2012年 · 第15卷第03期

Abstract：Simultaneous isolated bilateral patellar fractures are very rare injuries and most often associated with systemic disorders such as hyperparathyroidism,osteoporosis,stress fracture and kidney failure.Isolated bilateral traumatic fracture of patella following an unusual mode of injury is seldomly reported in the literature.We reported such a case following a road traffic accident without any associated injuries or co-morbid condition.The patella on the right side had transverse open fracture which was fixed with two Kirschner wires following tension band principle,and that on the left side sustained upper pole comminution which was treated by partial patellectomy.The patient achieved good outcome:at 6 months he was able to squat and sit cross legged; at one year he obtained nearly normal muscle strength and full range of motion.We discussed the injury mechanism,management and rehabilitation in such a case and reviewed the available literature regarding such a presentation。

There is a common misconception around medical practitioners who have never experienced war that all that is needed is to adapt their peace time experience to different circumstances.While no one can dispute the need for excellent basic training in one's chosen specialty and considerable experience before entering a war zone,we are all unpleasantly surprised at how different it is to practice front line war surgery compared to the relatively placid circumstances back home。

Abstract：Objective: To study the adherence,proliferation and osteogenesis of mesenchymal stem cells (MSCs) cultured on different HA/ZrO2 composites.Methods: The simplex and graded HA/ZrO2 composites were prepared using dry-laid method.The surface topography of the composites was observed by scanning electron microscope (SEM).The MSCs were isolated from rabbits and cultured on experimental groups (simplex HA/ ZrO2 composite,graded HA/ZrO2 composite,pure HA or pure ZrO2 coatings respectively) and control group (ordinary culture plate).Then,we observed the adherence,proliferation and osteogenesis of the MSCs,detected the cellular alkaline phosphatase (ALP) activities,extracted total RNA and detected the mRNA expression of collagen Ⅰ,osteocalcin and osteopontin using the reverse transcription and polymerase chain reaction (RT-PCR) method.Results: The SEM images confirmed that the surfaceof the simplex HA/ZrO2 composite was coverd by discontiguous HA layer with clear visualization of the partial ZrO2 matrix,while the surface of the graded HA/ZrO2 composite was fairly rough with porosity.X-ray diffraction showed that after high temperature sintering,the ZrO2 phase still remained,while the HA phase was transformed to β-Ca3 (pO4)2,α-Ca3(PO4)2 and CaZrO3 phases on the surface of both composites.Cell culture indicated that the HA/ ZrO2 composites supported cell attachment.Neither ALP expression nor mRNA expression of collagen Ⅰ,osteocalcin or osteopontin from RT-PCR results showed significant deviation among four groups.Conclusion:Among these four composites,the graded HA/ZrO2 composite promotes the MSCs proliferation and the osteogenic differentiation to a certain extent。

Abstract：Objective: To assess the value of ankle fusion with a retrograde locked intramedullary nail in the treatment of sequela of lower extremity compartment syndrome.Methods:Thirty-five cases of equinus deformity following tibiofibular compartment syndrome treated by means of ankle fusion with a retrograde locked intramedullary nail from January 2001 to December 2010 were retrospectively reviewed.The complications,the time needed for bony fusion of the ankle joint assessed by anteroposterior and lateral X-ray photographs as well as patients' subjective evaluation were recorded and analysed.Results: Among the 35 patients,15 had previously undergone surgical treatment twice on the same limb,13 had thrice and 7 had to be operated on four times before ankle fusion.An anterior midpoint approach to the ankle joint was adopted in 29 cases,while anterior midpoint approach plus a small incision on the posterior ankle joint was made in 17 cases,whereas lateral approach in 6 cases.Tarsus joint fusion was performed on 4 cases.The follow-up period ranged 6-124 months,averaged 40.6 months.Bone grafting was not performed in this series.Preoperative tibial shaft fracture occurred in one patient and was healed after conservative treatment.Incision dehiscence located at previous Achilles tendon incision was found in two patients.As a result,one received an intramedullary nail emplacement at calcaneoplantar part while the wound at anterosuperior part of the other one was healed by dressing change.Two patients failed to bony union 5 months postoperatively,in which one healed 10 weeks after retrieval of proximal tibial nail and another by iliac grafting.Terminal necrosis of the toe due to blood supply dysfunction was not found in this series.All the patients were satisfied with the ankle joint function postoperatively.The time for bony union on X-rays was 9.8 weeks on average.Except for one patient who demanded removal of intramedullary nail,all the intramedullary nails were not retrieved at the end of follow-up.Nail breakage happened in one patient and no other breakage or backing out of the nail was found.Conclusions:Lower extremity compartment syndrome and residual ankle deformity often extremely impact ambulation and are bard to deal with because several pathologic phenomena might exist in these patients,for instance,poor skin conditions due to repeated preexisting surgery;poor perfusion in distal limbs following blood vascular injury;reflux limitation and long-term limb swelling due to muscle strength disturbance; osteoporosis as a result of long-term immobilization or limb disuse.Ankle fusion with a retrograde locked intramedullary nail is an optimal protocol to solve these clinical symptoms and rather ensures a definite fusion and firm fixation to these patients with simple manipulation and few complications。

Abstract：Objective: Injury is a major cause of morbidity and mortality in the world.The assessment of patterns and severity of injury in high-risk groups is crucial for planning and service development.On a large scale national household survey,we estimated the annual incidence and the patterns of injury,the demographics of the injured people,as well as the service use for all injuries in Iran.The current study aims at assessing the reliability of the questionnaire before carrying out a national survey.Methods: In a pilot study using cluster random sampling approach,73 people were interviewed.The interviewers asked the participants to report all injuries occurred in them and the care provided during the previous 12 months,based on "Short Form Injury Questionnaire 7".About two weeks later,the interview was repeated by another interviewer.Results: In our test-retest reliability,Kappa score was good for three and moderate for four questions.The question on the injured organ had the highest test-retest reliability with a Kappa score of 0.84.Conclusions:The reliability of the questionnaire and the procedure of questioning are confirmed.The questionnire is proper for utilization in large national surveies。

Abstract：Objective: Yoga is becoming more and more popular in the female society while the concomitant sports injury is seldom mentioned.Many clinicians have noted that yoga may result in knee problems,which though requires more researches to corroborate.This investigation was conducted to ascertain the relationship between yoga and meniscus injury as well as the extent of impairment according to variant yoga practice periods.Methods: Totally 819 women aged 20-49 years who practiced yoga or other popular sports including badminton,jogging,climbing hills,etc for at least one hour per day were selected to participate in this research.These subjects were required to complete a questionnaire and receive relevant physical examination.Magnetic resonance (MR) scan of the knee was recommended for the suspicious subjects for ultimate diagnosis.The subject with abnormal meniscus MR signals was defined as a case and matched with two controis in terms of age and body mass index (BMI).Altogether there were 273 cases and 546 controls.The nested casecontrol model was adopted to assess the risk of meniscus injury between variant exposures in practicing yoga and several other popular sports.Moreover,the 181 yoga subjects were subdivided into three groups according to different exercise durations,followed by further analysis with the variables of age,BMI and Lysholm score.Results:Yoga was found associated with a higher risk (P=0.008,OR=1.621) of meniscus injury compared with badminton,jogging and climbing hills.The three yoga subgroups showed statistical difference between each other in terms of Lysholm score (P=0.027) and BMI (P=0.003).The subjects with longer-term yoga practice had lighter weight but lower Lysholm scores.Conclusions:Yoga perhaps exerts destructive impact on the meniscus for Chinese women,yet it needs further verifications.Furthermore,the female yoga players with longer exercise duration are more susceptible to meniscus injury though they can become leaner。

Abstract：Objective: To study whether the range of knee flexion (ROF) is affected by geometrical mismatch of the femoral component and the resultant change in the posterior condylar offset (PCO) after high-flexion posterior-stabilized total knee arthroplasty (TKA).Methods:One hundred osteoarthritic patients (50 males and 50 females) underwent femoral osteotomy by the anterior referencing technique.The PCO for each patient was measured from lateral radiographs before,during and 2 years after TKA.The thickness of the joint cartilage was measured by magnetic resonance imaging before TKA and added onto the radiographic measurement.The relationship between changes in the PCO and improvements in the ROF before,during and 2 years after TKA were statistically analyzed.Results: Compared with the preoperative value,the PCO was reduced by (3.45±3.28) mm after TKA,with a significantly larger reduction observed in female patients than male patients (P＜0.05).When examining the subject population as a whole,there was a significant positive correlation between PCO and ROF improvement during TKA (P＜ 0.05),but this improvement was not maintained 2 years after TKA (P＞0.05).However,when male and female patients were analyzed separately,there was a significant positive correlation between PCO change and ROF improvement for both sexes at both time points (all P＜0.05).Conclusions: Restoration of PCO plays an important role in the optimization of knee flexion even after posteriorstabilized TKA.Femoral components based on Caucasian anatomic characteristics could not match the native anatomy of distal femurs in Chinese population especially female Chinese.Rotated resection of distal femur with anterior referencing technique usually leads to a decreased PCO and therefore reduces maximal obtainable flexion。

Abstract：Objective: To present our experience in using decompressive craniectomy (DC) among severe traumatic brain injury (TBI) patients during operation and to discuss its indication.Methods:From October 2008 to May 2009,41 patients aged between 18 and 75 years with severe TBI were included in this study.They underwent DC or non-DC (NDC)according to their intraoperative findings.Postoperative intracranial pressure (ICP),complications,requiring second operation or not and outcomes were observed.Results: Fifteen patients underwent DC and 26 patients did not.The average postoperative ICP of each patient was lower than 20 mm Hg.For patients received DC,2had seizures after operation and 1 developed cerebrocele in the follow-up period; only 1 NDC patient had post-traumatic seizures,but none of them had delayed haematoma,cerebrospinal fluid fistula,cerebrocele or infections.At the end of follow-up,10 patients died,6 had the GOS of 2,2 of 3,9 of 4 and 14 of 5.Conclusions: DC is necessary to manage fulminant intracranial hypertension or intraoperative brain swelling.If there was not brain swelling after removal of the haematoma and necrotized neural tissues,it is safe to replace skull flap.The intraoperative finding is an important factor to decide whether to perform DC or not。

Abstract：Objective: To determine the pattern of causalities of Iraqi ballistic missile attacks on Tehran,the capital of Iran,during Iraq-Iran war.Methods: Data were extracted from the Army Staff Headquarters based on daily reports of Iranian army units during the war.Results: During 52 days,Tehran was stroked by 118 Al-Hussein missiles (a modified version of Scud missile).Eighty-six missiles landed in populated areas.During Iraqi missile attacks,422 civilians died and 1579 injured (4.9 deaths and 18.3 injuries per missile).During 52 days,8.1 of the civilians died and 30.4 injured daily.Of the cases that died,101 persons (24％) were excluded due to the lack of information.Among the remainders,179 (55.8％) were male and 142 (44.2％) were female.The mean age of the victims was 25.3 years±19.9 years.Our results show that the high accuracy of modified Scud missiles landed in crowded areas is the major cause of high mortality in Tehran.The presence of suitable warning system and shelters could reduce civilian casualties.Conclusion: The awareness and readiness of civilian defense forces,rescue services and all medical facilities for dealing with mass casualties caused by ballistic missile attacks are necessary。

Abstract：Objective: To examine the contribution of flexion and extension radiographs in the evaluation of ligamentous injury in awake adults with acute blunt cervical spine trauma,who show loss of cervical lordosis and neck pain.Methods: All patients who presented to our emergency department following blunt trauma were enrolled in this study,except those with schiwora,neurological deficits or fracture demonstrated on cross-table cervical spine X-rays,and those who were either obtunded or presented after cervical spine surgery.Adequacy of flexion and extension views was checked by the neurosurgery and radiology team members.All these patients underwent cross-table cervical spine view followed by flexion/extension views based on the loss of lordosis on cross-table imaging and the presence of neck pain.Results: A total of 200 cases were reviewed,of whom 90 (45％) underwent repeat X-rays because of either inadequate exposure or limited motion.None of the patients with loss of lordosis on cross-table view had positive flexion and extension views of cervical spine for instability.Conclusions: Our results show that in patients who underwent acute radiographic evaluation of blunt cervical spine trauma,flexion and extension views of the cervical spine are unlikely to yield positive results in the presence of axial neck pain and/or loss of cervical lordosis.We can also hypothesize that performing flexion and extension views will be more useful once the acute neck pain has settled。

Abstract：Objective: To analyze the injuries of motorcyclists involved in fatal motorcycle frontal crashes.Methods: A survey group involving multi-discipline experts was built to randomly collect data on fatal motorcycle frontal collision accidents that occurred in Chongqing during 2006-2010.The sampled information included medical or autopsy reports,blood alcohol concentration (BAC)level,helmet use,accident witness,field sketch as well as field photos.The motorcyclist injuries were scored according to the Abbreviated Injury Scale (AIS) 2005.The involved riders with a BAC level≥20 mg/ml were attributed to alcohol use.Data were processed statistically with nonparametric test via software SPSS 11.0.Results:A total of 86 fatal motorcycle frontal crashes were sampled and further analyzed.The age of motorcyclists enrolled in this investigation showed nominal distribution and the middle-aged (30-39 years) occupied the highest percentage of fatalities.There were only 14 motorcyclists (16.3％) wearing helmets at the moment ofcollision.And 12.8％ of these motorcyclist crashes were attributable to alcohol use.Impact injury was the main fatal cause,accounting for 72％ of motorcyclist deaths,followed by tumbling injury (26％) and run-over (2％).Respectively 84％,22％ and 19％of motorcyclists who sustained head,chest and abdominal trauma died.Extremity injury was the most frequently observed injury type.Conclusions: This investigation is helpful to build accident prevention programs and develop protection devices which may effectively mitigate injuries and prevent deaths following motorcycle frontal collision accidents.Further investigations on motorcycle collision accidents are still needed。

Abstract：Objective: To retrospectively evaluate the early results of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction and compare with the results of native ACL of the contralateral knee.Methods: The results of a consecutive series of 118 patients receiving arthroscopic ACL reconstruction were evaluated.Eight patients were lost to the latest follow-up,leaving a total of 110 patients available for study within at least 3 years' clinical follow-up.Among them,63 patients underwent postoperative MRI and CT scan,as well as clinical evaluation.Results: After reconstruction,the knees were stable and pain-free.Mean postoperative Lysholm score was 95.54 in 110 patients after 3 years.CT and MRI assessment showed that the reconstruction centered in the femoral footprint of ACL (n=63).The sagittal ACL angle in the reconstructed ACL (52.16°±2.45°) was much close to that in the contralateral intact ACL (51.31 °±2.18°,P＞0.05).By ACL-Blumensaat line angle analysis,there was no difference between doublebundle reconstructed knees and their contralateral normal knees (4.67°±0.43° vs.4.62°±0.60°,P＞0.05).Conclusion:Anatomic double-bundle ACL reconstruction can place grafts more precisely in the anatomic footprint of the ACL and better restore knee kinematics。