2013年 · 第126卷第20期

To the editor:The diagnosis of juvenile dermatomyositis (JDM) is much more challenging when lacking the cutaneous manifestations as well as muscular biomarkers.Here we report an interesting case of JDM. A 15-year-old boy was admitted to our hospital due to progressive weakness of limbs for about one year.He reported a weight loss of 5 kg and no family history of musculoskeletal disease.On physical examination,his cheek was a little swelling,but there was no rash or lymphadenopathy.Neurologic examination revealed muscle atrophy in the trunk and limbs while muscle tenderness was negative.Bilateral symmetric muscle weakness affected the proximal shoulder and hip-girdle muscles in the scale of 2-3.He was walking in a waddling gait while the Gower's sign was positive。

Increasing human longevity is complicated by aging related physiological deteriorations.Osteoporosis,weakening of the skeletal bony units,is one of the major concerns which has developed into a major public health problem.1 According to the World Health Organization,osteoporosis affects approximately 75 million people in Europe,USA,and Japan.Although data are not available in China,with her large population,a vast number of people would be expected to be affected。

Chines,e arthroplasty has made great progresses since the 1970 s,treating almost all the diarthrosis from hip to knee,shoulder,elbow,ankle and interphalangeal joints.Hip and knee,among them,are the most representative ones. CURRENT STATUS OF CHINESE ARTHROPLASTY Epidermiology According to the result of the national survey of 1275 of 1383 hospitals (92.3％) conducted in 31 provinces in 2005,the numbers of total joint arthroplasty (TJA) procedures was increasing at 14％-20％ per year and numbered 34 395 cases in 2005.Based on the personal estimation of the author,there have been approximately 280 000 total hip/knee arthroplasty (THA/TKA) cases as of 2012,including 200 000 THA cases and 80 000 TKA cases.In the USA,however,over 600 000 TKA had been performed in just one year (2008).1 We strongly believe that there will be an explosive increase of TJA cases in China in the coming years with the improvement of economic level,medical insurance policy,surgical techniques in arthroplasty and the predicted increased life span (Table 1)。

Abstract：Background Cervical disc arthroplasty is an alternative surgery to standard cervical decompression and fusion for disc degeneration.Different types of cervical disc prosthesis are used in China.The aim of this study was to evaluate the radiographic outcomes of cervical arthroplasty using the ProDisc-C prosthesis.Methods Radiographic evaluation,including static and dynamic flexion-extension lateral images,was performed at baseline and at final follow-up.Results Twenty six patients who had single-level ProDisc-C arthroplasty were followed up for a mean period of 63 months (56-76 months).The range of motion at the operated level was 9.3°±3.7° at baseline and 7.3°±3.5° at final follow-up,with a significant difference (P ＜0.05).Seventeen of 26 levels (65.4％) developed heterotopic ossification:three were classified as grade Ⅱ,13 were classified as grade Ⅲ,and 1 as grade Ⅳ,according to McAfee's classification.Forty nine adjacent segments were evaluated by lateral Ⅹ-ray and 18 (36.7％) segments developed adjacent segment degenerations.Conclusions ProDisc-C arthroplasty had acceptable radiographic results at 5-year follow-up.The range of motion was preserved.However,more than 60％ of the patients developed heterotopic ossification。

Abstract：Background Bryan cervical disc arthroplasty can be used to restore and maintain the mobility and function of the involved cervical spinal segments.The efficiency of posterior longitudinal ligament (PLL) resection in anterior cervical decompression and fusion has been demonstrated.However,no clinical reports have compared PLL removal with preservation in Bryan cervical disc arthroplasty.This study aimed to assess the role of removal of PLL in Bryan cervical disc arthroplasty at an 18-month follow-up.Methods We performed a prospective investigation of clinical and radiological outcomes in patients after Bryan cervical disc arthroplasty.Sixty patients who underwent Bryan cervical disc arthroplasty were included.The PLL was removed in 35 patients (investigational group) and preserved in 25 patients (control group).All of the patients were followed up for more than 18 months.Clinical (Japanese Orthopedic Association score and Visual Analogue Scale pain score) and radiological (functional spinal unit (FSU) angle,range of movement (ROM),and diameter of the spinal cord) parameters were compared between the two groups before and after surgery (18 months).Results Clinical outcomes in the investigational group were significantly superior to those in the control group.There were no significant differences in the FSU angle and ROM (P=-0.41 and 0.16,respectively) between the two groups.However,the increase in diameter of the spinal cord in the investigational group was significantly greater than that in the control group (P ＜0.01).Conclusions Removal of the PLL can improve the clinical outcomes of Bryan cervical disc arthroplasty.This procedure does not have a large effect on imbalance and motion of the cervical spine。

Abstract：Background Wound infection following spinal instrumented surgery is a frequent complication.The optimal treatment of acute deep wound infection following spinal instrumentation fusion remains controversial because of variability in cohort identification,definition of an infection,and the instrument used to measure outcomes.This retrospective study evaluated the clinical curative effect for postoperative spinal infection after instrumented spine fusion with extensive debridement,or implant removal.Methods From January 2004 to October 2009,851 patients were identified who underwent surgical treatment of spinal diseases.The medical records of patients who developed infections were reviewed in detail.Results Of 851 patients,41 (4.9％) developed an infection.Thirty-three were acute,and eight were delayed.Acute infected cases were managed with antibiotic therapy,and aggressive debridement of the wound and soft tissues leaving all instrumentation in situ in all but one patient.The most common symptoms of acute infection included:posterior incisional drainage (26 of 33 patients),back pain (22 of 33 patients) and fever (13 of 33 patients).Among patients with delayed onset infection,five of eight patients had local pain,four of eight patients had incision drainage,and one patient had a prolonged period of intermittent fever.The most frequent causative organism for postoperative spinal infection following spine surgery is Staphylococcus aureus.Pseudarthrosis was noted in long-term follow-up in four of 41 patients.Conclusions We recommend irrigation and debridement,no instrumentation removal,and,if necessary,repeat debridement followed by delayed primary closure for the treatment of acute deep infection with instrumentation。

Abstract：Background Surgical treatment of thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) is technically demanding,and the results tend to be unfavorable.Various operative approaches and treatment strategies have been attempted,and posterior decompression with transforaminal thoracic interbody fusion (PTTIF) may be the optimal method with which the anterior-posterior compression was removed in one step.It is comparatively less traumatic with fewer serious complications.Methods Sixteen patients with thoracic myelopathy due to concurrent OLF and OPLL at the same level underwent PTTIF.We investigated clinical outcomes and neurological improvements.Magnetic resonance imaging (MRI) was performed on all patients preoperatively and postoperatively,and intramedullary signal changes were evaluated.Results The mean operating time was 275 minutes,and the mean operative bleeding amount was 1031 ml.Cerebrospinal fluid leakage occurred in three patients and healed well after repair.Neurological symptom deterioration occurred in one patient,but the patient recovered to nearly the preoperative level after methylprednisolone treatment.The follow-up period ranged from 28 to 47 months.The mean score on the Japanese Orthopedic Association scale improved from 4.3±1.2 preoperatively to 7.3±1.7 at 3 months postoperatively to 8.5±1.5 at the final follow-up (P ＜0.01),with a recovery rate of (63.6±20.0)％.Postoperative images showed a significant improvement in local kyphosis (P ＜0.01).Eleven patients (68.8％) showed increased signal intensity (ISI) on preoperative T2-weighted MRI.At the final follow-up,the intramedullary ISI totally recovered in five patients.Neurological improvement was worse in patients with persistent ISI than in the other patients (P ＜0.05).Conclusions PTTIF is an effective therapeutic option for combined OPLL and OLF and provides satisfactory neurological recovery and stabilized thoracic fusion through a single posterior approach.Intramedullary signal changes do not always indicate a poor prognosis; only irreversible ISI is correlated with a poor clinical result。

Abstract：Background With aging,the human fracture risk gradually increase.This is mainly due to the corresponding changes of the biomechanical parameters of human bone presents with aging.We measured the microstructural parameters of lumbar bone from women in several age groups by micro-computed tomography and scanning electron microscopy.We observed changes in lumbar cancellous bone mineral density and in biomechanical parameters with aging to elucidate the relationship between age and risk of fracture.We provide theoretical support for human pathology,fracture risk increased with age and the individualized of each age group.Methods Thirty-two fresh L3 vertebral bodies were donated from 32 women,aged 20-59 years and were divided into four age groups:20 to 29 years (group A); 30 to 39 years (group B); 40 to 49 years (group C); and 50 to 59 years (group D).Conventional lumbar separation was performed by removing soft tissue and subsidiary structures,leaving only the vertebral body.The vertebral body was cut into halves along the median sagittal plane,maintaining the upper and lower end-plates of each half,and used for biomechanical,morphological,and density measurements.Results Comparing group A to B,the rod-like trabecular thickness (Tb.Th) decreased; the trabecular spacing (Tb.Sp) increased; the plate-like Tb.Th decreased; bone mineral density,tissue mineral density,bone volume fraction,and bone surface fraction decreased,and the elastic modulus and the ultimate stress decreased (all changes P ＜0.05).Similar significant (P ＜ 0.05) trends were obtained when comparing group C to D.With aging,the collagen cross-linking capacity declined,the thickness of the collagen fibrils was variable (ranging from almost the same to loose,sparse,or disordered),and the finer collagen fibrils between the thick filaments were disorganized.Conclusions In women aged 20 to 59 years,the rod-like and plate-like Tb.Th of the vertebral body decreased,while Tb.Sp increased.Additionally,the density,elastic modulus,and ultimate stress of the cancellous bone decreased with age.These associated changes in bone microstructure,density,and biomechanics with age may lead to an increasing risk of osteoporosis and fracture。

Abstract：Background This study was designed to analyze three tibial axis reference lines including the anterior tibial cortex (ATC) line,the fibular line (FL),and the anatomical axis of tibia (AAT) line,to determine which line most closely parallels the mechanical axis (MA) of the tibia in the sagittal plane.The clinical relevance of the study is that through finding a reliable landmark on the leg,a surgeon may minimize posterior tibial slope measurement errors thereby and improving the technique for assuring proper alignment of total knee arthroplasty.Methods The material for this study included CT scans of the tibia from 85 consecutive patients and 168 knees (78 without osteoarthritis (OA) and 90 knees with OA).Measurements of the angles between the tibial mechanical axis and each of three reference lines in the sagittal plane were carried out using 3D imaging software.Results Mean angles of 168 knees were as follows:aMT (3.96±0.85)°,aMF (0.70±0.58)°,and aMA (1.40±0.66)°,(aMT:an angle between MA and ATC,aMF:an angle between MA and FL,aMA:an angle between MA and AAT.All abovementioned angles were measured in the sagittal plane of tibia) and the aMF was significantly smaller than the others (P ＜0.0001).The mean value of the medial tibial slope angle vs.the MA was (9.19±3.97)°,and this was significantly larger than the mean lateral slope angle of (6.62±4.23)° (P ＜0.0001).The difference between aMF without OA and with OA was not statistically significant (P=0.5015) and the association between the aMT and aMA was strong (r=0.82,P ＜0.01).Conclusions FL was more closely parallel to the MA of tibia,and more showed less variation between OA and nonOA controls than ATC and AAT lines.Furthermore,the amount of posterior slope in medial plateau was greater than that in lateral plateau.The findings of this analysis suggest that when using the anterior tibial cortex line as is commonly done with extramedullary tibial resection guides,the tibial resection should be sloped approximately four degrees more posteriorly。

Abstract：Background Osteonecrosis of the femoral head (ONFH) is the result of dysfunctional blood supply,but associations between specific damaged arteries,imaging changes and clinical sign require more understanding.We investigated characteristics of ONFH that pertain to blood supply,imaging appearance,and clinical feature to judge the prognosis of ONFH.Methods Clinical data were collected for 92 patients (118 hips) with ONFH,including gender,age,duration of pain (from initial clinical presentation to arthroplasty),cause,stage,and classification.Magmatic resonance imaging and Ⅹ-rays were obtained of all patients to diagnose ONFH.The sizes of lesions were classified by necrotic index.The location of necrosis was classified as Type A,B,or C using the grading system by magmatic resonance imaging and Ⅹ-rays.All hips were imaged with digital subtraction angiography to visualize their blood-supply characteristics.Hips were divided into groups based on the source artery for femoral head damage:superior retinacular artery (S),inferior retinacular artery (Ⅰ),and combined superior and inferior retinacular arteries (S+I).Via digital subtraction angiography,imaging appearances and clinical data in three groups were compared.Results ONFH was caused by damage in either the superior or inferior retinacular artery,or both,in all of 118 hips.The group with only inferior retinacular artery damage reported longer hip pain duration than the other groups.The probability of the lesion extending laterally to the acetabular edge in group S was much more than it in group Ⅰ.Necrosis indices of the patients in S and S+I were higher than those in group I.Conclusions ONFH associated with interruption of the superior and inferior retinacular arteries in this study.When the former alone was damaged,the necrosis of the volume was larger,the risk of femoral head collapse was higher and the time from initial clinical presentation to arthroplasty was shorter。

Abstract：Background Multimodal cocktail periarticular injection (MCPI) with a large volume of low concentration local anesthetics,adrenaline,and anti-inflammatory agents such as non-steroidal anti-inflammatory drug or steroids have shown good pain control and improvement in range of motion after surgery.This study compares the efficacy of pain control after total knee arthroplasty,using multimodal cocktail periarticular injection with steroid or without steroid.Methods This is a prospective,double-blinded,randomized and control study.Seventy-two patients with osteoarthritis that met clinical criteria for total knee arthroplasty were recruited into the study,and were randomized to receive either multimodal cocktail periarticular injection with steroid or without steroid.Pain was assessed by visual analogue scale (VAS) at preoperative and postoperative at rest,and during activity.The range of motion was recorded preoperatively and postoperatively.The amount of daily and cumulative morphine consumption were measured by patient-controlled analgesia in the first 72 hours postoperatively.The duration of celecoxib usage was also recorded at the last follow-up.Results There were no differences between the non-steroid and steroid groups with regard to VAS at rest and during activity,or range of motion,at any postoperative observation time.The postoperative Knee Society Knee Score in the steroid group improved significantly as compared with that in non-steroid group at the one-month (84.1±13.1 and 65.9±12.1; P ＜0.0045),three-month follow-up (90.2±16.3 and 72.5±16.6; P ＜0.0027),but after postoperative six-month the Knee Society Knee Score showed no significant difference between the groups.There was no significant difference in consumption of the morphine about daily or total consumption within 72 hours between the two groups.The duration of celecoxib usage in patients in the steroid group was significantly shorter than that in the non-steroid group ((7.2±0.7) compared with (10.5±1.9) weeks; P=-0.012).Conclusion The patients who received the steroid injection had faster rehabilitation and less non-steroidal antiinflammatory drugs consumption。

Abstract：Background Patellar fracture and cruciate ligament injury are a common consequence of traumatic knee injury.Patellar fracture combined with cruciate ligament injury is rarely reported,although the mechanisms of two things are similar.This study aimed to evaluate the incidence of closed patella fracture combined with cruciate ligament injury.Methods From 2012 March 1 to June 30,magnetic resonance images of 60 patients with unilateral closed patellar fracture were studied in our institution.The mean age of the patients at presentation was 40.2 years (range,13-64 years) and 48 patients were men.First,patients were divided according to the cause of injury.Twenty-eight patients had highenergy trauma from a falling injury or motor vehicle accident,and 32 patients had low-energy trauma resulting from a tumbling injury.Second,according to the fracture pattern,31 patients had a transverse fracture and 29 patients had a comminuted fracture.Results We found seven cases of closed patellar fracture combined with cruciate ligament injury among 60 patients,including two cases of a completely ruptured posterior cruciate ligament,two with a partially torn posterior cruciate ligament,and three with a partially torn anterior cruciate ligament.The percentage of this combined injury was 11.6％ (7/60).The incidence of a combined injury of the cruciate ligament with a comminuted fracture (6/29,20.7％) was significantly higher than that with a transverse fracture (1/31,3.2％,P ＜0.05).The most common mechanism of injury in patellar fracture combined with cruciate ligament injury was high-energy trauma from road traffic accidents (94％),whereas in the patellar fracture alone,it was tumbling (62％).The incidence of combined injury with high-energy trauma (6/28,21.4％) was significantly higher than that with low-energy trauma (1/32,3.1％,P ＜0.05).Conclusions These data suggest that high-energy trauma often results in a comminuted patellar fracture,which is often combined with cruciate ligament injury.Traffic accidents are the main risk factor for this combined injury.Understanding the relationship between patellar fracture and cruciate ligament injury for diagnosis and treatment is important。

Abstract：Background Surgical treatment of insertional Achilles tendinopathy should be considered when a variety of conservative measures fail.To achieve a satisfactory outcome,thorough debridement of the Achilles tendon is critical,besides excision of the bursitis and the calcaneal exostosis.Central tendon-splitting provides straightforward access to the calcified or degenerative tissue within the Achilles tendon.For Achilles tendon reconstruction if detachment is present,several surgical techniques have been reported.Controversy surrounds the technique can provide maximum security for reattachment of the Achilles tendon.The SutureBridge double-row construct,initially used in rotator cuff repair,is probably a good choice.Methods Ten consecutive patients with insertional Achilles tendinopathy underwent tendon reattachment using the SutureBridge technique through a central tendon-splitting approach.We retrospectively evaluated the surgical outcomes,which included pre-and postoperative visual analog scale (VAS),postoperative Maryland Foot Score (MFS),postoperative range of motion of the affected ankle,and related complications.Follow-up was performed in the outpatient department.Results One patient was lost to follow-up.Nine patients (two male and seven female; 12 feet) were reviewed with a minimum follow-up of six months (range 6-30 months).The postoperative VAS pain scores were markedly lower than the preoperative scores.Postoperative MFS was 92.1±8.0 (range 74-100).No intra-or postoperative complications were found,except for one case of delayed healing incision.At last follow-up,all affected ankles achieved their normal range of motion,and patients were able to resume daily activities without any assistive device.Conclusions Although a randomized control trial with a larger sample may be necessary to compare the central tendonsplitting combined with the SutureBridge technique with other techniques,our results confirmed that it was a promising alternative for treatment of insertional Achilles tendinopathy。

Abstract：Background Mortality rates for patients with gas gangrene from trauma or surgery are as high as 25％,but they increase to 50％-80％ for patients injured in natural hazards.Early diagnosis and treatment are essential for these patients.Methods We retrospectively analyzed the clinical characteristics and therapeutic results of 19 patients with gas gangrene of the limbs,who were injured in the May 2008 earthquake in the Wenchuan district of China's Sichuan province and treated in our hospital,to seek how to best diagnose and treat earthquake-induced gas gangrene.Results Of 226 patients with limbs open injuries sustained during the earthquake,53 patients undenwent smear analysis of wound exudates and gas gangrene was diagnosed in 19 patients.The average elapsed time from injury to arrival at the hospital was 72 hours,from injury to definitive diagnosis was 4.3 days,and from diagnosis to conversion of negative findings on wound smear analysis to positive findings was 12.7 days.Anaerobic cultures were also obtained before wound closure.The average elapsed time from completion of surgery to recovery of normal vital signs was 6.3 days.Of the 19 patients,16 were treated with open amputation,two with closed amputation,and 1 with successful limb salvage; 18 patients were successfully treated and one died.Conclusions In earthquakes,rapid,accurate screening and isolation are essential to successful treatment of gas gangrene and helpful in preventing nosocomial diffusion.Early and thorough debridement,open amputation,and active supportive treatment can produce satisfactory therapeutic results。

Abstract：Background Olfactory ensheathing cell (OEC) transplantation is a promising or potential therapy for spinal cord injury (SCI).However,the effects of injecting OECs directly into SCI site have been limited and unsatisfied due to the complexity of SCI.To improve the outcome,proper biomaterials are thought to be helpful since these materials would allow the cells to grow three-dimensionally and guide cell migration.Methods In this study,we made a new peptide hydrogel scaffold named GRGDSPmx by mixing the pure RADA16 and designer peptide RADA16-GRGDSP solution,and we examined the molecular integration of the mixed nanofiber scaffolds using atomic force microscopy.In addition,we have studied the behavior of OECs in GRGDSPmx condition as well as on RADA16 scaffold by analyzing their phenotypes including cell proliferation,apoptosis,survival,and morphology.Results The experimental results showed that GRGDSPmx could be self-assembled to form a hydrogel.Inverted optical microscopic and scanning electron microscopic analyses showed that OECs are viable and they proliferate within the nanostructured environment of the scaffold.Thiazolyl blue (MTT) assay demonstrated that OEC proliferation rate was increased on GRGDSPmx scaffold compared with the pure RADA16 scaffold.In addition,OECs on GRGDSPmx scaffolds also showed less apoptosis and maintained the original spindle-shaped morphology.Calcein-AM/PI fluorescence staining revealed that OECs cultured on GRGDSPmx grew well and the viable cell count was 95％.Conclusion These results suggested that this new hydrogel scaffold provided an ideal substrate for OEC threedimensional culture and suggested its further application for SCI repair。

Abstract：Background Percutaneous vertebroplasty (PKP) has proved its effectiveness regarding minimal invasion,rapid pain reduction,safe cement augmentation,restoring vertebral height,and accelerating complete recovery of osteoporotic vertebral compression fractures (OVCFs).Whether unipedicular or bipedicular PKP provides a better outcome is controversial.Methods We searched PubMed,Cochrane Database of Systematic Reviews,Cochrane Central Register of Controlled Trials,Web of Knowledge,Chinese Biomedical Literature Database,and Wanfang Data from January 1980 to March 2013 with "kyphoplasty","unipedicular","bipedicular","compression fracture",and "randomized controlled trial".Risk of bias in the included studies was assessed according to a 12-item scale.Meta-analysis was performed.Dichotomous and continuous variables were calculated using the odds ratio (OR) and standardized mean difference (SMD),respectively.Results Seven studies involving 440 patients and 559 vertebral bodies met the criteria for inclusion.Among them,one randomized controlled trial had a high risk of bias and six a low risk.The pain visual analogue scale (VAS) SMDs were -0.02 (P=0.88) for short-term follow-up (≤3 months) and 0.03 (P=0.82) for long-term follow-up (≥ 1 year).Oswestry Disability Index (ODI) SMDs at short-and long-term follow-up were not statistically significant (-0.04,P=0.77 and-0.07,P=0.74,respectively).This meta-analysis showed greater polymethylmethacrylate volume (SMD-1.08,P=0.00) and operation time (SMD-2.40,P=0.00),favoring unipedicular PKP.Radiographic outcomes-preoperative kyphosis angle,restoration rate,reduction angle,loss of reduction angle-were not statistically different between the groups.Pooled analyses of cement leakage and subsequent adjacent OVCFs showed no significant differences between the groups,with OR=0.82 (P=0.79) and OR=1.41 (P=0.70),respectively.Conclusions This meta-analysis comparing unipedicular and bipedicular PKP demonstrated no significant differences regarding VAS,ODI,radiographic outcomes,or complications.Considering the longer operation time and radiation exposure with bipedicular PKP,we recommend unipedicular PKP over bipedicular PKP for treating OVCFs。

Abstract：Background Transforaminal lumbar interbody fusion (TLIF) through a minimally invasive approach (mTLIF) was introduced to reduce soft tissue injury and speed recovery.Studies with small numbers of patients have been carried out,comparing mTLIF with traditional open TLIF (oTLIF),but inconsistent outcomes were reported.Methods We conducted a meta-analysis to evaluate the effectiveness of mTLIF and oTLIF in the treatment of degenerative lumbar disease.We searched PubMed,Embase and Cochrane Database of Systematic Reviews in March 2013 for studies directly comparing mTLIF and oTLIF.Patient characteristics,interventions,surgical-related messages,early recovery parameters,long-term clinical outcomes,and complications were extracted and relevant results were pooled.Results Twelve cohort studies with a total of 830 patients were identified.No significant difference regarding average operating time was observed when comparing mTLIF group with oTLIF group (-0.35 minute,95％ confidence interval (C/):-20.82 to 20.13 minutes).Intraoperative blood loss (-232.91 ml,95％ CI:-322.48 to-143.33 ml) and postoperative drainage (-111.24.ml,95％ CI:-177.43 to-45.05 ml) were significantly lower in the mTLIF group.A shorter hospital stay by about two days was observed in patients who underwent mTLIF (-2.11 days,95％ CI:-2.76 to-1.45 days).With regard to long-term clinical outcomes,no significant difference in visual analog scale score (-0.25,95％ CI:-0.63 to 0.13) was observed; however,there was a slight improvement in Oswestry Disability Index (-1.42,95％ CI:-2.79 to-0.04) during a minimum of 1-year follow-up between the two groups.The incidence of complications did not differ significantly between the procedures (RR=1.06,95％ CI:0.7 to 1.59).Reoperation was more common in patients in mTLIF group than in oTLIF group (5％ vs.2.9％),but this difference was not significant (RR=1.62,95％ CI:0.75 to 3.51).Conclusion Current evidence suggests that,compared with traditional open surgery,mTLIF reduces blood loss and allows early postoperative recovery,while achieving comparable or slightly better long-term outcomes,and with a comparable risk of complications。

Abstract：Objective The objective of this article is to summarize the development of evaluation and treatment of posterior malleolus fracture (PMF).Data sources Data used in this review were mainly from English literature of PubMed data base.Study selection Articles were included in this review if they were related to the PMF or trimalleolar fracture.Results No consensus was found regarding what sizes of posterior malleolus fragments would lead to ankle instability thus affecting prognosis and should be fixed.Ⅹ-ray measurement is unreliable,while CT scan is widely recommended and it can recognize the occult posterior malleolus fractures associated with tibia shaft fractures,which are always undetected previously.Direct posterior malleolus fixation is suitable to stabilize syndesmotic injury.The basic and clinical researches support direct reduction and buttress plate fixation of posterior malleolus fracture through the posterolateral approach.Operative indications and timing of weight bearing are still in discussion.Conclusions Knowing whether ankle instability occurs and the proper methods to diagnose,evaluate,and operate can help manage the fracture.Further biomechanical research on ankle stability and clinical study to compare various treatment methods are required。

For healthcare organizations,there is increasing needs to share data among applications to deliver quality patient care.It is a key for successful diagnosis and treatment to view accurate and up-to-date patient data in a single information dashboard in real time.But the fact is that many hospitals and healthcare providers today are struggling with legacy system or internally developed systems that cannot easily scale to support new interfaces;the plethora of inflexible point-to-point interfaces make changing in one system deleteriously impact other systems;some systems could not support information sharing;and the standards followed by different systems are not compatible to each other.This is making it increasingly difficult to meet the rapidly changing and demanding of healthcare service。

With improvements in the technology of clinical diagnosis of aortic diseases,more and more cases have been found on such vascular lesions as aortic dissection and abdominal aortic aneurysm,which lead to aortic biomechanical changes.Aortic biomechanics research will become a hot spot in the near future.At the same time,stent grafts (SGs) are widely used in the endovascular treatment of vascular diseases.The biomechanical properties of SGs will also become a focus of research.Understanding the relation between the aorta and SGs will better cater to clinical services by improving the success rate of surgery for aortic diseases and reducing intraoperative and postoperative complications.This article reviews researches on the biomechanics of the aorta and SGs。

Meniscal allograft transplantation (MAT) may offer an attractive alternative to restore the normal biomechanical structure of knees.The mean early failure rate (≤2 years) of MAT is approximately 10％.1-3 A successful outcome of MAT depends on the ligamentous stability of knee,limb alignment,graft types,and graft fixation methods.4,5 Graft fixations include the meniscal homs and the peripheral rim.Techniques for fixation of the peripheral rim include sutures or a meniscal repair device such as FasT-Fix (Smith & Nephew Inc,Andover,MA,USA).Here we present an unusual case of early graft failure using FasT-Fix sutured to the peripheral rim of the graft。

Congenital insensitivity to pain with anhidrosis (CIPA) is an autosomal recessive form of sensory neuropathy manifesting with the lack of perception of pain.1 There have been few reports of Charcot spine in patients with CIPA,2 and surgery for such cases was accompanied by high revision proportion.3,4 The purpose of this report is to describe a patient with CIPA who developed a recurrent Charcot arthropathy in her lumbar spine and was treated by revision surgery,with the aim to discuss the strategy of surgical management for such cases。

Patella infera is a rare condition caused by pathological shortening of the patellar tendon.The term "patella infera" was coined by Caton et al1 in 1982 and the condition can severely affect knee function.Patella infera has been reported as a complication of non-operative treatment for patellar fracture;2 anterior cruciate ligament reconstruction;tibial tubercle osteotomy;surgically-treated patellar fracture;unicompartmental and total knee replacement;high tibial osteotomy;surgically-treated habitual dislocation with coexistent patella alta;and retrograde nail insertion for femoral shaft fracture.Traumatic causes of patella infera include quadriceps tendon rupture,femoral shaft fracture,and intraarticular fracture of the knee.3 Our case occurred because of closed trauma on the patellar tendon leading to partial cicatricial contracture of the patellar tendon and eventual patella infera.Z-plasty lengthening of the patellar tendon and post-operative rehabilitation were effective treatments.Despite its association with other injuries and surgeries around the knee,no previous report has discussed the connection between closed traumatic contracture of the patellar tendon and patella infera。

Isolated extramedullary ocular relapse of acute lymphoblastic leukemia (ALL) after allogeneic peripheral blood stem cell transplantation (allo-PBSCT) without concomitant involvement of the bone marrow is very rare,while the common sites of extramedullary relapse are the central nervous system,skin,bone,and breasts.1 This is the report of isolated ocular relapse without any extraocular involvement of ALL after allo-PBSCT confirmed by histopathology。

Atorvastatin (trade name:Lipitor,Pfizer) is a common medicine for hyperlipidemia,but eosinophilia caused by atorvastatin is a rare condition.The exclusion method was used to look for specific causes of eosinophilia.It requires a long-term follow-up and step by step confirmation.Switching to another statin may be one of the treatment options。

To the editor:Systemic lupus erythematosus (SLE) can have multiple neuropsychiatric manifestations,which also are main reasons of disability and death.Neuromyelitis optica (Devic's syndrome/NMO) is one of the rarest and most serious neurological manifestations,with limited cases reported.1 Here,we report a patient who developed neuromyelitis optica with SLE。

To the editor:We report a 23-year-old Chinese man,who presented with a 2-month history of recurrent eruptions of asymptomatic,red,necrotic papules on his face and extremities.The skin lesions would regress spontaneously within several days,leaving atrophic scars.He had no systemic symptoms.A physical examination revealed many papules and nodules on his trunk and extremities (Figure IA).Some papules had a necrotic center covered by black crusts.No lymphadenopathy was found.The results of peripheral blood counts,biochemical tests and urinalysis were within normal limits.The findings of chest CT and abdominal ultrasonography were unremarkable.Histological evaluation of the biopsy specimens from the abdomen and thigh showed lymphoid infiltrations in the dermis and superficial subcutaneous layer.The infiltrates in the superficial dermis were denser,composed of medium-to-large,atypical lymphoid cells with round or slightly irregular nuclei and showed pronounced epidermotropism,with scattered necrotic keratinocytes (Figure 1B)。

To the editor:A 31-year-old primigravida was referred to our hospital at 20 weeks of gestation.Ultrasound examinations were performed using a Prosound αtl0 (Aloka Co,Ltd,Tokyo,Japan) with a 2-6 MHz transabdominal probe.The initial sonographic findings were suggestive of a hyperechoic,homogeneous,and well-defined mass on the right lower lung,18 mm at its maximum diameter.There were no other abnormalities.We considered it to be fetal congenital cystic adenomatoid malformation (CCAM).Follow-up ultrasonography at 25 weeks of gestation showed an irregular mass of 29 mm×22 mm×23 mm within the pericardium,partially protruding into the mediastinum.Sonographic findings show the mass pulsates with the heart beat,but the heart was normal.The thickness of the fetal pericardial fluid areas was about 5.2 mm (Figure 1A and B).Differential diagnosis includes extralobar pulmonary sequestration (EPS),CCAM,and cardiac tumor。

To the editor:In migraine with aura (MA),atypical aura may occur and can raise difficult diagnostic questions due to their clinical expression,their mode of onset or their duration.1 Differential diagnostics,including cerebrovascular disease,must be always considered and brain magnetic resonance imaging (MRI) is usually required to carefully search for the underlying cause.Here we report a patient who presented with neuroradiologic imaging findings during prolonged migraine aura。