关节镜下射频消融术是治疗臀肌挛缩症的有效微创手术方式.传统开放手术创伤大、具有较高的并发症风险,微创手术则创伤小、切口小、术后并发症少.该术式根据挛缩组织的位置在股骨大转子顶点周围作两小切口,经切口使用刮匙将皮下筋膜与挛缩组织钝性分离,形成一个大小足够的人工腔室,以置入整个关节镜器械;使用射频消融技术将臀肌挛缩带松解离断.该术式适用于Ⅰ级、Ⅱ级患者,而对于Ⅲ级患者或X线检查发现已有骨盆倾斜、骨盆变窄、变长,股骨颈干角增大等骨性改变的患者则慎用.关节镜下射频消融术治疗GMC临床疗效肯定,具有术中出血少、住院时间短、下床活动早、术后康复快及满意度高等优点.但该术式所伴随的并发症仍不可忽视,如血肿、坐骨神经损伤、外展肌肉无力、伤口感染及术后复发等.本文着重对关节镜下射频消融术治疗GMC的适应证选择、手术方法、临床疗效、并发症等几个方面作综述.

OBJECTIVE:To construct a three-dimensional (3D) finite element mechanical model of total hip arthroplasty for comparison of biomechanical differences of the hip joint following capsule repair and postoperative rehabilitation.METHODS:Six frozen specimens of hip joint posterior capsule ligament complex were collected in a bone-capsule-bone manner, and the load-strain curve and other mechanical properties of the specimens were tested using a universal material testing machine. Thin-section CT data of the pelvis and lower limbs obtained from a volunteer were imported into Mimics software to construct a 3D model of the hip joint. Digital models of the cup, femoral prosthesis and joint capsule were created in CATIA software and imported into Mimics to simulate total hip arthroplasty; the assembled data were imported into ABAQUS software. The properties of the capsule were set according to results of the mechanical test, anatomical studies, and constitutive equations, and the biomechanics of the anatomically repaired and conventionally repaired capsules were compared during hip flexion.RESULTS:The results of testing on the 6 capsule specimens showed a mean ultimate tensile strain of (39.21±5.23)% and a mean of ultimate tensile strength of 1.65±0.38 MPa. The stress-strain curve of the finite element model was consistent with the results of mechanical test on the specimens and the biochemical characteristics of the capsule. The stress was distributed evenly in the anatomically repaired capsule during hip flexion but not in the capsule repaired through the conventional approach; the tensile stress in the lower part of the conventionally repaired capsule reached the ultimate tensile stress measured on the capsule specimens at a 90° flexion.CONCLUSIONS:The finite element model allows dynamic, quantitative and visual assessment of stress distribution in the hip joint capsule, and compared with the conventional approach, anatomical repair can achieve better biomechanical properties of the capsule.

OBJECTIVE:To explore the tensile mechanics and anatomical characteristics of the posterior hip capsule, and provide biomechanical and anatomical evidence for capsule repair in total hip replacement.METHODS:Six bone-capsule-bone specimens were obtained from posterior hip joint of fresh frozen cadavers. The maximum strain, load, elastic modulus and load strain curves of the capsule ligament complex specimens were recorded by Instron Universal Material Testing Machine. Twelve cadaveric hip specimens were dissected to the capsule. The tensile strain of normal capsule and conventionally reconstructed capsule at 90 degrees of hip flexion were documented. The suture area of the posterior capsule was divided into nine sections, and the thicknessof different sections was measured and compared. Posterior capsule of the cadavers was repaired in conventionally way and anatomical way separately and simulated rehabilitation was conducted. The effect of rehabilitation on the repaired capsule was observed.RESULTS:The load-strain curve of capsule ligament complex conforms to rheological and viscoelastic characteristics. The maximum tensile strain of the complex was (39.21±5.23)%, the maximum load was (142.06± 34.15) N, the tensile strength was (1.65±0.38) MPa, and the elastic modulus is (14.23±5.62) MPa. At 90 ° hip flexion, the tensile strain of repaired capsule was higher than that of normal capsule, and the difference was statistically significant (P< 0.05). Tensile strain of conventionally reconstructed capsule is:upper part (37.0±4.9)%, middle part ( 53.3±1.1)%, lower part (68.3±6.2)%, tensile strain of normal capsule is:upper part (17.0±2.6)%, middle part (24.1±1.4)%, lower part (26.0± 4.3)% . The thickness of the posterior joint capsulein different sections is statistically significant (P<0.05), and capsule at 0.5cm proximal to the femoral insertion is suitable for suture. There the average thickness of capsule is:upper part (3.48 ± 0.11) mm, middle part (2.36 ± 0.09) mm, lower part (1. 59±0.24) mm. The posterior inferior joint capsule is thinnest at (1.42± 0.02) cm proximal to the femoral insertion, and sutures should be avoided here. After simulating rehabilitation, avulsion occurred in the lower part of the posterior capsule repaired conventionally (10/12), and the anatomically repaired capsule remained intact.CONCLUSION:The lower part of conventionally repaired capsule is overstretched and tends to fail. Anatomically repaired capsule conforms to tensile mechanics and is helpful to reduce the failure rate of repair.

目的 探索应用3D打印导板结合数字技术辅助手术治疗复杂距骨骨折的方法.方法 选取2013年1月至2017年6月收治的复杂距骨骨折病例15例,男性13例,女性2例;年龄16～57岁,平均年龄36.8岁.将患者的薄层CT扫描数据导入Mimics软件,构建距骨骨折的三维模型.在Solidworks软件中建立螺钉的三维数字模型导入Mimics,模拟手术入路、复位、固定骨折块,设计、打印导板.术中根据数字技术模拟的方案选择入路、复位骨折,根据螺钉导板选择合适的螺钉和角度固定骨折.术后将骨折复位内固定结果与术前方案比较,随访患者远期踝关节功能,评价3D打印结合数字技术治疗复杂距骨骨折的效果.结果 15例患者解剖复位10例,良好3例,可2例.螺钉安放与术前设计基本一致,无螺钉误入关节、长度合适.美国足踝外科协会(American orthopaedic foot and ankle society,AOFAS)踝-后足评分:优9例,良4例,可2例.结论 3D打印结合数字技术为复杂距骨骨折的术前设计、术中植入螺钉提供了直观、有效的手段,能提高手术内固定的精确性.

目的 利用有限元方法分析缝合锚钉固定下胫腓联合损伤对距骨应力分布的影响.方法 选取1例下胫腓联合损伤患者右踝螺旋CT扫描图像,利用Mimics 10.01等软件进行骨骼的三维重建、模拟韧带连接和生成关节接触等,在模型中分别采用下胫腓螺钉和缝合锚钉固定下胫腓联合损伤,模拟前抽屉试验、内翻试验、内旋试验时所受外力,进行加载运算.结果 下胫腓螺钉:踝关节位于背屈20°、背屈10°、中立位、跖屈10°、跖屈20°,在模拟前抽屉试验时距骨的应力分别为6.496 MPa、5.653 MPa、3.882 MPa、5.875 MPa、6.946 MPa.在模拟内翻试验时距骨的应力分别为7.543 MPa、6.765 MPa、5.432 MPa、6.269 MPa、6.843 MPa.在模拟内旋试验时距骨的应力分别为8.269 MPa、7.541 MPa、6.712 MPa、7.668 MPa、8.683 MPa.缝合锚钉:踝关节位于背屈20°、背屈10°、中立位、跖屈10°、跖屈20°,在模拟前抽屉试验时距骨的应力分别为3.327 MPa、3.253 MPa、2.122 MPa、2.713 MPa、3.795 MPa.在模拟内翻试验时距骨的应力分别为4.475 MPa、4.113 MPa、3.351 MPa、4.352 MPa、4.795 MPa.在模拟内旋试验时距骨的应力分别为5.382 MPa、4.615 MPa、3.985 MPa、4.727 MPa、5.352 MPa.结论 通过有限元分析,相对于下胫腓螺钉而言,缝合锚钉固定下胫腓联合损伤可减轻距骨应力集中,且更符合下胫腓联合韧带的生物力学特征.

BACKGROUND:Reducing blood loss could help to prevent the complications of total knee arthroplasty, relieve the swelling and discomfort postoperatively and accelerate the rehabilitation. OBJECTIVE:To explore the methods for reducing blood loss during total knee arthroplasty. METHODS:Totally 63 patients undergoing primary unilateral total knee arthroplasty were divided into two groups. Group 1 included 27 patients who received the conventional surgical techniques using tourniquet during the whole procedure with wound drainage, as control group. Group 2 included 36 patients who received the modified procedure only using tourniquet during prosthesis implantation without wound drainage, as experimental group. In the experimental group, we stitched the capsule closely. The preoperative and postoperative hemoglobin, decrease of hemoglobin, knee pain score, range of motion blood transfusion rate and wound healing were compared between the two groups. RESULTS AND CONCLUSION:(1) There was no significant difference in preoperative hemoglobin between the two groups. At 1, 4 and 7 days postoperatively, the hemoglobins were significantly lower in the control group than in the experimental group, and the decreases of hemoglobins were significantly lower in the control group than in the experimental group. (2) Knee pain score was not significantly different between the two groups. (3) The range of motion of the knee was significantly larger in the experimental group than in the control group at 7 days. (4) Blood transfusion rate was 18.5%in the control group, and wound healing was poor in one patient. There was no transfused case and wound problem in the experimental group. All wounds were healed normally. (5) There was no infection or hematoma in two groups. (6) With the modified procedure, we could reduce blood loss during total knee arthroplasty without blood transfusion after surgery, which was helpful to postoperative rehabilitation.

目的:探讨多学科联合诊疗在帕金森病合并髋关节骨折的围手术期的作用.方法:对骨科收治的21例帕金森病合并髋关节骨折患者行手术治疗,用多学科联合诊疗对围手术期风险和并发症给予积极处理.结果:4例患者术后出现谵妄现象,对症处理后症状消失;1例患者出现急性腔隙性脑梗死,对症处理好症状明显好转;1例患者出现了肺部感染,予以对症抗感染治疗后,症状好转消失.其余患者髋关节功能恢复良好,无围手术期并发症发生.结论:多学科联合诊疗在帕金森病合并髋关节骨折围手术处理和治疗中有积极意义,能有效地提高患者手术的耐受力,减少围手术期的相关并发症.

Objective To explore the influence of the different strategies for using tourniquet on perioperative bleed loss in total knee arthroplasty ( TKA ) .Methods A total of 59 patients who underwent TKA were randomized into two groups.In group 1(29 patients),the tourniquet was inflated just before incision and deflated after the last suture of the skin.In group 2(30 patients),the tourniquet was inflated after osteotomy and deflated after the bone cement solidified.Gross and Nadler formulas were used to calculate the total perioperative blood loss.Results The estimated blood loss in group 1 was significantly lower than in group 2 on the first postoperative day ( P<0 .05 ) .No significant difference on the total blood loss between the two groups was detectable on the third postoperative day ( P>0 .05 ) .No complications such as joint hematoma and deep vein thrombosis appeared in both groups.Conclusion All course tourniquet application can not reduce the total perioperative blood loss in TKA.

目的:分析首次全膝置换术患者静滴氨甲环酸对改善术后失血的效果,以提升医疗质量.方法:回顾性分析我院收治的86例首次全膝置换术患者的临床资料,按入院顺序将其平均分成对照组与观察组各43例,对照组静滴生理盐水,观察组静滴氨甲环酸,对比两组患者术后的失血情况.结果:对比两组患者的术后失血量、术后输血量与输血率,观察组均明显低于对照组,差异显著,均有统计学意义(P＜0.05).结论:首次全膝置换术患者静滴氨甲环酸,能够有效改善术后失血情况,值得在临床上广泛推广与应用.

目的 评估手术治疗高能量闭合性Pilon骨折的临床疗效.方法 高能量闭合性Pilon骨折患者29例均接受切开复位内固定治疗.受伤至接受手术时间为伤后3h-8 d.Ruedi-Allgower分型:Ⅱ型损伤21例,Ⅲ型损伤8例.采用改良Mazur评分评估临床疗效.结果 术后改良Mazur评分:优9例,良13例,可6例,差1例;优良率75.9％. 29例患者术后均未发生严重切口并发症.结论 为降低软组织并发症的风险、提高疗效,手术治疗高能量Pilon骨折需要根据骨折类型和伴发软组织损伤情况选择合适的手术时机和个性化的手术方案.