2011年 · 第124卷第23期

Ten years have silently passed by since the beginning of the 21st century.Looking back upon the history of Chinese Orthopedics development,we cannot but feel amazed at its great progressions and remarkable achievements in such broad fields。

Over the past decade,evidence-based medicine (EBM)is increasingly advocated as the “gold standard” of clinical practice.In 2001,the New York Times identified it as one of the ideas that made a difference,1 although EBM was still an academic concept in 1990.In 1996,Sackett et al2 first defined EBM as the conscientious,explicit,and judicious use of current best evidence in making decisions about the care of individual patients.It means integrating the best research evidence with clinical expertise and patient values.In China,EBM related studies seem to still be a “step behind”.For example,a PubMed search of “spine and China,limited to randomized controlled trial (RCT)” revealed two citations before 2000,but by 2012,the number was 183;compared with total published papers on spine limited to RCT found 842 citations before 2000 and by 2012,3895citations。

STATUS OF TRAFFIC INJURY IN CHINA According to WHO statistics,every year there are more than 1.2 million people who die in traffic accident,around three thousand every day,and about 50 million people injured in traffic accident.Economic loss due to traffic accidents is as high as 518 billion US dollar。

Abstract：Background Various surgical approaches have been successfully used in the treatment of thoracolumbar disc herniation (TLDH).Although the anterior transthoracic approach has a reputation for better visualization than the posterolateral and lateral approaches,it involves the manipulation of the thoracic and pulmonary structures.Thus,this approach is technically demanding and prone to compromising the respiratory system.An ideal approach would involve adequate visualization and be accomplished through the posterior midline approach that is familiar to spine surgeons.The objective of this retrospective preliminary clinical study was to introduce a new surgical procedure,circumspinal decompression through a single posterior incision,for the treatment of TLDH (T10/11-L1/2) and to evaluate the surgical outcome of this procedure by comparing it to the conventional anterior transthoracic approach.Methods In this study,15 patients (10 males,5 females; mean age 51 years) with symptomatic TLDH underwent the circumspinal decompression through a single posterior incision procedure between January 2008 and December 2009.Altogether,17 herniated discs were excised,with 2 discs at T10/11,4 discs at T11/12,5 discs at T12/L1 and 6 discs at L1/2.Of these patients,13 were followed up with a mean follow-up period of 23.5 months.Clinical outcomes,including operative time,blood loss,perioperative complications,postoperative time of hospitalization,neurologic status improvement,back pain and correction of local kyphosis,were investigated by comparing these data with the results from patients who underwent the anterior transthoracic approach for TLDH during the same period.The patients' neurologic status was evaluated by a modified Japanese Orthopedic Association (JOA) scoring system of 11 points.Neurologic status improvement after the surgery was assessed by calculating the recovery rate,which was equal to the (postoperative JOA score-preoperative JOA score)/(11-preoperative JOA score)x100％.The rates of patients who improved at the final follow-up were also assessed.Results The mean operative time was 183 minutes,the mean blood loss was 1067 ml,and the mean postoperative hospitalization time was 8.4 days.Three patients suffered perioperative complications,but none of these complications involved the respiratory system.Local kyphotic angles at the fusion levels were reduced.Of the 13 patients that were followed up,12 improved at the final follow-up,with a mean recovery rate of 52.8％.Patients who underwent the circumspinal decompression procedure showed a higher percentage of improvement at the final follow-up,a higher degree of local kyphosis correction and a lower percentage of complications (especially respiratory complications) compared to patients who underwent the anterior transthoracic decompression procedure.Conclusions The circumspinal decompression through a single posterior incision procedure is an effective and safe technique that is comparable to anterior tranthoracic approach for the surgical treatment of TLDH patients.It could be an attractive choice in certain circumstances。

Abstract：Background Pulmonary problems often occur in patients with early-onset scoliosis (EOS).However,lung function in patients with EOS after growing rod surgery has not been documented.The aim of this study was to investigate lung function after the treatment for EOS with growing rod and its possible correlative factors.Methods Eight patients with EOS were treated with growing rod surgery at Peking Union Medical College Hospital from September 2002 to September 2009.Four patients had finished the final fusion surgery (group 1),and the other 4 (group 2) were in the process of periodic lengthening.Preoperative forced vital capacity (FVC),ratio of FVC to predicted FVC,forced expiratory volume in 1 second (FEV1),ratio of FEV1 to predicted FEV1,and radiographic measurements of Cobb's angle and C7-S1 distance were recorded.Lung function changes and correlations between lung function changes and radiographic changes (Cobb's angle and C7-S1 distance) were analyzed.Results In group 1,FVC and FEV1 both increased.FVC showed a significant difference (P=0.01),but FEV1 did not (P =0.05).In group 2,FVC and FEV1 also increased,and both showed a significant difference (F=0.04 and P=0.02,respectively).Ratio of FVC to predicted FVC and ratio of FEV1 to predicted FEV1 changed similarly and did not show statistical differences in the 2 groups.There were no significant correlations between lung function changes and radiographic changes (Cobb's angle and C7-S1 distance) (P=0.10 and P=0.41,respectively).Conclusions Lung function increases after growing rod surgery in patients with EOS.Lung function changes do not correlate with Cobb's angle changes or C7-S1 distance changes。

Abstract：Background Adolescent cervical kyphosis refers to manifestation characterized by loss of physiological cervical lordosis with involvement of multiple cervical vertebrae.There is no standard treatment strategy for this disease,especially in those patients who need surgical intervention.The aim of this study was to evaluate the surgical staged treatment for moderate to severe adolescents cervical kyphosis.Methods A total of 26 adolescent with cervical kyphosis were retrospectively assigned into following two groups according to the magnitude of kyphosis:moderate group (n=17),the Cobb angle was 46.6°±4.8°.The surgical procedure was that skull traction was first carried out for 5-7 days and then the anterior fusion and instrumentation were performed.Severe group (n=9),the Cobb angle was 61.6°±4.8°.The treatment strategy was that the anterior release were first performed,followed by skull traction for 7-10 days,and then anterior fusion were performed.Radiographic evaluation was performed postoperatively.Results Three days after surgery,the X-ray examination showed that the Cobb angle was -8.9°±6.8° in the moderate group and -6.0°±6.3° in the severe group.The deformed appearance was obviously corrected,with neck pain and neurologic function improved significantly.Further magnetic resonance imaging (MRI) indicated the physiology curvature of the cervical spine had been reconstructed.Conclusion Surgical staged treatment may be an ideal therapeutic intervention for cervical kyphosis patients with a Cobb angle exceeding 35° in adolescents。

Abstract：Background In recent years,a variety of minimally invasive lumbar surgery techniques have achieved desirable efficacy,but some dispute remains regarding the advantages over open surgery.This study aimed to compare minimally invasive lumbar interbody fusion via MAST Quadrant retractor with open surgery in terms of perioperative factors,postoperative back muscle function,and 24-month postoperative follow-up results.Methods From September 2006 to June 2008,patients with single-level degenerative lumbar spine disease who were not responsive to conservative treatment were enrolled in this study.Patients were randomized to undergo either minimally invasive surgery (MIS,transforaminal lumbar interbody fusion via MAST Quadrant retractor,41 cases) or open surgery (improved transforaminal lumbar interbody fusion,38 cases).Results The MIS group had longer intraoperative fluoroscopy time than the open surgery group,and the open surgery group had significantly increased postoperative drainage volume and significantly prolonged postoperative recovery time compared with the MIS group (P ＜0.05 for all).MRI scanning showed that the T2 relaxation time in the multifidus muscle was significantly shorter in the MIS group than in the open surgery group at 3 months after surgery (P ＜0.01).Surface electromyography of the sacrospinalis muscle showed that the average discharge amplitude and frequency were significantly higher in the MIS group than in the open surgery group (P ＜0.01).The Oswestry disability index and visual analog scale scores were better at 3,6,12 and 24 months postoperatively than preoperatively in both groups.Both groups of patients met the imaging convergence criteria at the last follow-up.Conclusions MIS can effectively reduce sacrospinalis muscle injury compared with open surgery,which is conducive to early functional recovery.In the short term,MIS is superior to open surgery,but in the long term there is no significant difference between the two procedures。

Abstract：Background Degenerative lumbar scoliosis is common in older patients.Decreased bone density and the degeneration of intervertebral discs are considered to be correlated with degenerative lumbar scoliosis.A means of quantifying the relative signal intensity for degenerative disc disease has not been previously discussed.The purpose of this study was to compare bone mineral density and intervertebral disc degeneration between degenerative lumbar scoliosis and lumbar spinal stenosis patients in a nine-year retrospective study.Methods From January 2001 to August 2010,96 patients with degenerative lumbar scoliosis were retrospectively enrolled and 96 patients with lumbar spinal stenosis were selected as controls.Cobb angle,height of the apical disc and the contiguous disc superiorly and inferiorly on convex and concave sides,the height of the convex and concave side of the apical and the contiguous vertebral body superiorly and inferiorly were measured in the scoliosis group.The height of L2/L3,L3/L4,L4/L5 discs and the height of L2/L4 vertebral body was measured in the control group.The grade of intervertebral disc degeneration was evaluated using T2WI sagittal images in both groups.The bone density of lumbar vertebrae was measured with dual-energy X-ray.Results In scoliosis group,the intervertebral disc height on the convex side was greater than the height on the concave side (P ＜0.001 ).The vertebral body height on the convex side was greater than the height on the concave side (P=0.016).There was a significant difference between the scoliosis group and the control group (P=0.003),and between T-value and the rate of osteoporosis between the two groups (both P ＜0.001).Results were verified using multiple linear regression analysis.Conclusions Degenerative lumbar scoliosis is accompanied by height asymmetry between the intervertebral disc and vertebral body regarding the convex and concave surfaces.There is a positive correlation between the angle of scoliosis and the disc index,the degree of degeneration of the intervertebral disc,and a negative correlation between the angle of scoliosis and bone density。

Abstract：Background The surgical outcomes of decompression for thoracic spinal stenosis (TSS) are unfavorable.The purpose of this study was to determine the efficacy of intraoperative ultrasonography during “cave-in” 360° circumferential decompression surgery in patients with TSS.Methods Thirteen patients with TSS underwent “cave-in” 360° circumferential decompression surgery between May 2010 and November 2010.Intraoperative ultrasonography was used after removal of the posterior wall of thoracic spinal canal to assess the morphologic restoration of the spinal cord and the anterior surface of the spinal canal.In seven patients,ultrasonography was used again after circumferential decompression to compare the cross-sectional area of the spinal cord before and after circumferential decompression.Results The average period of follow-up was (12±2) months (range 9-15 months).The Japanese Orthopedic Association score was significantly higher at the final follow-up (8.5±2.1,range 3-10) than preoperatively (5.2±1.1,range 3-7; P ＜0.01).The cross-sectional area of the spinal cord was (30.8±6.6) mm2 before and (53.6±19.1) mm2 after circumferential decompression (P ＜0.01).For five patients with TSS caused by thoracic disc herniation,the levels of circumferential decompression performed corresponded to those expected preoperatively.In contrast,for eight patients with TSS caused by ossification of the posterior longitudinal ligament,on average 1.6t±0.9 fewer levels of circumferential decompression were performed than expected preoperatively.Conclusions “Cave-in” 360° circumferential decompression is an effective therapeutic option for TSS.Intraoperative ultrasonographic evaluation may reduce the levels of circumferential decompression and ensure sufficient decompression,and increase the efficacy of this surgical technique。

Abstract：Background Assessing the radiographic features of knee osteoarthritis (OA),especially joint space narrowing,is important for evaluating disease progression.The purpose of this study was to quantitatively analyze joint space narrowing by measuring 2 new variables:the average joint space width (aJSW) and the articulate angle (AA) on X-ray films,and to evaluate the relationship between the 2 variables,knee function and OA symptoms.Methods Using the web-based radiology viewer (Cedara I-ReachTM 4.1.1),we measured the 2 variables in 50 knees of 41 patients with knee OA participating in the Shanghai OA Study.We also evaluated the Kellgren-Lawrence (K-L) grade,the Western Ontario and McMaster Universities OA Index (WOMAC),and additional questionnaire in OA knees.The study was approved by the ethics committee of Shanghai Ninth People's Hospital (No.2009-28).Results The aJSW correlated with the K-L grade (r=-0.57,P ＜0.001),kneeling (r=0.29,P=0.04),sitting cross-legged on the floor (r=-0.31,P=0.03),WOMAC pain (r=-0.31,P=0.03),WOMAC disability (r=-0.35,P=0.01),pain while squatting (r=-0.37,P=0.01),and defecating in a squatting position (r=-0.39,P=0.01).The AA correlated with defecating in a squatting position (r=0.29,P=0.05),WOMAC disability (r=0.30,P=0.04) and K-L grade (r=0.44,P＝0.003).The K-L grade also correlated with pain while squatting (r=-0.40,P=0.005) and defecating in a squatting position (r=-0.34,P=0.02),WOMAC pain (r=0.30,P=0.04),and WOMAC disability (r=0.30,P=0.04).Conclusions The aJSW closely correlated with knee OA symptoms and function scores,and was more sensitive to knee OA related disabilities than K-L grade and the AA.The aJSW could be used as a new variable for knee OA evaluation。

Abstract：Background This work was carried out to evaluate the clinical efficacy and the complications of S-ROM modular hip arthroplasty combined with transverse subtrochanteric shortening for Crowe type IV congenital dislocation of the hip (CDH).Methods A totoal of 28 consecutive patients with Crowe type IV CDH received treatment using this surgical technique from June 2003 to June 2010.The follow-up was conducted at 3 days,1,6,and 12 months after the operation and later annually at the outpatient of our hospital.Sequential pelvic plain film and normotopia film of the affected hip joint were taken.The limp and the Trendelenburg sign were also assessed,the ischiadic nerve injury was also evaluated by electromyogram,and Harris hip scores were recorded.Results After operation,both the alignment and the position of the transverse osteotomies were good.None of the patients had presented complications of joint infection,prosthesis loosening,joint dislocation,or nerve injury.Conclusions S-ROM modular hip arthroplasty combined with transverse subtrochanteric shortening was a satisfactory and safe technique for the Crowe type IV congenital hip dislocation within a mean follow up of 53 months.Transverse subtrochanteric shortening could effectively prevent the distraction injury of sciatic nerve。

Abstract：Background Total knee arthroplasty (TKA) is a successful surgical technique for patients with advanced knee osteoarthritis; however,some peri-operative complications can not be predicted or avoided completely.This study aimed to investigate the factors affecting limb swelling after primary total knee arthroplasty,to guide and improve patient rehabilitation.Methods Using a hospital database,we retroactively analyzed the mean changes in limb circumferences of 286 consecutive patients who underwent primary unilateral total knee arthroplasty between October 2007 and August 2009.The lower limb circumference change was calculated and analyzed statistically.The influence of age,gender,body mass index,the presence of deep vein thrombosis,methods of anti-coagulation,operation time,hidden blood loss,and type of prosthesis on post-operative lower limb swelling was studied.Results Swelling was most pronounced from the third to the fifth post-operative day and usually occurred in both lower limbs.Swelling was significantly more pronounced in the operated limb than in the non-operated limb.The swelling above the knee was also significantly greater than that below the knee.The change in limb circumference at 10 cm above the knee was significantly different between the patients with body mass index ＜25 kg/m2 and those with body mass index ＞25 kg/m2.However,the change in limb circumference at 10 cm below the knee was not significantly different between the two groups.There was no statistically significant difference in limb swelling between different age groups (P ＞0.05).Similarly,gender,methods of anti-coagulation,the presence of deep vein thrombosis,the type of prosthesis,and operation time did not significantly affect post-operative limb swelling.Multivariate linear regression showed that the factors affecting post-operative limb swelling were body mass index and hidden blood loss.Conclusions Lower limb swelling after total knee arthroplasty is related to early post-operative hidden blood loss.The patient's hemoglobin level should be monitored.The degree of limb swelling is correlated with the patient's body mass index and the amount of hidden blood loss.Early intramuscular deep vein thrombosis formation has little effect on limb swelling。

Abstract：Background Intramedullary nails have been widely used in treating femoral shaft fractures.However,end caps falling into soft tissue intraoperatively may cause trouble to surgeons,prolong operative time and increase radiation exposure.Additionally,difficulties may be encountered when removing nails because of callus formation over the nail tip.We performed a prospective study to compare two types of nails in managing femoral shaft fractures.Methods Group I consisted of seventy-four patients with unilateral femoral shaft fractures treated with cannulated interlocking anatomical femoral intramedullary nails.Group Ⅱ consisted of seventy-eight patients treated with cannulated interlocking anatomical femoral intramedullary nails with tail wires.The patients' ages,fracture severity,duration of operation,fluoroscopy time,blood loss and falls of end caps into soft tissue were recorded.Nails were removed after fracture healing.The duration of operation and blood loss during nail removal were recorded.Results There were no significant differences between groups with respect to age and fracture severity (P＞0.05).End caps fell into soft tissue 17 times in 15 cases in group Ⅰ and 21 times in 16 cases in group Ⅱ.An average of seven minutes was spent recovering a lost cap in group Ⅰ.In group Ⅱ,all lost caps were recovered immediately.The duration of operation and fluoroscopy time in group Ⅱ was significantly less than in group Ⅰ (P ＜0.05).Asymptomatic palpable nodules were detected in 4 cases in group Ⅱ.Nail removals were performed on 58 patients in group Ⅰ and 69 patients in group Ⅱ.The duration of operation,blood loss and complications in group Ⅱ were less than in group Ⅰ (P＜0.05).Conclusion Intramedullary nails with tail wires facilitate both fracture fixation and nail removal,which can be used to treat femoral shaft fractures with less radiation exposure,shorter surgical time and fewer complications。

Abstract：Background Peripheral nerve injury causes a high rate of disability and a huge economic burden,and is currently one of the serious health problems in the world.The use of nerve grafts plays a vital role in repairing nerve defects.Acellular nerve grafts have been widely used in many experimental models as a peripheral nerve substitute.The purpose of this study was to test the biomechanical properties of acellular nerve grafts.Methods Thirty-four fresh sciatic nerves were obtained from 17 adult male Wistar rats (age of 3 months) and randomly assigned to 3 groups:normal control group,nerve segments underwent no treatment and were put in phosphate buffered saline (pH 7.4) and stored at 4℃ until further use; physical method group,nerve segments were frozen at -196℃ and then thawed at 37℃; and chemical method group,nerve segments were chemically extracted with the detergents Triton X-200,sulfobetaine-10 (SB-10) and sulfobetaine-16 (SB-16).After the acellularization process was completed,the structural changes of in the sciatic nerves in each group were observed by hematoxylin-eosin staining and field emission scanning electron microscopy,then biomechanical properties were tested using a mechanical apparatus (Endura TEC ELF 3200,Bose,Boston,USA).Results Hematoxylin-eosin staining and field emission scanning electron microscopy demonstrated that the effects of acellularization,demyelination,and integrity of nerve fiber tube of the chemical method were better than that of the physical method.Biomechanical testing showed that peripheral nerve grafts treated with the chemical method resulted in some decreased biomechanical properties (ultimate load,ultimate stress,ultimate strain,and mechanical work to fracture) compared with normal control nerves,but the differences were not statistically significant (P ＞0.05).Conclusion Nerve treated with the chemical method may be more appropriate for use in implantation than nerve treated with the physical method。

Abstract：Background There is lack of consensus regarding the best option for the treatment of acute Achilles tendon ruptureoperation or non-operation.The purpose of this meta-analysis was to identify and summarize the randomized controlled trials comparing the operative and non-operative lines of treatment of acute Achilles tendon ruptures.Methods We searched multiple databases in English (including EMBASE,PubMed,and OVID) and in Chinese (including CNKI,WANFANG,and VIP),as well as reference lists of articles and main orthopaedic and sports medical journals.Two reviewers independently screened the studies for eligibility,evaluated the quality and extracted data from eligible studies,with confirmation by cross-checking.The major results and conclusions were concluded,and the different complication rates and functional outcomes were compared.Meta-analysis was processed by RevMan 5.0software.Results Eight randomized controlled trials (RCTs) involving 777 patients met the inclusion criteria.The rerupture rate in non-operative group was significantly higher (Z ＝3.33,P ＜0.01).However,the moderate (Z=4.27,P ＜0.01) and minor (Z=5.59,P ＜0.01) complication rate in the operative group were significantly higher.No significant difference in comparing the major and total complication rates.The return to work time in the operative group was shorter (Z=2.65,P ＜0.01).The inability to return to previous level sporting rate and ankle joint decreased range of motion (ROM) rate showed no significant difference in the two groups.Other functional outcomes were similar in the two groups.Conclusions Operation could significantly reduce the risk of rerupture; however,it was associated with a higher risk of other complications.The functional outcomes were similar in two treatment methods except an earlier return to work in patients treated operatively.Thus operative treatment is preferable for patients with good physical condition.Non-operative treatment is an acceptable alternative especially for the older and patients with lower sporting requirements。

Abstract：Background There is currently no consensus regarding the best graft type for anterior cruciate ligament reconstruction.Therefore,the aim of this study was to investigate the effects of patellar and hamstring tendon grafts on long-term knee function after anterior cruciate ligament reconstruction.Methods This meta-analysis was conducted according to the methodological guidelines outlined by the Cochrane Collaboration.An electronic search of the literature was performed and all trials published between January 1966 and August 2011 comparing knee function after anterior cruciate ligament reconstruction using patellar tendon grafts with knee function after reconstruction with hamstring tendon grafts were pooled.Six studies were included in the final meta-analysis.Results Anterior cruciate ligament reconstruction using hamstring tendon grafts resulted in greater pain upon kneeling than reconstruction using pateliar tendon grafts (P=0.001).However,both grafts resulted in similar levels of anterior tibial translation,and similar results regarding isokinetic extension/flexion tests,Lysholm scores,and the stair-hop test (P ＞0.05).Conclusion Anterior cruciate ligament reconstruction using patellar or hamstring tendon grafts results in similar long-term knee function。

Abstract：Background The evidence for non-invasive positive pressure ventilation (NIPPV) used in patients with severe stable chronic obstructive pulmonary disease (COPD) is insufficient.The aim of the meta-analysis was to assess the treatment effects of long-term NIPPV on gas change,lung function,health-related quality of life (HRQL),survival and mortality in severe stable COPD patients.Methods Randomized controlled trials (RCTs) and crossover studies comparing the treatment effects of NIPPV with conventional therapy were identified from electronic databases and reference lists from January 1995 to August 2010.Two reviewers independently assessed study quality.Data were combined using Review Manager 5.0.Both pooled effects and 95％ confidence intervals were calculated.Results Five RCTs and one randomized crossover study with a total of 383 severe stable COPD patients were included.NIPPV improved gas change significantly when using a higher inspiratory positive airway pressures.The weighted mean difference (WMD) for the partial pressure of carbon dioxide in artery (PaCO2) was -3.52 (-5.26,-1.77) mmHg and for the partial pressure of oxygen in artery (PaO2) 2.84 (0.23,5.44) mmHg.There were significant improvements in dyspnea and sleep quality,but gained no benefits on lung function.The standardized mean difference (SMD) for the forced expiratory volume in 1 second (FEV1)was 0.00 (0.29,0.29).And the benefits for exercise tolerance,mood,survival and mortality remained unclear.Conclusions Patients with severe stable COPD can gain some substantial treatment benefits when using NIPPV,especially improvements in gas change,dyspnea and sleep quality.Studies of high methodological quality with large population,especially those based on a higher inspiratory positive airway pressures are required to provide more evidences。

Abstract：Objective This coronary artery spasm review aimed to explore the most possible pathogenic trigger mechanism of vulnerable plaque rupture.Data sources Data used in this coronary artery spasm review were mainly from Medline and Pubmed in English.Study selection These reports from major review on coronary artery spasm.and these research included coronary artery conception,pathogenesis of spasm,mechanisms of plaque rupture,epidemiological evidence,clinical manifestation and the relationship between coronary artery spasm and vulnerable plaque rupture.Results Coronary artery spasm is somehow related to the presence of atherosclerotic intima disease in the coronary artery.However,chronic low-grade inflammation causes coronary vessel smooth muscle cell hypersensitivity,which can directely cause coronary artery spasm.Myocardial infarction and sudden cardiac death may be initiated by a sudden intense localized contraction of coronary artery smooth muscle.Conclusion Coronary artery spasm may be one trigger that can initiate and exacerbate vulnerable plaque rupture。

Abstract：Objective To lessen the occurrence of contrast-induced nephropathy (CIN),the preventive measures of CIN were reviewed.Data sources The data used in this review were from PubMed with relevant English articles and from Chinese Knowledge Information (CNKI) published from 1989 to 2009.The search terms were “contrast medium”,“contrast-induced nephropathy” and “prevention”.Articles involved in prevention of CIN were selected.Study selection CIN is the third most common cause of acute kidney injury and is associated with an unfavorable prognosis.The best treatment is prophylaxis because CIN can not be reversed or ameliorated.Results Thirty articles were included.Among various preventive measures,pericatheterization hydration is almost universally accepted as an appropriate and safe measure to prevent CIN,although there is no agreement as to composition,amount,and timing of hydration.Based on the use of concomitant nephrotoxic agents or high doses of contrast medium (CM) is one of risk factors for CIN,discontinuation of potentially nephrotoxic drugs 2-3 days before and after the procedure until renal function recover,and using the lowest possible dose of CM can decrease the risk of CIN.It is promising that removing the majority of CM from the coronary sinus,before it enters the systemic circulation,during coronary angiography can reduce the risk for CIN in animal studies and in limited clinical trials.Inconsistent data exist with respect to application of some vasodilators (endothelin antagonists and adenosine antagonists) and antioxidants (N-acetylcysteine and statins) in preventing CIN in high-risk patients,and new vasodilators and antioxidants continue to be tested.Conclusions Pericatheterization hydration,discontinuation of nephrotoxic drugs,and using the lowest possible dose of CM are effective measures to lessen the risk for CIN.Other prophylactic strategies and some drugs are promising,but further confirmation is required。

Abstract：Background This study evaluated the feasibility,efficacy and safety of CT-guided percutaneous radiofrequency ablation in patients with spinal osteoid osteoma.Methods Two patients suffered spinal osteoid osteoma were treated with CT-guided percutaneous radiofrequency ablation under local anesthesia.Lesions located in sacral vertebrae and cervical vertebrae,which were adjacent to nerve root and spinal canal respectively.Tumors were treated under 90°C radiofrequency temperature lasting 4 minutes by an electrode placement.Visual analog scale was used to evaluate the pain improvement.Results No complications were observed pre- and post-operation.Patients recovered to normal activities immediately and achieved complete pain relief in 24 hours.No symptoms were recurrent in 5 months and 4 months follow up.Mild scoliosis has been recovered in case 2.Conclusions CT-guided percutaneous radiofrequency ablation of spinal osteoid osteoma is safe,effective and has more clinical benefits.The long-term outcome needs further observation。

Abstract：Background Presacral tumors are highly infrequent tumors located in the space known as presacral or retrorectal space.Although there have been substantial improvements in the prognosis of patients with malignant presacral tumors,the development of newer surgical strategy is likely to further improve the oncologic outcomes of malignant presacral tumors.The aim of this article was to report our experience in 33 cases,and to review the surgical strategy,pathological features and the prevention of complications from our experience.Methods A retrospective analysis was conducted on 33 cases (20 male and 13 female) with presacral tumors surgically treated in our hospital between January 1998 and April 2009.The surgical approaches included trans-abdominal in 10cases (30％),trans-sacral in 18 cases (55％) and combined abdominal-sacral in 5 cases (15％).All patients got followed up (14-123 months,mean of 45.1 months).At last,the general information,clinical symptoms,histodiagnosis,surgical types and postoperative complications of all cases in our series were assessed.Results Ages of 33 patients ranged from 18 to 71 years,with an average of 48.5 years.Pathological findings:6 epidermoid cysts,5 teratomas,3 leiomyomas,9 neurofibromas,5 neurilemmomas,1 enterogenous cyst,1 liposarcoma,1 leiomyosarcoma,1 angiosarcoma,and 1 neurofibrosarcoma.All tumors were excised with no perioperative death.A colostomy was taken in one case with angiosarcoma involving the rectum because of the intraoperative injury of the rectum.Blood loss during surgery was 400-11 000 ml (mean of 2400 ml).Four (12％) cases had local recurrence during follow-up:2 because of inadequate drainage after dermoidectomy,both of them were cured by surgical resection and drainage; recurrence occurred in a case of teratoma in 18 months after surgery,cured by a trans-sacral excision; local recurrence and lung metastasis occurred simultaneously in a case of angiosarcoma in 6 months postoperatively and the patient died one month later of respiratory failure.Conclusions The main treatment of most presacral tumors is surgical resection.Selection of surgical approach is very important for complete resection of the presacral tumors.The location,size and peculiarities of tumors,conditions of the skin and soft tissues and the patients' somatotype are all determinative factors.Multidisciplinary cooperation is also very necessary。

Abstract：Background Laparoendoscopic single-site surgery (LESS) approaches have been reported for treating various kidney and pelvic procedures,and are feasible and effective in selected patients.In this study,we aimed to present the initial experience and evaluate the efficacy of laparoscopic radical prostatectomy performed through a single incision using a multichannel port.Methods Between July 2010 and April 2011,six patients diagnosed with early stage prostate cancer underwent LESS radical prostatectomy (RP) in our institute.A multichannel port was inserted transperitoneally through a 2-cm umbilical incision.Specially articulating and flexible laparoscopic were used.Some technical tricks and points were applied during the operation to overcome the drawbacks and reduce the difficulties of this approach.Two continuous urethrovesical sutures in both sides were performed to complete both lateral aspects of anastomosis.The two ends of the suture threads were fixed by double Lapro-Clips,instead of the difficult knot-tying.Results Total operative time was (265±43) minutes.Mean blood loss was (230±65) ml.All cases were completed successfully,without conversion to open surgery or adding additional abdomen ports.No patient required a blood transfusion and no intraoperative complications occurred.The Foley catheter was removed at the 14th day (range 12th-16th) after surgery.At the 12th week of follow-up,all patients had an undetectable prostate-specific antigen level.Two patients used 2 or 1 pad for continence daily; other patients had achieved good continence.Conclusion In selected cases,LESS-RP is feasible and effective; these technic points and the flexible-articulating instruments are helpful to reduce the operation difficulties。

Abstract：Osteoid osteoma is very rarely located in the patella,and can represent a significant diagnostic challenge,resulting in a delay of treatment.Patients with osteoid osteoma of the patella often present with knee pain that is also a typical symptom of trauma or of other diseases such as arthritis,which are much more common than osteoid osteoma.We present two young male patients diagnosed with osteoid osteoma of the patella.Each of these patients had a history of intense knee pain; however,accurate diagnosis of osteoid osteoma in the patella had been delayed for more than one year.Computed tomography (CT) scans or magnetic resonance imaging (MRI) showed a circumscribed lesion of the patella in both patients,whereas X-ray examination (posteroanterior projection) was not able to detect the tumor.Different surgical procedures were performed in these patients for resection of the tumors,and the pathology findings confirmed the diagnosis of osteoid osteoma.Both patients recovered completely from surgery。

Abstract：A patient with both a femoral attachment injury (peel-off injury) and musculotendinous junction avulsion of the popliteus,a so-called “floating popliteus tendon injury”,received arthroscopy-assisted popliteus reconstruction.The injured ligaments were addressed in the same procedure,including mini-open direct repair of the femoral avulsed fibular collateral ligament (FCL),suture repair of the grade 3 medial collateral ligament (MCL),and reconstruction of the posterior cruciate ligament (PCL)。

Abstract：Diagnosis of spontaneous coronary artery dissection (SCAD) is challenging because of its rarity and uncertain etiology.It frequently occurs in young women during pregnancy and in the postpartum period,and rarely found in elder women with no history of cardiovascular disease or coronary risk factors.In this article we report a case of SCAD in a 75-year-old woman without traditional cardiovascular risk factors who presented with syncope and mild chest discomfort.There were no abnormal electrocardiographic changes and no elevated cardiac enzymes were detected.Computed tomography of brain revealed nothing abnormal.Coronary artery disease was suspected.Coronary angiogram revealed dissection in the middle left circumflex artery.The patient underwent percutaneous transluminal coronary angioplasty and was free of symptoms at 6-month follow-up.Our report suggests that emergency coronary angiography is indicated if syncope caused by coronary artery disease is suspected。

Abstract：We present a case of severe persisting unconjugated hyperbilirubinemia in a Uigur infant boy,eventually diagnosed as Crigler-Najjar syndrome type I.DNA analysis of his blood of the UGT1A1 gene sequence demonstrated that he was homozygous for an insertion mutation causing a change of the coding exons with a frame-shift,resulting in the substitution of 27 abnormal amino acid residues in his hepatic bilirubin uridine diphosphoglucuronyl transferase enzyme.Both of his parents were heterozygous for the same mutation.A novel frame-shifting mutation of the UGT1A1 gene was found,confirming the diagnosis of Crigler-Najjar syndrome type Ⅰ for this patient。

Abstract：Endovascular aneurysm repair (EVAR) has been proven to be an effective and safe technique for abdominal or iliac artery aneurysm.However,for aneurysms extending to both iliac bifurcations,routine EVAR will occlude both internal iliac arteries (IIAs),which may increase the risk for pelvic ischemia.New endovascular techniques have been developed to preserve the pelvic perfusion in EVAR for such situation.This article reports an endovascular repair of an aortoiliac aneurysm with an external iliac artery (EIA) to the IIA endograft to preserve the pelvic perfusion.First,an endograft was advanced into the left IIA under the help of an inflated aortic balloon.Coils were deployed to embolize the distal type-1 endoleak from the tunnel around the endograft,and an aortouniiliac endograft and an iliac extension were deployed below the renal arteries extending to the right EIA.Finally,a right-to-left femoro-femoral artery bypass was constructed.Angiography at completion and computed tomography after 6 months demonstrated patency of all grafts and complete exclusion of the aneurysm without any endoleak.Endovascular repair with an EIA-to-IIA endograft to preserve the pelvic inflow is a feasible and effective technique for aortoiliac aneurysms.Coil embolization might be an option to repair the distal type of endoleak.The balloon assisted U-turn technique may help advance the endovascular device over a sharp-angled vessel bifurcation。

Abstract：An internal-external fixator for stabilization in three cases with unstable pelvic fractures were reported.Compared with external fixation,the internal-external fixator,which is placed in the subcutaneous layer,decreased the risk of pin-track infection,pin site pain,and bowel obstruction; meanwhile,it had the advantage of external fixation:it was easy to apply,controlled damage,and resulted in minimal injury。

Abstract：When a large visceral artery is ruptured,uncontrolled bleeding may lead to hemodynamic collapse.Use of endovascular occlusion balloon catheter may provide rapid control of hemorrhage and facilitate definitive therapy.We reported two patients with massive hemorrhage from ruptured celiac-hepatic artery after pancreaticoduodenectomy,who were initially treated percutaneously by temporary selective balloon occlusion.They became critically hemodynamic unstable during the angiographic procedure.Through an 8Fr sheath,a 6Fr compliant latex occlusion balloon was placed proximal to the celiac trunk and inflated,and upon patient stabilization surgical revision and stent-graft placement were successfully performed in the two patients,respectively.Temporary selective balloon occlusion provides fast and effective bleeding control for patient with critically uncontrollable visceral arterial hemorrhage,permitting subsequent use of conventional techniques for management of the arterial bleeding source。

Abstract：Internal lenticonus is a very rare morphologic abnormality of crystalline lens which has been reported in only several cases in the literature.We herein reported the clinical characteristics and surgical findings of the anterior internal lenticonus accompanied by congenital nuclear cataract.Cataract extraction accompanied with intraocular lens implantation was uneventfully performed,and a good visual outcome was achieved in this case.Viral infection during embryonal and fetal period might account for the formation of the anterior internal lenticonus and congenital nuclear cataract in our case。