Objective To investigate the distribution and influence of comminution in femoral neck fracture (FNF) patients after cannulated screw fixation (CSF). Methods From January 2019 to June 2020, a total of 473 patients aged 23–65 years with FNF treated by CSF were included in the present study. Based on location of the cortical comminution, FNF patients were assigned to two groups: the comminution group (anterior comminution, posterior comminution, superior comminution, inferior comminution, multiple comminutions) or the without comminution group. The incidence of postoperative complications, quality of life and functional outcomes was recorded at 1-year follow-up. Results Comminution was more likely to appear in displaced FNF patients (86.8%) compared with non-displaced FNF patients (8.9%), and the rate of comminution was closely associated with Pauwels classification (3.2% vs 53.5% vs 83.9%, P < 0.05). The incidence of osteonecrosis of the femoral head (ONFH, 11.3% vs 2.9%, P < 0.05), nonunion (7.5% vs 1.7%, P < 0.05), femoral neck shortening (21.6% vs 13.4%, P < 0.05) and internal fixation failure (11.8% vs 2.9%, P < 0.05) was significantly higher in FNF patients with comminutions, especially with multiple comminutions, than those without. Furthermore, there was a significant difference in the Harris hip score (HHS, 85.6 ± 15.6 vs 91.3 ± 10.8, P < 0.05) and EuroQol five dimensions questionnaire (EQ-5D, 0.85 ± 0.17 vs 0.91 ± 0.18, P < 0.05) between FNF patients with comminution and those without. There was no significant difference in Visual analogue scale scores (VAS, 1.46 ± 2.49 vs 1.13 ± 1.80, P > 0.05) between two groups at 1 year post-surgery. Conclusion Comminution is a risk factor for postoperative complications in young- and middle-aged patients with displaced and Pauwels type III FNF who undergo CSF. This can influence the recovery of hip function, thereby impacting quality of life. Further evaluation with a more comprehensive study design, larger sample and long-term follow-up is needed.

旋转对线不良是目前全膝关节置换术(TKA)失败的主要原因之一。各种常用的胫骨假体旋转对线方法中, Insall线存在过度外旋倾向;Akagi线虽是目前认可度最高的解剖轴, 但仍存在一定内旋倾向。胫骨后髁轴不适合对称型假体, 而曲面重叠技术则不适合解剖型假体。此外, 参考任何固定解剖标志放置胫骨假体均不能保证伸膝位胫股假体的旋转一致性, 而自我形合技术虽有利于胫股旋转同步, 但其临床应用效果并不稳定。尽管如此, 上述各种主流技术及其改良方法均可使多数患者获得良好的髌骨轨迹与临床效果。在"金标准"明确之前, 骨科医师可按照自己最习惯的手术方式来确定胫骨假体旋转对线位置。随着对膝关节解剖、生物力学与运动学理解的加深, 数字化辅助技术或许有望成为TKA胫骨旋转对线领域的突破点。

全膝关节置换术(total knee arthroplasty,TKA)是治疗终末期膝关节骨病的有效方法[1].在年龄超过60岁的亚洲老年人口中,约15％的女性及6％的男性患有膝关节骨关节炎0.大多数骨科医生在TKA中采用止血带,止血带的使用会提供更好地手术视野、减少术中出血量及手术时间、改善骨-骨水泥之间的交联[3].但是由于止血带的使用及随后释放引发的机械性压迫和缺血再灌注(ischemia and reperfu-sion,I/R),会造成骨骼肌、神经、血管及脑、肺、肾等脏器的损伤[4],最终导致患者术后股四头肌萎缩、肌力下降,疼痛加剧,活动功能降低,康复及住院时间延长[5],也可增加患者术后总出血量以及深静脉血栓等并发症发生率[6].这些由于止血带引起的副作用通常被称为止血带相关损伤[4].近年来,国内外报道了很多关于TKA术后止血带相关损伤并提出了相应的改善方法,本文对此进行总结归纳,现综述如下.

随着人口老龄化,髋部骨折的发生率正在迅速增加,由于高病死率,髋部骨折现在已成为世界范围内最重要的健康问题之一.手术时机对其预后的影响已被广泛讨论,尽管老年髋部骨折的治疗指南各不相同,但大多数机构建议尽快行早期手术,以帮助患者获得最有利的结果.根据研究报道,虽然关于延迟手术与术后病死率之间的关系有不同的看法,但是早期手术与术后结果的改善(例如褥疮发生、术后功能改善、住院时长)有很强的相关性.不足之处是,现有的研究主要是基于观察性研究,这些研究容易受到固有偏见的影响.希望未来能通过大规模的随机对照实验来进一步明确手术时机对预后的影响,为手术时机的确定提供更精准的数据.

Abstract Objectives To evaluate the efficacy of resistance training (RT) combined with beta‐hydroxy‐beta‐methylbutyric acid (HMB) in the treatment of elderly patients with sarcopenia after hip replacement. Methods From January 1, 2018 to December 31, 2018, 200 elderly patients (68 men, mean age 76.3 years and 137 women, mean age 79.1 years) who experienced femoral neck fracture with sarcopenia after hip arthroplasty were assigned to four groups: RT + HMB group, RT group, HMB group, and negative control group. Baseline data, body composition, grip strength, Barthel index (BI), Harris hip score (HHS), and visual analog scale score (VAS) were compared among the four groups before and 3 months after surgery. Results A total of 177 participants completed the trial, including 43 in the HMB + RT group, 44 in the HMB group, 45 in the RT group, and 45 in the negative control group. At the 3‐month follow‐up, the body composition and grip strength of the HMB + RT group and RT group were significantly improved compared with those before operation. The HMB group had no significant change, while the measures in the negative control group significantly decreased. Postoperative BI and HSS did not reach pre‐injury levels in any of the four groups, but postoperative VAS score was significantly improved. However, there was no significant difference in BI, HSS, or VAS among the four groups. Conclusion RT, with or without HMB supplementation, can effectively improve body composition and grip strength in elderly patients with sarcopenia after hip replacement at short‐term follow‐up. Simultaneously, use of exclusive HMB supplementation alone may also help to prevent decreases in muscle mass and grip strength in these patients.

张洪鹏教授认为阳气亏虚,恣食肥甘厚味,寒湿内生,邪气痹阻经络关节,久则郁而化热,不通则痛是急性痛风性关节炎的病机本质,治疗上采用温阳祛湿散结通络之法,临床取得较好疗效.文章阐述了运用该法治疗急性痛风性关节炎的理论基础,并附医案一则加以说明.

Objective:To investigate the effects of cortical comminution on therapeutic outcomes and postoperative complications in young patients with femoral neck fracture after fixation with femoral neck system (FNS).Methods:A retrospective study was conducted of the 86 patients with femoral neck fracture who had been treated by FNS fixation from January 2020 to December 2020 at Department of Hip Orthopaedic Trauma, Tianjin Hospital. Of them, 41 had cortical comminution at the fracture ends of the femoral neck. They were 16 males and 25 females with a mean age of 53.0 (40.5, 57.0) years. The other 45 patients had intact cortical bone at the fracture ends of the femoral neck. They were 21 males and 24 females with a mean age of 55.0 (44.5, 62.5) years. The 2 groups were compared in terms of incidence of postoperative complications, Harris hip score, Barthel index and visual analogue scale (VAS) pain score after 6-month follow-up.Results:There were no statistically significant differences between the 2 groups in baseline data or reduction mode except for fracture classification, showing comparability between groups ( P>0.05). In the cortical comminution group, the incidences of nonunion [17.1%(7/41)] and femoral neck shortening [29.3%(12/41)] were significantly higher than those in the cortical intact group [0% (0/45) and 11.1% (5/45)], the Harris hip score and Barthel index [82.0 (72.5, 91.5) points and 100.0 (90.0, 100.0)] at 6 months postoperatively were significantly lower than those in the cortical intact group [94.0 (88.0, 98.0) points and 100.0 (100.0, 100.0)], the VAS pain score [1.5 (0, 4.5) points] was significantly higher than that in the cortical intact group [0 (0, 1.0) points] (all P<0.05). However, there was no significant difference between the 2 groups in osteonecrosis of the femoral head or internal fixation failure ( P> 0.05). Conclusions:Cortical comminution following femoral neck fracture is a major risk factor for post-operative complications after FNS fixation, because it may seriously affect the recovery of hip function and quality of life in young patients.