微创技术治疗跟骨骨折进展

正跟骨骨折发病率占跗骨骨折发病率的60%,全身骨折的2%~([1])。不及时或治疗方法选择错误常导致患足出现严重的功能障碍,致残率可高达30%。传统的"L"形经外侧扩大入路切复内固定术一直被视为治疗移位跟骨骨折的首选方法,但这一方法常会发生术后切口皮肤坏死、感染和内植物外露等诸多并发症~([2]),极大地影响了跟骨骨折的手术疗效,如何最大限度减少手术并发症成了足踝创伤外科医生们积极探索的目标和动力。近年来随着微创技术和理念运用到各类跟骨骨折的治疗中并已取得了满意的疗效,现将这些微创技术方法做一简要阐述。     

切开复位外侧边缘骨皮质植骨加内固定治疗跟骨关节内骨折移位

跟骨骨折是跗骨中最常见的骨折,占跗骨骨折的20%～30%[1].目前,对移位的跟骨关节内骨折有保守和手术治疗两大类.保守治疗包括患肢的抬高、冷敷、早期关节活动、石膏外固定以及夹板固定.手术治疗包括闭合的经皮撬拨术、切开复位内固定术及距下关节融合术[2].近十年来,随着研究的深人和内固定器材的发展,对有移位的跟骨关节内骨折越来越多的采取手术内固定治疗.已有较多文献报道内固定加植骨术取得成功[1,3].但骨源多为髂骨和人工骨.我们自2004年1月至2007年6月,采用切开复位外侧边缘骨皮质植骨加内固定治疗跟骨关节内骨折移位60例,疗效满意,报告如下.     

跟骨骨折的治疗现状与微创趋势

<正>跟骨骨折占全身骨折的2%,全部跗骨骨折的60%~([1])。在发展中国家,实际发病率可能更高。跟骨骨折会导致患足出现严重的功能障碍,致残率很高,患者多为青壮年,一旦遗留残疾,对家庭、社会都会造成巨大的损失。经典的外侧扩大"L"形切口经跟骨外侧切开复位内固定术一直被认     

跟骨骨折的治疗进展

<正>跟骨骨折占全身骨折的2%左右,也是致残率很高的骨折之一~([1])。早期伤口处理、长期疼痛、创伤后关节炎、再手术等都是跟骨骨折常见的问题。跟骨骨折的治疗很有挑战性,也有很多争议。近年来微创治疗跟骨骨折有增加的趋势,并取得了很好的临床疗效。1跟骨骨折的发病机制及分型多数跟骨骨折属于高能量损伤,以高处坠落伤     

跟骨关节内骨折的诊断与治疗

跟骨骨折是跗骨中最常见的骨折,约75%的跟骨骨折为关节内骨折。虽然跟骨骨折的治疗经验日益增多,但对其诊断和处理仍存在争论,包括最合适的分类方法、治疗方法的选择、手术治疗的指征、手术入路及术后处理等。本文对跟骨关节内骨折的诊断和治疗进行综述。对于有移位的跟骨关节内骨折,手术疗效优于保守治疗。     

跟骨关节内骨折的手术治疗

跟骨骨折是临床常见骨折之一,约占全身骨折的1%~2%[1],以青壮年居多。跟骨关节内骨折如果早期处理不当,可导致严重的疼痛跛行,甚至病废。我们自2000年始对严重的跟骨关节内骨折采用手术治疗,取得了满意的效果,现报告如下。1临床资料本组25例(28足),男21例,女4例;年龄18~42岁,平     

手术治疗跟骨关节内骨折效果不良原因分析

跟骨关节内骨折占跟骨骨折的85%-95%以上[1].以往大部分跟骨骨折采用保守治疗,但随着各类型跟骨钢板的广泛应用目前已倾向于手术治疗,而且取得了较满意的效果[2].但仍有部分患者行手术治疗后效果较差,功能恢复不满意,现就其原因进行讨论.     

手术与非手术治疗跟骨关节内移位骨折的疗效对比

正跟骨骨折是最常见的足部骨折,其中75%为关节内骨折。尽管影像学及手术技巧的发展日益进步,但是关于跟骨关节内移位骨折的最佳治疗方案目前仍存在争议。本研究对跟骨关节内移位骨折患者进行前瞻性多中心随机对照临床试验,比较手术与非手术治疗患者遗留性疼痛程度、功能恢复情况及生活     

跟骨关节内骨折

跟骨是足部诸骨中最大的一块跗骨,由跟骨后关节面与距骨距下面构成跟距关节(又称距下关节),承担着约45%左右的人体体重。当跟骨发生骨折时,如果骨折线累及到跟距关节面称为跟骨关节内骨折。如果骨折线未累及跟距关节面,则称为跟骨关节外骨折,后者治疗方法简单,且预后良好,本文不予赘述。跟骨骨折中85%～90%以上均为跟骨关节内骨折,但在20世纪70年代以前,跟骨关节内骨折的治疗结果一直令人失望。Ｍａｇｎｕｓｏｎ[1]在总结了大量病例后曾指出:没有一种骨折象跟骨关节内骨折那样带来30%～70%的足部功能障碍。近年来,随着对跟骨关节内骨折生物…     

跟骨关节内骨折的微创治疗进展

目前对于跟骨关节内骨折的最佳治疗方法尚未达成共识,而经典的"L"型外侧扩大切口由于可彻底暴露跟骨、保护腓肠神经,以及降低腓骨肌腱炎的发病率,临床应用最为广泛.但该入路导致的软组织并发症发生率高[1].Folk等[2]报告了190例跟骨骨折患者术后的软组织并发症发生率为25％,其中21％的患者需要二期手术.伤口软组织并发症严重影响了跟骨骨折手术治疗的最终疗效,甚至有些学者质疑了手术干预的必要性.但跟骨关节内骨折仍是手术治疗的绝对指征,因此,如何减少跟骨骨折术后软组织并发症仍是目前临床的一大难题.随着微创技术在足踝部手术中的应用受到越来越多的重视及其推广应用,为跟骨关节内骨折的治疗提供了新思路.本文对跟骨关节内骨折的微创治疗进展做一综述.     

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.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

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.     

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.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

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.     

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.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.