godfather of surgery

Chapter 955 Don’t ask me for medical expenses

The reason for the disappearance of the femur has now become clear. What is left for everyone is to learn this knowledge through discussion. Through this case, everyone has a preliminary understanding of idiopathic osteolysis. When encountering such cases again in the future, at least they have a basic concept in mind.

However, sometimes it is rare to encounter such a case in a lifetime of practicing medicine. Most of them are recognized when reading literature. This urges everyone to study more and read more papers. This is the only way for doctors to break through the limitations of experience.

Song Zimo used an imaging tool on a tablet to measure the distance of the femoral defect. Since the effect of Ilizarov's technology in treating this disease is uncertain, there is only one way with a certain effect - customized prosthesis implantation and replacement with customized metal. Defective femur.

There are conditions for metal femur to replace the original defective femur. The remaining distal and proximal femur must be able to provide good fixation for the prosthesis. This fixation is not only temporary mechanical fixation, but also provides reliable biological fixation in the long term.

This requires a certain length remaining at the distal and proximal ends. Song Zimo measured the remaining length of the distal and proximal ends of the femur and found that it could barely meet the requirements, so the method of implanting a femoral prosthesis was feasible.

Another method - using the Ilizarov technique, is theoretically feasible and should be the best, but it requires a longer treatment time. The most troublesome thing is that the patient's family currently has a dispute with the Municipal People's Hospital. In this case, no doctor would dare to use a new method, even if the method may be very effective.

At this time, the doctor will definitely use conservative treatment methods so as not to trap himself. The implementation of new methods must require the active cooperation of the patient.

"With the femoral prosthesis, can the muscle attachment be solved? If the muscles are not attached, will it still affect the movement of the lower limb on this side? There is only a bracket but no power?"

Li Guodong's thinking is still very active and he can see the problem.

Song Zimo's eyes stayed on the tablet in his hand: "I have just measured that there are enough muscle attachment points on the remaining femurs near and far. As for the muscle attachment points of the femoral shaft, the current biotype customized femoral prosthesis can provide attachment. But it takes some time to form an attachment.”

One trainee was worried about another question: "Currently, the patient has severe muscle atrophy, and the difference in thickness between the thighs on both sides is very obvious. The thigh on the affected side is as thin as an arm. Can it be restored in the future?"

This graduate student was in the same group as Zhao Wenbo. Zhao Wenbo immediately explained: "Muscles are plastic and follow the law of use or disuse. He has not walked normally for a year and will definitely suffer from muscle atrophy. As long as there is no muscle fibrosis, he can recover." With good and standardized rehabilitation training in the future, muscle volume and strength can be restored.”

"Yes, judging from the time, there is no fibrosis in the thigh muscles at present, and they can recover in the future. Don't forget, the fact that fitness athletes can train their muscles to be so strong is the best proof of muscle plasticity." Li Guodong took over the conversation.

The current topic does not involve traditional Chinese medicine. Li Guodong and Zhao Wenbo get along well with each other and can discuss it calmly. It must involve traditional Chinese medicine. The two of them are at odds with each other and will not give up until there is a winner.

“Is fibrosis irreversible?”

someone asked.

"Irreversible, pathologically, muscle tissue is replaced by fibrous connective tissue."

Lao Jin replied.

A graduate student realized something: "I can't understand it this way. Some patients with high-level peripheral nerve injuries often have poor functional recovery after nerve anastomosis, while some patients with low-level nerve injuries recover better after surgery. The reason is not that the high-level nerve injuries The distance from the control target is too slow, and the growth rate of less than one millimeter per day is too slow. By the time the nerves grow to their destination, the muscles have already become fibrotic and there is no way to recover? "

"You are talking about motor nerves. Could it be that the terminal target organs of sensory nerves, such as sensory corpuscles, also suffer from fibrosis?" said another graduate student.

Song Zimo immediately solved their confusion: "Yes, the terminal structures innervated by sensory nerves will also degenerate and irreversibly degenerate after long-term denervation, but compared with muscle fibrosis, it is obviously much slower. This is The reason why sensory nerves generally recover better than motor nerves after nerve damage at the same location. In addition to the degeneration of the terminal structure, there is another reason that affects the recovery of nerves, and that is the mismatch and loss during the growth process, the farther away from the terminal. , the greater the loss.”

''I understand. In fact, I have been thinking about this issue, but it has been very vague, and now I really understand it. "The graduate student who just asked the question was relieved.

Through this free discussion, everyone also understood the treatment method of this disease: first, we must treat bone resorption, use anti-osteoporosis drugs to inhibit bone resorption and improve bone density, and then use surgical methods to implant femoral prostheses. , restore the normal function of the femur.

"Do you have any ideas about idiopathic osteolysis? Dr. Song! This weekend's rare disease literacy program will start with idiopathic osteolysis."

Yang Ping felt that the discussion was almost complete and he could move on to the next topic.

"Okay, we will add lecture content on idiopathic osteolysis this weekend. No one has any objections. Let's discuss the solitary kidney just mentioned." Song Zimo asked the graduate student operating the projector to switch images.

Solitary kidney is clinically an anatomical variation. The so-called anatomical variation means that the anatomy of a certain part of the body of some people is different from that of normal people, but it does not affect the function. Another concept is anatomical malformation, which also means that the anatomy of a certain part of the body is different from that of normal people. It's different, it has affected normal functions.

A solitary kidney, as long as the only kidney is healthy, even if there is only one kidney, it can still complete the work of the two kidneys. That is, a person only needs one healthy kidney to live a healthy life.

This is the medical basis for living donor allogeneic kidney transplantation. A healthy person can cut off one kidney and give it to someone else, and rely on the remaining kidney to maintain a healthy existence.

Although having only one kidney does not affect a person's health and survival, it still has shortcomings. Without a "backup", once there is a problem with the only kidney, there will be no other kidney to replace it.

Now the CT picture of the patient's urinary system appeared on the screen. Yang Ping stood up and walked closer:

"You see, there is a clear difference between solitary kidney and nephrectomy. The basis of any imaging is anatomy. The biggest difference between them is that solitary kidney is a single kidney by nature. The side without kidney does not have a kidney, and naturally there are no blood vessels and peripheral nerves to match it. However, nephrectomy, no matter which surgical procedure is used at the time, will definitely leave behind the remnants of the original set of blood vessels and nerves. Look, on this side without kidney, can you see the remaining part of the renal artery and vein that match it?"

Yang Ping likes to see the essence through phenomena, so when he speaks, he tries to grasp the most fundamental things. To be able to grasp the most essential things, he must have studied the object thoroughly.

Everyone immediately looked at the tablets in their hands. Because they all had proficient knowledge of anatomy and were extremely proficient in image reading, it didn't look troublesome. Indeed, there were no remnants of renal arteries and veins on this side, and there were no natural blood vessels or severed ones. The blood vessel remnants are still very different, they are completely different. "Zhang Lin, please talk to the Department of Urology and ask them to help retrieve some images after nephrectomy, including those within one week after nephrectomy, three months, six months, one year, and three years after nephrectomy. The pictures are representative. Let’s take a look at the images of nephrectomy. It would be better if we could retrieve some images of solitary kidneys, so that they would be more comparable.” Yang Ping asked Zhang Lin to do this. thing.

The principle of science is to seek truth from facts, and medical records are the best basis for explanation.

The HIS system in the hospital is connected to the Internet, so Zhang Lin made a phone call on the spot. Teacher Zhang from the Institute of Surgery still had the authority. A graduate student on duty in the Department of Urology immediately retrieved some images and sent them to Zhang Lin.

After everyone carefully read these pictures, it turns out that there is an essential difference between them. The solitary kidney does not have supporting blood vessels and nerves, while the remnants of the original blood vessels and nerves are still left after one kidney is removed. This difference is like the difference between men and women. Even if a man undergoes sex reassignment surgery, his chromosomes will still be XY. This is the most essential thing and cannot be changed.

What a true message! The doctors present immediately remembered what Yang Ping just said.

"The Municipal People's Hospital is now talking to the patient's family. The hospital requires a medical appraisal. It says whether it is a single kidney or a postoperative bone defect has anything to do with the hospital's surgery. It will be discussed after a medical appraisal. However, the family refuses to go through the medical appraisal process. , refused to take legal channels," Song Zimo introduced.

"They knew well and knew that this matter had nothing to do with the hospital, so they pretended to be confused. Once they enter the identification process, not everything will be exposed. Similarly, once they enter the legal process, everything will be revealed. How can he still hold on to this matter? Ask the hospital for money."

Zhang Lin said angrily.

"Don't think so bad of everyone! In the beginning, human nature is good!" Xiao Wu was like a philosopher.

Zhang Lin immediately said: "Human nature is all evil. It's not that I think it's bad, it's really bad."

Yang Ping was not interested in these digressions: "We only study the condition. Things other than the condition are the business of the Municipal People's Hospital. I am only responsible for thoroughly studying the condition and then trying to cure it. As for other things, it is not our job. This is a case discussion, and we only talk about the condition! However, during the diagnosis and treatment process, everyone must strictly follow the process. No step can be skipped. It doesn’t matter if you go slower, but you can’t skip steps. The doctor in charge will make an appointment with the patient’s family, and I will talk to him about the patient face to face. For certain conditions, follow-up treatment will cost more and take longer, and there is a certain risk of failure, so this must be explained clearly beforehand.”

Although this kind of case is a rare disease, it is not the most difficult to treat. The biggest problem is sociology. Yang Ping classifies this type of patients as sociological high-risk patients, because this type of patient is likely to be treated by doctors. Unreasonable entanglement after huge efforts.

After the case discussion, Yang Ping met the patient and his family members in the interview room. The patient was a twelve-year-old boy, and the family member was the boy's father. As soon as he saw Yang Ping's face, the boy's father began to complain endlessly about the conditions of the Municipal People's Hospital. All kinds of bad things, calling those doctors quacks and black doctors.

"The management of this hospital is chaotic. I heard that the previous director was arrested. The child's kidney must have been stolen by them. I am not done with them."

When he said this, the boy's father was vicious and gritted his teeth.

"Let's not talk about these things for now. Let's talk about the child's condition." Yang Ping reminded the boy's father to get back to business.

"We need to know some information from you now. Has your child ever had a kidney CT or B-ultrasound before?" Yang Ping asked.

The child licked his dry lips and wanted to speak. The child's father immediately glared at him: "I've done it before! I remember clearly that there were two kidneys in the B-ultrasound before. It's unmistakable. One kidney disappeared after the operation. Look, even the bones here are missing."

"Where was the B-ultrasound done before? Do you still have the report?" Yang Ping asked.

"It was done a long time ago. The report has long since disappeared, but I remember that there are two kidneys." The boy's father was very sure.

"Do you know which hospital it was done in?" Yang Ping continued to ask.

"I don't remember! Who can remember this long ago? It's certain that he had two kidneys at that time." The boy's father insisted.

It stands to reason that the child's father cannot not remember such an important thing, because doing B-ultrasound cannot be random or frequent. This kind of experience must be very clear. Now that the child's father says he does not remember, Yang Ping is suspicious. This father is lying.

In fact, judging from the imaging pictures, it has been confirmed that it is a solitary kidney. However, the father insists that he had two kidneys before and lost one kidney after the operation. If the previous test results can be found, this matter will be much easier to handle.

"Let's not talk about this matter for now. Regarding the issue of the child's right femur missing, now we plan to do a puncture to get some bone for examination. Only after the examination can we finally determine what the disease is." Regarding the solitary kidney, Yang Ping just wanted to find out. That’s all.

"What is the purpose of this examination?" the boy's father asked cautiously.

"Help find the cause of the child's missing femur." Yang Ping explained.

"Weren't the bones stolen by doctors? Do we need to diagnose this? We are not here to diagnose, but to treat diseases. As long as you cure the child's disease, we know what caused it. No need to bother you." The boy's father was very impatient.

"Look, this is an X-ray taken just after the child's surgery. The femur is still fine, but there has been no follow-up examination. The X-ray taken a year later shows that most of the femoral shaft has disappeared. We suspect that the child has a strange disease. It's called idiopathic osteolysis, so we need to puncture and take bone tissue to confirm. Judging from the medical history and symptoms, it is likely to be this disease. "

"Well, it can be said that the femur has not been absorbed. It is impossible that the kidney has also been absorbed." The boy's father said while looking at the X-ray.

"Let's not talk about the kidneys for now, because you also said that it is not within the scope of diagnosis and treatment this time. We are only talking about the problem of missing femurs." Yang Ping stopped mentioning this matter for the time being.

Next, Yang Ping roughly talked about the follow-up diagnosis and treatment plan. The boy's father thought for a while and said: "How much will it cost? It's a lot! I tell you, don't ask me for medical expenses. You go to the Municipal People's Hospital to ask for money. I Not a penny will be paid.”