微创喙锁韧带重建与锁骨钩钢板置入内固定治疗TossyⅢ型肩锁关节脱位：功能恢复的对照比较

背景：以往采用交叉克氏针固定、克氏针张力带固定、喙锁螺钉、桥接技术等治疗TossyⅢ型肩锁关节脱位的效果都不是很满意。 目的：分析微创喙锁韧带重建与锁骨钩钢板置入内固定治疗TossyⅢ型肩锁关节脱位的疗效差异。 方法：将63例TossyⅢ型肩锁关节脱位患者随机分为两组,分别采用微创喙锁韧带重建与锁骨钩钢板置入内固定治疗。 结果与结论：微创喙锁韧带重建组治疗后第1个月Karlesson疗效评价肩锁关节功能优质率为92%,第3个月为88%;锁骨钩钢板置入内固定组治疗后1个月Karlesson疗效评价肩锁关节功能优质率为79%,第3个月为76%。微创喙锁韧带重建组治疗后第1,3个月肩锁关节功能恢复优质率高于锁骨钩钢板置入内固定组(P < 0.05)。说明运用微创喙锁韧带重建治疗TossyⅢ型肩锁关节脱位较锁骨钩钢板置入内固定操作方便,创伤较小,疗效更加安全可靠。     

AO钩型接骨板置入治疗NeerⅡ型锁骨远端骨析

背景：既往锁骨远端骨折常采用克氏针张力带或普通钢板螺钉固定,易出现张力带钢丝的松弛、螺钉松动及钢板断裂、针道感染,甚至内固定失败等现象。近年来,AO钩板内固定治疗该类骨折取得良好疗效,但是由于钩型接骨板中板钩的存在,理论上仍然影响肩关节功能,在这一点不同学者有不同的观点。 目的：观察AO钩型接骨板并喙锁韧带修复或重建治疗NeerⅡ型锁骨远端骨折的效果。 方法：北京大学人民医院创伤骨科2002-09/2008-03使用AO钩型接骨板置入治疗NeerⅡ型不稳定性锁骨远端骨折27例,并在术中采用了直接修复或肌腱移植方法重建喙锁韧带,术后2周开始康复训练。X射线检查判断骨折愈合情况,采用Constant-Murley评分系统评价肩关节功能。 结果与结论：27例患者得到6个月以上随访,置入后3个月骨折愈合,置入后平均8.2个月取出内固定,肩关节功能恢复满意,Constant-Murley评分平均87分。结果表明AO钩型接骨板内固定是治疗锁骨远端NeerⅡ型骨折较理想的方法,但在内固定的同时必须注意喙锁韧带的修复或重建。     

锁骨钩钢板置入治疗RockwoodⅢ型肩锁关节脱位56例

背景：目前对Ⅲ型肩锁关节脱位的治疗是行保守治疗还是手术治疗,以及采用何种手术方式治疗,仍存在很大争议。 目的：观察锁骨钩板置入治疗RockwoodⅢ型肩锁关节脱位的临床疗效。 方法：选择2005-12/2008-06宜昌市夷陵区医院骨科收治的RockwoodⅢ型肩锁关节脱位患者56例,男42例,女14例,年龄16~65岁,平均32岁。均采用锁骨钩钢板置入进行治疗,分别于术前、术后1年取出内固定前、取出内固定后3个月采用目测类比评分、美国肩肘外科医师评分、Constant and Murley评分系统进行评定,比较钢板置入前后患者肩关节功能的变化及有无并发症发生。 结果与结论：全部患者均顺利完成手术且获得随访,随访时间15~30个月,平均20个月。均在1年左右取出内固定,行喙锁韧带修复者32例,未行喙锁韧带修复者24例。取出内固定后肩锁关节脱位复发2例,均未行喙锁韧带修复。本组有2例出现肩痛、异物感,无内固定失败病例。术后1年取内固定前目测类比评分较术前降低,ASES、Constant and Murley评分较术前升高(P < 0.01);取内固定后3个月目测类比评分较术后1年取内固定前降低,ASES、Constant and Murley评分较术后1年取内固定前升高(P < 0.05)。提示锁骨钩板置入治疗RockwoodⅢ型肩锁关节脱位,操作简单,创伤较小,是一种比较理想的内固定。     

金属缝合锚治疗肩锁关节脱位20例

背景：肩锁关节脱位由于固定难度大,后期并发症高,临床治疗较为棘手。对于严重肩锁关节脱位的治疗,存在诸多争议。 目的：介绍应用锁骨远端切除缝合锚重建喙锁韧带治疗肩锁关节脱位的方法,以及临床病例随访疗效分析。 方法：对四川省骨科医院2006-11/2009-01收治的20例肩锁关节脱位患者进行随访,均行锁骨远端切除,缝合锚临时重建喙锁功能,联合腱外1/2转位重建喙锁韧带,可避免肩锁关节炎的发生。最终随访时应用放射学评估,并采用UCLA评分、Constant评分以及肩关节简明测试问卷SST进行肩关节功能评估。 结果与结论：重建后随访9~26个月,所有患者术中锁骨远端高度均达到解剖复位。终末随访时,平均UCLA评分为33分,平均Constant评分为91.6分,平均前屈上举146.4°,平均外旋45.6°,肩关节简明测试问卷SST的肯定答案平均为 12个,总体优良率为85%(17/20)。缝合锚组织相容性好,生物适应性佳,固定坚固可靠,可确保充分的初期固定;锁骨远端切除预防了肩锁关节炎的发生;联合腱外侧半作为移植物的来源有足够的长度,同时也避免牺牲喙肩韧带,从而保存了完整的喙肩弓。提示应用锁骨远端切除缝合锚重建喙锁韧带治疗肩锁关节脱位,可恢复喙锁韧带维持喙锁间隙的功能,手术时间短,重建后并发症少,无需二次手术,配合重建后功能锻炼,肩关节功能能够恢复至原有水平。     

锁骨钩钢板联合松质骨螺钉置入治疗肩锁关节脱位合并喙突骨折3例并

回顾性分析2006-01/2008-03解放军第二军医大学长海医院骨科收治的肩锁关节脱位合并喙突骨折患者3例，男2例，女1例；年龄28~37岁，平均32.3岁；2例左侧，1例右侧。3例患者均行切开复位锁骨钩钢板置入内固定，喙突松质骨螺钉置入内固定。置入后通过肩锁关节脱位评分系统ASSS对患者肩功能进行评定。摄X射线平片观察复位和骨折愈合情况及内固定位置。3例患者置入均顺利完成，手术时间55~70 min，平均62.3 min，未见相关并发症发生。置入后按指导完成功能锻炼，康复满意。随访6个月~1年，所有患者喙突骨折均愈合，喙突解剖对位或接近解剖对位。肩锁关节复位，肩关节无疼痛，可从事各种活动，肩关节外展、前展、后伸受限小于10°，ASSS功能评定为优。通过对文献分析，喙突骨折的发生是由于附着于喙突之上的喙肱肌与肱二头肌联合肌腱、胸小肌肌腱强力收缩牵拉所致，而并非喙锁韧带牵拉。锁骨钩钢板联合松质骨螺钉置入内固定喙突，可有效治疗肩锁关节脱位合并喙突骨折，置入后肩关节功能恢复良好，并发症少。     

锁骨钩钢板内固定联合异体肌腱移植重建喙锁韧带的功能评价

锁骨钩钢板是依照肩锁关节部位解剖特点设计，与锁骨外形匹配，并与骨干良好贴附。内固定不经过关节具有使用方便、固定可靠、允许被固定的肩锁关节有一定的微动，患者可早期活动关节、避免骨性关节炎产生等优点。异体肌腱来源充足、取材方便、修复时间短、减少患者新的损伤。经深低温冷冻后其抗原性及免疫排斥反应显著降低，组织相容性好，修复后不需要使用免疫抑制剂。采用异体肌腱重建的喙锁韧带经过重塑形而成熟，具有较好的材料强度，能满足局部应力要求，能较好地替代喙锁韧带的完整性及功能，效果确切，操作简便，在去除钢板后发挥永久固定作用，是锁骨钩钢板固定的重要补充。锁骨钩钢板内固定联合异体肌腱移植符合肩锁关节稳定性重构的治疗要求，有效提供了早期机械性稳定及后期生物性稳定，最大限度地恢复了肩锁关节的结构及功能。     

肩锁关节脱位手术治疗中修复重建方式及修复材料的临床应用研究与进展

目的：目的：综合分析目前国内外肩锁关节脱位手术治疗中关于重建修复方式及修复材料的研究进展。 资料来源：检索人为第一作者,检索文献时限1996-01/2009-04,检索数据库包括CNKI 中国知网数据库 (http://dlib.cnki.net)、PubMed数据库 (http://www.ncbi.nlm.nih.gov/pubmed/)。英文检索词为“acromioclavicular joint, dislocation, operative treatment, literature review”;中文检索词为“肩锁关节,脱位,手术治疗,综述” 。检索文献类型包括基础研究、临床研究、综述及病例报告。 资料选择：纳入具有原创性、论点论据可靠的试验文章,观点明确、分析全面的文章及文献主题内容与课题联系紧密的文章。排除重复研究。 结局评价指标：选取与肩锁关节脱位手术治疗中关于重建修复方式及修复材料的相关文献,其中中文206篇,英文229篇。排除391篇内容陈旧或重复文献,纳入44篇符合标准的文献。 结果：肩锁关节脱位是临床上较为常见的脱位之一,由于肩锁关节是非刚性关节、微动关节,传统的坚强固定都只是非解剖固定方法,总体疗效欠佳。在探索治疗方法过程中,逐渐认识到喙锁韧带在肩锁关节稳定中的重要性,其重建修复方式及修复材料已是目前研究重点。 结论：目前肩锁关节脱位手术包括肩锁关节固定、喙锁间固定、喙锁韧带重建修复、动力性肌肉转移及锁骨远端切除等,各有优缺点。传统固定方法需要解决如何解剖复位固定肩锁关节的问题,重建修复喙锁韧带方法需要在修复材料选择、生物力学、长期临床随访方面进一步完善。 关键词：肩锁关节;脱位;手术治疗;综述     

三重固定纽扣钢板肩锁关节复位的生物力学

背景：研究表明喙锁韧带在维持肩锁关节的稳定性中起重要作用,因而重建喙锁韧带至关重要。 目的：对比观察三重固定纽扣钢板重建肩锁关节复位的生物力学性能。 方法：采集新鲜肩关节标本15具,造成肩锁关节脱位,分别行三重固定纽扣钢板重建和双Endobutton钢板重建,进行生物力学应力分析,对照比较两者重建肩锁关节的性能和效果。 结果与结论：三重固定纽扣钢板技术在应力-应变关系中,强度比正常喙锁韧带和双Endobutton钢板分别高25%和15%,弹性模量分别高17%和14%,轴向刚度分别高24%和14%,差异均有显著性意义(P < 0.05)。 结果提示,三重固定纽扣钢板重建肩锁关节的生物力学性能,在强度、刚度均远超过初始的喙锁韧带的生物力学性能,而三重固定纽扣钢板重建肩锁关节复位的性能和效果比双Endobutton钢板重建更具有力学上的优势。     

同种异体肌腱重建喙锁韧带治疗肩锁关节脱位及锁骨远端骨折23例

背景：临床研究表明，经过消毒和深低温处理的异体肌腱不会引起全身的免疫反应，局部的免疫反应也轻微，其力学性质不受影响，应用异体肌腱移植治疗膝关节韧带损伤的临床效果与自体肌腱移植相比无明显差异。 目的：探讨应用异体肌腱重建喙锁韧带治疗肩锁关节脱位及锁骨远端骨折的效果。 方法：23例(侧)患者，男17例，女6例；年龄19~45岁，平均30.4岁。其中TossyⅢ型肩锁关节脱位18例，NeerⅡ型锁骨外端骨折5例。右侧15例，左侧8例，均为新鲜脱位或骨折，其中1例肩锁关节脱位合并臂丛牵拉伤。应用同种异体肌腱，通过锁骨远端的两个钻孔，绕过喙突基底部，分别重建锥形韧带和斜方韧带。 结果与结论：23例患者均获随访，随访时间12~26个月，平均16.5个月。切口均一期愈合，5例锁骨远端骨折患者，4个月骨折愈合，未见畸形愈合。按Karlsson标准评定优19例，良4例。未发生与材料有关的生物相容性反应，未引起全身和局部免疫反应。结果提示应用同种异体肌腱重建喙锁韧带，手术操作简单、创伤小、疗效满意。     

肱骨近端锁定钢板置入结合Osteoset人工骨治疗肱骨近端骨折随访：22例

背景：螺钉、克氏针张力带钢丝、髓内钉、三叶草钢板等置入内固定肱骨近端骨折的疗效欠佳,常出现螺钉固定不牢或松动等现象,影响肱骨头血运与肩关节外展功能。 目的：观察肱骨近端锁定钢板置入内固定结合Osteoset人工骨植入治疗肱骨近端骨折的临床效果。 方法：应用肱骨近端锁定钢板置入内固定结合Osteoset人工骨植入治疗22例肱骨近端骨折病例。 结果与结论：所有病例随访12~24个月均骨性愈合,根据Neer疗效评分标准,优13例,良7例,可2例,差0例,优良率为91%;治疗后X射线显示所有肱骨近端骨折及肩关节脱位均获得了满意复位。说明肱骨近端锁定钢板置入内固定结合Osteoset人工骨植入治疗肱骨近端骨折疗效肯定。     

Denervation study of synapses of organ of corti of old world monkeys

Fine structural characteristics of synapses in the spiral organ of Corti were examined, with reference to differences between inner and outer haircell systems, and to location of neurons of origin of efferent axons. Surgical interruption of crossed olivocochlear bundle, of vestibular nerve, of facial nerve, and excision of superior cervical ganglia were used to determine the pathways of efferent axons. Interruption of the vestibular nerve near the brainstem results in degeneration of all efferent terminals on outer hair cells. Mid-line lesions at, and caudal to, the facial colliculus result in degeneration of about half of these efferent terminals. Efferent synaptic bulbs to the inner hair-cell system are small, of the order of one micron, and form type 2 junctions with afferent dendrites. They tend to have more large dense-core vesicles (about 80 nm) than the large efferent terminals of the outer hair-cell system, and appear to be the terminals of axons in the habenula perforata, which exhibit varicosities laden with large dense core vesicles. The varicosities are unaffected by excision of the superior cervical ganglia. So far as our material can reveal, it appears that the varicosities in the habenula perforata do not survive vestibular root interruption, nor do the efferent processes in the internal spiral bundle or at the base of inner hair cells. Most interestingly, the afferent processes of the inner hair-cell system, as identified for example by their relation to pre-synaptic bodies in the inner hair cells, are subject to a trans-synaptic reaction after severance of the vestibular root. They undergo a dramatic cytological transformation, characterized by increase of volume, engorgement with microtubules, microfilaments, microvesicles of various sizes, and clusters of lysosomes. Thus, both the efferent and afferent terminals of the inner hair-cell system show marked cytological differences from the corresponding terminals of the outer hair cell system.     

Mechanism of action of tubocurarine on nicotinic cholinoreceptors of neurons of the sympathetic ganglia of rats

Tubocurarine (Tc) effect on membrane currents elicited by acetylcholine (ACh) was studied in isolated superior cervical ganglion neurons of rat using patch-clamp method in the whole-cell recording mode. The "use-dependent" block of ACh current by Tc was revealed in the experiments with ACh applications, indicating that Tc blocked the channels opened by ACh. Mean lifetime of Tc-open channel complex, tau, was found to be 9.8 +/- 0.5 s (n = 7) at -50 mV and 20-24 degrees C. tau exponentially increased with membrane hyperpolarization (e-fold change in tau corresponded to the membrane potential shift by 61 mV). Inhibition of the ACh-induced current by Tc (3-30 microM/1) was completely abolished by membrane depolarization to the level of 80-100 mV. Inhibition of ACh-induced current was augmented at increased ACh doses. It is concluded that the open channel block produced by Tc is likely to be the only mechanism for Tc action on nicotinic acetylcholine receptors in superior cervical ganglion neurons of rat.     

The effect of age of onset of PD on risk of dementia

Background Dementia occurs in the majority of patients with Parkinson’s disease (PD). Late onset of PD has been reported to be associated with a higher risk for dementia. However, age at onset (AAO) and age at baseline assessment are often correlated. The aim of this study was to explore whether AAO of PD symptoms is a risk factor for dementia independent of the general effect of age. Methods Two community-based studies of PD in New York (n = 281) and Rogaland county, Norway (n = 227) and two population-based groups of healthy elderly from New York (n = 180) and Odense, Denmark (n = 2414) were followed prospectively for 3–4 years and assessed for dementia according to DSM-IIIR. All PD and control cases underwent neurological examination and were followed with neurological and neuropsychological assessments. We used Cox proportional hazards regression based on three different time scales to explore the effect of AAO of PD on risk of dementia, adjusting for age at baseline and other demographic and clinical variables. Findings In both PD groups and in the pooled analyses, there was a significant effect of age at baseline assessment on the time to develop dementia, but there was no effect of AAO independent of age itself. Consistent with these results, there was no increased relative effect of age on the time to develop dementia in PD cases compared with controls. Interpretation This study shows that it is the general effect of age, rather than AAO that is associated with incident dementia in subjects with PD. Received in revised form: 22 December 2005     

Limits of deinstitutionalization--perspectives of relatives of psychiatric patients

After a hopeful beginning, the social process of the reintegration of those with severe mental illness has come to a standstill. I am led to wonder whether "the community" really wants to live together with people suffering from severe mental illness, and if so, how closely? As long as the medical treatment of mental illness provided by the general practitioners is fundamentally deficient, as they are not able to prescribe the necessary interventions--such as out-patient psychiatric nursing, and service providers in the out-patient sector are content with offering increasingly intensive forms of care for the less seriously ill at the cost of the Social Welfare System--the reintegration of those with serious mental illness remains an illusion--which is mainly to the benefit of providers of residential care in homes and hostels.     

Summary of legislation of 1935 of interest to the department of Mental Hygiene

Psychiatric Quarterly -