老年股骨转子间骨折手术治疗若干问题探讨

股骨转子间骨折指发生在股骨颈关节囊外至小转子下缘之间的骨折^[1]。除部分年轻患者为高能量损伤引起外,绝大部分的转子间骨折为高龄患者的脆性骨折,该部位主要有松质骨构成,是老年性骨质疏松的好发部位;同时其近端和远端比邻骨密度相对较高的股骨颈和转子下区,是股骨近端骨质相对薄弱区域,重力在该部位产生内翻力矩,应力的相对集中也是转子间好发骨折的原因之一。此外,老年人因视觉、听觉功能下降,神经系统及运动系统综合反应能力降低,外伤概率明显增高,这也是老年人易发生转子间骨折的重要原因。     

An unusual case of pulmonary embolism after arthroscopic meniscectomy

Although the incidence of pulmonary embolism (PE) following arthroscopic knee surgery has not been well established, such occurrences place the patient at high risk. In this report we present a case of PE following arthroscopic meniscectomy. The patient was a 63-year-old woman, with no definite risk factors for PE, who underwent successful arthroscopic meniscectomy. However, on the postoperative 9th day she developed dyspnea and tachycardia. Investigations carried out in the emergency department, including EKG, echocardiography, and CT angiography, supported the diagnosis of a PE. Heparin therapy was initiated, and the patient’s condition then improved sufficiently to allow follow-up at our outpatient department.     

Massive pulmonary embolism after off-pump coronary artery bypass surgery

An 88-year-old woman developed an acute massive pulmonary embolism after off-pump coronary artery bypass surgery. She experienced dyspnea while walking on the sixth day after operation. Her chest radiograph showed pleural effusion. Initially, she was treated for heart failure due to bypass graft occlusion. A repeat echocardiogram revealed enlargement of the right ventricle. Multislice computed tomography showed a massive embolus in the pulmonary artery. Surgical embolectomy was performed, and her postoperative course was easy. Recently, the incidence of pulmonary embolism in Japanese people has been rising. In addition, widespread implementation of off-pump coronary artery bypass compromises the protective effect against pulmonary embolus after cardiac surgery. Although the incidence of pulmonary embolism after coronary artery bypass surgery is still low in Japan in comparison to that in Western countries, prophylaxis against pulmonary embolism after off-pump coronary artery surgery is becoming more important.     

非高危肺栓塞患者肺动脉CT阻塞指数与肺栓塞严重程度的相关性研究

目的探讨临床非高危肺栓塞(PE)肺动脉CTA阻塞指数(CTOI)与肺栓塞严重程度指数(PESI)及简化PESI(sPESI)评分、血清脑钠肽(BNP)的相关性。方法回顾性分析94例非高危PE患者的CTA图像、临床PESI、sPESI评分及血清BNP水平,采用Spearman相关分析判断CTOI与PESI、sPESI评分及血清BNP之间的相关性。结果 CTOI与PESI无相关性(r=0.096,P=0.357),CTOI与sPESI及血清BNP之间存在较好的相关性(r=0.278,P=0.007;r=0.634,P0.001)。结论对于临床非高危PE患者,CTOI和sPESI及血清BNP水平在反应临床严重程度上存在一致性,而与PESI并不存在相关性。     

急性肺动脉栓塞的介入治疗

目的　探讨通过介入方法治疗急性肺动脉栓塞的临床疗效。　方法　对 38例急性肺动脉栓塞的病人 ,经肺动脉造影明确诊断 ,通过旋转猪尾导管碎栓、抽吸导管抽吸和局部溶栓来开通肺动脉。观察临床症状、动脉血氧分压 (PaO2 )、肺动脉平均压 (PAPM)和肺动脉开通情况。　结果　术后症状即刻缓解 36例 ,完全开通 30例 ,与术前相比PaO2 明显升高 (P <0 0 5 ) ,PAPM明显降低 (P <0 0 5 ) ,并发脑出血 1例 ,死亡 2例 ,36例存活。　结论　介入放射学方法是诊断、治疗及预防急性肺动脉栓塞有效、微创的方法。     

手术后肺栓塞的临床特点与诊治

目的 探讨手术后肺栓塞(pulmonary embolism,PE)的临床特点与诊疗策略.方法 回顾性分析2001年1月至2010年12月51例术后PE病例的临床表现、诊治情况及转归等资料.结果 术后PE骨科患者占25.50％( 13/51),恶性肿瘤患者占45.10％ (23/51).术后1周内发病者占70.59％(36/51),其中术后第2天发病人数最多(13/51,26.92％).最常见主诉为呼吸困难、胸闷或憋气(34/51,66.67％),术后猝死也是PE的常见发病形式(18/51,35.29％).多数病例存在术前对PE危险因素评估不足,而术后出现可疑高危PE时,对床旁超声心动图的应用价值认识不足.本组术后PE的治疗仍以抗凝为主(23例,占治疗病例的79.31％),静脉溶栓3例,导管介入治疗3例.结论 PE是外科患者术后死亡的常见原因,加强防治非常重要.     

髋关节置换术治疗老年陈旧性髋部骨折

目的探讨髋关节置换技术治疗老年髋部陈旧性骨折的可行性和问题。方法回顾本组采用半髋或全髋关节置换术等方法治疗老年陈旧性骨折患者20例,其中9例为小于6个月的陈旧性骨折患者,11例为大于6个月的陈旧性骨折患者,最长时间的陈旧性骨折为144个月。通过临床资料分析总结这部分患者术前准备、患侧骨质疏松改变、术中处理以及功能恢复情况。结果全部患者顺利进行了手术,随访10～96个月,全部恢复负重行走功能,Harris髋关节评分,平均87.6分。术后髋关节功能评分与骨折陈旧时间无明显相关;大于6个月的陈旧性骨折,患髋骨质疏松明显加重;术中大粗隆截骨者术后髋关节功能评分下降。结论髋关节置换术是治疗老年髋部陈旧性骨折的可行方法,应重视术前准备和术中细节处理。陈旧时间大于6个月者是否使用骨水泥假体柄,更多取决于医师的术前计划和术中判断;应尽可能避免大粗隆截骨。     

脊柱手术后并发肺栓塞11例临床分析

目的分析脊柱手术后并发肺栓塞的临床特点,探讨早期诊断、治疗方法。方法1995年1月至2006年5月,在我院接受脊柱手术患者10993例,其中术后出现肺栓塞患者11例。回顾性分析该11例患者的临床特点及诊断、治疗方式。结果脊柱术后肺栓塞占同期我院脊柱手术总数的0．1％;出现肺栓塞的时间为术后5～14d（平均9．8d）,患者可见呼吸困难、心悸、胸痛、咯血等特征性肺栓塞症状;本组死亡5例,死亡率45．5％。早期使用肺动脉造影明确诊断、早期经肺动脉导管介入治疗可以显著降低死亡率。结论肺栓塞是脊柱手术后的严重并发症,术后1～2周是致死性肺栓塞的高危时段,死亡率高;肺动脉造影与介入治疗在早期诊断、治疗中占有重要地位。     

多排螺旋CT肺动脉造影与血浆D-二聚体水平对诊断肺动脉栓塞的意义

目的探讨多排螺旋CT肺动脉造影与D-二聚体检测水平对诊断肺动脉栓塞的价值。方法采用多排螺旋CT对34例肺动脉栓塞患者进行影像学表现与血浆D-二聚体水平的分析。结果 34例经MSCTPA诊断肺动脉栓塞的患者有30例血浆D-二聚体水平明显高于正常值,有4例阴性。结论血浆D-二聚体水平检测只能作为肺动脉栓塞初步筛选,MSCTPA是肺动脉栓塞最可靠、最直接的首选方法。     

Amplatz血栓消融术治疗大块肺栓塞——附2例报告

目的 探讨Amplatz血栓消融器治疗大块肺栓塞(PE)的可行性。方法 对2例年轻男性经溶栓无效或贻误有效溶栓时机的大块PE患者行Amplatz血栓消融术。结果 术后肺血流灌注亚急性PE患者明显改善,慢性PE再发患者略有改善。前者PaQ2由术前53．8mmHg升至67．3mmHg,2个月后升至80．0mmHg。7个月后核素肺灌注显像大致正常。后者术中症状明显减轻,术后PaO2由66．4mmHg升至83．6mmHg。3个月后,肺动脉压由53．5mmHg降至24mmHg。仅1例术中轻微左侧胸痛。结论 对大块亚急性PE患者实施Amplatz血栓消融术技术上可行,但需进一步评价。     

术前筛查下肢血栓对防止肺栓塞的意义

目的：探讨术前彩色多普勒超声（CDFI）筛查骨折患者下肢静脉血栓对防止肺栓塞的意义。方法：回顾性分析2010年1月至12月,因创伤致下肢骨折入院,拟行切开复位术的2000例患者,男1140例,女860例;年龄18～94岁,平均（54.78±21.45）岁。所有患者入院时伤肢肿胀明显,均经外敷和口服中药治疗,伤肢肿胀好转后（3～14d）,行骨折复位术,手术前1d筛查骨折患者下肢血栓,并对其临床资料（性别、年龄、骨折部位、病程）进行回顾性分析。结果：①2000例创伤骨折患者术前经CDFI筛查,证实并发深静脉血栓（deepveinthrombosis,DVT）共128例（6.4%）。血栓类型：髂-股静脉血栓52例,腘-胫静脉血栓20例,小腿肌肉静脉血栓56例。对胫静脉以上DVT72例采取溶栓治疗或放置下腔静脉滤网,溶栓有效20例,放置下腔静脉滤网17例,溶栓失败和未放置腔静脉滤网患者28例,这65例均实施了骨折复位术,另外7例采取保守治疗。1例术中发生肺栓塞,经及时溶栓治疗获得成功。小腿肌肉静脉血栓56例中51例未行特殊处理,实施了复位术;另5例行保守治疗。②DVT发生与性别无关;血栓发生最小年龄22岁,41岁以上组血栓发生率高于40岁以下年龄组;多发骨折、股骨骨折高于胫骨、腓骨骨折;血栓发生病程最短3d,病程越长,血栓发生率越高。结论：创伤骨折患者无论是否存在形成DVT的高危因素,骨折复位手术前均应常规行CDFI筛查DVT,对降低麻醉、手术风险,防止致命性肺栓塞有重要意义。     

慢性肺动脉栓塞的诊断和手术治疗(附3例报告)

目的 探讨慢性肺动脉栓塞的诊断和外科治疗方法及疗效。方法 1999年11月于2000年4月对3例确诊为慢性肺动脉栓塞的病人,在低温体外循环或间断深低温停循环下,行血栓清除和内膜剥膜术治疗。结果 3例无死亡,无严重并发症。随访3－6个月,效果满意。结论 肺动脉切开取栓并行内膜剥脱,对慢性肺动脉栓塞病人是行之有效的外科治疗方法。     

Vasoactive peptides in a pulmonary embolism model

Abstract. Purpose: To investigate changes in atrial natriuretic peptide (ANP) and angiotensin II (AT-II) levels in a canine model of pulmonary embolism (PE), created by embolizing the left posterior pulmonary artery with gelatin powder. Methods: Pulmonary arterial pressure (PAP) was measured before, immediately after, and 1 day after pulmonary artery embolization. Plasma ANP and AT-II levels were measured by radioimmunoassay (RIA) before and 1, 3, 7, 14, 21, and 28 days after embolization. ANP and AT-II levels were also measured by RIA in both embolized and nonembolized lung tissue 28 days after embolization. Results: No changes in plasma ANP or AT-II were seen within 28 days after embolization. Although the ANP level in the nonembolized lung tissue was significantly increased, the level in the embolized lung tissue was significantly decreased compared with that of sham-operated control lung tissue. The AT-II level in the nonembolized lung tissue was significantly decreased compared with that of the control lung tissue, but the level in the embolized lung tissue did not change. Conclusion: Both ANP and AT-II in the nonembolized lung tissue reacted to compensate for vasoconstriction caused by the PE in this model. Received: August 22, 2001 / Accepted: March 5, 2002     

老年踝关节骨折的手术治疗

目的：分析总结老年人踝关节骨折手术治疗的效果、以及增加手术成功率的手术技巧。方法：回顾性分析2003年1月至2008年12月老年踝关节骨折手术治疗病例128例,男26例,女102例;年龄50～82岁,平均69岁。根据Lange-Hanson分型：旋后外旋型113例,旋前外旋型8例,旋后内收型5例,旋前外展型2例。所有患者施行切开复位内固定术,记录手术方法、早期并发症、患者满意度,应用美国足踝外科协会(AOFAS)踝与后足评分评定手术效果。结果：128例术后获得随访,时间6个月～6年,平均36个月。伤口延迟愈合11例(8.6%);无深部感染、骨折不愈合、内固定翻修等情况发生。AOFAS评分疼痛评分(33.5±5.6)分,功能评分(40.2±7.4)分,后足的排列均得到10分,总分(83.6±6.3)分。结论：手术治疗骨质疏松性老年人踝关节骨折应是多数情况下的首选方法。虽然骨质疏松使内固定手术的难度增加,但是通过手术方法的改进,能够使老年踝关节骨折取得好的治疗效果。     

Fatal pulmonary embolism following removal of a central venous catheter

A 1-year-old child developed fatal septic pulmonary embolism upon removal of a central intravenous catheter. Histologically identical material was found in the pulmonary arteries and in the inferior vena cava at the catheter tip site. The pathophysiology of pulmonary embolism occurring during childhood is reviewed.     

Twenty-year results of surgical pulmonary thromboembolectomy in acute pulmonary embolism

Background. Acute massive pulmonary embolism is often a life-threatening condition and should be treated immediately. The aim of this study was to investigate risk factors and clinical outcomes of patients undergoing emergency pulmonary embolectomy for acute massive pulmonary embolism. Methods. We evaluated 49 patients undergoing emergency pulmonary embolectomy in our institution between 1995 and 2015, retrospectively. We reviewed preoperative conditions and risk factors, surgical complications, postoperative courses, predictors of mortality and long-term survival. Results. At the time of presentation, the median patients’ age was 58 years. Preoperatively, seven (14%) individuals had cardiac arrest and required cardiopulmonary resuscitation. At the time of surgery, other 23 (47%) patients presented with cardiogenic shock. The most common risk factor for development of pulmonary embolism was major surgery in the last 30 days (29%, n?=?14). Five (10%) patients received systemic thrombolysis preoperatively. The median cardiopulmonary bypass (CPB) time was 82?minutes. The median length of stay in the intensive care unit and in hospital were 1 and 14 days, respectively. Postoperative complications included revision as a consequence of mediastinal bleeding (6%, n?=?3), stroke (2%, n?=?1), and acute renal failure requiring temporary dialysis (4%, n?=?2). The 30-day mortality was 29% (n?=?14) with four (8%) cases of death during the surgery. The one-, five- and 15-year survival rates were 65%, 63%, and 57%, respectively. Conclusion. Pulmonary embolectomy can be performed in high-risk patients with massive pulmonary embolism with acceptable clinical outcome and good long-term survival.     

螺旋CT增强扫描在诊断和治疗肺动脉栓塞中的应用

目的 评价螺旋CT在诊断和治疗肺动脉栓塞（肺栓塞）中的作用。方法 对16例（年龄35－74岁）行螺旋CT检查的肺栓塞病人进行回顾性分析。使用PQ6000型单层螺旋CT机,连续容积增强扫描。结果 共计分析176支肺动脉分支,受累89支,占50．2％;双侧下叶主支受累最多（达31．5％）;累及左、右肺动脉主干者为16％,累及肺叶以下分支达84％,未见累及主肺动脉的病例。肺动脉栓塞螺旋CT增强扫描的直接征象为肺动脉腔内偏心性、类圆形充盈缺损,附壁性类环形充盈缺损,管腔闭塞,血栓位于管腔中央的“轨道症”;并存的间接征象包括主肺动脉增宽、局限性肺纹理稀疏、肺梗死和胸腔积液。结论 在肺动脉栓塞的诊断,螺旋CT增强扫描是一种有效的无创性检查手段,且安全、快速。在肺栓塞的定性定量诊断和指导选择治疗方法上,可以起到重要作用。     

Shunt complication after pulmonary embolism

Summary We report a case of severe pulmonary embolism followed by upward kinking of the catheter seven months after a ventriculo-auricular shunt operation. Possible causes are discussed.     

Cardiorespiratory symptoms during pregnancy--not always pulmonary embolism

We describe a case of sudden onset severe cardiorespiratory compromise in a parturient at 36 weeks' gestation. She received treatment for infection, pulmonary oedema and pulmonary embolism before a diagnosis of aortic dissection was made. Successful repair was undertaken following caesarean section. We discuss the difficulties of diagnosis of cardiorespiratory symptoms and the potential hazards of instituting therapy before a definitive diagnosis is reached. The value of a multidisciplinary team approach and the use of portable echocardiography in the investigation of both pulmonary embolism and cardiac disease are emphasised.