后踝骨折治疗的研究进展

<正>踝关节骨折是常见的骨折类型,其中累及后踝的骨折最为复杂,治疗也相对困难。有报道其发生率占所有踝关节骨折的7%~44%[1,2]。由于踝关节的结构特点及损伤机制,暴力损伤以及距骨撞击穹窿通常导致外踝、内踝或胫骨远端先受到损伤,若暴力继续作用才会损伤后踝,所以后踝骨折很少单独发生。1分型踝关节骨折及胫骨远端Pilon骨折均可以涉及后踝,二者损伤机制不同,因此遵循的分类方法也不同。临床上踝关     

成人踝关节骨折生物力学分类的临床观察

作者在对160例成人踝关节骨折进行生物力学分析的基础上,建立了一种改良的根据损伤机制的分类法,能包括所有间接暴力所致的骨折,较Lauge-Hansen分类简单、合理、实用性强。     

踝关节骨折的手术治疗（附71例报告）

踝关节骨折常见,多为闭合骨折。不同暴力、位置可引起骨与韧带不同程度的损伤。目前对踝关节骨折的分类及治疗意见不一,传统的手法复位或石膏固定时间长且不确实,尤其是下胫腓联合的踝关节损伤疗效往往不满意。我院自1983年以来手术治疗71例踝关节骨折。获得满意疗效。报告如下。     

腓骨近段横形骨折合并下胫腓关节、腓总神经损伤1例

目的目的探讨腓骨近段横形骨折合并下胫腓关节、腓总神经损伤的临床诊治及其与Maisonneuve骨折鉴别。方法通过1例腓骨近段横形骨折合并下胫腓关节、腓总神经损伤患者的临床诊治体会,从损伤机制、临床表现及治疗方面与Maisonneuve骨折相鉴别。结果根据本病例的损伤机制、临床表现采取相应的治疗,治疗方法与Maisonneuve骨折不同,按照Baird—Jackson踝关节功能评定标准评分,结果97分。结论对于小腿近段直接暴力损伤造成腓骨近段横形骨折,其损伤机制、临床表现及治疗方面有别于Maisonneuve骨折。     

掌根部按压治疗踝关节损伤心得体会

踝关节损伤是中伤科门诊常见病，多由间接暴力所致。常由高处坠落、走不平道路、平路滑倒所致。由于踝关节不稳，使其过度向内、向外翻转所致，踝关节损伤可分骨折脱位和踝关节软组织损伤。我院多年来一直采取掌根部按压治疗踝关节部位骨折或踝关节软组织损伤，均取得良好效果，现总结报告如下。     

暴力致下胫腓关节分离的处理(附24例报告)

目的：探讨暴力致下胫腓关节分离的损伤机制及骨蚴栓在治疗下胫腓关节分离的临床应用价值。方法：对1994－1999年24例下胫腌联合分离患者，综合分析损伤机制，进行手术复位、骨螺栓固定术，术后早期功能练习。结果：所有24例患者均获得随访，6－8周去除螺栓后，踝穴稳定，踝关节功能无障碍。结论：踝关节多因暴力致下胫腓联合分离，常合并有踝关节骨折，骨螺栓固定治疗胫腌联合分离，固定可靠，并发症少，有利于踝关节早期负重和功能练习。     

踝关节Logsplitter损伤临床诊疗现状

踝关节作为人体最大的关节之一,在人体承重和日常生活中发挥着不可替代的作用,其骨折在临床中较为常见,约占骨折总数的3.92％[1].多数踝关节骨折为低能量损伤,以旋转暴力为主,有些骨折还会合并有下胫腓联合损伤,破坏了踝关节的稳定性[2],但很少伴有踝关节脱位.随着现代工业的迅速发展,以高能量垂直暴力为主的踝关节骨折呈现增...     

旋前外旋型踝关节骨折的诊断与治疗体会

踝关节是人体重要的负重关节,其结构复杂、关节活动度大.在人们日常行走、体育锻炼以及工作中,踝关节损伤时有发生.随着对踝关节骨折研究的深入和内固定技术的发展,踝关节损伤的治疗效果得到了显著的提升.但踝关节损伤后遗留慢性疼痛以及创伤性关节炎,并最终出现功能障碍的病例并不少见,除了踝关节本身结构精细、关节灵活和周围韧带结构复杂的原因外,医生对于踝关节损伤机制的认识不够深刻以及忽视病史及体格检查的重要性也是部分病人踝关节骨折术后功能恢复不满意的原因.     

旋前型踝关节骨折、脱位的研究进展

踝关节骨折、脱位是创伤骨科最常见的骨折、脱位之一。旋前型踝关节骨折、脱位的损伤机制较为复杂,包括下胫腓联合损伤。本文通过复习近 10年的文献,介绍旋前型踝关节骨折的生物力学特性、 X线评价和治疗方法。 临床上对踝关节骨折、脱位最普遍的分类方法有两种,即 Lauge- Hansen和 AO- Danis- Weber分类方法。 Lauge- Hansen按损伤机制将踝关节骨折、脱位分为旋后－内收、旋后－外旋、旋前－外展、旋前－外旋和垂直压缩五型;而 AO- Danis- Weber则主要根据腓骨骨折的水平将其分为 A、 B、 C三型。由于旋前－外展和旋前－外旋型…     

Maisonneuve骨折的诊疗研究进展

Maisonneuve骨折(MFF)是指旋转暴力引起的内踝结构、下胫腓联合的损伤及腓骨上端骨折的不稳定型踝关节损伤。MFF临床发病率低但漏诊率较高,详细询问病史了解受伤机制及完善的临床检查可减少漏诊。MFF的诊断及治疗方案目前仍存在较大争议,主要集中在受伤机制存在变异、三角韧带及下胫腓联合损伤是否修复及如何修复等问题。本文通过对相关文献进行回顾,对MFF的诊断与治疗方案的研究进展进行综述。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.