随着时代的发展,科技的进步,人民生活水平的提高,我国医疗水平也在飞速发展,随着我国高龄老人人口的增加,我国从2000年已经进入老龄化社会,对于随之而来的高龄老人的健康问题,也是对医疗工作者提出新的挑战。人们常说:60岁花甲之年,70岁古稀之年,80岁90岁耄耋之年。近日,今年98岁的高龄老人吴奶奶在家中不慎摔倒,于附近的医院检查显示股骨颈骨折,也是称髋部骨折,被医学界称之为老年人的“”人生最后一次骨折“”,因为此部位的骨折若处理不当,可带来一系列灾难性的并发症。尤其吴奶奶如此高龄,心肺功能较差,很多医院没有救治如此高龄患者的经验与医疗条件,成为治疗吴奶奶骨折的一座似乎难以逾越的高山。家属随后拿着X光片慕名找到中国医科大学附属第一医院关节外科的张杭州教授及梁庆威教授,擅长治疗股骨颈、髋臼和股 骨粗隆间骨折等关节周围复杂骨折有十分丰富的经验。患者家属向医生请教哪种治疗手段对于98岁如此高龄,心肺功能较差的老人,是选择保守治疗还是手术治疗。不手术存才哪些问题,手术后最需要注意哪些方面?这种手术对技术的要求高不高?手术费用大约多少?梁庆威主任向该患者家属详细介绍了老年人股骨颈骨折发生的原因、治疗方案,并明确回答了家属提出的几个问题。 多数股骨颈骨折有移位,骨折线越平直越稳定,称为外展型骨折。斜度越大越不稳定,称为内收型骨折。骨折线可位于股骨头下,称为头下型。头下型血管损伤严重,股骨头缺血坏死可能性大。骨折线位于股骨颈中部为经颈型,股骨头缺血坏死的可能性仍很大。骨折线位于股骨颈基部为基底型,基底型多数稳定,固定也较容易,股骨头缺血坏死可能性较小。股骨颈骨折的类型不同,治疗方法也不同。应认真分析骨折特点,选择合适的治疗方法。病人的年龄及身体状况也是选择治疗方法的重要依据。一、 保守治疗骨折处没有移位,患者年龄符合条件,心肺功能极差,无法耐受麻醉及手术等。保守保守治疗时,由于患者卧床时间比较长,所以常因长期卧床而引起肺部感染、泌尿道感染、褥疮、下肢深静脉血栓形成等并发症, 循证医学文献显示高龄患者因股骨颈骨折长期卧床带来的并发症非常常见。二、 手术治疗1、 闭合复位内固定:目前有条件的医院可以在X光机的配合下,不切开皮肤或只切一个很小的伤口,对骨折处进行内固定。但这种手术,要求卧床时间较长,约三个月左右方可下床活动。当然,期间可以在床上坐起等。另外一个问题就是不能完全避免后期的股骨头坏死的可能性,可能带来一系列卧床引起的严重并发症。2、 切开复位内固定:如果医院没有条件进行闭合式固定,就只能切开关节囊进行复位,并对骨折处进行固定。这种手术方法损伤较大,身体状况较差,高龄老人就不能承受。3、 人工股骨头置换术:骨质疏松严重,或者全身状况比较差的老人,或者60岁以上的老人,出现股骨头下型骨折、经颈型骨折,或者已经合并骨关节炎、股骨头坏死,选择人工股骨头置换术。对于合并有脑血管病后遗症的老人,或者受伤前生活质量极差的老人,可以选择人工半髋置换(股骨头置换)术。这种手术将断了的股骨头去掉,更换一个人造的关节。这种手术能较早的下床活动(一般术后一周左右),疗效很好,但费用较高,相对打钉子而言,技术要求很高,最好选择市级三级甲等医院骨关节外科有丰富经验的专家进行手术。 针对这位老人股骨颈骨折的治疗,梁庆威教授强烈建议不要采用保守治疗,打钉子也不可取,最佳选择是人工股骨头置换手术。张杭州教授第一时间安排吴奶奶住院,张主任医师迅速针对吴奶奶身体情况及病情给与了个体化诊治,针对病情给予止痛,卧床,患肢制动,患肢牵引,开出各项物理生化检查,为手术做好充足的准备,详细研究了患病老人的入院各项物理生化检查,发现老人肺功能较差,第一时间联系呼吸科,循环内科,麻醉科,重症医学科等相关科室院内会诊,为老人手术排除手术禁忌,评估手术风险。入院2天后在我院麻醉科的帮助下,急诊手术顺利进行,为患者进行了人工股骨头置换术,手术只用了30分钟的时间,手术非常顺利,术中切口非常小,手术速度很快,同时也刷新了中国医科大学附属第一医院手术室患者的最高年龄,术后患者安返病房。术后6小时后老人可以正常进食进水,老人髋部的疼痛解除了,老人可以在半坐位进食,极大程度上避免了由于平卧位进食带来的食物误吸,肺炎等严重并发症。术后3天患者下床进行功能锻炼,避免了长期卧床带来的灾难性并发症,极大改善了高龄老人的生活质量,吴奶奶与家属非常感激梁庆威主任冒着巨大风险为老人施行手术,体现了中国医大一院医生的仁心仁术,吴奶奶与家属的坚持要与梁主任合影留念。吴奶奶近日准备出院回家进行康复锻炼,梁庆威主任详细向家属讲述了回家后的注意事项及锻炼方法,叮嘱家属定期复查,吴奶奶及家属也表示对康复充满信心,吴奶奶及家属更表示康复后要常来医大一院看望梁庆威主任及张杭州教授。
张杭州医生团队荣获2017年辽宁省医学科技进步奖二等奖
对口支援义县人民医院帮扶计划2016年7月1日至今日期间中国医科大学附属第一医院派遣运动医学关节外科主治医生张杭州到义县人民医院骨科进行对口支援工作,完成以下任务。1.骨科门诊工作:接诊患者近百人次,会诊疑难病例,并对受限于当地诊疗技术的病例联系转诊。结合科室业务学习内容,宣教骨关节炎的治疗,膝关节前交叉韧带损伤的诊疗,指导患者选择治疗方案。2.骨科病房工作:进行教学查房,参加前交叉韧带重建,后交叉韧带重建等手术50余例。3.业务教学结合临床工作中遇到的病例和出现的问题,讲解相关的专业基础知识、诊疗规范、操作技术指南、专业新进展等内容,并建立微信群,发布精简实用的学习内容,共享网络资源,不在院期间也保持和骨科医师及时互动。
目的 探讨采用同种异体跟腱胫骨 Inlay 技术重建膝关节内侧副韧带(medial collateral ligament,MCL)的临床疗效。 方法 回顾分析 2011 年 1 月- 2012 年 12 月,采用同种异体跟腱胫骨 Inlay 技术重建 MCL 的 21 例 MCL 损伤患者临床资料。男 13 例,女 8 例;年龄 19 ~ 62 岁,平均 32 岁。致伤原因:运动伤 15 例,交通事故伤 6 例。病程 15 d ~ 3 个月,平均 1.5 个月。按照国际膝关节文献委员会(IKDC)2000 的 MCL 损伤程度分度标准,Ⅱ度 5 例,Ⅲ度 16 例。膝关节外翻应力试验均为阳性。术后记录并发症发生情况,采用 Lysholm 评分、IKDC 2000 主观评分评价膝关节功能。 结果 术中发生同种异体跟腱骨块碎裂 1 例。术后 1 例切口未愈合,经植皮修复后愈合;余 20 例切口均Ⅰ期愈合。无膝关节僵直、血管及神经损伤、膝关节感染等并发症发生。患者均获随访,随访时间 7 ~ 29 个月,平均 18.5 个月。末次随访时,膝关节外翻应力试验阴性 20 例,Ⅰ度阳性 1 例。除 1 例屈膝受限 15° 外,余均无伸、屈膝受限。膝关节 Lysholm 评分从术前(45.4 ± 13.6)分提高至末次随访的(87.5 ± 9.4)分,IKDC 2000 主观评分从术前的(46.5 ± 14.0)分提高至末次随访的(88.4 ± 9.3)分,比较差异均有统计学意义(P < 0.05)。复查 MRI 示移植物连续性良好。 结论 同种异体跟腱胫骨 Inlay 技术重建 MCL 后膝关节稳定性恢复良好,近期疗效满意,远期疗效有待进一步观察明确。
目的 回顾分析同种异体肌腱单切口重建内侧副股韧带和双切口重建内侧副股韧带的临床疗效差异。方法 选取2010年1月至2012年12月我院收治的膝关节内侧不稳定患者26例(26膝),均采用内侧副韧带重建;其中单切口重建内侧副韧带12例,双切口重建内侧副韧带14例。术前、术后按照IKDC及Lysholm评分评价膝关节功能并测量术后膝关节内侧开口、膝关节活动度、膝关节稳定性。结果 所有患者均获得随访,术后平均随访26个月(14~49个月)。末次随访2种方法术后IKDC评分分别为(84.33±7.85)分和(84.21±7.67)分;Lysholm评分分别为(84.41±8.67)分和(84.5±7.52)分,与术前相比评分明显提高;2种方法术后IKDC及Lysholm评分比较差异无统计学意义(P> 0.05)。关节活动度与内侧关节间隙在术后得到明显改善,2种方法的术后测量值差异无统计学意义(P> 0.05)。结论 单切口重建内侧副股韧带和双切口重建内侧副股韧带治疗膝关节内侧不稳定的临床疗效相同。
Background: In cases of chronic anterior cruciate ligament (ACL)–medial collateral ligament (MCL) lesions, nonoperative treatment of the MCL lesion may lead to chronic valgus instability and rotatory instability. The optimal management for patients who have combined ACL-MCL injuries remains controversial.Purpose: To present a case series of 21 patients who underwent simultaneous ACL-MCL reconstruction with a 2- to 5-year follow-up.Study Design: Case series; Level of evidence, 4.Methods: From October 2007 to December 2010, a total of 21 patients with chronic ACL-MCL injuries, for which the 2 ligaments were reconstructed during the same surgical procedure, were studied. All patients were available for follow-up for at least 2 years. The International Knee Documentation Committee (IKDC) subjective knee scores, valgus and sagittal stability, anteromedial rotatory stability, range of motion, and complications were assessed both preoperatively and postoperatively.Results: At follow-up, valgus and sagittal laxity were not observed in any of the patients. The mean medial knee opening was significantly reduced to 0.80 6 0.96 mm (range, –1.2 to 2.6 mm) postoperatively compared with 8.0 6 1.3 mm (range, 6.1 to 10.7 mm) preoperatively (P\ .01). The mean postoperative side-to-side difference measured with the KT-1000 arthrometer was reduced to 0.8 6 0.9 mm (range, –1.2 to 2.3 mm) compared with 8.4 6 1.6 mm (range, 6.2 to 13.2 mm) preoperatively (P \ .01). Preoperative anteromedial instability was seen in 71% of patients (15/21), whereas none of the patients had anteromedial rotatory instability at the last follow-up. The mean IKDC subjective score improved overall from 45.3 6 12.0 (range, 28.7-69.0) preoperatively to 87.7 6 8.2 (range, 65.5-100.0) at the last follow-up (P\ .01). Most patients (20/21) had normal or nearly normal range of motion of the knee joint; only 1 patient (5%) had a limitation of flexion of 15 compared with the contralateral knee at the last follow-up.Conclusion: In patients with chronic ACL-MCL lesions, simultaneous reconstruction of the ACL and MCL can significantly improve the medial, sagittal, and rotatory stability of the knee at short-term follow-up.
Although various surgical procedures have been described for the medical collateral ligament (MCL) reconstruction, none can accurately reestablish its original anatomy and orientation. The purpose of this study was to present a technique restoring the anatomy and stability of the medial knee with an Achilles tendon allograft using a tibial inlay technique. The bone block was fixed into a cancellous trough created on the medial surface of the tibia with a cancellous screw and washer, while the tendinous portion was fixed into the femoral insertion site of the superficial MCL with a bioabsorbable interference screw. This technique can successfully reproduce the native anatomy and orientation of the MCL
The goal for current orthopedic implant research is to design implants that have not only good biocompatibility but also antibacterial properties. TiO2 nanotubes (NTs) were fabricated on the titanium surface through electrochemical anodization, which added new properties, such as enhanced biocompatibility and potential utility as drug nanoreservoirs. The aim of the present study was to investigate the antibacterial properties and biocompatibility of NTs loaded with vancomycin (NT-V), both in vitro and in vivo. Staphylococcus aureus was used to study the antibacterial properties of the NT-V. There were three study groups: the commercially pure titanium (Cp-Ti) group, the NT group (nonloaded vancomycin), and the NT-V group. We compared NT-V biocompatibility and antibacterial efficacy with those of the NT and Cp-Ti groups. Compared with Cp-Ti, NT-V showed good antibacterial effect both in vitro and in vivo. Although the NTs reduced the surface bacterial adhesion in vitro, implant infection still developed in in vivo studies. Furthermore, the results also revealed that both NTs and NT-V showed good biocompatibility. Therefore, the NTs loaded with antibiotic might be potentially used for future orthopedic implants