ruedi-Allgower分型）Pilon骨折患者施行切开复位有限内固定结合跨踝关节外固定支架治疗,其中男29例,女13例;年龄19～69岁,平均38岁。结果所有病例均随访7～25个月,平均14个月。均未发生皮肤坏死或骨不愈合。结论有限内固定结合外固定支架治疗Ⅲ型Pilon骨折疗效确切,值得临床推广应用。     

胫骨远端解剖锁定钢板治疗复杂Pilon骨折

目的 探讨胫骨远端“L”型解剖锁定钢板治疗复杂Pilon骨折的临床疗效及手术技巧.方法 对17例复杂Pilon骨折行骨折切开复位、胫骨远端“L”型解剖锁定钢板内固定、植骨术.结果 术后15例切口一期愈合,2例出现2mm的切口边缘坏死,经换药后愈合.本组随访8～18个月,平均15.5个月.骨折愈合时间14～20周,平均1...     

有限切开复位内固定结合外固定架治疗严重Pilon骨折

目的探讨有限切开复位内固定结合外固定架治疗严重Pilon骨折的临床疗效。方法回顾性分析2008 年 1 月至 2011 年 6 月河南大学淮河医院收治的 19 例 Ruedi-AllgowerⅡ、Ⅲ型 Pilon 骨折患者的临床资料,所有患者于伤后7～14 d行有限切开复位内固定结合外固定架治疗,观察手术时间、出血量、骨折愈合及并发症情况,术后12个月根据Tornetta标准进行临床疗效评价。结果手术时间50～130 min,平均手术时间70 min;术中出血量80～120 mL,平均术中出血量110 mL。所有患者获12～30个月随访,平均随访时间18.3个月。愈合时间3～16个月,平均愈合时间6.5个月。随访期间未发生螺钉松动、深部感染、骨髓炎及骨不愈合;2例切口不愈合、1例钉道感染,经清创换药及负压吸引后愈合。术后12个月临床疗效评价：优13例、良4例、可1例、差1 例。结论有限切开复位内固定结合外固定架治疗严重 Pilon 骨折能有效维持解剖复位,减少术后并发症,有利于创面与骨折愈合。     

开放性Pilon骨折治疗方法的选择及疗效探讨

目的:探讨开放性Pilon骨折的治疗方法及疗效评价。方法:回顾性分析1996年2月至2009年3月治疗126例开放性Pilon骨折患者,男72例,女54例;年龄17～65岁,平均36岁。按Ruedi-Augower分类方法,Ⅰ型28例,Ⅱ型58例,Ⅲ型40例。外固定支架结合有限内固定31例,切开复位解剖钢板内固定80例,切开复位交叉克氏针内固定15例。结果:所有患者获得随访,时间10～26个月,平均16个月。骨愈合时间8～14周,平均10周。根据踝关节评价标准,优89例,良26例,可9例,差2例,优良率达91.2%。结论:采用"个性化"治疗原则,有效避免并发症的发生且利于关节功能的恢复。     

足舟骨骨折的手术治疗

目的 探讨不同类型足舟骨骨折的手术治疗方式及临床疗效.方法 2001年5月至2009年4月采用切开复位内固定治疗14例足舟骨骨折患者,男9例,女5例;年龄19～53岁,平均36.5岁.按照骨折部位分类:背侧撕脱骨折2例,舟骨结节撕脱骨折1例,舟骨体骨折11例.舟骨体骨折按照Sangeorzan等提出的分型系统分型:Ⅰ型1例,Ⅱ型 7例,Ⅲ型3例.14例患者根据不同的骨折类型选择螺钉或钢板固定等手术方式治疗.受伤至手术时间为5～20 d,平均11.5 d. 结果 14例患者术后获12～40个月(平均25.6个月)随访.骨折愈合时间为10～15周,平均11.3周.末次随访时按美国足踝外科协会踝与后足评分评定:平均为87.6分(37～100分).随访过程中末出现内固定断裂及复位丢失.2例患者术后出现不同程度的足舟骨缺血性坏死合并距舟关节创伤性关节炎,其中1例患者足舟骨塌陷较严重,并累及后足,二期行三关节融合术. 结论 足舟骨骨折根据不同的骨折类型,采用合理的术式和恰当的内固定可以取得较好的疗效.     

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.     

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.     

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.