髌股关节退行性病变的摄影方法学研究

目的 探讨髌股关节多角度侧位投照方法的临床价值.方法 收集50例膝关节疼痛的患者,分别采取180°、135°、90°膝关节屈伸角度侧位等多角度髌股关节X线摄影,比较髌股关节退行性病变的X线表现.结果 多角度髌股关节侧位投照显示,髌骨后缘关节面增生毛糙50例,股骨滑车面增生硬化及髌股关节间隙变窄43例,胫股关节间隙变窄23例,髌骨同定6例,而常规位置阳性显示率较低.2种投照摄影方法比较,股骨滑车、髌骨后缘、髌股关节间隙及髌骨活动范围等部位显示率差异有统计学意义(P＜0.05).多角度投照方法对观察股骨滑车面、髌骨关节面、髌骨移动范围、髌股和胫股关节间隙以及确定髌骨高位等退变特征有明显优势.结论 多角度髌股关节侧位投照是一种相对客观的显示髌骨位置及髌股关节间隙的X线摄影方法,可在临床检查中广泛使用.     

手舟状骨X线DR投照体位探讨

目的：探讨舟状骨显示较为理想的X线DR投照体位,提高平片对舟状骨骨折的诊断准确性,降低舟状骨骨折并发症的发生率。方法：选取健康志愿者2例（男女各1例）,分别对腕关节采用不同体位进行投照。根据舟状骨显示情况对投照体位进行评分,比较各投照体住对舟状骨的显示情况。另选取志愿者6例．进一步验证上述预实验所优化的投照体位。结果：舟状骨握拳尺偏位、旋前60°和旋后45°斜位片及侧位片可以从不同角度显示舟状骨。结论：舟状骨握拳尺偏位、旋前60°和旋后45°斜位片及侧位相结合是用于评价舟状骨骨折较为理想的X线投照体位。     

悬吊防护屏对介入医师最佳防护方案的体模研究

目的：探讨悬吊防护屏规格及摆放位置对介入手术中第一及第二术者辐射防护效果,为选择悬吊防护屏最佳辐射防护方案提供科学依据。方法在第一及第二术者站位,从地面20 cm至180 cm处,每隔20 cm放置一个个人计量仪。投照体位选择正位与左侧位。悬吊防护屏为铅玻璃(简称玻璃式)与铅玻璃下接铅橡胶皮(简称混搭式)两种。防护屏摆位分别为靠近术者、远离术者、在术者左侧及贴近球管4种。测量2种投照体位下,不同防护屏规格与摆位在第一及第二术者位9个高度的实时辐射剂量率,计算剂量屏蔽率。结果两种防护屏防护效果接近,以玻璃式略优。对于第一术者,正位投照时以近术者摆位的防护效果最佳,侧位投照则以术者左侧摆位的防护效果最好;对于第二术者,正及侧位投照均以近术者摆位防护效果最优。在最佳摆位情况下：正位投照时第一术者在120 cm高度、侧位投照时第一及第二术者各高度仍可检测到较高的辐射剂量率;第一与第二术者总体接受的辐射剂量接近;第一术者的剂量屏蔽率除正位120 cm高度稍低(玻璃式为60.11%,混搭式为39.89%)外,其余各点均高达93%以上,第二术者剂量屏蔽率为57%~97%;侧位屏蔽率整体略高于正位屏蔽率。结论两种防护屏防护效果接近,均能取得较好的防护效果,但正位投照时第一术者的120 cm高度及侧位投照时2位术者的各高度辐射剂量率仍相对较高,需加强对120 cm高度的辐射防护,并尽量少用侧位投照。     

悬吊防护屏对介入医师最佳防护方案的体模研究

目的：探讨悬吊防护屏规格及摆放位置对介入手术中第一及第二术者辐射防护效果,为选择悬吊防护屏最佳辐射防护方案提供科学依据。方法在第一及第二术者站位,从地面20 cm至180 cm处,每隔20 cm放置一个个人计量仪。投照体位选择正位与左侧位。悬吊防护屏为铅玻璃（简称玻璃式）与铅玻璃下接铅橡胶皮（简称混搭式）两种。防护屏摆位分别为靠近术者、远离术者、在术者左侧及贴近球管4种。测量2种投照体位下,不同防护屏规格与摆位在第一及第二术者位9个高度的实时辐射剂量率,计算剂量屏蔽率。结果两种防护屏防护效果接近,以玻璃式略优。对于第一术者,正位投照时以近术者摆位的防护效果最佳,侧位投照则以术者左侧摆位的防护效果最好;对于第二术者,正及侧位投照均以近术者摆位防护效果最优。在最佳摆位情况下：正位投照时第一术者在120 cm高度、侧位投照时第一及第二术者各高度仍可检测到较高的辐射剂量率;第一与第二术者总体接受的辐射剂量接近;第一术者的剂量屏蔽率除正位120 cm高度稍低（玻璃式为60．11%,混搭式为39．89%）外,其余各点均高达93%以上,第二术者剂量屏蔽率为57%～97%;侧位屏蔽率整体略高于正位屏蔽率。结论两种防护屏防护效果接近,均能取得较好的防护效果,但正位投照时第一术者的120 cm高度及侧位投照时两位术者的各高度辐射剂量率仍相对较高,需加强对120 cm高度的辐射防护,并尽量少用侧位投照。     

髋关节改良侧位摄影的实际应用

目的 设计一种既操作简便又与常规髋关节侧位同样拍摄效果的新体位.方法 采用不同摄影角度对骨骼模型进行X线摄影,测量股骨头、颈充分显示时中心线倾斜角度和骨骼模型倾斜角度,并对头、颈显示情况评分;对30例髋关节X线摄影患者加照新侧位,并与常规侧位的实际可操作性和图像质量进行对比.结果 模拟摄影得出中心线向头侧倾斜35°~45°,身体冠状面与探测器角度60°~70°,评分为3分;新侧位具有可行性,对关节面、间隙显示率均为96.7%,股骨头、颈均为100%,大粗隆为80%,小粗隆为100%.结论 改良髋关节侧位摄影方法同样可以显示股骨头、颈和其余诸组成骨情况.     

实用投照角度在缺血性脑血管病介入检查及治疗中的应用

目的 探讨缺血性脑血管病DSA检查及介入治疗过程中能够清晰显示血管病变的最佳实用投照角度,为其影像诊断及介入治疗提供精确图像数据信息.方法 通过对随机抽取的1 000例缺血性脑血管病患者全脑血管造影或介入治疗图像进行分析,得出被选择血管的最佳实用投照角度.本组病例均对双侧锁骨下动脉、双侧椎动脉、双侧颈内动脉起始段及颅内段等相关血管进行常规正侧位DSA图像采集,有针对性地进行斜位投照.结果 基底动脉狭窄病变的最佳实用投照角度为向足侧斜(CAUD)28°±5°;椎动脉颅内段狭窄病变的最佳实用投照角度为右前斜位(RAO)25°±3°或者左前斜位(LAO)25°±3°;右椎动脉起始段狭窄病变的最佳实用投照角度为LAO 20°±5° 向头侧斜(CRAN)15°±5°;左椎动脉起始段狭窄病变的最佳实用投照角度为RAO 20°±5°;右侧锁骨下动脉起始段狭窄病变的最佳实用投照角度为RAO 40°±7° CAUD 20°±7;左侧锁骨下动脉狭窄病变的最佳实用投照角度为LAO 50°±6°;大脑中动脉M1段近端的最佳投照角度为RAO 15°±5°或者LAO 15°±5°;大脑中动脉M1段靠近分叉处狭窄病变的最佳实用投照角度为LAO 25°±5°或者RAO 25°±5°.结论 应用最佳实用投照角度,能够清晰显示目标血管狭窄病变的形态、程度等信息,为介入治疗提供最佳的工作位置,有助于缺血性脑血管病的影像诊断和介入治疗.     

头颅汤氏位不同投照角度成像效果比较

 目的 探讨头颅汤氏位不同投照角度对不同头型患者照片显示效果的影响.方法 根据头颅指数选取长、中、短3例头型头颅骨骼标本, 分别使用不同角度进行投照,对比成像效果选取最佳的头颅汤氏位显示角度.对132例头颅外伤需要拍摄头颅汤氏位患者,根据头颅指数,分为长头型组、中头型组及短头型组,分别使用传统投照角度以及先期头颅标本投照时得到的头颅汤氏位最佳显示角度分别进行投照.结果 头颅骨骼标本汤氏位显示最佳角度:长头型以35°,中头型以30°,短头型以20°进行投照比较适宜.应用于132例头颅外伤患者的汤氏位同时验证了这一结果.结论 头颅汤氏位的成像应根据头型不同选取不同的投照角度.     

X线检查在新生儿气腹的应用及诊断

目的探讨腹部立位片、床旁胸腹联合仰卧前后位及仰卧水平投照侧位片在新生儿气腹中的应用及诊断。方法回顾性分析28例新生儿气腹的投照体位、方法及X线表现。结果 28例气腹患者中,11例仰卧前后位即可确诊,3例腹部仰卧前后位加水平投照侧位片后确诊,1例腹部仰卧位加拍腹部立位片后确诊。8例仅采用腹部立位检查的患儿及5例仅采用腹部水平侧位投照的患儿均能明确诊断。结论腹部立位片、床旁胸腹联合仰卧前后位及及仰卧水平投照侧位片的结合有利于气腹的检出,在指导临床的治疗上具有重要的应用价值。     

心血管造影中应用角度投照的初步体会

在心血管造影中应用常规的互成直角的双向投照有时还不能全面地显示重要的病理解剖。Kattan(1),Stein(2),Elliott,Bargeron(3)和太田（4）等分别提出头足向角度投照，瓣孔轴位，肝锁位等成角投照的方法，对显示肺动脉主干及分叉部，左冠动脉主干，主动脉瓣和二尖瓣孔，四个心腔相互分开投影显示房间隔和室间隔缺损等，较常规的投照位置有明显的优点，上海市胸科医院在近半年中，参考了上述作者提出的各种方法，根据我们实际条件作了适当的修改后，进行了41例各种位置的角度投照，其中包括头足向正位角度投照用于法乐氏四联症30例，右心室双出口2例，二尖瓣关闭不全1例，左前斜位头足向角度投照用于选择性左侧冠状动脉造影5例，主动脉窦瘤伴室间隔缺损1例，多数取得了较常规正侧位更好的诊断效果。     

改善腰骶关节照片质量的方法

要获得一张满意的腰骶关节侧位片甚难,因为每个病人腰骶关节平面都有其独特的角度,所以摄片时必须予以矫正。常用的投照技术是投照者必须确定病人的脊椎是否平行于台面。其方法是触摸病人每个腰椎的棘突并在其间画一假想线,如果该线平行于台面,则脊椎是平直的。反之,投照者必须用可透过射线的物体垫平脊椎;或者倾斜中心线以矫正腰骶关节间隙的角度。多数病人需要矫正。因为在一般情况下肩部和髋部的宽度是不等的,致使脊椎向下弯曲有些病人不需调整中心线,有些则需向尾侧倾斜3～25°,还有的需向头侧倾斜25°左右。摄好每一张腰骶关节侧位片的关键在于确定腰骶关节的角度。如有需要,曝光前调整球管的方向和角度则是必须的。作者提出下面简单易行的方法:     

The radiological evaluation of multiple pin fixation of the femoral head

Following pin fixation of the femoral neck, extrusion of a pin tip into the joint space cannot be excluded with conventional bi-plane radiography. A per-cervical pin was allowed to extrude from the head of a dried femur. Anteroposterior and lateral photographs and roentgenograms of this preparation, simulating corresponding intra-operative radiology, demonstrated misleadingly that the pin tip was wholly within the head. Careful intra-operative and post-operative screening is considered important to detect unwanted joint penetration and so avoid avascular necrosis and late degenerative change.     

The widened teardrop distance: a plain film indicator of hip joint effusion in adults

The teardrop distance is defined as the distance from the lateral margin of the pelvic teardrop to the most medial aspect of the femoral head as seen on anteroposterior pelvic radiographs. The structure responsible for the teardrop is the anteroinferior portion of the acetabular fossa with contributions from the ischium and from the superior pubic ramus. Anteroposterior pelvic radiographs of 10 patients with documented cases of unilateral hip effusion were retrospectively evaluated for teardrop distance widening on the affected side. Proof of the presence of hip effusion was based on the results of percutaneous hip joint aspirations as described in the patient's medical records. A teardrop distance widening of 1 mm or more was always consistent with hip joint fluid. In addition, radiographs from 20 patients with no known hip abnormalities were reviewed as a control population. These showed side-to-side symmetry in 16 cases (80%) and widening of less than 1 mm in the remaining four cases (20%). Thus, hip joint effusion in adults can be accurately diagnosed from plain radiographs in the presence of a teardrop asymmetry of 1 mm or more and in the absence of degenerative joint disease.     

Internal fixation of femoral head fractures (Pipkin I) using hip arthroscopy

A hip arthroscopy technique for the reduction and internal fixation of a displaced femoral head fracture is presented. Open treatment is often required for femoral head fractures. However, it is shown below how large fragments of a femoral head fracture-dislocation were reduced and internally fixated using hip arthroscopy. This was performed in the supine position using skeletal traction. The accessory distal anterior portal was used for internal fixation when a hip was positioned in abduction with external rotation. A satisfactory outcome was reported. Recovery was immediate and cosmetics were excellent. We conclude that hip arthroscopy is a valuable option for managing femoral head fracture-dislocations (Pipkin I). Level of evidence V.     

Intraprosthetic dislocation: a potentially serious complication of dual mobility acetabular cups

Though dual mobility cups have gained growing popularity as a solution for instability in total hip replacements, these promising devices are subject to a specific implant failure mode, named intraprosthetic dislocation. We present the case of a patient sustaining such an adverse event. The planned revision surgery was postponed 12 months due to a severe heart condition, allowing a rare opportunity to document the natural history of this unusual complication. The small femoral head was found dislodged in the superior part of the metallic shell and had remarkably lost its sphericity. Severe metallic debris and granuloma were found in the proximal femoral region, associated with major periprosthetic bony and soft tissue damage. Surgeons, radiologists, and general practitioners should be aware of this specific complication, its incidence (almost 5 %) and mechanisms (femoral neck to mobile polyethylene insert impingement, leading to rim fatigue and wear of the insert at the capturing area). Diagnosis is mainly based on anteroposterior and modified Lowenstein lateral radiographs of the hip, as an eccentric position of the small femoral head, lying against the concave inner surface of the shell. Prompt component revision should be planned, since delayed management could lead to severe irretrievable damages.     

The relationship of lateral anatomic structures to exiting guide pins during femoral tunnel preparation utilizing an accessory medial portal

Anatomic reconstruction of the anterior cruciate ligament through an accessory medial portal has become increasingly popular. The purpose of this study is to describe the relationship of guide pin exit points to the lateral anatomic structures when preparing the anterior cruciate ligament femoral tunnel through an accessory medial portal. We utilized seven fresh frozen cadaveric knees. Utilizing an anteromedial approach, a guide wire was placed into the center of each bundle’s footprint. Each guide wire was advanced through the lateral femoral cortex. The guide pins were passed at 90, 110, and 130° of knee flexion. The distances from each guide pin to the closest relevant structures on the lateral side of the knee were measured. At 90° the posterolateral bundle guide pin was closest to the lateral condyle articular cartilage (mean 5.4 ± 2.2 mm) and gastrocnemius tendon (mean 5.7 ± 2.1 mm). At 110° the posterolateral bundle pin was closest to the gastrocnemius tendon (mean 4.5 ± 3.4 mm). At 130° the posterolateral bundle pin was closest to the gastrocnemius tendon (mean 7.2 ± 5.5 mm) and lateral collateral ligament (mean 6.8 ± 2.1 mm). At 90° the anteromedial bundle guide pin was closest to the articular cartilage (mean 2.0 ± 2.0 mm). At 110° the anteromedial bundle pin was closest to the articular cartilage (mean 7.4 ± 3.5 mm) and gastrocnemius tendon (mean 12.3 ± 3.1 mm). At 130° the AM bundle pin was closest to the gastrocnemius tendon (mean 8.2 ± 3.2 mm) and LCL (mean 15.1 ± 2.9 mm). Neither guide pin (anteromedial or posterolateral bundle) put the peroneal nerve at risk at any knee flexion angle. At low knee flexion angles the anteromedial and posterolateral bundle guide pins closely approximated multiple lateral structures when using an accessory medial arthroscopic portal. Utilizing higher flexion angles increases the margin of error when preparing both femoral tunnels. During preparation of the anterior cruciate ligament femoral tunnel through an accessory anteromedial portal the tunnels should be drilled in at least 110° of knee flexion in order to move guide pin exit points away from important lateral knee structures.     

Reliability of ultrasonography in the follow-up of hip dysplasia in children above 2 years of age

PURPOSE: The aim of the present study was to assess whether ultrasonography (US) was reliable in the follow-up of children above 2 years of age who had previously been treated for congenital or developmental hip dislocation or dysplasia (HD). MATERIAL AND METHODS: As part of the routine follow-up, we examined 53 children (106 hips), aged 2-12 years (mean 6 years). Using US, the coverage of the femoral head was assessed by the distance from the lateral tangent of the ossified femoral head to the lateral bony acetabular rim (lateral head distance, LHD). The corresponding distance was measured on radiographs (LHDR). The radiographic femoral head coverage was assessed by the migration percentage (MP) and the center-edge (CE) angle. RESULTS: We found a good accordance between sonographic LHD and the radiographic parameters MP and CE in all age groups, indicating that femoral head coverage was reliably assessed by US. There was also a high correlation between LHD and LHDR (r=0.85). All hips with subluxation were detected by US. In 11 hips that appeared normal on US, but with dysplasia or uncertain findings by radiography, the condition spontaneously normalized in 9 out of 9 examined hips with further follow-up. CONCLUSION: Because a reliable assessment of the hip is obtained, we recommend that US should be used as the primary imaging technique in the routine follow-up of children above 2 years of age with previous HD. Radiography should be omitted when US shows normal findings and is only needed when the US LHD is above the upper normal limit or the hip looks abnormal or suspicious by subjective evaluation.     

Radiographic landmarks for tunnel placement in reconstruction of the medial patellofemoral ligament

Purpose

To verify the findings of previous studies in confirming radiographic landmarks for the femoral attachment of the medial patellofemoral ligament (MPFL), but also to define radiographic landmarks for the patellar attachment. Assess the effect of limb rotation upon these radiographic landmarks.

Methods

The medial patellofemoral ligament was identified in ten fresh-frozen human cadaveric knees. A headed pin was used to mark the centre of the femoral and patellar attachments. True lateral radiographs were performed followed by lateral radiographs in 10° and 20° of internal and external rotation. Posterior-anterior and proximal?Cdistal position of the headed pin was evaluated.

Results

The femoral attachment averaged 3.8?±?5.0?mm anterior to the posterior femoral cortical line and 0.9?±?2.4?mm distal to the perpendicular line intersecting the posterior aspect of Blumensaat??s line. The patellar attachment averaged 7.4?±?3.5?mm anterior to the posterior patellar cortical line, 5.4?±?2.6?mm distal to the perpendicular line intersecting the proximal margin of the patellar articular surface. There was a significant relationship between limb rotation and distance of femoral and patellar attachment from the posterior cortical line (P?<?0.0001 and P?<?0.0002 respectively).

Conclusion

Radiographic landmarks for the femoral attachment of the MPFL identified in this study are comparable with other recent work. This study describes new radiographic landmarks for the patellar attachment of the MPFL and highlights that it is essential to acquire true lateral radiographs if these radiographic landmarks are to be interpreted accurately.     

经皮动力髋螺钉治疗股骨转子间骨折

目的总结应用动力髋螺钉（DHS）经皮固定股骨转子间骨折的初步经验。方法自2003年5月应用DHS经皮固定股骨转子间骨折15例。其中男10例，女5例；年龄65～80岁，平均71岁，，先将插入克氏针的瞄准器放在髋关节的前方，在C形臂监测下，使克氏针位于股骨头的中央，且瞄准器的股骨部分紧贴股骨的外缘。另将1枚导针经皮沿克氏针指示的方向打入股骨头．在导针下做一小切口，切口长2.8～3，5cm，拧入拉力螺钉。拔出导针将动力髋接骨板沿肌层插入，将导针穿过接骨板的套轴重新插入拉力螺钉内，并按常规方法将套轴套在螺钉的尾部。手术时间45～80min，平均55min，术中出血100～200ml，无一例需术中输血。结果2例伤口表浅感染，2例发生下肢深静脉血栓，但无肺栓塞发生。骨折术后3～4个月全部愈合，随访时间9～13个月，3例髋关节伸屈轻度受限，余皆正常。结论经皮DHS治疗股骨转子间骨折手术时间短，出血少，术后康复快，是一个很有前途的治疗方法。     

股骨颈骨折内固定治疗的生物力学研究进展

随着交通事故的增多和人口的老龄化,股骨颈骨折患者逐年增多。内固定术后易出现股骨头缺血性坏死、骨不连和股骨颈短缩等并发症。近年来随着髋部骨折生物力学研究的深入和内固定器械的不断发展,固定方式由常规的3枚空心拉力螺钉倒"品"字固定,演变至不同数目、不同角度的螺钉固定,以及通过髓内系统、钉板结合系统固定,股骨颈骨折的治疗效果取得了一系列进展。本文就近年来国内外有关股骨颈骨折内固定治疗的生物力学研究作一综述。