髋关节置换后股骨假体柄周围骨折9例

背景：髋关节置换后股骨假体周围骨折因金属假体存在、局部骨质质量下降,治疗难度大,治疗方式选择存在诸多争议。 目的：总结髋关节置换后股骨假体柄周围骨折治疗方式的选择及相应临床治疗效果。 方法：回顾性分析新疆石河子大学医学院第一附属医院骨一科2001-02/2009-06收治的9例股骨假体柄周围骨折患者,依据Vancouver骨折分型,A型骨折1例,B1型骨折3例,B2型骨折4例,C型骨折1例。分别采用保守治疗、钢丝环扎、长柄翻修术结合钢丝环扎和钢板内固定治疗骨折,观察治疗效果及其不良事件。 结果与结论：9例患者跟踪随防1.1~4.5年,平均随访2.5年,6例患者治疗后获得骨折愈合,平均愈合时间为6个月。2例长柄翻修结合钢丝环扎内固定的B2型患者和1例钢板固定C型患者骨折未愈合。提示根据骨折部位、假体稳定性和骨组织质量选择恰当的治疗方式,以及尽量保护骨折端血运是治疗股骨假体周围骨折的关键。     

Treatment of periprosthetic femoral fractures with two different minimal invasive angle-stable plates: Biomechanical comparison studies on cadaveric bones

Introduction

The introduction of fixed-angle plate osteosynthesis techniques has provided us a further means to treat periprosthetic femoral fractures. The goal of this experimental study is to evaluate the biomechanical properties and stability of treated periprosthetic fractures when using two different plate systems, which vary in the locking mechanism and the screw placement (monocortical or bicortical) with respect to the prosthesis stem.

Materials and methods

Using five pairs of formalin-fixed femora, a Vancouver B1 periprosthetic fracture was treated either with a 13-hole LISS^® titanium plate using four monocortical periprosthetic screws or with a non-contact bridging plate (NCB) DF^® plate using bicortical angle-stable blocked screws positioned ventrally or dorsally to the prosthesis stem. Bones were loaded under axial and cyclic compression with a progressively increased load until failure. Displacement at the osteotomy gap was measured during loading using an ultra-sound measuring system.

Results

The mean displacement in the region of the fracture gap was not significantly different at any time during the experiments for the two models. The mean force resulting in subsequent model failure was similar in both models; the failure morphology varied slightly between the models, however. Four of the five LISS^® models exhibited either a tear-out of the monocortical screws or a decortication from the bony shaft of the cortical lamella surrounding the screws. On the other side, two of the NCB models showed macroscopically visible fissures along the osteosynthesis plates at the height of the osteotomy gap, and were hence considered implant failures. Only one NCB model showed tear-out of the bicortically placed screws.

Conclusion

Bicortical screw placement provides more stable anchoring when compared to monocortical screw fixation. However, in relation to the amount of motion at the osteotomy gap and to failure loads, stabilisation of periprosthetic femoral fractures can be equally well achieved using either the LISS^® plate with periprosthetic monocortical screws or the NCB plate with poly-axially placed bicortical screws.     

人工髋关节置换术后假体柄周围股骨骨折的治疗

目的探讨人工髋关节置换术后假体柄周围股骨骨折的治疗计划以及临床效果。方法回顾自1988年1月至2001年6月本组收治的45例患者,依Vancouver分类系统,共有7例A型骨折,24例B1型骨折,7例B2型骨折,4例B3型骨折以及3例C型骨折。分别根据假体稳定度作骨折内固定或人工髋关节翻修手术,应用钢板加钢丝或钢索、Dall—Miles钢板、异体结构骨、异体骨碎片等,翻修手术应用常规骨柄或组合式股骨柄,并分析各类型骨折及各种治疗方式的结果与并发症。结果A型及B1型骨折的愈合率高,但必须注意钢板的长度;B2型骨折要注意翻修手术时的角度,避免术后出现脱臼;至于B3及C型则由于骨折复杂,并发症及失败率极高。因此,本研究提出关于这类损伤的治疗流程,让整个复杂程序更具逻辑性、简单性。结论人工髋关节置换术后假体柄周围股骨骨折是一个较复杂的问题。要获得成功的治疗,必须清楚判断骨折的特性,善用各种骨折治疗材料,以一个逻辑性思考做术前治疗计划,因此适当的分类系统显得特别重要。     

Increasing incidence of ampicillin resistance in Hemophilus influenzae.

The incidence of ampicillin resistance in Hemophilus influenzae and its medical significance have not been extensively determined. During 1975-1977, we tested for ampicillin resistance 489 consecutive middle-ear isolates of HI obtained from children in Huntsville, Alabama, and 719 consecutive laboratory isolates of HI from Children's Hospital, Boston. The annual incidence of Amp resistance rose progressively in each survey, from initial values of 1.4 to 5.3% in 1975, to 14 to 16% in 1977 (P less than 0.05), a mean annual rate of increase approximately twofold. Resistance was equally prevalent among type b and non-b isolates and among nasally carried and disease-associated isolates (from blood, CSF, middle ears). Patients harboring AmpR isolates were much more likely to have had recent exposure to beta-lactam antibiotics (P less than 0.01).     

Clinical and immunocytochemical findings in a case of melanoma-associated retinopathy

OBJECTIVE: To describe an unusual case of melanoma-associated retinopathy (MAR). DESIGN: Retrospective, observational case report and experimental study. PARTICIPANTS: A 61-year-old man with a history of cutaneous melanoma, acquired bilateral central scotomas, and night blindness. INTERVENTION: Serial full-field electroretinography (ERG) and Goldmann perimetry were performed. Serum was screened for cancer-associated retinopathy (CAR) antibodies by Western blotting. Sections of human and rat retina were examined by immunofluorescence microscopy to determine whether retinal cells were reactive with this patient's serum. A metastatic workup was performed. MAIN OUTCOME MEASURES: Electroretinography, Goldmann visual field testing, and immunocytochemistry were performed. RESULTS: The results were as follows: (1) The ERG showed a profound loss of the b-wave amplitude and a "negative" b-wave characteristic of congenital stationary night blindness; (2) a central scotoma and peripheral constriction were identified on Goldmann visual field tests; (3) as in other patients with MAR, bipolar cells in human and rat retinas were immunolabeled with this patient's serum; and (4) a previously unsuspected focus of metastatic melanoma was discovered. CONCLUSIONS: Recognition of this condition may help to identify an occult focus of metastatic melanoma.     

Undifferentiated (embryonal) sarcoma of the liver: ultrastructural and immunohistochemical similarities with malignant fibrous histiocytoma

Two undifferentiated (embryonal) sarcomas of liver were studied ultrastructurally and immunohistochemically. Electron microscopic examination of the pleomorphic tumor cells revealed fibroblastic and histiocytic characteristics. There were no specific findings to support rhabdomyoblastic, leiomyoblastic, or epithelial differentiation. Cytoplasmic peroxidase-antiperoxidase (PAP) immunohistochemical staining for vimentin, alpha1-antitrypsin, and alpha1-antichymotrypsin was found. No staining for epidermal or internal organ cytokeratins, desmin, myoglobin, or alpha-fetoprotein was observed. The ultrastructural correlates of the cytoplasmic periodic acid-Schiff-positive, diastase-resistant hyaline globules were large, membrane-bound, heterogenous electron-dense inclusions, probably lysosomal in origin. These inclusions did not react on either alpha1-antitrypsin or alpha1-antichymotrypsin PAP staining. Tumor specimens from two metastatic sites were also examined. Neither contained the ducts or cysts that characterized the primary tumor. These studies confirm the mesenchymal nature of this uncommon childhood neoplasm and support the suggestion that the cytoplasmic hyaline globules represent a degenerative phenomenon. There are ultrastructural and immunohistochemical similarities with malignant fibrous histiocytoma.     

Débridement of the burn wound with sutilains ointment

Twenty-one patients with fresh full-thickness burns received a course of two daily applications of sutilains ointment to an area of their burn wound not exceeding 9 per cent of the body surface. Twelve had a mirror-image control burn site of equivalent depth and extent, which was treated identically except sutilains applications were omitted. Good débridement, defined as a wound free of adherent eschar, was observed in 9 patients (43 per cent). The remaining patients' wounds had adherent eschar at the end of the test, or demonstrated equal débridement of both the test and control site. Good débridement was not promoted by increasing the frequency of wet dressings between sutilains applications. Débridement was better in patients receiving more than 8 days of applications. A higher percentage of patients receiving silver sulphadiazine demonstrated good débridement than those receiving gentamicin or no topical antibacterial agent. Burn wound bacterial colonization pattern in sutilainstreated patients did not vary from that observed in those patients receiving only topical antibacterial agents alone.Histological examination revealed that areas with good débridement showed an intense inflammatory cell response and dissolution of the elastic fibres. Control sites and areas with poor débridement showed a lesser inflammatory response and preservation of elastic fibres. No explanation for the variable response to sutilains was apparent histologically. Because of pain associated with application, cost and the unpredictability, sutilains should not be used indiscriminately without monitoring its response carefully and should be used only in conjunction with a topical antibacterial.