腘动脉损伤的诊断与治疗

目的探讨腘动脉损伤的早期诊断和治疗措施,以提高保肢率。方法回顾性分析2000年1月—2010年12月收治的168例腘动脉损伤患者临床资料,其中锐性伤27例(16.1%),钝性伤141例(83.9%),合并休克24例(14.3%),骨折/脱位125例(74.4%),神经损伤81例(48.2%),静脉损伤66例(39.3%)。比较不同受伤机制以及手术与非手术治疗的结果,分析致残的原因及与合并症的关系。结果血供完全恢复68例(40.5%),改善59例(35.1%),完全恢复率手术组(43.4%)高于非手术组(12.5%)(P<0.05)。截肢41例(24.4%),钝性伤截肢率(28.4%)明显高于锐性伤(3.7%)(P<0.05),手术组的截肢率(25.0%)与非手术组(18.8%)无明显差异;合并休克者截肢率(41.7%)高于无休克者(21.5%)(P<0.05),合并伴行静脉损伤者截肢率(33.3%)高于无静脉损伤者(18.6%)(P<0.05),合并骨折/脱位及神经损伤者截肢率与不合并者间无统计学差异(均P>0.05)。结论受伤至治疗的时间是影响预后的主要因素,相关合并症是致残的主要原因。早期诊断、彻底清创、...     

Popliteal aneurysms: from John Hunter to the 21st century

Popliteal aneurysms are rare and tend to occur in older men with significant co-morbidity. Historically, management of popliteal aneurysms can be considered in three broad groups: (i) the technique of Antyllus; (ii) techniques relying upon a collateral circulation; and (iii) techniques involving maintenance or restoration of circulation. Bypass and exclusion is currently been challenged by endovascular techniques which show promise in selected cases. Current controversies in popliteal aneurysms management are: when to repair asymptomatic aneurysms, what operation to do and how to manage acute thrombosis. These have been addressed by studying, prospectively, 73 patients presenting with 116 popliteal aneurysms. Diameter greater than 2 cm is often stated as being an indication for elective operation in asymptomatic popliteal aneurysms. However, distortion of the aneurysm appears to be at least as important as size in determining whether symptoms are likely to develop. Of 17 popliteal aneurysms followed for a median of 34 months with a diameter 2-3 cm and distortion less than 45 degrees , none thrombosed. This is no worse than patency following elective bypass (P = 0.064). Popliteal aneurysms greater than 3 cm in diameter in patients who are unfit or who declined an operation were significantly more likely to develop thrombosis or any other symptom (P = 0.01 and P = 0.004, respectively). Popliteal aneurysms less than 3 cm in diameter with distortion less than 45 degrees can safely be managed by ultrasound surveillance. Popliteal aneurysms with greater diameter or distortion are best operated upon. Bypass, combined with proximal and distal ligation of the aneurysm, resulted in 5-year graft patency of 78% and 65% for popliteal aneurysms originally patent or thrombosed, respectively, with good long-term exclusion of the aneurysm. In addition to the general complications of intra-arterial thrombolysis, acute deterioration of the limb during lysis appears to be a particular problem when dealing with thrombosed popliteal aneurysms. It occurs in about 13% of cases which compares with 2% when dealing with thrombosed grafts or native arteries. Intra-arterial thrombolysis for thrombosed popliteal aneurysms is associated with unacceptably high numbers of complications and thrombolysis should be reserved for intra-operative use only.     

Hereditary Multiple Exostoses with Pseudoaneurysm

A 16-year-old male patient with hereditary multiple exostoses (HME) was found to have a pseudoaneurysm of the left popliteal artery caused by osteochondroma in the lower femur. The diagnosis was confirmed by ultrasound, magnetic resonance imaging and magnetic resonance angiography without the need to perform an angiogram. The osteochondroma was excised and the popliteal artery was repaired with a saphenous graft. Vascular complications are extremely rare in HME, pseudoaneurysm being the most common and mostly located in the popliteal artery. This complication should be considered in young HME patients with a mass at the knee region. The radiological spectrum of investigations allows the diagnosis of this complication with proper and less invasive management procedures for the patient.     

An inconstant ligament in the popliteal region associated to the superior genicular arteries: surgical importance

Materials and methods In the dissection of 60 knees of 30 cadavers (13 women and 17 men), a ligament was located in the posterior femur face above the lateral or medial condyle.Results This ligamentous structure was found in 12 (20%) out of 60 knees studied (38% of the women and 35% of the men). It had a vertical arrangement and a constant direct relation to the superior (lateral or medial) genicular artery, and in no case it appeared as a posterior reinforcement of the capsule. The superior vessels were fixed by this ligament.Discussion This fixation may provide stability to the vascular tree but it could be a cause of post-surgical hemarthrosis in arthroscopy of the posterior knee area or in posterior or lateral knee approaches or it could be even implicated in vascular injury of the popliteal artery during knee dislocation.Conclusion The objective was to describe this inconstant ligament and to study its clinical relevance for surgical procedures, and particularly for those using the posterior approach to the knee joint.     

Human fetal anatomy of the posterior semimembranosus complex at the knee with special reference to the gastrocnemio-semimembranosus bursa

There is little information on the fetal anatomy of the posterior semimembranosus tendinous complex and its associated bursa. We examined histological sections (transverse or sagittal) of the right or left knee in 13 mid-term human fetuses (12-25 weeks of gestation). The medial head of the gastrocnemius provided an aponeurosis facing or attached to the muscles of the pes anserinus by 12 weeks of gestation. The peritendinous tissue of the semimembranosus provided a bursa continuous with a laterally extending plate-like tissue by 15 weeks, but sometimes the typical bursa was absent. The aponeurosis of the medial head consistently accompanied a bursa-like space (false bursa) surrounded by heterogenous structures including the popliteus and a wall of the semimembranosus bursa. Sagittal sections displayed notches on the medial head surface that received the semimembranosus and semitendinosus overriding the medial head of the gastrocnemius. In contrast to a real bursa originating from the peritendinous tissue of the semimembranosus, a false bursa without a homogeneous wall consistently develops at the origin of the medial head of the gastrocnemius. Due to mechanical stress from the tendons, the false bursa is likely to develop into a structure similar to a real bursa with a synovial lining even if the real bursa is absent in the fetus. We hypothesize that the adult gastrocnemio-semimembranosus bursa, largely or partly, originates from the fetal false bursa. Absolute resection of the false bursa is difficult because it is a mere gap between normal tissues.     

Assessment of popliteal neurovascular safety during all-inside suturing of the posterior horn of the lateral meniscus using Upright MRIs of the knee joint

BackgroundTo examine the risk of injury to the popliteal neurovascular bundle (pNVB) during all-inside repair of the posterior horn of the lateral meniscus (PHLM) using Upright-MRIs.MethodsUpright-MRIs of 61 knees in extension (ext) and 90°-flexion (flex) were included. Distance D from the PHLM to the pNVB was compared between extended and 90°-flexed position, subgroups with/without joint-effusion and evaluated according to demographics. Portal safety was assessed simulating suturing of the PHLM via four arthroscopy portals. Distance d (shortest space from the simulated suturing-device trajectory lines to the pNVB) was compared among portals in increasing distances from the posterior cruciate ligament (PCL).ResultsD is longer in flex (17.3 ± 6.0 mm) than in ext (11.3 ± 4.2 mm, p < 0.0001). MRIs with joint-effusion displayed longer values of D than scans without joint-effusion (flex: 20.4 ± 7.1 mm vs. 16.1 ± 5.2 mm, p = 0.012). Shorter distances are associated with female gender, lower body weight and lower BMI. At 0 mm from the PCL, the 1 cm-lateral portal was the safest (p < 0.0001) whereas at 3 mm/6mm/9mm/12 mm the 1 cm-medial portal showed the longest d values (p < 0.0001 each).ConclusionAll-inside suturing of the PHLM is safer in 90°-flexion, in presence of intraarticular fluid and in male patients with increasing weight/BMI. Sutures of the PHLM at 0 mm from the PCL are safer from a 1 cm-lateral portal whereas for tears located ≥ 3 mm from the PCL a 1 cm-medial portal involves a lower neurovascular risk. Upright-MRI proves excellent for preoperative planning to minimize neurovascular risks.     

腘动脉瘤开放手术与腔内修复术的对比研究

目的:比较腘动脉瘤(PAA)开放手术与腔内修复术的治疗效果。方法:回顾性分析2008年1月—2017年12月收治的33例PAA患者的临床资料,其中22例(23条肢体)行开放手术(开放手术组),11例(13条肢体)行腔内修复术(腔内修复组),分析、比较两组患者的一般资料、围手术期情况、随访结果。结果:腔内修复组患者年龄与高血压病合并症比例明显大于开放手术组(χ~2=8.250,P=0.008;χ~2=6.203,P=0.024),而两组在其他合并症、术前瘤体直径、术后伤口并发症方面均无统计学差异(均P0.05)。开放手术组均在全麻下完成手术,腔内修复组6例(54.5%)全麻下完成腔内手术(χ~2=12.257,P=0.002)。腔内修复组术后住院时间与总住院时间明显少于开放手术组(t=-4.221,P=0.000;t=-3.090,P=0.002)。中位随访时间36个月(1~120个月),开放手术组有5例再次干预,其中2例行截肢术;腔内修复组有2例再次干预。Kaplan-Meier分析显示两组患者免于再次干预率的差异无统计学意义(P0.05)。结论:对于高龄、外科手术风险高、解剖学条件合适、流出道情况良好的PAA患者,腔内修复术短中期疗效确切、住院时间短、围手术期恢复快,可替代外科手术成为首选治疗方案。     

TurboHawk斑块切除系统联合药物涂层球囊在治疗股腘动脉硬化闭塞性疾病中的应用

目的:评价应用Turbo Hawk斑块切除系统联合药物涂层球囊(DCB)治疗股腘动脉硬化闭塞性疾病的安全性和有效性。方法:2016年4月—2017年10月,对17例股腘动脉硬化闭塞性疾病患者应用Turbo Hawk斑块切除系统联合DCB治疗。17例患者平均年龄(66.9±10.5)岁;其中男14例,女3例;股腘动脉狭窄病变13例,闭塞性病变4例;术前Rutherford分级2~5级;术前踝肱指数(ABI)为0.49±0.18。结果:17例患者的血管病变全部经腔内开通成功,其中1例股动脉穿孔患者行补救性覆膜支架植入术,另1例远端栓塞患者经股动脉切开球囊导管取栓后血流恢复通畅,技术成功率88.2%。术后ABI为0.99±0.27,明显高于术前(P=0.03)。术后3、6个月一期通畅率分别为94.1%,88.2%,二期通畅率100%。结论:Turbo Hawk斑块切除系统联合药物涂层球囊治疗股腘动脉硬化闭塞性疾病安全有效,早期效果满意。