2011年 · 第14卷第06期

Abstract：Objective:To evaluate the role of high risk factors in octogenarians and nonagenarians with hip trauma,which may lead to excessive mortality and morbidity postoperatively.Methods:Fifty-four octogenarians and nonagenarians patients were enrolled in the study,receiving surgical repair of hip fracture in our hospital from January 2006 to January 2010.High risk factors were recorded preoperatively in detail.Complications and survival state were followed up by telephone for 2 years postoperatively.All the data were analyzed by Chi-square test with SPSS 13.0.Results:Twenty-six males (48.1％),aged from 80 to 94years with a mean age of 84.2 years,and twenty-eight females (51.9％),aged from 80 to 95 years with a mean age of 83.4 years,were presented in the cohort study.The hip traumas were caused by daily slight injuries (52 cases) and car accidents (2 cases),respectively.Twenty-eight patients (51.9％) with femoral neck fracture while 26 patients (48.1％)with intertrochanteric fracture were diagnosed through an anterior-posterior pelvic radiophotograph.In this series,39patients (72.2％) suffered from one or more comorbidities preoperatively.The morbidity was 48.1％ and the major cause was urinary tract infection,while a significant difference was noted between females and males.The mortality was 20.4％ with a predominant cause of acute renal failure.Conclusions:The gender should be considered as a critical high risk factor in octogenarians and nonagenarians with hip trauma postoperatively.Females are more likely to suffer complications postoperatively,which is especially obvious in senile patients over 80 years (P＜0.05).Urinary tract infection is the most frequent complication after hip surgery,followed by low limb embolism and malnutrition.The mortality is dramatically greater in patients over 80 years old than those below,and major causes are acute renal failure,multiple organ dysfunction syndrome and mental deterioration.Multidisciplinary consultations and mental assessment are encouraged in patients over 80 years old after hip trauma and surgery.Hip fractures in octogenarians and nonagenarians deserve special attention because of their advanced age and comorbidities。

Abstract：Objective:To evaluate the potential effects of uncultured adipose-derived stromal vascular fraction on tendon healing.Methods:Twenty five adult male New Zealand white rabbits weighing 2.5-3.0 kg were used.Five rabbits were used as donors of adipose tissue and the rest were divided into control and treatment groups.The injury model was completed by unilateral tenotomy through the middle one third of deep digital flexor tendon.Immediately after suture repair,either fresh stromal vascular fraction from enzymatic digestion of adipose tissue or placebo was intratendinously injected at tendon stumps in treatment and control groups,respectively.Immobilization with cast was continued for two weeks after surgery.Animals were sacrificed at eight weeks after surgery and tendons underwent histological,immunohistochemical,and mechanical evaluations.Statistical analyses of quantitative and qualitative data were assessed using one-way analysis of variance and MannWhitney U-test,respectively.Results:Histological evaluations demonstrated superior fibrillar linearity and continuity,and decreased vascularity in treatment group indicated improved organization and remodeling of neotendons.Immunohistochemistry demonstrated a significant increase in collagen I expression in treatment group.Ultimate load and energy absorption capacity were both significantly increased in cell-treated repairs compared with controls.Conclusion: The present study shows that intratendinous injection of uncultured adipose-derived stromal vascular fraction results in improved structural and mechanical properties of tendon repairs and it could be an effective modality for treating tendon injury。

Abstract：Objective:Trauma is the leading cause of mortality and morbidity among young age groups in Saudi Arabia and developed countries.This study aimed to evaluate the fall of platelet count in children with traumatic brain injury (TBI) as a potential predictor for clinical severity and outcome.Methods:Totally 74 patients with TBI were admitted to the Pediatric Intensive Care Unit (PICU) of our hospital from the beginning of January 2008 to the end of March 2010 (27months).Baseline enrolling criteria were age ≤ 12 years,admission within 4 hours after trauma event,and abbreviated injury scale (AIS)＜3 for extracranial injuries.Injury severity was classified as mild,moderate and severe according to their Glasgow Coma Scale (GCS) scores.Clinical outcomes at discharge were defined as poor (death,severe neurological morbidity) and favorable (moderate disability and good recovery).Platelet count was taken 2-3 times on the first day after admission and thereafter once daily.The percentage fall of platelet count (PFP) was calculated and taken as an index of change.PFP was considered zero if the platelet count was higher than the initial value.Results:PFP was significantly higher in patients with poor outcomes (mean 56.0％±3.8％,median 55.5％) compared to those with favorable outcomes (mean 25.3％±3.2％,median 20.5％,P＜0.01).PFP was also closely related to the severity of TBI,GCS score,clinical outcome and length of stay for survivors (P＜0.01 for each).The frequency of thrombocytopenia was significantly higher in poor outcome parents than in favorable outcome patients (P＜0.05).The validity of thrombocytopenia as a risk factor to predict poor outcome after TBI was:specificity,77.4％; odd ratio (OR),3.1;relative risk (RR),2.15.Receiver operating characteristic (ROC) curve and Youden index showed that the optimum cutoff point of PFP was at 51.5％.Conclusion:PFP is increased with the severity of TBIand it can be taken as a significant independent predicting factor for its outcome as well。

Abstract：Objective:To investigate the occurrence of posttraumatic hydrocephalus (PTH) in severe braininjured patients who underwent decompressive craniectomy (DC) and to discuss the management.Methods:A total of 389 patients suffering from severe head trauma between January 2004 and May 2010 were enrolled in this study.Clinical data were analyzed retrospectively.Of them,149 patients who underwent DC were divided into two groups according to the presence of PTH:hydrocephalus group and nonhydrocephalus group.Clinical factors including preoperative Glasgow Coma Score (GCS),bilateral or unilateral decompression,and duraplasty in DC were assessed by single factor analysis to determine its relationship with the occurrence of PTH.Results:Of the 149 patients undergoing DC,25(16.8％) developed PTH; while 23 developed PTH (9.6％)among the rest 240 patients without DC.Preoperative GCS,bilateral or unilateral decompression,duraplasty in DC were significantly associated with the development of PTH.Ventriculoperitoneal shunt was performed on 23 of 25 patients with PTH after DC.Frontal horn was preferred for the placement of the catheter.Sixteen of them were operated upon via frontal approach and 7 via occipital approach.After shunt surgery,both radiological and clinical improvements were confirmed in 19 patients.Radiological improvement was found in 2 patients.One patient died eventually of severe pneumonia.Shunt-related infection occurred in 1patient,which led to the removal of the catheter.Conclusions:It is demonstrated that the occurrence of PTH is high in patients with large decompressive skull defect.Patients with low GCS and bilateral decompression tend to develop PTH after DC.Duraplasty in DC might facilitate reducing the occurrence of PTH.Patients with PTH concomitant skull defect should be managed deliberately to restore the anatomical and physiological integrity so as to facilitate the neurological resuscitation。

Abstract：Objective:To strengthen the current Injury Surveillance System (IS System) in order to better monitor injury conditions,improve protection ways and promote safety.Methods:At first we carried out a study to evaluate the frameworks of IS System in the developed countries.Then all the available documents from World Health OrganizationEastern Mediterranean Regional Organization,as well as Minister of Health and Medical Education concerning Iran were reviewed.Later a national stakeholder's consultation was held to collect opinions and views.A national workshop was also intended for provincial representatives from 41 universities to identify the barriers and limitations of the existing program and further to strengthen injury surveillance.Results:The evaluation of the current IS System revealed many problems,mainly presented as lack of accurate pre- and post-hospital death registry,need of precise injury data registry in outpatient medical centers,incomplete injury data registry in hospitals and lack of accuracy in definition of variables in injury registry.The five main characteristics of current IS System including flexibility,acceptability,simplicity,usefulness and timeliness were evaluated as moderate by experts.Contusions:Major revisions must be considered in the current IS System in Iran.The following elements should be added to the questionnaire:identifier,manner of arrival to the hospital,situation of the injured patient,consumption of alcohol and opioids,other involved participants in the accident,intention,severity and site of injury,side effects of surgery and medication,as well as one month follow-up results.Data should be collected from 10％ of all hospitals in Iran and analyzed every 3 months.Simultaneously data should be online to be retrieved by researches。

Abstract：Objective:To investigate the dynamic activity of NF-κ B at the early stage of injury in multiple trauma patients and the protective effects of ulinastain.Methods:From January 2008 to May 2010,patients with multiple traumas admitted to our emergency department were enrolled in this study.Their age varied from 20-55 years.All enrolled patients were assigned randomly into control group (26 cases of multiple injury without ulinastain treatment),ulinastain group (25 cases of multiple injury with ulinastain treatment),and mild injury group (20 cases) for basic control.The inclusion criteria for mild injury group were AIS-2005 ≤ 3,single wound,previously healthy inhospital patients without the history of surgical intervention.In addition to routine treatment,patients in ulinastain group were intravenously injected 200 000 IU of ulinastain dissolved in 100 ml of normal saline within 12hours after injury and subsequently injected at the interval of every 8 hours for 7 days.NF- κ B activity in monocytes and the level of TNF- α,IL-1,IL-6 in serum on admission (day 0),day 1,2,3,4,and 7 were measured.Data were compared and analyzed between different groups.Results:NF-κB activity in monocytes and TNF- αIL-1 and IL-6 of these patients reached peak levels at 24hour after trauma,with gradual decrease to normal at 72hour after trauma.NF-κ B activity and levels of TNF- a,IL-l and IL-6 were lower in ulinastain group than control one,without any significant difference between the two groups.The mean duration for systemic inflammatory response syndrome and multiple organ dysfunction syndrome was 7 d±3.1 d and 10 d±3.5 d in ulinastain group and control group respectively,and showed a significant difference.Conclusions:NF-κB activity in monocytes and the levels of inflammatory cytokines in multiply injured patients increased transiently at the early stage of trauma.Ulinastain may shorten the duration of systemic inflammatory response syndrome and multiple organ dysfunction syndrome,but does not show the ability to decrease the activity of NF- κ B。

Abstract：Objective:To investigate the epidemiological characteristcs of eye injuries sustained by military personnel in Chinese army.Methods:Eleven military evacuation hospitals located in different regions were selected for this study.We reviewed all the medical records of eye injuries sustained by military personnel between January 2005 and December 2009.Patients' information was collected.All data were put into database and analyzed statistically.Results:Totally there were 415 inpatients with eye injuries (442 eyes) and their mean age was 24.40 years.Eye injury accounts for 13.51％ of all eye diseases in this study.From 2006 to 2009,the number of eye injury increased gradually.Among them,175 (42.17％) were injured in leisure time,and 145 (34.94％) in working time.Twenty-two (5.30％)patients had an eye surgery or history of eye disease before injury.In all,246 patients (59.28％) were sent to evacuation hospital within 24 hours and 64 (56.64％) underwent surgeries in 24 hours after injury.There were 389 patients (93.73％)hospitalized for 1 time.Visual acuities of 187 eyes (42.31％)were grade 1 (≥ 20/40) after injury.When discharge,349eyes (78.96％) obtained a visual acuity of grade 1.Conclusion:Eye injury has a very frequent incidence in Chinese army and much more attention should be paid to prevent it。

Abstract：Pelvic fractures are serious injuries.Death within 24 hours is most often a result of acute blood loss.The emergency management of these patients is challenging and controversial.The key issues in its management are identifying the site(s) of hemorrhage and then controlling the bleeding.Management of hemodynamically unstable patients with pelvic fracture requires a multidisciplinary team.The issues addressed in this management algorithm are diagnostic evaluation,damage control resuscitation,indications for noninvasive pelvic stabilization,preperitoneal pelvic packing and the critical decisions concerning surgical options and angiography.This review article focuses on the recent body of knowledge on those determinations。

Abstract：The authors reported the case of a 27-year-old man who sustained an irreducible postero-lateral traumatic dislocation of the hip with capsular and labral entrapment.Initial X-rays showed only a small acetabular fragment.After two attempts to reduce the hip with muscle paralysis under general anaesthesia failed,the patient was treated by immediate open reduction through a posterolateral approach.Surgical exploration of the hip revealed a small osteochondral fragment attached to a large piece of labrum and capsule,clogging the acetabulum.The femoral head crossed over the torn capsule with a buttonhole effect.These elements were relieved,the bone fragment was fixed with a 2 mm screw and the capsule was repaired.At the 10-year follow-up,the functional outcome was excellent with a Harris score of 100 points and no signs of necrosis or osteoarthritis.The authors propose a literature review of this uncommon lesion。

Abstract：Intraarticular nonunion of tibial plateau is rare.In the literature,only 9 patients were found to be treated for intraarticular tibial plateau nonunion and they got varying results.Internal fixation along with bone grafting was done as a standard treatment in all cases.We treated 4 different profile cases of intraarticular tibial plateau nonunion in our institution by 4 different methods.We treated these cases with plaster of paris cast,internal fixation along with bone graft,arthrodesis with K-nail and total knee replacement.Case 1 was treated with plaster of paris (POP)cast as the patient refused surgery.The fracture was united and the patient was fully satisfied with full range of motion despite valgus malalignment.Case 2 was managed with open reduction internal fixation along with bone grafting.The patient had a good union and got full range of motion at the knee joint.Case 3 was treated with total knee arthroplasty due to her old age and got satisfactory result.Case 4 was an infected nonunion.Arthrodesis was done and the patient could walk with full weight bearing independently.We conclude that internal fixation along with bone grafting may not be suitable in all cases of intraarticular nonunion of tibial plateau.Causes of nonunion,present condition and range of motion of the knee joint,as well as the age of patient should be all considered and the treatment should be individualised according to each patient's situation。

Abstract：Hoffa fracture associated with ipsilateral femoral shaft fracture is very rare.Three cases of this rare type of injury were retrospectively reviewed.The sites of femoral shaft fractures and Hoffa fractures were documented.All femoral shaft fractures were managed with internal fixation.The rate of misdiagnosis for the Hoffa fractures was documented.Functions of the affected knees were evaluated according to the modified Hospital for Special Surgery (HSS) scores at two years follow-up.Femoral fractures were either transverse or composite in all three cases.Ipsilateral Hoffa fractures occurred at medial condyle in two cases,and lateral condyle in one case.Only one Hoffa fracture was identified preoperatively.All the femoral shaft fractures healed uneventfully.In the patient whose Hoffa fracture was correctly diagnosed,the modified HSS score was 94.In another patient,whose Hoffa fracture was treated by a second operation,the modified HSS score was 93.And in the third case,who refused additional operation for the Hoffa fracture,the modified HSS score was only 70.Conclusively femoral shaft fracture can be associated with ipsilateral Hoffa fracture,especially in motorcycle accident.This type of injury is very rare and misdiagnosis is common。