目的 通过文献回顾分析PBL教学方法与医学生毕业后职业方向之间的关系.方法 进行系统性文献回顾,对包括PubMed,Medline,Cochrane和ERIC数据库以及合适的参考书目进行分析.职业发展轨迹通过官方匹配方案、问卷调查和正式定义的职业发展里程碑来确定.结果 有11篇研究符合入选条件.大部分研究均显示PBL教学方法并不能使学员更易于从事某种特定专业(7/11,64％),但有三篇研究报道相对于无PBL教学的学员,PBL教学的毕业生更倾向于从事社区医疗.结论 文献显示PBL教学方法并不能使医学生更易于从事社区医疗或其他专业,未来还需要大量的相似研究继续探讨.

目的 探讨双侧矢状面交叉穿刺经皮穿刺椎体成形术(PVP)治疗Kümmell病的疗效.方法 2015年6月至2017年9月重庆大学附属中心医院骨科收治的78例Kümmell病病人实施该手术.观察指标包括骨水泥渗漏、椎体内骨水泥分布、伤椎前缘高度、矢状面Cobb角、视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI).结果 78例病人均获得24个月随访.1例病人出现骨水泥渗漏,无严重并发症发生.骨水泥在椎体内分布均匀,同时接触上、下终板.伤椎前缘高度、Cobb角、VAS、ODI评分术后2 d[(21.5±2.4)mm、(12.7±2.3)°、(2.3±0.6)分、(25.1±4.1)％]、1月[(20.7±2.5)mm、(13.1±2.0)°、(2.1±0.5)分、(22.1±3.5)％]、12月[(20.4±2.2)mm、(13.3±2.1)°、(1.9±0.4)分、(21.1±3.1)％]、24月[(20.1±1.6)mm、(14.1±1.5)°、(2.2±0.1)分、(24.1±2.5)％]较术前[(14.1±2.1)mm、(21.1±3.0)°、(7.7±0.9)分、(73.9±3.3)％]显著改善(P<0.05),术后1月、12月、24月与术后2 d相比较差异无统计学意义(P>0.05).随访24个月,病人无骨水泥松动、移位及手术椎体再骨折发生.结论 双侧矢状面交叉穿刺PVP治疗Kümmell病疗效确切,安全可靠.此技术能使骨水泥同时接触上、下终板,全椎体强化,降低手术椎体再骨折风险.

[目的]探讨非植骨融合单纯经皮短节段椎弓根螺钉固定治疗伴有后方韧带复合体损伤的屈曲-牵张型(AO分类B型)不稳定胸腰段脊柱骨折的临床疗效.[方法]回顾性分析2015年1月～2018年10月本院采用非植骨融合单纯经皮短节段椎弓根螺钉固定治疗的39例伴后方韧带复合体损伤的屈曲-牵张型不稳定胸腰椎骨折患者,总结围手术期、随访和影像资料.[结果]所有患者手术顺利完成,术中未发生脊髓神经根、血管损伤;手术时间(85.52±6.10) min,术中出血量(60.34±23.12) ml,支具保护下地行走时间(2.61±0.35)d,住院天数(9.47±1.61)d.所有患者随访(14.22±1.16)个月,随时间推移,39例患者的VAS和ODI评分均显著减少(P＜0.05).影像方面,与术前相比,术后39例患者椎体前缘高度显著增加(P＜0.05),而矢状面Cobb角显著减少(P＜0.05).术后椎体前缘高度和矢状面Cobb角无显著改变(P＞0.05).至末次随访时,未出现内固定断裂或松动.[结论]非植骨融合单纯经皮微创后路短节段椎弓根螺钉固定治疗无神经功能损害的伴有后方韧带复合体损伤的屈曲-牵张型不稳定胸腰段脊柱骨折安全有效.

少数病例报告描述了与急性髌骨脱位有关的股骨髁骨软骨骨折[1-3].其发生率并不十分确切.如果骨软骨块几乎全部是软骨性的,而骨性很小,则可能无法通过普通X线影像诊断.这种损伤的发病机理尚不清楚.髌骨与股骨滑车之间的高速低能量剪切力会导致软骨或骨软骨骨折[4],这与引起髌骨脱位的机制相似,这类骨折可以发生在股骨髁的多个部位.通常情况,轻度屈膝状态下的髌骨脱位,骨折部位好发于股骨前外侧髁的非承重部分和髌骨下内缘[5-6].创伤性骨软骨碎块通常仅作为关节内游离体,在手术清创时切除[7-9].骨折部位通过形成纤维软骨样组织愈合,最终导致膝关节疼痛、早期退行性关节炎.

目的:比较微创前外侧入路(orthop dische chirurgie München,OCM)与常规后外侧入路(posterolateral approach,PLA)在初次全髋关节置换中的早期临床疗效.方法:分析2014年8月至2016年10月重庆市第四人民医院收治的82例行初次全髋关节置换术患者,根据入路方式不同随机分为OCM组与PLA组,分别对2组的切口长度、手术时间、手术总出血量、输血率、术后开始下床时间、术前与术后髋关节Harris评分、疼痛视觉模拟评分(visual analogue scores,VAS)、术后放射学检查假体位置等进行对比评估.结果:2组在切口长度,手术时间,手术总出血量,术后开始下床时间,术后24 h、48 h、72 h VAS及术后1周、1个月、3个月Harris评分比较,差异均有统计学差异(P＜0.05);而2组输血率,术后1周VAS,术后6个月、12个月、24个月髋关节Harris评分及假体位置无统计学差异(P＜0.05).2组患者均无脱位情况发生,OCM组患者1例(0.71％)术中发生股骨距骨折,经钢丝环扎固定处理,随访过程显示假体稳定,无松动、下沉.结论:与PLA入路比,OCM入路初次全髋关节置换切口小,出血少,早期临床效果更佳.

目的 探讨己酮可可碱(PTX)对液体复苏后创伤失血性休克大鼠心血管功能及血液流变学的影响.方法 30只健康雄性Wistar大鼠随机分为3组.采用股骨骨折+颈外静脉放血方法构建创伤失血性休克模型,观察和记录各组大鼠在复苏不同阶段心血管参数变化,同时抽血检测各组血细胞比容(Hct)和全血及血浆黏度改变情况.结果 经液体复苏后,PTX组大鼠平均动脉压恢复较明显,复苏后360 min恢复到(83.55±2.40)mm Hg,明显高于LR组的(75.53±7.95)mm Hg(P<0.01);复苏后360 min,PTX组大鼠心率恢复到(447±17)次/分钟,接近SS组的(458±9)次/分钟,明显高于LR组的(376±16)次/分钟(P<0.01);大鼠中心静脉压波动明显,复苏后360 min PTX组为(36.13±2.03)cm H2 O,明显低于LR组的(48.44±3.09)cm H2 O(P<0.001).经液体复苏后,两组左心室压力最大上升和下降速度均有不同程度回升,PTX组恢复更明显;液体复苏后PTX组大鼠左心室收缩压(LVSP)逐渐恢复至(122.25±2.70)mm Hg,明显高于LR组的(96.08±7.43)mm Hg(P<0.01).复苏后4.5、6.5 h,PTX组大鼠Hct、全血及血浆黏度均明显低于LR组(P<0.01).结论 PTX对经液体复苏后创伤失血性休克大鼠有一定疗效,可改善心血管功能及血液流变学指标.

目的:探讨防旋型股骨近端髓内钉(PFNA)内固定术对股骨粗隆间骨折患者生物力学性能的影响.方法:选取重庆市急救医疗中心2015年6月～2017年6月收治的股骨粗隆间骨折患者132例,根据患者的手术方式分成A组(n=66)与B组(n=66).A组行PFNA内固定术,B组行人工髋关节置换术.比较两组围手术期指标,包括手术时间、术中出血量、卧床时间、术后引流量、住院时间、骨折愈合时间;采用Harris评分评价两组术前、术后6个月、术后12个月的关节功能恢复情况;分别在术后6个月、术后12个月比较两组生物力学特性,包括扭转1.5°时的扭转刚度与扭矩以及荷载800 N时的压缩刚度与压缩位移;并记录两组并发症发生率.结果:A组术中出血量小于B组,手术时间、卧床时间、住院时间及骨折愈合时间短于B组,差异有统计学意义(P<0.05).两组术后6个月、术后12个月的Harris评分高于术前,且A组术后6个月的Harris评分高于B组,差异有统计学意义(P<0.05).两组术后12个月扭转1.5°时扭转刚度、扭转1.5°时扭矩、荷载800 N时压缩刚度均高于术后6个月,荷载800 N时压缩位移小于术后6个月,且A组术后6个月扭转1.5°时扭转刚度、扭转15°时扭矩、荷载800 N时压缩刚度均高于B组,荷载800 N时压缩位移小于B组,差异有统计学意义(P<0.05).A组和B组的并发症发生率分别为6.06％和9.09％,差异无统计学意义(P>0.05).结论:与人工髋关节置换术相比,股骨粗隆间骨折患者行PFNA内固定术能取得更显著效果,可进一步促进术后机体功能恢复,改善术后6个月的生物力学性能,未增加并发症风险,临床推广价值更高.

目的 探讨Klammer分型对后Pilon骨折手术入路和内固定方式的临床指导意义.方法 2013年8月—2015年8月重庆市急救医疗中心骨科收治17例后Pilon骨折,其中男性11例,女性6例;年龄18～64岁,平均45.8岁.采用踝关节三维CT扫描,根据后踝、内踝骨折情况应用Klammer分型.17例均合并外踝骨折,其中Ⅰ型9例,全部采用后外侧入路;Ⅱ型5例,采用单独后外侧入路3例,联合内侧入路2例;Ⅲ型3例,均合并内踝完全骨折,采用后外侧联合后内侧入路进行固定.术后以Burwell-Charnley放射学评价标准判定关节面复位质量,末次随访根据美国足踝外科协会(AOFAS)踝与后足评分系统对术后踝关节功能进行评估,采用VAS评分评估踝关节疼痛情况.结果 所有患者术后获11～23个月(平均13.2个月)随访,无腓骨肌腱激惹,无胫后神经麻痹,无腓肠神经损伤表现.骨折均愈合,愈合时间12～19(平均13.5)周.术后2例出现切口浅表感染,经非手术治疗后愈合,无螺钉松动、断裂及内固定失效等并发症.术后第2天根据Burwell-Charnley影像学评价标准判定骨折复位质量,其中解剖复位12例,一般复位5例.末次随访时踝关节活动范围背伸(24.9±3.8)°,跖屈(42.1±5.3)°;跟距关节内翻(27.7±1.9)°,外翻(32.5±2.4)°.临床疗效根据AOFAS评分进行评估:术前为(33.4±1.4)分,术后为(46.5±4.7)分,而末次随访为(86.4±5.9)分,其中优9例,良6例,可2例,优良率为88.2％(15/17).末次随访时采用VAS评分,静息时VAS评分为0～3分,平均0.7分;行走时为0～5分,平均1.9分.结论 基于三维CT的Klammer分型简单实用,对后Pilon骨折手术入路和固定方式的选择有较好的指导意义.

目的:了解骨质疏松性椎体压缩性骨折(OVCF)早期进行经皮椎体成形术(PVP),或经皮椎体后凸成形术(PKP)围手术期指标和疗效的差异.方法:回顾性分析86例骨质疏松性椎体压缩骨折患者,其中PVP组52例、PKP组34例.比较两组围手术期指标(手术时间、骨水泥注入总量、术后伤椎增加高度、术后VAS评分)和随访指标(椎体前缘高度、后凸Cobb角、椎体压缩率)的统计学差异.结果:PVP组(27.7±6.0)手术时间短于PKP组(37.3±8.1);PVP组(4.6±1.4)骨水泥注入总量小于PKP组(6.0±2.7),PVP组(2.6±1.5)术后伤椎增加高度小于PKP组(9.0±2.0),PVP组(2.4±0.4)术后VAS评分小于PKP组(1.9±0.2),差异均有统计学意义(P<0.05).两组患者术后比较,PVP组(19.85±2.16)椎体前缘高度低于PKP组(24.18±3.07),PVP组(12.43±2.08)后凸Cobb角大于PKP组(8.01±3.45),PVP组(24.89±5.52)椎体压缩率大于PKP组(20.23±3.49)差异均有统计学意义(P<0.05).术前术后比较,两组患者椎体前缘高度均显著增加、后凸Cobb角和椎体压缩率均显著降低(P<0.05).结论:PKP相比PKP能进一步改善OVCF病椎的裂隙修复,尽可能恢复椎体高度,术后疼痛程度轻;但手术时间较长,骨水泥注入量相对较多,且不适用于重度压缩骨折.

对57例骨质疏松压缩性骨折采用术前牵引过伸复位,再行经皮椎体成形术(PVP)治疗,术后患者疼痛明显减轻,椎体高度显著恢复,无严重并发症.闭合复位联合PVP是治疗骨质疏松性椎体压缩骨折的有效方法.

Objective: The aim of the present study was to develop a more realistic finite element (FE) model of the human anterior cruciate ligament (ACL) tibial insertion and to analyze the stress distribution in the ACL internal fibers under load.Methods: The ACL tibial insertions were processed histologically. With Photoshop software, digital images taken from the histological slides were collaged, contour lines were drawn, and different gray values were filled based on the structure. The data were exported to Amira software and saved as ".hmascii" file. This document was imported into HyperMesh software. The solid mesh model generated using HyperMesh software was imported into Abaqus software. The material properties were introduced, boundary conditions were set, and load was added to carry out the FE analysis.Results: The stress distribution of the ACL internal fibers was uneven. The lowest stress could be observed in the ACL lateral fibers under tensile and shear load.Conclusion: The establishment of ACL tibial insertion FE model and mechanical analysis could reveal the stress distribution in the ACL internal fibers under load. There was greater load carrying capacity in the ACL lateral fibers which could sustain greater tensile and shear forces.

目的观察一期植骨联合负压封闭引流治疗大面积皮肤缺损伴感染性骨不连的临床疗效.方法28例感染性骨折不愈合或骨缺损患者,彻底清除患处失活的软组织和骨组织,直至骨折端点状出血.一期植入自体松质骨颗粒,外固定架固定.创面用负压封闭引流装置(VSD)覆盖,术后敏感抗生素静滴,创面每7~10d更换VSD,直至创面新鲜肉芽覆盖,二期植皮.结果平均随访20(12~38)个月.术后平均36(25~48)d移植骨质表面覆盖肉芽组织,VSD时间平均30(23~46)d,术后28例均待肉芽生长良好后行植皮术,2例行2次植皮后存活,其余均一次植皮成功,植皮术后创面平均16(14~24)d愈合.术后骨折愈合时间平均6.5(3~12)个月,平均8.5(5~16)个月去除外固定.结论一期植骨联合VSD技术是一种有效治疗大面积皮肤缺损伴感染性骨不连的方法.

前路减压植骨内固定手术治疗胸腰椎爆裂骨折51例,术后伤椎椎体高度、Cobb角及椎管容积明显改善,脊髓不完全性损伤患者神经功能按Franke分级有1～3级不同程度的恢复。

目的 探讨关节镜下复位、Herbert钉固定治疗胫骨髁间棘骨折的临床疗效.方法 对2006年6月至2010年4月采用关节镜下herbert钉固定治疗的27例胫骨髁间棘骨折患者进行回顾性分析.按Meyers-McKeever-Zaricznyj骨折分型:Ⅱ型6例,Ⅲ 型17例,Ⅳ型4例.结果 平均随访15.7个月,所有患者膝关节症状基本消失,Lachman试验均阴性,术后6个月Lysholm评分(90.4±2.9)分,术后12个月Lysholm评分(93.3±3.4)分.结论 关节镜下Herbert钉固定可靠、对关节腔影响小,是治疗胫骨髁间棘骨折的理想固定材料之一.

Objective To evaluate the effects of pentoxifylline(PTX) on the organ blood flow and the survival rate in rat traumatic-hemorrhagic shock.Methods 30 male Wistar rats were randomly divided into 3 groups:normal group(SS),control group(LR) and therapy group(PTX),10 cases in each group.All rats in the three groups were wounded by laparotomy and fracture of left femur.The rats in control group and therapy group were bled from the right femoral artery to reduce the mean arterial pressure(MAP) to(40±2.0)mm Hg with in 10 min after trauma.MAP was kept at this level for 1.5 h and then the rats were resuscitated with lactated Ringer′ s solution(LR),four times of shed blood volume,through the right external jugular vein within 1 h.At 15 min before the end of resuscitation,the rats in therapy group were infused PTX(30 mg/kg body weight) through the vein within 95 min during and after resuscitation,simultaneously,the rats in control group were given the same volume of normal saline solution during the same period.The organ blood flow of liver,kidney and spleen were determined respectively at 4.5,6.5 h after PTX treatment.The rat survival rates at 8,16 h were calculated.Results The experiment results indicated that the organ blood flow(liver,spleen and kidney) was significantly higher in PTX group than in LR group(P<0.05).Conclusion PTX restores the blood flow of liver,kidney and spleen and increases the survival rate of animals after PTX administration.

Objective To analyze the clinical operation treatment methods of hip fracture-dislocation combined sciatic nerve injury.Methods 30 cases of hip fracture-dislocation and combined sciatic nerve injury taken operation were chosen out for study and took sciatic nerve exploration surgery.Kocher-Langenbeck(KL) incision were chosen out,among which 5 cases were combined with ilioinguinal approach.Acetabular fractures should take fixation treatment with acetabular bone plates and screws.Operation methods included neural lysis and nerve anastomosis.Results Nerve function recovery was assessed by Sunderland.After operation,recovery of neurological function(excellent 7 cases,good 8 cases,yes 8 cases,poor 7 cases) was significantly improved than before operation(excellent 0 cases,good 4 cases,yes 12 cases,poor 14 cases)(P<0.01).Nerve conduction velocity after tibial nerve injury and peroneal nerve injury operation were 41.26±2.49 mm/s and 36.78±2.68 mm/s,which were significantly improved than that before operation(35.06±2.08 mm/s,30.32±2.30 mm/s)(P<0.01).Conclusion Operation is an useful method to treat hip fracture-dislocation combined sciatic nerve injury.Surgical approach should choose Kocher-Langenbeck firstly.

Objective To investigate the effect of external fixation in treating patients with comminuted distal radius fractures,and to compare the functional outcomes of dynamic external fixation and static external fixation.Methods Totally 78 cases of comminuted distal radius fractures admitted into our hospital from Jan.2007 to Dec.2010 were analyzed.They were randomly divided into static external fixation group(32 cases),and dynamic external fixation group(46 cases).The injured wrist of the dynamic fixation group was partially unlocked and allowed wrist joint activity after 3 weeks for external fixation.The wrist was fixed all the time in the static external fixation group.All surgeries were performed within 48 hours of admission.All patients were managed with closed reduction and applied external fixator(Orthofix),supplied bone graft and K-wires fixation to stabilize the fracture if necessary.The fixator was maintained for 6-8 weeks and was removed after bone healing.The functional outcome was assessed using Dienst score at 6 months after operation.Results Dynamic and static external fixators both achieved good outcomes for patients with comminuted distal radius fractures,and the clinical curative effect of dynamic external fixation group was better than that of static external fixation group(P0.05).Conclusion External fixation for treating patients with comminuted distal radius fractures has good curative effect,with advantages of reliable fixation,early functional exercise and satisfactory recovery.Dynamic external fixation is worthy to be widely applied in clinic.

Objective To evaluate the efficacy of surgical treatment of dual column acetabular fractures.Methods A retrospective analysis was conducted on 33 cases of dual column acetabular fractures treated surgically in our hospital from January 2004 to January 2011.Different approaches were chosen according to the types of the fractures and the reconstruction plates and lag screws were used for internal fixation.Results There were 20 cases(61%) of anatomic reduction,11 cases(33%) of satisfied reduction and 2 cases(6%) of unsatisfied reduction.The hip joint function was excellent in 22 cases(67%),good in 9 cases(27%) and fair in 2 cases(6%),with the excellence rate of 94%.Complications included heterotopic ossification in 4 cases(12%),osteoarthritis in 3 cases(9%),necrosis of the femoral head in 2 cases(6%).Conclusion The correct treatment of comorbidities,the appropriate choices of operation approaches and anatomical reduction of the acetabular articular surface are the keys to obtain satisfactory clinical effects in the surgical treatment of dual column acetabular fractures.

Objective To investigate the clinical effect of arthroscopic reduction and polydioxanone suture(PDS)fixation in treating tibial eminence fracture.Methods Totally 32 patients with tibial eminence fracture treated by arthroscopic reduction and PDS fixation were followed up effectively.According to Meyers-McKeever-Zaricznyj classification systems,there were 5 cases of type Ⅱ,15 cases of type Ⅲ,and 12 case of type Ⅳ.Results The patients were followed up with an average of 17.1 months(6 to 28 months).All symptoms in their knees were disappeared,and the Lachman tests indicated negative result.The average Constant score was 91.2±3.1 at 6 months after operation and 94.3±3.6 at 12 months after operation.Conclusion Arthroscopic reduction and PDS fixation is effective,widely used,less invasive to the joint.So it's an ideal method to treat tibial eminence fractures.

Objective To analyze the influencing factors of adjacent segment degeneration of patients with anterior cervical discectomy and fusion.Methods Totally 250 cases of anterior cervical discectomy and fusion were selected for study.The incidence of adjacent segment degeneration was observed and the indexes of degeneration group and non-degeneration group were compared statistically.Results There were 72 cases(75 segment) of adjacent segment degeneration(28.8%),including 48 cases of degradation score of 1,21 cases of degradation score of 2,3 cases of degradation score of 3.The preoperative D value of degradation group was(1.26±1.30)mm,while(3.76±3.10)mm after operation,indicating significantly lower than that of non-degradation group(P0.05).The postoperative D value of degradation group increased by(2.5±3.21)mm,notably lower than that of non-degradation group(3.95±3.13)mm(P0.05).The age,gender distribution,JOA score and Cobb's angle of the two groups had no statistical difference(P0.05).Conclusion The incident rate of adjacent segment degeneration in patients with anterior cervical discectomy and fusion is high.The small degree of cervical lordosis and slight improvement of the degree of cervical lordosis after operation are important influencing factors leading to adjacent segment degeneration.