Chapter 624: Fairy plucking hair
Although patients with metal allergies are rare, Yang Ping has encountered two at Sanbo Hospital.
When he first came to Sanbo Hospital, Yang Ping encountered a case. The patient was a fourteen-year-old boy. He underwent surgery for an old fracture of the left carpal navicular bone and implanted two metal countersunk screws. Multiple manifestations of synovitis occur.
Later, he was diagnosed with "metal ion reactive arthritis". After the two screws were removed, the symptoms of synovitis in each joint gradually eased.
The two screws of this little boy have no friction between metal and metal or metal and other materials. In fact, the ions released are very few, but the allergic reaction has nothing to do with the dose. Even a little bit can trigger an allergic reaction.
For example, if you are allergic to penicillin, some sensitive patients will suffer from anaphylactic shock even if they smell the smell of penicillin.
Now Mr. Wu is allergic to so many metals. This case can be written and published in an article.
Zhang Lin and Xiao Wu heard that the patient who had been transferred was a metal allergy patient. They hurriedly checked the medical records in advance. They found out that the patient had been allergic to metals for so many years. They felt like they had found a treasure.
Song Zimo and Xu Zhiliang are probably not interested in this kind of case report. They want to follow the professor to do big things. Zhang Lin and Xiao Wu can use this case to write an article as the first author and choose a better magazine to publish it.
Usually Corey published articles with their names trailing off, so the two worked hard to make some noise. The monographs on Lagouxue alone were not enough to determine their academic status, so the two came up with the idea of these case reports.
In short, I have to pick up some things that Song Zimo and Xu Zhiliang are not interested in and write articles.
After dinner, Yang Ping and Xiao Su went to play tennis.
Song Zimo, Xu Zhiliang, August and Robert all ran to the hospital library to read books and research information.
The library of Sanbo Hospital is very good. There is basically no shortage of medical monographs and periodicals. The library is open from 8 a.m. to 10 p.m. with no breaks in between. It is also open on Saturdays and Sundays, so it is very convenient to read books and check information.
The four of them met Director Gao in the library. Director Gao was engrossed in reading and taking notes from time to time.
Anyway, Song Zimo often bumped into Director Gao when he came to the library. Since he was immersed in reading, he didn't say hello.
In the past, Song Zimo hated Director Gao. He felt that it was too much for him to be thick-skinned and pretend to study diligently and show courtesy to Yang Ping. Later, he felt that this person was really not just pretending, but was really dedicated to studying.
The four of them stayed together until the library closed. Song Zimo consulted a large amount of information to learn how patients with metal allergies deal with severe knee arthritis.
However, there are very few papers in this area. Perhaps when encountering patients with severe metal ions, most doctors give up joint replacement.
———
Mr. Wu's MRI examination was scheduled for the afternoon of the next day.
Yang Ping took the time to personally participate in the magnetic resonance examination. He specializes in understanding the magnetic resonance of articular cartilage and the magnetic resonance of ordinary joints. There is a big difference in parameter setting and technical application during the examination. Some special technologies need to be used to observe and evaluate the cartilage. Quantitative evaluation is also needed.
Personalized treatment for each patient must rely on familiarity with the patient's condition, a comprehensive and in-depth grasp of relevant medical knowledge, and rich experience in the treatment of this type of disease, all three of which are indispensable.
Lao Du in the Radiology Department, named Du Haibin, is an attending doctor in his thirties. Because he is a bit fat, especially with an obvious beer belly, and looks rather mature, and has the demeanor of a director, everyone affectionately calls him Lao Du.
Lao Du heard that Yang Ping was coming to the magnetic resonance room and came to work during his shift today. He had long wanted to have a relationship with Yang Ping.
Yang Ping's reputation in the hospital is known to everyone, and there are many legends about him.
I heard that Director Gao is a non-staff trainee in general surgery and Yang Ping's disciple. He has learned some real things and now makes the sports medicine center prosperous, almost as good as the sports medicine center attached to the first hospital.
Duan Guangtou from the Department of Hai Fu Knife got a little bit of information from Yang Ping. This three-way stock god who lost money every year suddenly transformed into an expert on uterine fibroids, and his reputation became more and more famous. I heard that the flying knife in the city is lower than three Qian Buqian, all the hospitals that have Haifu knife are begging to hire Duan Guangtou. Haifu knife company also attaches great importance to Duan Guangtou and promotes Duan Guangtou as a gold medal surgeon. Hai helps him make appointments everywhere.
Xu Zhiba, an emergency department doctor, has not only improved his professional skills by leaps and bounds since he entered the general surgery department, he also started to perform scoliosis surgery himself, and he also found a beautiful civil servant girlfriend.
Lao Du felt itchy and was waiting in the MRI room very early.
Lao Du went out to take a look from time to time and asked the nurse: "The patients from the general surgery department haven't arrived yet?"
"We're here!" The nurse was also very busy, pointing to the old man in a wheelchair who was surrounded by his family members in the hall.
Not far away, Professor Yang and his group were walking this way.
Lao Du quickly stepped forward to greet him, and stretched out his hand from afar: "Welcome."
"Lao Du, are you in the magnetic resonance room today?" Song Zimo asked.
"I have a day off today. I didn't hear that Professor Yang came to the MRI room in person. I came here specifically to see if I could help." Lao Du did have a day off today, but there were not many opportunities like this, so he came here to take a break.
If you can learn a little bit from Yang Ping like Duan Guangtou did, you might be able to be invited to read films.
In fact, medicine involves a wide range of things. If you study in depth any small field, you can produce experts.
There is a radiologist who specializes in studying CT images of pulmonary nodules. He has seen more than 100,000 CT images of various pulmonary nodules and published hundreds of articles. Patients with pulmonary nodules from all over the country are looking for them. When he reads the film, others can tell accurately that some patients are suspected to have lung cancer and require surgery. The expert takes a few glances and concludes that this does not require surgery, so it is definitely not lung cancer.
While walking and chatting, we came to the doctor's operating room in the magnetic resonance room.
As the host, Lao Du arranged for everyone to sit down, then went out to say hello to the nurse, and asked the patients from the general surgery department to arrange for a check-up. It seemed that he was usually popular, and the nurse was relatively cooperative, so he secretly adjusted the order.
The patient has completed the contraindication screening and signed before the examination. The nurse once again checked whether there were any metal parts on the body. After confirming that they were correct, the nurse asked two interns to help the patient into the examination room. The wheelchair was left outside.
Because the wheelchair has metal parts, sometimes I forget to push it out of the examination room. When the machine is turned on, the wheelchair will be attracted by the magnetic field and fly up.
When the patient enters the examination room, Dr. Ao and Dr. Luo immediately enter the examination room from the operating room and move the patient onto the machine together.
Magnetic resonance does not contain ionizing radiation, but it is afraid of magnetic metals. Therefore, during magnetic resonance examination, not only should there be no magnetic metal in the body, but all magnetic metal parts on the body should also be removed to prevent being moved by the huge magnetic field during the examination and causing danger.
Song Zimo made a gesture, and Dr. Ao and Dr. Luo came out. The door of the examination room was closed. Lao Du turned on the machine remotely through the glass window. The machine slowly pushed the patient into the scanning black hole.
"Professor Yang?"
Lao Du smiled and chatted a few words when he had time to get closer.
But Yang Ping was so absorbed in waiting for the scanned pictures that he didn't hear what Lao Du said.
Lao Du couldn't help but feel a little embarrassed, so he had to say to Song Zimo: "Mr. Song, if you have any special patients in the future, you have to come down in person and tell me, I will be on call."
These are not polite words, Lao Du is really ready to be at your call. Lao Du analyzed Duan Guangtou's counterattack story and learned a lot from it.
The Philips 3.0 light speed magnetic resonance examination is extremely fast. The examination of different parts of the body is several to twenty times faster than the ordinary magnetic resonance scan.
Slowly the scan was completed and the patient was moved out. Lao Du shut down the machine and opened the examination room door. Dr. Ao and Dr. Luo consciously rushed in to move the patient.
Even foreigners work so hard, so what reason do I, Du Haibin, have to make salted fish? Lao Du immediately followed to help carry the patient.
Yang Ping carefully read the magnetic resonance images. His initial judgment was the same. The lateral condyle cartilage of both knees was fine, but the medial condyle was bare. The anterior and posterior cruciate ligaments were fine. The lateral meniscus was fine, but the medial meniscus was torn due to degenerative degeneration. A few millimeters of the periphery can be preserved, and the symptoms of synovitis are also very mild.
The distal tibia and talus cartilage of both ankle joints are worn, but the cartilage quality in a large surrounding area is good.
The outline of the clever Song Zimo's mind was looming. He had been thinking about this patient's plan. He was even thinking about it in his dream yesterday, and his head felt hot in the morning.
Yang Ping paid so much attention to the cartilage of the patient's knees and ankles that he personally went down to do a new MRI and used some new methods to quantitatively evaluate the cartilage.
In addition, he also pays great attention to the patient's lower limb alignment.
If artificial joint replacement is performed, it is a routine preparation to pay attention to the alignment of the lower limbs before surgery, but it is obviously redundant to pay so much attention to articular cartilage. For artificial knee replacement, all articular cartilage must be amputated, so paying attention before surgery is meaningless.
"Do you want to perform an osteotomy on the lateral fibula? Use Academician Zhang Yingze's uneven settlement theory to perform an osteotomy on the fibula? Let the tibial platform settle evenly and move the inner force outward bit by bit?" Song Zimo finally realized what Yang Ping His intention was to have knee-preserving surgery.
Academician Zhang Yingze's theory believes that uneven or differential settlement of human bones caused by osteoporosis in the elderly plays an important role in the occurrence and development of degenerative knee joint disease.
The tibial plateau is the main component of the knee joint. The differential settlement of the medial and lateral tibial platforms often causes the medial side to settle too quickly and the force to increase. The medial cartilage is compressed beyond its load-bearing limit and becomes thinner and degenerated under pressure. If the Pressure aggravates the grinding and degeneration of articular cartilage, leading to knee osteoarthritis.
Just like a car, if the load on the inside is always higher than on the outside, the tires on the inside will naturally wear faster.
Differential settlement, also called uneven settlement, is a mechanical phenomenon that occurs when objects are affected by gravity and is ubiquitous in nature.
For example, if the foundation collapses and the house collapses on one side, this is uneven settlement.
Human bones will also subside unevenly due to the influence of gravity. When osteoporosis occurs in human bones, microfractures may occur in the loose parts under the pressure of body weight. When these microfractures accumulate over time, they will cause the bones to collapse and sink. , joint deformation and other diseases.
This phenomenon is most significant and typical in the spine and proximal tibia, the bones that receive the most concentrated stress.
The inner side of the tibial platform bears two-thirds of the body's weight, and the outer platform bears one-third of the weight. The outer platform is supported by the fibula, which rarely causes osteoporosis.
It is equivalent to having pillars for support on the outside of the knee joint, but no pillars for support on the inside.
Therefore, when the medial platform is osteoporotic and unevenly subsides, the height drops and is lower than the lateral platform, the pressure distribution becomes uneven, and the medial cartilage wears faster, causing osteoarthritis.
After Song Zimo said this, Xu Zhiliang was instantly enlightened.
Yang Ping nodded slightly: "Although this patient has terminal osteoarthritis, judging from the medical history, physical examination and magnetic resonance imaging, the symptoms of synovitis are not severe, and the pain symptoms are concentrated in the medial compartment. If this situation is accurately grasped, , unicondylar replacement can be performed.”
Unicondylar replacement does not require replacing the entire knee joint, but only a part, usually the medial side.
"But unicondylar replacement cannot escape the metal component, so we can only save the knee. If we want to save the knee, we can only use Academician Zhang's theory."
He is indeed a smart guy. Thinking of this is nothing, but thinking of this in this case shows that Song Zimo has a very profound and extensive understanding of knee joints.
"But all the medial condylar cartilage is missing. Even if the fibula is osteotomized, the varus deformity is corrected, and the stress point is moved inward, it still doesn't work. The new stress point still has no cartilage?" Xu Zhiliang asked a new question.
This is why no doctor wants to save the knee. This case does not fit Academician Zhang’s theory.
"After fibula osteotomy, autologous cartilage transplantation is performed?" Song Zimo asked tentatively.
"Re-doing magnetic resonance is to determine the distribution of cartilage wear? Because after fibular osteotomy, both sides of the tibial platform settle evenly and the stress shifts outward. This requires determining whether the lateral condyle cartilage can withstand this change. It also needs to be done on the medial condyle.
Find new stress points for cartilage grafting? ”
Song Zimo took advantage of the victory to pursue.
"Also, he already has osteoarthritis in both ankle joints and has suffered from chronic pain for many years, which cannot be cured. Do you want to transplant the cartilage from the ankle joint to the knee joint and then fuse the ankle joint?"
Song Zimo finally figured out the entire plan. Everyone knew every theory and every operation, but if it had to be combined flexibly, no one could have thought of applying it to this case.
This requires a thorough integration of all knowledge, and each step must be calculated accurately, otherwise it will be counterproductive.
Song Zimo couldn't help but sigh. He regarded every case as a research object and made it a classic. Even for this case that others had given up on, he racked his brains and used all existing technologies to complete the operation.
Academician Zhang's knee-preserving surgery combined with autologous cartilage transplantation, if the ankle joint can be fused and the force on the foot can be adjusted to adjust the alignment of the lower limbs, then the problems of the four joints can be solved at once.
Song Zimo had a refreshing feeling. He had not figured it out all night last night and always felt that something was wrong. Today he had it all figured out.
Xu Zhiliang was still thinking about Song Zimo's words.
"Prepare for surgery the day after tomorrow, and talk to his family tomorrow." Yang Ping finalized the surgery plan.
After careful evaluation, this plan is feasible and has a high degree of certainty.
"Professor Yang, can you teach me the magnetic resonance technology you just used to quantitatively evaluate articular cartilage? If it were like your general surgery department, we would all have to be laid off. I don't understand why you are so familiar with magnetic resonance?" Lao Du He said with his chubby belly.
Yang Ping said modestly: "We are amateurs. We are not as professional as you. We just read a few books and papers. Come here and let's study together."
Fairy plucking hair!
Lao Du leaned over and almost rolled off his chair.
There are many friends who have rewarded me during this period. When I have time, I will post a chapter list to thank you.
(End of chapter)