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下肢骨折術后肺動脈栓塞治療的臨床觀察

【摘要】目的回顧性總結下肢骨折并發肺動脈栓塞（PE）的診治和轉歸情況,為臨床預防、及早發現并及時治療骨折并發PE提供參考。方法收集筆者所在科室近年收治的20例資料完整的骨折并發PE患者病歷,回顧性分析其診治方法及轉歸,總結防治策略。結果在20例患者中,2例住院期間因PE死亡,其余18例治愈出院隨訪至今效果滿意。結論提高對PE的認識,是早期發現PE的前提,應對PE的最好措施是積極預防,特別是預防下肢靜脈血栓形成。提高醫生觀察、判斷病情的能力,爭取治療及搶救時機可減少PE的病死率。

Comparative analysis of clinical outcomes of three endovascular techniques for femoral-popliteal artery lesions in lower extremity arteriosclerosis obliterans

ObjectiveTo compare the efficacy of three surgical approaches, including percutaneous transluminal angioplasty (PTA), PTA+bare metal stent (BMS), and Rotarex+PTA+drug coated balloon (DCB), in treating femoropopliteal artery lesions in arteriosclerosis obliterans (ASO), and to explore the prognostic factors of femoropopliteal artery lesions in ASO. MethodsA retrospective analysis was conducted on 314 patients with femoropopliteal artery lesions in ASO who were treated in the Department of Vascular and Thyroid Surgery in the First Affiliated Hospital of Xinjiang Medical University from March 2018 to March 2024. inverse probability of treatment weighting was used to balance the baseline characteristics of the three groups. The clinical examination, imaging examination, and ankle-brachial index (ABI) results of the three groups at 3 months, 12 months, and 24 months after surgery were compared. Log-rank test was used to compare the incidence of all-cause mortality (ACM) and major adverse limb events (MALEs) among the three groups, and Cox proportional hazards regression model was used to analyze the prognostic factors of femoropopliteal artery lesions in ASO. ResultsA total of 314 patients with ASO femoropopliteal artery lesions were enrolled, comprising 153 cases in the PTA group, 89 cases in the PTA+BMS group, and 72 cases in the Rotarex+PTA+DCB group. After inverse probability of treatment weighting based on propensity scores, baseline characteristics were balanced across all groups (all P>0.05). Postoperative follow-up results demonstrated the following patency rates: at 3 months, 58.4% (87/149) for the PTA group, 79.5% (66/83) for the PTA+BMS group, and 87.5% (63/72) for the Rotarex+PTA+DCB group; at 12 months, 78.0% (60/79), 68.3% (43/63), and 80.0% (44/55), respectively; and at 24 months, 98.1% (52/53), 89.7% (35/39), and 100.0% (43/43), respectively. The Rotarex+PTA+DCB group exhibited significantly superior patency rates, claudication distances, ankle-brachial index (ABI), and Rutherford classification compared to both the PTA and PTA+BMS groups at 3 months (P<0.05). Furthermore, the Rotarex+PTA+DCB group showed lower incidence of ACM/MALEs compared to the other two groups (χ2=18.70, P<0.001). Survival analysis revealed that the Rotarex+PTA+DCB group had significantly better survival outcomes compared to the PTA+BMS group (χ2=14.27, P<0.001) and the PTA group (χ2=3.92, P=0.016). Cox proportional hazards regression analysis identified elevated red cell distribution width (RDW) as an independent risk factor for ACM/MALEs following endovascular therapy in ASO patients, with a relative risk of 1.006 [95%CI (1.002, 1.011), P=0.006]. ConclusionsThe Rotarex+PTA+DCB demonstrate superior outcomes compared to both the PTA and PTA+BMS in terms of patency rate, claudication distance, ABI, and Rutherford classification at 3 months postoperatively, along with the better survival. Furthermore, elevated RDW may serve as a prognostic factor for adverse outcomes in patients with ASO femoropopliteal artery lesions.

Diagnosis of Arteriosclerosis Obliterans of Lower Extremity in Early Stage

Objective To explore the methods of early diagnosis of arteriosclerosis obliterans of lower extremity (ASOLE). Methods The related literatures on ASOLE detection means adopted clinically were reviewed, and their advantages and disadvantages were compared.Results Asymptomatic ASOLE could be discovered by determination of ankle brachial index (ABI) and toe brachial index (TBI), which was a good index for arterial function assessment of lower extremity. Pulse wave velocity (PWV) was more vulnerable and less sensitive than ABI, and therefore more suitable for screening of a large sample. ASI was an index to assess arterial structure and function, and it had a good correlation with PWV. Flow-mediated dilation (FMD) was a measurement evaluating the function of endothelial cell; Pulse wave measurement was simple, sensitive, and its result was reliable. Color Doppler ultrasonography could localizate the lesion and determine the degree of stenosis at the same time. Multiple-slice CT angiography (MSCTA) was more accurate than color Doppler ultrasonography, but its inherent shortcomings, such as nephrotoxicity of contrast agent, was still need to be resolved. 3D-contrast enhancement magnetic resonance angiography (CEMRA) had little nephrotoxicity, but a combination of other imaging methods was necessary. Microcirculation detections required high consistency of the measurement environment, but they were simple, sensitive and noninvasive, and therefore could be used for screening of ASO. Conclusion Publicity and education of highrisk groups, and reasonable selection of all kinds of detection means, are helpful to improve the early diagnosis of ASOLE.

綜合預防老年下肢手術深靜脈血栓的臨床觀察

目的　探討采用綜合措施預防老年下肢骨科手術后深靜脈血栓的臨床療效。 方法　對2009年1月－2010年12月間收治的116例行下肢骨科手術患者，其中男41例，女75例；年齡65～94歲，平均77.8歲。術后采用下肢關節收縮運動、間歇性空氣壓力波治療儀、低分子肝素鈣等綜合措施預防術后深靜脈血栓。 結果　術后1周經二維彩色超聲檢查，發生股靜脈上段周圍型血栓2例，腘靜脈血栓1例，發生率2.6%。隨訪12個月以上患者血栓未脫落、長大，下肢也無明顯腫脹。 結論　采用綜合措施預防老年患者下肢骨科手術后深靜脈血栓，方法簡便、療效可靠。

The Effect of Comprehensive Rehabilitation System on the Treatment of 54 Earthquake Patients with Lower Limb Fracture

目的：探討綜合康復治療體系對54例地震致下肢骨折患者功能恢復的影響。方法：采用綜合康復治療方法治療“5·12”汶川大地震所致54例下肢骨折患者，臨床觀察患者傷口的愈合情況和骨折的復位情況，有無骨折并發癥，分析比較治療前后患者下肢功能恢復情況及日常生活活動能力的改善。結果：康復治療后關節活動度明顯改善，由入院時的平均218.61°增加至出院時的237.5°（P＜0.001）。Barthel指數由入院時的平均55.4增加至出院時的70.8（P＜0.001），日常生活活動能力有較大幅度提高。結論：綜合康復治療體系對于地震傷致下肢骨折患者的功能恢復至關重要，一套完善的體系應包括：①康復治療早期介入，功能鍛煉長期堅持；②發揮大型綜合性醫院的優勢，多學科交叉，多部門合作；③功能康復和心理康復并重；④專業人士與社會團體共同參與。

下肢手術后嗎啡、羅哌卡因和地塞米松配伍鎮痛效果比較

【摘要】 目的 總結嗎啡、羅哌卡因和地塞米松三種藥物復合在下肢手術后硬膜外單次給藥維持鎮痛的時間及并發癥。方法 2006年3月—2009年8月收治ASAⅠ~Ⅱ級骨科下肢手術患者120例,隨機分為兩組,每組60例。A組嗎啡2.5 mg加羅哌卡因20 mg,B組嗎啡2.5 mg加羅哌卡因20 mg加地塞米松5 mg,均用生理鹽水稀釋至10 mL,于手術后分兩次注入硬膜外腔。觀察兩組患者術后6、12、24 h VAS評分情況；術后鎮痛(VAS≤3分)維持時間及另一側下肢運動功能恢復時間；術后呼吸抑制、惡心嘔吐和皮膚瘙癢的副作用發生情況。結果 兩組患者術后6、12 h VAS評分均＜3分,但24 h A組VAS評分(＞4分)明顯高于B組；B組患者術后無痛時間明顯長于A組,術后另一側下肢運動功能恢復時間兩組基本相同；兩組患者均未發生呼吸抑制,惡心嘔吐發生率相似,但A組皮膚瘙癢發生率高于B組(Plt;0.05)。結論 嗎啡加羅哌卡因加地塞米松硬膜外給藥可維持下肢手術患者術后鎮痛24 h以上,且并發癥少。

Catheter Directed Thrombolysis versus Mechanical Thrombectomy Combined with Catheter Directed Thrombolysis for Lower Extremity Deep Vein Thrombosis

目的研究置管溶栓聯合球囊擴張導管碎栓治療下肢深靜脈血栓形成（DVT）的療效及安全性。 方法回顧性分析2011年9月至2015年1月本院收治的82例急性下肢DVT患者的臨床資料。將患者分成兩組：A組行單純經導管直接溶栓（CDT）治療，共32例，其中男10例、女22例，平均年齡（56±15）歲；B組行CDT聯合機械碎栓（球囊擴張導管碎栓）治療，共50例，其中男18例、女32例，平均年齡（57±17）歲。比較2組治療前后靜脈通暢率、靜脈通暢度評分、健側和患側下肢周徑差，比較2組尿激酶用量及溶栓導管留置時間，以出血并發癥、肺栓塞的發生率評價治療的安全性。 結果2組共82例患者完成溶栓及碎栓療程，B組較A組溶栓時間更短，A組平均9（7，12）d；B組平均5（4，7）d，2組差異有統計學意義（P<0.01）；B組較A組尿激酶用量更少，A組平均7.250（6.355，8.255）×106 U，B組平均4.925（3.715，5.810）×106 U，2組差異有統計學意義（P<0.01）；B組治療后的靜脈通暢度評分顯著優于A組，A組65.0%（40.5%，86.5%），B組為100%（90%，100%），差異有統計學意義（P<0.01）。治療后2組出血并發癥發生率差異無統計學意義（P=0.0976）。2組患者隨訪時間3～18個月，A組隨訪率50.0%，B組隨訪率58.0%，均未發生肺動脈栓塞。 結論在下腔靜脈濾器保護下，CDT聯合球囊擴張導管碎栓治療急性下肢DVT較單純CDT治療，溶栓效果好、尿激酶用量少、不增加肺栓塞及出血發生率。

Effects of femoral offset and mechanical axis of the lower extremity on hip after osteotomy for adult developmental dysplasia of the hip

Objective To investigate the effects of femoral offset and mechanical axis of the lower extremity on hip after osteotomy for adult developmental dysplasia of the hip (DDH). Methods A clinical data of 62 adult patients with DDH (62 hips), who underwent periacetabular osteotomy combined with femoral osteotomy between January 2016 and May 2019 and met selective criteria, was retrospectively analyzed. There were 6 males and 56 females. The age ranged from 18 to 38 years, with an average of 24.4 years. Body mass index ranged from 15.8 to 31.8 kg/m2, with an average of 21.8 kg/m2. There were 44 cases of Hartofilakidis typeⅠ and 18 cases of typeⅡ. According to the modified T?nnis osteoarthritis staging, 46 cases were stage 0 and 16 cases were stageⅠ. There were 13 cases with pelvic anteversion, 40 cases with normal pelvis, and 9 cases with pelvic retroversion. Intraoperative blood loss, length of hospital stay, and complications were recorded. Postoperative hip function was evaluated by Harris score and International Hip Outcome Tool (iHOT) score. The femoral offset, collo-diaphyseal angle, hip-knee-ankle angle (HKA), knee valus angle, CE (Wiberg central-edge angle), anterior CE angle, and acetabular index angle were measured and the osteotomy healing was observed on X-ray films. Patients were grouped according to postoperative femoral offset (≥48 mm or <48 mm) and HKA [varus group (HKA<177°), normal group (HKA 177°-183°), and valgus group (HKA>183°)]. Harris score and iHOT score were compared between groups. Results Intraoperative blood loss ranged from 200 to 1 550 mL, with an average of 476 mL. The length of hospital stay ranged from 8 to 21 days, with an average of 13.3 days. All incisions healed by first intention. All patients were followed up 2.0-4.5 years, with an average of 2.8 years. At 1 year after operation, the Harris score and iHOT score of the hip joint significantly increased when compared with those before operation (P<0.05); there were significant differences in the femoral offset, collo-diaphyseal angle, HKA, knee valus angle, CE angle, anterior CE angle, and acetabular index angle between pre- and post-operation (P>0.05). According to the modified T?nnis osteoarthritis staging, 38 cases were stage 0 and 24 cases were stageⅠ; and there was no significant difference between pre- and post-operation (χ2=2.362, P=0.124). There were 11 cases with pelvic anteversion, 38 cases with normal pelvis, and 13 cases with pelvic retroversion, showing no significant difference when compared with that before operation (χ2=0.954, P=0.623). The pubic branch osteotomy did not heal in 9 cases, proximal femur osteotomy did not heal in 2 cases, and inferior pubic ramus stress fracture occurred in 5 cases. There were significant differences (P<0.05) in the Harris score and iHOT score between femoral offset≥48 mm group (n=10) and femoral offset<48 mm group (n=52). There was no significant difference (P>0.05) in Harris score and iHOT score between varus group (n=13), normal group (n=40), and valgus group (n=9). Conclusion Periacetabular osteotomy combined with femoral osteotomy can improve the femoral offset and mechanical axis of the lower extremity of patients with DDH, and improve the functional score of the hip. However, excessive increase of femoral offset during femoral osteotomy is not desirable, resulting in low postoperative functional score.

腓腸神經營養血管皮瓣修復小腿及足踝部軟組織缺損

目的 總結腓腸神經營養血管逆行皮瓣修復小腿中下部及足踝部軟組織缺損的臨床效果。 方法 2001 年1 月－ 2006 年12 月，采用腓腸神經營養血管逆行皮瓣修復小腿中下部及足踝部軟組織缺損12 例。男7 例，女5 例；年齡23 ～ 56 歲。車禍傷5 例，重物壓傷3 例，皮帶絞傷2 例，慢性潰瘍2 例。缺損部位：小腿中下部8 例，足跟部2 例，內、外踝各1 例。軟組織缺損范圍為5 cm × 3 cm ～ 11 cm × 8 cm。均伴骨、關節、肌腱或鋼板外露。急診手術1 例，擇期手術11 例。 結果 術后2 例皮瓣邊緣壞死，經對癥處理后成活；余皮瓣均順利成活。供區傷口Ⅰ期愈合，植皮順利成活。12 例均獲隨訪，隨訪時間9 個月～ 2 年。皮瓣質地良好，厚薄均勻，色澤與周邊皮膚相似，下肢負重、行走正常。 結論 腓腸神經營養血管逆行皮瓣質地良好，厚薄均勻，是修復小腿中下部及足踝部軟組織缺損的理想皮瓣。

肝硬化低蛋白血癥并雙下肢水腫皮膚破潰滲液護理一例