#61
|
|||
|
|||
Ýòè ïðóæèíêè äîáàâëÿþò ïîäâèæíîñòü â ïÿñòíî-ôàëàíãîâûõ ñóñòàâàõ ïàëüöåâ, êàê àêòèâíîå ñãèáàíèå ïðîòèâ íàòÿæåíèÿ ïðóæèíîê, òàê è ïàññèâíîå ðàçãèáàíèå â ýòèõ æå ñóñòàâàõ çà ñ÷åò òÿãè ïðóæèí. Ïîòîìó ÷òî øèíà - äèíàìè÷åñêàÿ. Ïðè ñòàòè÷åñêîé øèíå-ãèïñå ýòîãî íåò. Íè÷åãî ïðîòèâ ñâîáîäíîãî âûáîðà ïàöèåíòà íå èìåþ âîçðàçèòü: ÷òî åìó óäîáíåå, òî ïóñêàé è èñïîëüçóåò. Íî ìûøöû ðàçãèáàòåëåé æåëàòåëüíî ñîêðàùàòü àêòèâíî â ïåðèîäû, ñâîáîäíûå îò øèíèðîâàíèÿ.
|
#62
|
||||
|
||||
__________________
Ñ óâàæåíèåì, Äìèòðèé Âëàäèìèðîâè÷ |
#63
|
|||
|
|||
ïðîâåë ýêñïåðèìåíò, ïðèìîòàë îáðåçîê äåðåâÿõè ñâåðõó ëó÷åçàïÿñòíîãî ñóñòàâà ýëàñòè÷íûì áèíòîì. Ñìîã íîðìàëüíî ïî÷èñòèòü êàðòîôåëèíó, óâåðåííî äåðæà íîæ â ïðàâîé ðóêå. Êàðòîôåëèíó êîíå÷íî äâèãàë ëåâîé, íî íîæ äåðæàëñÿ ÷åòêî. Ïå÷àòàòü íà êîìïå íåðåàë, åñëè áèíò çàõîäèò íà ïàëüöû îíè ñëåïëåíû âìåñòå, åñëè íå çàõîäèò ñêðþ÷åíû êàê îáû÷íî. Ìûøà êàê-òî äåðæàòü ìîæíî, åñëè ïðèïð¸ò, íî íåóäîáíî.
Äðóã êóëèáèí ãîâîðèò íå îñòàíàâëèâàòüñÿ íà äîñòèãíóòîì, íàéòè â ãàðàæå æåëåçÿêó ïîõîæåé ôîðìû, è âìåñòî ïðóæèí ðåçèíêè îò òðóñîâ. Åñëè áóäåò óäîáíî, ñìåëî çàêàçûâàòü. |
#64
|
|||
|
|||
|
#65
|
|||
|
|||
Êîðî÷å çàêàçûâàþ. Ëó÷øå ïîïðîáîâàòü, è ïîæàëåòü, ÷åì íå ïîïðîáîâàòü, è ïîæàëåòü. Ñóììà áîëåå ÷åì âìåíÿåìàÿ, âðåìÿ äîñòàâêè òîëüêî ðàññòðàèâàåò, à óæå çäåñü íå ñìîã íàéòè, êàê íå ñòàðàëñÿ. Êàê ïðèäåò òîãäà ñ ìåíÿ îò÷åò
|
#66
|
|||
|
|||
Öèòàòà:
Óæå ïðèäóìàë ïðîãðàììó òåñòîâ-èñïûòàíèé: 1. ìîòîöèêë, êíîïêà çàâîäà, ïåðåäíèé òîðìîç, ðó÷êà ãàçà 2 êîìïüþòåðíàÿ êëàâèàòóðà è ìûøü 3. ñèíòåçàòîð (ëó÷åçàïÿñòíûé ñóñòàâ â îñíîâíîì ïðÿìîé) 4. àêêîðäåîí (ëó÷åçàïÿñòíûé ñóñòàâ ÷óòü ñîãíóò) 5. ãèòàðà Íó è ïî äîìó-ñòðîéêå.... |
#67
|
||||
|
||||
Öèòàòà:
Äà. Ñðàçó ó÷èëñÿ ïî çàðóáåæíûì è íà àíãëèéñêîì. Èç íàøåãî ïî ìèêðîõèðóðãèè òîëüêî Áåëîóñîâà, íàñêîëüêî ÿ ïîìíþ, ÷èòàë. Ëè÷íî èññëåäîâàíèé â ýòîì ïëàíå íå ïðîâîäèë. Èç òîãî, ÷òî ÿ âèäåë, ðåçóëüòàòû øâà íåðâà áåç ïðèìåíåíèÿ óâåëè÷åíèÿ áûëè ïðàêòè÷åñêè âñåãäà õóæå, ÷åì ñ ïðèìåíåíèåì. Ïîñêîëüêó øèëè ðàçíûå õèðóðãè, òî êîíå÷íî, ñðàâíèâàòü ðåçóëüòàòû íåëüçÿ. Íî òåì íå ìåíåå, ñîçäàâàëîñü âïå÷àòëåíèå, ÷òî òå, êòî çíàåò, ÷òî äåëàåò, øüåò ïîä ìèêðîñêîïîì (èëè â áèíîêóëÿðàõ). ß, êîãäà ðàññìàòðèâàë ïîä ìèêðîñêîïîì ñâîè øâû âûïîëíåííûå áåç ìèêðîñêîïà è ïîä ìèêðîñêîïîì, âèäåë î÷åíü áîëüøèå ðàçëè÷èÿ â êà÷åñòâå øâà, â àäàïòàöèè íåðâîâ èëè ñòåíîê ñîñóäîâ. Ýòî , ïðîñòî, çåìëÿ è íåáî. Íî, ìîæåò, ýòî, êîíåí÷î, ÿ òàê ïëîõî øüþ áåç ìèêðîñîêïà, à âñå îñòàëüíûå îäèíàêîâî âèðòóîçíî ìîãóò âñå ñîïîñòàâèòü è ñ ìèêðîñêîïîì, è áåç. ß ñåé÷àñ íå çàíèìàþñü ìèêðîõèðóðãèåé, ïîýòîìó íå óòâåðæäàþ, ÷òî ïåðèíåâðàëüíûé øîâ ëó÷øå ÷åì ýïèíåâðàëüíûé (ÿ òàê ñ÷èòàþ, íî íå áîëåå ýòîãî), íî ÿ óòâåðæäàþ, ÷òî ìèêðîõèîðóðãè÷åñêàÿ òåõíèêà ïîçâîëÿåò íàëîæèòü øâû áîëåå êà÷åñòâåííî è ïîëó÷èòü ëó÷øèå ðåçóëüòàòû. |
#68
|
|||
|
|||
Öèòàòà:
Hamid Karimi, Kamal Seyed Forootan, Gholamreza Moein, Seyed Jaber Mosavi, Batol Ghorbani Iekta. Survey of the results of acute sciatic nerve repair comparing epineural and perineurial techniques in the lower extremities of rat //Journal of Acute Disease (2015)18-22. Óñòðàèâàåò? Åñëè íå óñòðàèâàåò, òî ïðèâåäèòå èññëåäîâàíèÿ, êîòîðûå ïîäòâåðæäàþò Âàøè ËÈ×ÍÛÅ îùóùåíèÿ èëè íàïèøèòå ðàçîáëà÷èòåëüíûå ïèñüìà àâòîðàì, êîòîðûå âñå-òàêè óòâåðæäàþò: Direct nerve repair with epineural microsutures is still the gold standard surgical treatment for severe axonotmesis and neurotmesis injuries. Epineural repair is performed when a tension-free coaptation can be achieved in a well-vascularized bed which was developed by Millesi. Gross fascicular matching between the proximal and distal nerve ends results from lining up both the internal nerve fascicles and the surface epineural blood vessel patterns. Other repairs include grouped fascicular repair requiring intranerve dissection and direct matching and suturing of fascicular groups [9]. This is more practical distally in a major peripheral limb nerve. However, the theoretical advantages of better fascicle alignment with this technique are offset by increased trauma and scarring to the healing nerve internally due to the presence of permanent sutures. Despite its anatomical attractiveness, overall group fascicular repair is no better than epineural repair in functional outcomes [10]. K. S. Houschyar,A. Momeni,M. N. Pyles,J. Y. Cha, Z. N. Maan,D. Duscher,O. S. Jew, F. Siemers, and J. van Schoonhoven. Review Article. The Role of Current Techniques and Concepts in Peripheral Nerve Repair. // Plastic Surgery International. Volume 2016, Article ID 4175293, 8 pageshttp://dx.doi.org/10.1155/2016/4175293 Nerve repairs may be performed using either an epineurial or a fascicular suturing technique (Fig. 17.2). The superiority of one method over the other has never been conclusively demonstrated, either clinically or experimentally, and therefore there is no general consensus as to which is better. Intuitively, there would seem to be greater potential for the proper alignment of axonal pathways of the appropriate modality with the fascicular repair, but for several reasons this is not realized clinically. I. Chung, Kevin C. Hand and upper extremity reconstruction. – 2009. – ñòð. 233-234. Epineurial Versus Group Fascicular Repair There have been multiple basic science experimental and clinical studies comparing the various surgical repair techniques. No significant data or evidence indicates that any one technique is better. However, experimental studies in rats have shown that there is an improved specificity of muscle re-innervation after fascicular repair relative to epineurial repair of the sciatic nerve. Additionally, studies comparing epineurial to intrafascicular perineurial repairs have demonstrated no advantages for either of the surgical procedures. There have been no randomized clinical trials to date to compare epineurial and group fascicular repair in humans. In theory, group fascicular repair should produce a better clinical outcome. However, the potential benefits of improved fascicular matching may not be realized secondary to the increased surgical manipulation, leading to fibrosis and the possibility of fascicular mismatch. Although epineurial alignment is less precise, it may allow for a neurotrophic effect to influence the direction of axonal sprouting and growth. This may explain why an epineurial repair usually produces a similar outcome when compared with a group fascicular repair. Perhaps the technical aspects of group fascicular repair prohibit the realization of the theoretical advantages of this technique. Kasra Rowshan, Neil F. Jones, and Ranjan Gupta. Current Surgical Techniques of Peripheral Nerve Repair// Oper Tech Orthop 14:163-170 © 2004 Lundborg et al concluded that although this technique purportedly ensures correct orientation of regenerating axons, there is little evidence that it is superior to the less exact but simpler epineurial repair. Steve K. Lee, and Scott W. Wolfe. Peripheral Nerve Injury and Repair // J Am Acad Orthop Surg 2000;8:243-252 Epineural versus Fascicular Repair There have been clinical and experimental studies that were directed toward the identification of the superiority of one or the other of these two suture techniques (68,69,70,71,72 and 73). There has been no real conclusive evidence to suggest that one technique is better than another. The potential benefits of fascicular alignment are probably not experienced clinically because of the increased surgical manipulation that is required to execute the fascicular repair and the potential for mismatching fascicles. If it were possible to align the fascicles perfectly and with minimum surgical disruption, it is likely that fascicular repair would produce better clinical results than an epineural repair. Realistically, though, fascicular repairs unintentionally result in alignment of mismatched fascicles, thus resulting in guaranteed loss of nerve function, as well as causing additional intraneural damage to an already traumatized nerve. Although an epineural repair is not exact, it does allow for neurotropic effects to exert their influence on the direction of nerve fiber growth. This is probably why the less exact technique of epineural repair produces the same clinical results as fascicular repair. Berger R.A., Weiss A-P. Hand surgery. – 2004. – ñòð. 829. ...epineural repair remains the gold standard surgical reconstruction... D. Grinsell and C. P. Keating. Peripheral Nerve Reconstruction after Injury: A Review of Clinical and Experimental Therapies //BioMed Research International. Volume 2014, Article ID 698256, 13 pages [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Öèòàòà:
D. Grinsell and C. P. Keating. Peripheral Nerve Reconstruction after Injury: A Review of Clinical and Experimental Therapies //BioMed Research International. Volume 2014, Article ID 698256, 13 pages [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] .......Òî åñòü â ìåäóíèâåðå è ñ ïåðâûõ äíåé èíòåðíàòóðû Âû èçó÷àëè îðòîïåäèþ è òðàâìàòîëîãèþ ñðàçó æå ïî ó÷åáíèêàì íà àíãëèéñêîì ÿçûêå. Åñëè ýòî ïðàâäà, òî êðóòî! Ýòî - ïðàâäà? Öèòàòà:
|
#69
|
||||
|
||||
Öèòàòà:
Öèòàòà:
×èòàéòå âíèìàòåëüíî - ïðåèìóùåñòâà ÌÈÊÐÎÕÈÐÓÐÃÈ×ÅÑÊÎÃÎ ØÂÀ íàä ÝÏÈÍÅÂÐÀËÜÍÛÌ. Íà ñëåä.ñòðàíèöå òàáëèöà ñî ñðàâíèòåëüíûìè ðåçóëüòàòìè ïåðèíåâðàëüíîãî è ýïèíåâðàëüíîãî øâà. Ïîýòîìó ÿ è ñïðàøèâàë î ñîâðåìåííûõ èññëåäîâàíèÿõ, à âû ìíå ïðî ó÷åáíèêè â èíñòèòóòå.  ó÷åáíèêå íàïèñàíî, êàê ÿ ãîâîðþ. Ïðåêðàñíûå ðåçóëüòàòû ìèêðîõèðóðãè÷åñêîãî øâà ëó÷åâîãî íåðâà è íèçêèõ ïîâðåæäåíèé ñðåäèííîãî ÿ âèäåë äîñòàòî÷íî (è òàê æå äîñòàòî÷íî âèäåë ïëîõèõ ðåçóëüòàòîâ øâà ýòèõ íåðâîâ áåç óâåëè÷åíèÿ, ÷òî , âîçìîæíî, ñâÿçàíî è íå ñ ïîäõîäîì ê òåõíèêå øâà, à ñ òåì, ÷òî áåç óâåëè÷åíèÿ íåðâû øèëè ìåíåå ïðîôåññèîíàëüíûå õèðóðãè, îáû÷íî ïî ñêîðîé, êòî ïðèåäåò). Ëîêòåâîãî è âûñîêèõ ïîâðåæäåíèé ñðåäèííîãî? Èõ â ïðèíöèïå íå òàê ìíîãî áûëî, ÷òîá ÿ ìîã ñôîðìèðîâàòü î íèõ ñâîå ìíåíèå, à ïîñêîëüêó ñåé÷àñ ìèêðîõèðóðãèåé íå çàíèìàþñü, òî è ñòàòèñòèêîé ðåçóëüòàòîâ ñèëüíî íå èíòåðåñîâàëñÿ. À ÿ ãäå-òî ïèñàë ïðî "ïðåêðàñíûå ðåçóëüòàòû ... ñøèâàíèÿ ñðåäèííîãî è ëîêòåâîãî, îñîáåííî ïðè âûñîêèõ ïîâðåæäåíèÿõ"? |
#70
|
||||
|
||||
Ïî÷åìó-òî ñêðèíøîò ñòðàíèöû íå îòîáðàæàåòñÿ. Ïðîäóáëèðóþ åùå è çäåñü
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#71
|
|||
|
|||
Öèòàòà:
Öèòàòà:
Öèòàòà:
RESULTS OF OPERATION We know, however, that neurorrhaphy is never followed by full return of motor and sensory function. Rarely, full return is approached after suture of the radial nerve and occasionally after suture of the median nerve in children. A useful degree of recovery often occurs when the factors that influence recovery are favorable (see Factors that Influence Regeneration After Neurorrhaphy). The degree of recovery varies from nerve to nerve and with the relative extent of damage to the motor and sensory components within each nerve. Recovery of function of the limb as a whole is not proportionate to neurologic recovery. A patient may recover fairly good neurologic function, but, because of other defects in the limb, overall functional recovery may be unsatisfactory. Because it is helpful to know what result can be expected after suture of any given nerve, a statement is made at the end of the discussion of each nerve when this information is available. CAMPBELL’S OPERATIVE ORTHOPAEDICS, THIRTEENTH EDITION INTERNATIONAL EDITION. -2017. - Ð.3185. Ãäå íàïèñàíî, ÷òî ïîñëå íåéðîðàôèè ñ ðåçóëüòàòàìè âñå "íà óðà"? Åùå ññûëêè íóæíû?"Ïðàêòè÷åñêè âñþ èíòåðíàòóðó ÿ ïðîõîäèë â ìèêðîõèðóðãèè êèñòè ó ïðîô. Ñòðàôóíà (âû åãî çíàåòå). È íåðâû òîæå ÷óòü-÷óòü øèë ïîñëå ýòîãî)) Ó íèõ (è íå òîëüêî ó íèõ) òàêîé ïîäõîä. È ðåçóëüòàòû îòëè÷íûå. Ó ìåíÿ áûëî ñ ÷åì ñðàâíèâàòü." (Ñ). |
#72
|
||||
|
||||
 ñðåäíåé òðåòè ïëå÷à ïåðèíåâðàëüíûé øîâ ëó÷åâîãî íåðâà òàêàÿ íå íóæíàÿ õðåíü, êàê è äâóõïó÷êîâàÿ ïëàñòèêà ïðè ðàçðûâå ïåðåäíåé êðåñòîîáðàçíîé ñâÿçêè. Íàïðàâëåíèå àêñîíàì óêàæóò øâàííîâñêèå êëåòêè áåç ó÷àñòèÿ íèòîê õèðóðãà. Òóò ãëàâíîå ïðàâèëüíî è ïëîòíî ñîïîñòàâèòü êîíöû íåðâà. Ó ïåðèíåâðàëüíîé íåéðîððàôèè íåò íè÷åãî êðîìå êðàñèâîé êàðòèíêè, ïîêàçûâàþùåé àíàòîìè÷íîñòü âîññòàíîâëåíèÿ, è äîïîëíèòåëüíûõ ôèíàíñîâûõ ðàñõîäîâ. Ïîýòîìó è âåäóòñÿ ñåé÷àñ ðàçíûå èññëåäîâàíèÿ ïî óëó÷øåíèþ ýôôåêòèâíîñòè ýïèíåâðàëüíîé íåéðîððàôèè (èñïîëüçîâàíèå ýïèíåâðàëüíûõ ðóêàâîâ è ò.ï.), ò.ê. ñòàòèñòèêà íàãëÿäíî ïîêàçàëà îòñóòñòâèå ïðåèìóùåñòâ ïåðèíåâðàëüíîé íåéðîððàôèè íà êëèíè÷åñêèé ðåçóëüòàò.
__________________
Ñ óâàæåíèåì, Äìèòðèé Âëàäèìèðîâè÷ |
#73
|
||||
|
||||
Öèòàòà:
Öèòàòà:
Ïðè ýòîì ýòîò æå àâòîð ïèøåò Öèòàòà:
Ìîãó åùå îäèí îáçîð ïðåäëîæèòü: Perineurial (Fascicular or Funicular) Repair This technique was initially described by Langley and Hashimoto [20] in1917 and its superiority over epineurial repair is still questioned. This could be due to the controversial findings of researchers. Perineurial repair tends to be favoured over funicaular suture by Bora [21], Goto [22], Grabb et al., [23], Wise et al., [24] Yamamoto [25] and Brushart, Tarlov and Mesulam [26] ([Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]) Åñëè áû âû óòâåðæäàëè, ÷òî âñå ïîêà íåîäíîçíà÷íî, èëè ÷òî äëÿ ðàçíûõ óðîâíåé ïîâðåæäåíèÿ è ðàçíûõ íåðâîâ ïðåäïî÷òèòåëüíû ðàçíûå ñïîñîáû øâà, ÿ áû ñ âàìè ìîã ñîãëàñèòüñÿ. Íî ÿ ïîêà íå âèæó óáåäèòåëüíûõ äàííûõ è èññëåäîâàíèé ïðî ïðåèìóùåñòâà ýïèíåâðàëüíîãî øâà. |
#74
|
|||||
|
|||||
Öèòàòà:
Öèòàòà:
Öèòàòà:
Öèòàòà:
Öèòàòà:
This technique was initially described by Langley and Hashimoto [20] in1917 and its superiority over epineurial repair is still questioned. This could be due to the controversial findings of researchers. Î, áîæå. Äà ãäå ÿ ïèñàë î ÷åì-òî äðóãîì è î ÿâíîì ïðåèìóùåñòâå ýïèíåâðàëüíîãî øâà ïî ñðàâíåíèþ ñ ïåðèíåâðàëüíûì? |
#75
|
|||
|
|||
Ñïîñîá øâà íåðâà íå èìååò íèêàêîãî ïðàêòè÷åñêîãî çíà÷åíèÿ, ïîñêîëüêó ê òîìó âðåìåíè, êîãäà àêñîí ïðîðàñòåò, èííåðâèðóåìûå ìûøöû óæå ïîëíîñòüþ àòðîôèðîâàíû è çàìåùåíû ñîåäèíèòåëüíîé òêàíüþ
|