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Âîçìîæíî ëè âîññòàíîâëåíèå àìïóòèðîâàííîé êîíå÷íîñòè?
Óâàæàåìûå äîêòîðà!
Ïðèâåä¸ííûé íèæå òåêñò åñòü ðåçóëüòàò ìîèõ ðàçìûøëåíèé ïî ïðîáëåìå, îáîçíà÷åííîé â çàãîëîâêå òåìû.  í¸ì ïðåäëàãàåòñÿ íåêîòîðûé ïîäõîä ê ðåøåíèþ ïðîáëåìû, êîòîðàÿ î÷åíü âàæíà äëÿ äîâîëüíî áîëüøîãî ÷èñëà ëþäåé. Ïîæàëóéñòà, ïðî÷èòàéòå òåêñò è âûñêàæèòåñü ñ âàøåé ïðîôåññèîíàëüíîé òî÷êè çðåíèÿ. Óâàæàåìûå ïàöèåíòû! Èçëîæåííàÿ íèæå òåõíîëîãèÿ, íàñêîëüêî ìíå èçâåñòíî, íå ïðèìåíÿåòñÿ â ìåäèöèíñêîé ïðàêòèêå. Îäíàêî, êàê âû ìîæåòå óáåäèòüñÿ ñàìè, â íåé íåò êàêèõ-ëèáî ïîëîæåíèé, ïðîòèâîðå÷àùèõ ñîâðåìåííûì íàó÷íûì ïðåäñòàâëåíèÿì î òîì, êàê óñòðîåí è êàê ôóíêöèîíèðóåò ÷åëîâå÷åñêèé îðãàíèçì. Ïî ýòîé ïðè÷èíå, îíà ìîãëà áû áûòü âêëþ÷åíà â ìåäèöèíñêóþ ïðàêòèêó ïîñëå ïðîâåäåíèÿ íàäëåæàùèõ èññëåäîâàíèé è èñïûòàíèé. Î÷åíü íàäåþñü, ÷òî äàííàÿ òåìà â ôîðóìå ìîæåò ñòàòü äèñêóññèîííîé ïëîùàäêîé äëÿ êîíñòðóêòèâíîãî îáñóæäåíèÿ è ïîñëåäóþùåãî ïðîäâèæåíèÿ ïðåäëàãàåìîé òåõíîëîãèè. Ñ óâàæåíèåì, Ðóñëàí Øàðèïîâ. Öèòàòà:
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#2
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Î ïðîäâèæåíèè êàêîé "òåõíîëîãèè" Âû ãîâîðèòå?
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#3
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Èçëîæåííàÿ òåõíîëîãèÿ íèêîãäà íå áóäåò ïðèìåíÿòüñÿ â ìåäèöèíå â ïåðâóþ î÷åðåäü èç-çà ãóìàííîãî îòíîøåíèÿ ê ïàöèåíòàì, êîòîðûì è òàê äîñòàëîñü ïðè ïîòåðå êîíå÷íîñòè - îíà íèêîãäà íå ïðîéäåò îäîáðåíèÿ ýòè÷åñêîãî êîìèòåòà íè â îäíîé öèâèëèçîâàííîé ñòðàíå, ïîäîçðåâàþ, ÷òî â ìåíåå öèâèëèçîâàííûõ ñòðàíàõ (êàê-òî Ñåâ. Êîðåÿ) äàííàÿ òåõíîëîãèÿ óæå èñïðîáîâàíà íà çàêëþ÷åííûõ ìåñòíûõ ãóëàãîâ, òîëüêî îá åå ýôôåêòèâíîñòè èëè íå ýôôåêòèâíîñòè ìû íèêîãäà íå óçíàåì, ïîêà òàì áóäåò öàðèòü âîåííûé êîììóíèçì.
×òî-òî ïîäîáíîå äàâíî ïðèìåíÿåòñÿ ïðè àìïóòàöèè ïàëüöåâ íà ðóêå, íàïð.: J Plast Reconstr Aesthet Surg. 2007;60(7):720-3. Microvascular free on-top plasty in multidigital amputations. Cavadas PC. Reconstructive Microsurgery, Clínica Cavadas, Po Facultades 4, 46021 Valencia, Spain. Bidigital amputations proximal to the PIP joints severely impair function and cosmesis of the hand. The author presents a clinical series of five patients in which a three-fingered hand was reconstructed through microvascular transfer of one of the stumps on top of the other. Five male patients with amputation of two fingers proximal to the PIP joint were treated surgically. One of the stumps was transferred as a local free composite flap on top of the other stump. All five transfers were successful. The mean operative time was 2 h 15 min. The subjective improvement on hand function and cosmesis, as evaluated by the patients, was positive. Free microvascular on-top plasty is a straightforward and reliable procedure for improving cosmesis and function in hands with two fingers amputated proximal to the PIP joint, without additional donor morbidity outside the already injured hand. È â öèâèëèçîâàííûõ ñòðàíàõ ïðîñòî ïðîâîäÿò òðàíñïëàíòàöèþ ïîòåðÿííîé êîíå÷íîñòè ïðè íàëè÷èè ñîâìåñòèíîãî äîíîðà è äð. óñëîâèé, íàïð: Ann Surg. 2013 Feb;257(2):345-51. Upper-extremity transplantation using a cell-based protocol to minimize immunosuppression. Schneeberger S, è ñîàâò. Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. OBJECTIVE: To minimize maintenance immunosuppression in upper-extremity transplantation to favor the risk-benefit balance of this procedure. BACKGROUND: Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the risks and side effects of multidrug immunosuppression. We present our experience with upper-extremity transplantation under a novel, donor bone marrow (BM) cell-based treatment protocol ("Pittsburgh protocol"). METHODS: Between March 2009 and September 2010, 5 patients received a bilateral hand (n = 2), a bilateral hand/forearm (n = 1), or a unilateral (n = 2) hand transplant. Patients were treated with alemtuzumab and methylprednisolone for induction, followed by tacrolimus monotherapy. On day 14, patients received an infusion of donor BM cells isolated from 9 vertebral bodies. Comprehensive follow-up included functional evaluation, imaging, and immunomonitoring. RESULTS: All patients are maintained on tacrolimus monotherapy with trough levels ranging between 4 and 12 ng/mL. Skin rejections were infrequent and reversible. Patients demonstrated sustained improvements in motor function and sensory return correlating with time after transplantation and level of amputation. Side effects included transient increase in serum creatinine, hyperglycemia managed with oral hypoglycemics, minor wound infection, and hyperuricemia but no infections. Immunomonitoring revealed transient moderate levels of donor-specific antibodies, adequate immunocompetence, and no peripheral blood chimerism. Imaging demonstrated patent vessels with only mild luminal narrowing/occlusion in 1 case. Protocol skin biopsies showed absent or minimal perivascular cellular infiltrates. CONCLUSIONS: Our data suggest that this BM cell-based treatment protocol is safe, is well tolerated, and allows upper-extremity transplantation using low-dose tacrolimus monotherapy.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#4
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Âåðîÿòíåå âñåãî, áîëåå ïåðñïåêòèâíî áèîíè÷åñêîå ïðîòåçèðîâàíèå. Óæå ïðèìåíÿþòñÿ ïðîòåçû âåðõíèõ è íèæíèõ êîíå÷íîñòåé, èõ ôðàãìåíòîâ, êîòîðûå ïîçâîëÿþò çàâÿçûâàòü øíóðêè, çàíèìàòüñÿ ñêàëîëàçàíèåì, ïîäíèìàòüñÿ íà íåáîñêðåáû ïåøêîì, âûèãðûâàòü îëèìïèéñêèå èãðû è ò.ä. Îíè òàêæå ìîãóò èìåòü î÷åíü ýôôåêòíûé âíåøíèé âèä. Âîçìîæíî, ñêîðî íàñòàíåò âðåìÿ, êîãäà çäîðîâûå íà÷íóò çàâèäîâàòü èíâàëèäàì.
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Óâàæàåìûé Dr. Vad!
Ñïàñèáî çà ïðèâåä¸ííûé Âàìè ïðèìåð. Èç êîðîòêîãî àáñòðàêòà ïîíÿòíî, ÷òî ðå÷ü èä¸ò î ïÿòè ïàöèåíòàõ, ó êîòîðûõ áûëî àìïóòèðîâàíî äâà ïàëüöà. È èì ïåðåñàäèëè êóëüòþ ñ îäíîãî èç àìïóòèðîâàííûõ ïàëüöåâ, íàðàñòèâ êóëüòþ äðóãîãî ïàëüöà. Âñå îïåðàöèè ïðîøëè óñïåøíî. Ïî îöåíêàì ñàìèõ ïàöèåíòîâ ôóíêöèîíèðîâàíèå è âíåøíèé âèä ðóêè óëó÷øèëèñü. Èç êîðîòêîãî àáñòðàêòà íåÿñíî, áûë ëè âîññòàíîâëåí ñóñòàâ íà ìåñòå ñî÷ëåíåíèÿ ïåðåñàæåííîé êóëüòè è êîðíåâîé êóëüòè? Áûëè ëè ðåêîíñòðóèðîâàíû ìûøöû è ñóõîæèëèÿ è ïðèîáð¸ë ëè âîññòàíîâëåííûé ïàëåö åñòåñòâåííóþ ïîäâèæíîñòü? Óâàæàåìûé Dr. Vad! Âàø ïðèìåð ïîêàçûâàåò ñ ÷åãî íàäî íà÷èíàòü. Ñ óäëèíåíèÿ ôàëàíã ïàëüöåâ è ôîðìèðîâàíèÿ íåäîñòàþùèõ ôàëàíã. Åñëè ïîëó÷èòñÿ — ýòî ïðèäàñò óâåðåííîñòè äëÿ äàëüíåéøèõ äåéñòâèé. Íóæåí ìàëîðàçìåðíûé àïïàðàò Èëèçàðîâà. ß íå çíàþ, åñòü òàêîé èëè íåò. Íî äàæå åñëè íåò — åãî ìîæíî ñäåëàòü. Ñ óâàæåíèåì, Ðóñëàí Øàðèïîâ. |
#7
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Öèòàòà:
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#8
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Öèòàòà:
Çàìå÷àòåëüíî. Åñòü òîëüêî îäèí âîïðîñ. ÏÎ×ÅÌÓ? Ïî÷åìó âñå ýòî íå èäåò â øèðîêóþ ïðàêòèêó? Ïî÷åìó âîññòàíîâëåíèå àìïóòèðîâàííîé êîíå÷íîñòè íå âõîäèò â ïåðå÷åíü ìåäèöèíñêèõ óñëóã, ïóñòü äàæå î÷åíü äîðîãîñòîÿùèõ? Ñåé÷àñ ðàñïðîñòðàíèëîñü ìíåíèå, ÷òî íàäî ëèøü ÷óòîê ïîäîæäàòü. Âîò ïðèäóò 3D ïðèíòåðû, ñòâîëîâûå êëåòêè è ïðî÷èå ÍÀÍÎ-òåõíîëîãèè - è òîãäà âñå ñòàíåò ÷óäåñíî. Íî îíè ÷òî-òî íå ñïåøàò ïðèõîäèòü. Ìîæåò áûòü â ýòîé ñèòóàöèè âñå æå íå ñòîèò îòìàõèâàòüñÿ è îò áîëåå òðàäèöèîííûõ ïîäõîäîâ? Ìîæåò áûòü ñòîèò êàê-òî ñêîìáèíèðîâàòü òå ìåòîäû, ÷òî Âû ïåðå÷èñëèëè, äëÿ ðåøåíèÿ ïðîáëåìû âîññòàíîâëåíèÿ àìïóòèðîâàííîé êîíå÷íîñòè? Çàìåòüòå, ÿ íå ðåêîìåíäóþ. ß ëèøü ñïðàøèâàþ. Öèòàòà:
Ñ óâàæåíèåì, Ðóñëàí Øàðèïîâ. |
#9
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Öèòàòà:
Öèòàòà:
Öèòàòà:
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#10
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Öèòàòà:
À ìîæíî óçíàòü öèôðû. Íàñêîëüêî ìîæíî óäëèíèòü êîñòü? Åñòü ëè ïðåäåë? Íà ñàéòå [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ÿ íàøåë òàêîé òåêñò: Èíîãäà âîçìîæíî óäëèíèòü êîíå÷íîñòü îäíîìîìåíòíî è íà çíà÷èòåëüíî áîëüøóþ âåëè÷èíó (òåîðåòè÷åñêè ïðåäåë òàêîãî óäëèíåíèÿ íå óñòàíîâëåí; ñ÷èòàåòñÿ, ÷òî îí ëåæèò â ïðåäåëàõ 30-50%% îò äëèíû êîíå÷íîñòè ëèáî äî 100% îò äëèíû ñåãìåíòà êîíå÷íîñòè è çàâèñèò ëèøü îò ñïîñîáíîñòè íåðâíûõ ñòâîëîâ «âûäåðæàòü» òàêîå óäëèíåíèå). Ïîæàëóéñòà, ïðîêîììåíòèðóéòå ýòó èíôîðìàöèþ. |
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#13
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Äëÿ ïîëó÷åíèÿ ñïåöèôè÷åñêèõ îòâåòîâ ëó÷øå âñåãî ïîëüçîâàòüñÿ íå ôîðóìîì, à ïîèñêîì ïî ìåä. ñàéòàì, êîòîðûì ìîæíî âåðèòü, íàïð. çäåñü [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
íà ïðîñòîì àíãëèéñêîì óêàçûâàåòñÿ ñëåäóþùåå: BONE LENGTHENING This series of treatments involves several surgeries, a long recovery period, and a number of risks. However, it can add up to 6 inches of length to a leg. èëè äî 15 ñì ìîæíî óäëèííèòü ðåáåíêó íèæíþþ êîíå÷íîñòü, åñëè Âàñ èíòåðåñóþò äð. ìåñòà/êîñòè âîñïîëüçóéòåñü ïðèöåëüíûì ïîèñêîì...
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#14
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Öèòàòà:
Ïðåäïîëàãàþ, ÷òî óäëèíåíèå êîñòè íà âåëè÷èíó áîëüøå 10-15 ñì. íå ïðîèçâîäèëîñü ïðîñòî ïîòîìó, ÷òî íèêòî íå ïëàíèðîâàë âîññòàíàâëèâàòü êîíå÷íîñòü ÷åðåç òàêîå óäëèíåíèå. Öèòàòà:
ß çíàþ, ÷òî âíåäðåíèå íîâîãî ôàðì. ïðåïàðàòà òðåáóåò äëèòåëüíûõ èñïûòàíèé. À êàê îáñòîÿò äåëà ñ âíåäðåíèåì íîâûõ õèðóðãè÷åñêèõ ìåòîäèê è òåõíîëîãèé åñëè îíè à) íå òðåáóþò èñïîëüçîâàíèÿ íîâûõ ïðåïàðàòîâ, á) íå òðåáóþò èñïîëüçîâàíèÿ íîâûõ èíñòðóìåíòîâ, è ÿâëÿþòñÿ ëèøü íîâûì ñî÷åòàíèåì óæå èçâåñòíûõ ìåòîäèê è òåõíîëîãèé äëÿ äîñòèæåíèÿ öåëè, êîòîðàÿ ðàíåå ïðîñòî íå ñòàâèëàñü? Íàäî ëè çäåñü âûïîëíÿòü êàêèå-òî ôîðìàëüíîñòè? Åñëè äà, òî êàêîâû ýòè ôîðìàëüíîñòè? Ïðèåäïîëîæèì, ê âðà÷ó ïðèõîäèò ïàöèåíò è ãîâîðèò: "Äîêòîð, õî÷ó, ÷òîáû Âû âîññòàíîâèëè ìíå ðóêó (íîãó) ïî òàêîé âîò òåõíîëîãèè. Îñîçíàþ âñå ðèñêè è ïîäïèøó ëþáûå áóìàãè, âûðàæàþùèå ìî¸ ñîãëàñèå." Êàê äîëæåí ïîñòóïàòü âðà÷ â ïîäîáíîé ñèòóàöèè? Èìåþòñÿ ëè êàêèå-òî íîðìàòèâû (èíñòðóêöèè), ðåãëàìåíòèðóþùèå äàííóþ ñèòóàöèþ? Âîçìîæíî ýòè íîðìàòèâû (èíñòðóêöèè) ðàçëè÷íû â ðàçíûõ ñòðàíàõ. Êàêîâû îíè â ÑØÀ, â ÷àñòíîñòè â øòàòå Òåõàñ? Êàêîâû îíè íà Óêðàèíå? Êàêîâû îíè â Ðîññèè? |
#15
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Òîò ñòèëü, â êîòîðîì Âû çàäàåòå ñâîè âîïðîñû èëè îïèñûâàåòå ñèòóàöèþ, ãîâîðèò, ÷òî Âû ñòðàøíî äàëåêè îò ïîíÿòèé/ðåàëèé ñîâðåìåííîé ìåäèöèíû.
Ïåðåôðàçèðóþ Âàñ: "Ïðåäïîëîæèì, ê ñïåöèàëèñòó ïðèõîäèò êëèåíò è ãîâîðèò: "Ñïåö, õî÷ó, ÷òîáû Âû ñäåëàëè ìíå äîì (àâòîìîáèëü, êîñìè÷åñêèé êîðàáëü) ïî òàêîé âîò òåõíîëîãèè. Îñîçíàþ âñå ðèñêè è ïîäïèøó ëþáûå áóìàãè, âûðàæàþùèå ìî¸ ñîãëàñèå." Êàê äîëæåí ïîñòóïàòü ñïåö â ïîäîáíîé ñèòóàöèè? Èìåþòñÿ ëè êàêèå-òî íîðìàòèâû (èíñòðóêöèè), ðåãëàìåíòèðóþùèå äàííóþ ñèòóàöèþ?" ÷òî ïðîïóùåíî - ïðàâèëüíî: ôèíàíñîâàÿ ñòîðîíà âîïðîñà - åñòü â íàëè÷èå ñîòêà-äðóãàÿ òûñÿ÷ - îäíî ðåøåíèå, ïàðà-òðîéêà ìèëëèîíîâ - äðóãîå ðåøåíèå, à äåñÿòêè-ñîòíè ìèëëèîíîâ - òðåòüå. ïîïóòíî ìîæåòå îçíàêîìèòüñÿ ñ ðåçóëüòàòàìè íîâîé òåõíîëîãèè, êîòîðàÿ ïîëó÷èëà îäîáðåíèå ÔÄÀ: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Åñëè Âû äåéñòâèòåëüíî ïðîôåññèîíàëüíî çàèíòåðåñîâàíû â ðåøåíèè äàííîãî âîïðîñà - íàéäèòå ïðîôèëüíîãî ìåäèöèíñêîãî ýêñïåðòà è îïëàòèòå óñëóãè çà ýêñïåðòíîå çàêëþ÷åíèå, ëèêâèäèðóþùåå ïðîáåëû Âàøèõ ìåäèöèíñêèõ çíàíèé â äàííîé îáëàñòè. À òî òåìà ïîõîæà íà "êàê ñîáðàòü ìåðñåäåñ â ñàðàå ó äåäóøêè, èñïîëüçóÿ çàï÷àñòè îò ñòàðîãî çàïîðîæöà".
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |