膝下动脉闭塞的腔内治疗

Objective To evaluate the results of endovascular intervention for infrapopliteal arterial occlusion in 40 patients. Methods There were 41 affected limbs in these 40 patients receiving 44 times of endovascular intervention for infrapopliteal arterial occlusion during Nov. 2006 and Dec. 2007. The average age was 76±6. The ABI(ankle brachial index)before intervention was 0.39±0.20 in anterior tibial artery and 0.39±0.23 in posterior tibial artery. CLI (critical limb ischemia) was 80.49% (33/41). Results The after intervention ABI increased by 0.43±0.22 (P<0.01) in anterior tibial artery and 0.43±0.25(P<0.01)in posterior tibial artery. 35 patients (36 limbs) were followed-up for (6±3) months. The limbs of Fontaine Ⅰ and Fontaine Ⅱ A were 28 (77.78%), CLI decreased to 19.44% (7/36) (P<0.01). At follow-up the ABI in anterior tibial artery was 0.63±0.22 and 0.56±0.22 in posterior tibial artery. The difference were all significant when compared with that before intervention and after intervention. The perioperative amputation rate was 0. The perioperative mortality rate was 2.5%. The total mortality rate was 15%. The limb salvage rate were 100%. Conclusion The effect of endovascular intervention for infrapopliteal arterial occlusion is satisfactory.     

Surgical outcomes following nerve transfers in upper brachial plexus injuries

Background:

Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.

Materials and Methods:

We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).

Results:

Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).     

脉动波传导速度在外周血管病预测和诊断中的意义

目的 探讨脉动波传导速度在预测和诊断外周血管病(PAD)中的意义.方法 对国内15个医疗中心,1500例50岁以上2型糖尿病,具有一项或多项心血管疾病相关危险因素的患者,一期同时测定踝肱指数(ABI)和臂踝脉动波传导速度(bapWV).所有患者同时记录血压水平,高血压病程;血糖水平,糖化血红蛋白值,糖尿病病程;血脂水平;体质量指数;吸烟状况;心血管事件和脑血管病的患病情况.对数据进行统计分析.结果 2型糖尿病患者在ABI值正常时,baPWV表现为异常加速,且女性较男性更明显(P<0.01).2型糖尿病患者合并PAD后,ABI降低(右侧0.82±0.15,左侧0.80±0.16),baPWV和非合并PAD患者相比明显减速[右侧(1652.64±428.7)cm/s比(1699.1±316.3)cm/s,左侧(1655.3±477.2)cm/s比(1677.5±338.6)cm/s,P<0.01].ABI、baPWV和年龄、糖尿病病程、高血压等危险因素以及心血管事件间均呈正相关.年龄是PAD的重要危险因素,非PAD患者,baPWV随年龄增大而加速(P<0.01),PAD患者的baPWV则随年龄增加而明显减低(P<0.01).结论 baPWV可以和ABI一起作为PAD筛查和诊断的指标,可能会比ABI更早、更敏感地预测血管病变的存在和发生.     

Nerve transfer to the triceps after brachial plexus injury: report of four cases

These case reports review the clinical outcomes of 4 patients who underwent nerve transfer to a triceps motor branch of the radial nerve. Mean follow-up was 26 ± 15 months. Two patients had a transfer using an ulnar nerve fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4+ in the other. In 1 patient, a thoracodorsal nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial nerve fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable fascicles of the ulnar, thoracodorsal, and radial nerves are viable donors in the surgical reconstruction of elbow extension.     

Effects of botulinum toxin‐induced paralysis on postnatal development of the supraspinatus muscle

The mechanical environment plays an important role in musculoskeletal tissue development. The present study characterized changes in supraspinatus muscle due to removal of mechanical cues during postnatal development. An intramuscular injection of botulinum toxin type A (BTX) was used to induce and maintain paralysis in the left shoulders of mice since birth while the right shoulders received saline and served as contralateral controls. A separate group of animals was allowed to develop normally without any injections. Muscles were examined postnatally at various time points. The maximum isometric tetanic force generated by the muscle was significantly reduced in the BTX group compared to saline and normal groups. The paralyzed muscles were smaller and showed significant muscle atrophy and fat accumulation on histologic evaluation. Myogenic genes myogenin, myoD1, myf5, myf6, and fast type II myosin heavy chain (MHC) isoform were significantly upregulated while slow type I MHC isoform was significantly downregulated in the BTX group. Adipogenic genes C/EBPα, PPARγ2, leptin, and lipoprotein lipase were significantly upregulated in the BTX group. Results indicate that reduced muscle loading secondary to BTX‐induced paralysis leads to fat accumulation and muscle degeneration in the developing muscle. Understanding the molecular and compositional changes in developing supraspinatus muscles may be useful for identifying and addressing the pathological changes that occur in shoulder injuries such as neonatal brachial plexus palsy. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:281–288, 2011     

骨髓动员与非动员自体骨髓源单个核细胞移植治疗血栓闭塞性脉管炎的疗效比较

目的观察骨髓动员与非动员自体骨髓干细胞移植治疗血栓闭塞性脉管炎（TAO）的疗效并进行对比分析。方法25例严重缺血的TAO患者分为A、B两组,A组12例为骨髓动员组,B组13例为非动员组。两组患者抽取骨髓血150～200ml,分离纯化后行下肢肌肉注射法移植术,观察丰观及客观指标进行疗效评价。结果移植2个月后两组多数患者疼痛和冷感有缓解,但缓解率两组无差异,两组溃疡愈合率无差异;经平均10个月随访,两组主观症状缓解率及溃疡愈合率差异无统计学意义（P〉0．05）。移植2个月后踝肱指数（ABI）和经皮氧分压（TcPO2）较术前有显著提高,A、B两组间差异有统计学意义;经平均10个月随访,两组间ABI和TcPO,差异有统计学意义（P〈0．05）。两组各有2例2条患肢溃疡无改善,无步匕亡及高位截肢者,全部患者无严重并发症发乍。结论骨髓动员和非动员两种方式自体骨髓干细胞移植均是安全、有效的治疗TAO手段．尤其对改善患肢症状及促讲溃疡的愈合效果明显,而骨髓动员组的疗效优于非动员组．     

相同浓度不同容量罗哌卡因超声引导锁骨上臂丛神经阻滞对膈肌麻痹的影响

目的观察超声引导锁骨上臂丛神经阻滞(supraclavicular brachial plexus block,SCBPB)使用相同浓度不同容量罗哌卡因对膈肌麻痹的影响。方法选择拟行右上肢骨折术后取内固定装置术的患者72例,男32例,女40例,年龄18~65岁,ASA I或II级。随机分为两组:0.375%罗哌卡因20ml组(A组)和0.375%罗哌卡因30ml(B组),每组36例。所有患者在超声引导下行锁骨上臂丛神经阻滞,记录臂丛各主要神经根的感觉阻滞、运动阻滞的起效时间和持续时间,并观察两组患者不良反应的发生情况。采用M型超声测量阻滞前、阻滞后30min时两组平静呼吸和用力呼吸的膈肌移动度,通过观察膈肌移动度的变化来反映膈肌麻痹情况,并计算膈肌麻痹率。结果两组患者感觉阻滞起效时间、感觉阻滞和运动阻滞持续时间差异均无统计学意义。B组运动阻滞起效时间明显短于A组(P0.05)。阻滞后30min A组和B组分别有12例(33.3%)和22例(61.1%)患者出现膈肌麻痹,B组膈肌麻痹率明显高于A组(P0.05)。结论 0.375%罗哌卡因20 ml与30ml在超声引导下行锁骨上臂丛神经阻滞均可达到理想的臂丛阻滞效果,0.375%罗哌卡因20 ml引起膈肌麻痹较少。     

Use of ultrasound guidance and contrast enhancement: a study of continuous infraclavicular brachial plexus approach

Purpose: We describe our experience of combining the use of ultrasound (US) guidance with contrast enhancement and peripheral nerve stimulation for the insertion of infraclavicular brachial plexus catheters. Methods: Thirty patients scheduled to have upper limb surgery under regional block were studied. Under US guidance and peripheral nerve stimulation assistance, continuous peripheral nerve block needle and stimulating catheter were placed in the infraclavicular area. Needle and catheter tip location was confirmed with agitated 5% dextrose and seen under colour Doppler with US before injecting local anaesthetic (LA). Patients were evaluated in terms of onset times and efficacy of block. Post‐operatively, on block recession a catheter was stimulated and visualization of spread of LA during injection through the catheter was done. Secondary block (subsequent to re‐injection of LA) was assessed. Patients were followed‐up for a week. Results: Mean time to onset of block was 19.7 (± 4.9) min. There were no incomplete blocks and all components of the plexus were blocked completely. Post‐operatively, in 95.7% of patients, the spread of hand‐agitated LA via the catheter could be seen by color Doppler with ultrasonography. All patients had excellent post‐operative analgesia and high degree of satisfaction. There were no complications. Conclusion: Contrast enhancement with US guidance during infraclavicular brachial plexus block enables direct visualization of needle and catheter tip location. Our early experience suggests that this leads to successful initial and subsequent post‐operative block. Further controlled studies are needed to compare this technique with more prevalent and conventional techniques of catheter insertion.     

Shoulder dystocia without versus with brachial plexus injury: A case–control study

Objective. To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI).

Study design. A case–control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

Results. From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88).

Conclusions. Neither antepartum nor intrapartum factors can differentiate the patient who will have shoulder dystocia with vs. without BPI.