UID
524990
�Ķ�Ȩ��
6
רҵ��
����
��ҽ��
�ʻ�
ע��ʱ��
2007-11-17
|
����ע�ᣬ�ύ������ѣ����ø���ܣ�����������ת������
����Ҫ��¼�ſ������ػ�鿴��û���ʺţ�ע��
x
��ϣ���ܼӷ֣�����
Ŀ¼
Campbell's Operative Orthopaedics��the 10th edition��(�������ǿ�����ѧ,��ʮ��) Contents
Volume One PART I GENERAL PRINCIPLES���ձ�ԭ�� Chapter 1. Surgical Techniques and Approaches(��Ƽ�������·) Chapter 2. Magnetic Resonance Imaging in Orthopaedics���Ź�������ڹǿƵ�Ӧ�ã� PART II ARTHRODESIS���ؽ��ں����� Chapter 3. Arthrodesis of Ankle, Knee, and Hip���ؽڡ�ϥ�ؽڡ��Źؽ��ں����� Chapter 4. Arthrodesis of Shoulder, Elbow, and Wrist����ؽڡ���ؽڡ���ؽ��ں����� PART III ARTHROPLASTY���ؽڳ������� Chapter 5. Introduction and Overview�������������� Chapter 6. Arthroplasty of Ankle and Knee���ؽ���ϥ�ؽڵij������� Chapter 7. Arthroplasty of Hip���Źؽڳ������� Chapter 8. Arthroplasty of Shoulder and Elbow����ؽڡ���ؽڳ������� PART IV AMPUTATIONS����֫���� Chapter 9. General Principles of Amputations����֫���ۣ� Chapter 10. Amputations About Foot���㲿��֫�� Chapter 11. Amputations of Lower Extremity����֫��֫�� Chapter 12. Amputations of Hip and Pelvis���Źؽڼ������֫�� Chapter 13. Amputations of Upper Extremity����֫��֫�� Chapter 14. Amputations of Hand���ֲ���֫�� PART V INFECTIONS����Ⱦ�� Chapter 15. General Principles of Infection����Ⱦ���ۣ� Chapter 16. Osteomyelitis�������ף� Chapter 17. Infectious Arthritis����Ⱦ�Թؽ��ף� Chapter 18. Tuberculosis and Other Unusual Infections����˼������ټ���Ⱦ�� PART VI TUMORS�������� Chapter 19. General Principles of Tumors���������ۣ� Chapter 20. Benign Tumors of Bone�����Թ������� Chapter 21. Benign (Occasionally Aggressive) Tumors of Bone�����ԣ�żΪ���ԣ����Ĺ����� Chapter 22. Malignant Tumors of Bone�����Թ������� Chapter 23. Soft Tissue Tumors and Nonneoplastic Conditions Simulating Bone Tumors������֯���������������Ƶķ������Լ����� PART VII NO***AUMATIC SOFT TISSUE DISORDERS���Ǵ���������֯�쳣�� Chapter 24. Nontraumatic Soft Tissue Disorders���Ǵ���������֯�쳣�� Chapter 25. Miscellaneous Nontraumatic Disorders�����ַǴ������쳣��
Volume Two PART VIII CONGENITAL ANOMALIES�������Ի��Σ� Chapter 26. Congenital Anomalies of Lower Extremity����������֫���Σ� Chapter 27. Congenital and Developmental Anomalies of Hip and Pelvis�������Ժͷ������Źؽڼ�������Σ� Chapter 28. Congenital Anomalies of Trunk and Upper Extremity����֫�����ɲ������Ի��Σ� PART IX OSTEOCHONDROSIS������Dz��� Chapter 29. Osteochondrosis or Epiphysitis and Other Miscellaneous Affections������Dz����������������䣩 PART X NERVOUS SYSTEM DISORDERS IN CHILDREN����ͯ��ϵͳ�쳣�� Chapter 30. Cerebral Palsy����̱�� Chapter 31. Paralytic Disorders������Լ����� Chapter 32. Neuromuscular Disorders�����⼲���� PART XI FRACTURES AND DISLOCATIONS IN CHILDREN����ͯ������λ�� Chapter 33. Fractures and Dislocations in Children����ͯ������λ�� PART XII THE SPINE�������� Chapter 34. Spinal Anatomy and Surgical Approaches���������ʼ�������·�� Chapter 35. Fractures, Dislocations, and Fracture-Dislocations of Spine�������Ĺ��ۡ���λ����ۣ���λ�� Chapter 36. Arthrodesis of Spine�������ں����� Chapter 37. Pediatric Cervical Spine����ͯ���� Chapter 38. Scoliosis and Kyphosis�������������ձ��� Chapter 39. Lower Back Pain and Disorders of Intervertebral Discs������ʹ�����̼����� Chapter 40. Infections of Spine��������Ⱦ�� Chapter 41. Other Disorders of Spine����������������
Volume Three PART XIII SPORTS MEDICINE���˶�ҽѧ�� Chapter 42. Ankle Injuries���ؽ����ˣ� Chapter 43. Knee Injuries��ϥ�ؽ����ˣ� Chapter 44. Shoulder and Elbow Injuries����ؽ�����ؽ����ˣ� Chapter 45. Recurrent Dislocations����������λ�� Chapter 46. Traumatic Disorders�������Լ����� PART XIV ARTHROSCOPY���ؽھ��� Chapter 47. General Principles of Arthroscopy���ؽھ����ۣ� Chapter 48. Arthroscopy of Lower Extremity����֫�ؽھ��� Chapter 49. Arthroscopy of Upper Extremity����֫�ؽھ��� PART XV FRACTURES AND DISLOCATIONS����������λ�� Chapter 50. General Principles of Fracture Treatment�������������ۣ� Chapter 51. Fractures of Lower Extremity����֫���ۣ� Chapter 52. Fractures of Hip���Ų����ۣ� Chapter 53. Fractures of Acetabulum and Pelvis���ž��������ۣ� Chapter 54. Fractures of Shoulder, Arm, and Forearm���粿���ϱۡ�ǰ�۹��ۣ� Chapter 55. Malunited Fractures�����ۻ������ϣ� Chapter 56. Delayed Union and Nonunion of Fractures�������ӳ����ϺDz����� Chapter 57. Acute Dislocations��������λ�� Chapter 58. Old Unreduced Dislocations���¾���δ��λ����λ��
Volume Four PART XVI PE**HERAL NERVE INJURIES�����������ˣ� Chapter 59. Pe**heral Nerve Injuries�����������ˣ� PART XVII MICROSURGERY������ƣ� Chapter 60. Microsurgery������ƣ� PART XVIII THE HAND���֣� Chapter 61. Basic Surgical Technique and Aftercare������������������������� Chapter 62. Acute Hand Injuries�����������ˣ� Chapter 63. Flexor and Extensor Tendon Injuries�������졢�켡�����ˣ� Chapter 64. Fractures, Dislocations, and Ligamentous Injuries�����ۡ���λ���ʹ����ˣ� Chapter 65. Nerve Injuries�������ˣ� Chapter 66. Wrist Disorders����ؽڼ����� Chapter 67. Special Hand Disorders�������ֲ������� Chapter 68. Paralytic Hand��̱���֣� Chapter 69. Cerebral Palsy of the Hand����̱�֣� Chapter 70. Arthritic Hand���ֲ��ؽ��ף� Chapter 71. Compartment Syndromes and Volkmann Contracture����Ĥ�����ۺ�����Volkmann������ Chapter 72. Dupuytren Contracture��Dupuytren ������ Chapter 73. Carpal Tunnel, Ulnar Tunnel, and Stenosing Tenosynovitis������ۺ������߹��ۺ�������խ�������ף� Chapter 74. Tumors and Tumorous Conditions of Hand���ֲ����������������� Chapter 75. Hand Infections���ֲ���Ⱦ�� Chapter 76. Congenital Anomalies of Hand���ֲ������Ի��Σ� PART XIX THE FOOT AND ANKLE�������ؽڣ� Chapter 77. Surgical Techniques����Ƽ����� Chapter 78. Disorders of Hallux��Ĵֺ������ Chapter 79. Pes Planus����ƽ�㣩 Chapter 80. Lesser Toe Abnormalities����ֺ���Σ� Chapter 81. Rheumatoid Foot���㲿���ʪ�ԣ� Chapter 82. Diabetic Foot�������㣩 Chapter 83. Neurogenic Disorders����Դ�Լ����� Chapter 84. Disorders of Nails and Skin��ֺ�ס�Ƥ�������� Chapter 85. Disorders of Tendons and Fascia�������Ĥ������ Chapter 86. Fractures and Dislocations of Foot���㲿������λ�� C H A P T E R 1
Surgical Techniques and Approaches ����Ƽ�������·�� Andrew H. Crenshaw, Jr.
SURGICAL TECHNIQUES����Ƽ����� Tourniquets��ֹѪ���� Roentgenograms in the Operating Room��X�����������е�Ӧ�ã� Positioning of Patient������**�� Local Preparation of Patient���ֲ����� Draping(��ϴ) Special Operative Techniques(������������) SURGICAL APPROACHES(������·) Toes(��ֺ) Calcaneus(����) Tarsus and Ankle(���Ź�����) Tibia(�ֹ�) Fibula(���) Knee(ϥ) Femur(�ɹ�) Hip(��) Acetabulum and Pelvis(�ž������) Sacroiliac Joint(���Ĺؽ�) Spine(����) Shoulder(��) Humerus(�Ź�) Elbow(��) Radius(���) Ulna(�߹�) Wrist(��) Hand (��) SURGICAL TECHNIQUES����Ƽ����� This section describes several surgical techniques especially important in orthopaedics: use of tourniquets, use of roentgenograms and image intensifiers in the operating room, positioning of the patient, local preparation of the patient, and draping of the appropriate part or parts. To avoid repetition in other chapters, two operative techniques common to many procedures, fixation of tendons or fascia to bone and bone grafting, are also described. ��һ���������˼����ڽ�����Ʒdz���Ҫ����Ƽ���������ֹѪ����Ӧ�á�X����ͼ����ǿ���������ҵ�Ӧ���Լ����ߵ�**����������������λ��ಿλ���̵���Ϊ�˱����������½�������������Ĥ�̶����ǵķ���������ֲ����������������г��õļ���Ҳ�ڱ��¼��������� Tourniquets ��ֹѪ���� Operations on the extremities are made easier by the use of a tourniquet. The tourniquet is a potentially dangerous instrument that must be used with proper knowledge and care. In some procedures, a tourniquet is a luxury, whereas in others, such as delicate operations on the hand, it is a necessity. A pneumatic tourniquet is safer than an Esmarch tourniquet or the Martin sheet rubber bandage. Ӧ��ֹѪ��ʹ��֫���������Ӽ�������ֹѪ����һ�־���DZ��Σ���Ե��豸����ˣ�ʹ��ʱ����߱���ص�֪ʶ���ҷdz�С�ġ���һЩ�������У�ֹѪ���Ƕ���ģ�����һЩ��ϸ�������������������ֹѪ�����DZ���߱��ġ��밣˹���ֹѪ��(Esmarch tourniquet)�Լ�����Ĥ��(Martin sheet rubber bandage)��ȣ�����ֹѪ�������ȫ�� A pneumatic tourniquet with a hand pump and an accurate pressure gauge is probably the safest, but a constantly regulated pressure tourniquet is quite satisfactory if it is properly maintained and checked. A tourniquet should be applied by an experienced person and not delegated to someone who does not understand its use. �����ֶ���ѹ�ü���ȷ��ѹ��ij���ֹѪ����������Ϊ��ȫ�ģ�����ֻҪ��ȷ�����ͼ�飬������ѹʽֹѪ��Ҳ�൱���⡣ֹѪ����Ӧ�ñ������о�����������У������ܽ�����Щ���������÷���������������� Several sizes of pneumatic tourniquets are available for the upper and lower extremities. The upper arm or the thigh is wrapped with several thicknesses of smoothly applied cotton cast padding. Krackow described a maneuver that improves positioning of the tourniquet in obese patients. An assistant manually grasps the flesh of the extremity just distal to the level of tourniquet application and firmly pulls this loose tissue distally before the cast padding is placed. Traction on the soft tissue is maintained while the padding and tourniquet are applied and the latter is secured. The assistant's grasp is then released, resulting in a greater proportion of the subcutaneous tissue remaining distal to the tourniquet. This bulky tissue tends to support the tourniquet and push it into an even more proximal position. All air is expressed from the sphygmomanometer or pneumatic tourniquet before application. When a sphygmomanometer cuff is used, it should be wrapped with a gauze bandage to prevent its slipping during inflation. Every effort is made to decrease tourniquet time; the extremity often is prepared and ready before the tourniquet is inflated. The extremity is then elevated for 2 minutes, or the blood is expressed by a sterile sheet rubber bandage or a cotton elastic bandage. Beginning at the fingertips or toes, the extremity is wrapped proximally to within 2.5 to 5 cm of the tourniquet. If a Martin sheet rubber bandage or an elastic bandage is applied up to the level of the tourniquet, the latter will tend to slip distally at the time of inflation. The tourniquet should be inflated quickly to prevent filling of the superficial veins before the arterial blood flow has been occluded. ���ж��ֳߴ������ֹѪ���ɹ��Ͻ�����֫ʹ�á���֫�������Ҫ������������Ĺ����档Krackow������һ����θ����ȷ��ֵIJ��˰���ֹѪ���ĸ������������ֽ�֫��Ҫ��ֹѪ���IJ�λ������֯�����ܵ�����Զ�ˣ���ά�ֶ�����֯����ѹֱ���漰ֹѪ�����źã����ַ�������֯����ʱֹѪ��Զ��ά���н϶��Ƥ����֯����Щ����֯��֧��ֹѪ������������֫����ˡ�Ӧ��ֹѪ����Ѫѹ��ʹ��ǰѹ������ʣ�����塣��ʹ��Ѫѹ������ʱ����Ҫ�ñ�ɴ�������������Է���ѹʱ���ֻ�����Ӧ��һ�п��ܼ���ʹ��ֹѪ����ʱ�䣬֫��Ҫ��ֹѪ����ѹǰ������ƣ�ʰ��2���ӻ�ʹ����������������������Ѫ����ָ�����ֺ��ʼֱ����ֹѪ��2.5��5cm���������ʹ������Ĥ������������Ѫʱ������ֹѪ������������ϣ�Ѫ����ѹʱ��������Զ�˻�����ֹѪ����ѹҪ�㹻�죬�Է��������ǰ��Ѫ��ʹdz�����ٴγ�ӯ�� The exact pressure to which the tourniquet should be inflated has not been determined. Evidence indicates that pressures greater than necessary have been used for many years. The correct pressure depends somewhat on the age of the patient, the blood pressure, and the size of the extremity. Reid, Camp, and Jacob[1] used pneumatic tourniquet pressures determined by the pressure required to obliterate the pe**heral pulse using a Doppler stethoscope; they then added 50 to 75 mm Hg to allow for collateral circulation and blood pressure changes. Tourniquet pressures from 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis. Estersohn and Sourifman[2] recommended pressures of 90 to 100 mm Hg above the preoperative systolic arm blood pressure for the lower extremity. This resulted in an average tourniquet pressure of 210 mm Hg. Others have recommended 50 to 75 mm Hg above the systolic blood pressure for surgery in the upper extremity and 100 to 150 mm Hg for surgery in the lower extremity. 1. Reid HS, Camp RA, Jacob WH: Tourniquet hemostasis: a clinical study, Clin Orthop 177:230, 1983. 2. Estersohn HS, Sourifman HA: The minimum effective midthigh tourniquet pressure, J Foot Surg 21:281, 1982. ֹѪ����ѹ����ľ�ȷѹ����δȷ������֤�ݱ����������������ʹ�õ�ѹ��ƫ��������Ҫ����ȷѹ����ij�̶ֳ���Ҫ���ݻ������䡢Ѫѹ�Լ�֫����ܾ���ȷ����Reid��Camp �� Jacob[1]�����ڶ�����������(Doppler stethoscope)����ʹ����������ʧ�����ѹ�������Դ�ȷ��ʹ��ֹѪ������ѹ�������ǵ���֧ѭ����Ѫѹ�ı仯�����ǽ���ѹ�����50~75 mmHg����ֹѪ��ѹ������֫Ϊ135~255 mmHg����֫Ϊ175~305 mmHg��ά�ִ�ѹ�����ɴﵽ�����ֹѪЧ����Estersohn ��Sourifman[2]�Ƽ���ֹ֫Ѫ����ѹ��Ӧ����ǰ����֫����������ѹ��90~100 mmHg����˲���ƽ����ֹѪ��ѹ��Ϊ210 mmHg������һЩ�����Ƽ���ֹ֫Ѫ��ѹ��������ѹ��50~75 mmHg����֫���100~150mmHg�� According to Crenshaw et al.[1], wide tourniquet cuffs are more effective at lower inflation pressures than are narrow ones. Pedowitz et al.[2] demonstrated that curved tourniquets on conical extremities require significantly lower arterial occlusion pressures than straight (rectangular) tourniquets (Fig. 1-1). The use of straight tourniquets on conical thighs should be avoided, especially in extremely muscular or obese individuals. 1�� Crenshaw AG, Hargens AR, Gershuni DH, et al: Wide tourniquet cuffs more effective at lower inflation pressures, Acta Orthop Scand 59:447, 1988. 2�� Pedowitz RA, Gershuni DH, Botte MJ, et al: The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and integrated cuff inflation system, Clin Orthop 287:237, 1993. ����Crenshaw[1]���˵��о�������ѹ���ϵ�ʱ���ֹѪ����խ��ֹѪ����Ϊ��Ч��Pedowitz[2]����֤ʵ���û���ֹѪ��(curved tourniquet)��Բ�ε�֫�岿�ּ�ѹʱ��ʹ�������������ѹ����ʹ��ֱֹѪ��(�����Σ�straight tourniquet)��������(ͼ1��1)�������Բ�εĴ�����Ӧ����ʹ��ֱֹѪ��������������Щ����dz��������ȷ��ֵĻ��ߡ�
Fig. 1-1 A, Straight (rectangular) tourniquets fit optimally on cylindrical limbs. B, Curved tourniquets best fit conical limbs. (From Pedowitz RA, Gershuni DH, Botte MJ, et al: Clin Orthop 287:237, 1993.) ͼ1��1��A��ֱ�������Σ�ֹѪ�����ʺ�������״��֫�塣B������ֹѪ��������Բ�ε�֫�塣 Any solution applied to the skin must not be allowed to run beneath the tourniquet, or a chemical burn may result. Sterile pneumatic tourniquets are available for operations about the elbow, and the limb may be prepared and draped before the tourniquet is applied. Rarely, a superficial slough of the skin may occur at the upper margin of the tourniquet in the region of the gluteal fold. This usually occurs in obese individuals and is probably related to the use of a straight instead of a curved tourniquet. �κ���Ƥ����ʹ�õ�Һ���������������ֹѪ���£���������ѧ�����ˡ��ⲿ��Χ��������ʹ��������ֹѪ������Ӧ��ǰ֫����Ƚ���Ƥ���������̵���ż�����ι���ֹѪ�����Ͻ紦�ɳ��ֱ�dz����Ƥ(superficial slough)���ⳣ����һЩ���ֻ��ߣ���������ֱֹѪ��ȡ������ֹѪ���йء� Pneumatic tourniquets should be kept in good repair, and all valves and gauges must be routinely checked. The inner tube should be completely enclosed in a casing to prevent the tube from ballooning through an opening, allowing the pressure to fall or causing a "blowout." The cuff also should be carefully inspected. On older tourniquets, the firm plastic band that keeps the tourniquet from rolling must lie superficial to the inflatable cuff to prevent damage to the underlying structures. Damage has been reported when the plastic band had been inserted between the skin and the inflatable cuff. ����ֹѪ����Ҫ���õı��������еķ��źͼ�����Ӧ�����飬ֹѪ���ڵ�Ӧ��ȫ����������֮�ڣ��Է������ѿڴ����������ѹ�����ͻ�ͻȻ���ѡ�����(cuff)ͬ��ҲӦС�ļ�飬��һЩ��ʽ��ֹѪ���У�������ֹֹѪ�������ļ�����ϴ��������ڿɳ���������dz���Ա����λ�����·�����֯�ṹ������ˡ��б���˵�����������ϴ�����ֹѪ��������Ƥ��֮��ʱ��������ˡ� Any aneroid gauge must be calibrated frequently. The newer gauges carry instruction cards with them. They are sold with test gauges so that the gauges on the tourniquets can be tested for proper calibration. However, the test gauge also is an aneroid gauge and thus is subject to error itself. Therefore the test gauge must be tested for accuracy by a mercury manometer. The test gauge should be checked once a week, and each tourniquet gauge should be tested with a test gauge before it is used. If a discrepancy of more than 20 mm between the tourniquet and the test gauge is present, then the equipment should be discarded, and other equipment that does test properly should be used. One of the greatest dangers in the use of a tourniquet is an improperly registering gauge, and gauges have been found to be as much as 300 mm off calibration. In a number of tourniquet injuries, the gauges were later checked and found to be grossly inaccurate, allowing excessive pressure. �κ�һ�ַ�Һѹ������뾭��У��һ�����µ���ѹ�������һ��˵������ͬʱ������һ��У����ѹ�����ڲ���ֹѪ������ѹ���Ƿ�ȷ��Ȼ������У�Ա�Ҳ�Ƿ�Һѹ�����������Ҳ����������У�Ա������ˮ����ѹ��У��У�Ա�һ��У��һ�Σ���ֹѪ����ѹ���������ÿ��ʹ��ǰУ�ԣ����ֹѪ��ѹ����ͬУ�Ա���ڴ���20mmHgѹ���IJ��죬��ô���ѹ����Ӧ�����ϣ���ʹ��У�Ժ�ȷ����һֻѹ����ֹѪ��ʹ��������Σ������֮һ����ʹ�ò�ȷ��ѹ����У����Щ��ʱ�������������ɸߴ�300%����һЩӦ��ֹѪ����ɵ������У����������Щѹ����ʱ���������˵�ԭ���������ԵIJ�ȷ������ѹ������ Tourniquet paralysis can result from (1) excessive pressure, (2) insufficient pressure, resulting in passive congestion of the part, with hemorrhagic infiltration of the nerve, (3) keeping the tourniquet on too long, or (4) application without consideration of the local anatomy. There is no rule as to how long a tourniquet may be safely inflated. The time may vary with the age of the patient and the vascular supply of the extremity. In an average healthy ** under 50 years of age, we prefer to leave the tourniquet inflated for no more than 2 hours. If an operation on the lower extremity takes longer than 2 hours, it is better to finish it as rapidly as possible than to deflate the tourniquet for 10 minutes and then reinflate it. It has been found that up to 40 minutes is required for the tissues to return to normal after prolonged use of a tourniquet. Consequently, the previous practice of deflating the tourniquet for 10 minutes appears to be inadequate. ֹѪ������������̱���������¼���ԭ�����£���ѹ������ѹ�����㵼�¾ֲ�������Ѫ��������Ѫ����ֹѪ������ʹ��ʱ���������ʹ��ʱ�����˾ֲ����ʡ�Ŀǰ����֤ʵֹѪ��ʹ�öʱ���ǰ�ȫ�ģ����ʱ�������ߵ����估֫���Ѫ�����졣50�����µĽ������ˣ�����һ������ֹѪ���ĵ���ʹ��ʱ������2Сʱ�������֫��������Ҫ2Сʱ����ʱ��Ӧ�跨�����������������ɿ�ֹѪ��10���Ӻ��ٴν�ֹѪ���������á�Ŀǰ���ֳ�ʱ��ʹ��ֹѪ������֯��ҪԼ40���Ӳ��ָܻ��������������ǰ�ɿ�ֹѪ��10���ӵĹ�����Ȼ�Dz����ġ� Posttourniquet syndrome, as first recognized by Bunnell[1], is a common reaction to prolonged ischemia and is characterized by edema, pallor, joint stiffness, motor weakness, and subjective numbness. This complication is thought to be related to the duration of ischemia and not to the mechanical effect of the tourniquet. Sapega[2] et al. have documented interstitial edema, increased capillary permeability, microvascular congestion, and decreased muscle contractility after 2 to 3 hours of ischemia. Posttourniquet syndrome interferes with early motion and results in increased ** requirements. Spontaneous resolution usually occurs within 1 week. 1�� Bunnell S, ed: Surgery of the hand, ed 2, Philadelphia, 1948, JB Lippincott. 2�� Sapega AA, Heppenstall RB, Chance B, et al: Optimizing tourniquet application and release times in extremity surgery: a biochemical and ultrastructural study, J Bone Joint Surg 67A:303, 1985. ֹѪ���ۺ���������Bunnell[1]��ʶ����֫��Գ�ʱ��ȱѪ�Ĺ�ͬ��Ӧ������Ϊˮ�ס��ס��ؽڽ�Ӳ���˶������Լ����۸о���ľ������Ϊ��ȱѪ����ʱ���йأ�����ֹѪ���Ļ�е�����ء�Sapega[2]��֤ʵ��ȱѪ2~3Сʱ����ˮ�ף�ëϸѪ��ͨ�����ӣ�СѪ�ܳ�Ѫ�������������½���ֹѪ���ۺ����������ڻ������**�����������ӣ�ͨ����1������Ȼ���ˡ� Compartment syndrome, rhabdomyolysis, and pulmonary emboli are rare complications of tourniquet use. Vascular complications can occur in patients with severe arteriosclerosis or prosthetic grafts. A tourniquet should not be applied over a prosthetic vascular graft. ʹ��ֹѪ���ټ��IJ���֢�м����ۺ��������Ƽ��ܽ�֢����˨����Ѫ�ܲ���֢���������ض���Ӳ��������û����ˡ�ֹѪ����������Ѫ�ܼ�����ֲ���� Pneumatic tourniquets usually are applied to the upper arm and thigh. Khuri and coworkers[1] found in a prospective study that applying a tourniquet to the forearm is safe and effective for surgery of the hand and wrist. Michelen and Perry also concluded after a prospective study that a well-padded proximal calf tourniquet is safe for foot and ankle surgery. 1�� Khuri S, Uhl RL, Martino J, Whipple R: Clinical application of the forearm tourniquet, J Hand Surg 19A:861, 1994. ����ֹѪ��ͨ�������ϱۺʹ��ȡ�Khuri and coworkers[1]ͨ��ǰհ���о����֣������ֺ���������ֹѪ������ǰ�۰�ȫ��Ч��Michelen and Perryͬ��ͨ��ǰհ���о����ԣ���������ײ��������ԣ������óĵ��С��ֹѪ���ǰ�ȫ�ġ� The Esmarch tourniquet is still in use in some areas and is the safest and most practical of the elastic tourniquets. It is never used except in the middle and upper thirds of the thigh. This tourniquet has a definite although limited use in that it can be applied higher on the thigh than can the pneumatic tourniquet. The Esmarch tourniquet is applied in layers, one on the top of the other; a narrow band produces less tissue damage than a wide one. ��˹���ֹѪ����Esmarch tourniquet����ijЩ��λ�Կ���Ӧ�ã����ǵ���ֹѪ�����ȫ����ʵ�õ�һ�֣���ֻ�����ڴ��ȵ���1/3����1/3������ֹѪ����Ӧ����Ȼ���ޣ��������ڴ��ȸ������˵IJ�λӦ�ã���һ���dz���ֹѪ��������ȵġ�ֹѪ���Ƿֲ�ʹ�õģ�һ��ѹһ�㣬խ�ı����ȿ���ܼ��ٶ���֯���˺��� The Esmarch tourniquet should not be applied until the patient is well anesthetized; otherwise, persistent adductor muscle spasm may cause the tourniquet to be too loose after the muscles have relaxed. A hand towel, folded lengthwise in four layers, is wrapped snugly as high as possible around the upper thigh. The tourniquet is then applied over the towel as follows. The chain end is held over the lateral surface of the thigh with one hand; the other hand is passed under the thigh and grasps the rubber strap near the chain and pulls it taut. The strap is allowed to slip between the thumb and fingers as the hand is brought under and around the thigh; properly performed, this slipping produces a singing sound from friction. When it completely encircles the thigh, the tourniquet is overlapped layer on layer, with no skin or towel caught between the layers. This is repeated, keeping constant tension on the strap, until its application is complete. The hook on the end of the strap is then caught in one of the links of the chain. Care must be taken that excessive tension is not built up gradually as the tourniquet is applied. ��˹���ֹѪ��Ӧ�����������ʹ�ã��������ռ��ɳں�ֹѪ���ͻ���ɡ�ȡһ��ë����������۳��IJ㣬�����ܸߵ�ƽ�������ڴ��Ƚ��ˣ�Ȼ���������水������������ֹѪ����һֻ���ڴ���������ץסֹѪ�������ˣ���һֻ�ִӴ������洩������ץ��������������Ƥ����������������Ƥ���ڴ�������Ȧʱ����������Ĵָ������ָ֮�们�������������ȷ�����ֻ���Ħ���ܲ��� �ָ質���������������������һ�ܺ�ʼһ���ѹһ���ص����ƣ����Ҳ�����м䲻Ҫ����Ƥ����ë���������ƣ���Ƥ��Ҫ���ֳ�����ѹ��ֱ�����ƽ�����Ȼ������Ƥ��ĩ�˵Ĺ�����������ס��ֹѪ��Ӧ��ʱӦ�dz�С�ģ������ڲ���ʱ���γɹ��ߵ������� A Martin rubber sheet bandage can be safely used as a tourniquet for short procedures on the foot. The leg is elevated and exsanguinated by wrapping the rubber bandage up over the malleoli of the ankle and securing it with a clamp. The distal portion of the bandage is then released to expose the operative area. ������Ƥ�������㲿�Ķ�ʱ��������Ҳ�ɰ�ȫʹ�ã���̧֫�߲��Ա�������Ѫ���ؽ��Ϸ���ǯ�й̶������ɿ�Զ�˱�����¶��Ұ�� Fig. 1-2 A and B, Portable C-arm image intensifier television fluoroscopy set up for fracture repair. C-arm rotates 90 degrees to obtain lateral view. C and D, Technique for two-plane roentgenograms during hip surgery with a portable machine for anteroposterior view and lateral view. Film cassette for lateral view is positioned over superolateral aspect of hip. ͼ1��2 A��B ���ڹ����������������ʽC�α�Ӱ����ǿӫ����ʽ�ӻ�C�αۿ���ת90���Ի�ȡ��λͼ��������C��D���Źؽ�����ʱ�������X����������λX��Ƭ�ķ����������λƬʱ��Ƭ�������Źؽڵ����Ϸ���
Roentgenograms in the Operating Room X�����������е�Ӧ�� Often it is necessary to obtain roentgenograms during an orthopaedic procedure. Roentgenographic technicians who work in the operating room must wear the same clothing and masks as the circulating personnel. These technicians must have a clear understanding of aseptic surgical technique and draping to avoid contaminating the drapes in the operative field. Portable roentgenogram units used in the operating room should be cleaned regularly and ideally are not used in any other area of the hospital. ����������������У�������Ҫ����X��Ƭ���������еķ�������Ա������ȫ����Աһ�����봩ͬ����ϴ���²������֣���������Ա������֪����Ƽ����Լ��̵��Է�ֹ��Ⱦ��Ұ����������������ʹ�õ����X�����붨����࣬�û�����ò�������������ʹ�á� When an unsterile roentgenogram cassette is to be introduced into the sterile field, it should be placed inside a sterile double pillowcase or sterile plastic bag that is folded over so that the exterior remains sterile. This is covered by a large sterile towel, thus ensuring at least two layers of sterile drapes on the cassette. The operative wound should be covered with a sterile towel when anteroposterior view roentgenograms are made to avoid possible contamination from the machine as it is moved into position. ����������Ұʹ��δ������Ƭ��ʱ��Ӧ���������˫���������л��۵��������ϴ��У��Ա�֤�������Ȼ���ٸ��������Ա�֤���������ٸ���2����������ǰ��λX��Ƭʱ�����п������̸��������Ա�֤������λʱ����Ⱦ��Ұ�� Portable C-arm image intensifier television fluoroscopy allows instantaneous evaluation of the position of fracture fragments and internal fixation devices. Many of these machines have the ability to make permanent roentgenograms. When used near the sterile field, the C-arm portion of the machine must be sterilely draped (Fig. 1-2, A and . As with any electronic device, failure of an image intensifier can occur. In this event, backup plain roentgenograms are necessary. Two-plane roentgenograms can be made, even of the hip when necessary, using portable equipment (Fig. 1-2, C and D). Closed intramedullary nailing or percutaneous fracture fixation techniques may need to be abandoned for an open technique if the image intensifier fails. Ӧ������C�α۷����ӻ����ԶԹ��۶϶˼��ڹ̶�װ�õ�λ��������ʱ�ļ�飬���ֻ����������������ñ����X��Ƭ����C�α۲���Ӧ��������Ұʱ��Ӧʹ����������(ͼ1��2��A�� �������������豸һ����C�α��ӻ���ʱҲ���ֹ��ϣ�����������£��뱸��X��Ƭ�������Ҫ����ʹ���Ų�Ҳ�ɲ������ʽ�豸����������λX��Ƭ(ͼ,1��2��C��D)���ӻ���������ʱ������Ҫ�����պ�ʽ������̶���Ƥ���۹̶�������֮���п���λ�̶��� All operating room personnel should avoid exposure to roentgenograms. Proper lead-lined aprons should be worn beneath sterile operating gowns. Thyroid shields, lead-impregnated eyeglasses, and rubber gloves are now available to decrease exposure further. ��������ȫ����ԱӦ���Ⱪ¶�ڷ������£�����������ɴ���ר�ŵ�ǦΧȹ�������״�ٷ���������Ǧ���۾�����Ƥ���ף��Լ����ڷ������µı�¶�� Positioning of Patient������**�� The position of a patient on the operating table should be adjusted to afford maximum safety to the patient and convenience for the surgeon. A free airway must be maintained at all times, and unnecessary pressure on the chest or abdomen should be avoided. This is of particular importance when the patient is prone; in this position, sandbags are placed beneath the shoulders and a thin pillow beneath the symphysis pubis and hips to minimize pressure on the abdomen and chest. Large, moderately firm chest rolls extending from the iliac crests to the clavicular areas may serve the same purpose. ����������̨�ϵ�**Ӧ�Ȱ�ȫ�ֱ������ҽ���IJ������κ�����±��뱣�ֲ��˺�����ͨ���������ڲ����ظ�����ɲ���Ҫ��ѹ���������ڲ��˴��ڸ���λʱҪ�ر�ע�⡣Ϊ�˼��ٶ��ظ�����ѹ�ȣ����ߵ�˫����Ӧ��ɳ�棬�����ڳܹ������·����Źؽ��¼ӵ污��ʹ�ô����������������е�Ӳ�ȵ��ز���Ͳ״��Ҳ�ɴﵽͬ��Ŀ�ġ� ) Fig. 1-3 Anatomical relations of brachial plexus when limb is hyperabducted. Inset, With patient in Trendelenburg position, brace at shoulder is in poor position because limb has been abducted and placed on arm board. ͼ1��3������֫������չʱ�۴��ֲ����ʹ�ϵ���Ӳ帽ͼ�������߰ڷ���Trendelenburgλ��������֫��չ��������֫�а��ϣ��粿֧��λ�÷��ò���ȷ�� When the patient is supine, the sacrum must be well padded, and when on the side, the greater trochanter and the fibular neck should be similarly protected. When a muscle-relaxant drug is used, the danger of stretching a nerve or a group of nerves is increased. Fig. 1-3 shows traction on the brachial plexus from improper positioning of the arm. The brachial plexus can be stretched when the arm is on an arm board, particularly if it is hyperabducted to make room for the surgeon or an assistant or for administration of intravenous therapy. The arm should never be tied above the head in abduction and external rotation while a body cast is applied because this position may cause a brachial plexus paralysis. Rather, the arm should be suspended in flexion from an overhead frame, and the position should be changed frequently. Fig. 1-4 shows the position of the arm on the operating table that may cause pressure on the ulnar nerve, particularly if someone on the operating team leans against the arm. The arm must never be allowed to hang over the edge of the table. Padding should be placed over the area where a nerve may be pressed against the bone, that is, the radial nerve in the arm, the ulnar nerve at the elbow, and peroneal nerve at the neck of the fibula. �����ߴ�������λʱ������Ӧ�ӵ汣��������λʱ�������ڴ��¡����Ǿ����ӵ����Ա�������Ӧ�ü��ɳ�ҩ�������ܵ�ǣ����Σ���Խ����ӣ�ͼ1��3��ʾ���Ͻ�����ȷ**���±۴����ܵ�ǣ������֫�����а���ʱ�ɷ���ǣ�����ˣ��ر�����Ϊ�˸����������ó������ռ䣮��Ϊ���㾲��ע���ʹ��֫������չʱ���������ڽ�������ʯ��̶�ʱ�ϱ۾���������չ����λ����������ͷ��ˮƽ������һλ�ÿɵ��±۴�����ԡ�Ϊ�˱�����һ������ϱ�Ӧ����������ͷ���ϣ���Ӧ��������λ�á�ͼ1��4��ʾ�ϱ�������̨�ϲ���ȷ��λ�õ��³�����ѹ��������ر�����������������˿�ѹ�ϱ�ʱ����λ�ø����³������ˡ���֫����������������̨�ߡ���һ�п��ܵ������ܹ���ѹ�ȵ�λ�ü����汣���������ϱ���������ؽڳ����������Сͷ���������д���
Fig. 1-4 Points at which nerves of arm may be damaged by pressure. Inset, Pressure is applied to medial side of arm because patient is poorly positioned on operating table. ͼ1-4 ����������֫����;���п�����ѹ����IJ�λ���Ӳ帽ͼ�����ڻ���������̨�ϲ���ȷ��λ�ö�����֫�ڲ���ѹ��
Local Preparation of Patient ������Ƥ������ Superficial oil and skin debris are removed with a thorough 10-minute soap-and-water scrub. We prefer a skin cleanser containing 7.5% povidone-iodine solution that is diluted approximately 50% with sterile saline solution. Hexachlorophene-containing skin cleanser is substituted when allergy to shellfish or iodine is present or suspected. After scrubbing, the skin is blotted dry with sterile towels. This scrub can be performed in the patient's room just before surgery or in the operating room. If performed outside the operating room, the extremity must be wrapped securely with sterile sheets. �÷����ˮ������ϴƤ��10���ӣ���ȥ��Ƥ��������ͼ�Ƥм�������Ƽ�ʹ�õ�Ƥ����ϴ��Ϊ����7.5%�ľ���ϩ������ͪ���Һ�壬����������ˮϡ��50%��ʹ�á��ڻ��ɻ���ȷʵ���ڶԵ⼰���ද�����ʱ�����Ը��ú������ȷӵ�Ƥ������Һ��ˢϴ��Ϻ�����ë�����Ƥ�������ֲ�ϴӦ����ǰ�ڲ��������������ڽ��У����������������У���ô֫��Ӧ�����������á� After a tourniquet has been applied, if one is required, the sterile dressings applied during the earlier preparation should be removed. Care should be taken that the operative field does not become contaminated because the effectiveness of the preparation will then be partially lost. With the patient in the proper position, the solutions are applied, each with a separate sterile sponge stick, beginning in the central area of the site of the incision and proceeding pe**herally. Tincture of iodine containing 85% alcohol is still widely used as a skin preparation. Once painted on, it is allowed to dry and then is taken off with plain alcohol. Ether is no longer added to skin preparation solutions because of regulations governing volatile fluids in the operating room. Povidone-iodine solution is used routinely by some surgeons, especially when the risk of a chemical burn or an irritation from tincture of iodine is significant. The immediate operative field is prepared first; the area is then enlarged to include ample surrounding skin. The sponges used to prepare the lumbar spine are carried toward the gluteal cleft and anus rather than in the opposite direction. Sponges should not be saturated because the solution will extend beyond the operative field and must be removed. Excessive iodine, even in the operative field, should be removed with alcohol to prevent chemical dermatitis. If the linen on the table or the sterile drapes become saturated with strong antiseptic solutions, they should be replaced by fresh linen. Solutions should not be allowed to flow underneath a tourniquet. ����Ӧ��ֹѪ������ô�ڰ���ֹѪ��֮���ٽ��������ƿ���Ϊ�˲�ʧȥ��������Ч����Ҫ�dz�С���Ա������������Ⱦ�����˰ں�**����ʼͿ������Һ������ÿ��ʹ��һö��ɴ��������ȡ����Һ��ʼ�������������п���������������չ������85%�ƾ��ĵ�����Ƥ����������Ȼ���㷺Ӧ�á�����������Ӧ������Ȼ�������75%�ľƾ��ѵ⡣��Ƥ������Һ�У��Ѳ��ټ���**����Ϊ������Ӧ���ƻӷ���Һ���ʹ�á�һЩ���ҽ������ʹ�þ���ϩ������ͪ���������ر���ʹ�õ������������ԵĻ�ѧ���˼�**Σ����ʱ��Ϊ���á���������ֱ����Ұ���ģ�Ȼ����������Χ����ֱ���㹻��Ƥ����Χ��������ʱ��������Ӧ��ͷ�������ι���**������Ҫ���෴�����ƶ�����������ʱ��Ҫպ̫������Һ������������Ұ�����Ƥ���ϣ�����������ֲۿ�����ؽ�����Һ���øϽ�������ĵ�������ʹ����Ұ�ڣ�Ҳ�����þƾ��ϸ��ѵ⣬������ֻ�ѧ��Ƥ�ס������������̨�IJ�����������������Һ����Ӧ�������µ�������Һ��Ӧ����ֹѪ���¡� If a patient is allergic to iodine, plain alcohol can be used as a skin preparation. Colored proprietary antiseptics, commonly used in abdominal surgery, are not suitable in surgery of the extremities when preparation of the toes or fingernails is involved. Most of these solutions are difficult to remove, and the residual red, pink, or orange color makes evaluation of the circulation difficult after surgery. ������߶Ե����������ɵ��þƾ�����������ɫ��ר������Һ����Ӧ���ڸ���������������������������ֺ��ָ����֫��������������Һ����ɫ���Բ����������ĺ�ɫ���Һ�ɫ��ۻ�ɫ�ͻ�Ӱ�������֫��ѪҺѭ���Ĺ۲졣 When traumatic wounds are present, tincture of iodine and other alcohol-containing solutions should not be used for antiseptic wound preparation. Povidone-iodine or hexachlorophene solutions without alcohol should be used instead to avoid tissue death. �������������оƾ���Һ�岻��Ӧ���ڿ������˿ڵ����������Ը��þ���ϩ������ͪ������ȷӵȲ��Ͼƾ�������Һ���Ա�����֯������ In operations about the upper third of the thigh, the pelvis, or the lower lumbar spine in male patients, the genitals should be displaced and held away from the operative field with adhesive tape. A long, wide st** of tape similarly helps cover the gluteal cleft, a potential source of infection. In female patients the genital area and gluteal cleft also are covered longitudinally by st**s of adhesive tape. Adherent, sterile, plastic drapes can be used for these purposes. �����Ի��ߵĴ�����1/3�����輰��������ʱ��Ӧ������ֳ������Ұ�ƿ����ý����̶����ó��ҿ�Ľ���ͬ�������ڸ����ι����DZ�ڵĸ�ȾԴ��Ů�Բ��˻��������ι�Ҳ���ɳ����������ǡ�Ӧ��������������Ĥ����Ҳ��ͬ��Ŀ�ġ� Before the operative field in the region of the lower lumbar spine, sacroiliac joints, or buttocks is prepared, the gluteal cleft is sponged with alcohol, and sterile dry gauze is inserted about the anus so that iodine or other solutions are prevented from running down to this region, causing dermatitis. �������������Ĺؽڻ��β�����Ұ����ǰ�����þƾ������ι�����������ɴ������**��Χ���Է�ֹ��������������Һ���˸���������Ƥ�����ˡ� Brown[1] et al. and others recommend that before total joint arthroplasty the extremity should be held by a scrubbed and gowned assistant because this reduces bacterial air counts by almost half. They also recommend that instrument packs not be opened until skin preparation and draping are completed. 1. Brown AR, Taylor GJS, Gregg PJ: Air contamination during skin preparation and draping in joint replacement surgery, J Bone Joint Surg 78B:92, 1996. Brown[1]���Ƽ��ڽ���ȫ�ؽڳ�����ʱӦ��ϴ�����������µ�����̧֫��Զ�ˣ���Ϊ��������ʹ����ϸ���������ͽ�һ�롣���ǻ��Ƽ��������̽���������е���� When these preparations are done in haste, the gown or gloves of the sterile assistant preparing the area may become contaminated without the assistant's knowledge. To prevent this, a nurse or anesthetist should be appointed to watch this stage of preparation. ��Ƥ���������ʣ��������ֵ����������»ᱻδ������Ƥ����Ⱦ��Ϊ�˷�ֹ��������ķ�������ָ��һ����ʿ������ʦ�ල�������̡� WOUND IRRIGATING SOLUTIONS���˿ڳ�ϴҺ�� We routinely irrigate clean surgical wounds to keep them moist with sterile isotonic saline or lactated Ringer solution. Occasionally, if the risk of wound contamination is high, antimicrobial irrigating solutions are used. Dirschl and Wilson[1] recommend a t**le antibiotic solution of bacitracin, neomycin, and polymyxin, since it provides the most complete coverage in both clean and contaminated wounds. Antibiotic solutions should remain in the wound for at least 1 minute. Pulsatile lavage systems are more effective in wound irrigation than simple basting-type syringes. ����ͨ����������ˮ���ָ���Һ��ϴ��������˿�������ʪ��ż������ȾΣ���Խϴ���˿ڣ�ʹ�ú��п����صij�ϴҺ��Dirschl and Wilson[1]�Ƽ�ʹ�ú��˾��ġ���ù�غͶ�ճ�������ֿ����ص�Һ�壬�����������Ⱦ���˿ھ����ṩ����ȫ���ǡ�������Һ�����˿������ٱ���1���ӡ�����ʽ��ϴϵͳ(Pulsatile lavage system)�ϼ�ϴ��(simple basting-type syringe)���˿ڳ�ϴ��Ϊ��Ч�� Draping(�����̵�) Draping is an important step in any surgical procedure and should not be assigned to an inexperienced assistant. Haphazard draping that results in exposure of unprepared areas of skin in the middle of an operation can be catastrophic. Considerable experience is required in placing the drapes, not only to prevent their becoming disarranged during the operation, but also to avoid contamination of both the surgeon and the drapes. If there is the least doubt as to the sterility of the drapes or the surgeon when draping is complete, the entire process should be repeated. Unless assistants are well trained, the surgeon should drape the patient. �̵������κ�����������Ƿdz���Ҫ��һ������˲��ܽ���ȱ���������������ɡ�����ġ��ƻ����̵���������������������δ������Ƥ����¶����Ұ�������������Եĺ�����̵���Ҫ�൱�ľ��飬����Ҫ��ֹ���������������б�Ū�ң����һ�Ҫ��ֹ����ҽ������������Ⱦ���̵����̽���ʱ��ֻҪ���ҽ������������״���С�˿���ɣ���Ӧ���½����̵����������־������õ�ѵ������������ҽ��Ӧ���Ը������̵��� In the foundation layer of drapes, towel clips or skin staples are placed not only through the drapes but also through the skin to prevent slipping of the drapes and exposure of the contaminated skin. In every case the foundation drapes should be placed to overlap the prepared area of skin at least 3 inches (7.5 cm). During draping the gloved hands should not come in contact with the prepared skin. �̵��ĵײ���Ӧ�ý�ǯ��Ƥ���̶�������Ҫ������������Ҫ����Ƥ�����Է�ֹ���������л��䣬�����Ұ�б�¶��Ⱦ��Ƥ����������εײ�����Ӧ��Ƥ���������ص�����3Ӣ��(7.5cm)���������̵������У��������ֲ��ܽӴ�������Ƥ���� Paper drapes give off blue or green lint that collects on exposed horizontal surfaces in the operating room if those surfaces are not cleaned daily. Disposable paper or fiber drapes and operating gowns provide satisfactory barriers as a rule but require much more room for storage, are not cost effective, and carry with them the hazard of contamination from manufacturing defects or punctures in the packages. Heavy cloth drapes, after continued use, also must be inspected for perforations before they are sterilized. ֽ����������ɫ����ɫ�����ޣ��粻ÿ�ս�����ɨ���ɻ��������������κ�ƽ���ϡ�һ����ֽ����ά������������һ����������ṩ������������ã�������Ҫ�ܶ����Ŀռ����ڴ��棬������Ҫ���Ѹ�����ʽ�ͬʱ��Ҳ�������������������еĴ�����װ���������������Ⱦ��Σ�ա���ͳ����֯������ʹ�ú�ÿ������ǰ����ϸ����Ƿ������� FOOT AND ANKLE������ף� Two full-sized sheets are placed across the lower half of the table and the opposite extremity (Fig. 1-5). During this procedure the nurse should stand with the back toward the head of the table and, with outstretched arms, grasp the extremity just distal to the knee to prevent the leg from dangling. A towel is then placed transversely across the table with its distal edge level with the middle third of the calf of the leg. The sterile assistant grasps the foot with a sterile towel as the limb is placed on the table. The towel at the calf is folded snugly across the leg and is fastened in place with two towel clips. A second double layer of sheets is then placed over the extremity to extend from a point just distal to the towel proximally over the body to the chin. A sterile pillowcase or double sheet is next slipped transversely beneath the extremity and is fastened with towel clips to the top or proximal sheet, drawing the two snugly together around the extremity. The pillowcase or double sheet forms a "drag," which prevents exposure of contaminated areas when the knee and the hip are flexed. ������̸�������̨�°벿���Բ��½�������(��ͼ1��5)�����̽�����У���ʿ�豳�Ի���ͷ����վ������̨�ߣ�˫���쿪��˫��ץס����֫���ϥ�ؽ���Զ�ˣ���ֹС���´���Ȼ���ٽ�һ���������ƽ���и���������̨��ʹ��Զ����λ��С����1/3ˮƽ�����������µ�������������ץ��ס�㲿�������������̨�ϡ�С�Ȳ������ƽ������۵�������֫���������ѽ�ǯ�̶����ٴ�С�ȴ����ƽ����Զ��������˫������Ȼ����С���·��ӵ�����������˫�㵥�����ý�ǯ���Ϸ������Ĵ̶���ǣ������ʹ����������֫�壬�·�������˫�㵥���γ�һ�������ڡ��������Ķ�������ֹ������ϥ�����ؽ�ʱ�����Ⱦ����ı�¶�� Fig. 1-5 Draping of foot and ankle. A, Skin prepared from toes to just distal to knee; foundation sheets and towel in place. B, Leg enveloped in sterile towel. Towel clips includeportion of skin. C, Top sheet fastened to drag sheet by towel clips. ͼ1��5������ײ��̵���AƤ��������ֺ��ϥ�ؽ���Զ�ˣ��������ƽ����̺á�BС���������������ǯ��Ƥ�̶��������봹�����Խ�ǯ�̶��� KNEE ��ϥ��
A double layer of foundation sheets is laid across the lower half of the table and the opposite extremity. They should extend from the level of the gluteal fold distally well over the end of the table. A towel is placed on the table longitudinally so that its proximal end is level with the proximal third of the leg, and a second towel is laid on the table transversely at the level of the middle of the thigh. The extremity is placed in the center of these two towels. The distal towel is folded around the foot, ankle, and distal half of the leg and is fastened in place by towel clips attached longitudinally (Fig. 1-6). The towel should be wide enough to cover the extremity completely and overlap 4 inches (10 cm) or more. With the aid of an assistant, the foot is inserted into a pillowcase, and the edges of the case are held together with a towel clip. To make a compact mass of these rather voluminous drapes, a sterile bandage is wrapped snugly from the toes proximally to the proximal edge of the towel and pillowcase. Alternatively, a sterile stockinette rolled from the toes to the groin can be used. The area over the knee is cut away as described in the section on draping the edges of the incision. The stockinette is then covered with a sterile bandage to just below the knee. The remainder of the drapes are placed as described for the foot. ��˫�����������̨�°벿���Բ�֫���Ϸ������β�������Զ�˳�������̨ĩ��һ�����롣��һ�����ƽ�������������̨��ʹ�����λ��С�Ƚ�1/3ˮƽ��ȡ��һ�����ƽ�������ڴ�����1/3ˮƽ������֫�������������ƽ�����룬Զ�����ƽ�����С��Զ�����Σ�����Զ�����ѽ�ǯ�̶�(ͼ1��6)�����ƽ�Ŀ������ȫ����֫�壬������4Ӣ��(10cm)���ص��������ְ����½���������ף����ױ�Ե�ɽ�ǯ�̶���һ��Ϊʹ����գ�����������������ֺ���������ƽ�����Ľ��˱�Ե��Ҳ�ɸ��������ĵ���֯�����ֺ�������ɹ���ϥ�ؽڱ����֯��Ӧ���г�����ͬ�п���Χ�̵��н��ܵķ��������ֵ���֯����ϥ�ؽ����µIJ��������������ƹ̶��������̵��������㲿�̵���ͬ��
Fig. 1-6 Draping of knee. A, Skin prepared from groin to ankle. Foot and distal leg enveloped in sterile towel; foundation sheets and towel in place. B, Foot and distal leg enveloped in sterile pillowcase; proximal towel surrounds thigh, fastened in place by towel clips. C, Drapings of foot and leg rendered less bulky by snug application of sterile roller bandage. Drag sheet fastened at frequent intervals to top sheet, permitting wide range of motion of knee and hip without exposing unsterile field. ͼ1��6��ϥ���̵���AƤ�������Ը��ɹ����ס����С��Զ�������ƽ�������ײ�����ƽ����̺á�B���С��Զ�˰��������ף��������ƽ��ƴ��ȣ����Խ�ǯ�̶���C�����㼰С�ȵ����ƽ���������������������ӷ�ף����Խ�С���ദ�̶��ڶ�����ϥ���Źؽڴ�Χ�Ҳ���ᱩ¶δ��������
HIP���ţ�
The foundation drapes are applied as described for the knee, except that two towels (or a sheet) are placed longitudinally to envelop the limb from well proximal to the knee to the toes (Fig. 1-7). The pillowcase and bandage are then applied. The operative area is outlined with four towels laid in a rectangular position and fastened by towel clips at intervals of 5 cm. The top sheet is placed transversely across the body with its distal edge well distal to the proximal level of the prepared field. The gap between the foundation sheet and the top sheet is filled with two wide pillowcases fixed in place by numerous towel clips, both at the edge of the operative field and to the distal and proximal sheets. Alternatively, a sterile stockinette rolled from toes to groin can be used. The medial portion of the rolled edge is then cut, and the upper portion of the stockinette is fanned out over the operative area and secured with clips. �ײ����̷���ϥ�ؽ��̵�������ͬ�����ڰ��ŵ��������з��õ����ƽ���е�Ӧ����ֺ���ϴ�����ؽ�(ͼ1��7)��Ȼ�������������Ա����̶�����Ұ��Χ���Ŀ����ƽ��γɳ����Σ�ÿ��5cm�ý�ǯ�̶������ϲ���и������壬Զ�˱�ԵҪ�����Ұ���ˣ��ײ����ϲ��֮��ļ�϶�����������ײ��䣬���Զ�ѽ�ǯ����̶�����Ұ��Ե��Զ�����˵������ϡ���Ӧ��������֯������ֺ���������ɹ���Ȼ���г����ڲ�Ե��֯������ϰ벿�ּ��γ����θ�����������֮�ϣ��ý�ǯ����̶��� When one hip is ankylosed in adduction, the preparation is made easier by abduction of the unaffected extremity or by separation of the affected extremity from the opposite one by bending of the lumbar spine. When both hips are ankylosed, the patient is turned to one side, and the foundation sheets are slipped between the two extremities. Care and dexterity are required to avoid contaminating the drapes. ��һ���Źؽڴ�������ǿֱ״̬ʱ���ɽ�������֫��չ�����������ﵽ�����뻼��ķ��룬Ƥ�������������С���˫�Źؽڴ�������ǿֱ״̬ʱ����ɽ�����ת��һ�࣬������ͨ��˫��֫���ʻ��룬�˹�����Ҫ�dz�С�ģ�����Ҫ���ݣ��Է�ֹ��������Ⱦ��
Fig. 1-7 Draping of hip. A, Lower extremity from groin to toes encased in sterile towels and sterile pillowcase; these in turn surrounded by sterile roller bandage. Operative field outlined by four sterile towels held in place by clips through skin at frequent intervals. B, Interval between top sheet and foundation drapes covered by sterile pillowcases. Drag sheet on inner aspect of thigh in turn attached to sterile pillowcase with towel clips at frequent intervals, preventing exposure of perineum on abduction of hip. ͼ1��7�Ų��̽�A��֫�Ը��ɹ�����ֺ����������������ڣ������λ�������������Ұ��Χ���Ŀ������ƽ����Խ�ǯ�̶���Ƥ����B�ϵ������϶���������ǡ������ڲ��ϵ������ý�ǯ�̶��������ף���ֹ����չʱ��¶��**�� SPINE �������� Drapes for the spine are applied in a manner similar to that for abdominal operations and require no special desc**tion. ���������̵������븹���������ƣ������������������ UPPER EXTREMITY ����֫�� The shoulder and elbow are draped in a manner similar to that described for the hip and knee, respectively. See Chapter 61 for draping for hand surgery. �����ؽ��̵��ֱ����Źؽں�ϥ�ؽ��̵��������ơ��ֲ��̵���61�¡� DRAPING EDGES OF INCISION(�пڱ�Ե���̵�) The gloved hand should not come in contact with the skin before the incision is made. For the extremities, a section of sterile stockinette is drawn proximally over the operative field. Then the stockinette is grasped proximally and distally and cut with scissors to uncover the area of the proposed incision. Its cut edges are pulled apart, and the area is covered by a transparent adhesive-coated material. A large transparent plastic adhesive drape may be wrapped entirely around the extremity or over the entire operative field so that the stockinette is not needed. The incision is then made through the material and the skin at the same time. Thus not only are the edges of the incision neatly draped, but the operative field is virtually waterproof. This prevents the cloth drapes in some areas from becoming soaked with blood, which can be a source of contamination. The plastic adhesive drape minimizes the need for towel clips or staples around the wound edge and allows the entire undraped field to be easily seen. This is especially important when there are scars from previous injuries or surgery that must be accommodated by a new incision. ������������Ƥ֮ǰ������Ƥ���Ӵ���֫��������Ӧ�õ���֯��������������������棬Ȼ��ץס����֯��Ľ��˼�Զ�ˣ���ľҰ���ü����������������ı�Ե�������ڱ�¶����Ұ��Ƥ����������Ƥ����Ĥ��Ҳ��ʹ���ܻ��Ƹ�������֫���ȫ����Ұ�Ĵ����Ĥ�������õ���֯���Ƥ���пڵ�ͬʱ�п�Ƥ����Ĥ����������ʹ�пڱ�Ե����������������������ҰҲ�ܲ�ˮ����ͼ��������ڳ�Ѫ��ʪ������������Ⱦ�Ŀ����ԡ���������Ƥ����Ĥ���Դ������п���Χ��ǯ��Ƥ����ʹ�ã���������������ʹ��Ұ���̵��������ɼ��������п�����Ӧ��ǰ�����˻���������̺�ʱ����һ����������Ҫ�ġ� PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) TRANSMISSION ����������ȱ�ݲ���(HIV)�ķ����� We agree with the American Academy of Orthopaedic Surgeons [1](AAOS) Task Force recommendations on AIDS, which go beyond those recommended for health care personnel by the Centers for Disease Control and Prevention and the American Hospital Association. We believe that every effort should be made to prevent further transmission of AIDS/HIV in all areas of medical care. For specific recommendations the reader is referred to the AAOS Task Force guidelines. 1��American Academy of Orthopaedic Surgeons Task Force on AIDS and Orthopaedic Surgery: Recommendations for the prevention of human immunodeficiency virus (HIV) transmission in the practice of orthopaedic surgery, Chicago, 1989, The Academy. ����ͬ�������ǿ�ҽ��ѧ��(AAOS)ר��С���йذ��̲�(���������ȱ���ۺ���)�����Ľ��顣��Щ����֮�ϸ��˼���������Ԥ�����ĺ�����ҽԺ���ϻ��������ҵ��Ա��Ҫ��������Ϊ��ҽ�����ι����У��κλ��ڶ�Ҫ��һ��Ŭ����ֹAIDS��HIV���Ľ�һ�����������ھ���ϸ�ڶ��߿ɲο�AAOSר��С���ָ���ֲᡣ We strongly agree with the following AAOS recommendations regarding HIV precautions in the operating room: ���Ǽ��ӵ��AAOS������������HIV�����Ľ��顣 Do not hurry an operation. Excess speed results in injury. The most experienced surgeon should be responsible for the surgical procedure if the risk of injury to operating room personnel is high. ������Ҫͼ�죬�����������ٶ������������ߵ����ˣ�������Ա����Σ���Դ�IJ���Ӧ�����о�������ҽ��������ɡ� Wear surgical garb that offers protection against contact with blood. Knee-high, waterproof, surgical shoe covers, water-impervious gowns or undergarments, and full head covers should be worn. ������������Ӧ�����ɷ�ֹ�뻼��ѪҺ�Ӵ�������װ����������ϥ�ҷ�ˮ�����Ь�ף���ˮ��������ϴ���£�����Ҫ���������ͷ�֡� Double gloves should be worn at all times. ����Ӧ��˫�����ס� Surgical masks should be changed if they become moist or splattered. ���ֳ�ʪ��ʪ��Ӧ��ʱ������ Protective eyewear (goggles or full face shields) that covers exposed skin and mucous membranes should be used. Ӧ�û���װ��(��Ŀ��������)��������ͷ����¶��Ƥ����ճĤ�� To avoid inadvertent injury to surgical personnel, the surgeon should: Ϊ��ֹ��������Ա���������ˣ����ҽ��Ӧ�������� Use instrument ties and other "no-touch" suturing and sharp instrument techniques when possible. ������ʱ������Ӧ����е��ᣬ��Ϻ�ʹ��������еʱӦ�������á��ǽӴ��������� Avoid tying with a suture needle in hand. ��Ҫ���ִ��ŷ����ᡣ Avoid passing sharp instruments and needles from hand to hand; instead they should be placed on an intermediate tray. ���в�Ҫ����������е��������ֱ�Ӵ��ݣ�Ҫ�����Ƿ����ڹ������ڴ��ݡ� Announce when sharp instruments are about to be passed. ������������еʱҪ��ͷ���ѡ� Avoid having two surgeons suture the same wound. ��Ҫ����ͬʱ���һ���˿ڡ� Take extra care when performing digital examinations of fracture fragments or wounds containing wires or sharp instrumentation. ������ָ̽�������Ƭ���и�˿������������е���˿�ʱ��Ҫ����С�ġ� Avoid contact with osteotomes, drill bits, and saws. ��Ҫ���������ڹǵ��С���ͷ������ϡ� Use space suit type garb when splatter is inevitable, such as when irrigating large wounds or using power equipment. ���ڳ�ϴ����˿ڻ�ʹ�ö�����еʱ��ѪҺ�������ɱ��⣬Ӧ�������ʽ�����¡� Routinely check gowns, masks, and shoe covers of operating room personnel for contamination during the surgical procedure and change as necessary. ����Ҫ������������Ա�������������ּ�Ь���Ƿ���Ⱦ�������ҪӦ��ʱ������ Special Operative Techniques ���������������� These measures are used in a variety of procedures and are therefore described here so that repetition in other chapters will be unnecessary. The methods of tendon or fascia fixation and bone grafting are discussed here. The methods of tendon suture are discussed in Chapter 63. ��Щ������������������õ�������ڱ����м����������Ա������½������ظ���������Ҫ���ܼ���ͽ�Ĥ�̶�����������ֲ�������Ϸ�������63�½��ܡ� FIXATION OF TENDON TO BONE (������ǵĹ̶�) The principles of tendon suture are described in Chapter 63 on the hand, in Chapter 46, in which disorders of muscles and tendons are discussed, and under the discussion of tendon transfers in Chapter 68. The following deals only with the methods of attaching a tendon to bone. �����ϵ�ԭ���ڵ�63������Ʋ������ۡ������뼡�첡���ڵ�46�������ۣ�����תλ�ڵ�68���н��ܡ����潫Ҫ���ܵĽ����Ǽ�����ǵĹ̶������� In the fixation of a tendon to bone the apposing surfaces of both bone and tendon should be scarified to hasten attachment. Thus the periosteum must be incised and elevated enough to expose the bony surface and permit scarification. After completion of the tendon fixation, an attempt should be made to close the periosteum over the tendon, although this usually is impossible. Instead, the periosteum may be sutured to the edges of the tendon. �ڼ�����ǹ̶�ʱ��Ϊ�ӿ���ߵ����ϣ�Ӧ�ڼ�����ǵĽӴ�������ֲ��棬��Ĥ�����п��������Ա�¶�㹻�ĹDZ��棬����ɦ��ȥ������Ƥ�ʡ��ڼ���̶�֮��Ҫ��ȡ�ڼ�����渲�Ƿ�Ϲ�Ĥ��������ͨ���Dz����ܵģ�����Ϊ����ɽ���Ĥ��Ϲ̶��ڼ����Ե�� The simplest method of tendon fixation consists of placing a suture in the end of the tendon by one of the techniques described in Chapter 63. With this suture the tendon is pulled distally, all slack is removed, and the point of its attachment is determined. Just distal to this point, a hole is drilled transversely into the bone. The sutures on each side of the tendon are then passed through this hole in opposite directions and tied tightly over the shaft of the bone (Fig. 1-8, A). If the tendon is long enough, the end is passed through the hole in the bone and sutured to itself (Fig. 1-8, . ��ļ���̶�������Ҫ����63�������ķ���֮һ���ڼ���ĩ�˷���һ����ߣ������ڴ˷��߽�����ǣ��Զ�ˣ�ʹ����ֱ��ȷ������Ĺ̶��㣮�ڴ˵���Զ��Ĺ��Ϻ�����ף���������ķ��߽��洩���ǿף��ڹǸɱ�����( ͼ1-8A)��������쳤���㹻�Ļ����ɽ����촩���ǿף����ۻ����뼡�������Ϲ̶�(ͼ1-8 ��
Fig. 1-8 Fixation of tendon to bone. ͼ1-8 ������ǵĹ̶� Passing a tendon or a piece of fascia through a hole drilled in bone is often difficult because inserting the material into the bone at the point of entry is difficult or because the tendon or fascia becomes caught inside the tunnel. Krackow and Cohn[1] have devised a technique that provides both traction to and constriction of the tendon or fascia and decreases the difficulties of pulling the tissue into and through a tunnel. A homemade Chinese finger-trap is constructed from two pieces of suture woven about the tendon. If a distally based st** of iliotibial band is to be inserted into bone, the part of the band that is to be inserted is rolled into a cylindrical shape, and a suitable length of strong, nonabsorbable suture is wrapped around the fascia in a crisscross fashion beginning about 4 cm proximal to the end of the st**. At the end of the st** the suture is tied into a knot, leaving the ends long (Fig. 1-9, A). A second piece of suture is then wrapped around the fascia in the same way but out of phase with the first piece of suture (Fig. 1-9, . This suture also is tied at the end. The ends of the suture are passed through the hole in the bone (Fig. 1-9, C), followed by the rolled up fascial st**. Finally, the sutures are cut just proximal to the knots at the apex of the finger-trap and are easily removed, one at a time. 1��Krackow KA, Cohn BT: A new technique for passing tendon through bone: brief note, J Bone Joint Surg 69A:922, 1987. ʹ�����һ���Ĥ��֯�����ǿ������dz����ѣ���Ϊ���ѽ������ǿ��˿ڣ����������ں��ֿ��ڹǿ�ͨ���ڿ�ס��Krackow ��Cohn������һ�ּ���������ǣ��������������Ĥ��������ǣ����֯����ʹ����ǿ�ͨ�������ѡ��ö������߱�֯���ƣ��ɹ����ɡ��й�ʽָ�ס���״����������Ĥ��Զ�˲���ǿ��У��轫��Ĥ�����벿�־��Բ���Σ���һ���㹻���ȵġ���ʵ�IJ����շ����Ծ��Ĥĩ��4cm����ʼ��ʮ�������ƣ�ֱ��ĩ�ˡ��������߽�����ĩ���ϣ�����ĩ������(ͼ1-9A)��ȡ��һ���߰�ͬ���������Ƽ�Ͼ������λ�����һ�����ߴ�(ͼ1-9 ���˷���Ҳ��ĩ�˽�������������ĩ�˴����ǿ�(ͼ1��9C)�������ƵĽ�Ĥ�����룬�����ָ�Ķ���������Խ�����Ϸ��ߣ����������������ߡ�
Fig. 1-9 Krackow and Cohn technique for passing tendon or fascia through hole in bone. A, Suture is wrapped in crisscross fashion about distal end of tendon or fascia and is tied in knot, leaving ends of suture long. B, Second suture is wrapped in similar fashion but out of phase with first suture. C, Chinese finger-trap suture fits tightly about tendon or fascia and allows it to enter hole without difficulty. (Redrawn from Krackow KA, Cohn BT: J Bone Joint Surg 69A:922, 1987.) ͼ1-9 Krackow �� Cohn��������Ĥ�����ǿļ�����A�ڼ�����Ĥĩ���н���ʽ������ĩ�˴�ᣬ�ҽ�����ĩ�������㹻�ij��ȡ�B�ڶ������߰����Ƶķ�����������λӦ���һ�����ߴ���C���й�ָ�ס� ʽ��֯�ķ��߽������ϼ�����Ĥ��ʹ������Ĥ���ڴ���ǿס� A broad, firm, bony attachment must be ensured for the larger muscles; it may be obtained by the method shown in Fig. 1-8, C. The advantage of this method is that drilling a transverse hole through the shaft of the bone is unnecessary; such a procedure is sometimes difficult in deep wounds, and exposure requires considerable st**ping of soft tissues from the bone. The method of fixing a tendon in the medullary c** is as follows. After placing the suture in the end of the tendon and leaving two long, free strands, a trapdoor is made in the bone, exposing the medullary c** at the predetermined point of attachment. Just distal to the trapdoor, two holes are drilled through the cortex into the medullary c**. The free ends of the suture are then passed through the trapdoor and out through the two holes. When these sutures are pulled taut, the end of the tendon is drawn through the trapdoor into the medullary c**. The trapdoor may be partially replaced or broken into small fragments and packed into the defect as grafts. ���ڽϴ�ļ�����뱣֤�ؽ�����ι̵Ĺ��Ը��ţ��ɲ���ͼ1��8C��ʾ�ķ����������ŵ��Dz���Ҫ�����Ǹɺ�����ף��ڽ������Ұ�У��˲�����ʱ��Ϊ���ѣ�ͬʱΪ�˸��õشӹ�����¶����Ϲ㷺�ذ�������֯�����½��ܽ�����̶�����ǻ�ڵķ����������촩�÷��ߣ�ĩ�˱�����������ͷ���ڹ�������������š�����Ԥ���ĸ��ŵ㴦��¶��ǻ�����ڡ�����š�����Զ��������ף���Ƥ��������ǻ������������˴���������š����ӹǿ��д������������ߺ���ǣ������ĩ��ͨ��������š�������ǻ��������š����ʿ��Բ��ָ�λ��ҧ��������ȱ����ֲ�ǡ� Krackow, Thomas, and Jones[1] have devised a locking loop suture that is relatively simple to use and is especially suited to attaching flat structures such as the tibial collateral ligament, joint capsule, or patellar tendon to bone. It allows the application of tension to the structure, resists pulling out, and does not cause major purse stringing or bunching. When used with strong suture material, a doubled suture was found by the authors to be nearly twice as strong as stable fixation to bone. When the suture is used in combination with a staple, fixation is significantly improved. Fig. 1-10 illustrates the technique used to create the fixation suture. The tendon or ligament is approached from the raw end, and three or more locking loops are placed along each side of the structure. Tension is applied during the procedure to remove excess suture material within the locking loops. This suture may be re***rced proximal to the first suture. The tendon or ligament and the suture are then attached to bone through holes drilled in the bone, or the suture is tied over a screw or staple fixed in the bone. 1��Krackow KA, Thomas SC, Jones LC: Ligament-tendon fixation: **ysis of a new stitch and comparison with standard techniques, Orthopedics 11:909, 1988. Krackow��Thomas �� Jones������һ���÷������߷�Ϲ̶�����ļ������ر��ʺ������ֲั�ʹ����ؽ��һ����ʹ��ȱ�ƽ��֯��ǵĹ̶����������ַ����ɶ�������֯ǣ������˺�ѣ�Ҳ�����������ԵĴ��������������߷��ֲ��ý�ʵ��ϲ���ʱ��˫�߷�ϵ�ǿ�Ƚӽ��������֮��̶�ǿ�ȵĶ������˷�Ϸ�������Ӧ��һö��U���ζ�ʱ���̶�Ч����������ߡ�ͼ1��10��ʾ���������߷�ϼ���ķ������ڼ�����ʹ��Ķ϶˿�ʼ��ϣ�����ÿ���������������ᣬÿ�����߷�Ͼ�Ӧ���������ڵ�һ����߽��˽�һ����ǿ��ϣ�Ȼ������ʹ���ͬ���ߴ����ǿ����ڹ����ϣ������ڹ̶��ڹ��ڵ���˿����u���ζ��ϴ�ᡣ
Fig. 1-10 Krackow, Thomas, and Jones technique for ligament or tendon fixation to bone. A to G, Detail of placement of suture in wide tendon. (Redrawn from Krackow KA, Thomas SC, Jones LC: Orthopedics 11:909, 1988.) ͼ1-10 Krackow��Thomas�� Jones��������ʹ���ǹ̶��ļ�����A-G�������ϸ��Ϸ�����(ժ��Krackow KA, Thomas SC, Jones LC: Orthopedics 11:909, 1988.) Because of the scarcity of surrounding soft tissue and the nature of the bone, Cole's method is especially applicable to the fixation of tendons to the dorsum of the tarsus, to the calcaneus, or to the phalanges of the fingers (Fig. 1-11). ������Χ����֯ȱ���ǵ����ԡ��ƹDZ��桢���ǻ�ָ�ǵļ���̶��ر��ʺϲ�����Cole��(ͼ1-11)�� The tendon is prepared, and a pull-out suture is placed in the end of the tendon, as described for end-to-end sutures (see Chapter 63). A small flap of bone is reflected with a chisel, and at the apex of the flap a tunnel is drilled through the bone. Both ends of the wire suture are placed on a long, straight skin needle. The needle is passed through the hole in the bone and out through the skin on the opposite side, drawing the end of the tendon into the tunnel. The wire is then snugly anchored over a loop of gauze or a padded button. If considerable tension is necessary, as in the tendocalcaneus, the skin should be padded with heavy felt, and a cast is applied with the wires protruding through the bottom of the cast. After the plaster sets, the wire is anchored over a button on the outside of the cast. �������ã�����66�������Ķ˶Զ��Ϸ�����ĩ�˷���һ��ǣ���ߡ��ù������һƬС�ǰ꣬�����䶥����ף�������˿ĩ�˴���һö��ֱƤ���ϣ��봩���ǿף��������Բ�Ƥ����������ĩ������ǿ��У�Ȼ��˿�����ع̶���Ƥ��ɴ�����ϻ�������ť���ϡ������Ҫ�ϴ��������������̶�ʱ��Ƥ��Ӧ�ӵ��ëձ��ʯ����̶�����˿����ʯ�࣬ʯ��Ӳ�̺�˿��ʯ��ײ���ť�۱�����̶���
Fig. 1-11 Cole method of anchoring tendons to bone. Ends of wire suture are passed on straight skin needle through hole drilled in bone. Needle is drawn through skin on opposite side. Wire sutures are anchored over rubber tube or button. To prevent necrosis of skin when suture is under considerable tension, ends of wire may be passed through bottom of cast. Subsequently, wire is anchored over button on outside of cast. ͼ1-11 Coleʽ������ǹ̶��ķ�������˿����ĩ��ͨ��ֱ��Ƥ�봩���ǿף����봩���Բ�Ƥ��������������Ƥ��̶�����Ƥ�ܻ�ť�۱��棬Ϊ��ֹ�̶�ѹ�������µ�Ƥ���������ɽ���˿ĩ�˴���ʯ��ײ���Ȼ����ʯ����ť�۱���̶��� Suture-anchoring devices also are useful in securing tendon, ligament, or capsule to bone (Fig. 1-12). The pull-out strength of these devices is at least equal to that of a suture passed through drill holes in bone, and they are especially useful in deep wounds with limited room, such as in the shoulder. �ڼ��졢�ʹ����ؽ�����ǵĹ̶��У�����ê��װ��Ҳ�dz�����(ͼ1��12)������װ�õ�����ǿ�������൱�ڷ��ߴ����ǿ̶���ǿ�ȡ����ַ�������ҰС���˿��������·dz����ã������ڼ�ؽ������С� A tendon or ligament also can be secured to bone through a drill hole using a screw for an interference fit as in anterior cruciate ligament reconstruction procedures (see Chapter 43). Allograft cortical bone is now being commercially machined into screws for such a purpose. ������ʹ�Ҳ��ͨ����ǿ����ݶ����пɿ��ĽӴ��̶�������ǰ�����ʹ�����ʱ��(����43��)��Ϊ��������ͬ������Ƥ�ʹ��Ƴɵ������ݶ���
Fig. 1-12 Suture-anchoring implants. A, Statak (Zimmer) suture-anchoring device is drilled into bone. B, QuickAnchor (Mitek) suture anchor consists of hook device with suture that is anchored into drill hole in bone. ͼ1-12 ����ê��ֲ���A. Statak (Zimmer)���߹̶�װ�ÿ�ֱ��������ڡ�B. QuickAnchor (Mitek)���߹̶�װ�ô��е����ͷ��ߣ��ɹ̶��ڹǿ��ڡ� FIXATION OF OSSEOUS ATTACHMENT OF TENDON TO BONE(����ֹ���Ƭ�ļ�����ǵĹ̶�) When larger muscles are transferred, such as the quadriceps or the abductor muscles of the hip, better fixation is secured if the tendon is removed with a portion of its bony attachment. Sufficient bone is removed to ensure a cancellous surface. The bony segment is drawn distally, and the location of its reattachment is determined. At this point the periosteum is elevated, the surface of the shaft is scarified, and the attachment of the tendon is fixed to the raw area by two threaded pins inserted obliquely or by a screw (Fig. 1-13, A). Stone and du Toit staples also are useful for anchoring a ligament or a tendon to bone (Figs. 1-14 and 1-15). Wire loops passed through holes drilled into the bone (Fig. 1-13, B and C) are efficient. Silk, polyester, or chromic catgut no. 2 sutures may be used instead of metal for fixation of tendons in the less powerful muscles. If desired, a trapdoor may be made in the shaft of the bone, and the osseous attachment of the tendon can be countersunk into the defect and held by a suture, as illustrated in Fig. 1-8. �������ͷ�����Źؽ���չ���Ƚϴ�ļ���תλʱ������������һ���ָ��ŵĹ��ʣ���ɻ�ø��õĹ̶������µĹǿ�������㹻�Ĵ�С����ȷ������������ʹǡ����ǿ�����Զ��ȷ���ظ��ŵ�λ�ã������Ĥ��������ĥ�ֲڣ�Ȼ���츽�Źǿ��ö�ö������б�ι̶�����һö��˿���̶��ڴֲڹ�����(ͼ1��13A)��Stone �� du Toit ��U���ζ��ڽ�������ʹ��̶�����ʱҲ�dz�����(ͼ1��14��1��15)��ͨ����ǿײ�����˿ҫ�̶�Ч������(ͼ1��13B��C)��˿������������2�ų��߿ɴ����˿��ͬ���������������ļ��졣���Ը�⣬���ڹǸ�����һ���Ųۣ�����Ĺ��Ը��ſ������ȱ��������ͼ1��8�ķ����Է��߹̶���
Fig. 1-13 Fixation of osseous attachment of tendon to bone. A, Fixation by screw or threaded pins. B, Fixation by mattress suture of wire through holes drilled in bone. C, Fixation by wire loops. ͼ1-13 ���йǿ�ļ�����ǵĹ̶�������A.Ӧ����˿����������̶���B.Ӧ�ø�˿��ʽ��ϣ�ͨ���������̶���C.��˿��̶���
Fig. 1-14 Stone staple, used most frequently for anchoring tendinous tissue to bone. ͼ1-14 Stoneʽ��U���ζ�����ڽ�������֯�̶����ǡ�
Fig. 1-15 Modified du Toit staples. Barbs make extrusion of staple less likely. Several widths and lengths of staples are shown. ͼ1-15 ������du Toitʽ��U���ζ����ò�Ʒ���е��̣���ʹ��̶����ȶ�����������ͼ��չʾ���ֿ�Ⱥͳ��ȵġ�U���ζ��� BONE GRAFTING (ֲ��) The principles, indications, and techniques of bone grafting procedures were well established before "the metallurgic age" of orthopaedic surgery. Because of the necessity of using autogenous materials such as bone pegs or, in some cases, using wire loops, fixation of grafts was rather crude. Lane[1] and Sandhu introduced internal fixation; Albee[2] and Kushner, Henderson[3], Campbell[4], and others added osteogenesis to this principle to develop bone grafting for nonunion into a practical procedure. The two principles, fixation and osteogenesis, were not, however, efficiently and simply combined until surgeons began osseous fixation with inert metal screws. Then came the bone bank with its obvious advantages. Much work, both clinical and experimental, is being done to improve the safety and results of bone grafting: donors are being more carefully selected to prevent the transmission of HIV and other diseases; tissue typing and the use of immunosuppressants are being tried; autologous bone marrow is being added to autogenous and homogenous bone grafts to stimulate osteogenesis; and bone graft substitutes have been developed. 1�� Lane JM, Sandhu HS: Current approaches to experimental bone grafting, Orthop Clin North Am 18:213, 1987. 2�� Albee FH, Kushner A: Bone graft surgery in disease: injury and deformity, New York, 1940, D Appleton-Century. 3�� Henderson MS: Nonunion in fractures: the massive bone graft, JAMA 81:463, 1923. Henry MO: Homografts in orthopedic surgery, J Bone Joint Surg 30A:70, 1948. 4�� Campbell WC: Ununited fractures, Arch Surg 8:782, 1924. �й�ֲ�ǵ�ԭ����Ӧ֤��ֲ�Ƿ������ڽ�����ơ�ұ��ʱ����֮ǰ���ѳ��ȷ������ʱ�����ڱ���ʹ��������ϣ����˨�ȣ���ʱ����ʹ�ø�˿�� ��������ֲ�ǵĹ̶������൱ԭʼ��Lane��Sandhu[1]�������ڹ̶�������Albee[2] �� Kushner��Henderson[3]�� Campbell[4]���˽��ɹǵĸ�������ֲ�ǵ�ԭ���У�ʹ����ֲ���ƹDz�����Ϊһ��ʵ�õ�������Ȼ��ֱ�����ҽ����ʼӦ�ö��Խ����ݶ����йǹ̶�֮��ֲ�ǹ̶��ͳɹ������ԭ��ű�����Ч�ؽ���������˺�����˹ǿ⣬�������������ŵ㡣Ϊ���ֲ�ǵİ�ȫ��Ч�������ڽ����Ŵ������ٴ��ͻ����о�����������������ѡ���Ϊ��������Ԥ��HIV�����������Ĵ�����Ӧ����֯���ͼ��������Ƽ����ڳ��ԣ�����Ǽ�ͬ��������в����������**�����ɣ���ֲ�ǵ����ƷҲ�ѳ��֡� Indications(��Ӧ֤) Bone grafts may be used for the following purposes: 1. To fill cavities or defects resulting from cysts, tumors, or other causes 2. To bridge joints and thereby provide arthrodesis 3. To bridge major defects or establish the continuity of a long bone 4. To provide bone blocks to limit joint motion (arthrorisis) 5. To establish union in a pseudarthrosis 6. To promote union or fill defects in delayed union, malunion, fresh fractures, or osteotomies ֲ�ǿ��������¼���Ŀ�ġ� (1)������ڹ����ס�����������ԭ�����µĹ�ȱ����ǻ�� (2)�ؽڼ��Žӽ��йؽ��ںϡ� (3)�ŽӴ�Ĺ�ȱ��������������ԡ� (4)�ṩ�����赲�����ƹؽڻ(�ؽ��ƶ���)�� (5)��ʹ�ٹؽ����ϡ� ���ӳ����ϡ��������ϡ����ʹ��ۻ���нع���ʱ�ٽ����ϻ�����ȱ�� Structure of Grafts (��ֲ�ǵĽṹ) Cortical bone grafts are used primarily for structural support, and cancellous bone grafts for osteogenesis. Structural support and osteogenesis may be combined; this is one of the prime advantages of using bone graft. These two factors, however, vary with the structure of the bone. Probably all or most of the cellular elements in grafts (particularly cortical grafts) die and are slowly replaced by creeping substitution, the graft merely acting as a scaffold for the formation of new bone. In hard cortical bone this process of replacement is considerably slower than in spongy or cancellous bone. Although cancellous bone is more osteogenic, it is not strong enough to provide efficient structural support. When selecting the graft or combination of grafts, the surgeon must be aware of these two fundamental differences in bone structure. Once a graft has united with the host and is strong enough to permit unprotected use of the part, remodeling of the bone structure takes place commensurate with functional demands. Ƥ�ʹ���ֲ��Ҫ���ڽṹ��֧�ţ����ʹ���ֲ���ڳɹǡ��ṹ֧�źͳɹǿɼ����֮������ֲ��������Ҫ�ŵ�֮һ��Ȼ��֧�źͳɹǹ��ܿ���ǵĽṹ��ͬ���кܴ��������ֲ��(�ر���Ƥ�ʹ�)�ڵ�ϸ���ɷֿ��ֻܴ�ȫ��������Ȼ���������������������ֲ�ǽ�����Ϊ�¹��γɵ�֧�ܡ���Ӳ��Ƥ�ʹǵ�������̴�����ں���ǻ����ʹǡ���Ȼ���ʹǵĹ��γ����ø�ǿ����ȴû���㹻��ǿ���ṩ��Ч�Ľṹ��֧�š���ѡ��������ֲ��ʱ�����ҽ����������������йعǽṹ���ܵĻ��������ֲ�������������ϲ��ﵽ�㹻ǿ�������ޱ���ʹ�úǵĽṹ����ݹ��ܵ���Ҫ������Ӧ�ĸĽ��� Source of Grafts(��ֲ�ǵ���Դ) Autogenous Grafts. (�������ֲ) When the bone grafts come from the patient, the grafts usually are removed from the tibia, fibula, or ilium. These three bones provide cortical grafts, whole bone transplants, and cancellous bone, respectively. Rarely is a resected rib appropriate. ��ֲ����Դ�ڻ��߱���ʱ�����ʳ�ȡ���ֹǡ���ǻ��Ĺǡ��������ǿɷֱ��ṩƤ�ʹǡ�����Ǻ����ʹǡ��г����߹Ǻ���ʹ�á� When internal or external fixation appliances are not used, which is rare now, strength is necessary in a graft used for bridging a defect in a long bone or even for the treatment of pseudarthrosis. The subcutaneous anteromedial aspect of the tibia is an excellent source for such grafts. In **s, after removal of a cortical graft, the plateau of the tibia supplies cancellous bone. Apparently, leaving the periosteum attached to the graft has no advantage; however, suturing to the periosteum over the defect has definite advantages. The periosteum seems to serve as a limiting membrane to prevent irregular callus when the defect in the tibia fills in with new bone. The few bone cells that are st**ped off with the periosteum can help in the formation of bone needed to fill the defect. �ڲ�ʹ������̶���еʱ(Ŀǰ�Ѻ���)����ֲ�DZ������һ��ǿ�����Žӳ��ǵ�ȱ�������������Ƽٹؽڡ�λ��Ƥ�µ��ֹ�ǰ�ڲ������ṩ����ֲ�Ǽ��õIJ�λ���ڳ��ˣ�ȡ��Ƥ�ʹǺ�ɽ�һ�����ֹ�ƽ̨ȡ�����ʹǡ�����ֲ���ϱ�����Ĥ��Ȼ��û�кô��ģ�Ȼ����ȡ�Ǵ���ȱ���������Ϲ�Ĥ���������Ե���Խ�ԡ��ֹ�ȱ���¹����ʱ��Ĥ�����������ã���ֹ������Ĺdz��γɣ����Ĥһͬ�������������ϸ������Э���ɹ�����ȱ�� Disadvantages to the use of the tibia as a donor area include the following: (1) a normal limb is jeopardized; (2) removal of the graft adds to the duration and magnitude of the procedure; (3) convalescence is prolonged, and ambulation must be delayed until the defect in the tibia has partially healed; and (4) the tibia must be protected for 6 to 12 months to prevent fractures. For these reasons, structural autografts from the tibia are now rarely used. ���ֹ���Ϊ����Ҳ�в���ȱ�㣺��Σ��������֫�壻��ȡ���ӳ�������ʱ�䣬������������Χ�����ӳ��˻ָ��ڣ��ֹ�ȱ�����ڲ������Ϻ���ܿ�ʼ���У����ֹDZ��뱣��6��12������Ԥ�����ۡ�������Щԭ���ֹ�ȡ�ǽ��нṹ������ֲ�����Ѻ���Ӧ�á� The entire proximal two thirds of the fibula may be removed without materially disabling the leg. However, a study by Gore[1] et al. indicates that most patients have complaints and mild muscular weakness after removal of a portion of the fibula. The configuration of the proximal end of the fibula is an advantage: the proximal end has a rounded prominence, which is partially covered by hyaline cartilage, and thus forms a satisfactory transplant to replace the distal third of the radius or the distal third of the fibula. After transplantation the hyaline cartilage probably degenerates rapidly into a fibrocartilaginous surface; even so, this surface is preferable to raw bone. 1��Gore DR, Gardner GM, Sepic SB, et al: Function following partial fibulectomy, Clin Orthop 220:206, 1987. �ֹǵĽ���2��3������ȡ�Ƕ�����������֫�����ع����ϰ�����CM���˵��о���ʾ������������ȡ��������Ǻ����ֲ��ʺ���ȵ���������ǽ��˵Ĺ������������������Խ�ԣ�����˴���Բ�۵�¡���沿�ֱ���Ǹ��ǣ�ʹ���Ϊ������Զ��1��3�����Զ��1/3��������ֲ���ֲ�����������ܺܿ��˱��Ϊ��ά����棬����ʹ��ˣ����ֱ���Ҫ���ڴֲڵĹ��档 The middle one third of the fibula also can be used as a vascularized free autograft based on the peroneal artery and vein pedicle using microvascular technique. This graft is recommended by Simonis, Shirall, and Mayou[1] for the treatment of large defects in congenital pseudarthrosis of the tibia (see Chapter 26). Portions of iliac crest also can be used as free vascularized autograft. The use of free vascularized autografts has limited indications, requires expert microvascular technique, and is not without donor site morbidity. 1. Simonis RB, Shirall HR, Mayou B: Free vascularized fibular grafts for congenital pseudoarthrosis of the tibia, J Bone Joint Surg 73B:211, 1991. ����������Ƽ������ɽ���ǵ���1��3���ڴ��趯�������ٵ������������ֲ��������ֲ������Simonis��Shirall�� Mayou[1]�ᳫ���������ֹ������Լٹؽڵľ��ȱ��(����26��)����������ͬ������������Ѫ�ܵ������������ֲ����Ѫ�������������ֲ����Ӧ֤���ޣ���������Ҳ��Ҫ���õ�����Ƽ��������ҹ������ܳ��ֺ���֢�� Allogenic Grafts. (�������ֲ)An allogenic graft, or allograft, is one that is obtained from a person other than the patient. Before the development of the bone bank (see discussion that follows), allografts were used only when autogenous grafts were not available or when there were objections to their use. In small children the usual donor sites do not provide cortical grafts large enough to bridge defects, or the available cancellous bone may not be enough to fill a large cavity or cyst; furthermore, the possibility of injuring a physis must be considered. Therefore grafts for small children usually were removed from the father or mother. Larger structural allografts have been used successfully for many years in revision total joint surgery, pe**rosthetic long bone fractures, and reconstruction after tumor excision. Osteochondral allografts are now being used with some success in a few centers to treat distal femoral osteonecrosis. ����ǻ�������ȡ�Ի���֮������塣�ڹǿ����֮ǰ(�����������)�����������ȱ�����߷���ʹ��ʱ�Ų�������ǡ������Ķ�ͯ�����õ�ȡ�Dz�λ���ṩ�Žӹ�ȱ������Ĵ��Ƥ�ʹǣ���ȡ�������ʹ�Ҳ���������ϴ�ն���������Ҫ�����⣬���迼�ǵ����˹����Ŀ��ܡ����������ֲ���Ӹ�ĸ����ȡ�ǡ����ṹ���������ֲ�ɹ�����ȫ�ؽڷ����û������������г�����ؽ��������ж��ꡣ�ڼ���ҽ�����ģ�����������ֲ�����������ƹɹ�Զ�˹ǻ�������ȡ����һ���ijɹ��� Heterogenous Grafts. (���ֹ���ֲ) Because of the undesirable features of autogenous and allogenic bone grafting, heterogenous bone, that is, bone from another species, was tried early in the development of bone grafting and was found to be almost always unsatisfactory. The material more or less retained its original form, acting as an internal splint but not stimulating bone production. These grafts often incited an undesirable foreign body reaction. Consistently satisfactory heterogenous graft material still is not commercially available, and its use is not recommended. �����������ֲ��ͬ���������ֲ������ȱ�㣬�ڹ���ֲ��չ�����ڽΣ����dz�����ȡ�Զ�������ֹ���ֲ������������Dz����⡣��ֲ����һ���̶��Ͽɱ���ֲ��ʱ����״���ṩ���ڵ�֧�ţ�����**�ɹǡ�������ֲ�ﳣ�շ����������ﷴӦ����Ч�ȶ������ֹ���ֲ���ϻ�δ�����ۣ�Ҳ���ᳫʹ�á� Cancellous Bone Substitutes. (���ʹ������)Hydroxyapatite and tricalcium phosphate, synthetic and naturally occurring materials, are now being used as substitutes for cancellous bone grafts in certain circumstances. These porous materials are invaded by blood vessels and osteogenic cells, provide a scaffold for new bone formation, and are, in theory, eventually replaced by bone. Their primary usefulness is in filling cancellous defects in areas where graft strength is not important. Bucholz[1] et al. found hydroxyapatite and tricalcium phosphate materials to be effective alternatives to autogenous cancellous grafts for grafting tibial plateau fractures. A synthetic bone graft substitute composed of biphasic ceramic (60% hydroxyapatite and 40% tricalcium phosphate) plus type I bovine collagen and marketed as Collagraft (Zimmer, Warsaw, Ind.) has recently undergone clinical trials. Chapman[2] et al. found that Collagraft could be substituted effectively for autogenous bone graft material for the treatment of long bone fractures undergoing operative fixation. Anticollagen antibodies to bovine collagen occurred in less than 3% of subjects and were of no consequence. Collagraft is mixed with 2.5 to 5 ml of bone marrow aspirate from the iliac crest just before use. 1�� Bucholz RW, Carlton A, Holmes RE: Hydroxyapatite and tricalcium phosphate bone graft substitutes, Orthop Clin North Am 18:323, 1987. 2�� Chapman MW, Bucholz R, Cornell CN: Treatment of acute fractures with a collagen calcium phosphate graft material: a randomized clinical trial, J Bone Joint Surg 79A:495, 1997. Ŀǰ���ϳɼ���Ȼ�ǻ���ʯ������������ijЩ���������������ʹǡ���Щ��ײ�������Ѫ�ܺ�ĸϸ�����룬Ϊ�¹��γ��ṩ֧�ܣ��������������տɱ��¹������������Ҫ������ֲ��ǿ��Ҫ�ߵIJ�λ������ʹ�ȱ��Bucholz[1]���˷����ǻ���ʯ���������ƿ���Ч����������ʹ������ֹ�ƽ̨����ֲ�ǡ�һ����˫���մ�(60%�ǻ���ʯ��40%��������)����I��ţ��ԭ����CollagraftΪ�����еĺϳɹ���ֲ��������ͨ���ٴ����顣Chapman[2]���˷��ֶ��ڳ��ǹ������ƣ���ţ��ԭ�Ŀ���ԭ����ij�������3%�Ҳ���Ҫ������������collagraft������Ч����������ֲ���ϡ�Collagraft��ʹ��ǰ���2.5��5ml��������ȡ�Ĺ��衣�� Numerous other osteoinductive bone graft substitutes have recently become available, and others are currently being tested in multiple clinical trials. ����ڶ������й��յ��ԵĹ���ֲ�������Ͷ��ʹ�á�����һЩ���ڽ��ж��ٴ����顣 Bone Bank(�ǿ�) Opinions differ among orthopaedic surgeons regarding the use of preserved allogenic bone, although its practical advantages are many. Fresh autogenous bone must generally be obtained through a second incision, which adds to the size and length of the operation and to the blood loss. After removal of a cortical graft from the tibia, the leg must be protected to prevent fracture at the donor site. At times it is not possible to obtain enough autogenous bone to meet the needs of the operation. ���ڱ����ͬ������ǵ�ʹ���ڹǿ�ҽ���л��в�ͬ�Ŀ����������������ʵ�ʵ��ŵ㡣���������һ�����ͨ�������п�ȡ�ǣ��������������Χ���ӳ�����ʱ�䲢��������ʧѪ�����ֹ�ȡ��Ƥ�ʹǺ���֫�������Ա�����ֹ�������ۣ���ʱ������ȡ���㹻�������������������Ҫ�� If osteogenesis is the prime concern, fresh autogenous bone is the best graft. Autogenous bone is preferable when grafting nonunions of fractures of the long bones. If stability is not required of a graft, cancellous autogenous iliac grafts are superior to autogenous grafts from the tibia. Allografts are indicated in small children, aged persons, patients who are poor operative risks, and patients from whom enough acceptable autogenous bone is not available. Autogenous cancellous bone can be mixed in small amounts with allograft bone as "seed" to provide osteogenic potential. Mixed bone grafts of this type will incorporate more rapidly than allograft bone alone. ����ɹ�����Ҫ��Ŀ�ģ������������ʹ�����õ���ֲ���ϣ����Ƴ��ǹ��۲�������ò����������ֲ������Ҫ��ֲ���ṩ�ȶ�����ʱ��ȡ���Ĺǵ��������ʹ�����ȡ���ֹǵ�����ǡ�ͬ���������ֲ���������������ˡ�����Σ���Դ�IJ����Լ�������㹻������ֲ�ǵĻ��ߡ��������������ʹǿ��Ի����ͬ�����������Ϊ�����ӡ����ӳɹǵ�DZ�������ֻ����ֲ�ǿɱȵ�������Ǹ���ز����������ǡ� To efficiently provide safe and useful allograft material, a bone banking system is required that uses thorough donor screening, rapid procurement, and safe, sterile processing. Standards outlined by the American Association of Tissue Banks[1] must be followed. Donors must be screened for bacterial, viral (including HIV and hepatitis), and fungal infection. Malignancy (except basal cell carcinoma of the skin), collagen-vascular disease, metabolic bone disease, and the presence of toxins are all contraindications to donation. 1.American Association of Tissue Banks: Standards for tissue banking 1984, Arlington, Va, 1984, The Association. Ϊ����Ч���ṩ��ȫ��ʵ�õ�ͬ������Dz��ϣ���Ҫ�����ǿ�ϵͳ��ȡ��ǰҪ�Թ���������ɸѡ��ȡ��ҪѸ�٣������а�ȫ������������������������֯��Э�����ƶ��ı������߱�������й�ϸ��������(����HIV����)�������Ⱦ�ļ�顣���Լ���(Ƥ������ϸ��������)����ԭ��Ѫ�ܲ�����л�ԹDz����ж�������ֲ�ǹ���Ľ���֤�� Bone and ligament and bone and tendon are now banked for use as allografts. The use of allograft ligaments and tendons in knee surgery is discussed in Chapter 46. Bone can be stored and sterilized in several forms; it can be harvested in a clean, nonsterile environment, sterilized by irradiation, strong acid, or ethylene oxide, and then freeze-dried for storage. Bone under sterile conditions can be deep frozen (-70��-80��) for storage. Fresh frozen bone is stronger than freeze-dried bone and therefore better as structural allograft material. Articular cartilage also can be cryopreserved in this manner. Cancellous allografts incorporate to host bone, as do autogenous cancellous grafts. These allografts are mineralized and therefore are not osteoinductive, although they are osteoconductive. Cancellous allografts can be obtained in a demineralized form that increases osteogenic potential but greatly decreases resistance to compressive forces. �Ǻ��ʹ��Լ��Ǻͼ���Ŀǰ�ѱ���������ͬ��������ֲ��ϥ�ؽ������ж��ʹ��ͼ����Ӧ���ڵ�46�����ۡ��ǵĴ���������ж��ַ�����������൫�����Ļ�����ȡ�ǣ��÷����ߡ�ǿ���������������Ȼ�ɴ��档�������������¿�ͨ���(-70��-80��)���档�����䶳��ǿ�Ƚ϶��ɹǴ������Ϊ�ṹ������ֲ�Dz���Ч�����á��ؽ����Ҳ�������Ʒ������档ͬ���������ʹ��������ǻ�����������ʹ���ֲ���ơ���Щͬ������DZ������гɹǴ������õ��ɹ��յ����á�ͬ���������ʹǽ����Ѹƴ����ɹ����ܵõ���ǿ����ѹ���ֿ����͡� Enneking and Mindell[1] observed that cortical allografts are invaded by host blood vessels and substituted slowly with new host bone to a limited degree, especially in massive allografts. This probably accounts for the high incidence of fracture in these grafts because dead bone cannot remodel in response to cyclic loading and therefore fails. 1��Enneking WF, Mindell ER: Observations on massive retrieved human allografts, J Bone Joint Surg 73A:1123, 1991. Enneking �� Mindell[1]�۲쵽ͬ������Ƥ�ʹ���ֲ������Ѫ�����뼰����������������ģ������Ǵ���ͬ������ǡ���Ҳ��˵��Ϊʲô��ֲ�ǵĹ��۷����ʽϸߣ���Ϊ���Dz���Ӧ��������Ӧ���������ʧ�ܡ� Indications for Various Techniques (����ֲ�Ǽ�������Ӧ֤) Single Onlay Cortical Grafts. (����Ƥ�ʹ�������ֲ) Until relatively inert metals became available, the onlay bone graft (see Chapter 56) was the simplest and most effective treatment for most ununited diaphyseal fractures. Usually the cortical graft was supplemented by cancellous bone for osteogenesis. The onlay graft is still applicable to a limited group of fresh, malunited, and ununited fractures and after osteotomies. ����Զ��ԵĽ���ʹ��֮ǰ������ֲ��(����56��)�����ƹǸɹ�����Ϊ������Ч�ķ�������Ƥ�ʹ���ֲ��ͨ���ٸ������ʹ���ֲ���Լ�ǿ�ɹǡ�����ֲ����Ȼ�������������ʹ��ۡ����ۻ������ϡ��������Լ��عǵIJ����� Cortical grafts also are used when bridging joints to produce arthrodesis, not only for osteogenesis but also for fixation. Fixation as a rule is best furnished by internal or external metallic devices. Only in an extremely unusual situation would a cortical onlay graft be indicated for fixation, and then only in small bones and when little stress is expected. For osteogenesis the thick cortical graft has largely been replaced by thin cortical and cancellous bone from the ilium. Ƥ�ʹ���ֲҲ�������Žӹؽڣ��ٽ��ؽ��ںϣ������ٽ������ɣ����������ڹ̶���һ������¹̶���ý������ڡ��������е��ֻ���ڼ�Ϊ���������²�ѡ��Ƥ�ʹ�������ֲ��Ϊ�̶��ֶΣ�����ֻ���ڶ̹Ǻ�Ӧ����С������¡��Թ�����ΪĿ��ʱ�����ʹ��ȡ���Ĺǵı�Ƥ�ʹǺ����ʹǣ����Ǻ�Ƥ�ʹǡ� Dual Onlay Grafts. (˫������ֲ��) Dual onlay bone grafts are useful when treating difficult and unusual nonunions or for the bridging of massive defects (see Chapter 56). The treatment of a nonunion near a joint is difficult, since the fragment nearest the joint is usually small, osteoporotic, and largely cancellous, having only a thin cortex. It is often so small and soft that fixation with a single graft is impossible because screws tend to pull out of it and wire sutures cut through it. Dual grafts provide stability because they g** the small fragment like forceps. Nonunion of shaft fractures in elderly patients whose bones are osteoporotic also should be treated with dual grafts. ˫������ֲ�Ƕ��������ѵġ��ټ��IJ����ϻ��ŽӾ��ȱ������(����56��)���ؽڸ����IJ��������Ʒdz����ѣ���Ϊ�����ؽڵĹǿ鳣����С���������ɣ���Ϊ���ʹǣ�ֻ�б���Ƥ�ʹǡ������ǿ���С����ʹ����ֲ�������У���Ϊ�ݶ����ѳ�����˿����ܽ����и˫��ֲ�����ͨ���а����üг�סС�ǿ���ﵽ�ȶ������������ɵ����껼�ߵĹǸɹ���ҲӦ����˫��ֲ�����ơ� The advantages of dual grafts for bridging defects are as follows: (1) mechanical fixation is better than fixation by a single onlay bone graft; (2) the two grafts add strength and stability; (3) the grafts form a trough into which cancellous bone may be packed; and (4) during healing the dual grafts, unlike a single graft, prevent contracting fibrous tissue from compromising transplanted cancellous bone. After a large defect in the lower extremity is bridged by dual grafts, protection from full weight bearing is necessary for a long time. Consequently, if shortening will not be too great, the defect should be obliterated, and the fragments should be apposed before the grafts are applied. A whole fibular graft usually is better than dual grafts for bridging defects in the upper extremity, except when the bone is osteoporotic or when the nonunion is near a joint. ˫��ֲ���Žӹ�ȱ����ŵ�������ٻ�е�̶����ñȵ�������ֲ�Ǹ��ã���˫��ֲ�ǿ�����ǿ�Ⱥ��ȶ��ԣ���˫���ֲ�ǿ��γ�һ�Dzۣ���������ѹ�����ʹǣ����뵥��ֲ�Dz�ͬ��˫��ֲ�������Ϲ����пɷ�ֹ��������ά��֯Σ����ֲ�����ʹǡ�����˫��ֲ���Ž���֫��Ĺ�ȱ����볤ʱ�������ȫ���ء���ˡ������������̫�࣬��ֲ��ǰӦ�Ƚ��ǿ��λ��������ֹ�ȱ���Ž���֫��ȱ��ʱ��ȫ�����ֲ����˫��ֲ��Ч�����ã����ǰ��й������ɻ�ӽ��ڹؽڵĹDz����ϡ� The disadvantages of dual grafts are the same as those of single cortical grafts: (1) they are not as strong as metallic fixation devices; (2) an extremity must usually serve as a donor site if autogenous grafts are used; and (3) they are not as osteogenic as autogenous iliac grafts, and the surgery necessary to obtain them has more risk. ˫��ֲ�ǵ�ȱ���뵥��Ƥ�ʹ�ֲ�ǵ�ȱ�����ƣ���ǿ�Ȳ�������̶���е���ڲ����������ֲʱ����ѡ��֫����Ϊ�������۳ɹ����ܲ��������Ĺ���ֲ��ȡ������Ҳ�и���ķ��ա� Inlay Grafts. (��Ƕֲ��) By the inlay technique a slot or rectangular defect is created in the cortex of the host bone (see Chapter 56), usually with a power saw. A graft the same size or slightly smaller is then fitted into the defect. In the treatment of diaphyseal nonunions, the onlay technique is simpler and more efficient and has almost replaced the inlay graft. The latter is still occasionally used in arthrodesis, particularly at the ankle (see Chapter 3). ������Ƕֲ��ʱ��������Ƥ�ʹ������������εĹDzۻ��ȱ��(��56��)����ʹ�õ綯�������Ȼ����ͬ��С����С����ֲ��Ƕ��ȱ���С������ƹǸɲ�����ʱ������ֲ�Ƿ�����Ϊ��㡢��Ч��������ȫ�������Ƕֲ�ǡ���������ʱ���ڹؽ��ںϣ��������ؽ�(����3��)��
Peg Grafts. (��˨ֲ��)Peg grafts are usually considered an innocuous means of internal fixation rather than a means of osteogenesis. Since they are weaker than metal, their use is limited to such conditions as nonunions of the medial malleolus and some of the small bones of the hand, wrist, or foot. ��˨ֲ��ͨ�����������ڹ̶�����������ڴٽ��ɹǡ�������ǿ�ȽϽ����������ǵ�ʹ�ý����������֡��㡢�̹ǵIJ����ϡ� Medullary Grafts. (��ǻ��ֲ��) Medullary bone grafts were tried early in the development of bone grafting techniques for nonunion of the diaphyseal fractures. Fixation was insecure, and healing was rarely satisfactory. This graft interferes with endosteal circulation and consequently can interfere with healing. Medullary grafts are rarely used except in the metatarsals, the metacarpals, and the distal end of the radius. �ڹ���ֲ������չ�����ʣ������Բ�����ǻ��ֲ�����ƹǸɹ��۲����ϣ����ڹ̶����ι̣����Ϻ������⡣��ǻ��ֲ�ǻ�����ڹ�ĤѪҺѭ������˻���Ź��۵����ϡ��������Źǡ��ƹ��Լ����Զ��֮�⣬��ǻ��ֲ���Ѻ��ٲ��á� Osteoperiosteal Grafts. (��-��Ĥ��ֲ) Osteoperiosteal grafts are less osteogenic than multiple cancellous grafts and are now rarely used. ��-��Ĥ��ֲ�ijɹ������������ʹ���ֲ�����Ѻ��ٲ��á� Multiple Cancellous Chip Grafts. (�������ʹ���Ƭֲ��) Multiple chips of cancellous bone are widely used for grafting. Segments of cancellous bone are the best osteogenic material available. They are particularly useful for filling cavities or defects resulting from cysts, tumors, or other causes, for establishing bone blocks, and for wedging in osteotomies. Being soft and friable, this bone can be packed into any nook or crevice. The ilium is a good source of cancellous bone, and if some rigidity and strength are desired, the cortical elements may be retained. In most bone-grafting procedures that use cortical bone or metallic devices for fixation, supplementary cancellous bone chips or st**s are used to hasten healing. Cancellous grafts are particularly applicable to arthrodesis of the spine, since osteogenesis is the prime concern. �������ʹ���Ƭֲ�DZ��㷺���á����ʹ���Ƭ����õijɹ��յ����ϣ��ر��ʺ������������������������ԭ������Ĺǿ�ǻ���ȱ��Ҳ�����ؽ�֧�Źǿ飮�Լ����ع������Ш��ȱ���������������飬��˿��������������ǿ��С����϶���Ĺ������õ����ʹ���Դ�������Ҫһ����Ӳ�Ⱥ�ǿ�ȿɱ���Ƥ�ʹǡ���ֲ������Ӧ��Ƥ�ʹ�ֲ�Ǻͽ������Ͻ��й̶���Ӧ�����ʹ���Ƭ����������϶���Դٽ������ϡ����ڼ�����·�ں����й�����������Ҫ��Ŀ�ģ���ˣ����ʹ�ֲ���ر������ڼ����ںϡ� Hemicylindrical Grafts. (��Բ��״ֲ��) Hemicylindrical grafts are suitable for obliterating large defects of the tibia and femur. A massive hemicylindrical cortical graft from the affected bone is placed across the defect and is supplemented by cancellous iliac bone. A procedure of this magnitude has only limited use, but it is applicable for resection of bone tumors when amputation is to be avoided. ��Բ��״ֲ�������������ֹǺɹǴ��ȱ���������Բ��״Ƥ�ʹǷ����ڹ�ȱ���ٲ����Ĺ����ʹ�ֲ�ǡ����ִ��ֲ�Ƿ�����Ӧ�÷�Χ���ޣ��������������ڹ������г�������ɵĹ�ȱ���Ա����֫�� Whole Bone Transplant. (���ι���ֲ)The fibula provides the most practical graft for bridging long defects in the diaphyseal portion of bones of the upper extremity, unless the nonunion is near a joint. A fibular graft is stronger than a full-thickness tibial graft, and when soft tissue is scant, a wound that could not be closed over dual grafts may be closed over a fibular graft. Disability after removing a fibular graft is less than after removing a larger tibial graft. In children the fibula can be used to span a long gap in the tibia, usually by a two-stage procedure (see Chapter 56). The shape of the proximal end of the fibula makes it a satisfactory substitute for the distal end of the fibula or distal end of the radius (see Chapter 19). ��������֫�Ǹɳ��ι�ȱ��ʱ�����������ֲ����ʵ�õ�ֲ�Ƿ��������Dz����ϵIJ�λ�����ؽڡ����������ֲ��ȫ����ֹ�ֲ��ǿ�Ⱥã����ң�������֯����ʱ��˫��ֲ�Ǻ����Ապ��˿ڣ����������ֲ���п��ܹر��˿ڡ�ȥ��һ����ǶԻ�����ɵ�Ӱ���֮ȡһ����ֹ�ȫ��ǿ�Ϊ�ᡣ�ڶ�ͯ�������ֲ�������Ž��ֹǴ��ȱ��ͨ���ֶ�����������(����56��)o������ǵĽ���������ĩ���Լ����Զ�����ƣ���˿�����Ϊ�����������������(����19��)�� A free vascularized fibular autograft has greater osteogenic potential for incorporation but is technically much more demanding. Bone transplants consisting of whole segments of the tibia or femur, usually freeze-dried or fresh frozen, are available. Their greatest use is in the treatment of defects of the long bones produced by massive resections for bone tumors or complex total joint revisions (see Chapters 19 and 56). ��Ѫ�ܵ����������������ֲ�Ǿ��и�ǿ�IJ��ͳɹ����������и��ߵļ���Ҫ�ɹǻ��ֹǵ�������ֲ�ǣ���Ϊ��ɹǻ������䶳�ǣ��������ô��������������г�����ɵij��ǹ�ȱ����ӵ��˹��ؽڷ������еĹ�ȱ��(����19�º�56��)�� Conditions Favorable for Bone Grafting (ֲ��Ӧ�߱�������) The conditions favorable for bone grafting are discussed in Chapter 56. ֲ��������������52�½��ܡ� Preparation of Grafts (��ֲ�ǵ���) Removal of Tibial Graft (�ֹ�ֲ�ǿ����ȡ) TECHNIQUE 1-1 (��������) To avoid excessive loss of blood, a tourniquet, preferably pneumatic (see Tourniquets), should be used when a tibial graft is removed. After removal of the graft, the tourniquet may be released without disturbing the sterile drapes. ����ȡ�ֹ�ֲ�ǿ�ʱ��Ϊ����ʧѪ��Ӧʹ������ֹѪ��(��ֹѪ����)��ȡ����Ϻ���ֹѪ������Ҫ��Ⱦ������ Make a slightly curved longitudinal incision over the anteromedial surface of the tibia, placing it so as to prevent a painful scar over the crest. Without reflecting the skin, incise the periosteum to the bone. With a periosteal elevator, reflect the periosteum, medially and laterally, exposing the entire surface of the tibia between the crest and the medial border. For better exposure at each end of the longitudinal incision, incise the periosteum transversely; thus the incision through the periosteum is shaped like an I. Because of the shape of the tibia, the graft is usually wider at the proximal end than at the distal. This equalizes the strength of the graft, since the cortex is thinner proximally than distally. Before cutting the graft, drill a hole at each corner of the anticipated area (Fig. 1-16). With a single-blade saw remove the graft by cutting through the cortex at an oblique angle, thus preserving the anterior and medial borders of the tibia. Do not cut beyond the holes, especially when cutting across at the ends; overcutting here weakens the donor bone and may serve as the starting point of a future fracture. This is particularly true at the distal end of the graft. As the graft is pried from its bed, an assistant grasps it firmly to prevent its dropping to the floor. Before closing the wound, remove additional cancellous bone from the proximal end of the tibia with a curet. Take care to avoid the articular surface of the tibia or in a child the physis. ���ֹ�ǰ�ڲ���һ���������пڣ��п�λ��ѡ����������ֹ�����������ʹ�̺ۡ���Ҫ��תƤ�����п���Ĥ���Թ�Ĥ�����������������Ĥ����¶�ֹ������ֹ��ڲ��Ե֮��������ֹ��档Ϊ�������пڵ����˸��õ���¶���ɼ��к��пڣ�ʹ��Ĥ�пڳʡ�I���Ρ��ֹǵ���״�����˹ǿ�Ľ��˱�Զ��Ҫ�������ڽ��˵Ĺ�Ƥ�ʱ�Զ��Ҫ�������Թǿ��ǿ���Ǿ��ȵġ���ȡ��֮ǰ����Ԥ����ȡ�������ĽǸ���һ��(ͼ1-16)��Ȼ����һ��Ƭ��б���ж�Ƥ��ȡ�¹ǿ飬�����ɱ����ֹǵ�ǰ���ڲ��ߡ�ȡ��ʱ����Ҫ�����ĸ��ǹǿķ�Χ���ر��������˵Ŀ�ȷ�Χ��������ǿ�Ȼ������������պ�Ĺ��ۡ�������ȡ�ǵ�Զ��ʱҪ�ر�ע�⡣���ǿ�ӹǴ�������ʱ������Ӧ����ץס����������ذ��������Ⱦ���ڹر��п�֮ǰ���ùγ����ֹǽ���ȡһЩ���ʹǣ���Ҫע�ⲻҪ�����ֹǽ��˵Ĺؽ��棬�ڶ�ͯ��Ҫ�������塣
Fig. 1-16 Method of removing tibial graft. Graft is wider proximally than distally. A hole is drilled at each corner before cutting to decrease stress riser effect of sharp corner after removal of graft. Cortex is cut through at oblique angle. ͼ2-16 �ֹ�ֲ�ǿ��ȡ�Ƿ�����ֲ�ǿ���˿���Զ�ˣ�����ȡǰ����ȡ�����ĽǸ���һ�ǿף��Խ���ȡ�Ǻ���Ǵ���Ӧ�����С�Ƥ�ʹ���һ��б����ȡ�� The periosteum over the tibia is relatively thick in children and usually can be sutured as a separate layer. In **s, however, it is often thin, and closure may be unsatisfactory; suturing the periosteum and the deep portion of the subcutaneous tissues as a single layer is usually wise. ��ͯ�ֹǹ�Ĥ�Ϻɵ�����Ϲرգ������ֹǹ�Ĥ�ϱ�������������ص�����������Ĥ�����Ƥ����֯һ���������ǵġ� If the graft has been properly cut, little shaping is necessary. Our practice is to remove the endosteal side of the graft for two reasons: first, the thin endosteal portion provides a graft to be placed across from the cortical graft; second, the endosteal surface, being rather rough and irregular, should be removed to ensure good contact of the graft with the host bone. ���ȡ�Ƿ�**ȷ������ȡ��ֻ���Լ���������������ԭ�����dz����г��ǿ���ڹ�Ĥ�沿�֣���һ�ǽ�խ���ڹ�Ĥ�沿�ֿ�������ֲ�Ǽ���Ƥ�ʹ����ӹǿ飻����������ڹ�Ĥ����ڲ��������г�����ʹֲ�ǿ��������Ǹ��õؽӴ��� Removal of Fibular Graft (���ֲ�ǿ����ȡ) TECHNIQUE 1-2 (Figs. 1-17 and 1-18) (��������)(ͼ1-17��1-18) Three points should be considered in the removal of a fibular graft: (1) the peroneal nerve must not be damaged; (2) the distal fourth of the bone must be left to maintain a stable ankle; and (3) the peroneal muscles should not be cut. ����ȡ���ֲ�ǿ�ʱ��Ҫע���������㣺�������������������Զ��1��4Ӧ�豣��������Ӱ���ؽ��ȶ����۲�Ҫ�ж���Ǽ��� For most grafting procedures, resect the middle third or middle half of the fibula through a Henry approach (see Fibula). Dissect along the anterior surface of the septum between the peroneus longus and soleus muscles. Reflect the peroneal muscles anteriorly after subperiosteal dissection. Begin the st**ping distally and progress proximally so that the oblique origin of the muscle fibers from the bone will tend to press the periosteal elevator toward the fibula. Next drill small holes through the fibula at the proximal and distal ends of the graft. Connect the holes by multiple small bites with the bone-biting forceps to osteotomize the bone; otherwise the bone may be crushed. A Gigli saw, an oscillating power saw, or a thin, air-powered cutting drill can be used. An osteotome may split or fracture the graft. The nutrient artery enters the bone near the middle of the posterior surface and may occasionally require ligation. ��ֲ������������Henry�п�(����ǽ�)����ȡ����жε�һ���1��3���ȡ�����dz�����Ե���Ŀ�㼡ǰԵ�������ǰ����룬��Ĥ�°������Ǽ���ǰ��ת�������������Զ������˰��룬��˲�������ϵ�б�м��������ʹ��Ĥ�������ع����н���Ȼ����ȡ�������¶˸��꼸���ף���ҧ��ǯ�������ҧ��������ͨ�ǿף���������׳������ѡ�Ҳ��Ӧ���߾⡢�綯�ھ���������ϸ�и��꣬�ǵ��Ϲǻ�����ǿ�����ѻ���ۡ���ʱҪ�����������1/3���������ڵ����������� Fig. 1-17 Cross sections of leg showing line of approach for removal of whole fibular transplants or tibial grafts. Shaded segment shows portion of tibia to be removed. Note that thick, strong angles of tibia are not violated. ͼ1-17 ��ʾȡ�������ֲ�ǿ���ֹ�ֲ�ǿ�ʱ�����п���·��С�Ⱥ���档б�߲�����ʾ�ֹ�ȡ�ǵIJ��֡�ע��ʺ�ʵ���ֹdzɽDz���δ����
If the transplant is to substitute for the distal end of the radius or for the distal end of the fibula, resect the proximal third of the fibula through the proximal end of the Henry approach and take care to avoid damaging the peroneal nerve. Expose the nerve first at the posteromedial aspect of the distal end of the biceps femoris tendon and trace it distally to where it winds around the neck of the fibula. In this location the nerve is covered by the origin of the peroneus longus muscle. With the back of the knife blade toward the nerve, divide the thin slip of peroneus longus muscle bridging it. Then displace the nerve from its normal bed into an anterior position. As the dissection continues, protect the anterior tibial vessels that pass between the neck of the fibula and the tibia by subperiosteal dissection. After the resection is complete, suture the biceps tendon and the fibular collateral ligament to the adjacent soft tissues. �����ȡ��ǽ�������������Զ�˻����Զ�ˣ���ô��ͨ��Henry�пڵĽ��˲�����ȡ��ǵĽ���1/3��Ҫע�����������������ڹɶ�ͷ����Զ�˺��ڷ���¶������˳����Զ�������������ͷ�IJ��֣��˴���������dz�����㸲�ǣ����ֵ���ָ�����������Ͽ�Խ�IJ�����Ǽ���ά��Ȼ����������������λ��ת����ǰ�Ƶ�λ�á���������ʱ��Ҫͨ����Ĥ�·��뱣����Ǿ����ֹ�֮�����ǰѪ�ܡ���ǽ���ֲ�ǿ���ȡ��Ҫ���ɶ�ͷ�������ั�ʹ����ڽ�������֯��Ϲ̶��� |
|