影响人工全髋关节置换稳定性的因素

背景：人工全髋关节置换后出现假体松动的现象较常见，了解影响人工全髋关节稳定性的因素对提高人工全髋关节置换疗效是十分必要的。 目的：总结近年人工全髋关节置换稳定性影响因素的最新研究进展，进一步认识人工全髋关节的稳定性。 方法：应用计算机检索中国期刊全文数据库1997-01/2010-12有关人工髋关节置换后假体无菌性松动的相关文章，检索词“人工关节，置换，稳定性”。检索文献量总计98篇，最终纳入符合标准的文献30篇。 结果与结论：人工全髋关节置换稳定性的影响因素及发病机制较为复杂，其主要原因是力学因素，其次是生物学因素，它们共同结果是造成骨吸收、骨溶解，最终导致假体松动、骨质破坏。其过程还与许多细胞因子的参与密切相关。针对引起人工全髋关节稳定性的影响因素，可以从关节材料、安放角度、抑制磨损颗粒移动、促进成骨及抑制骨吸收等方面来防治。     

股骨颈保留型人工髋关节置换42例：5年同一机构治疗者≥12个月结果随访

背景：继往的人工髋关节置换切除股骨颈,将严重改变压应力系统和张应力系统之间的受力平衡。而保留股骨颈则保留了股骨颈健康骨结构,使假体应力沿股骨近端生理状况分布,亦可防止股骨近端骨质疏松导致假体松动。 目的：评价股骨颈保留型人工髋关节在髋关节置换中的应用效果。 方法：2003-03/2008-04施行股骨颈保留型人工髋关节置换42例52髋,均应用S-ROM假体(Depuy,美国),假体分为髋臼部分和股骨部分。记录髋关节置换时间、术中出血量、置换后住院天数、Harris评分及围手术期并发症。置换后摄标准髋关节正侧位X射线片,并测量髋臼外展角和前倾角。 结果与结论：全部病例随访12~61个月,平均39个月。全髋关节置换时间30~70 min,平均45 min。术中出血70~200 mL,平均110 mL。置换后X射线片测量髋臼外展角平均44.1°,前倾角平均21°。置换后第5天髋关节摄片确认置入假体正常后即要求扶助行器下地活动。置换前髋关节功能Harris评分平均(32.7±6.3)分,置换后3个月Harris评分平均(93.2±4.1)分。提示股骨颈保留型人工髋关节置换具有创伤小、出血少、符合人体生物力学、假体稳定、假体磨损小的特点,可以作为传统股骨柄的替代治疗。     

高龄股骨转子间骨折人工关节置换的特点及假体选择

目的：探讨高龄不稳定型转子间骨折人工关节置换不同假体的选择策略及临床治疗特点。 方法：采用电子检索的方式,在万方数据库(http://www.wanfangdata.com.cn/)中检索2000-01/2010-08有关高龄股骨转子间骨折人工关节置换的研究文章,关键词为“股骨转子间,骨折,人工关节,高龄”。排除重复研究、普通综述或Meta分析类文章,筛选纳入25篇文献进行评价。 结果：高龄股骨转子间骨折人工髋关节置换前正确的假体选择很重要,应根据Evans标准分类以及股骨近端骨折情况进行选择。根据人工髋关节假体的类型,目前分为3类：第一类是根据不同的柄长来选择,即加长柄人工关节与普通柄长人工关节的选择;第二类是全髋关节假体与双极人工股骨头假体的选择;第三类是骨水泥型柄与生物型柄假体的选择。另外应该按照骨质情况选择,骨水泥型假体可获得置换后即刻稳定,因此绝大多数高龄不稳定型骨骨转子间骨折更适合于选择骨水泥型假体。 结论：根据骨折类型以及患者全身情况选择不同类型的人工关节假体来治疗高龄股骨转子间骨折安全有效,功能恢复快,并发症少。     

金属对金属髋关节表面置换后的有限元分析*

背景：与全髋关节置换相比,髋关节表面置换术有着诸多优势,如保留股骨头、股骨颈,方便于日后翻修,保存了股骨近端的生理力学分布,已成为年轻或对髋关节活动度要求较高的髋关节骨关节炎终末期患者更具吸引力的手术治疗方式。 目的：观察人工髋关节表面置换术后股骨及假体的应力分布。 设计、时间及地点：单一样本观察,于2007-09/2008-04在南方医科大学解剖及生物力学实验室完成。 对象：选择南方医科大学珠江医院收治的行金属对金属髋关节表面置换术男性患者1例(自愿参与实验),年龄40岁,检查排除健侧髋关节疾患。 方法：建立股骨和假体有限元模型,分析在步行峰值关节载荷作用下,表面置换术后股骨颈及假体的应力水平。 主要观察指标：股骨侧与假体的应力。 结果：①髋关节表面置换术后股骨受力总体模式不变,股骨颈存在应力遮挡。应力峰值存在于股骨颈基底部,与其他区应力值相比,差异具有显著性意义(P < 0.001),特别是转子窝附近以及骨-假体界面。②假体应力分布：应力峰值存在于髋臼及股骨假体外上方、髋臼杯沿与股骨假体交界处以及骨-假体界面。 结论：髋关节表面置换术后股骨受力总体模式不变,股骨颈存在应力遮挡。峰应力存在于股骨颈基底部及骨-假体界面,为了减少术后股骨颈骨折的发生率,术中应特别加以保护上述区域。     

人工髋关节置换后假体无菌性松动的因素及其防治

目的：通过对近些年关于人工髋关节置换后假体无菌性松动的不同方面最新进展进行汇总、探讨,进一步认识人工髋关节置换后假体无菌性松动。 方法：应用计算机检索中国期刊全文数据库1997-01/2008-12有关人工髋关节置换后假体无菌性松动的相关文章,检索词“人工关节;置换;无菌性松动”。纳入标准: ①人工髋关节置换后假体无菌性松动的诊断标准、生物及机械因素。②人工髋关节置换后假体无菌性松动的治疗、预防。 结果：人工髋关节置换后假体无菌性松动的发病机制较为复杂,其主要原因是磨损颗粒,其次是力学因素,它们共同结果是造成骨吸收、骨溶解,最终导致假体松动。其过程还与许多细胞因子的参与密切相关。针对引起关节假体无菌性松动的发病机制,可以从关节材料、抑制磨损颗粒移动、促进成骨及抑制骨吸收等方面来防治。 结论：人工髋关节置换后假体无菌性松动发病机制较为复杂,是多种因素作用的结果,涉及不同的学科领域。随着各学科的发展,人工髋关节置换后假体无菌性松动将逐步被彻底认识。     

高龄不稳定性股骨转子间骨折的髋关节置换：先置入假体再行骨折内固定

背景：近年来人工关节置换成为治疗高龄股骨转子间骨折的一种新方法。以往学者多习惯先处理骨折后置入假体,或先处理小转子,置入假体后再修复大转子。对于加长柄与标准柄长的使用,争论较大。 目的：验证人工关节置换治疗高龄不稳定性股骨转子间骨折的治疗效果,观察置换过程中置入假体与固定大小转子骨折块的操作顺序对修复效果的影响。 方法: 回顾性分析2006-01/2008-12解放军第451医院骨科应用人工关节置换治疗高龄股骨转子间不稳定型骨折28例的临床资料,20例行人工股骨头置换,8例行全髋关节置换,均采用骨水泥型人工关节。人工关节置换后观察X射线片、髋关节功能Harris评分变化及其并发症。 结果与结论：全组病例人工关节置换后随访1~4年,平均2.8年,疗效优良率为89.3%,未发现髋内翻、感染、松动、脱位者。人工关节置换能迅速恢复患肢功能,减少并发症的发生。置换要点是大、小转子骨折与人工假体关系的处理,应先置入假体,后以假体为支撑、行骨折内固定;做到假体与股骨近段紧密压配,是置换后假体稳定性的保证,加长柄与标准柄长均可使用。 关键词：人工关节置换;股骨转子间骨折;高龄;髋;不稳定性骨折;髋关节假体     

含抗生素骨水泥股骨柄与非骨水泥髋臼金属托结合全髋置换治疗中老年股骨颈骨折内固定失败19例

背景：中老年股骨颈骨折内固定失败后的治疗充满挑战性,最佳治疗方法尚未达到一致。 目的：观察含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合的全髋关节置换治疗股骨颈骨折内固定失败的效果。 方法：纳入股骨颈骨折内固定失败后行人工全髋关节置换患者19例,假体均为含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合的全髋关节。髋臼侧采用生物性假体压配固定,股骨侧采用带抗生素骨水泥假体固定。12例选取金属-聚乙烯承重界面,7例选取陶瓷-聚乙烯承重界面。置换后随访,定期摄片监测假体位置,并指导功能锻炼,记录髋关节功能恢复状况。 结果与结论：手术时间(110±55) min,术中出血量(510±60) mL,置换后出血量(310±40) mL。切口均一期愈合,未见局部红肿,脓性渗出。双下肢畸形恢复,长度相差均小于1 cm。19例全部获得随访,随访期间所有病例均未见假体松动征象。置换后1年随访Harris髋关节评分显著高于置换前(P < 0.05),其中优10例,良8例,中1例,差0例,优良率为94.7%。提示全髋关节置换治疗股骨颈骨折内固定失败有一定困难,采用含抗生素骨水泥股骨柄与非骨水泥髋臼金属托组合,可加强围手术期处理以及针对性的功能锻炼,患者关节疼痛以及活动度可得到明显改善。     

高龄患者锥形股骨柄假体全髋置换后的中期疗效

背景：目前越来越多的高龄髋关节病变患者需要接受全髋置换治疗。但由于老年患者常存在骨质疏松,骨量易丢失,以及骨愈合能力差等问题,在施行全髋置换时,应选择何种固定类型以及何种设计的全髋股骨柄假体最为理想仍存在不同意见。 目的：观察高龄患者锥形股骨柄假体全髋置换的中期疗效。 方法：选择2002-02/2004-02苏州大学附属第一医院骨科收治的70岁以上应用锥形股骨柄假体实施全髋关节置换患者65例(70髋),术前诊断：股骨颈骨折35例,髋关节骨关节炎10例,股骨头缺血性坏死8例,人工股骨头术后松动9例,类风湿性髋关节炎2例,先天性髋关节发育不良1例。分别于置换后1周、3,6个月随访,以后每年随访1次,对髋关节功能(Harris评分)和X射线平片进行复查。 结果与结论：6例因癌症死亡,4例死于心脑血管疾病。其余55例随访六七年,平均6.5年。末次随访髋关节Harris评分85~95分,平均90分。2髋出现轻度大腿痛,无一髋需行翻修治疗。置换后1年内X射线平片显示假体下沉小于1.5 mm者36髋。此后未再出现假体下沉。置换后3~6个月在Gruen 6区近段羟基磷灰石涂层部位出现典型的骨锚固征及松质骨和皮质骨密度增高影像。此后所有患者包括Dorr C型髓腔者均无柄端周围的骨质增生或“底座征”,也无股骨近段或远段髓内骨溶解及假体松动。按Engh标准评定全部患者均获骨性固定。提示锥形股骨柄假体的锥形设计特征既可获得置入髓腔后的初始固定,又可获得由于负重行走后的假体适度下沉所产生的二次稳定,用于高龄患者生物型全髋置换中期疗效满意。     

全陶瓷型人工髋关节置换治疗股骨头缺血性坏死23例☆

目的：全髋关节置换存在的主要问题是假体无菌性松动，为此许多不同特质的关节假体界面被研究利用，陶瓷对陶瓷型假体就是其中的一种。观察陶瓷-陶瓷人工髋关节置换治疗股骨头缺血性坏死的中短期疗效，并评估其临床应用价值。 方法：于2006-01/2008-12对23例(28髋)采用陶瓷-陶瓷非骨水泥型假体置换治疗的股骨头缺血性坏死患者进行随访，所有关节假体均使用BiCONTACT®全陶瓷关节假体。应用Harris评分标准进行功能评价，应用股骨Gruen与髋臼Delee-Charnly分区方法进行影像学评价。 结果：平均随访28个月。患者Harris评分从置换前平均39.45分提高至置换后平均88.57分，差异具有显著性意义(P < 0.05)。影像学上无明显的假体松动、下沉。 结论：对于股骨头缺血性坏死患者，新型陶瓷-陶瓷假体短期随访置换效果良好，影像学表现无明显松动。     

全髋关节置换后髋关节内外旋活动范围计算

背景：全髋关节置换后髋关节内外旋活动范围能否满足日常活动需要直接影响患者对手术的满意度和假体的使用寿命,目前全髋关节置换后髋关节内外旋活动范围及决定因素研究主要集中在临床研究。 目的：探讨全髋关节置换后髋关节内外旋活动范围的计算方法。 设计、时间及地点：探索性实验,于2008-10在山东省单县中心医院完成。 材料：人工髋关节由山东省菏泽恒源医疗器械有限公司提供。 方法：用数学方法推导人工髋关节不同臼柄水平截面摆动角的计算公式：绘制臼杯截面分别为半圆,大于半圆,小于半圆的臼柄水平截面示意图。设截面上股骨假体颈柄的宽度2L,臼杯截面开口宽度为2L’,截面所在圆的半径为R。求得臼杯截面大于半圆时摆动角Q=90°-arcsinL/R-arccosL’/R。臼杯截面小于半圆时摆动角Q=90°-arcsinL/R+arccosL’/R。臼杯截面等于半圆时摆动角Q=90°-arcsinL/R。用数学方法推导人工髋关节内旋和外旋时臼柄撞击平面位置的数学表达式：假设臼杯(人工股骨头)的半径为R,股骨假体颈柄的半径为L,股骨假体颈干角减90°为J,臼杯的外展角为B。通过复合函数求导数的方法确定人工髋关节内旋和外旋时臼柄截面摆动角最小值时的截面位置。人工髋关节内旋和外旋时臼柄撞击平面位于旋转中心下方h=(sinJR2-sinBLR)/ ,其中B∈[0 arcsin(sinJL/R)]。随外展角的增大撞击平面逐渐上移至h=sinJ 截面,B≥arcsin(sinJL/R)时,撞击平面保持不变均位于h=sinJ 平面。推导人工髋关节内旋和外旋活动范围的计算公式。 主要观察指标：全髋关节置换后髋关节内外旋活动范围计算公式。 果：人工全髋关节置换后髋关节内旋和外旋活动范围ROM=2{90°-arcsin1/ + arcos [ /cosB ]},(k=R/L)。 结论：全髋关节置换后髋关节关节内外旋活动范围与髋臼杯外展角、股骨假体颈干角、头颈比呈正相关,该公式简单、准确,值得临床参考。     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.     

Clobazam for Treatment of Intractable Epilepsy: A Critical Assessment

Summary: Clobazam (CLB), a 1,5-benzodiazepine, is a remarkably effective add-on drug for individual patients with refractory partial epilepsy. CLB has an excellent safety record. As with all benzodiazepines used for treating epilepsy, sedation and withdrawal effects, together with the development of tolerance, limit its usefulness. Recent efforts to prevent or reverse tolerance with intermittent administration of CLB or periodic injection of a benzodiazepine antagonist, flumazenil, are encouraging and justify further investigations.     

La passion de Torquemada et le terrorisme islamique : quelques points de comparaison

This original research compares the doctrinal, psychopathological and operational standpoints of the 15th century Spanish Inquisition (Torquemada) with those of radical Islamism from 1988 to 2005 (Al-Qaeda). The following are reviewed: (a) the main texts codifying the procedure for conducting the criminal investigation of a Holy Office trial (Directorium inquisitorum); (b) the life and work of the grand inquisitor Tomás de Torquemada (1420–1498); (c) the psychopathological relations between passion (passionate psychoses, passionate idealism, paranoid personality) and fanaticism; (d) “the madmen, the enlightened and the criminals” of Islamic terrorism; (e) the cognitive and emotional motives for engagement in the jihadist radicalization of young people; (f) the common principles of monotheistic fanaticism (Inquisition, Al-Qaeda) and the particular dogmas of Islamic terrorism in our time; (g) the operating modes of the Inquisition and the Jihadist holy war. The author concludes that the rigour and seriousness of the inquisitorial judicial procedure, which was precise, individual and personalized, contrasts with the revolutionary pamphlets of Al-Qaeda, which only provide broad guidelines for the modus operandi of the fight against infidels, who are usually random victims.     

Claustration et collectionnisme : réflexions à propos d’un cas de syndrome de Diogène avec vols kleptomaniaques et vengeurs

Social withdrawal is a pathognomonic behaviour that is consistently associated with mental illnesses. Compulsive hoarding can also be interpreted as a pathological behaviour, even when it does not involve kleptomania. Diogenes syndrome (DS) was first described in 1975, and is characterized by both behaviours - social withdrawal and compulsive hoarding. Even though it is often the manifestation of a psychiatric condition, its aetiology is diverse. The most frequent ones are however: dementia, schizophrenia and mental retardation. In this study, we describe an atypical case presenting with DS. Il consists of a young man, seen in a forensic setting, who had been diagnosed with kleptomania in the past, presents with compulsive hoarding, and whose recent thefts were fuelled by revenge. Finally, to our knowledge, the way social withdrawal is viewed is seldom taken into account. We analyse its implication on social withdrawal.     

Neurological soft signs and schizophrenia: a review of current knowledge

Schizophrenia is a frequent and disabling disorder emerging during adolescence or early adulthood. The identification of underlying processes has been hampered by the complex clinical expression and the probable etiological heterogeneity. The frequency of neurological soft signs (NSS) in patients with schizophrenia and their presence early in life (during the first two years) in high risk subjects support the hypothesis that schizophrenia is a "brain disease" reflecting pre- or perinatal insults during development. The growing interest for NSS has lead to multiple studies that are often difficult to compare. The objective of this review is to summarize the current knowledge on NSS, methodological issues and the future perspectives.     

Lacan, lecteur de Minkowski : l'approche structurale

The notion of structure occupies a predominant place in the theory of Lacan. He indicates that was developed from the work of Minkowski. In fact, through his phenomeno-structural approach, Minkowski does not limit himself to purely observable phenomena, but attempts to determine the underlying structure. He refers to the comprehensive phenomenology and psychopathology, and this method provides him with clinical finesse and another means of determining a diagnosis. Thus Lacan has used this as a basis for his approach to structure to develop a theory regarding the individual. This implies that the structure of the individual is based on his relation to language. From this concept, he then develops the clinical structures of neurosis, psychosis, and perversion. These structural landmarks also have an effect on the course of treatment.