2007年 · 第10卷第02期

Abstract：Objective: To elucidate the details of operative technique of anastomotic posterior urethroplasty for traumatic posterior urethral strictures in attempt to offer a successful result.Methods: We reviewed the clinical data of 106 patients who had undergone anastomotic repair for posterior urethral strictures following traumatic pelvic fracture between 1979 and 2004. Patients' age ranged from 8 to 53 years (mean 27 years). Surgical repair was performed via perinea in 72 patients, modified transperineal repair in 5 and perineoabdominal repair in 29. Follow-up ranged from 1 to 23 years (mean 8 years).Results: Among the 77 patients treated by perineal approaches, 69 (95.8%) were successfully repaired and 27 out of the 29 patients (93.1%) who were repaired by perineoabdominal protocols were successful. The successful results have sustained as long as 23 years in some cases. Urinary incontinence did not happen in any patients while impotence occurred as a result of the anastomotic surgery.Conclusions: Three important skills or principles will ensure a successful outcome, namely complete excision of scar tissues, a completely normal mucosa ready for anastomosis at both ends of the urethra, and a tension-free anastomosis. When the urethral stricture is below 2.5 cm long, restoration of urethral continuity can be accomplished by a perineal procedure. If the stricture is over 2.5 cm long, a modified perineal or transpubic perineoabdominal procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely (5.7%) to urethroplasty。

Abstract：Objective: To investigate the effects of two fluid resuscitations on the bacterial translocation and the inflammatory factors of small intestine in rats with hemorrhagic shock. Methods: Fifty SD healthy male rats were randomly divided into 5 groups (n=10 per group):Group A (Sham group), Group B (Ringer's solution for 1 h), Group C (Ringer's solution for 24 h), Group D (hydroxyethyl starch for 1 h) and Group E ((hydroxyethyl starch for 24 h). A model of rats with hemorrhagic shock was established. The bacterial translocation in liver, content of tumor necrosis factor-α (TNF-α) and changes of myeloperoxidase enzyme (MPO) activities in small intestine were pathologically investigated after these two fluid resuscitations, respectively. Results: The bacterial translocation and the expression of TNF-α in the small intestine were detected at 1 h and 24 h after fluid resuscitation. There were significant increase in the number of translocated bacteria, TNF-α and MPO activities in Group C compared with Group B, significant decrease in Group E compared with Group D and in Group B compared with Group D. The number of translocated bacteria and TNF-α expression significantly decreased in Group E as compared with Group C.Conclusions: The bacterial translocation and the expression of TNF-α in the small intestine exist 24 h after fluid resuscitation. 6% hydroxyethyl starch can improve the intestinal mucosa barrier function better than the Ringer's solution。

Abstract：Objective: To discuss the application of MRI in indirect temporomandibular joint injury without condylar fracture. Methods: MRI examination on temporomandibular joint was conducted in 28 patients with indirect injury to temporomandibular joint without condylar fracture. The scanning sequence included T1WI, PDWI on oblique sagittal section at both open and closed mouth positions,and T1WI,T2WI on oblique coronal section. The MRI appearance was analyzed by 2 senior radiologists. Results: Among the 56 temporomandibular joints of 28 patients, 35 joints exhibited pathological changes on MRI, in which there were 9 bone injuries, 21 articular disc dislocation, 24 intracapsular hematocele and hydrops. Conclusions: MRI can clearly reveal bone injury, articular disc dislocation as well as articular capsule abnormality in the indirect injury of temporomandibular joint without condylar fracture. It is highly advocated in clinical use。

Abstract：Objective: To investigate the biomechanical effect of different volume,distribution and leakage to adjacent disc of bone cement on the adjacent vertebral body by three-dimensional osteoporosis finite element model of lumbar.Methods: L4-L5 motion segment data of the cadaver of an old man who had no abnormal findings on roentgenograms were obtained from computed tomography (CT) scans. Three-dimensional model of L4-L5 was established with Mimics software, and finite element model of L4-L5 functional spinal unit (FSU) was established by Ansys 7.0 software. The effect of different loading conditions and distribution of bone cement after vertebroplasty on the adjacent vertebral body was investigated.Results: This study presented a validated finite element model of L4-L5 FSU with a simulated vertebroplasty augmentation to predict stresses and strains of adjacent untreated vertebral bodies. The findings from this FSU study suggested the endplate and disc stress of the adjacent vertebral body was not influenced by filling volume of bone cement but unipedicle injection and leakage to the disc of bone cement could concentrate the stress of adjacent endplate.Conclusions: Asymmetric distributions and leakage of cement into intervertebral disc can improve the stress of endplate in adjacent vertebral body. These results suggest that optimal biomechanical configuration should have symmetric placement and avoid leakage of cement in operation。

Abstract：Objective: To evaluate the application of injury severity score (ISS) to multiple injuries headed by spinal cord injury.Methods: The data of 55 cases (40 males and 15 females, aged 17-69 years, mean=41 years) of multiple injuries headed by spinal cord injury treated in our hospital from January 2000 to December 2004 were reviewed and analyzed with ISS (Version of AIS-2005) to explore their relationship. Results: The ISS values increased with the number of injured regions, so did the complications. The recovery rate was negatively related to ISS values. During the period of immunity observation, the patients with ISS＞25 could undergo planned operations safely. Conclusions: Treatment for multiple injuries headed by spinal cord injury closely depends on the general and local conditions of the patients. ISS may provide useful data for the choice of treatment methods。

Abstract：Objective: To compare the potential incidence of nerve root (ventral and dorsal ramus) injury caused by cervical transarticular screws and Roy-Camille lateral mass screws.Methods: Insertion techniques with Klekamp transarticular screws and Roy-Camille lateral mass screws were respectively performed in this study. Each technique involved four specimens and 40 screws, which were inserted from C3 to C7. And 20-mm-long screws were used to overpenetrate the ventral cortex. The anterolateral aspect of the cervical spine was carefully dissected to allow observation of the screw-ramus relationship.Results: The overall percentage of nerve invasion was significantly lower with Klekamp (45%) technique than with Roy-Camille (85%) technique (P＜0.05). The largest percentage of nerve invasion for Klekamp transarticular screws was found at the dorsal ramus (25%), followed by the ventral ramus (15%) and the bifurcation of the ventral dorsal ramus (5%). The largest percentage of nerve invasion for Roy-Camille lateral mass screws was found at the ventral ramus (80%).Conclusion: The potential risk of nerve root invasion is lower with Klekamp transarticular screws than with Roy-Camille lateral mass screws。

Abstract：Objective: To determine whether an adenoviral construct containing bone morphogenetic protein-4 (BMP-4) gene can be used for lumbar spinal fusion. Methods: Twelve New Zealand white rabbits were randomly divided into two groups, 8 in the experimental group and 4 in the control group. Recombinant, replication-defective type 5 adenovirus with the cytomegalovirus (CMV) promoter and BMP-4 gene (Ad-BMP-4) was used. Another adenovirus constructed with the CMV promoter and β-galactosidase gene (Ad-β-gal) was used as control. Using collagen sponge as a carrier, Ad-BMP-4 (2.9×108 pfu/ml ) was directly implanted on the surface of L5-L6 lamina in the experimental group, while Ad-β-gal was implanted simultaneously in the control group. X-ray was obtained at 3, 6, and 12 weeks postoperatively to observe new bone formation. When new bone formation was identified, CT scans and three-dimensional reconstruction were obtained. After that, the animals were killed and underwent histological inspection.Results: In 12 weeks after operation, new bone formation and fusion were observed on CT scans in the experimental group, without the evidence of ectopic calcification in the canal. Negative results were found in the control group. Histological analysis demonstrated endochondral bone formation at the operative site and fusion at early stage was testified.Conclusions: In vivo gene therapy using Ad-BMP-4 for lumbar posterolateral spinal fusion is practicable and effective。

Abstract：Objective: To study the anatomic basis of the bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing the composite Achilles tendon defect. Methods: The pedicle anatomy of the bi-pedicled V-Y gastrocnemius myocutaneous flap was examined on 30 cadaver specimens. The sliding distances of the flap were measured at different knee flexion degrees. The bi-pedicled V-Y gastrocnemius myocutaneous flap was applied in 12 cases of Achilles tendon defect with simultaneous skin and soft tissue defect. Results: The sural arteries could be classified into four types. After cutting off the gastrocnemius origin with a "Z-shaped" incision, the sliding distance of the flap reached (3.7±0.5)cm when the knee flexed 0°,(4.9±0.7)cm when the knee flexed 30°,(6.7±0.7)cm when the knee flexed 60°and (9.2±0.9)cm when the knee flexed 90°. All the defects healed. The patients recovered ambulation with satisfactory knee and ankle function.The follow-up was 4 months -12 years. Conclusions: Different sural artery types should be noticed during the harvest of the bi-pedicled V-Y gastrocnemius myocutaneous flap. With 90°knee flexion,this flap is suitable for one-stage repair of composite Achilles tendon defect within 9.2 cm±0.9 cm。

Abstract：Objective: To investigate the clinical curative effect of reconstruction of finger pulp defect by anastomosis of reversed fasciocutaneous island flap with dorsal branch of the digital nerve of the same finger. Methods: The restoration of finger pulp defect with fasciocutaneous island flap from the same finger was conducted in 25 cases (30 fingers) from January 2002 to June 2003. Nine patients (11 fingers) whose flaps with dorsal branch of the digital nerve anastomosed with the digital inherent nerve around the surface of the wound were Group A and the others were Group B. The follow-up was carried out at 3 and 9 months after the operation to observe the shape of finger pulp and the sense restoration between two groups.Results: All flaps of 25 cases (30 fingers) survived. Three months after operation, the patients had fully grown finger pulps and recovered the superficial sensation and tactile sense of finger pulps. The two point discrimination on average was 5.00 mm ± 0.23 mm in Group A and 6.00 mm ± 0.30 mm in Group B. The difference between two groups was highly significant. Nine months later, their senses of finger pulps between two groups were recovered basically. Conclusions:The reversed fasciocutaneous island flap from the same finger is the first choice to reconstruct the finger pulp defect, and the anastomosis of dorsal branch of the digital nerve shall be determined according to the specific condition。

Abstract：Objective: To introduce a practical, economical, and time-saving method to stain (with osmic acid) the myelin sheath in normal and regenerated peripheral nerves. Methods: A total of 12 Sprague Dawley rats, weighing 250-320 g (mean=276 g±38 g),were divided into two groups: a normal nerve group (n=6) and a regenerated nerve group (n=6).In the normal nerve group, the ventral and dorsal roots of L4 to L6 and their sciatic nerves were harvested for histological analysis. While in the regenerated nerve group, the right sciatic nerves were severed and then repaired with an epineurial microsuture method. The repaired nerves were harvested 12 weeks postoperatively. All the specimens were fixed in 4% paraformaldehyde and transferred to 2% osmic acid for 3-5 days. Then the specimens were kept in 75% alcohol before being embedded in paraffin. The tissues were cut into sections of 3 μm in thickness with a conventional microtome. Results: Under a light microscope, myelin sheaths were clearly visible at all magnifications in both groups. They were stained in clear dark colour with a light yellow or colorless background, which provided high contrast images to allow reliable morphometric measurements. Morphological assessment was made in both normal and regenerated sciatic nerves. The ratios of the myelin area to the fibre area were 60.28%±7.66% in the normal nerve group and 51.67%±6.85% in the regenerated nerve group, respectively (P＜0.01). Conclusions: Osmic acid staining is easy to perform and a very clear image for morphometrical assessment is easy to obtain. Therefore, it is a reliable technique for quantitative evaluation of nerve morphology。

Abstract：Objective: To evaluate the expression of glucose transporter-4 (GLUT4) mRNA in skeletal muscle and subcutaneous adipose tissues and investigate the mechanism of posttraumatic insulin resistance.Methods: Sixteen adult male Wistar rats were randomly divided into 2 group (n=8 in each group), i.e., severe traumatic brain injury (TBI) group due to falls from a height and normal control group. Blood glucose and serum insulin were measured at 0.5 h before trauma and 3 h, 24 h, 72 h, 7 d after trauma, respectively. And insulin sensitivity was calculated by insulin activity index (IAI) formula. Skeletal muscle and subcutaneous adipose tissue samples were collected at the same time when blood was sampled. The changes of expression of GLUT4 mRNA were observed using reverse transcription-polymerase chain reaction (RT-PCR).Results: Accompanied by the decrease of insulin sensitivity, the expression of GLUT4 mRNA was significantly decreased in adipose tissues at 24 h and 72 h after trauma (P＜0.01), however, such phenomena did not appear in skeletal muscle samples.Conclusions: To some extent, the development of posttraumatic insulin resistance is related to the abnormality of transcription activity of GLUT4 gene. Adipose tissues show some difference in the transcriptional level of GLUT4 gene after trauma as compared with skeletal muscle tissues。