2014年 · 第127卷第22期

Chinese shoulder and elbow surgery started late and lagged behind the developed countries.However,it began to thrive and grow in the last decade. In fact,the predecessors of Chinese orthopaedic surgeons,including Profs.Feng Chuanhan,Guo Shiba,and Huang Gongyi,published Shoulder Surgery,which systematically stated the professional acknowledgment of shoulder surgery in China.1 The communication with foreign counterparts has intensified nowadays as increasing numbers of doctors have devoted themselves to shoulder surgery.They have accepted foreign advanced ideas and taught them in China,which has been helpful to improve the technical level of shoulder surgery。

Validity in research is referred to the closeness of the observed results to the truth or the degree to which an inference drawn from a study.1 Guarantee and pursuit of validity is always a challenge through the whole course of a research.What blocks research to reach validity?-Bias.Generally speaking,the more complicate the study is,the larger the bias and the lower the validity are.The cohort study,especially for a prospective cohort study,is a kind of epidemiological study which can provide strong evidences for medical practices and policy-making。

Abstract：Background The long term outcome of patellar resurfacing in Chinese has not been well described.This study evaluated more than 10-year clinical outcomes and survivorship of patellar resurfacing or nonresurfacing in total knee arthroplasty.Methods From January 1993 to December 2002,265 patients accepted total knee arthroplasty in Department of Orthopaedic Surgery,Peking Union Medical College Hospital.Among them,226 patients (246 knees) were successfully followed up,with 176 knees for patellar resurfacing and 70 knees for nonresurfacing.The survivorship of total knee arthroplasty between two groups and the hospital for special surgery knee score (HSS),patellar score,patellar related complication and radiological results were studied at the latest follow-up.Results The HSS knee score increased from 55.9±12.2 preoperatively to 92.0±10.9 postoperatively for patellar resurfacing group and from 56.6±9.9 to 94.2±11.4 for nonresurfacing group after average 11.4-year follow-up.Patellar score increased from 13.93±2.42 preoperatively to 28.33±2.20 for resurfacing group and from 13.55±2.73 to 27.8±2.37 for nonresurfacing group.There was no statistically significant difference for both HSS score,patellar score between the two groups with higher rate of anterior knee pain for nonresurfacing group.Patellar nonresurfacing had higher lateral subluxation than resurfacing group according to radiological evaluation.Patients with rheumatoid arthritis had 5.5 fold patellar related complication than patients with osteoarthritis.The 10-year survival rate was not statistically significant different between the two groups (P=0.12).Conclusions There was no significant difference of long-term clinical outcome and survivorship between patellar resurfacing and nonresurfacing.Patellar nonresurfacing can be advisable during primary total knee arthroplasty especially in Chinese patients with osteoarthritis.Selective patellar resurfacing for patients with rheumatoid arthritis can achieve lower patella related complication。

Abstract：Background Percutaneous pedicle screw use has a high rate of cranial facet joint violations (FVs) because of the facet joint being indirectly visualized.Computer-assisted navigation shows the anatomic structures clearly,and may help to lower the rate of FVs during pedicle screw insertion.This study used computed tomography (CT) to evaluate and compare the incidence of FVs between percutaneous and open surgeries employing computer-assisted navigation for the implantation of pedicle screw instrumentation during lumbar fusions.Methods A prospective study,including 142 patients having lumbar and lumbosacral fusion,was conducted between January 2013 and April 2014.All patients had bilateral posterior pedicle screw-rod instrumentation (top-loading screws) implanted by the same group of surgeons; intraoperative 3-dimensional computer navigation was used during the procedures.All patients underwent CT examinations within 6 months postoperation.The CT scans were independently reviewed by three reviewers blinded to the technique used.Results The cohort comprised 68 percutaneous and 74 open cases (136 and 148 superior-level pedicle screw placements,respectively).Overall,superior-level FVs occurred in 20 patients (20/142,14.1％),involving 27 top screws (27/284,9.5％).The percutaneous technique (7.4％ of patients,3.7％ of top screws) had a significantly lower violation rate than the open procedure (20.3％ of patients,14.9％ of top screws).The open group also had significantly more serious violations than did the percutaneous group.Both groups had a higher violation rate when the cranial fixation involved the L5.A 1-level open procedure had a higher violation rate than did the 2-and 3-level surgeries.Conclusions With computer-assisted navigation,the placement of top-loading percutaneous screws carries a lower risk of adjacent-FVs than does the open technique; when FVs occur,they tend to be less serious.Performing a single-level open lumbar fusion,or the fusion of the L5-S1 segment,requires caution to avoid cranial adjacent FVs。

Abstract：Background This retrospective study aimed to investigate the difference of the intra-dural reserving space for spinal cord in magnetic resonance imaging (MRI) between patients with and without developmental cervical stenosis and its clinical significance.Methods A total of 264 patients with cervical spondylotic myelopathy who had decompression surgeries were recruited.The average follow-up was 29 months.Based on their lateral radiographs,they were divided into stenosis group and non-stenosis group.On the magnetic resonance images,the ratio of the sagittal diameter of the dural sac to that of the vertebral body was measured and calculated as MRI Pavlov ratio at the mid-vertebral level on T2-weighted sagittal images from C3 to C7.The ratio of the transverse area of the spinal cord to that of the dural sac was measured and calculated as occupation ratio on T2-weighted axial images at the same levels.The MRI Pavlov ratio and occupation ratio were compared between the two groups.The stenosis group was further divided into space-reserving and non-space-reserving subgroups based on the occupation ratios; then clinical parameters were compared between the two subgroups to determine the clinical significance of the reserving space.Results The MRI Pavlov ratio of the stenosis group was significantly smaller than that of the non-stenosis group at C3-C7 (P ＜0.01),while the occupation ratio was significantly larger only at C7 (P ＜0.05).For the space-reserving subgroup,the postoperative recovery rate was lower (P ＜0.05).The postoperative recovery rate was (23±6)％ in anterior approach,larger than (-23±15)％ in posterior approach (P ＜0.05).Conclusions Developmental cervical stenosis is associated with a smaller sagittal diameter of the dural sac,but does not lead to a significant decrease in intra-dural space available for the cord.For patients with normal intra-dural space,the recovery after anterior decompression surgery was better than posterior approach。

Abstract：Background Scheuermann's disease (SD) is a spinal disorder and includes both a classic form and an atypical form.Interestingly,its existence among the general population as well as the disc disease patients is common.One of our previous studies showed that about 18％ of the hospital staff members meet the SD criteria.On the other hand,another study has demonstrated that 95.2％ of the symptomatic thoracolumbar disc herniation (STLDH) patients meet the SD criteria,which suggests that STLDH is very likely a special form of SD.The purpose of this study was to discriminate the factors contributing to the development of STLDH by comparing STLDH patients with the healthy SD-like hospital staff members.Methods This is a retrospective study including 33 STLDH patients who met the SD criteria and 30 SD-like hospital staff members.The STLDH group was chosen from a group of patients who underwent surgery after a diagnosis of STLDH (T10/11-L1/2) at our hospital between June 2007 and June 2010.SD-like hospital staff members were chosen from a database created in 2007,which contained a lumbar MR and low back pain (LBP) questionnaire of 188 hospital staff members.The demographic and radiologic characteristics were compared between groups.Results There was no statistical difference in sex,age,and height between the two groups.The STLDH patients had higher body weight,boby mass index,and thoracolumbar kyphotic angle than SD-like hospital staff members.In addition,STLDH patients had more levels of Schmorl's nodes (3.5±1.7 vs.2.0±1.9,t=3.364,P=0.001) and irregular endplateson (4.0±1.9 vs.2.7±1.9,t=2.667,P=0.010) compared to the SD-like hospital staff members.Conclusions Higher body weight,higher body mass index,larger thoracolumbar kyphosis,and more Schmorl's nodes and irregular endplates on MR may be associated with the development of STLDH in "SD-like people."

Abstract：Background Adjacent segment disease (ASD) is common after cervical fusion.The aim of this study was to evaluate the risk factors for ASD on X-ray and magnetic resonance imaging (MRI).Methods Patients included in this study had received revision surgeries after developing symptomatic ASD following anterior decompression and fusion.A control group that had not developed ASD was matched 1:1 by follow-up time and fusion segments.Plate-to-disc distances (PDDs),developmental cervical canal stenosis on X-ray,cervical disc degeneration grading,and cervical disc bulge impingements on preoperative MRI were measured and compared between the ASD group and the control group.Results Thirty-four patients with complete radiographic data were included in the ASD group.The causative segments of ASD included nine cases of C3-4,18 cases of C4-5,three cases of C5-6,and four cases of C6-7.The ASD occurred at the upper adjacent segments in 26 patients and at the lower adjacent segments in eight patients.PDD distributions were similar between the ASD group and the control group.Developmental cervical canal stenosis was a risk factor for ASD,with an odd ratio value of 2.88.Preoperative cervical disc degenerations on MRI were similar between the ASD group and the control group.In the upper-level ASD group,the disc bulge impingement was (19.7±9.7)％,which was significantly higher than that of the control group of (11.8±4.8)％.Conclusions ASD was more likely to develop above the index level of fusion.Developmental cervical canal stenosis and greater disc bulge impingement may be risk factors for the development of ASD。

Abstract：Background Cervical disc replacement (CDR) as a substitute for traditional fusion surgery has been widely used in treating degenerative cervical disc diseases.The objectives of this study were to assess the clinical and radiological findings for patients with heterotopic ossification (HO) following CDR and to detect the risk factors of HO after CDR.Methods A total of 125 patients with symptomatic cervical single-or double-level disc diseases,who underwent CDR procedure with Discover prosthesis in Department of Spine Surgery,Changzheng Orthopedics Hospital from March 2009 to March 2011,were enrolled in this retrospective study.Occurrence of HO was defined by the McAfee classification on cervical lateral X-rays in this study.Prosthesis vertebral ratio (PVR) was used to determine the matching degree between the cervical disc prosthesis and cervical vertebra.Logistic regression analyses were performed to determine the risk factors of HO.Variables evaluated for their association with HO occurrence included age,gender,high-intensity signal in spinal cord,preoperative range of motion (ROM),postoperative ROM,operation level number,and PVR.Results Mean follow-up time was (26.4±5.8) months.All the patients had significant symptoms and neurological function improvements during the follow-up period.The ROM of the operated segment from the preoperative period to the last follow-up was relatively well maintained.The rate of HO in this cohort of patients,who underwent Discover disc,was 27.92％ per surgical level and 24.8％ per patient by the last follow-up.There were 19 patients (19.79％) with HO in the single-level group while 12 patients (41.38％) in the double-level group.Conclusions We identified preoperative high-intensity signal in spinal cord,postoperative ROM of surgical level,number of operation level,and PVR as significant risk factors for postoperative HO occurrence。

Abstract：Background The imaging evaluation of pain in patients who have had a hip arthroplasty (HA) is challenging,and traditional imaging techniques,including magnetic resonance imaging (MRI) and computerized tomography (CT),are limited by metallic artifact.The purpose of the present study was to investigate the use of modified MRI techniques to visualize periprosthetic soft tissues and the bone-implant interface,and to evaluate the value of MRI for the assessment of patients with painful hip arthroplasty.Methods Fifty-six painful hips in fifty-six patients following primary HA were assessed using optimized MRI,CT and standardized radiographs.The diagnosis of MRI was correlated with intraoperative findings as well as with microbiological and histological examinations (when available).The sensitivity and the specificity of MRI diagnosis were determined according to final diagnosis.The chi-square test was performed to detect a difference between MRI and final diagnosis.Results Forty-eight patients have received revision surgery and final diagnosis were established.MRI was demonstrated high sensitivity and specificity in detecting aseptic loosening (93％ and 95％),periprosthetic infection (94％ and 97％),adverse local tissue reaction (100％ and 100％) and periprosthetic fracture (100％ and 100％).MRI was determined to be the most sensitive technique in detecting implant loosening for any reason,with a sensitivity of 93.8％ for acetabular shell and 97.1％ for femoral stem,compared to 81.3％ and 80.0％ on CT,75.0％ and 77.1％ on radiographs.Conclusions Optimized MRI was effective for the assessment of the periprosthetic soft tissues and bone.The use of modified magnetic resonance imaging parameters provided a useful adjunct to conventional examinations for the evaluation of patients with painful hip arthroplasty。

Abstract：Background The thermal injury during bipolar radiofrequercy results in chondrocyte death that limits cartilage repair.The purpose was to determine the effects of various factors of bipolar radiofrequency on human articular cartilage after thermal injury,offering suitable working conditions for bipolar radiofrequency during arthroscopy.Methods Osteochondral explants from 28 patients undergoing total knee arthroplasty (TKA) in Department of Orthopaedic,Peking University Reople's Hospital from October 2013 to May 2014,were harvested and treated using bipolar radiofrequency in a light contact mode under the following conditions:various power setting of levels 2,4 and 6; different durations of 2 seconds,5 seconds and 10 seconds; irrigation with fluids of different temperatures of 4℃,22℃,and 37℃; two different bipolar radiofrequency probes ArthroCare TriStar 50 and Paragon T2.The percentage of cell death and depth of cell death were quantified with laser confocal microscopy.The content of proteoglycan elution at different temperatures was determined by spectrophotometer at 530 nm.Results Chondrocyte mortality during the treatment time of 2 seconds and power setting of level 2 was significantly lower than that with long duration or in higher level groups (time:P=0.001; power:P=0.001).The percentage of cell death after thermal injury was gradually reduced by increasing the temperature of the irrigation solutions (P=0.003),the depth of dead chondrocytes in the 37℃ solution group was significantly less than those in the 4℃ and 22℃ groups (P=0.001).The proteoglycan elution was also gradually reduced by increasing the temperature (P=0.004).Compared with the ArthroCare TriStar 50 group,the percentage of cell death in the Paragon T2 group was significantly decreased (P=0.046).Conclusions Thermal chondroplasty with bipolar radiofrequency resulted in defined margins of chondrocyte death under controlled conditions.The least cartilage damage during thermal chondroplasty could be achieved with lower power,shorter duration,suitable temperature of irrigation solutions and chondroprotective probes.The recommendations for the use of bipolar radiofrequency to minimize cartilage damage could be achieved with a power setting of level 2,treatment duration of 2 seconds,suitable fluid temperature (closer to body temperature of 37℃) and chondroprotective Paragon T2 probes。

Abstract：Background Several studies,including those done in China,report that paravertebral vascular injury during posterior spinal surgery can greatly harm patients,though it is a relatively rare complication.However,few studies have examined their course and anatomic relationship to the spine.The aim of this study was to measure the course of the major paravertebral vessels and their positional relationships to the vertebral bodies in Chinese subjects using computed tomography.Methods We studied a total of fifty subjects who underwent thoracolumbar computed tomography from T1-S1 at our institution.We measured the theoretical distance,actual distance,theoretical angle,and actual angle of the paravertebral vessels at each thoracolumbar intervertebral disc.Results The paravertebral artery actual angle at T4-L4 ranged from-11.41 to 79.75° and the actual distance from 16.98 to 52.53 mm.The actual angle of the inferior vena cava at L1-L5 intervertebral disc ranged from-40.75 to 34.50° and the actual distance from-36.63 to 61.69 mm.There was no significant difference in the actual angle of the paravertebral vein or in the actual distance in the thoracic segments according to gender (P ＞0.05).However,the actual distance in the lumbar segments were significantly different according to gender (P ＜0.05).Conclusions The major paravertebral vessels' course is closer to the mid-sagittal plane as they move posterior along the vertebrae,and the actual distance of the paravertebral artery and azygos vein increase,while the actual distance of the inferior vena cava decreases.The course of the lumbar paravertebral vessels varies,especially at L4/L5,and may be more prone to intraoperative injury in female subjects。

Abstract：Background Calcaneal fractures are relatively common but complex,while the treatment of these fractures is still controversial.The objective of this study was to compare the biomechanical stability of minimally invasive,locking,and non-locking plating systems used for fixing Sanders type Ⅱ and type Ⅲ calcaneal fractures.Finite element analysis was used for comparing the three types of plating systems.This study helped in guiding the clinical management of calcaneal fractures.Methods The CT data acquired from a volunteer was used to construct a finite element model of calcaneus.The fracture lines were made according to Sanders type Ⅱ (A,B,C) and type Ⅲ (AB,AC,BC) and six calcaneal fractures models were constructed accordingly.Three fixation methods used in clinical treatment were simulated by design tools (minimally invasive plating with percutaneous screws,Y-size non-locking plating,and locking plating) and then fixed to these fracture models with the help of clinical principles.The single minimally invasive plating fixation was also tested to compare the function of percutaneous screws.Then,the neutral force was applied on established methods.The displacement and presses distribution condition in various plating models were analyzed and compared.Results The levels of displacement and compressive press on the bone around fixation or strains on plating were within the physiological limit,indicating that the three methods were suitable for application.Compared with the locked and unlocked plates,the minimally invasive plating caused a relatively lower displacement without the high stress in bone or fixation.The minimum stress in fixation was observed in locking plate as the distribution of stress was concentrated in the anterior part of locking plate.Conclusions The minimally invasive plating method could be a better alternative method in treating Sanders type Ⅱ and type Ⅲ calcaneal fractures.The observed stiffness of locking plate was not obviously stronger than unlocked plate。

Abstract：Background Bladder cancer is widely known as the most common malignant tumor in the urinary tract,with 75％-85％ of patients suffering from nonmuscle invasive bladder cancer (NMIBC).However,the optimal dose of Bacillus Calmette-Guérin (BCG) remains controversial.The aim of this study was to compare the therapeutic efficacy of full dose (FD) with the reduced dose (RD) of BCG.Methods Randomized controlled trials (RCTs) were selected through the Cochrane Library,PubMed and Embase and were supplemented by hand searching of bibliographies.The end points include overall survival rate,recurrence rate,progression rate and side effects.Results Five RCTs that included a total of 1 473 patients (727 in the reduced dose group vs 746 in the full dose group),with a median follow-up period from 33.5 month to 7.1 year.Disease in 80 of 687 (11.6％) patients assigned to the RD group progress to the muscular layer or distant metastasis,compared with 81 of 698 (11.6％) patients assigned to the FD group (RR=1.02; 95％ CI,0.77-1.36; P=0.89).The incidence of recurrence at three year was reported in all five studies to be 41.1％ (299 of 727) and 36.1％ (269 of 746) in the RD and FD groups,respectively (RR=1.13; 95％ CI,1.00-1.29; P=0.05).The 5-year survival rate was 75.9％ (502 of 662) in the RD group,and 75.8％ (510 of 673) in the FD group.In the RD group 41 of 655 (6.3％) patients and 56 of 663 (8.7％) patients in the FD group did not complete the treatment due to systemic or local side effects (RR=0.75; 95％ CI,0.51-1.10; P=0.14) Conclusions In general,the results of our study demonstrate a trend towards a reduction of the toxicity in reduced dose group without affecting the efficacy of treatment when compared with full dose.More trials with large sample size are still necessary to explore the prognosis of the patients with high risk of tumor in different dose group。

Abstract：Objective Little information is available to guide treatment strategies regarding patients with unexpected positive cultures (UPC),including Propionibacterium acnes (PA),without overt signs of infection in revision shoulder arthroplasty (RSA).The purpose of our study was to analyze the prevalence,clinical meaning,treatment and prognosis of UPC in RSA.Data sources and study selection We performed a systematic review of the literature between 1950 and 2013 for all studies reporting on UPC for PA.Studies with the prevalence and prognosis of patients with UPC in RSA were analyzed.Results Six studies meeting our inclusion criteria yielded data for 1 402 patients who underwent a total of 1405 RSA.Based on the available data,following RSA 235 shoulders had UPCs with a pooled percentage of 16.7％ (235/1405).The most commonly isolated bacteria from shoulders following RSA with UPCs was PA with pooled percentages of 63.4％ (149/235).Occurrence of true infection from UPCs after RSA was seen in 24 shoulders (24/235,10.2％).Antibiotic use did not influence the rate of the occurrence of true infection from UPCs (P=0.498).Conclusions Our study showed a low risk of having a true infection from UPCs after RSA without clinical signs of preoperative infection at the time of the surgery.Therefore,prolonged antibiotic therapy may not be necessary in these patients。

Abstract：Objective To review the common genotyping techniques of Chlamydia trachomatis in terms of their principles,characteristics,applications and limitations.Data sources Data used in this review were mainly from English literatures of PubMed database.The search terms were "Chlamydia trachomatis" and "genotyping".Meanwhile,data from World Health Organization were also cited.Study selection Original articles and reviews relevant to present review's theme were selected.Results Different genotyping techniques were applied on different occasions according to their characteristics,especially in epidemiological studies worldwide,which pushed the study of Chlamydia trachomatis forward greatly.In addition,summaries of some epidemiological studies by genotyping were also included in this work for reference and comparison.Conclusions A clear understanding of common genotyping techniques could be helpful to genotype C.trachomatis more appropriately and effectively.Furthermore,more studies on the association of genotypes of Ch/amydia trachomatis with clinical manifestations should be performed。

Articular cartilage has only a limited capacity of selfhealing.Once seriously damaged,articular cartilage lesions will not regenerate;and any joint surface damage,if left untreated,will invariably deteriorate and eventually spread to surrounding areas.1 The end result of such a process is often the development of osteoarthritis (OA),which often occurs in large load-bearing joints,such as knee and femoral joint.So much attention has been focused on how to eliminate symptoms,repair damaged cartilage,restore the integrity of the articular surface,prevent or halt joint degeneration,and improve joint function.But it still remains a challenging problem for orthopedic surgeons.In recent years,the role of growth factors (GFs) on tissue repair has become a hot research topic.The biological effect of GFs on cartilage repair has been well documented in vivo and in vitro.2-4 At present,most GFs are obtained mainly through genetic engineering technology and extracted from the animals;the preparation process is cumbersome,expensive,and inconvenient。

Conventional simultaneous bilateral open nephroureterectomy combined with resection of bladder cuffs seems not optimal for bilateral upper tract urothelial carcinoma (UTUC) in renal transplant and dialysis patients with enormous invasion related to large morbidity,delayed gastrointestinal function,and late recovery.1 This study reports the largest series of minimally invasive procedures of simultaneous bilateral retroperitoneoscopic nephroureterectomy (SBRNU) via a midline lower abdominal incision in renal recipients。

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease mainly involving motor neurons in spinal cord,brain stem,and motor cortex of brain,characterized by variable combinations of limb weakness,muscle atrophy,and pyramidal signs.TAR DNA-binding protein 43 (TDP-43) serves as the pathological protein for both ALS and a proportion of frontotemporal dementia (FTD),where lies the foundation of a disease complex,ALS-FTD.Delusion and hallucination,core features of schizophrenia,are also regarded as common symptoms in the context of neurodegenerative dementia,including Alzheimer disease and dementia with Lewy body.Although rare in the course of FTD,these manifestations could be rather notable,causing a great challenge to differentiate FTD from schizophrenia.Emphasis of psychotic phenomenon also lies in its importance of predicting the progression to ALS-FTD and its underlying genetic mutation.Herein we report two cases of ALS-FTD presented with psychosis。

Congenital insensitivity to pain and anhidrosis (CIPA) is a rare entity.CIPA patients are subjected to repeated injuries,which are easily neglected.There is no specific treatment for CIPA,but supervision by parents and patient training are important to avoid further damage and to maintain quality of life.We present two cases of CIPA involving a brother and sister,whose parents did not have a consanguineous marriage。