2015年 · 第128卷第21期

According to the latest data released by the National Bureau of Statistics, the total population of the mainland of China is 1.33 billion in 2010, including 177 million people aged 60 years or older, accounting for 13.25% of the total population, which increased to 15.53% in 2014. With the degree of growing aging population in our country, patients with musculoskeletal diseases increased greatly, which are the most common cause of severe chronic pain and physical disability among older people. Meanwhile, with the fast development of economy and industrialization in China, the number of patients of traffic injury and construction injury increases rapidly. Taken together, the expenses in orthopedics and traumatology will inevitably increase, challenging the existed medical and health system, presenting significant financial and emotional burden on the society. To address this challenge and improve the patient’s care, the innovation of advanced concepts, surgical skills, and novel instruments for accurate diagnostic and treatment methods in orthopedics and traumatology has become more and more vital and imperative in our country.

Nontraumatic osteonecrosis of the femoral head (NONFH) is a debilitating disease that represents a significant financial burden for both individuals and healthcare systems. Despite its significance, however, its prevalence in the Chinese general population remains unknown. This study aimed to investigate the prevalence of NONFH and its associated risk factors in the Chinese population.

A nationally representative survey of 30,030 respondents was undertaken from June 2012 to August 2013. All participants underwent a questionnaire investigation, physical examination of hip, and bilateral hip joint X-ray and/or magnetic resonance imaging examination. Blood samples were taken after overnight fasting to test serum total cholesterol, triglyceride, and high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels. We then used multivariate logistic regression analysis to investigate the associations between various metabolic, demographic, and lifestyle-related variables and NONFH.

NONFH was diagnosed in 218 subjects (0.725%) and the estimated NONFH cases were 8.12 million among Chinese people aged 15 years and over. The prevalence of NONFH was significantly higher in males than in females (1.02% vs. 0.51%, χ² = 24.997, P< 0.001). Among NONFH patients, North residents were subjected to higher prevalence of NONFH than that of South residents (0.85% vs. 0.61%, χ² = 5.847, P= 0.016). Our multivariate regression analysis showed that high blood levels of triglycerides, total cholesterol, LDL-cholesterol, and non-HDL-cholesterol, male, urban residence, family history of osteonecrosis of the femoral head, heavy smoking, alcohol abuse and glucocorticoid intake, overweight, and obesity were all significantly associated with an increased risk of NONFH.

Our findings highlight that NONFH is a significant public health challenge in China and underscore the need for policy measures on the national level. Furthermore, NONFH shares a number of risk factors with atherosclerosis.

To avoid the irritation of tendons and soft tissues as well as hardware-related problems, we designed an intramedullary fixation with bioabsorbable rods for the treatment of the metacarpal shaft fractures.

Five patients with nine shaft fractures of the fourth and fifth metacarpi were treated with intramedullary absorbable implants and followed up with an average of 4.2 months postoperatively.

At final follow-up, all patients achieved fracture union with no signs of inflammatory or subcutaneous effusion. There was no shortening, angulatory, or rotatory deformity. There was almost full active extension range of motion (ROM) of the metacarpophalangeal joints while the active flexion ROM of these joints was 80.7 ± 9.6°. Compared with the contralateral hand, the grip strength of the injured hand was 94.0 ± 9.6%. X-rays showed that the arch of the second to fifth metacarpal heads was smooth. There were no intramedullary lytic changes and soft tissue swellings.

The intramedullary absorbable implants are a safe, simple, and practical treatment for fourth and fifth metacarpal fractures with good early clinical outcomes and no significant complications.

Currently, various calculation methods for evaluating blood-loss in patients with total knee arthroplasty (TKA) are applied in clinical practice. However, different methods may yield different results. The purpose of this study was to determine the most reliable method for calculating blood-loss after primary TKA.

We compared blood-loss in 245 patients who underwent primary unilateral TKA from February 2010 to August 2011. We calculated blood-loss using four methods: Gross equation, hemoglobin (Hb) balance, the Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) formula, and Hb-dilution. We determined Pearson’s correlation coefficients for the four methods.

There were large differences in the calculated blood-loss obtained by the four methods. In descending order of combined correlation coefficient based on calculated blood-loss, the methods were Hb-balance, OSTHEO formula, Hb-dilution, and Gross equation.

The Hb-balance method may be the most reliable method of estimating blood-loss after TKA.

Osteoarthritis often affects the joint bilaterally, and the single-stage (SS) unicompartmental knee arthroplasty (UKA) is advantageous in terms of a single anesthesia administration, a short hospital stay, lower medical costs, and enhanced patient convenience. However, the complication risk of SS UKA continues to be debated. The aim of this article was to evaluate the clinical effectiveness, complications, and functional recovery of SS and two-stage (TS) UKA.

From January 2008 to December 2013, we compared a series of 36 SS UKA with 45 TS UKA for osteoarthritis. The mean age was 65.4 years (range: 55–75 years). The mean body mass index was 25.2 kg/m² (range: 22–29 kg/m²). The pre- and post-operative Oxford Knee Scores (OKSs), complications, operative times, tourniquet times, the amount of drainage, and hemoglobin (Hb) were evaluated. The Chi-square test, Fisher’s exact test, and paired and grouped t-tests were used in this study.

The mean follow-up was 50 months. No complications of death, fat embolism, deep vein thrombosis, and prosthetic infection were reported. Patients who underwent SS UKA had a shorter cumulative anesthesia time (113.5 vs. 133.0 min, P< 0.01). There were no significant variations between the values of the mean tourniquet time, the amount of drainage, pre- and post-operative Hb in the different groups. No patient required a blood transfusion. No statistical differences were found in the complications between two groups (P > 0.05). At the final follow-up, the mean OKS improved from 39.48 ± 5.69 to 18.83 ± 3.82 (P < 0.01), with no statistical differences between the two groups (P > 0.05). Patients who underwent SS UKA had a faster recovery.

The single-staged UKA offers the benefits of a single anesthesia administration, reduced total anesthetic time, decreased overall rehabilitation time, and absence of an increase in perioperative mortality or complications compared with the TS bilateral UKA.

Joint line (JL) is a very important factor for total knee arthroplasty (TKA) to restore. The objective of this study was to evaluate the early clinical and kinematic results of TKAs with posterior-stabilized (PS) or cruciate retaining (CR) implants in which the JL was elevated postoperatively.

Data were collected from patients who underwent TKA in our department between April 2011 and April 2014. The patients were divided into two groups based on the prosthesis they received (PS or CR). At 1-year postoperatively, clinical outcomes were evaluated by the American Knee Society (AKS) knee score, AKS function score, and patella score. In vivo kinematic analysis after TKA was performed on all patients and a previously validated three-dimensional to two-dimensional image registration technique was used to obtain the kinematic data. Anteroposterior (AP) translation of the medial and lateral femoral condyles, and axial rotation relative to the tibial plateau, were analyzed. The data were assessed using the Mann–Whitney test.

At time of follow-up, there were differences in the AKS knee scores (P = 0.005), AKS function scores (P = 0.025), patella scores (P = 0.015), and postoperative range of motions (P = 0.004) between the PS group and the CR group. In the PS group, the magnitude of AP translation for the medial and lateral condyle was 4.9 ± 3.0 mm and 12.8 ± 3.3 mm, respectively. Axial rotation of the tibial component relative to the femoral component was 12.9 ± 4.5°. In the CR group, the magnitude of AP translation for the medial and lateral condyle was 4.3 ± 3.5 mm and 7.9 ± 4.2 mm, respectively. The axial rotation was 6.7 ± 5.9°. There were statistically different between PS group and CR group in kinematics postoperatively.

Our results demonstrate that postoperative JL elevation had more adverse effects on the clinical and kinematic outcomes of CR TKAs than PS TKAs.

Controversies about the rational positioning of the tibial component in unicompartmental knee arthroplasty (UKA) still exist. Previous finite element (FE) studies were rare, and the results varied. This FE study aimed to analyze the influence of the tibial component coronal alignment on knee biomechanics in mobile-bearing UKA and find a ration range of inclination angles.

A three-dimensional FE model of the intact knee was constructed from image data of one normal subject. A 1000 N compressive load was applied to the intact knee model for validating. Then a set of eleven UKA FE models was developed with the coronal inclination angles of the tibial tray ranging from 10° valgus to 10° varus. Tibial bone stresses and strains, contact pressures and load distribution in all UKA models were calculated and analyzed under the unified loading and boundary conditions.

Load distribution, contact pressures, and contact areas in intact knee model were validated. In UKA models, von Mises stress and compressive strain at proximal medial cortical bone increased significantly as the tibial tray was in valgus inclination >4°, which may increase the risk of residual pain. Compressive strains at tibial keel slot were above the high threshold with varus inclination >4°, which may result in greater risk of component migration. Tibial bone resection corner acted as a strain-raiser regardless of the inclination angles. Compressive strains at the resected surface slightly changed with the varying inclinations and were not supposed to induce bone resorption and component loosening. Contact pressures and load percentage in lateral compartment increased with the more varus inclination, which may lead to osteoarthritis progression.

Static knee biomechanics after UKA can be greatly affected by tibial component coronal alignment. A range from 4° valgus to 4° varus inclination of tibial component can be recommended in mobile-bearing UKA.

The properties of subchondral bone influence the integrity of articular cartilage in the pathogenesis of osteoarthritis (OA). However, the characteristics of subchondral bone alterations remain unresolved. The present study aimed to observe the dynamic alterations in the microarchitecture, mineralization, and mechanical properties of subchondral bone during the progression of OA.

A medial meniscal tear (MMT) operation was performed in 128 adult Sprague Dawley rats to induce OA. At 2, 4, 8, and 12 weeks following the MMT operation, cartilage degeneration was evaluated using toluidine blue O staining, whereas changes in the microarchitecture indices and tissue mineral density (TMD), mineral-to-collagen ratio, and intrinsic mechanical properties of subchondral bone plates (BPs) and trabecular bones (Tbs) were measured using micro-computed tomography scanning, confocal Raman microspectroscopy and nanoindentation testing, respectively.

Cartilage degeneration occurred and worsened progressively from 2 to 12 weeks after OA induction. Microarchitecture analysis revealed that the subchondral bone shifted from bone resorption early (reduced trabecular BV/TV, trabecular number, connectivity density and trabecular thickness [Tb.Th], and increased trabecular spacing (Tb.Sp) at 2 and 4 weeks) to bone accretion late (increased BV/TV, Tb.Th and thickness of subchondral bone plate, and reduced Tb.Sp at 8 and 12 weeks). The TMD of both the BP and Tb displayed no significant changes at 2 and 4 weeks but decreased at 8 and 12 weeks. The mineral-to-collagen ratio showed a significant decrease from 4 weeks for the Tb and from 8 weeks for the BP after OA induction. Both the elastic modulus and hardness of the Tb showed a significant decrease from 4 weeks after OA induction. The BP showed a significant decrease in its elastic modulus from 8 weeks and its hardness from 4 weeks.

The microarchitecture, mineralization and mechanical properties of subchondral bone changed in a time-dependent manner as OA progressed.

The self-consciousness and practicality of preferentially prescribed essential medicines (EMs) are not high enough in county hospitals. The purposes of this study were to use the information-motivation-behavioral skills (IMB) model to identify the predictors of essential medicines prescribing behavior (EMPB) among doctors and to examine the association between demographic variables, IMB, and EMPB.

A cross-sectional study was carried out to assess predictive relationships among demographic variables and IMB model variables using an anonymous questionnaire administered in nine county hospitals of Anhui province. A structural equation model was constructed for the IMB model to test the instruments using analysis of moment structures 17.0.

A total of 732 participants completed the survey. The average age of the participants was 37.7 ± 8.9 years old (range: 22–67 years old). The correct rate of information was 90.64%. The average scores of the motivation and behavioral skills were 45.46 ± 7.34 (hundred mark system: 75.77) and 19.92 ± 3.44 (hundred mark system: 79.68), respectively. Approximately half (50.8%) of respondents reported that the proportion of EM prescription was below 60%. The final revised model indicated a good fit to the data (χ²/df = 4.146, goodness of fit index = 0.948, comparative fit index = 0.938, root mean square error of approximation = 0.066). More work experience (β = 0.153, P< 0.001) and behavioral skills (β = 0.449, P< 0.001) predicted more EMPB. Higher income predicted less information (β = −0.197, P< 0.001) and motivation (β = −0.204, P< 0.001). Behavioral skills were positively predicted by information (β = 0.135, P< 0.001) and motivation (β = 0.742, P< 0.001).

The present study predicted some factors of EMPB, and specified the relationships among the model variables. The utilization rate of EM was not high enough. Motivation and behavior skills were crucial factors affecting EMPB. The influence of demographic variables, such as income and work experience, on EMPB should be fully appreciated. Comprehensive intervention measures should be implemented from multiple perspectives.

Criteria for determining brain death (BD) vary between China and the United States. We reported the results of an investigation designed to compare procedures to determine BD in two countries.

The latest criteria in the United states were published in 2010. The latest criteria in China were published in 2009. We used these two types of BD criteria to evaluate patients who were considered to be BD. The time, cost, and accuracy of the diagnosis were compared.

From January 1, 2012 to October 8, 2013, there were 37 patients which were applied for BD evaluation in the Neurological Intensive Care Unit of Beijing Tiantan Hospital. The cause of coma were known as subarachnoid hemorrhage (18 patients, 48.6%), intracerebral hemorrhage (8 patients, 21.6%), cerebral ischemia (9 patients, 24.3%), brain stem tumor (1 patient, 2.7%), and intracranial infection (1 patient, 2.7%). The clinical examinations were done for all of the patients except 1 patient who had low blood pressure. Three patients had brainstem reflexes that were excluded from BD. Twenty-five patients had apnea tests, and 20 tests were completed that were all positive. Confirmatory tests were completed differently: Transcranial Doppler (30 patients, positive rate 86.7%), electroencephalogram (25 patients, positive rate 100%), and somatosensory evoked potential (16 patients, positive rate 100%). Thirty-three patients were diagnosed BD by criteria of the United States. Only 9 patients were diagnosed BD by Chinese criteria. The use of time and money in the USA criteria was obviously fewer than those in Chinese criteria (P = 0.000).

Compared with BD criteria of the United States, Chinese criteria were stricter, lower positive rate, more cost in money and time, and more reliable by families and doctors.

Mutations of transthyretin (TTR) cause the most common type of autosomal-dominant hereditary systemic amyloidosis, which occurs worldwide. To date, more and more mutations in the TTR gene have been reported. Some variations in the clinical presentation are often observed in patients with the same mutation or the patients in the same family. The purpose of this study was to find out the clinicopathologic and genetic features of Chinese patients with hereditary TTR amyloidosis.

Clinical and necessary examination materials were collected from nine patients of eight families with hereditary TTR amyloidosis at Peking University First Hospital from January 2007 to November 2014. Sural nerve biopsies were taken for eight patients and skin biopsies were taken in the calf/upper arm for two patients, for light and electron microscopy examination. The TTR genes from the nine patients were analyzed.

The onset age varied from 23 to 68 years. The main manifestations were paresthesia, proximal and/or distal weakness, autonomic dysfunction, cardiomyopathy, vitreous opacity, hearing loss, and glossohypertrophia. Nerve biopsy demonstrated severe loss of myelinated fibers in seven cases and amyloid deposits in three. One patient had skin amyloid deposits which were revealed from electron microscopic examination. Genetic analysis showed six kinds of mutations of TTR gene, including Val30Met, Phe33Leu, Ala36Pro, Val30Ala, Phe33Val, and Glu42Gly in exon 2.

Since the pathological examinations of sural nerve were negative for amyloid deposition in most patients, the screening for TTR mutations should be performed in all the adult patients, who are clinically suspected with hereditary TTR amyloidosis.

Through reviewing the relevant literature from the past decades, to summarize the assessment and management of fractures of the clavicle, and provide an overview of the clinical results of a range of treatment options.

The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1960 to 2015.

Studies involving assessment of fractures of the clavicle were reviewed. Further literatures were gathered regarding the conservative and surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted.

Through retrieving and reading the abstract, a total of 42 representative articles were selected, which covered all aspects of the conservative treatment and surgical treatment, and compared the advantages and disadvantages of different treatment options.

Although the majority of recent data suggest that surgery may be more appropriate as it improves functional outcome and reduces the risk of complications, we recommend that the treatment should be individually assessed.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. By the year 2020, COPD will be the third leading cause of mortality and the fifth leading cause of disability worldwide.^[1]In a population based study conducted at multiple international sites, approximately 10% of participants 40 years of age or older were found to have airflow obstruction of at least moderate severity according to spirometric criteria.^[2]In China, the overall prevalence of COPD in individuals 40 years of age or older was 8.2%.^[3]COPD is a slowly progressive respiratory disease, which, although preventable and treatable, is not curable. The final years for patients with advanced COPD are characterized by progressive functional decline, frequent exacerbations, poor quality of life, increasing dependency on informal caregivers and on the health care system.^[4]According to the literature, 5-year survival from diagnosis is estimated to be 78% in men and 72% in women with mild disease, but only 30% in men and 24% in women with advanced COPD.^[5]

Ischemic stroke accounts for 70% of all the cerebrovascular diseases. Severe stenosis and occlusions of extracranial and intracranial artery are all important risk factors causing ischemic stroke. Based on the widespread observation worldwide, intracranial atherosclerosis is the most common vascular lesions in Asians, Hispanics, and Africans.^[1]Therefore, accurate and noninvasive methods for early diagnosis of stroke in individuals without significant stenosis of the extracranial carotid artery is of considerable clinical interest.

Leprosy caused byMycobacterium leprae(M. leprae), is a chronic granulomatous disease affecting the skin and peripheral nervous system, which is transmitted through direct contact with nontreated or inadequate treatment patients.^[1]Diagnosis of leprosy depends on the clinical signs and symptoms and slit skin smear positivity. However, it’s sometimes similar with other granulomatous disease caused by mycobacterial infection. Early stage leprosy is difficult to diagnose by clinical criterion alone because the sensitivity of acid-fast bacilli staining is quite low. The polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) shows the great advantage in rapid identification and diagnosis for early cases and has a differentiation between leprosy and nonleprosy cases.

Few studies have focused on the possible change in the axial alignment of the lower limb after lateral meniscectomy. Here, we present a patient with valgus deformity of the knee following the partial removal of lateral discoid meniscus. With the distal femur osteotomy and fixation, this complication was treated successfully. This case suggested that we should pay more attention to the axial alignment of the lower limb in patients with torn discoid lateral meniscus before meniscectomy, as a severe valgus inclination may develop in some of these patients.

Brain death (BD) is that someone’s brain stops functioning, even though their heart may be kept beating using a machine. After brain function had ceased, somatic function being sustained by mechanical ventilation for a long time. Further treatment is inappropriate in a dead patient. Hence, in many countries, the law provides that treatment can be legitimately removed from a patient who was diagnosed BD and the donation of organs for transplantation can start.

Anti-N-methyl-D-aspartate receptor (anti-NMDA-R) encephalitis is a newly recognized neuro-autoimmune disease. Patients usually present with a series of neurological and psychiatric syndromes including memory impairment, seizures, dyskinesia, autonomic nervous system dysfunction, etc. Anti-NMDA-R encephalitis usually affects young women with teratoma being a common co-existing condition in nearly 47% of the diagnosed patients. Previous studies have shown that teratoma removal, being the current first-line therapy, may enhance the effectiveness of autoimmune therapy and decrease the incidence of relapse.^[1]However, poorly controlled encephalitis poses as a perioperative anesthetic risk. Therefore, timing of the surgery is of great concern and is a question yet to be answered. Due to low incidence of anti-NMDA-R encephalitis in general population, literature of the perioperative management in these group of patients is scarce. Only few case reports were found yet, none has discussed the issue of surgery timing. In this study, 6 patients with anti-NMDA-R encephalitis undergoing teratoma removal were reviewed, and timing of surgery and anesthetic management for these patients were discussed.

In the article, "Prevalence and Risk Factors of Atrial Fibrillation in Chinese Elderly: Results from the Chinese Longitudinal Healthy Longevity Survey" , which appeared in the pages 2426-2432, Issue 18, Vol 128 ofChinese Medical Journal,^[1]the financial disclosure section is missing. It should be written as following:

Due to the carelessness of the authors, in the article, "Comparison of C₅₀for Propofol-remifentanil Target-controlled Infusion and Bispectral Index at Loss of Consciousness and Response to Painful Stimulus in Elderly and Young Patients" , which appeared in the pages 1994-1999, Issue 15, Vol 128 ofChinese Medical Journal,^[1]the word "Weight, kg" in Table 1 under the first column is incorrectly written instead of "Age, years".

To the Editor: Cervical radiculopathy (CR) is a common problem with an episodic course that affects a large proportion of the population.^[1]The review indicated that nonoperative treatment is the main course. However, there is little high-quality evidence on the nonoperative therapy for CR. The purpose of this conservative therapy was built up to serve for the clinical practice. Our research team adopt a Delphi technique.^[2]First, we randomly selected an expert panel composed 22 spine surgeons, 3 physiotherapist, and 3 pain management doctors from the medical experts in China. Second, using the Delphi process and iterative rounds, agreement ≥80% was considered consensus. Repeat voting for consensus was performed. Third, we put forward to the following conclusions: (1) Nonoperative treatment is the appropriate initial approach for most patients; (2) a short period (1 week) of immobilization in a cervical collar may relieve radicular pain; (3) typically, eight to 12 lb of traction is applied at an angle of approximately 24° of flexion for 15–20-min intervals should be provide to patient in hospital;^[3](4) a short period (3 days) of using steroid and dehydrating agents should be provide, according to the patient’s condition; (5) patients are able to use interventional treatment (translaminar and transforaminal epidural injection or selective nerve root block) to relieve acute radicular pain; (6) as the pain improves, a gradual, isometric strengthening program may be initiated with progression to active range-of-motion and resistive exercises as tolerated; (7) patients should routinely receive nonsteroidal anti-inflammatory drugs (NSAIDs); (8) as breakthrough supplements to NSAIDs or in patients who cannot tolerate NSAIDs, opiate should be used; (9) patients should routinely receive relaxants; (10) patients should routinely receive physiotherapy such as heat and electrical nerve stimulation; (11) patients should receive neurotrophic drugs; (12) as supplement of CR therapy, Chinese herbal medicine about promoting blood circulation for removing blood stasis should be selected; (13) patients should receive tramadol (Ultram) to alleviate chronic neuropathic pain; (14) patients should considerate surgical intervention if there is intractable radicular symptoms unresponsive to nonoperative management over an 8 week period;^[4](15) patients have the recurrent pain of neck and shoulders, or the recurrent pain and numbness of upper limb more than 6 months, which seriously affect the patients’ work and lives and aggravate recently; (16) patients have obvious strings pain and numbness of upper limb accompanied by one side muscle atrophy and decreased muscle strength, whose imaging examination showed cervical vertebral disc herniation, or osteophyte formation of Luschka joint compress the dural sac, or the section of the lesion is significantly instability. These could serve the clinical practice as a reference in the future. However, more studies are also needed to provide the high-quality evidence for these strategies.

To the Editor: Total knee arthroplasty (TKA) is one of the most common orthopedic surgeries to reduce pain and improve function for patients with osteoarthritis. However, TKA is associated with high-risk of perioperative morbidity and mortality. We presented a patient who developed severe acute respiratory distress syndrome (ARDS) postoperatively after bilateral TKA procedure.

To the Editor: Tandem mass spectrometry (MS/MS)-based expanded newborn screening was first introduced in Pediatric Endocrinology/Genetics of Xin Hua Hospital in 2003. The screening is expected to detect genetic disorders leading to a secondary increase in blood phenylalanine (Phe) in newborns.^[1]

To the Editor: A 58-year-old man was presented with the complaints of epigastric pain, nonbilious vomiting, and progressive distension of the abdomen for the last 1 month. There was no significant history. Physical examination was within normal limit except abdominal distension with hyperactive peristalsis. Laboratory examinations were normal except blood urea nitrogen: 35 mg/dl, creatinine: 1.45 mg/dl, hemoglobin: 10.5 g/dl, and leukocyte counts: 17,000/mm³.