关节镜下骨栓腘绳肌腱结嵌入固定法重建膝前后十字韧带

目的探讨关节镜下以自体骨栓绳肌腱结嵌入固定法联合重建膝前、后十字韧带损伤的应用价值。方法2000年2月～2003年6月,采用自体骨栓绳肌腱结嵌入固定法同期联合重建前、后十字韧带损伤15例,男10例,女5例;年龄19～31岁,平均23岁;左9例,右6例。取自体绳肌腱,断端编织缝合并预张力后,在双股肌腱的中间打结嵌入骨栓并缝合固定。股骨隧道采用阶梯联合钻一次成形,呈倒置的瓶颈状。然后定位并建立前、后十字韧带的胫骨隧道。将“T”形的骨栓肌腱结嵌入瓶颈状股骨隧道内,两组肌腱缝线经胫骨隧道穿出,反复屈伸膝关节20次,在胫骨骨桥上交叉打结并缝合固定。术后患膝以支具固定在屈曲0°～30°位。结果15例患者均获得随访,随访时间5～26个月,平均9个月。膝关节功能评估采用Lysholm功能评分标准,术前平均(61.5±4.6)分,终末随访时平均(92.5±3.7)分,差异有显著性(P<0.05)。膝关节稳定,功能明显改善。结论骨栓绳肌腱结嵌入固定联合重建前、后十字韧带的方法为生物固定,避免使用高值耗材和分次手术,降低手术费用,利于术后功能康复。     

肌腱结嵌压固定保留胫骨止点的腘绳肌腱重建前交叉韧带

目的：探讨以自体骨栓肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建膝前交叉韧带的临床效果及应用价值。方法：采用自体骨栓肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建膝前交叉韧带断裂20例,男15例,女5例;年龄18～32岁,平均22岁;左、右膝各10例。取自体胭绳肌腱,保留肌腱的胫骨止点,两端编织缝合后预张。建立胫骨、股骨隧道,并制作胫骨骨桥结构,股骨隧道为内窄外宽结构。骨栓肌腱结嵌入股骨隧道内,牵引线带着肌腱结远端的腱束经股骨、胫骨隧道穿出,与胫骨止点上的肌腱交叉,在胫骨骨桥上打结并缝合固定。术后患膝以支具固定在屈曲45。位。结果：20例患者均获得随访,随访时间8—24个月,平均11个月。膝关节功能评估采用Lysholm功能评分标准,术前平均（61．5±4．6）分,终末随访时平均（92．5±3．7）分,差异有统计学意义,P〈0．05。结论：骨栓肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建膝前交叉韧带的方法为生物学固定,避免使用高值耗材,降低了手术费用,且有利于腱-骨愈合。     

肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建前交叉韧带

目的：探讨以自体骨栓肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建膝前交叉韧带的临床效果及应用价值。方法：采用自体骨栓肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建膝前交叉韧带断裂20例，男15例，女5例；年龄18～32岁，平均22岁；左、右膝各10例。取自体胭绳肌腱，保留肌腱的胫骨止点，两端编织缝合后预张。建立胫骨、股骨隧道，并制作胫骨骨桥结构，股骨隧道为内窄外宽结构。骨栓肌腱结嵌入股骨隧道内，牵引线带着肌腱结远端的腱束经股骨、胫骨隧道穿出，与胫骨止点上的肌腱交叉，在胫骨骨桥上打结并缝合固定。术后患膝以支具固定在屈曲45。位。结果：20例患者均获得随访，随访时间8—24个月，平均11个月。膝关节功能评估采用Lysholm功能评分标准，术前平均（61．5&#177;4．6）分，终末随访时平均（92．5&#177;3．7）分，差异有统计学意义，P〈0．05。结论：骨栓肌腱结嵌压固定保留胫骨止点的胭绳肌腱重建膝前交叉韧带的方法为生物学固定，避免使用高值耗材，降低了手术费用，且有利于腱-骨愈合。     

腘绳肌腱结嵌压固定法重建交叉韧带的临床应用与生物力学研究

目的探讨腘绳肌腱结嵌压固定法重建交叉韧带的可行性。方法对52例陈旧性前、后交叉韧带损伤患者在关节镜下行双股腘绳肌腱中间打结,嵌入瓶颈状股骨隧道内固定,胫骨端采用肌腱编织缝合在骨桥上打结固定,重建交叉韧带。其中前交叉韧带25例,前、后十字韧带同时重建15例,后交叉韧带12例。生物力学实验采用猪膝关节。股骨端固定分为肌腱结嵌入组(n=13)和骨髌腱骨(B PT B)介面螺钉固定组(B PT B介面钉组,n=11)。胫骨端固定分为肌腱编织缝合线在骨桥打结组(n=7)、肌腱编织缝合介面螺钉组(n=8)。进行最大拔出强度、最大位移和固定刚度等力学实验。结果术后随访49例,平均14 6个月,Lanchman试验阴性46例,阳性3例。术后Lysholm评分由术前56 7分提高到92 8分。按膝关节疗效评定标准,优46例,良3例。生物力学实验最大拔出强度肌腱结嵌入组高于B PT B介面钉组;固定刚度肌腱结嵌入组小于B PT B介面钉组;最大位移肌腱结嵌入组大于B PT B介面钉组。胫骨端固定抗拉强度和刚度骨桥打结组优于介面螺钉组。结论腘绳肌腱结嵌压固定重建交叉韧带生物力学抗拉强度能满足生理需求,方法可行;可克服位移因素,降低韧带松弛率,提高疗效。     

Guo绳肌腱结嵌压固定法重建交叉韧带的临床应用与生物力学研究

目的探讨Guo绳肌腱结嵌压固定法重建交叉韧带的可行性。方法对52例陈旧性前、后交叉韧带损伤患者在关节镜下行双股Guo绳肌腱中间打结，嵌入瓶颈状股骨隧道内固定，胫骨端采用肌腱编织缝合在骨桥上打结固定，重建交叉韧带。其中前交叉韧带25例，前、后十字韧带同时重建15例，后交叉韧带12例。生物力学实验采用猪膝关节。股骨端固定分为肌腱结嵌入组(n=13)和骨-髌腱-骨(B-PT-B)介面螺钉固定组(B-PT-B介面钉组，n=11)。胫骨端固定分为肌腱编织缝合线在骨桥打结组(n=7)、肌腱编织缝合介面螺钉组(n=8)。进行最大拔出强度、最大位移和固定刚度等力学实验。结果术后随访49例，平均14．6个月，Lanchman试验阴性46例，阳性3例。术后Lysholm评分由术前56．7分提高到92．8分。按膝关节疗效评定标准，优46例，良3例。生物力学实验最大拔出强度：肌腱结嵌入组高于B-PT-B介面钉组；固定刚度肌腱结嵌入组小于B-PT-B介面钉组；最大位移肌腱结嵌入组大于B-PT-B介面钉组。胫骨端固定抗拉强度和刚度骨桥打结组优于介面螺钉组。结论Guo绳肌腱结嵌压固定重建交叉韧带生物力学抗拉强度能满足生理需求，方法可行；可克服位移因素，降低韧带松弛率，提高疗效。     

嵌压固定法重建前交叉韧带不同肌腱移植物的选择

[目的]探讨嵌压固定法重建前交叉韧带(ACL)不同肌腱移植物的选择。[方法]采用嵌压固定法重建前交叉韧带101例,男68例,女33例。运动伤62例,交通伤22例,生活伤17例。采用绳肌腱结42例、骨栓绳肌腱结32例、带髌骨块的股四头肌腱27例。选用自体半腱肌腱和股薄肌腱,两端编织缝合预张力后在双股肌腱中间打结。将绳肌腱结内嵌入5 mm×11 mm的矩形骨栓,制成直径11 mm的骨栓肌腱结;带髌骨块的股四头肌腱全长70~80 mm,骨块11 mm×9 mm×7 mm。采用阶梯状联合钻建立股骨隧道,根据患者个体情况不同,选用自体绳肌腱结、骨栓绳肌腱结或带髌骨块的股四头肌腱,进行嵌压固定法重建ACL。将肌腱结或带髌骨块的股四头肌腱完全嵌入到瓶颈状股骨隧道内,在胫骨隧道外口分两股穿出,交叉打结固定在胫骨桥上。[结果]98例患者得到随访,膝关节稳定,功能恢复良好。按照膝关节疗效评定标准,优88例,良6例,可4例,优良率85.7%。[结论]根据患者个体情况选择绳肌腱结、骨栓肌腱结或带髌骨块的股四头肌腱,进行嵌压固定法重建ACL,生物固定、方法简便、固定可靠、创伤小、费用低。     

腘绳肌腱结嵌入固定结合双监视法解剖等长技术重建前交叉韧带

目的探讨在关节镜下采用腘绳肌腱结嵌入固定结合双监视法解剖等长技术重建前交叉韧带(ACL)的可行性及近期疗效。方法对10例ACL损伤采用自体半腱肌、股薄肌腱中间打结,股骨端嵌入挤压固定法镜下重建ACL。半腱肌腱和股薄肌腱预张力后,肌腱中间打结,测量结与肌腱的直径,备用。用双监视法解剖等长技术,建立股骨胫骨端等长点,胫骨端用肌腱相同直径的钻头建立胫骨隧道。股骨端用自制的台阶样联合钻建立隧道。股骨隧道下30mm的直径为6～8mm,股骨隧道近端为11～12mm。将肌腱从股骨隧道的近端经关节腔牵入胫骨隧道,将肌腱拉紧、膝关节屈伸活动20次,使肌腱结完全嵌入瓶颈状股骨隧道内。将4股肌腱从胫骨隧道和其下方10mm处分别穿出,交叉打结并缝合固定在骨桥上。结果10例随访5～12个月,平均9个月。根据Lysholm膝关节功能评分,术前评分:20～45分,(29.80±12.79)分;术后半年评分:81～91分,(86.80±3.46)分(t=20.93,P<0.01)。结论腘绳肌腱结嵌入固定结合双监视法解剖等长技术重建ACL具有定位准确、手术操作简单、韧带等长重建、生物固定、不用内固定耗材、节约手术费用、疗效确切等优点,值得临床推广应用,尤其适用于广大部队伤病员。     

保留韧带残端的自制台阶样联合钻手术系统在腘绳肌腱结嵌入固定法重建前交叉韧带中的应用

目的探讨保留韧带残端的自制台阶样联合钻手术系统在胭绳肌腱结嵌入固定法重建前交叉韧带（ACL）中应用的可行性。方法对16例ACL损伤患者采用自体半腱肌、股薄肌腱中间打结、股骨端嵌入挤压固定法镜下重建ACL。股骨隧道采用保留韧带残端的自制台阶样联合钻手术系统建立。保留原有的ACL残端。将肌腱从股骨隧道的近端经关节腔牵人胫骨隧道,将肌腱拉紧、膝关节屈伸活动20次,使肌腱结完全嵌入瓶颈状股骨隧道内。将4股肌腱从胫骨隧道和其下方10mm处分别穿出,交叉打结并缝合固定在骨桥上。结果16例均获随访,时间6～18（10±3．85）个月。根据Lysholm膝关节功能评分：术前20-55（34．36±11．16）分;术后6个月81～97（89．44±4．62）分,术前术后比较差异有显著性（t=26．07,P〈0．01）。未见滑膜炎、韧带断裂、活动明显受限等并发症。结论保留韧带残端的自制台阶样联合钻手术系统具有台阶样股骨隧道建立准确、手术操作简单、使用方便等优点,值得临床推广应用。     

关节镜下股骨双隧道双束腘绳肌肌腱重建后十字韧带

目的探讨关节镜下采用可吸收界面螺钉固定双束腘绳肌肌腱,股骨双隧道重建后十字韧带(PCL)的方法和疗效。方法24例PCL损伤患者,年龄为17￣42岁,平均32岁。在关节镜下应用可吸收界面螺钉固定,股骨双隧道胫骨单隧道双束腘绳肌肌腱重建PCL。3股半腱肌肌腱在屈膝15°￣30°位拉紧、固定,重建前外侧束;3股股薄肌肌腱在屈膝60°￣70°位拉紧、固定,重建后内侧束。结果24例患者术后随访6￣19个月,平均9.4个月。术后膝关节活动度均在正常范围,无疼痛,无创伤性关节炎。后抽屉试验、反向Lachman试验、胫骨结节塌陷征和反向轴移试验均为阴性,术后Lysholm评分为(92.7±6.4)分,较术前(49.4±9.3)分有显著提高(t=3.12,P<0.01)。术后Tegner活动评分为(6.7±1.4)分,较术前(3.2±0.9)分有显著提高(t=3.13,P<0.01)。结论股骨双隧道胫骨单隧道双束自体腘绳肌肌腱重建PCL能够较好的重建膝关节在不同伸屈角度的稳定性。生物可降解螺钉为PCL重建的理想的内固定材料。     

肌腱结嵌压固定法重建前交叉韧带生物力学实验研究

目的探讨绳肌腱结嵌压固定法重建前交叉韧带(ACL)影响初始固定效果的相关因素及对策。方法采用猪膝关节模拟重建ACL不同术式,即绳肌腱结股骨隧道嵌压固定和胫骨端肌腱编织缝合骨桥打结固定法,与骨-髌腱-骨两端界面螺钉固定法,比较其生物力学初始固定最大拔出载荷、抗拉刚度和位移等生物力学指标。结果最大抗拉载荷肌腱结组与正常ACL组接近,无显著性差异;肌腱结组大于骨-髌腱-骨界面螺钉固定组。抗拉载荷在100N和400N时的位移两组无显著性差异。胫骨端肌腱编织缝合骨桥上打结固定组最大抗拉载荷大于BPTB界面螺钉固定组和肌腱编织缝合后界面螺钉固定组。抗拉刚度正常ACL组>骨-髌腱-骨组>绳肌腱结组。最大位移正常ACL<髌腱骨组<肌腱结组。结论绳肌腱结嵌压固定法抗拉强度和刚度完全可以满足重建后ACL的生理需求;术中克服位移因素,是有效防止ACL重建术后松弛的关键。     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.