针刀松解法对膝骨关节炎大鼠中枢不同部位亮氨酸-脑啡肽的影响

目的：通过观察针刀松解法干预后膝骨关节炎（KOA）大鼠中枢不同部位亮氨酸-脑啡肽（L-ENK）的变化并与电针干预相比较,探讨针刀松解法在脊髓及脊髓以上水平的镇痛机制。方法：将60只健康SD大鼠随机分为空白组、模型组、电针组和针刀组。将4%木瓜蛋白酶溶液与0.3mol/L半胱氨酸溶液按1：1混合静置0.5h后分别于造模第1、4、7天注射于后3组大鼠左膝关节腔,每次20μl。造模第36天开始,相应给予针刀松解治疗或电针治疗,治疗3周后取大鼠腰膨大处脊髓及脑组织,分别测定脊髓、延髓、中脑、丘脑、海马的L-ENK含量。结果：造模后,模型组大鼠L-ENK含量在脊髓、中脑、海马较空白组差异均有统计学意义（P〈0.01）,延髓和丘脑L-ENK含量与空白组差异无统计学意义（P〉0.05）。针刀和电针干预后,针刀组海马中L-ENK含量较模型组升高,差异有统计学意义（P〈0.05）;针刀组中脑L-ENK含量较模型组降低,差异有统计学意义（P〈0.05）;海马中L-ENK含量针刀组较电针组高,差异有统计学意义（P〈0.05）;其余部位差异均无统计学意义（P〉0.05）。结论：针刀松解法对KOA大鼠中枢各水平的L-ENK有一定调节作用,其镇痛作用的发挥可能与其对中枢L-ENK的调节有关。     

全膝关节置换术后髌骨位置及活动度对全膝关节功能的影响

目的探讨全膝关节置换（TKA）术后患者髌骨位置、活动度的变化以及其对膝关节功能和活动的影响.方法 自1998年9月至2006年6月在上海交大医学院附属第九人民医院收治的205例初次TKA患者中选取资料完整、获得良好随访的51例患者（62个膝关节）,平均随访时间38.7个月,对其进行髌骨高度、倾斜角及侧方移动度进行测量,与术前对照,并与膝关节活动度做相关性统计分析,综合研究髌骨方面对膝关节功能影响的关键因素.结果 （1）TKA术后髌骨高度较术前下降,差别有统计学意义（P〈0.01）,髌骨外翻倾斜角减小;（2）髌腱短缩〉 10%时,其短缩程度与膝关节活动度呈负相关（r=-0.79,P〈0.01）;（3）髌骨活动度与膝关节活动度呈正相关（r=0.53,P〈0.01）.结论 （1）TKA术后髌韧带存在一定程度的短缩,髌骨不存在明显外翻;（2）髌骨位置及髌骨活动度影响膝关节功能：当髌腱短缩〉10%时,髌骨位置越低,膝关节活动度越小,膝关节功能越差;髌骨活动度越差,膝关节活动度越小.     

膝关节镜手术中局部麻醉和脊椎麻醉的临床比较

目的比较局部麻醉和脊椎麻醉在膝关节镜手术中的效果、可靠性及安全性.方法 自2008年6月至2010年5月对478例在脊椎麻醉或者局部麻醉下行膝关节镜检查的患者进行回顾性研究,其中局部麻醉186例（38.9%）,脊椎麻醉292例（61.1%）.局部麻醉患者用2%利多卡因加肾上腺素,局部及关节腔内注射,脊椎麻醉患者用0.75%布比卡因.对比以下指标：术中疼痛、患者及术者的满意度、术后疼痛、术后首次排尿时间、术后并发症.结果 局部麻醉和脊椎麻醉组中,分别有94.1%（175/186）和98.3%（287/292）的患者术中未感觉到疼痛;两组中分别有93.0%（173/186例）和96.2%（281/292例）的患者表示对麻醉效果满意或者很满意;术后6 h内患者疼痛比较,局部麻醉组与脊椎麻醉组间有统计学差异（P〈0.05）;术后首次排尿时间,局部麻醉组与脊椎麻醉组间有统计学差异（P〈0.05）;术后并发症的发生,两组间统计学上有明显差异,局部麻醉组明显低于脊椎麻醉组（P〈0.05）.结论 局部麻醉对于膝关节镜手术是一种简单、有效的麻醉方法,相比脊椎麻醉更具有可靠性和安全性,对于那些膝关节镜检查或者清理冲洗、游离体取出术甚至普通的半月板成形术均可采用局部麻醉下进行.     

TKA胫骨平台冠状位倾斜度与临床结果

目的研究TKA患者膝关节胫骨平台冠状位倾斜度与临床结果之间的关系。方法回顾性分析我科自2004年1月至2005年2月期间TKA的骨关节炎病例261例。按术后胫骨平台假体内外翻情况分为3组：A组（外翻组）、B组（中立组）和C组（内翻组）。结果 A、B、C三组间在患者性别比例、年龄、体重指数、止血带时间、术后引流量、术后住院时间方面无显著差异。术前膝关节畸形情况各组间无显著差异。各组间术前ROM及HSS评分无显著差异。在术后2周时的膝关节活动度方面,A组与B、C两组间均存在显著差异（P〈0.01）,B组与C组间存在显著差异（P〈0.05）。术后2周时HSS评分,A组与B、C两组间均存在显著差异（P〈0.05）,但B组与C组间无显著差异。术后2年HSS评分A、B、C三组间无显著差异。A组中有1例、B组中有2例,C组中有2例伤口脂肪液化;B组中有3例、C组中有1例术后出现患肢小腿肌间静脉血栓。结论 TKA术后冠状位倾斜度与术前因素、手术因素及手术并发症之间无显著相关性。TKA术后力线对近期临床结果可能有显著影响。通过进一步康复锻炼可弥补力线对长期临床结果的影响。     

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。     

碱性成纤维细胞生长因子缓释微球治疗兔膝骨关节炎的实验研究

目的 研究壳聚糖包被碱性成纤维细胞生长因子(bFGF)的缓释微球对实验兔膝关节骨性关节炎的治疗作用.方法 2008年11月至2009年7月,选取健康成年新西兰大白兔54只,随机分成6组:对照组、模型组、PBS微球组(PBS-M)、bFGF溶液组(bFGF-S)、10μgbFGF微球组(10-bFGF-M)及100μg bFGF微球组(100-bFGF-M).膝关节腔内注射木瓜蛋白酶建立兔膝骨关节炎模型(对照组除外).除模型组外其余各组分别于建模后第3周和第6周于关节腔内注射1ml干预液,分别含PBS微球、bFGF溶液、10μg bFGF微球及100μg bFGF微球.于第9周处死动物后取材,通过大体及组织病理学检查评价实验结果.结果 根据Ink评分及Mankin评分结果,模型组关节软骨损伤程度重于对照组(t=8.22,P=0.00;t=17.20,P=0.00),PBS-M组、bFGF-S组的关节软骨损伤程度与模型组近似(Ink评分:t=0.26,P=0.79;t=0.80,P=0.45;Mankin评分:t=1.51,P=0.17;t=0.56,P=0.60),而10-bFGF-M组和100-bFGF-M组关节软骨损伤程度较模型组明显减轻(Ink评分:t=3.58,P=0.01;t=6.82,P=0.00;Mankin评分:t=3.41,P=0.01;t=5.00,P=0.00).100-bFGF-M组与10-bFGF-M组相比关节软骨损伤程度明显减轻(t=50.29,P=0.00;t=2.80,P=0.02).结论 bFGF缓释微球能维持bFGF关节腔内的有效浓度,可能通过加速蛋白多糖的合成并抑制其分解等作用机制逆转了关节软骨损伤的病理过程.

Abstract：

Objective To study the therapeutic effect of chitosan-coated basic fibroblast growth factor (bFGF) slow-releasing microspheres on the knee osteoarthritis in the rabbit. Methods From November 2008 to July 2009, 54 New Zealand rabbits were divided into 6 groups at random, which were the control group, the model group, the PBS-M group, the bFGF-S group, the 10-bFGF-M group and the 100-bFGF-M group, respectively. The model of knee osteoarthritis was induced by the injection of papain in the rabbit. Except the control and model groups, all the experimental groups were implanted 1 ml intervention solution at the third and sixth weeks, including the PBS microspheres, bFGF solution, 10 pμg bFGF microspheres and 100 μg bFGF microspheres, respectively. The rabbits were sacrificed at the ninth week after operation, and then articular cartilage was conducted the morphological and histopathological evaluation. Results The damage of articular cartilage in the model group was more serious than that in the control group, with statistical differences according to the Ink score (t = 8. 22, P = 0. 00) and Mankin score (t = 17. 20, P =0. 00). The damage of articular cartilage in the PBS-M and bFGF-S groups were similar with that in the model group, according to the Ink score (t =0. 26, P =0. 79; t =0. 80, P =0.45) and Mankin score (t =1.51, P=0. 17; t =0.56, P=0.60). The Ink and Mankin scores in the 10-bFGF-M and 100-bFGF-M groups were better than that in the model group (Ink score: t =3.58, P =0. 01; t =6. 82,P=0.00; Mankin score: t =3.41, P=0.01; t =5.00, P=0.00), with the 100-bFGF-M group much better (t =5.29, P =0. 00; t =2. 80, P =0. 02). Conclusions The bFGF slow-releasing microsphere can keep its effective intra-articular concentration, which may accelerate the synthesis of protcoglycan and inhibit its decomposition to reverse the damage of articular cartilage.     

壳聚糖微球转染人IL-1Ra与TGF-β1基因治疗兔骨关节炎

目的 探讨壳聚糖微球转染人IL-1Ra与TGF-β1基因治疗兔膝关节早期骨关节炎的方法与效果.方法 制备分别包裹IL-1Ra质粒DNA和TGF-β1质粒DNA的壳聚糖微球缓释系统,分组向兔膝关节早期骨关节炎模型关节腔注射含IL-1Ra基因和(或)TGF-β1基因的壳聚糖微球、不含上述基因的壳聚糖溶液,定期处死,使用ELISA检测关节腔灌洗液的IL-1Ra、TGF-β1浓度,取关节标本Mankin评分、苏木精-伊红(HE)染色、番红O染色及免疫组化检测.结果 经过60 d观察,壳聚糖微球转染基因组的IL-1Ra与TGF-β1的基因可持续表达,双基因组的软骨标本从外观、染色观察,损伤程度轻于单基因组.双基因组的Mankin评分明显低于单基因组(P＜0.05),单基因组的Mankin评分明显低于空白组(P＜0.05).结论 关节腔注射壳聚糖微球转染IL-1Ra与TGF-β1基因能抑制软骨的退变和促进软骨的修复.

Abstract：

Objective To explore the method and effect of transinfection of rabbit early knee osteoarthritis models via chitosan microsphere with gene of recombined human IL-1Ra gene and TGF-β1 gene. Methods Chitosan microspheres with plasmids of IL-1Ra gene and TGF-β1 gene, and rabbit early knee osteoarthritis models were prepared. Rabbits in different groups had intra-articular injections of chitosan microsphere containing IL-1Ra gene and / or TGF-β1 gene, and chitosan solution as control group before being executed regularly and randomly. The joint specimens were evaluated by HE staining, lycopene red O staining and immunohistochemical analysis and Mankin's score. ELISA was used for detection of IL-IRa and TGF-β1 concentration of articular cavity fluid in each group. Results The control group was consistent with the pathological changes of early OA. In co-transinfection group, judging from the appearance and staining of cartilage,the OA damage of the specimens was less serious than other groups'. Its Mankin's score was significantly lower than single-gene transinfection group (P ＜ 0.05), and the latters Mankin's score were significantly lower than control group (P ＜ 0.05). Conclusion Intra-articular injection of chitosan microspheres containing both IL-1Ra gene and TGF-β1 gene could inhibit the degeneration of cartilage and promote cartilage repair.     

自体腘绳肌腱鞘内重建前交叉韧带的临床观察

目的：观察在自体腘绳肌腱重建前交叉韧带（anterior cruciate ligament,ACL）手术中,保留原ACL胫骨残端的鞘内重建方法,对术后2年膝关节功能的影响。方法：2007年1月至2009年6月,江苏省昆山市中医院骨科收治的ACL损伤病例中,经关节镜下证实ACL胫骨端韧带残端保留1/3以上18例,男11例,女7例;平均年龄28.2岁（18～42岁）;从第1次受伤到术前平均6.8个月（1～18个月）。取自体腘绳肌腱（半腱肌腱和股薄肌腱）分别对折后编织成移植物备用。保留ACL胫骨残端,制备股骨和胫骨隧道后,将移植物经ACL残端纤维束内引入骨隧道,ACL残端呈鞘状包绕移植物。股骨端Rigidfix固定,胫骨端Intrafix固定。记录术后最后一次随访时的Lysholm评分,以评价膝关节功能;同时评价患者膝关节的稳定性和活动度;并通过再成角试验评估患膝本体感觉功能。结果：18例均获随访,时间15～24个月,平均17.3个月,术后无滑膜炎、韧带再断裂、活动明显受限等并发症。术前和术后最后一次随访时Lysholm评分,分别为（49.43±2.85）分和（91.56±4.60）分（P〈0.05）。术后最后一次随访时在屈膝15°、30°、45°位置的再成角试验,患侧与健侧差异无统计学意义（P〉0.05）。结论：保留原有残端的ACL重建术,能有效恢复膝关节功能,并有利于本体感觉的重建。     

Acute primary total knee arthroplasty for peri-articular knee fractures in patients over 65 years of age

Peri-articular knee fractures in osteoporotic or osteoarthritic bone present a challenge to fixation, mobilisation or non-operative management. We present a series of 15 proximal tibial and 11 distal femoral fractures treated with total knee arthroplasty at over mean follow-up period of 38.8 months. The mean age of the patients was 80 years. The choice of the implant and level of constraint was determined as per the nature of injury and preference of the surgeon dealing with the fracture. Patients were allowed rapid mobilisation with immediate full weight-bearing. Good clinical results were achieved with fracture healing, sound fixation and well-aligned flexible knees. Mean Knee Society knee score was 90.2; Knee Society function score was 35.5; Oxford Knee score was 39.5; and Short Form (SF)-36 physical function score was 37.3 and mental score 50.6. Good correlation was noted between Knee society knee score and SF-36 physical function score (Pearson's 0.76, p = 0.001), suggesting that generic health would dictate the final function achieved, whilst high knee scores suggest the satisfactory results of the operation. Analogous to arthroplasty for hip fractures, this technique should be considered as a treatment option in elderly peri-articular knee fractures with osteoporosis and/or osteoarthritis.     

膝关节多发韧带损伤的修复与重建

目的 探讨关节镜下重建膝关节前十字韧带(anterior cruciate ligament,ACL)、后十字韧带(posterior cruciate ligament,PCL)、后内侧韧带结构(posteromedial complex,PMC)或后外侧韧带结构(posterolateral complex,PLC)损伤的疗效.方法 2005年3月至2007年5月,43例膝关节多发韧带损伤患者采用异体肌腱于关节镜下重建ACL和PCL,同期重建增强PMC或PLC损伤.其中24例行ACL和PCL重建+PMC重建,19例行ACL和PCL重建+PLC重建.根据国际膝关节文献委员会(International Knee Documentation Committee,IKDC)评分和Lysholm膝关节功能评分表对患膝功能进行评估.结果 全部患者随访24～48个月,平均(33.10±9.65)个月.患者在0°和20°应力测试时稳定性均完全恢复.IKDC评分入院时均为显著异常(D级),术后随访时正常(A级)29例(67%,29/43)、接近正常(B级)11例(26%,11/43)、异常(C级)3例(7%,3/43).患者术前Lysholm膝关节功能评分为(46.7±4.2)分,末次随访时为(89.6±2.8)分,差异有统计学意义(t=8.563,P＜0.01).结论 膝关节多发韧带损伤可于关节镜下行ACL和PCL联合重建,同期行关节外韧带结构修复增强,能有效恢复关节功能,治疗效果满意.

Abstract：

Objective To describe the surgical technique and outcomes of arthroscopic reconstruction anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) and repair of the injured posteromedial complex (PMC) or posterolateral complex (PLC) structures of the knee joint in treatment of multiple ligaments injuries of knee. Methods From March 2005 to May 2007, 43 patients with multiple ligaments injuries of knee underwent arthroscopic reconstruction. Twenty-four patients were treated with arthroscopic reconstruction of combined ACL and PCL with allograft tendons and augmentation of PMC. The other 19 patients were treated with repair the PLC in addition to reconstruction of ACL and PCL. The International Knee Documentation Committee (IKDC) and Lysholm knee score were used for function evaluation. Results All patients were followed up for 24 to 48 months with an average of 33.10±9.65 months. The stability recovered when stress was applied to the knee at 0° and 20° of flexion. According to IKDC there was a significant improvement from severely abnormal (graded D) in 43 cases before surgery to normal (graded A) in 29 cases (67%), nearly normal (graded B) 11 cases (26%) and abnormal (graded C) 3 cases (7%) at follow-up. The average Lysholm score of the all cases were 46.7±4.2 and 89.6±2.8 before operation and at final follow-up, respectively (t=8.563, P＜0.01). Conclusion Excellence clinical results and good stability were achieved with arthrescopic reconstruction of ACL and PCL combined with repair or augmentation of the PMC and PLC simultaneously.