直接前方入路与后外侧入路全髋关节置换治疗股骨颈骨折的疗效比较及术后髋关节功能的影响因素分析

摘要 目的：比较直接前方入路与后外侧入路全髋关节置换治疗股骨颈骨折的疗效及术后髋关节功能的影响因素分析。方法：选取2019年5月至2021年12月徐州医科大学附属医院收治并行全髋关节置换治疗股骨颈骨折患者96例,按照手术方法的不同分为直接前方入路组（n=48）和后外侧入路组（n=48）。观察两组围术期指标、并发症发生情况,比较两组治疗前后Harris评分、视觉模拟评分法（VAS）。并应用单因素、多因素Logistic回归分析患者术后髋关节功能的影响因素。结果：直接前方入路组下床时间、切口长度、住院时间显著短于后外侧入路组,术中失血量、术后引流量显著低于后外侧入路组,而手术时间显著长于后外侧入路组（P<0.05）。直接前方入路组术后1、3个月Harris评分显著高于后外侧入路组,VAS评分显著低于后外侧入路组（P<0.05）。两组术后并发症发生率比较,无统计学差异（P＞0.05）。两组治疗6个月后髋关节功能优良率比较,差异无统计学意义（P>0.05）。多因素Logistic回归分析结果显示：体质量指数≥24 kg/m²、术后锻炼时间<3 h/d、合并骨质疏松是接受全髋关节置换治疗的股骨颈骨折患者术后髋关节功能不良的危险因素（P＜0.05）。结论：直接前方入路全髋关节置换术较后外侧入路全髋关节置换术短期内优势明显,表现为对患者的创伤更小,术后疼痛程度较轻,有利于患者的髋关节功能恢复。体质量指数≥24 kg/m²、术后锻炼时间<3 h/d、合并骨质疏松是接受全髋关节置换治疗的股骨颈骨折患者术后髋关节功能不良的危险因素。     

不同剂量右美托咪定联合超声引导下多点髂筋膜间隙阻滞在老年全髋关节置换术中的应用效果分析

摘要 目的：探讨超声引导下多点髂筋膜间隙阻滞联合不同剂量右美托咪定在老年全髋关节置换术（THA）中的应用效果。方法：选取2019年11月-2022年12月北京积水潭医院贵州医院择期行THA的老年患者120例,按照随机数字表法分为A组（n=40）、B组（n=40）、C组（n=40）,三组均接受超声引导下多点髂筋膜间隙阻滞治疗,在此基础上,A组、B组、C组分别给予0.5 μg/kg、1.0 μg/kg、1.5 μg/kg右美托咪定注射液。对比三组临床指标、血流动力学指标、应激反应指标、脑神经损伤情况,观察三组围术期间不良反应发生情况。结果：B组、C组的阻滞消退时间、拔管时间长于A组,首次下床时间短于A组（P<0.05）。B组、C组的阻滞消退时间、拔管时间、首次下床时间对比无差异（P>0.05）。三组麻醉诱导后即刻（T1）~手术结束时（T3）时间点心率（HR）、平均动脉压（MAP）升高后降低（P<0.05）。B组、C组的T1~T3时间点HR、MAP均低于A组,且B组低于C组（P<0.05）。三组T3时间点皮质醇（Cor）、白介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）升高（P<0.05）。B组、C组的T3时间点Cor、IL-6、TNF-α均低于A组,且B组低于C组（P<0.05）。B组、C组的T3时间点中枢神经特异性蛋白（S100β）均低于A组,且B组低于C组（P<0.05）。B组、C组的T3时间点脑源性神经生长因子（BDNF）均高于A组,且B组高于C组（P<0.05）。三组不良反应发生率组间对比无差异（P>0.05）。结论：超声引导下多点髂筋膜间隙阻滞联合1.0 μg/kg右美托咪定在THA中具有更好的麻醉效果,可缩短首次下床时间,减轻机体应激反应、血流动力学波动以及脑部神经损伤。     

超声引导下隐神经联合IPACK阻滞对老年全膝关节置换术患者应激反应、炎性细胞因子及膝关节活动度的影响

摘要 目的：探讨超声引导下隐神经联合腘动脉与膝关节后囊间隙（IPACK）阻滞对老年全膝关节置换术（TKA）患者应激反应、炎性细胞因子及膝关节活动度的影响。方法：根据随机数字表法,将无锡市中医医院2021年3月~2022年9月期间收治的102例初次行TKA的老年患者分为观察组（超声引导下隐神经联合IPACK阻滞镇痛处理）和对照组（超声引导下隐神经镇痛处理）,每组各51例。对比两组疼痛情况、炎性细胞因子、应激反应指标、不良反应发生率、膝关节活动度。结果：观察组术后6 h、术后12 h、术后24 h视觉模拟评分法（VAS）评分低于对照组（P<0.05）。观察组术后48 h肿瘤坏死因子-α（TNF-α）、白细胞介素（IL）-6、IL-1β、β-淀粉样蛋白（Aβ）低于对照组（P<0.05）。观察组术后48 h血管紧张素Ⅱ（AngⅡ）、皮质醇（COR）低于对照组（P<0.05）。观察组术后24 h、术后48 h膝关节活动度大于对照组（P<0.05）。两组不良反应发生率对比无差异（P>0.05）。结论：超声引导下隐神经联合IPACK阻滞用于TKA患者,具有较好的镇痛效果,可减轻应激反应,抑制炎性细胞因子过度分泌,改善膝关节活动度,麻醉效果较好。     

右美托咪定复合罗哌卡因对膝关节置换术后镇痛镇静效果、睡眠质量及应激反应的影响

目的:探讨右美托咪定复合罗哌卡因对膝关节置换术后的临床效果。方法:选取2015年2月～2018年12月期间在武警陕西省总队医院择期行膝关节置换术患者103例,根据随机数字表将患者分成对照组(n=51)和研究组(n=52),对照组股神经阻滞时给予罗哌卡因,研究组在对照组基础上联合右美托咪定。比较两组患者镇痛镇静效果、睡眠质量、应激反应以及不良反应。结果:研究组术后12 h、术后24 h、术后48 h视觉模拟评分(VAS)低于对照组(P0.05),Ramsay镇静评分则高于对照组(P0.05)。研究组术后24 h、术后48 h阿森斯失眠量表(AIS)评分均低于术前,且呈先降低后升高趋势(P0.05)。研究组术后24 h、术后48 h AIS评分低于对照组(P0.05)。两组患者手术开始即刻、术毕的去甲肾上腺素(NE)、肾上腺素(E)水平均上升,且呈先升高后降低趋势(P0.05);研究组手术开始即刻、术毕的NE、E水平低于对照组(P0.05)。两组不良反应发生率对比无统计学差异(P0.05)。结论:右美托咪定复合罗哌卡因方案应用于膝关节置换术,镇痛镇静效果确切,可减轻术中应激反应,有效改善睡眠质量,且不增加不良反应发生率,临床应用价值较高。     

七氟烷复合麻醉对老年骨科患者术后早期认知功能的影响

摘要 目的：探讨七氟烷复合麻醉对老年骨科患者术后早期认知功能的影响。方法：选择2017年12月~2019年6月在西安医学院第二附属医院（本院）骨科诊治单侧老年全膝关节置换手术患者112例,随机数字表法分为七氟烷组与对照组,各56例。对照组给予常规静脉注射全身麻醉,在此基础上七氟烷组给予七氟烷吸入麻醉,记录与调查两组术后早期认知功能。结果：经过对比,两组手术时间、术中出血量对比差异无统计学意义(P>0.05),而七氟烷组的术后苏醒时间(7.10±0.22)min、拔管时间(8.65±0.46)min等都显著短于对照组(14.09±1.09)min、(18.76±1.44)min,两组对比有统计学意义(P<0.05)。所有患者在T1、T2、T3与T4时间点的心率和血氧饱和度均表现正常,对比均无统计学意义(P>0.05)。七氟烷组术后1 d、术后14 d的血清白介素(Interleukin,IL)-6、肿瘤坏死因子(Tumor necrosis factor,TNF)-α值显著低于对照组,对比有统计学意义(P<0.05),且两组术后14 d的血清IL-6与TNF-α值均显著低于术后1 d (P<0.05)。术后1个月七氟烷组的认知功能障碍发生率为1.8 %（1/56）,显著低于对照组的12.5 %（7/56）,两组间对比有统计学意义(x²=4.846,P=0.028)。结论：七氟烷复合麻醉在老年骨科患者中的应用能促进患者康复,安全性比较好,能抑制炎症因子的释放,从而减少术后早期认知功能障碍的发生。     

右归丸对大鼠膝骨关节炎的干预作用及其机制*

目的: 探讨右归丸对膝骨关节炎(KOA)模型鼠关节软骨组织骨诱导因子(OGN)、骨黏连蛋白(ON)和纤维蛋白原2(FBN2)的影响。方法: 将大鼠随机分为假手术组,模型组,硫酸氨基葡萄糖组(硫酸氨基葡萄糖),右归丸(高、中、低剂量)组,每组10只。采用改良Hulth法制备大鼠KOA模型,假手术组和模型组给予等体积生理盐水灌胃,右归丸高、中、低剂量组分别灌胃给予右归丸4.8,2.4,1.2 g/kg,硫酸氨基葡萄糖组灌胃给予硫酸氨基葡萄糖 0.17 g/kg,连续给药8周。干预结束24 h后取鼠膝关节软骨,采用HE染色法观察各组软骨的病理改变,并进行Mankin评分;免疫组化法检测各组关节软骨组织中OGN、ON和FBN2的表达;Western blot法检测各组关节软骨组中糖原合成酶激酶-3β(GSK-3β)的表达。结果: 与假手术组比较,模型组大鼠软骨组织Makin 评分显著升高,软骨组织FBN2蛋白表达水平上显著增加,OGN、ON和GSK-3β蛋白表达水平上的显著降低(P＜0.01);模型组关节软骨边缘严重破坏,软骨细胞排列紊乱。与模型组比较,右归丸高剂量干预组大鼠软骨组织Makin 评分和FBN2蛋白表达水平显著降低,GSK-3β蛋白表达水平上显著增加,且右归丸中、高剂量组OGN、ON蛋白表达水平均显著增加(P＜0.05或P＜0.01),软骨结构趋于正常,软骨细胞分布仅偶见不均,关节软骨表面欠光滑。结论: 右归丸能够延缓关节软骨退变,其可能机制是通过提高骨诱导因子和骨粘连蛋白的表达水平来促进关节软骨的骨化和重构。     

Effects of branched-chain amino acid supplement on knee peak torque and indicators of muscle damage following isokinetic exercise-induced delayed onset muscle soreness

[Purpose] This study aimed to investigate the effects of branched-chain amino acid (BCAA) supplement on delayed onset muscle soreness (DOMS) by analyzing the maximum muscle strength and indicators of muscle damage.[Methods] Twelve men with majors in physical education were assigned to the BCAA group and placebo group in a double-blinded design, and repeated measurements were conducted. DOMS was induced with an isokinetic exercise. Following BCAA administration, the changes in the knee extension peak torque, flexion peak torque, aspartate aminotransferase (AST), creatine kinase (CK), and lactate dehydrogenase (LDH) concentrations were analyzed. The maximum knee muscle strength was measured at the baseline (pre-D0) following BCAA administration for 5 days before exercise (-D5, -4D, -3D, -2D, -1D). In contrast, the post-treatment measurements (D3) were recorded after BCAA administration for 3 days (post-D0, D1, D2). Blood samples were obtained before (pre-D0), immediately after (post-D0), 24 h (D1), 48 h (D2), and 72 h (D3) after the exercise to analyze the indicators of muscle strength. BCAA was administered twice daily for 8 days (5 days and 3 days before inducing DOMS and during the experimental period, respectively).[Results] There was no difference in the flexion peak torque between the groups. However, the BCAA group showed a significantly higher extension peak torque at D3 (second isokinetic exercise), compared to the placebo group (p<.05). There was no difference in AST changes between the groups. Nonetheless, the CK and LDH were significantly reduced in the BCAA group, compared to the placebo group. There was no correlation between the extension peak torque and flexion peak torque. However, the CK and LDH increased proportionately in DOMS. Moreover, their concentrations significantly increased with a decreasing peak torque (p<.01).[Conclusion] An exercise-induced DOMS results in a decrease in the peak torque and a proportional increase in the CK and LDH concentrations. Moreover, the administration of BCAA inhibits the reduction of the extension peak torque and elevation of CK and LDH concentrations. Therefore, BCAA might be administered as a supplement to maintain the muscle strength and prevent muscle damage during vigorous exercises that may induce DOMS in sports settings.     

不同麻醉方式对老年糖尿病患者全膝置换术后糖代谢的影响

目的:探讨不同麻醉方式对老年糖尿病患者全膝置换术(total knee arthoplasty,TKA)后糖代谢的影响。方法:2018年2月到2020年3月选择在本院进行择期TKA的老年糖尿病合并膝关节骨性关节炎患者88例,随机原则分为研究组与对照组,各44例。对照组给予常规静吸复合全身麻醉,研究组在对照组麻醉的基础上给予复合股神经阻滞,检测两组术后空腹血糖值,并记录两组膝关节功能改善情况。结果:研究组术后1 d、3 d与7 d静息状态下和活动状态下的疼痛视觉模拟评分法(Visual Analogue Scale/Score,VAS)评分都显著低于对照组(P<0.05)。研究组术后1 d、3 d与7 d的空腹血糖值都显著低于对照组(P<0.05)。研究组术后1 d、3 d与7 d的患肢膝关节活动度都显著高于对照组(P<0.05)。结论:股神经阻滞联合全麻在老年糖尿病患者TKA中的应用能缓解术后疼痛,减低术后血糖水平,并且促进提高膝关节活动度有益预后。     

A Three-Dimensional Musculoskeletal Model of the Human Knee Joint. Part 2: Analysis of Ligament Function

A three-dimensional model of the knee is used to study ligament function during anterior-posterior (a-p) draw, axial rotation, and isometric contractions of the extensor and flexor muscles. The geometry of the model bones is based on cadaver data. The contacting surfaces of the femur and tibia are modeled as deformable; those of the femur and patella are assumed to be rigid. Twelve elastic elements are used to describe the geometry and mechanical properties of the cruciate ligaments, the collateral ligaments, and the posterior capsule. The model is actuated by thirteen musculotendinous units, each unit represented as a three-element muscle in series with tendon. The calculations show that the forces applied during a-p draw are substantially different from those applied by the muscles during activity. Principles of knee-ligament function based on the results of in vitro experiments may therefore be overstated. Knee-ligament forces during straight a-p draw are determined solely by the changing geometry of the ligaments relative to the bones: ACL force decreases with increasing flexion during anterior draw because the angle between the ACL and the tibial plateau decreases as knee flexion increases; PCL force increases with increasing flexion during posterior draw because the angle between the PCL and the tibial plateau increases. The pattern of ligament loading during activity is governed by the geometry of the muscles spanning the knee: the resultant force in the ACL during isometric knee extension is determined mainly by the changing orientation of the patellar tendon relative to the tibia in the sagittal plane; the resultant force in the PCL during isometric knee flexion is dominated by the angle at which the hamstrings meet the tibia in the sagittal plane.     

An improved OpenSim gait model with multiple degrees of freedom knee joint and knee ligaments

Musculoskeletal models are widely used to investigate joint kinematics and predict muscle force during gait. However, the knee is usually simplified as a one degree of freedom joint and knee ligaments are neglected. The aim of this study was to develop an OpenSim gait model with enhanced knee structures. The knee joint in this study included three rotations and three translations. The three knee rotations and mediolateral translation were independent, with proximodistal and anteroposterior translations occurring as a function of knee flexion/extension. Ten elastic elements described the geometrical and mechanical properties of the anterior and posterior cruciate ligaments (ACL and PCL), and the medial and lateral collateral ligaments (MCL and LCL). The three independent knee rotations were evaluated using OpenSim to observe ligament function. The results showed that the anterior and posterior bundles of ACL and PCL (aACL, pACL and aPCL, pPCL) intersected during knee flexion. The aACL and pACL mainly provided force during knee flexion and adduction, respectively. The aPCL was slack throughout the range of three knee rotations; however, the pPCL was utilised for knee abduction and internal rotation. The LCL was employed for knee adduction and rotation, but was slack beyond 20° of knee flexion. The MCL bundles were mainly used during knee adduction and external rotation. All these results suggest that the functions of knee ligaments in this model approximated the behaviour of the physical knee and the enhanced knee structures can improve the ability to investigate knee joint biomechanics during various gait activities.