关节镜下自体腘绳肌肌腱移植重建膝前交叉韧带的临床观察

目的探讨关节镜下自体腘绳肌肌腱移植重建膝前交叉韧带的临床疗效。方法自2006年12月-2010年1月,对215例膝关节前交叉韧带损伤患者采用关节镜下自体腘绳肌肌腱移植重建（包括单束和双束）。比较患者术前、术后Lysholm膝关节评分和膝关节稳定性改变。结果本组215例中210例获得随访,1例患者在术后6周出现膝关节内感染,予行关节镜下清理、抗感染等处理后治愈。术前和术后1个月、术后6个月、术后1年Lysholm膝关节评分分别比较差异均有统计学意义（P〈0.05）。术前215例患者物理检查均表现为膝关节不稳,术后所有患膝不稳定表现消失。结论关节镜下自体腘绳肌肌腱移植重建膝前交叉韧带疗效可靠,依据病人实际情况个性化合理选择单双束重建。     

三七总皂苷促进腱骨愈合的实验研究

目的：研究三七总皂苷对腱骨愈合的影响。方法：取20只成年新西兰大白兔,随机分为PNS组及空白对照组,每组10只。两组动物均切断双侧膝关节前交叉韧带,以趾长伸肌腱重建前交叉韧带,制作腱骨愈合模型。PNS组骨隧道内注射三七总皂苷注射液,干预腱骨愈合。空白对照组不予干预措施。术后4周及8周每组各处死5只新西兰大白兔,获取腱骨愈合标本。通过肉眼、组织学切片观察两组腱骨愈合的变化及差异。结果：顺利完成所有手术,20只大白兔无死亡及关节感染。大体观察,两组动物4周时腱骨界面为纤维连接,8周时腱骨间隙已不容易辨认。组织学观察,PNS组腱骨界面细胞成熟度更高,sharphy纤维生长更加密集,间质钙化程度更高,新骨形成量更多。8周时界面组织形态分类,两组分布差异有统计学意义。结论：三七总皂苷能够促进腱骨界面细胞成熟,促进腱骨界面胶原生长,促进新骨形成,加快腱骨愈合速度,提高腱骨愈合质量。但本研究尚未对各项指标进行定量测量,三七总皂苷促进腱骨愈合的详细机制尚未完全明确。     

Anterior endoscopically assisted transcervical reconstruction of the upper cervical spine

Anterior decompression and/or reconstruction can be an effective method for the surgical treatment of ventral spinal cord compression in the upper cervical spine. Options for traditional surgical approaches include transoral, transnasal, and extraoral. The risk and complex anatomy with the aforementioned approaches induces surgeons to use the transcervical route to expose the upper cervical spine. A traditional transcervical approach, however, carries the disadvantages of a deep operative field and steep trajectory. We performed a new endoscopically assisted method of anterior reconstruction for the treatment of ventral lesions in upper cervical spine. Six patients were treated from January 2005 to December 2007. Among those six patients, three patients were diagnosed with fixed atlantoaxial dislocations, two with plasmacytomas, and one with a giant cell tumor. All patients were treated by combined endoscopically assisted anterior reconstruction and posterior fusion. One patient with a fixed atlantoaxial dislocation sustained a cerebrospinal fluid leak in the immediate postoperative period, which spontaneously resolved 7 days after surgery. None of the patients had any neurologic deterioration following surgery, nor did any require admission to the intensive care unit for any reason. At the final follow-up, all patients were found to have evidence of a successful clinical outcomes and radiographic fusion. There were no implant failures or radiographic signs of implant migration or loosening. In conclusion, this study demonstrates that an anterior transcervical decompression using endoscopic visualization combined with a posterior arthodesis can achieve good clinical and radiographic outcomes.     

关节镜下前交叉韧带重建后内侧和外侧半月板同期移植术

目的 探讨全关节镜下前交叉韧带重建后内侧和外侧半月板同期移植的微创手术技术.方法 2008年8月对1例实施膝关节双束双通道前交叉韧带重建、内侧和外侧半月板切除的患者,在关节镜下实施内侧和外侧半月板同期移植微创手术.内侧半月板移植采用前后角骨栓固定方法,外侧半月板移植采用前后角骨桥固定方法.术后结果采用VAS疼痛评分、Cysholm评分和国际膝关节评分委员会(IKDC)分级评价.关节稳定性检查包括Lachman试验、抽屉试验和轴移试验.结果 术后随访26个月,患者膝关节屈曲、伸直和负重行走功能正常.VAS膝关节疼痛评分较术前降低2分,Lysholm评分较术前升高20分.IKDC分级由术前C级上升到B级.膝关节稳定性检查基本正常.术后1年MRI检查显示,重建前交叉韧带连续性完整,内侧和外侧移植异体半月板外形均较好,内侧半月板后角和外侧半月板前角有轻微萎缩.术后18个月关节镜复检观察到,外侧和内侧移植半月板均愈合良好,形态完整,但前角表面均有轻度磨损现象.结论 对膝前交叉韧带损伤和内、外侧半月板切除的患者,在前交叉韧带重建术后同期实施内侧和外侧半月板移植术可以尽量恢复膝关节的稳定性和力学平衡,对年轻患者是可供选择的治疗方式.术中建议采用同一供体的内侧和外侧异体半月板,制作各骨道时须注意其方向以避免骨道相互交通.

Abstract：

Objective To discuss the minimal invasive arthroscopic surgery technique and clinical results of both the medial and lateral meniscal transplantation following the anterior cruciate ligament reconstruction with double bundles and bone tunnels.Methods In August 2008 a minimal invasive surgery of both the medial and lateral meniscal allograft transplantation following anterior cruciate ligament reconstruction was preformed for 1 case with both the medial and lateral menicectomy by arthroscopic surgery.The method of two bone plugs attached on tibial plateau was employed for medial meniscal allograft transplantation and the technique the bridge in slot for lateral meniscal allograft transplantation.The VAS,Lysholm score and IKDC rating were recorded before and after operation.The stability of knee was assessed by Lachman test,drawer sign and pivot shift test.Results The patient was followed up 26 month after the operations.The degrees of knee flexion,extension and function of walk were normal.The Lachman test,drawer sign and pivot shift test were nearly normal.The VAS after operation was 2 points lower than that before operation.The Lysholm score post-operation was 20 points higher than pre-operation.The IKDC became B degree in late following-up from C degree before the operation.MRI revealed anterior cruciate ligament graft was continuous and the meniscal allograft was normal shape on year 1 after the operation.The posterior horn of medial meniscal allograft and anterior corner of lateral meniscal allograft showed slightly shrunk.The second-look arthroscopy showed that the healing occurring between meniscal allograft and the capsule and meniscal allograft was normal shape on month 18 after the operation.The anterior horn of medial and lateral meniscus was slightly worn.Conclusions Both the medial and lateral meniscal transplantation following the anterior cruciate ligament reconstruction in appropriately selected patients with the medial and lateral meniscus-deficient knee may recover the knee mechanic balance and stability,which is a option of treatment for that young and activity patients.It is proposed that the medial and lateral meniscal grafts harvested from a single donator.Attention should be paid to the direction of the bone tunnels fixing the horns of the meniscus in order to avoid communication with the tunnels of anterior cruciate ligament reconstruction.     

正向、反向束间构型在前十字韧带双束重建中的临床效果比较

 目的比较关节镜下前十字韧带(anterior cruciate ligament. ACL)双束重建中正向、反向束间构型的初期临床效果。方法 2008年 4月至 2009年 8月.采用 8股自体腘绳肌肌腱双束重建 ACL治疗单纯 ACL损伤患者 97例.根据患者入: 时住: 号的奇偶数随机分成正向组(采用正向束间构型. 47例)和反向组(采用反向束间构型.50例).移植物均采用微型钢板纽扣进行悬吊式固定。术后患者随访期均超过 1年.根据 IKDC、Lysholm和 Tegner评分标准进行膝关节功能评估。结果术后随访 12~17个月.平均(13.71±1.32)个月。末次随访时.正向组 2例(4.2%)患者伸膝活动受限 10°.5例(10.6%)膝关节轻度屈曲受限(均<15°);反向组所有患者伸膝活动正常.4例(8.0%)屈曲受限约 5°。根据 Lachman试验.正向组 1例(2.1%)I度阳性和 1例(2.1%) II 度阳性.反向组 1例(2.0%) II 度阳性。 KT-1000(屈膝 30°.30N)双膝松弛度差异值正向组为(1.04±1.11) mm.反向组为(0.86±1.12) mm。按照 IKDC客观评级标准.正向组 46例(97.9%)正常或接近正常.反向组 48例(96.0%)正常或接近正常。根据 IKDC、 Lysholm和 Tegner评分标准.两组的差异均无统计学意义。结论采用 8股自体腘绳肌肌腱正向、反向束间构型双束重建 ACL均能有效地恢复膝关节稳定性.两组短期临床效果的差异无统计学意义。但反向束间构型能有效地防止移植物和髁间凹的撞击。     

升主动脉替换联合三分支支架血管术中置入治疗急性A型主动脉夹层

目的 总结升主动脉人工血管替换联合三分支支架血管术中置入治疗急性Stanford A型主动脉夹层的初步经验.方法 2008年6月至2009年9月20例急性A型主动脉夹层病人接受了升主动脉人工血管替换和三分支支架血管置入术.体外循环鼻咽温度降至20℃时,停止下半身灌注,经无名动脉近端升主动脉横断切口,将三分支支架血管置入主动脉弓和近端胸降主动脉真腔内,并将其分支支架血管依次置入左锁骨下动脉、左颈总动脉和无名动脉.将主干支架血管的近端与无名动脉近端的升主动脉切口重建后与替换近端升主动脉的人工血管端端吻合.结果 所有病人术中均顺利地置入三分支支架血管,平均体外循环(163.2±19.2)min,主动脉阻断(89.4±10.0)min,低流量选择性脑灌注和下半身缺血(32.7±6.6)min.术后出现短暂性神智障碍1例,急性肾功能衰竭1例.20例均治愈出院.术后3个月电子束CT检查结果示,主干支架血管及分支支架血管通畅、无扭曲;支架血管置入部位夹层假腔闭合;16例远端胸降主动脉夹层假腔闭合.结论 三分支支架血管术中置入是简化急性主动脉夹层者主动脉弓重建、提高手术安全性的一种有效方法.主要适应证为弓内内膜无破口而需主动脉弓重建的急性A型主动脉夹层病人.支架血管大小、分支支架血管间的距离选择和放置过程中避免内膜损伤是术中三分支支架血管成功放置的关键.

Abstract：

Objective To report the primary experience of open placement of triple-branched stent graft for acute Stanford type A aortic dissection. Methods Between June 2008 and September 2009, 20 well-selected patients with acute Stanford type A aortic dissection underwent open placement of triple-branched stent graft for total arch reconstruction. When core cooling to a 20℃ nasophageal temperature, perfusion to the lower body was discontinued and the ascending aorta was transected at the base of the innominate artery. Through a transverse incision, the triple-branched stent graft was inserted into the true lumen of the arch and descending aorta, and each side arm of the stent graft was positioned one by one into the arch branches.The transected stump of the ascending aorta was reconstructed by inner proximal stent-free dacron tube of the main graft and outer teflon felt, and subsequently continuous anastomosis to the 1-branched dacron tube graft was made. Results Open placement of triple-branched stent graft was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time and lower body arrest time were (163.2 ±19.2) min, (89.4 ±10.0) min and (32. 7 ±6. 6)min, respectively. Transient postoperative neurological dysfunction was observed in 1 patient and acute renal failure in 1 patient. All patients were discharged from the hospital. Their computed tomographic scans at 3 months postoperatively showed that all stent grafts were fully opened without distortion. In the vascular stent implantation site the dissected false lumen was eliminated. The false lumen of the descending aorta distal to the stent graft was closed with thrombus in 16 cases. Conclusion Open placement of triple-branched stent graft is a new effective technique for total arch reconstruction in acute type A aortic dissection. Patients have the indications of the extensive primary repair of the thoracic aorta without primary intimal tears in the arch may be the best candidates for this new technique. The size of the stent graft, the distances between two neighboring side arm grafts and the prevention of the intimal trauma during the placement are crucial for successful open placement of triple-branched stent graft.     

Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

In the elderly population, reported union rates with anterior odontoid screw fixation (AOSF) for odontoid fracture (OF) treatment vary between 23 and 93% when using plain radiographs. However, recent research revealed poor interobserver reliability for fusion assessment using plain radiographs compared to CT scans. Therefore, union rates in patients aged ≥60 years treated with AOSF have to be revisited using CT scans and factors for non-union to be analysed. Prospectively gathered consecutively treated patients using AOSF for odontoid fracture with age ≥60 years were reviewed. Medical charts were assessed for demographics, clinical outcomes and complications. Patients’ preoperative radiographs and CT scans were analysed to characterize fracture morphology and type, fracture displacement, presence of atlanto-dental osteoarthritis as well as a detailed morphometric assessment of fracture surfaces (in mm²). CT scans performed after a minimum of 3 months postoperatively were analysed for fracture union. Those patients not showing CT-based evidence of completely fused odontoid fracture were invited for radiographic follow-up at a minimum of 6 months follow-up. Follow-up CT-scan were studied for odontoid union as well as the number of screws used and the square surface of screws used for AOSF and the related corticocancellous osseous healing surface of the odontoid fragment (in %) were calculated. Patients were stratified whether they achieved osseous union or fibrous non-union. Patients with a non-union were subjected to flexion–extension lateral radiographs and the non-union defined as stable if no motion was detected. The sample included 13 male (72%) and 5 female (18%) patients. The interval from injury to AOSF was 4.1 ± 5.3 days (0–16 days). Age at injury was 78.1 ± 7.6 years (60–87 years) and follow-up was 75.7 ± 50.8 months (4.2–150.2 months). 10 patients had dislocated fractures, 14 had Type II and 4 “shallow” Type III fractures according to the Anderson classification, 2 had stable C1-ring fractures, 8 had displayed atlanto-dental osteoarthritis. Fracture square surface was 127.1 ± 50.9 mm² (56.3–215.9 mm²) and osseous healing surface was 84.0 ± 6.8% (67.6–91.1%). CT-based analysis revealed osseous union in 9 (50%) and non-union in 9 patients (50%). Union rates correlated with increased fracture surface (P = 0.02). Statistical analysis revealed a trend that the usage of two screws with AOSF correlates with increased fusion rates (P = 0.06). Stability at C1–2 was achieved in 89% of patients. CT scans are accepted as the standard of reference to assess osseous union. The current study offers an objective insight into the union rates of odontoid fractures treated with AOSF using CT scans in consecutive series of 18 patients ≥60 years. Literature serves evidence that elderly patients with unstable OF benefit from early surgical stabilization. However, although using AOSF for unstable OF yields segmental stability at C1–2 in a high number of patients as echoed in the current study, our analysis stressed that using follow-up CT scans in comparison to biplanar radiographs dramatically reduces osseous union rates compared to those previously reported for AOSF.     

胰腺癌组织微血管密度及淋巴管密度的改变及临床意义

目的：研究胰腺癌组织中微皿管密度（MVD）和淋巴管密度（LVD）的变化、与胰腺癌临床病理的联系及相互关系。方法：采用免疫组织化学SABC法应用CD34检测41例胰腺导管腺癌患者配对癌组织和正常胰腺组织中MVD的表达情况,应用D2—40检测配对癌组织、癌旁组织及正常胰腺组织中LVD的表达情况,分析MVD和LVD与肿瘤分化程度、分期和淋巴转移间的相关性以及癌组织MVD与癌旁组织LVD表达之间的关系。结果：癌组织及正常胰腺组织MVD分别为46585±16,935和11．100±4．036,两组差异有统计学意义（P=0．000）。癌组织、癌旁及正常胰腺组织LVD分别为11．244±4．800、15．829±7．470和13．512±5．139;其中癌旁组织与正常胰腺组织LVD差异无统计学意义（P=0．060）,癌旁组织与癌组织的LVD差异有统计学意义（P=0．000）。胰腺癌组织MVD与癌旁组织LVD间存在相关性（P=0.025〈0．05）。结论：胰腺导管腺癌组织中MVD及LVD与肿瘤分化程度、病理分期及淋巴转移相关;胰腺癌组织内MVD与癌旁组织LVD间存在相关性。     

纤维桩用于前牙残冠修复的临床应用

目的探讨纤维桩在前牙残冠修复中的临床应用。方法将恒前牙残冠残根病例共36例随机分为纤维桩(观察组)和金属桩核修复组(对照组),随访观察6、12个月。结果观察组1例发生牙体折裂、修复体脱落,对照组根折3例,脱落4例。结论纤维桩在恒前牙核桩冠修复中固位与金属桩无显著差异,而很少会发生根折或牙折,在恒前牙残冠残根修复中具有广阔的应用前景。