Beijing Jishuitan Hospital Research Articles

Observation on the effect of liquid paraffin as adjuvant therapy in treating residual wounds of patients with severe burns

Objective: To observe the effect of liquid paraffin as adjuvant therapy in treating residual wounds of patients with severe burns. Methods: From January 2016 to October 2017, 58 patients with residual wounds in the later stage of severe burns were admitted to Beijing Jishuitan Hospital. Those patients met the inclusion criteria of this study and were enrolled in this retrospective cohort study. All the patients received wound disinfection, petrolatum gauze dressing change and silver ion-bearing antimicrobial dressing every other day to treat the residual wound until wound healing. From January to November 2016, 29 patients who were treated with iodophor and normal saline to clean and disinfect the wound before dressing change were enrolled in normal saline group, including 22 males and 7 females, aged (38±12) years. From December 2016 to October 2017, 29 patients who were treated with iodophor and liquid paraffin to clean and disinfect the wound before dressing change were enrolled in liquid paraffin group, including 20 males and 9 females, aged (37±12) years. The effective rate of treatment, infection control rate, and bacterial positive ratio of wound on post first treatment day (PFTD) 7, 14, and 21 and the complete wound healing time of patients were compared between the two groups. Data were statistically analyzed with independent sample t test, Wilcoxon rank-sum test, chi-square test, and Pearson chi-square test, continuity correction chi-square test, and Fisher's exact probability test after Bonferroni correction. Results: (1) On PFTD 7, 14, and 21, the effective rates of wound treatment in patients of liquid paraffin group were 34% (10/29), 59%(17/29), and 79%(23/29), respectively, which were significantly higher than 10% (3/29), 24% (7/29), and 38% (11/29) of normal saline group (χ(2)=5.857, 7.108, 10.235, P<0.05 or P<0.01). (2) The wound infection control rates in patients of liquid paraffin group on PFTD 7 and 14 were 79% (23/29) and 90% (26/29), respectively, which were significantly higher than 31% (9/29) and 52% (15/29) of normal saline group (χ(2)=13.663, 8.321, P<0.01). The wound infection control rate in patients of liquid paraffin group on PFTD 21 was 100% (29/29), which was significantly higher than 69% (20/29) of normal saline group (P<0.01). (3) The bacterial positive ratios in the wounds of liquid paraffin group were similar to those of normal saline group on PFTD 7 and 14 (χ(2)=2.097, 2.583, P>0.05). On PFTD 21, the wound bacterial positive ratio of liquid paraffin group was 8% (3/39), which was significantly lower than 49% (17/35) of normal saline group (χ(2)=13.625, P<0.01). (4) The complete wound healing time of patients in liquid paraffin group was 15.0 (11.0, 20.0) d, which was significantly shorter than 22.0 (15.0, 27.5) d of normal saline group (Z=2.256, P<0.05). Conclusions: In the treatment of residual wounds of severe burn patients, liquid paraffin as adjuvant therapy can effectively improve the treatment effective rate and the infection control rate of wounds, decrease the bacterial positive ratio, and shorten the wound healing time.

Microstructural changes in postoperative cervical cords with cervical spondylotic myelopathy evaluated by neurite orientation dispersion and density imaging: a preliminary study

IntroductionNeurite orientation dispersion and density imaging (NODDI) is a new diffusion magnetic resonance imaging technique that can provide specific microstructural evaluation including nervous tissue density, free water fraction, and neurite orientation dispersion. In this study, we explored the microstructural changes in reduced area (RA) and T2 high signal intensity (T2-HSI) postoperative cervical cords with cervical spondylotic myelopathy (CSM) by NODDI.Material and methodsA prospective study. CSM patients with surgery planned were recruited in Beijing Jishuitan Hospital from September 2016 to March 2017 (excluding other cervical spondylosis and spinal diseases and postoperative stenosis) and underwent postoperative NODDI scans and modified Japanese Orthopaedic Association (mJOA) scoring. The patients were divided into RA and T2-HSI, normal area (NA) and T2-HSI, and NA and non-T2HSI groups. The differences in NODDI metrics and mJOA score between different groups were assessed respectively.ResultsNervous tissue density in cervical cords with postoperative constant RA was decreased (RA-T2HSI (0.510, 0.330–0.670) vs. NA-T2HSI (0.585, 0.380–0.870) (p = 0.019), RA-T2HSI vs. NA-nT2HSI (0.620, 0.460–0.770) (p = 0.003)), and a certain degree of free water increase and nervous tissue density decline was observed in postoperative cervical cords with T2-HSI, even if not all of the outcomes were very significant. Moreover, the postoperative mJOA score in combined RA and T2-HSI was lower than that in single T2-HSI.ConclusionsThe microstructural changes in postoperative RA and T2-HSI cervical cords could be evaluated by NODDI metrics and RA and T2-HSI were useful as brief evaluations for postoperative CSM cervical cords.

Clinical characteristics and prognosis of renal cell carcinoma patients with bone metastases

Objective: To determine the status of bone metastasis (BM) and prognosis factors of patients with renal cell carcinoma (RCC) in our center. Methods: The clinical and medical records of RCC patients with BM, who were admitted to the Department of Urology, Bone Oncology and Spine Surgery, Beijing Jishuitan Hospital from August 2009 to August 2017 were collected. The gender, age, time of BM, location of BM, numbers of BM, presence or absence of visceral metastasis, pathological types of BM were investigated. The patients were followed up regularly, and the survival curves were analyzed by Kaplan-Meier method. Cox proportional hazard regression model was used to estimate the prognostic factors. Results: A total of 51 RCC patients with bone metastasis were collected. The age of patients ranged from 38 to 76 (58.6±8.2) years old, including 39 males (76.5%) and 12 females (23.5%). The ratio of male to female was 3.25∶1. The patients were followed up for 8 to 109 months, with a median follow-up time of 30 months. The follow-up rate was 90.2%. Thirty-one (60.8%) patients died at the last follow-up, with a median overall survival (OS) time of 25 months. The median OS was 38 months and 20 months in the solitary BM group (26 cases, 51.0%) and BM ≥ 2 group (25 cases, 49.0%), respectively. The difference between the two groups was statistically significant (P=0.021). The median OS was 30 months, 69 months and 17 months in the axis BM group (22 cases, 43.1%), appendicular BM group (19 cases, 37.3%) and both the axis and appendicular BM group (10 cases, 19.6%), respectively. The difference between the groups was statistically significant (P=0.012). The median OS was 22 months and 38 months in the patients with (15 cases, 29.4%) and without (36 cases, 70.6%) visceral metastases groups, respectively. The difference between the two groups was statistically significant (P=0.007). Univariate and multivariate Cox regression analysis showed that the numbers of BM (HR=3.130, 95%CI: 1.502-6.520, P=0.035) and visceral metastasis (HR=4.699, 95%CI: 1.810-9.545, P=0.001) were independent prognostic factors for RCC with BM. Conclusions: Solitary BM, no visceral metastasis are good prognostic factors for RCC with BM. For these patients, radical resection of BM is feasible to improve survival rate.

Gender and Low Albumin and Oxygen Levels are Risk Factors for Perioperative Pneumonia in Geriatric Hip Fracture Patients.

IntroductionPneumonia is a serious complication following hip fracture and is the primary risk factor for 30-day mortality after surgery. Modifying several laboratory factors may improve the outcomes of fragile hip fracture patients who are 80 years or older.PurposeTo investigate several adjustable factors for perioperative pneumonia in order to improve patient prognosis and reduce mortality.Patients and MethodsWe retrospectively reviewed in-hospital hip fracture data from patients who were 80 years or over between January 1, 2014, and November 31, 2014, from Beijing Jishuitan Hospital. Patients were divided into two groups: perioperative pneumonia (POP) group and non-perioperative pneumonia (non-POP) group. Logistic regression models were used to identify independent risk factors. Statistical significance was set at 5% (p<0.05).ResultsThe incidence of perioperative pneumonia (POP) in patients 80 years and older was 11.3% (33/293). Male patients had a higher incidence of POP (20/96 cases, 20.83%) compared to females (13/197, 6.6%)(P<0.001). Higher neutrophilic granulocyte percentages (78.148%±9.162% in POP vs 81.959%±6.142% in Non-POP, P=0.033) and lower albumin levels (χ2=2.25, P=0.039) were observed in the POP group at baseline. After multivariate logistic regression, we observed that males (OR=3.402, P=0.048), lower albumin levels (OR=10.16, P=0.001) and PaO2 levels (OR=2.916, P=0.007) were independent risk factors for POP.ConclusionLow albumin and oxygen levels and the male gender were risk factors for perioperative pneumonia in geriatric hip fracture patients.

Exploration on the method of aesthetic repair of the donor sites of flaps

Objective: To explore the excellent methods for aesthetic repair of the donor sites of flaps. Methods: From January 2013 to March 2018, 120 patients (94 males and 26 females, aged from 3 to 60 years) were admitted to the Department of Burns of Beijing Jishuitan Hospital. Wounds areas after debridement or removing scar were ranged from 8.0 cm×3.5 cm to 24.0 cm×18.0 cm. Twenty patients with facial and neck scar were repaired with expanded flaps, including 4 scalp flaps, 8 supraclavicular flaps, 4 deltoid flaps, and 4 trapezius myocutaneous flaps. The flaps in ideal donor sites were selected to repair the wounds in 40 patients, including 20 cases of hand wounds or scars repaired with inguinal flaps, 10 children of foot skin defects or scars repaired with cross inguinal skin flap, 10 cases of knee joint wounds repaired with medial or lateral thigh flaps. The optimal flap design was used to repair wounds in 50 patients. Among the patients, wounds of 36 patients were repaired with relaying flaps, including donor sites of free anterolateral thigh flaps of 8 patients repaired with anteromedial thigh perforator flaps and donor sites of free anterolateral thigh flaps of 8 patients repaired with ilioinguinal flaps or superficial abdominal artery flaps, and donor sites of flaps of 20 patients repaired with peroneal perforator relaying flaps. Besides, wounds of 9 patients were repaired with free lobulated anterolateral thigh flaps, and wounds of 5 patients were repaired with modified V-Y propelling latissimus dorsi myocutaneous flaps. The donor sites of flaps were repaired with allogenic acellular dermal matrix combined with autologous split-thickness skin grafts in 10 cases. The areas of the flaps or myocutaneous flaps were ranged from 6.0 cm×4.0 cm to 30.0 cm×20.0 cm. The survival of flap, myocutaneous flap, or skin graft and the repair of donor site after operation and during follow-up were observed. Results: Blood flow obstacle at 0.5 cm to the distal margin of the flap occurred in 1 patient repaired with expanded flap, which were healed after dressing change. Blood supply disorder occurred at the tip of the anteromedial thigh perforator flap of 1 patient repaired by optimal flap design, which were healed completely after second debridement and restitching. The other flaps or myocutaneous flaps survived well. The allogenic acellular dermal matrix and the autologous split-thickness skin graft survived with good color and texture. During follow-up of 3 months to 4 years, the donor sites of flaps had good appearance, only with linear scar and the function recovered well. The donor sites of skin grafts had no scar hyperplasia, only with scattered pigmentation. Conclusions: According to the characteristics of donor sites of flaps, individualized and reasonable design before the operation such as pre-expanding of the flaps, selecting the ideal donor sites, optimization of the flap design or allogenic acellular dermal matrix combined with autologous split-thickness skin graft to repair donor sites of flaps can minimize the damage for function and appearance of donor sites of flaps and achieve aesthetic effects of donor sites of flaps.

Comparison of traditional vascular reconstruction with covered stent in the treatment of subclavian artery injury

PurposeTo explore the significance of traditional vascular reconstruction and covered stent for limb salvage after subclavian artery injury. MethodsPatients with subclavian artery injury admitted to Beijing Jishuitan Hospital from January 2010 to December 2018 were retrospectively analyzed. All the injuries have been confirmed by intraoperative exploration, computed tomography angiography or digital subtraction angiography. Complete or partial amputation injuries were excluded. Mild artery defect or partial intimal damage was treated by interventional implantation, while other patients received open surgeries, including direct suture of small defect less than 2 cm and transplantation with autologous vein or artificial blood when the defect was more than 2 cm. Patients were divided into open surgery group and stent implantation group based on the treatment they received. Patients were followed up at 2 weeks (first stage) and 6 months (second stage) after operation to investigate limb salvage. Student's t-test was used to compare the general data between two groups and Chi-square test to analyze the rate of limb salvage. ResultsAltogether 50 cases of subclavian artery injury were treated, including 36 cases of open surgery and 14 cases of stent implantation. Combination of nerve injury was observed in 27 cases (75.0%) in open surgery group and 12 cases (85.7%) in stent implantation group. Amputation developed in 3 cases with open surgery and 1 case with stent implantation. Consequently the rate of successful limb salvage was respectively 91.7% (33/36) and 92.9% (13/14), revealing no significant difference (p > 0.05). ConclusionRapid reconstruction of blood circulation is crucial following subclavian artery injury, no matter what kinds of treatment strategies have been adopted. Interventional stent implantation can achieve a good effect for limb salvage.

Analysis of bone mineral density and bone metabolism in elderly hip fracture patients of different genders

Objective To understand changes and characteristics of bone mineral density(BMD)and early-stage bone turnover biochemical markers in elderly hip fracture patients of different genders. Methods This was a retrospective cohort study.A total of 1 161 elderly patients with hip fractures hospitalized in Beijing Jishuitan Hospital from May 2015 to December 2017 were enrolled.Based on gender, patients were divided into the female group(n=831)and the male group(n=330). Clinical data, BMD, serum type I procollagen amino terminal propeptide(P1NP), and 25-hydroxyvitamin D3 [25-(OH)VD3], type I collagen cross-linked carboxy terminal peptide beta degradation products(β-CTX), osteocalcin(OC)and parathyroid hormone(PTH)were measured and compared between the two groups. Results Of the 1 161 elderly patients with hip fractures, 831 were female and 330 were male.The BMD of the lumbar vertebrae and the total hip in the female and male groups showed that 30.4%(353/1 161)and 6.8%(79/1 161)had T≥-1.0 SD respectively; 36.6%(425/1 161)and 44.7%(519/1 161)had -2.5 SD 0.05). The levels of tP1NP, β-CTX, OC and PTH in females were higher than those in males, and the level of 25-(OH)VD3 was lower than that in males(all P<0.05). As the T value decreased, β-CTX and OC increased and 25-(OH)VD3 decreased accordingly(all P<0.05). Conclusions With the increase of age, the BMD T value in elderly patients with hip fractures shows a downward trend, but its decline in women is faster and earlier.Overall, the BMD T value is not sensitive enough for osteoporosis diagnosis or hip fracture prediction in the elderly, especially in men.In the early stage of fractures, the bone turnover biochemical markers show varying degrees of change, and bone resorption and bone formation are both reduced.The significance of OC, β-CTX and VD levels in early bone metabolic abnormalities requires further study. Key words: Osteoporosis; Hip fractures; Bone density

Quantitative analysis of paraspinal muscle atrophy after oblique lateral interbody fusion alone vs. combined with percutaneous pedicle screw fixation in patients with spondylolisthesis

BackgroundThere is no available literature for comparison on muscle atrophy between the “stand-alone” oblique lateral interbody fusion (OLIF) and regular OLIF (i.e., combined with percutaneous pedicle screws fixation (PPSF) in patients with spondylolisthesis). This study aimed to identify changes in back muscle atrophy between the two surgeries.MethodsThis was a retrospective cohort study of patients who underwent OLIF or OLIF+PPSF at Beijing Jishuitan Hospital and Shanghai ChangZheng Hospital between 07/2014 and 10/2017. Computed tomography (CT) was used to measure functional cross-sectional area (FCSA) and fat infiltration percentage (FIP) of the multifidus and erector spinae before and 24 months after surgery.ResultThere were no differences in FCSA and FIP between OLIF (n = 32) and OLIF+PPSF (n = 41) groups before surgery. In the OLIF group, the multifidus and erector spinae FCSA and FIP did not change at 24 months (FCSA: multifidus: from 8.59 ± 1.76 to 9.39 ± 1.74 cm2, P = 0.072; erector spinae: from 13.32 ± 1.59 to 13.55 ± 1.31 cm2, P = 0.533) (FIP: multifidus: from 15.91 ± 5.30% to 14.38 ± 3.21%, P = 0.721; erector spinae: from 11.63 ± 3.05% to 11.22 ± 3.12%, P = 0.578). In the OLIF+PPSF group, the multifidus and erector spinae FCSA decreased (multifidus: from 7.72 ± 2.69 to 5.67 ± 1.71 cm2, P < 0.001; erector spinae: from 12.60 ± 2.04 to 10.15 ± 1.82 cm2, P < 0.001), while the FIP increased (multifidus: from 16.13 ± 7.01% to 49.38 ± 20.54%, P < 0.001; erector spinae: from 11.93 ± 3.22% to 22.60 ± 4.99%, P < 0.001). The differences of FCSA and FIP between the two groups at 24 months were significant (all P < 0.001). The patients in the standalone OLIF group had better VAS back pain, and JOA scores than the patients in the OLIF combined group (all P < 0.05) at 1 week and 3 months after surgery. There were two cases (4.9%) of adjacent segment degeneration in the OLIF combined group, while there was no case in the OLIF alone group.ConclusionsStandalone OLIF had better clinical outcomes at 1 week and 3 months than OLIF+PPSF in patients with spondylolisthesis. OLIF may not result in paraspinal muscle atrophy at 24 months after surgery.

Treatment strategy for traumatic innominate arterial injury

PurposeTo discuss and share the experience of treatment of traumatic innominate arterial injury. MethodsA retrospective analysis was performed on patients with innominate arterial injuries admitted from January 2016 to July 2018 at the department of vascular surgery, Beijing Jishuitan Hospital, China. All the arterial injuries were confirmed by arteriography. Clinical data including mechanism of injury, type of injury, demographics, concomitant injuries, time interval from trauma to blood flow reconstruction, and operation methods were collected. Follow-up program included outpatient visit and duplex-ultrasonography. SPSS version 23.0 was adopted for data analysis. Categorical variables are presented as number and/or frequency and continuous variables as mean ± standard deviation. ResultAltogether 7 patients were included and 6 (85.7%) were male. The mean age of patients was (29.43 ± 7.98) years, range 19-43 years. Six patients had isolated innominate arterial injuries and the rest 1 combined innominate arterial and vein injuries. The injury causes were road accidents in 3 patients, stab wound in 2, gunshot wound in 1, and crush injury in 1. All the 7 patients presented hemorrhagic shock at admission, which was timely and effectively corrected. No perioperative death or technical complications occurred. Intimal injury (n = 2) and partial transaction (n = 2) of the innominate artery were treated with covered stents. Two patients with complete transection of artery received vascular reconstruction by artificial grafts. One patient with partial transaction received balloon dilation and open surgical repair (hybrid operation). The mean time interval from trauma to blood flow reconstruction was (4.27 ± 0.18) h, range 4.0–4.5 h; while the operation time was (48.57 ± 19.94) min, range 25–75 min. Cerebral infarction occurred in one patient with brain injury due to anticoagulation contraindication. The average follow-up was (13.29 ± 5.65) months, range 6–24 months. No severe stenosis, occlusion, and thrombosis of covered stents or artificial vessels were found by color Doppler ultrasound. ConclusionUrgent control of hemorrhage and restoration of blood supply are critical for the treatment of traumatic innominate arterial injury. Endovascular therapy is a feasible and effective method with short operation time and less trauma.

Analysis of the relationship between complement and lipid metabolism and bone mineral density in elderly population

Objective To investigate the diagnostic value of serum complement level and lipid metabolism level detection in senile osteoporosis. Methods A total of 215 elderly people who underwent physical examination and bone mineral density test in Beijing Jishuitan Hospital from January 2016 to June 2016 were divided into osteoporotic group(74) and non-osteoporotic group (141) according to bone mineral density classification. The relationship between serum complement C3, complement C4, low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), triglyceride (TG), total cholesterol (CHO) and bone mineral density were analyzed. The data were analyzed by t-test, non-parametric test, binary Logistic regression and the receiver operating characteristic (ROC) curve. Results The age and CHO,LDL, HDL, complement C3 and C4 in the osteoporosis group[(80.6±8.2)years, (4.43±1.25)mmol/L, (2.27±0.73) mmol/L, (1.33±0.39) mmol/L, (1.12±0.22) g/L, (0.29±0.09)g/L], were significantly higher than those in the non-osteoporosis group[(77.5±8.3)years,(4.04±1.02)mmol/L,(1.97±0.59)mmol/L,(1.19±0.32)mmol/L,(0.86±0.25)g/L,(0.21±0.06)g/L,t-value were 2.571,-3.848,-4.483,-3.951,-1.249,-1.185,P<0.05], and the the BMI bone mineral density T-Score value of DXA and in the osteoporosis group were significantly lower than those in the non-osteoporosis group[(22.33±3.8)kg/m2, -2.74±0.78 and (25.03±4.2)kg/m2, 0.14±0.9, while the t value was 6.151 and 4.624, respectively, P<0.05]. The level of TG in osteoporotic group was significantly lower than that in non-osteoporotic group[the median (quartile) was 1.21(0.67,1.44)mmol/L and 1.37(0.86,1.67)mmol/L, respectively, Z=-2.51, P<0.01].Gender and serum levels of HDL, LDL, C3 and C4 were independent risk factors for senile osteoporosis(OR=2.476,P=0.004;OR=1.305,P=0.038;OR=1.564,P=0.028; OR=1.018, P=0.025; OR=1.023, P=0.015, respectively). The risk of osteoporosis in women was 2.476 times higher than that in men of the same age. The corresponding risk of osteoporosis increased by1.305,1.564, 1.018 and 1.023 times as HDL, LDL, C3 and C4 increased by one unit. The areas under the ROC curve detected separately by HDL, LDL, C3 and C4 were 0.623,0.595,0.673 and 0.731 respectively, and the area under the ROC curve of the four items was 0.864. Conclusions The levels of blood lipids and complements play a great role in bone metabolism. The combined detection of blood lipid metabolism and complement can improve the diagnostic efficacy of senile osteoporosis. Key words: Bone density; Complement C3; Complement C4; Lipoproteins; Triglycerides; Osteoporosis

Role of histological evaluation of periprosthetic tissue in diagnosis of periprosthetic joint infection

Objective: To evaluate the role of histologicalpathology in the diagnosis of periprosthetic joint infection. Methods: A total of 145 cases of joint arthroplasty during October 2017 and October 2018 from Beijing Jishuitan Hospital were collected. There were 23 cases of infection, including knee joint arthroplasty (12 cases) and hip arthroplasty (11 cases). There were 17 females and 6 males. Patients' age ranged from 39 to 76 years (mean 63 years). The infection was diagnosed if there were >5 neutrophils per high power field in at least 5 high power field. The permanent sections were examined twice separately by two pathologists, and the interval time of histologic examination was at least two weeks. Sensitivity (SE), specificity (SP), positive predictivevalue (PPV), and negative predictive value (NPV) were calculated. The consistency evaluation of histologic examination of two pathologists was calculated by Kappa analysis. Results: The neutrophil cells could locate scattered or focally in the synovium tissue of periprosthetic joint infection. Somewhere, the infiltration of vessel and the perivascular distribution could also exist. Opportunity coincidence rate between two pathologists was 91.3% (Kappa=0.817). The results showed that SE was 60.9%, SP was 100.0%, NPV was 93.1%, PPV was 100.0%. Conclusions: The presence of polymorphonuclear cells in histologic examination is correlated with infection. There was high consistency between histologic examination and clinical diagnosis of joint arthroplasty.

Magnetic resonance imaging of the elbow joint tendon: imaging technique and clinical application

Objective: To explore the magnetic resonance imaging (MRI) imaging technique and the clinical application in ligament and tendons of elbow. Methods: The study was reviewed and approved by an institutional review board of Beijing Jishuitan Hospital. A total of 20 normal volunteers with 40 elbows including 12 males and 8 females, aged from 20 to 55 years, with an average age of 35 years and 38 patients with 38 elbows who complained elbow pain with elbow injuries including 23 males and 15 females, ranged in age from 9 to 77 years, with an average age of 41 years old were chosen to undergo magnetic resonance examination between May 2013 and October 2018.All subjects underwent examination on coronal T(1)WI scan and PD-FS on three planes respectively in a prone position. Then the MRI characteristics of tendons in elbow of healthy volunteers and patients with elbow injuries were studied and the MRI features of tendon injury were compared with the surgical results and confirmed by double-blind method. Results: Twenty normal volunteers without tendons or ligament injures showed homogeneous low-signal-intensity on T(1)-weighted and proton fat saturation sequence (PD-FS) images.In the 38 patients with elbow injuries, there were 44 tendon injuries, including 14 cases of common extensor tendon injuries, 10 cases of common flexor tendon injuries, 3 cases of biceps tendon injuries, 7 cases of brachialis tendon injuries and 10 cases of triceps tendon injuries. The injuried tendons became thicker and discontinuity in T(1)WI and demonstrated heterogeneously increased signal intensity with effusion of tendon sheath in PD-FS. Partial tear showed discontinuity and thickening of tendons and the complete tear showed that the tendons were interrupted, retracted, the fiber structure disappeared and was filled with liquid, and the surrounding soft tissue edema was found. Conclusions: MRI can demonstrate the anatomy and injuries features of tendons in elbow joint accurately. It is significance for the early diagnosis and treatment protocols of the tendons injuries.

Enhanced Recovery After Surgery used in close reduction of distal radius fracture in emergency traumatic patients: a prospective cohort study

Objective To compare the therapeutic effects between the anesthetic and non-anesthetic closed reduction protocols for distal radius fractures based on the concept of Enhanced Recovery After Surgery (ERAS). Methods A prospective study was conducted in a cohort of 186 patients with distal radius fracture who had been admitted to the Department of Orthopaedic Trauma, Beijing Jishuitan Hospital from September 2018 to January 2019. The patients were divided into 2 groups depending on the choice by themselves. Of them, 72 (intervention group) underwent the standardized closed reduction under brachial block anesthesia based on the concept of ERAS while the other 114 (control group) conventional closed reduction under no anesthesia. The 2 groups were compared in terms of emergency reduction times, swelling scores, reoperation rate, splint removal time, functional outcomes by the Patient-Rated Wrist Evaluation (PRWE) and radiographic outcomes by the Lidstrom criteria. Results The patients in both groups were followed up for 6 months. The reduction times were fewer in the intervention group than in the control group (1.1±0.1 versus 1.6±0.1, P 0.05). Conclusion Compared with conventional closed reduction, the closed reduction under anesthesia based on the ERAS concept is an effective method for the emergency treatment of distal radius fracture, because it may minimize the patients’ pain experience, increase the rate of successful reduction, decrease the rate of reoperation, shorten the splint fixation time and gain better functional outcomes. Key words: Radius fractures; Anesthesia; Ultrasonography; Brachial plexus; Closed reduction

Morphological analysis of posterior malleolus fracture fragments under different injury mechanisms

Objective To explore the morphological characteristics and differences of posterior malleolus fracture fragments in ankle fracture combined with posterior malleolus fracture and spiral fracture of middle and lower third of tibial combined with posterior malleolus fracture, and to analyze the relationship between the posterior malleolus fracture fragments and the above two types of fracture injury. Methods A retrospective analysis was performed. One hundred patients with ankle fracture were admitted to Beijing Jishuitan Hospital from January 2011 to December 2011, including 59 males and 41 females, aged (42.0±14.1) years, with an age range of 17-73 years. Among them, 57 patients who were ankle fracture combined with posterior malleolus fracture were in Group A. Meanwhile, 90 patients with spiral fracture of middle and lower third of tibial were admitted to Beijing Jishuitan Hospital from January 2013 to December 2013, including 42 males and 48 females, aged (45.2±13.0) years, with an age range of 18-77 years. Among them, 35 patients who were spiral fracture of middle and lower third of tibial combined with posterior malleolus fracture were in group B. A total of 92 patients in the two groups were examined by CT before operation. The patient′s fracture classification was determined according to Haraguchi classification. On axial plane, the angle between posterior malleolus fracture line and medial and lateral malleolus axis was defined as Ⅰa in Haraguchi Ⅰ, angles between posterior malleolus fracture line and medial and lateral malleolus axis were defined as Ⅱa and Ⅱb in Haraguchi Ⅱ, and angle Ⅰc and Ⅱc were angles between posterior malleolus fracture line and tibial axis on sagittal CT. Measurement data were expressed as mean±standard deviation (Mean±SD). Mann-whitney and Chi-square test were used to compare the differences of different angles in type I and type Ⅱ, and whether there were statistical differences in different angles between the two groups. Results In the 92 cases, 75 were type Ⅰ, 12 were type Ⅱ and 5 were type Ⅲ. The angle of Ⅰa was (26.6±5.6)°, the angle of Ⅰc was (15.4±4.1)°, the angle of type Ⅱa was (22.1±3.3)°, and the angle of Ⅱc was (16.4±5.4)°. The difference between Ⅰa and Ⅱa data was statistically significant (P=0.003), but there was no significant difference between Ⅰc and Ⅱc(P=0.667). In group A and group B, the angle of Ⅰa was (26.6±5.9)°and (26.6±5.1)°, the angle of Ⅰc was (15.7±4.2)°and (14.9±3.9)°, the angle of Ⅱa was (22.0±3.0)°and (22.2±4.3)°, the angle of Ⅱb was (45.4±9.0)°and (46.5±10.0)°, the angle of Ⅱc was (17.0±5.4)°and (15.3±6.2)°, respectively. There were no significant differences in the angles of Ⅰa, Ⅰc, Ⅱa, Ⅱb and Ⅱc between the two groups (P values were 0.862, 0.387, 1.000, 0.932 and 0.444, respectively). Conclusion The posterior malleolar fragments is not associated with fracture type of ankle fracture combined with posterior malleolus frature and the spiral fracture of middle and lower third of tibial combined with posterior malleolus fracture. Key words: Fracture; Ankle joint; Tibial fracture; Morphological study; Posterior malleolus

Reversed vascularized second metatarsal flap for reconstruction of Manske type IIIB and IV thumb hypoplasia with reduced donor site morbidity.

The predominant method for Manske type IIIB and IV thumb hypoplasia is pollicization. However, for those who are not willing to sacrifice the index finger, a method that could reconstruct a functionally capable and aesthetically acceptable thumb remains desirable. This study aimed to investigate and assess the functional and radiographic outcomes of utilizing a reversed vascularized second metatarsal composite flap for thumb reconstruction as a new alternative. From May 2014 to January 2017, 15 patients with Manske type IIIB or IV thumb hypoplasia who were admitted to the Department of Hand Surgery, Beijing Jishuitan Hospital were included in this study. An osteocutaneous flap containing a section of second metatarsal and its distal head was transferred in reversed position to reconstruct carpometacarpal joint. The donor site was reconstructed by a split half of the third metatarsal. Various functional reconstructions were commenced at second stage. The reconstructed thumbs were evaluated using the Kapandji score, pinch force, and the capacities of performing daily activities through a detailed questionnaire. Among these 15 patients (seven type IIIB and eight type IV), there were ten boys and five girls with median age of 4.2 years (range: 2.0-7.0 years). There were seven right, three left, and five bilateral thumbs for whom only the right thumb received surgery. There were 14 metatarsal flaps survived (14/15). With an average follow-up of 19.2 months, the reconstructed thumbs had acceptable functional and aesthetic outcomes and the donor foot presented in decent appearance without signs of impaired function. All 15 children have improved the Kapandji score (from 0 to an average of 6.7), pinch force (from 0 to an average of 1.5 kg), with ability of grip and pen holding. X-ray indicated continuous bone growth. Patients and parents had good acceptance of the new thumb. Reconstruction of an unstable hypoplastic thumb (Manske type IIIB and IV) with use of a vascularized metatarsal is an effective strategy. It offers an alternative solution for parents insisting on saving the thumb.

Synchronous multicentric osteosarcoma: treatment and prognostic factor analysis

Objective: To identify the clinical outcome and prognostic factors of synchronous multicentric osteosarcoma (SMOS). Methods: The clinical data of 2 602 conventional osteosarcoma patients admitted to Beijing Jishuitan Hospital from January 1995 to June 2018 were retrospectively analyzed. Finally, 56 (2.1%) cases were confirmed as SMOS according to clinical and imaging database, medical record and pathological results.All epidemiological data of SMOS cases,initial diagnosis time, tumor site, number of lesions, chemotherapy, surgical treatment, alkline phosphatase (AKP),lactate dehydrogenase (LDH) and oncological results were collected in our institution. The Survival rate, comparison of various parameters, univariate analysis and multivariate Cox regression were performed with statistical software. Results: There were 41 males and 15 females enrolled in this research, the median and mean ages were 15 and 18 years (range, 8-50 years) respectively. All of them were multi-site involved, whereas the initial complaints of sites distribution were 32 cases of femur, 13 cases of tibia, 4 cases of humerus, 3 cases of fibula, 2 cases of spine, 1 case of sternum and 1 case of calcaneus. Forty-four of 56 cases performed adjuvant chemotherapy and 31 of them underwent surgical treatment. The mean follow-up time was 15.4 (range, 1-186) months. Thirty-five cases died of disease at the end of the follow-up. The 5-year survival rate was 10.4%. According to the number of lesions stratification, the 2-year survival rates in patients with low (<5 sites) and high (≥5 sites) tumor load was 33.6% and 0, respectively (χ(2)=6.697, P=0.010). The 2-year survival rate of chemotherapy and non-chemotherapy patients was 20.8% and 0, respectively (χ(2)=6.998, P=0.008), the value of AKP after chemotherapy(median: 272 IU/L) significantly decreased when compared with that at the initial diagnosis (median: 454 U/L) (Z=-3.274, P=0.001).The 2-year survival rate in patients with and without standard chemotherapy was 55.6% and 0, respectively (χ(2)=8.798, P=0.003). The 2-year survival rate was 25.0% in the surgical group and 0 in the non-surgical group, respectively (χ(2)=7.942, P=0.005). Multivariate cox regression analysis with the forward Wald method indicated that standard chemotherapy was the only variable contributor to survival and prognosis of multifocal osteosarcoma. Conclusions: SMOS has low survival rate and poor prognosis. Chemotherapy and surgery can improve the survival rate, standard chemotherapy is an independent prognostic factor.

Incidence and surgical fixation-related factors of posterior malleolus fracture in treatment of ankle fractures

Objective To investigate the incidence and surgical fixation-related factors of posterior malleolus fracture in the treatment of ankle fractures. Methods A retrospective study was conducted of the 703 inpatients with ankle fracture at Department of Foot and Ankle Surgery, Beijing Jishuitan Hospital from June 1, 2017 to May 31, 2018. Of them, 464 suffered posterior malleolus fracture. The incidence and surgical fixation rate of posterior malleolar fracture were calculated. Of the patients with posterior malleolus fracture, the gender, age, injury energy, Lauge-Hanse classification, Bartonicek classification, talar backward subluxation, fragment area ratio (FAR) of posterior malleolus fracture on X-ray film and CT cross section, fragmental dislocation, and Die-punch fragment were analyzed to screen out the risk factors related to surgical internal fixation for posterior malleolus fracture. Results In this study, the incidence of posterior malleolus fracture was 66.00% (464/703) and the surgical fixation rate 43.97% (204/464). The gender, age, injury energy, Lauge-Hanse classification, direction of talar subluxation and displacement of Die-punch fragments were not the risk factors related to the surgical internal fixation for posterior malleolus fracture (P>0.05) while the Bartonicek classification, talar backward subluxation, FAR of posterior malleolus fracture on X-ray film and CT cross section, lateral fragmental displacement and Die-punch fragment were the risk factors related to the surgical internal fixation for posterior malleolus fracture (P<0.05). Logistic regression analysis indicated that the talar backward subluxation (OR=5.580, 95% CI:1.623~19.181, P=0.006) and the FAR ≥15% on CT cross section (OR=9.103, 95% CI: 3.342~24.800, P=0.000) were independent risk factors for surgical internal fixation of posterior malleolus fracture. Conclusions The incidence and surgical fixation rate of posterior malleolar fracture are very high. The talar backward subluxation and the fragment area ratio ≥15% on CT cross-section are independent risk factors for surgical internal fixation of posterior malleolus fracture. Key words: Ankle; Posterior malleolus; Fractures, bone; Fracture fixation; Related factors

Clinicopathological and ALVAL score analysis of pseudotumor-like tissue around aseptic joint arthroplasty

Objective: To analyze the clinicopathological features of pseudotumor-like tissue around aseptic joint arthroplasty and aseptic lymphocytic vasculitis-associated lesions (ALVAL) scores. The characters of wear granules were observed. Methods: Total 122 cases were retrieved from the surgical pathology files between May 2015 and August 2018 in the department of pathology in Beijing Jishuitan Hospital, which included the knee joint arthroplasty (10 cases) and hip arthroplasty (112 cases). There were 62 females and 60 males. Patients' age ranged from 29 to 86 years (mean 56 years). The pseudotumor-like tissue around aseptic joint arthroplasty were stained with HE and analyzed by two ALVAL score systems. The characters of wear granules were observed by light microscope and polarized light. Results: The cohort included 62 females and 60 males. Patients' age ranged from 29 to 86 years (mean 56 years). Compbell-ALVAL system includes synovial lining,inflammatory infiltrate and tissue organization. The scores were: low (0-4): 18cases; moderate (5-8): 101 cases; high (9-10): 3 cases. Oxford-ALVAL system only evaluated the inflammatory infiltrate,and the scores were:0 grade:56 cases; 1 grade:51 cases; 2 grade: 12 cases; 3 grade:3 cases. Cases with high score in the Compbell-ALVAL system were concordant with the 3 grade of the Oxford-ALVAL system. Under light microscope,the metal particles were small black granules; the polyethylene fibers were needle-like and easily visible in polarized light. The polymethylmethacrylate showed clear spaces because of particle melting. Conclusions: The Compbell-ALVAL scoring system is based on the histologic analysis of pseudotumor-like tissue around aseptic joint arthroplasty, and the Oxford-ALVAL scoring systems is based on lymphocytic response. The wear particles could be differentiated by the features in the light microscope.

Effects of perforator flaps in the reconstruction of hypertrophic scar contracture deformities in the large joints of extremities of patients after severe burns

Objective: To explore the clinical effects of perforator flaps in the reconstruction of hypertrophic scar contracture deformities in the large joints of extremities after severe burns. Methods: From January 2008 to January 2018, 72 patients (53 males and 19 females, aged 5 to 63 years) with hypertrophic scar contracture deformities and functional disorder in the large joints of extremities after severe burns were admitted to the Department of Burns of Beijing Jishuitan Hospital. Scar hyperplasia and contracture deformity were located at shoulder joints of 28 patients, elbow joints of 15 patients, hip joints of 7 patients, knee joints of 17 patients, and ankle joints of 5 patients. The wound area of patients after the scars were excised and released ranged from 7 cm×6 cm to 34 cm×12 cm. The wounds were repaired with corresponding unexpanded perforator flaps or expanded perforator flaps according to the joint location and existing soft tissue conditions. The size of flaps ranged from 7 cm×6 cm to 35 cm×14 cm. The donor sites of 51 patients were sutured directly; the donor sites of 21 patients were repaired by segmented grafts or mesh grafts. The adopted surgeries, the survival of flaps after surgery, and the functional recovery of the joints during follow-up were recorded. Results: Among the 72 patients, 53 patients had perforator flap repairing surgery only; 19 patients had perforator flap repairing surgery and skin grafting. Among them, 12 patients had expanded perforator flaps, 60 patients had unexpanded perforator flaps. The perforator flaps were performed free transplantation in 9 patients, pedicled transplantation in 61 patients, and groin transplantation in 2 patients. At last, 67 flaps survived completely, while 5 flaps had distal-end necrosis which were healed after dressing change or skin grafting after debridement. During follow-up of 6 months to 3 years, the joint function of all the patients was obviously improved. The abduction angles of shoulder joints were over 110°; the hip, knee, and elbow joints could reach the straight position, and the flexion was normal; the foot drop deformity was corrected, and the appearance of flaps was good with obvious extension compared with the original state. Conclusions: Perforator flaps are suitable for reconstruction of hypertrophic scar contracture deformities in the large joints of extremities of patients after severe burns. They can restore the joint function to the greatest extent as well as repair the wounds.

Effects of physeal bar resection in treating post-traumatic distal radius partial physeal arrest

Objective: To evaluate the effects of treatment of post-traumatic distal radius partial physeal arrest with physeal bar resection. Methods: From February 2007 to November 2017, 11 children with distal radius physeal arrest received physeal bar resection in the Department of Pediatric Orthopedics, Beijing Jishuitan Hospital. There were 2 females and 9 males. The average age of the patients was (10.1±1.8) years (range,7-13 years). All cases had previous history of distal radius trauma. The average duration from the previous fracture to the physeal bar resection operation was (22.8±3.2) months (range,22 to 41 months). Clinical and radiological evidence of distal radius physeal arrest were suggested in all patients. A CT or MRI scan was performed preoperatively to assess the size of the physeal bridge. Inclusion criteria were patients with a physeal bridge<30% of the physeal area,and with at least 2 years of growth remaining. The physeal bar resection operation was performed with the assistance of either fluoroscopy (5 cases) or intraoperative three dimensional navigation (6 cases). After resection, the void was then filled with bone wax in all cases and distal ulnar epiphysiodesis was conducted in 5 cases. The mean follow-up duration was (3.7±1.6) years (range,1-9 years). The clinical examination data and X ray were obtained during the follow up. Results: Four cases obtained fully recovery from the operation and the deformity got fully correction. The X ray showed no bone bridge recurred. The deformity did not aggravate in 1 case. The deformity aggravated and subsequent osteotomy was conducted in the left 6 cases. Three cases in the navigation group obtained fully recovery. One case in the fluoroscopy group obtained fully recovery. Conclusions: The intraoperative three dimensional navigation can precisely locate the bone bridge. The physeal bar resection is an effective technique in some post-traumatic distal radius partial physeal arrest.