小切口改良Mc Bride矫形术治疗足踇外翻畸形的临床疗效观察

目的:评估和总结使用小切口改良Mc Bride矫形术治疗足踇外翻畸形的临床疗效。方法:选择2010-2014年我院收治的明确诊断为踇外翻畸形的104例患者,所有患者均行小切口改良Mc Bride矫形术,观察和比较患者手术前和手术后3周、6个月时的VAS疼痛评分、踇外翻角测量(HVA)、跖骨间角测量(IMA)及足踝AOFAS评分。结果:所有患者均至少随访至术后6月,优良率为96.2%,患者术后3周、6月VAS评分、HVA与IMA的角度、AOFAS评分均较术前均明显改善,差异均具有统计学意义(P0.05)。仅3例患者在术后6个月时畸形复发,6例出现足部轻度疼痛,1例出现切口延迟愈合,余无明显并发症出现。结论:小切口改良Mc Bride矫形术能够有效纠正踇外翻畸形,并减轻患者的疼痛。     

应用VAS和KSS分析关节镜滑膜切除术后疼痛及膝关节功能

为了系统的评估膝关节类风湿性关节炎关节镜滑膜切除术后影响疼痛的因素和解决方法,本研究利用VAS和KSS系统评估了所在医院自2011年1月至2015年1月间57例膝关节类风湿关节炎行关节镜下滑膜切除术患者,我们将术后31例患者给予抗类风湿药物治疗6~12个月设为A组,26例病例未进行抗类风湿药物治疗或拒绝药物治疗的设为B组。术后3个月和6个月来院复查检测类风湿因子、血沉、C反应蛋白指标,疼痛模拟视觉评分(VAS)评分评估疼痛情况,膝关节功能KSS评分评估关节功能。所有患者进行多因素Logistic回归分析术后疼痛缓解因素,57例患者均获得术后6~18个月随访。研究结果表明,术后6个月膝前痛缓解率为73.7%(42/57),疼痛模拟视觉评分(VAS)平均(3.3±1.1)分;给予抗类风湿药物治疗的患者术后疼痛缓解率(80.6%,25/31)明显高于未给予药物治疗的患者(65.4%,17/26);单因素分析显示不同性别、年龄、手术时间等因素下患者行术后膝前痛的发生率差异无显著性(p0.05),多因素Logistic回归分析结果显示患者合并抗类风湿药物治疗是缓解膝关节类风湿关节炎关节镜滑膜切除术后膝前痛的独立影响因素(p0.05)。我们的评估分析初步表明:膝关节类风湿性关节炎患者行关节镜下滑膜切除术后发生膝前痛缓解率与术后合并抗类风湿药物有关,与患者年龄、性别、手术时间等无关。     

根据退行性脊柱侧凸患者症状选择不同手术方案的临床研究

目的:探究根据退行性脊柱侧凸患者症状选择不同手术方案的治疗效果。方法:随机选取我院2007年9月到2015年10月收治的退行性脊柱侧凸患者124例,根据症状不同分A组和B组。A组62例患者腰背痛,接受长节段矫形内固定术;B组62例患者下肢症状明显,接受责任节段减压内固术。治疗期间记录两组手术时间、术中出血量、固定节段数及腰前凸角度,于治疗前、治疗后1个月以及末次随访时腰椎侧凸处的Cobb角,并采用视觉模拟评分法(VAS)和Oswestry功能障碍指数(ODI)评价患者疗效。结果:A组手术时间、出血量、固定节段数及腰前凸角度显著高于B组(P0.05);治疗后和末次随访两组患者VAS评分、ODI指数及Cobb角均有明显好转(P0.05),两组治疗后和末次随访之间的差异无统计学意义(P0.05)。结论:退行性脊柱侧凸在治疗时需根据患者具体症状选择不同的手术方案,长节段矫形内固定术耗时长、术中出血量多,在治疗时应谨慎,预防相关并发症的发生。     

全膝关节置换术治疗类风湿性关节炎的临床效果分析

目的:探讨全膝关节置换术对类风湿性关节炎的临床疗效。方法:回顾性分析2012年10月至2014年1月在我院接受全膝关节置换术的80例风湿性关节炎患者的临床资料。采用HSS评分标准对膝关节疼痛情况进行评价,根据膝关节活动度(ROM)评价膝关节置换术的临床效果,观察患者术后并发症的发生情况,采用SF-36健康量表评估患者术后的生活质量。结果:患者术后膝关节疼痛评分低于术前(P0.05);患者术后膝关节活动度高于术前,且膝关节伸直和最大屈曲状态均优于术前(P0.05);术后膝关节冠状面和矢状面的畸形率均低于术前,差异具有统计学意义(P0.05);患者术后生存质量明显高于术前,差异具有统计学意义(P0.01)。术后发生感染2例,下肢深静脉血栓3例,膝前区疼痛2例,经对症治疗均获得缓解。结论:全膝关节置换术治疗类风湿性关节炎具有显著的临床效果,值得推广应用。     

重度脊柱侧凸后路一期小切口矫形对肺功能的影响

目的:探讨采用脊柱后路分期矫形策略治疗重度脊柱侧后凸,一期小切口矫形术对患者肺功能的影响。方法:自2007年05月-2010年12月采用脊柱后路分期矫形策略中一期小切口矫形术治疗重度脊柱侧凸患者32例,其中男12例,女20例,年龄5～25(13.5±6.12)岁。一期小切口矫形术前侧凸主弯冠状面Cobb’s角为108°～150°(128.75°±13.51°),胸腰段矢状位后凸角60°～140°(97.78°±27.88°)。测量一期矫形术前及术后2周、3月、6月肺功能,包括肺活量(VC)、用力肺活量(FVC)、第一秒时间肺活量(FEV1)、最大呼气中段流速(MMEF)、最大通气量(MVV),计算其占预计值的百分比[VC%、FVC%、FEV1%、MMEF%、MVV%]。观察患者术前与术后不同时期肺功能的变化。结果:术后3月时肺功能较术前有明显提高(P<0.05),术后6月较术后3个月无显著提高(P>0.05)。结论:对于严重的脊柱侧凸患者,后路一期小切口矫形术后3月肺功能即可获得明显改善,可行二期手术治疗。     

四肢骨折矫形术后患者慢性手术后疼痛的发生率及其危险因素分析

目的:研究四肢骨折矫形术后患者慢性手术后疼痛的发生率及其危险因素。方法:以2014年12月-2017年10月于我院接受四肢骨折矫形术患者300例为研究对象,于术后6个月分析慢性手术后疼痛的发生率。收集所有患者年龄、性别、体重、术前疼痛程度、二次手术、麻醉方式、术后镇痛、术后引流、合并骨质疏松、骨折类型以及骨折部位等资料,并采用单因素以及多因素Logistic回归分析术后疼痛的危险因素。结果:术后6个月内有96名患者术后发生慢性手术后疼痛,发生率为32.00%(96/300)。单因素分析结果显示:慢性手术后疼痛患者与术前疼痛程度、是否二次手术、麻醉方式、术后有无镇痛、是否合并骨质疏松、骨折类型、骨折部位有关(P0.05),与患者的性别、年龄、体重、术后是否引流无关(P0.05)。多因素Logistic回归分析结果显示:术前重度疼痛、二次手术、麻醉方式为非全麻、术后无镇痛、合并骨质疏松、开放性骨折以及下肢骨折均是四肢骨折矫形术后发生慢性手术后疼痛的独立危险因素(P0.05)。结论:四肢骨折矫形术后患者慢性手术后疼痛的发生率较高,术前重度疼痛、二次手术、麻醉方式为非全麻、术后无镇痛、合并骨质疏松、开放性骨折以及下肢骨折均增加了慢性手术后疼痛的发生风险,临床应根据危险因素给予针对性的干预措施。     

后路减压内固定融合矫形治疗退变性腰椎侧凸伴椎管狭窄的临床研究

目的:探讨后路减压内固定融合矫形治疗退变性腰椎侧凸伴椎管狭窄的临床疗效。方法:将我院2009年1月~2015年1月收治的退变性腰椎侧凸伴椎管狭窄患者按照手术方法分为两组,实验组进行后路减压内固定融合矫形术治疗,对照组进行单纯后路减压固定矫形术治疗,对比两组患者术前、术后6个月和18个月的Cobb角、腰椎前凸角、日本骨科学会(JOA)评分、疼痛视觉模拟量表(VAS)情况,SRS-22国际标准量表评分情况以及出血量情况。结果:实验组术后18个月的Cobb角、腰椎前凸角分别为(16.8±5.16)°和(36.8±5.82)°,均分别低于对照组的(20.2±6.61)°和(41.2±5.67)°,且均低于术前(P0.05),而术前及术后6个月时两组比较无差异(P0.05);两组患者术后6个月和18个月的JOA评分、VAS评分比较均较术前明显改善(P0.05),且组间比较显示,术后18月两组比较均存在显著差异(P0.05);SRS-22国际标准评估量表显示,术后18个月两组患者的自理能力、自我评价、精神状态方面无显著差异(P0.05),而疼痛情况存在显著差异(P0.05)。两组术中出血量比较无统计学差异(P0.05)。结论:后路减压内固定融合矫形术治疗退变性腰椎侧凸伴椎管狭窄疗效显著,且后路减压内固定融合矫形术在改善患者的腰椎侧凸程度、功能障碍及疼痛程度方面优于单纯后路减压矫形内固定术,值得临床推广。     

可吸收螺钉与金属螺钉治疗中重度拇外翻的临床应用效果

目的:探讨可吸收螺钉与金属螺钉治疗中重度拇外翻的临床应用效果。方法:选取2016年1月至2018年1月我院收治的28例中重度拇外翻患者作为研究对象,按照随机数字表法分为2组,分别采用金属螺钉或可吸收螺钉治疗对照组和观察组拇外翻患者。比较两组患者围手术期指标,手术前后拇外翻角(HVA),第1、2跖骨间夹角(IMA),美国矫形足踝学会足功能评分(AOFAS),以及并发症发生情况。结果:两组患者手术时间、术中出血量、住院时间比较无统计学差异(P0.05)。两组患者术后HVA、IMA、AOFAS均优于术前,比较具有统计学差异(P0.05);两组患者术后HVA、IMA、AOFAS比较无统计学差异(P0.05)。对照组治疗优良率为88.46%,观察组治疗优良率为92.31%,两组间无统计学差异(P0.05)。两组患者截骨端延迟愈合或不愈合发生率比较无统计学差异(P0.05);两组患者切口感染、拇外翻复发或者术后丢失矫正度数、跖骨发生背侧移位、出现转移性跖痛、拇内翻发生率比较无统计学差异(P0.05)。结论:拇外翻截骨后采用可吸收螺钉固定,可提供稳定固定,治疗效果显著,不增加并发症发生风险,值得广泛应用于临床。     

双膝骨性关节炎患者行全膝关节置换术前后足底压力分析

目的:分析双膝骨性关节炎(Osteoarthritis,OA)患者全膝关节置换(Total Knee Arthroplasty,TKA)手术前后足底压力分布变化。方法:选取2014年1月-2015年12月于西京医院就诊的25名双侧膝关节OA患者为研究对象,分别于术前、术后6个月两个时间点采用Footscan测量系统采集患者足底10个区域的压力数据,选择达峰值压力(Maximal Force,Max-F)、达峰值时间(Maximal Time,Max-T)作为主要参数进行统计分析。结果:双膝OA患者TKA术后与术前相比发现Max-F:重侧患肢足底分区第1足趾、第2-5足趾、第4、5跖骨头区减小;后足区增大;轻侧患肢足底分区前足、中足、后足均减小。Max-T:重侧足底分区第2-5足趾区、第一跖骨头区、中足、后足区增大;轻侧足底分区第2-5足趾区、第5跖骨头区减小。以上结果均存在显著性差异(P0.05)。结论:通过足底压力步态系统分析双膝OA患者手术前后的足底压力数据,可以更加科学、客观、量化的评价TKA手术疗效。     

UKA与TKA治疗膝关节内侧单间室骨性关节炎的临床对比

目的:探究膝关节单髁置换术(UKA)与全膝关节置换术(TKA)治疗膝关节内侧单间室骨性关节炎的临床治疗效果。方法:将2011年4月-2015年7月期间因膝关节单间室骨性关节炎入院接受治疗的89例患者纳入本研究,随机分为研究组和对照组,研究组44例,行UKA手术,对照组45例,采用TKA手术方式治疗。对两组患者进行术后随访,对比临床治疗效果。结果:两组术前均有明显膝关节疼痛,术后膝关节疼痛均明显改善,组间差别无显著统计学意义(X2=1.323,P=0.2500.05);术后膝关节屈曲角度、HSS评分相对于术前均显著改善,研究组术后膝关节屈曲角度(111.2±18.8)度高于对照组的(98.6±14.7)度,差异有统计学意义(P0.05);HSS评分(87.6±13.7)分高于对照组的(73.2±16.8)分,差异有统计学意义(P0.05);研究组膝关节屈曲至90度时间比对照组短,数据差异有统计学差异(t=-2.303,P=0.0240.05)。结论:膝关节内侧单间室骨性关节炎采用UKA与TKA均能取得一定临床效果,减轻患者痛苦,改善膝关节功能,但UKA临床疗效较好,手术创伤较小,术后恢复较快。     

Painful feet in rheumatoid arthritis

Pain in the feet is an important diagnostic feature and a major management problem of rheumatoid arthritis. Of 50 hospitalized patients, 28% recalled painful feet as the sole presenting symptom of their disease.Rheumatoid disease commonly affects the feet: 90% of the patients studied complained of foot pain at some time during the course of their disease, 86% had clinical involvement and 92% had radiological changes in their feet.The forefoot is most frequently involved. Midfoot involvement was noted in 68% but was symptomatic in only 22%. Changes in the ankle were least common but always symptomatic.     

甲状腺再次手术治疗的临床分析

目的:探讨甲状腺再次手术的原因、手术方式的选择和手术效果以及患者的预后情况。方法:统计哈尔滨医科大学附属第二医院普外科2001年1月到2015年9月期间收治的1600例初次行甲状腺手术的患者,回顾分析其中175例再次行甲状腺手术患者的临床资料。结果:甲状腺再次手术采用双侧甲状腺次全切除术为92例,单侧甲状腺次全切除术为72例,甲状腺癌根治术为11例。甲状腺再次手术患者术后出现甲状腺功能减退、气管和喉返神经损伤、出血以及缺钙引起的手足抽搦等概率高,与首次手术比较差异有统计学意义(P0.05)。术后1年内对再次手术的患者进行随访,其中复发12例(病理确诊为甲状腺癌3例,结节性甲状腺肿9例),其他类型甲状腺疾病无复发。结论:甲状腺再次手术较初次手术难度较大,术中及术后并发症较多,再次手术应谨慎选择术式及术中精细操作。     

Predictors of Barefoot Plantar Pressure during Walking in Patients with Diabetes,Peripheral Neuropathy and a History of Ulceration

ObjectiveElevated dynamic plantar foot pressures significantly increase the risk of foot ulceration in diabetes mellitus. The aim was to determine which factors predict plantar pressures in a population of diabetic patients who are at high-risk of foot ulceration.MethodsPatients with diabetes, peripheral neuropathy and a history of ulceration were eligible for inclusion in this cross sectional study. Demographic data, foot structure and function, and disease-related factors were recorded and used as potential predictor variables in the analyses. Barefoot peak pressures during walking were calculated for the heel, midfoot, forefoot, lesser toes, and hallux regions. Potential predictors were investigated using multivariate linear regression analyses. 167 participants with mean age of 63 years contributed 329 feet to the analyses.ResultsThe regression models were able to predict between 6% (heel) and 41% (midfoot) of the variation in peak plantar pressures. The largest contributing factor in the heel model was glycosylated haemoglobin concentration, in the midfoot Charcot deformity, in the forefoot prominent metatarsal heads, in the lesser toes hammer toe deformity and in the hallux previous ulceration. Variables with local effects (e.g. foot deformity) were stronger predictors of plantar pressure than global features (e.g. body mass, age, gender, or diabetes duration).ConclusionThe presence of local deformity was the largest contributing factor to barefoot dynamic plantar pressure in high-risk diabetic patients and should therefore be adequately managed to reduce plantar pressure and ulcer risk. However, a significant amount of variance is unexplained by the models, which advocates the quantitative measurement of plantar pressures in the clinical risk assessment of the patient.     

Comparison of in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects

The purpose of this study was to compare in vivo segmental foot motion during walking and step descent in patients with midfoot arthritis and asymptomatic control subjects. Segmental foot motion during walking and step descent was assessed using a multi-segment foot model in 30 patients with midfoot arthritis and 20 age, gender and BMI matched controls. Peak and total range of motion (ROM), referenced to subtalar neutral, were examined for each of the following dependent variables: 1st metatarso-phalangeal (MTP1) dorsiflexion, 1st metatarsal (MT1) plantarflexion, ankle dorsiflexion, calcaneal eversion and forefoot abduction. The results showed that, compared to level walking, step descent required greater MTP1 dorsiflexion (p<0.01), MPT1 plantarflexion (p<0.01), ankle dorsiflexion (p<0.01), calcaneus eversion (p=0.03) and forefoot abduction (p=0.01), in all subjects. In addition, step descent also necessitated greater MTP1 dorsiflexion (p<0.01), ankle dorsiflexion (p<0.01) and forefoot abduction (p=0.02) excursion compared to walking. Patients with midfoot arthritis responded differently to the step task compared to control subjects in terms of MT1 and calcaneus eversion excursion. During walking, patients with midfoot arthritis showed significantly less MT1 plantarflexion excursion compared to control subjects (p=0.03). However, during step descent, both groups showed similar MT1 plantarflexion excursion. During walking, patients with midfoot arthritis showed similar calcaneus eversion excursion compared to control subjects. However, during step descent, patients with midfoot arthritis showed significantly greater calcaneus eversion excursion compared to control subjects (p=0.03). Independently or in combination, these motions may contribute to articular stress and consequently to symptoms in patients with midfoot arthritis.     

Repair of bone defect of the lateral forefoot by double segment triangular fibula flap with vascular pedicle: A case report

Objective: To expound the clinical effect of a new operation by transplanting double segment triangular fibula flap with vascular pedicle to repair the forefoot with lateral bone defect, and to study how to improve the operation method in the following stage. Methods: The inclusion criteria: More than 2 phalangeal and metatarsal bones defects of the lateral forefoot, widespread skin and soft tissue defects on pelma and dorsal foot, and destruction of the anterior aspect of foot arch, which seriously affects the foot function. There was one case of clinical application in November 2014. The repairing method is as followed: the harvested vascularized free fibula was cut into 2 segments and then they were folded into a right angle. According to selected control points on the residual metatarsals, an optimal stereo triangular net was constructed. Meanwhile, according to flow-through mode, the free anterolateral thigh flap was incorporated to repair the forefoot and foot arch. Results: Postoperative bone flaps all survived. After a 17-month following up, it was found that the grafted fibular healed well, shape of the foot was good, weight-bearing walking was practical, a slight limp and discomfort with plantar pain existed, sensory recovery reached S3 level and functional recovery of weight-bearing walking by forefoot reached W3 level, comprehensive evaluation was good, and there were wear scar and ulcer on the plantar flap during long-time walking for patients, such results were excellent according to foot function scoring criteria. Conclusion: In this operation the grafted fibula was fold into a triangle according to actual need, which though not completely restores the tridimensional structure of the longitudinal, transverse arches of the lateral foot makes weight-bearing walking possible, besides, its appearance and function is satisfactory. Such an operation has overcome the shortage of non-tridimensional structure of the transverse arch etc. in traditional operations and it should be an ideal operation in repairing serious defects on the lateral forefoot through further improvement.     

两种微创术式治疗老年混合痔的临床疗效比较

目的:比较两种微创手术方式治疗老年混合痔的临床疗效和安全性。方法:选取2012年10月至2013年4月在湖南中医药大学第一附属医院肛肠科住院的162例老年混合痔患者并随机分成治疗组82例和对照组80例,治疗组采用自动痔疮套扎(RPH)术+外痔切除术治疗,对照组采用痔上粘膜环切钉合(PPH)术+外痔切除术治疗,观察周期为21天,随访3年。观察并比较分析两组患者术后疼痛积分、手术时间、术中出血量、术后恢复时间、术后并发症情况及远期疗效。结果:治疗组手术时间、术中出血量、术后恢复时间、术后24 h疼痛积分、首次排便疼痛积分及术后并发症(出血、水肿)的发生率均明显短于或低于对照组,差异有统计学意义(P0.05)。两组的远期疗效相当,差异无统计学意义(P0.05)。结论:自动痔疮套扎(RPH)术治疗老年混合痔患者的近期疗效和安全性较粘膜环切钉合(PPH)术+外痔切除术更好,而远期疗效与其相当。     

阿达木单抗注射液联合白芍总苷治疗甲氨蝶呤不耐受型类风湿关节炎的临床疗效

目的:探讨阿达木单抗注射液联合白芍总苷治疗甲氨蝶呤不耐受风湿关节炎患者的临床疗效。方法:收集我院治疗的86例甲氨蝶呤不耐受的类风湿关节炎患者,随机分为实验组和对照组,每组43例。对照组患者给予阿达木单抗注射液治疗,实验组患者在对照组基础上给予白芍总苷胶囊治疗。观察并比较两组患者的晨僵时间、血沉(ESR)、类风湿因子(FR)以及临床疗效进行检测并比较。结果:与治疗前相比,治疗后两组患者的晨僵时间、血沉(ESR)、类风湿因子(FR)水平均下降(P0.05);与对照组相比,实验组患者的晨僵时间、血沉(ESR)、类风湿因子(FR)水平较低(P0.05),临床治疗有效率较高(P0.05)。结论:阿达木单抗注射液联合白芍总苷能够降低甲氨蝶呤不耐受的类风湿关节炎患者的ESR、FR水平,改善患者的临床症状,临床疗效较好。     

经胸腔镜与开胸手术治疗胸腺瘤合并重症肌无力的临床疗效比较

目的:观察和比较经胸腔镜与开胸胸腺瘤扩大切除术治疗胸腺瘤伴重症肌无力(MG)患者的临床疗效和安全性。方法:回顾性分析2010年1月至2015年12月在新疆医科大学附属第一医院胸外科接受胸腔镜手术与开胸手术(本研究指胸骨正中劈开胸腺瘤扩大切除术)共120例胸腺瘤伴MG患者的临床资料,比较两组的手术时间、术后并发症、术后WHO病理分型、Masaoka分期、术后MGFA分级、远期随访总缓解率、术中出血量、术后拔管时间、术后住院天数和术后VAS疼痛评分。结果:两组手术时间、术后并发症、术后WHO病理分型、Masaoka分期、术后MGFA分级及远期随访总缓解率比较差异均无统计学意义(P0.05);开胸组肿瘤直径明显大于胸腔镜组,胸腔镜组术中出血量、术后拔管时间、术后住院天数和术后VAS疼痛评分明显短于或低于开胸组,差异均有统计学意义(P0.05)。结论:经胸腔镜与开胸胸腺瘤扩大切除术治疗MG的远期疗效相当,但胸腔镜手术创伤更小,有利于减少术后疼痛并加快患者恢复。     

复方雷公藤逐痛颗粒辅助治疗痰瘀互结型类风湿关节炎的临床效果观察

目的:评价复方雷公藤逐痛颗粒治疗活动期类风湿关节炎痰瘀互结证的临床有效性和安全性。方法:选择2013年2月～2015年5月在上海光华中西医结合医院类风关内科门诊及住院的活动性痰瘀互结型类风湿关节炎患者63例,按治疗方式分为对照组33例和中西医结合治疗组30例,对照组采用西医治疗(甲氨蝶呤+青霉胺),治疗组采用中西医结合治疗(复方雷公藤逐痛颗粒+甲氨蝶呤+青霉胺)。治疗12周后,比较两组患者的临床疗效及各项观察指标的改善情况。结果:治疗后,两组患者晨僵持续时间、关节肿胀数、关节压痛数、中医症候积分、血沉(ESR)、血清CRP水平,疼痛VAS评分、患者总体状态自我VAS评分及DAS28评分均较治疗前显著下降(P0.05),且治疗组患者的上述各项指标均明显低于对照组(P0.05)。治疗期间,两组患者均未出现严重不良反应而中断治疗的情况,监测肝肾功能指标均未发现明显异常。结论:复方雷公藤逐痛颗粒辅助治疗痰瘀互结型类风湿关节炎的临床疗效确切,明显优于单用西医治疗,其有助于增强西医治疗对患者临床症状的缓解效果,提高患者的生活质量,且用药安全。