[Objective] To explore the impact of syndesmotic injury on the stability of ankle joint.[Methods] Six fresh frozen cadaveric specimens were used to make a biomechanical testing.The specimens were amputated above the knee joint.Ligaments of the syndesmosis,interosseous membrane,and deltoid ligament were sequentially sectioned.The specimens were loaded under a combination of 600 N axial loading and 5 Nm external rotation loading.Motion of the syndesmosis and the external rotation angle of the ankle joint were measured.[Results] Sequential resection of the syndesmotic ligaments and deltoid ligament led to increase of the medial-lateral displacement,anterior-posterior displacement,and rotation angle (around its axis) of the distal fibula,as well as the external rotation angle of the ankle joint.[Conclusions] The syndesmosis takes an important part in maintaining the biomechanical stability of the ankle joint.The posterior tibiofibular ligament seems to be the most important syndesmosis ligament for the rotational stability of the ankle joint.Dissection of the deltoid ligament would make the ankle joint much more unstable following the syndesmosis resection.

Each of the syndesmotic ligaments has different biomechanical effects. Minimal movement occurs in the syndesmosis during the motion of the ankle joint,and the syndesmotic injury is associated with the ankle position and the patterns of external forces. Controversy still exists with respect to the optimal fixation of the syndesmosis. Malreduction of the syndesmosis would lead to abnormal pressure distribution on the ankle joint. Therefore,the flexible fixation might more accord with the physical movement of the syndesmosis. In this article,the biomechanical studies on syndesmosis are reviewed to provide the reference for proper treatment method for syndesmotic injury.

目的 总结旋后内收型Ⅱ度踝关节骨折的手术治疗经验.方法 从2008-09/2012-10月,作者医院对20例旋后内收型Ⅱ度踝关节骨折行手术治疗,其中男13例,女7例,年龄19～60岁,平均36.8岁,均为闭合型骨折,均采取手术治疗.内踝骨折采取前内侧入路,同时探查胫骨远端内侧关节面及距骨软骨面.对于不伴胫骨远端内侧关节面塌陷的予直接复位固定内踝,存在胫骨远端内侧关节面塌陷的予以复位植骨固定后再行内踝复位固定.对于存在距骨软骨面剥脱的,予以去除剥脱的软骨,暴露的骨面予微骨折处理.外侧结构损伤Ⅰ期修复.本组采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝-后足评分评估患踝术后功能.结果 20例中16例获随访,时间12～24个月,平均17个月.术后所有切口均Ⅰ期愈合,无感染,无神经损伤表现,随访期间内无影像学创伤性关节炎征象.术后末次随访AOFAS踝-后足评分为71～93(80.9±5.4)分,其中优6例,良11例,可3例,优良率85％.结论 对于旋后内收型Ⅱ度踝关节骨折,处理踝关节内外侧结构损伤的同时还需要注意胫距内侧关节面的情况,并予以处理,可提高手术疗效.

Objective To investigate the therapeutic outcomes of open reduction and internal fixation for fractures of the medial process of calcaneal tuberosity.Methods From January 2010 to January 2012,12 patients with fracture of the medial process of calcaneal tuberosity at 13 sides were treated by our department.They were 10 males and 2 females,with an average age of 30.5 years (range,20 to 39 years).One of the male patients suffered from bilateral fractures of the medial process of calcaneal tuberosity.The surgical treatments included open reduction,internal fixation by mini-plate or screws.In our cases,isolate screw fixation was used in 8 fractures,and mini-plate fixation was used in 5 fractures.Results Ten patients with 11 fractures were followed up for 14 months on average (range,12 to 24 months).All the cases healed uneventfully.No infection or fixation failure was found.The mean time of bone union was 11 weeks (range,8 to 13 weeks).Full weight bearing was achieved in a mean time of 12 weeks (range,9 to 14 weeks) with no obvious pain or discomfort.According to the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale,the mean score was 90.4 (range,84 to 100) at the final follow-up.Conclusions In the treatment of fractures of the medial process of calcaneal tuberosity,anatomic reduction and stable internal fixation is the key to recovery of the calcaneal morphology and normal gait.A suitable therapeutic strategy based on the fracture pattern can benefit the clinical outcomes.

目的 探讨经单一内侧切口撑开器辅助下行外侧软组织松解联合第1跖骨Scarf截骨治疗中重度足拇外翻的手术疗效.方法 自2011-12-2012-12诊治22例(25足)中重度足拇外翻,于第1跖骨内侧作单一切口,远端延长至第1跖趾关节,撑开器辅助下行外侧软组织松解及Scarf截骨矫正.结果 20例(23足)获得随访12～24个月,平均14个月.截骨愈合时间10～13周,平均11.5周.术前拇外翻角(HVA)30.3°～51.5°(40.0±5.6)°,第1、2跖骨间夹角(IMA)15.0°～21.4°(18.6±1.8)o,AOFAS评分41.7～67.1 (55.9±6.0)分;末次随访时HVA 5.8°～21.4°(13.3±4.0)°,IMA 6.2°～12.9°(10.8±1.8)°,AOFAS评分80.5～96.2(87.3±4.6)分,均较术前明显改善,差异有统计学意义(P＜0.05).结论 撑开器辅助下内侧单切口外侧软组织松解联合Scarf截骨能有效矫正中重度足拇外翻畸形,撑开器辅助下内侧单切口显露清楚、创伤小且外形更加美观.

Objectives To explore the anatomy of the plantar aponeurosis (PA) and its biomechanical effects on the first metatarsophalangeal (MTP) joint and foot arch. Methods Anatomic parameters (length, width and thickness of each central PA bundle and the main body of the central part) were measured in 8 cadaveric specimens. The ratios of the length and width of each bundle to the length and width of the central part were used to describe these bundles. Six cadaveric specimens were used to measure the range of motion of the first MTP joint before and after releasing the first bundle of the PA. Another 6 specimens were used to evaluate simulated static weight-bearing. Changes in foot arch height and plantar pressure were measured before and after dividing the first bundle. Results The average width and thickness of the origin of the central part at the calcaneal tubercle were 15.45 mm and 2.79 mm respectively. The ratio of the length of each bundle to the length of the central part was (from medial to lateral) 0.29, 0.30, 0.28, 0.25, and 0.27, respectively. Similarly, the ratio of the widths was 0.26, 0.25, 0.23, 0.19 and 0.17. The thickness of each bundle at the bifurcation of the PA into bundles was (from medial to lateral) 1.26 mm, 1.04 mm, 0.91 mm, 0.84 mm and 0.72 mm. The average dorsiflexion of the first MTP joint increased 10.16° after the first bundle was divided. Marked acute changes in the foot arch height and the plantar pressure were not observed after division. Conclusions The first PA bundle was not the longest, widest, or the thickest bundle. Releasing the first bundle increased the range of motion of the first MTP joint, but did not acutely change foot arch height or plantar pressure during static load testing.

中国已进入老龄化社会，老年急性阑尾炎发病率随着年龄的增大而逐年上升，老年性阑尾炎的发病率约2%~4%，占全部阑尾炎的3 %~4 %［1］。自 Semm［2］于 1983 年报道了首例腹腔镜阑尾切除术（laparoscopic appendectomy，LA）以来，LA 在世界各地广泛开展，随着腹腔镜设备的不断完善及手术者经验的积累，老年患者急性阑尾炎已不再是LA禁忌证，已越来越多地用于急性阑尾炎的治疗，作者自2009年1月至2013年3通过回顾性分析本院62例老年急性阑尾炎患者的临床资料，探讨腹腔镜治疗老年急性阑尾炎的临床效果，报告如下。

目的 探讨闭合复位经皮空心钉治疗纵行移位髌骨骨折的疗效.方法采用闭合复位经皮空心螺钉内固定治疗21例纵行髌骨骨折患者,术后早期功能锻炼.结果 失访4例,17例获得随访,时间12～24个月.无螺钉松动、断裂、骨折分离、感染及排斥反应等并发症.患者术后膝关节屈曲0°～135°.采用Bostman髌骨骨折功能评分标准:优15例,良2例.结论 闭合复位经皮螺钉固定治疗纵行髌骨骨折操作简单,创伤小,固定牢靠,恢复快,疗效满意.

Background and Objectives: One-stage laparoscopic management for common bile duct stones in patients with gallbladder stones has gained wide acceptance. We developed a novel technique using a transcystic approach for common bile duct exploration as an alternative to the existing procedures. Methods: From April 2010 to June 2012, 9 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. The main inclusion criteria included no upper abdominal surgical history and the presence of a stone measuring <5 mm. After the gallbladder was dissected free from the liver connections in a retrograde fashion, the fundus of the gallbladder was extracted via the port incision in the right epigastrium. The choledochoscope was inserted into the gallbladder through the small opening in the fundus of the gallbladder extracorporeally and was advanced toward the common bile duct via the cystic duct under the guidance of both laparoscopic imaging and endoscopic imaging. After stones were retrieved under direct choledochoscopic vision, a drainage tube was placed in the subhepatic space. Results: Of 9 patients, 7 had successful transcystic common bile duct stone clearance. A narrow cystic duct and the unfavorable anatomy of the junction of the cystic duct and common bile duct resulted in losing access to the common bile duct. No bile leakage, hemobilia, or pancreatitis occurred. Wound infection occurred in 2 patients. Transient epigastric colic pain occurred in 2 patients and was relieved by use of anisodamine. A transient increase in the amylase level was observed in 3 patients. Short-term follow-up did not show any recurrence of common bile duct stones. Conclusion: Our novel transcystic approach to laparoscopic common bile duct exploration is feasible and efficient.

<正>胫骨远端关节外骨折约占胫骨骨折的3%～10%[1]。尽管骨折不累及关节面,与典型的Pilon骨折的损伤机制及治疗有所不同,但是由于距离踝关节较近,骨折的复位及维持稳定仍相对困难。另外,胫骨远端骨折多为高能量损伤,且局部软组织较为薄弱,因而临床处理比较困难。Bstman等[2]报道,髓内钉治疗胫骨远端关节外骨折患者恢复正常工作或运

Objective To summarize the clinical experience of laparoscopic cholecystectomy in elderly patients.MethodsTotally 438 elderly patients with acute cholecystitis(65 to 88 years old with a mean of 72.6 years) underwent laparoscopic cholecystectomy(LC) from January 2007 to August 2012 in our hospital.They had suffered from the disease for 3 to 23 days(mean,3 days) before the operation.Results LC was completed in 406 of the patients(92.7%),including 378 cases of total resection and 28 cases of partial cholecystectomy,the other 32(7.3%) cases were converted to conventional open surgery.Eighteen cases(4.1%) of surgical complications were observed,including 5 cases of bile duct injury,2 cases of operative bleeding,6 cases of postoperative hemorrhage,and 5 cases of postoperative bile leakage;no death occurred in our series,all the patients were cured.Conclusion LC is safe and feasible for elderly patients.

Objective To compare the efficacy of varicose vein in lower extremity treated by great saphenous vein high ligation combined with endovenous laser treatment(EVLT) and great saphenous vein high ligation and stripping. Methods Two hundred and seventy-eight patients(342 limbs) with varicose vein in lower extremity treated in our hospital from March 2007 to February 2012 were divided into two groups. Group A(286 limbs) were treated by great saphenous vein EVLT combined with high ligation,while group B(56 limbs) were treated by great saphenous vein high ligation and stripping. Operative time,48-hour postoperative pain visual analogue scale(VAPS) values,getting out of bed for the first time after surgery and postoperative average hospital stay were compared between the two groups. CEAP classifications were compared before operation and 6 months after operation. Scores were evaluated for the effect of surgery and self satisfactions by patients themselves between the two groups. Results There were no significant differences in operative time and average hospital stay between two groups(P>0.05). However,the pain at 48 h after surgery and the time of getting out of bed were less and earlier in group A than those in group B(P<0.05). The change of CEAP classification and the scores of the effect of the operation were significantly different before and after surgery in the two groups(P<0.05). There were no significant differences between the two groups(P>0.05).However,postoperative evaluation was better in group A than that in group B(P<0.05). Conclusion EVLT combined with high ligation for treatment of varicose vein in lower extremity has a similar efficacy with great saphenous vein high ligation and stripping. Moreover,it has high self satisfaction rate,which is worth for clinical application.

Pilon骨折的治疗对骨科医师来说很有挑战性,高能量的pilon骨折常伴有严重的软组织损伤,有较高的并发症发生率.上世纪60年代提出的传统切开复位内固定在一部分低能量损伤中取得了相对好的疗效,但是处理高能量损伤会造成严重的软组织并发症.认识到保护软组织的重要性,外固定结合有限切开复位内固定从上世纪80年代开始受到欢迎,上世纪90年代分期切开复位内固定逐渐受到重视.不管是作为临时固定还是作为最终的治疗措施,外固定支架固定已成为治疗pilon骨折不可或缺的一部分.笔者拟从pilon骨折的研究现状和外固定治疗进展方面做一综述.

<正>跖板(跖盘,plantar plate)位于足跖趾关节底,作为梯形状的纤维软骨板参与跖趾关节构成,对维持跖趾关节稳定有着重要意义[1]。虽有学者将第1跖趾关节处的跖板以及相关组织的过伸性损伤称为人工草坪趾(turf toe)[2]。但跖板损伤引起的足底疼痛、肿胀往往被笼统地称为"跖痛症"。临床医师对其认识不足或漏诊可导致跖趾关节持续性疼痛以及后期关节畸形。近年来国内文献对于跖板,尤其是第2～5跖

复杂的pilon骨折是骨科临床难题,治疗棘手,处理好pilon骨折对骨科医生来说极具挑战.从Etienne Destot于1911年提出"pilon"概念以来,对pilon骨折的认识足足有100年的时间.从初期的保守治疗,到20世纪60年代提出的传统切开复位内固定,一直到后来提出的有限切开复位内固定、分期切开复位内固定,以及近年来提出的微创经皮接骨板技术(minimal invasive plate osteosytheses,MIPO)和相关微创技术,都为pilon骨折的治疗提供了诸多选择.本文对pilon骨折的切开复位内固定治疗进展做一综述.

背景袖状胃切除术由于手术操作简单、效果确切,在减肥手术中应用越来越多。但该手术后残胃漏是一个需要大家关注和研究的问题。方法用袖状胃切除术和漏作为关键词,在Medline检索。对检索出的文章,再用人工筛选,最后找出29篇文章,涉及4888例手术。文章重点集中在残胃漏发生率和影响漏产生的因素。结果在4888例袖状胃切除术中,术后残胃漏的发生率是2.4%。超级肥胖(BMI>50)残胃漏发生率为3.0%(23/771);而BMI<50病人术后残胃漏发生率为2.2%(92/4117)。吻合器钉匣的高度和一些切缘加强方法并不能减少袖状胃切除术后残胃漏的发生。用40Fr或以上型号的扩张器,袖状胃切除术后残胃漏发生率为0.6%;而小型号扩张器术后残胃漏发生率为2.8%。89%残胃漏发生在胃的近端,大部分残胃漏发生在手术第10天以后。残胃漏发生后,可在内镜下放置支撑架或腹腔镜下放置腹腔引流管进行治疗。结论袖状胃切除术后,残胃漏发生率为2.4%。在胃切除时,不要过于靠近食管胃结合处。一旦残胃漏发生,可采用微创方法处理。

Objective To reveal the importance that the plantar fascia takes to the stability maintenance of the first metatarsophalangeal joint and to investigate the feasibility of treating Hallux rigidus in its early stage through surgery.Methods 6 fresh cadaveric foot specimens were used in the experiment.A digital detective device was adopted to measure the motion range of the first metatarsophalangeal joint before and after the severance of the plantar fascia beneath the first metatarsal bone.During the measuring process,the distal end of the hallux was loaded to dorsiflexion with the whole specimen fixed to homemade braces.Results The dorsiflexion range of the first metatarsophalangeal joint was(68.34±3.05)°and(78.50±3.77)° before and after the severance of the plantar fascia,respectively.The motion range increased by(10.16±2.10)°after the plantar fascia was severed(t=11.83,P0.05).Conclusions The plantar fascia plays an important role in maintaining the stability of the first metatarsophalangeal joint.The injury of the plantar fascia should be treated in its earliest stage possible.Surgical release of the plantar fascia should be well-planned to minimize the effect on its structural and functional integrity.Partial section of plantar fascia may be used as an effective operative approach to deal with Hallux rigidus in its early stage.

<正>Pilon骨折作为骨折中较难治疗的一种创伤,往往存在胫骨干骺端压缩、粉碎,胫骨负重面不同程度碎裂,同时具有骨折高度不稳定、关节软骨损伤、关节面复位困难及严重软组织损伤的特点[1-2]。作为骨科治疗的热点之一,目前不断涌现出新的技术理念和内固定材料。值得关注的是,尽管众多学者报道75%～85%的Pilon骨折合并腓骨骨折,但专门针对Pilon骨折中腓骨骨折的临床或生物力学研究报道较少。另

2010年3月～2011年12月行免气腹单孔腹腔镜辅助空肠造口术3例。全麻后,在脐与剑突中点,向下做正中切口,切口长4 cm,进腹,置切口保护圈,安装腹壁悬吊装置,提起腹壁,建立腔镜操作空间。从切口置入10 mm腹腔镜,进行腹腔探查。用肠钳将横结肠向上牵拉,显露屈氏韧带,找到空肠的起始部。在距屈氏韧带40 cm处,将空肠肠襻从切口处拖出体外,按常规方法做空肠造口术。在脐与剑突连线中下1/4的左侧6 cm,将造口管引出体外。术中未发生出血和肠管损伤。术后无腹痛、出血、肠漏、肠梗阻等并发症。术后第2天开始行肠内营养,营养液输注通畅,没有外漏,病人耐受良好。术后第8天拆线,切口愈合好。我们认为腔镜空肠造口术是一种安全、易行的微创空肠造口方法。

目的:总结治疗胃癌No.13淋巴结转移引起胃癌术后黄疸的经验。方法:回顾性分析从2007年6月—2012年10月,收治5例胃癌术后No.13淋巴结转移引起的黄疸患者的临床资料。结果:5例患者中,放弃治疗1例,剖腹行胆总管置T管1例;另3例,在ERCP下,放置胆道内支撑架,2例置管成功,1例置管失败。胆总管置T管和ERCP置管成功者,术后2周左右黄疸消退,生存时间超过10个月。未行胆道引流者,生存时间为1~2个月。结论:有效的胆道引流可在短时间内迅速减退因胃癌No.13淋巴结转移压迫胆总管而引起的阻塞性黄疸,延长患者的生存时间。