目的 分析一期原位回植联合负压封闭引流技术(VSD)治疗下肢完全皮肤脱套伤的疗效,为临床四肢大面积皮肤脱套伤的治疗提供借鉴.方法 收集下肢完全脱套伤(占体表面积20％以上)患者25例,研究组14例行一期剥脱皮肤原位回植联合VSD治疗,对照组11例一期行彻底清创,VSD敷料覆盖,二期取对侧大腿皮植皮,观察对比植皮成活率、住院时间及并发症发生率等指标,评价远期患者功能恢复状况.结果 研究组14例患者脱套皮肤回植成活率为(90.65±2.25)％,对照组为(80.86±3.69)％,2组比较差异有统计学意义(P＜0.05);研究组成活效果优为11例,良为2例,差为1例,对照组成活优为5例,良为3例,差为3例;研究组术后并发症发生率为8％,对照组为28％;2组患者的平均住院时间比较差异有统计学意义(P＜0.05).结论 下肢皮肤大面积脱套伤行一期原位回植联合VSD治疗,回植皮肤成活率高,皮肤成活效果及肢体功能恢复好.

目的 通过对腓动脉穿支血管的研究,依据穿支血管的分布规律,使用远端腓动脉穿支皮瓣修复足踝部的创面,观察其对创面覆盖的临床疗效.方法 收集患者资料共22例,创面大小3.1 cm × 1.3 cm～7.5 cm × 4.6 cm.术中根据创面部位、创面状态及大小,CTA检查腓动脉穿支分布情况,术前使用Doppler超声精准定位远端穿支选择远端合适的穿支设计皮瓣,供区直接闭合,观察切取皮瓣的血供后,将皮瓣与创面无张力缝合.结果 22例患者腓动脉远端穿支皮瓣存活状态良好,其中3例患者皮瓣局部出现静脉危象,后期转归.经半年随访,19例患者患肢皮瓣不臃肿,3例患者患肢皮瓣略臃肿,均未见瘢痕形成,行走无差异.采用美国AOFAS标准评价患足功能的优良率为90.90％.结论 腓动脉最远端穿支近踝关节水平通过CTA及术前Doppler超声定位,其修复足踝部小面积缺损安全性较为可靠且具有距离优势、供区直接闭合、术后皮瓣色差小、美容效果佳、无臃肿、步态自然等优点,适宜临床推广.

1病例资料 患者,女,88岁,主因左腕部肿块伴左手指麻木2月余收住入院.自诉2月前发现左腕部肿块,且逐渐增大,并伴有左拇指、环指、中指感觉麻木,持物困难.查体:左腕部掌侧可触及大小约4 cm×2 cm×2 cm肿块,压痛,质韧,活动度可.

扁平足,由于其足弓结构改变和生物力学功能异常,可能会导致(砪)外翻、膝关节痛、胫骨骨膜炎、跟腱炎、骨质增生等并发症.SANDLIN等[1]分析认为,腓骨长短肌腱撕裂容易发生在3个区域,即外踝、跟骨滑车、长方体,其中,跟骨滑车容易发生部分撕裂,长方体容易发生完全撕裂.

Objective:To investigate the effects of lycium barbarum polysaccharide (LBP) on the survival state of rat dorsal random flap and postoperative inflammatory factors and apoptotic factors.Methods:Eighty-four male SD rats were randomly divided into 4 groups, and 4.5 cm 2 random flaps were designed on the back of the rats according to the sample cloth. The control group was perfused with normal saline (group LBP0) after operation, and the experimental group was perfused with 200, 400 and 800 mg/ (kg·d) LBP after operation, which were group LBP200, LBP400 and LBP800 respectively, lasting for 2 weeks. The general conditions of rats in each group after flap operation were recorded, including inflammatory exudation, edema, flap tension, skin temperature and necrosis. Three rats in each group were randomly selected at 0.5, 1, 3, 5, 7, 10 and 14 days after operation to measure the survival area of the flap. The flap tissue samples were cut and the mRNA expression of TNF-α and Caspase-3 factor in the flap tissue was detected by real-time fluorescent quantitative PCR (RT-PCR). Results:Three days after the modeling of rat dorsal random flap, bleeding and swelling in varying degrees were observed in the wound of the flap in each group, and some flaps gradually appeared dark red to cyan. The necrosis of the flap gradually appeared on the 7th day after the operation, and the necrosis boundary became clear on the 10th day after the operation. The scabs were formed in the necrotic area 2 weeks after the operation. Within one week after operation, there was no significant difference in the survival area of the flap in each group ( P>0.05). Three days after operation, the difference of mRNA expression of TNF-α between group LBP800 and LBP0 was significant ( P<0.05), and the difference was more obvious 10 days after operation ( P<0.01). Five days after operation, the difference of mRNA expression of TNF-α between group LBP400 and LBP0 was significant ( P<0.05), and the difference of mRNA expression of Caspase-3 factor between group LBP800 and LBP0 was significant ( P<0.05), with more obvious difference 14 days after operation ( P<0.01). Seven days after operation, there was a significant difference in the mRNA expression of Caspase-3 factor between group LBP400 and LBP0 ( P<0.05). Conclusion:LBP intervention with appropriate concentration can significantly reduce the mRNA expression of inflammatory response factor and apoptosis factor of skin flap, help to reduce the risk of skin flap tissue necrosis and improve the microenvironment of skin flap survival.

目的 探讨小腿远端蒂腓动脉穿支皮瓣修复小腿远端及足踝部创面的临床疗效.方法 采用小腿远端蒂腓动脉穿支皮瓣修复小腿远端和足踝部创面患者17例,创面缺损范围为4.1 cm×2.4cm～12.5 cm×5.7 cm.根据创面缺损大小、创面形状及位置,选择距创面部位最近的腓动脉穿支作为旋转点设计小腿外侧腓动脉穿支皮瓣,术中探查血管蒂后切开皮瓣旋转覆盖创面,皮瓣供区直接牵拉闭合或取同侧患肢全厚皮植皮,皮瓣无张力缝合并放置引流管.术后给予对症治疗,观察穿支皮瓣存活率、皮瓣形态.结果 术后17例患者穿支皮瓣全部存活,3例患者皮瓣远端出现暗红、后期转归仅部分表皮坏死,13例患者皮瓣供区一期牵拉闭合,4例患者皮瓣供区行全厚皮植皮.经半年随访,皮瓣形态不臃肿,质地柔软,皮瓣肤色接近周边皮肤.结论 选择小腿远端蒂腓动脉穿支皮瓣修复小腿远端和足踝部缺损具有创面全覆盖、住院时间短、术中不损伤重要血管、术后皮瓣成活率高、术后皮瓣外观自然、无臃肿、走路步伐自然、不影响日常生活及工作等优点,值得临床推广.

目的:探讨和比较经皮微创Ma-Griffith缝合法与经皮"回"形缝合法对于急性闭合性跟腱断裂的治疗效果。方法:选取2017年9月至2019年12月期间在宁夏回族自治区人民医院手足显微外科完成的27例急性闭合性跟腱断裂手术治疗的患者进行随访观察，其中男21例，女6例；经皮微创Ma-Griffith缝合患者15例，经皮"回"形缝合患者12例。分别于术后2、4、6、12、18、24个月进行随访，并使用美国足踝外科协会（AOFAS）踝-后足评分标准和跟腱完全断裂评分（ATRS）进行随访评估，进行统计学分析， P<0.05为差异有统计学意义。 结果:术后随访24~27个月，平均24.3个月。所有患者切口均获Ⅰ期愈合，无切口相关并发症发生，无跟腱再次断裂。两组患者ATRS评分，术后6、12、18个月经皮微创缝合组分别为（83.46±4.10）分、（86.86±1.92）分和（88.73±2.37）分，经皮"回"形缝合组分别为（86.91±1.83）分、（88.91±0.79）分和（90.66±1.55）分，两组差异均有统计学意义（ P<0.05）[ P值分别为0.014、0.002和0.023]；术后24个月，经皮微创缝合组为（94.40±1.84）分，经皮"回"形缝合组为（94.33±1.66）分，差异无统计学意义（ P>0.05）（ P=0.923）。两组患者AOFAS评分，术后12个月经皮微创缝合组（90.33±1.30）分，经皮"回"形缝合组（91.46±1.50）分，两组差异有统计学意义（ P<0.05）( P=0.047)；术后6、12、24个月时两组评分差异无统计学意义（ P>0.05） [ P值分别为0.360、0.871和0.509]。 结论:使用"回"形缝合法和经皮微创Ma-Griffith缝合法治疗的急性闭合性跟腱断裂患者在第24个月随访时跟腱恢复情况相似，但是"回"形缝合法在6~18个月的恢复情况更具有优势，值得进一步临床推广。

目的 探讨3D(3-Dimensions)床旁教学模式对在骨外科临床教学中实践应用的效果.方法 3D床旁教学模式是基于问题的学习(PBL)及案例的学习(CBL)二者并结合研讨会的一种新型教学方式,应用临床技能的测评工具Mini-CEX及调查问卷进行评估此教学模式效果.结果 实验组学生在临床技能及诊疗相关方面的Mini-CEX评分高于对照组(P＜0.05),在剩余3个维度的得分与照组比较差异无统计学意义(P＞0.05).问卷调查报告显示,实验组学生对3D床旁教学模式的兴趣度、教学效果明显高于对照组;在培养自身主观能动性方面获得实验组83％学生的认可,超过对照组2倍.知识点掌握程度2组占比差为12％.结论 通过3D教学模式的实践,认为此模式能适合于当今临床教学,可获得较好的教学效果.

目的 研究尺神经筋膜下前置术与原位减压术在治疗中度肘管综合征的临床效果.方法 收集收治的中度肘管综合征55例患者资料,分为2组,筋膜下前置组30例,原位减压组25例.分别行尺神经筋膜下前置术和原位减压术,对比2组术式患者术后的疗效.结果 手术时间以及切口长度原位减压组短于筋膜下前置组(P＜0.05);筋膜下前置组与单纯减压组术后的优良率比较差异无统计学意义(P＞0.05);2组患者住院时间及术后并发症的发生率对比差异无统计学意义(P＞0.05).结论 中度肘管综合征采用尺神经筋膜下前置术与尺神经原位减压术术后疗效无差异,但原位减压术操作更简单、术程更短、切口更小.

Objective:To investigate the effect of activated Schwann cells (ASCs) on bone marrow stromal cells (BMSCs) combined with xenograft (ANX) in the repair of sciatic nerve defects in rats.Methods:BMSCs were taken from the bone marrow cavity of rats. ASCs and normal SCs were taken for primary culture. The two kinds of cells were cultured in Transwell culture dish and divided into three groups: BMSCs group, SCs-BMSCs group and ASCs-BMSCs group. On the 2nd, 4th, 6th and 8th day after culture, the biological activity of BMSCs was detected by CCK-8 method, and the mRNA expression of brain derived neurotrophic factor (BDNF), nerve growth factor (NGF) and basic fibroblast growth factor (bFGF) were detected by q-PCR. The rat model of 10 mm sciatic nerve defect was made under aseptic condition, and the heterogenous nerve scaffold complex (tibial nerve from rabbit) was made. SD rats were divided into three groups (n=10): ANX+ BMSCs group, ANX+ SCs-BMSCs group and ANX+ ASCs-BMSCs group. These cells in each group were implanted into the scaffolds and cultured in composite scaffolds for 3 days. The sensory nerve conduction velocity (SCV) was measured by neuroelectrophysiology 8 weeks after operation, and the expression of neurotrophic factors (BDNF, NGF and bFGF) in nerve transplantation was detected by q-PCR. The recovery rate of cross-sectional area ratio of gastrocnemius muscle cells in the affected side/healthy side of the lower limbs was compared among the three groups.Results:CCK-8 assay showed that the proliferation activity of BMSCs group was stronger than that of single cell group, and there was no significant difference among the three groups on the 2nd and 4th day ( P>0.05). The proliferation activity of ASCs-BMSCs group was stronger than that of BMSCs group and SCs-BMSCs group on the 6th day and the difference was significant ( P<0.05). There was no significant difference between BMSCs group and SCs-BMSCs group ( P>0.05). The expression of BDNF, NGF and bFGF mRNA was the lowest in BMSCs group and the highest in ASCs-BMSCs group detected by q-PCR ( P<0.05). After 8 weeks of animal experiments, it was found that the SCV in ANX-ASCs-BMSCs group, the expression of related nerve factors in ANX and the cross-sectional area of gastrocnemius muscle cells in the affected side/healthy side of rats in ANX-ASCs-BMSCs group were the largest. Conclusion:ASCs can promote the differentiation and proliferation of BMSCs, and ANX-ASCs-BMSCs can promote the regeneration of peripheral nerve function.

目的 了解糖尿病足(Diabetic Foot)家庭照顾者家庭负担与生活质量,为护理人员制定个体化干预方案提供参考依据,为糖尿病足患者家庭照顾提供照护依据.方法 选用30例糖尿病足患者,入院时Wagner分级1级以上作为研究对象,采用混合型研究方法,由第一部分的横断面调查表(量性)与第二部分质性研究组成,采用横断面调查表照顾者负担量表调查法进行回归分析和质性研究中的现象学研究方法进行研究.结果 家庭经济条件越差,家庭关系越复杂,照顾者角色负担较重者,ZBI分数越高.家庭经济条件越优越,照顾者的个人负担程度越轻,ZBI分数越低.结论 糖尿病足家庭照顾者家庭负担与生活质量与患者家庭经济条件、家庭人际关系和家庭照顾者体验有关.

枸杞既可食用又可药用,作为中药材在我国具有悠久的使用历史.枸杞多糖作为枸杞的活性成分,在促进造血、降低血脂、保护肝脏、抗击癌症及修复周围神经方面有广泛的药理学作用[1-2].近年来,枸杞多糖的研究已逐步开展,并有大量实验数据证实了枸杞多糖的功效.本文就枸杞多糖对周围神经的修复的研究进展进行综述,为此方面进一步研究而提供参考或依据.

Objective To investigate the surgical method and clinical efficacy ofvasculafized anterior subcutaneous transposition of the ulnar nerve with inferior ulnar collateral artery for treatment of severe cubital tunnel syndrome through minimal incision in the medial elbow.Methods From June 2015 to June 2017,22 patients with severe cubital tunnel syndrome were admitted and divided into two groups according to different surgical methods:the vascularized anterior subcutaneous transposition of the ulnar nerve and the vascularized anterior subcutaneous transposition of the ulnar nerve through minimal incision in elbow.The conduction velocity of ulnar nerve through elbow joint,the two-point discrimination of the distal pulp of the little finger and the length of incision were compared between the two groups.Results All the 22 patients were follow-up for 8 to 15 months,with an average of 12.2 months.The excellent and good rate was 82.29％ in the vascularized anterior subcutaneous transposition of the ulnar nerve group and 80.91％ in the group with minimal incision in elbow.There was no significant difference between the two groups in the changes of ulnar nerve conduction velocity before and after the operation and in the recovery of two-point discrimination of the distal pulp of the little finger.After using the minimal incision in elbow,the average conventional incision of 13.4 cm was reduced to 4.7 cm.Conclusion The vascularized anterior subcutaneous transposition of the ulnar nerve operation ensures the blood supply of the local ulnar nerve of the elbow.It is a kind of operation method for the treatment of severe cubital tunnel syndrome.On this basis,the selection of the minimal incision on the medial side of the elbow can also achieve the clinical efficacy of the conventional incision length.The minimal incision can recover more quickly and the appearance of operation area is better.

1 病例资料 患者,男,42岁,主因“高处坠落伤致双下肢疼痛出血伴活动受限11h”于2018年9月2日入院.患者11h前从约2m的高处坠落,当即感双膝关节周围疼痛出血伴活动受限,当地医院给予伤口包扎止血后转入我院治疗.体格检查:BP70/40 mmHg,P 120次/min,右大腿远端内侧可见一处长约3cm不规则皮肤裂口,局部压痛叩击痛明显,纵向叩击痛阳性,右膝关节平面以下感觉减退,主动运动消失,右足背动脉搏动消失.左大腿远端前内侧及外侧各见一处约3 cm×4cm不规则皮肤裂口,左膝关节平面以下感觉减退,主动运动消失,左足背动脉搏动减弱.X线检查示:右股骨远端骨质粉碎.双下肢血管B超提示:双侧腘动脉,胫前、胫后动脉,足背动脉低血流灌注.检查完善后积极补液补血抗休克治疗,伤后17 h全麻下行双下肢清创探查缝合、右胫骨结节骨牵引术.

目的 探讨早期康复介入对手外伤患者术后手功能的影响.方法 根据康复介入的时间将129例手外伤患者分为实验组65例和对照组64例.实验组患者术后早期康复介入,由康复医生进行健康教育及指导康复训练,对照组患者术后3～4周由康复医生指导进行康复训练.2组患者术后8周门诊复查时采用手日常生活活动(ADL)评定量表进行患手功能评定,以手指关节总活动范围对患手功能进行全面评价.结果 术后8周实验组患者ADL指数明显高于对照组,实验组患者手指活动度评为优良61例,总优良率93.8％,高于对照组的77.6％,2组比较差异有统计学意义(P＜0.05).结论 早期康复介入可以有效地改善手外伤术后手功能,减少术后并发症的发生.

目的 比较外侧“L”形入路与跗骨窦入路治疗跟骨SandersⅡ型、Ⅲ型骨折的效果.方法 将42例跟骨SandersⅡ型、Ⅲ型骨折患者,按手术入路的不同分为外侧“L”形入路组(A组)22例和跗骨窦人路组(B组)20例.对比2组患者手术时间、术中出血量、术后引流量、B(o)hler角、Gissane角,并对患者进行随访,比较2组骨折愈合时间,使用足部Maryland评分系统评价术后1年功能恢复情况.结果 42例患者均获随访,随访时间6～18个月,所有患者均未出现切口感染、皮肤坏死、钢板松动外露等并发症,骨折愈合时间3～6个月.参照美国足踝外科Maryland足评分系统评价术后足部功能,A组22例患者中优14例,良5例,可3例,优良率86.4％;B组20例,优14例,良4例,可2例,优良率90％.结论 与外侧“L”形人路相比,跗骨窦入路治疗跟骨SandersⅡ型、Ⅲ型骨折术后患者足踝功能恢复更好,临床疗效可靠.

目的 观察经皮神经电刺激联合药物治疗轻度腕管综合征的效果.方法 将120例轻度腕管综合征患者分为单纯电刺激组、口服药物组(甲钴胺0.5 mg,维生素B15 mg,维生素B6 10 mg,地巴唑片5 mg,均为3次ad)、电刺激联合口服药物组,每组40例.分别在治疗前及治疗后1、3、6个月对患者进行电生理检测及临床评价.结果 3组患者在治疗后1、3、6个月BCTQ症状评分、3指感觉电位波幅较健侧下降幅度均较治疗前显著降低(P＜0.05),环指感觉电位潜伏期差值较治疗前显著缩短(P＜0.05).电刺激联合口服药物组在治疗后1、3、6个月BCTQ症状评分、3指感觉电位波幅较健侧下降幅度较电刺激组、口服药物组均显著降低,差异有统计学意义(P＜0.05);在治疗后1、3个月潜伏期差值较电刺激组、口服药物组均显著缩短,差异有统计学意义(P＜0.05).结论 经皮神经电刺激联合药物治疗对轻度腕管综合征患者有很好的治疗效果.

目的 研究数字化设计结合3D打印技术辅助手术治疗复杂胫骨平台骨折的效果.方法 回顾性分析20例复杂胫骨平台骨折患者采用数字化设计结合3D打印技术辅助进行手术资料.术前收集复杂胫骨平台骨折病例及常用的胫骨平台钢板的CT数据扫描建立标准件库,利用Mimics软件辅助植入钢板及螺钉,记录手术时间、术中出血量、骨折愈合时间、钢板一次性放置准确率、术后并发症、术前术后胫骨平台内翻角及内外侧后倾角度数、术后膝关节功能Rasmussen评分和末次随访时的纽约特种外科医院膝关节评分(HSS).结果 20例患者随访时间12～30个月(平均17.6个月),骨折均完全愈合,X线影像学平均愈合时间为11.4周,平均手术时间为(84.40±13.21)min,术中平均失血量(350±14.24)mL,钢板一次性放置准确率100％.术后即刻随访X线Ras-mussen评分:优15例,良4例,可1例,优良率为95％;术后12个月随访时膝关节HSS评分:优14例,良4例,可2例,优良率为90％.术后即刻及3、12个月TPA及内外侧平台PA较术前明显恢复,差异均有统计学意义(P＜0.05);术后即刻及3、12个月的胫骨平台TPA及内外侧平台PA之间比较差异均无统计学意义(P＞0.05).外侧切口皮缘部分坏死、感染1例,术后出现腓总神经损伤症状1例.结论 数字化设计结合3D打印技术应用于复杂胫骨平台骨折有助于制订术前计划、术中精确复位,临床效果满意,可实现精准化、个体化治疗.

目的 观察不同剂量地塞米松对人骨髓间充质干细胞增殖作用的影响.方法 使用人骨髓间充质干细胞,分为空白组(K组)、地塞米松组(D组),D组又按不同浓度共分为13个小组(D1～ D13).使用实时动态活细胞成像系统连续观察72 h,记录观察数据并进行统计学分析及绘图.结果 不同浓度地塞米松对人骨髓间充质干细胞具有不同的影响,较低浓度地塞米松(D1～D6组)可以促进人骨髓间充质干细胞的增殖,较高浓度地塞米松(D8、D10 ～ D13组)对人骨髓间充质于细胞具有抑制增殖作用.D9组对人骨髓间充质干细胞具有一定的增殖作用,较低浓度组差.结论 5×10-8 mol/L对人骨髓间充质干细胞的增殖作用最佳,并且在第36 ～ 48 h细胞增殖最好.高浓度地塞米松对人骨髓间充质干细胞具有抑制作用.