A nomogram for preoperative prediction of lymph node metastasis in patients with intrahepatic cholangiocarcinoma based on inflammation-related markers / 中华外科杂志

Objectives: To construct a nomogram for prediction of intrahepatic cholangiocarcinoma (ICC) lymph node metastasis based on inflammation-related markers,and to conduct its clinical verification. Methods: Clinical and pathological data of 858 ICC patients who underwent radical resection were retrospectively collected at 10 domestic tertiary hospitals in China from January 2010 to December 2018. Among the 508 patients who underwent lymph node dissection,207 cases had complete variable clinical data for constructing the nomogram,including 84 males,123 females,109 patients≥60 years old,98 patients<60 years old and 69 patients were pathologically diagnosed with positive lymph nodes after surgery. Receiver operating characteristic curve was drawn to calculate the accuracy of preoperative imaging examinations to determine lymph node status,and the difference in overall survival time was compared by Log-rank test. Partial regression squares and statistically significant preoperative variables were screened by backward stepwise regression analysis. R software was applied to construct a nomogram,clinical decision curve and clinical influence curve,and Bootstrap method was used for internal verification. Moreover,retrospectively collecting clinical information of 107 ICC patients with intraoperative lymph node dissection admitted to 9 tertiary hospitals in China from January 2019 to June 2021 was for external verification to verify the accuracy of the nomogram. 80 patients with complete clinical data but without lymph node dissection were divided into lymph node metastasis high-risk group and low-risk group according to the score of the nomogram among the 858 patients. Log-rank test was used to compare the overall survival of patients with or without lymph node metastasis diagnosed by pathology. Results: The area under the curve of preoperative imaging examinations for lymph node status assessment of 440 patients was 0.615,with a false negative rate of 62.8% (113/180) and a false positive rate of 14.2% (37/260). The median survival time of 207 patients used to construct a nomogram with positive or negative postoperative pathological lymph node metastases was 18.5 months and 27.1 months,respectively (P<0.05). Five variables related to lymph node metastasis were screened out by backward stepwise regression analysis,which were combined calculi,neutrophil/lymphocyte ratio,albumin,liver capsule invasion and systemic immune inflammation index,according to which a nomogram was constructed with concordance index(C-index) of 0.737 (95%CI: 0.667 to 0.806). The C-index of external verification was 0.674 (95%CI:0.569 to 0.779). The calibration prediction curve was in good agreement with the reference curve. The results of the clinical decision curve showed that when the risk threshold of high lymph node metastasis in the nomogram was set to about 0.32,the maximum net benefit could be obtained by 0.11,and the cost/benefit ratio was 1∶2. The results of clinical influence curve showed that when the risk threshold of high lymph node metastasis in the nomogram was set to about 0.6,the probability of correctly predicting lymph node metastasis could reach more than 90%. There was no significant difference in overall survival time between patients with high/low risk of lymph node metastasis assessed by the nomogram and those with pathologically confirmed lymph node metastasis or without lymph node metastasis (Log-rank test:P=0.082 and 0.510,respectively). Conclusion: The prediction accuracy of preoperative nomogram for ICC lymph node metastasis based on inflammation-related markers is satisfactory,which can be used as a supplementary method for preoperative diagnosis of lymph node metastasis and is helpful for clinicians to make personalized decision of lymph node dissection for patients with ICC.

Three-dimensional finite element analysis on mechanical behavior of the bone remodeling and bone integration between the bone-implant interface after hip replacement / 中国骨伤

<p><b>OBJECTIVE</b>To discuss the primary stability of the fixed interface between the cementless prosthesis and femur, and its influence on bone ingrowth and secondary stability under the roughened surface and press fit of different prostheses by finite element analysis.</p><p><b>METHODS</b>:A three-dimensional finite element module of total hip arthroplasty (THA) was developed with Mimics software. There was a collection of data when simulating hip arthroplasty. The frictional coefficient between the fixed interface was 0,0.15,0.40 and 1.00 representing the roughness of prosthesis surface. The press fit was 0, 0.01,0.05 and 0.10 mm according to the operation. The Vion Mises stress distribution and the contact pressure,friction stress and relative sliding displacement between the interface were analysed and compared when simulating the maneuver of climbing stairs.</p><p><b>RESULTS</b>At a fixed press fit of 0.05 mm,the contact pressure between the interface was 230 , 231, 222 and 275 MN under four different frictional coefficient (0,0. 15,0.40 and 1.00) with little change; the relative sliding displacement was 0.529, 0.129, 0.107 and 0.087 mm with a consistent and obvious decline. As the fixed frictional coefficient was 0.40,the contact pressure between the interface were 56.0,67.7 ,60.4 and 49.6 MN under four different press fit (0, 0.01, 0.05 and 0.10 mm) with a reduction; the relative sliding displacement was 0.064,0.062,0.043 and 0.042 mm with an obvious decline, and there was a maximal friction stress when press fit of 0.01 mm.</p><p><b>CONCLUSION</b>There is a dynamic process of the bone remodeling and bone integration between the interface after hip replacement, determining the long-term outcome. The interface clearance and the frictional coefficient are the key factors of the bone integration.</p>

Clinical apprehension on application of Tri-lock BPS total hip arthroplasty / 中国骨伤

<p><b>OBJECTIVE</b>To study short-term results and clinical application of Tri-lock BPS in total hip arthoplasty.</p><p><b>METHODS</b>From May 2010 to July 2011, 32 hips in 31 patients (18 males and 13 females, ranging in age from 50 to 77 years old, with an average of 60.5 years old) were treated by total hip arthroplasty with Tri-lock BPS, including 8 patients with osteonecrosis (ON), 13 patients with fresh femoral neck fracture, 10 patients with developmental dysplasia of the hip (DDH). The therapeutic effects were evaluated by self assessment form, preoperative and postoperative Harris hip score, radiographs, Engh score and bone in growth of femoral side described by Gruen. Based on the short-term results,its design characteristic and clinical properties were analyzed.</p><p><b>RESULTS</b>All the incisions healed well and there were no complications such as femoral fracture, infection, dislocation and neurovascular injuries. All the patients were followed up with an average time of 12.2 months (ranged, 10 to 14 months). All the joints had good or excellent clinical results. The Harris score increased from preoperative 38.3 +/- 4.9 to 92.5 +/- 11.2 at the latest follow-up (t = 27.53, P < 0.01). Radiographically, the positions of the prostheses were normal,the average limbs length and femoral eccentricity recovered to normal. X-ray of the hips showed that the femoral stem prosthesis was in line with good initial fixed standard. At 3 months after surgery, X-ray of the hips showed that bone in growth in Gruen II and VI of femoral side.</p><p><b>CONCLUSION</b>Short-term results show that the design of Tri-lock BPS is more in line with human anatomy, and has the advantages in rapid recovery of hip function and retains more bone mass. It offers a newly valuable technology for the treatment of osteonecrosis, femoral neck fracture and DDH and so on.</p>

Case-control study on combined therapy for preventing postsurgery stiffness after elbow fracture / 中国骨伤

<p><b>OBJECTIVE</b>To research the efficacy,security and necessity of combined therapy for preventing postsurgery stiffness after elbow fracture.</p><p><b>METHODS</b>From May 2009 to April 2010, 60 patients with elbow fractures treated by operation were randomly divided into two groups: combined therapy group and past procedure group. Thirty patients in the combined therapy group,including 12 males and 18 females, ranging in age from 23 to 63 years, averaged (43.53 +/- 7.74) years old; 15 patients had two parts fractures, including humeral intercondylar fractures combined with olecroanon and (or) ulna coronoid process fractures in 8 cases, fractures of exterior and interior humeral condyle combined with capitulum radius in 3 cases, fractures of olecroanon and ulna coronoid process in 3 cases, fractures of olecroanon and capitulum radius in 1 case; other 15 patients had one part fractures, including fractures of exterior or interior humeral condyle in 8 cases,fractures of olecroanon or ulna coronoid process in 6 cases, fractures of capitulum radius in 1 patient. Thirty patients in the past procedure group,including 11 males and 19 females, ranging in age from 24 to 67 years, averaged (46.13 +/- 6.22) years; 15 patients had two parts fractures, including fractures of humeral intercondylar fracture combined with olecroanon and(or) ulna coronoid process in 7 cases, fractures of exterior and interior humeral condyle combined with capitulum radius in 2 cases,fractures of olecroanon and ulna coronoid process in 5 cases,fractures of humeral intercondylar fracture combined with capitulum radius in 1 patient; 15 pa- tients had one part fracture, including fractures of exterior or interior humeral condyle in 6 cases, fractures of olecroanon or ulna coronoid process in 8 cases, fractures of capitulum radius in 1 patient; the patients in the past procedure group were treated with past procedure methods. Mayo Elbow Performance Score (including gmotion of elbow joint) and security (using X-ray to recheck displacement fracture, internal fixation failure and heterotopic ossification) were evaluated at postoperative 6 months. From 2002 to 2006, 30 patients were reviewed as historical control group, including 17 males and 13 females, ranging in age from 27 to 62 years, averaged (47.17 +/- 7.83) years; 15 patients had two parts fractures, including fractures of humeral intercondylar combined with olecroanon and(or) ulna coronoid process in 7 cases, fractures of exterior and interior humeral condyle combined with capitulum radius in 1 case, fractures of olecroanon and ulna coronoid process in 6 cases, fractures of ulna coronoid process and capitulum radius in 1 case; 15 patients had one part fractures,including fractures of exterior or interior humeral condyle in 9 cases, fractures of olecroanon or ulna coronoid process in 5 cases,fractures of capitulum radius in 1 case. The Mayo Elbow Performance Score of the patients in historical control group was evaluated retrospectively at postoperative 6 months and the results were compared with that of past procedure group.</p><p><b>RESULTS</b>Mayo score of combined therapy group was (91.00 +/- 7.81)surpassed to (76.83 +/- 10.71) of the past procedure group and (73.17 +/- 1.99) of historical control group (F = 24.98, P < 0.05). The range of motion of elbow was (102.40 +/- 9.16) degrees of combined therapy group surpassed to (83.57 +/- 6.21) degrees of the past procedure group (t = 9.325, P < 0.05). There were no internal fixation loose,obvious fracture displacement and heterotopic ossification in each X-ray examination of patients in the combined therapy group. The Mayo score of historical control group was (73.17 +/- 11.99), showing no significant differences when compared with (76.83 +/- 10.71) of the past procedure group (LSD, P = 0.172).</p><p><b>CONCLUSION</b>Combined therapy including different stage, different method combination and different subject to practice to prevent postsurgery stiffness after elbow fracture is effect, security and necessity.</p>

Clinical study on second-stage revision in the postoperative infection after total hip replacement / 中国骨伤

<p><b>OBJECTIVE</b>To study the therapeutic effects and clinical experiences of second-stage revision in postoperative infection after total hip replacement and to explore its security and validity.</p><p><b>METHODS</b>From January 2006 to March 2009, 17 hips in 17 patients (7 males and 10 females, ranging in age from 43 to 75 years, with an average of 58.5 years) were treated with second-stage revision. All the patients suffered from different degrees of hip pain. In bacilliculture of Synovial fluid or peritonsillar tissue, 11 patients showed positive results and 6 patient negative. The intraoperative periprosthetic histopathological examination showed that all the patients had acute inflammation. Eight patients had sinus communicating with prosthesis; 15 patients had increased ESR, and 15 patients had C reactive protein increased. All the patients had osteolysis, prosthesis loosening, and the performance of periosteal reaction in X-ray. All the patients were treated with second stage revision. In the first operation, thorough debridement was perfumed and the prosthesis was removed. Then the prosthesis of antibiotic--loaded acrylic cement was implanted. After giving antibiotics intravenously for 4 weeks, the antibiotics were taken orally for another six weeks. The ESR and C response protein were examined at regular time, and the second-stage revision surgery was perfumed when the ESR and C response protein were normal. The Harris score was used to evaluate therapeutic effects of second-stage revision surgery before and after treatment.</p><p><b>RESULTS</b>All the patients were followed up with an average of 19.5 months, ranged from 12 to 35 months. No complications occurred. Postoperative X-ray showed prosthesis in the correct position. The Harris score increased from preoperative (39.3 +/- 5.6) to postoperative (84.4 +/- 10.3) (t = 15.86, P < 0.01).</p><p><b>CONCLUSION</b>The second-stage revision in postoperative infection after total hip replacement has a good efficacy, safety and reliability advantages. This technology provides an alternative in postoperative infection after total hip replacement.</p>

Influence of positioning of the femoral tunnel for MPFL reconstruction on the isometric characteristics of grafts / 医用生物力学

Objective To explore the influence of positioning of the femoral tunnel for medial patellofemoral ligamentre (MPFL)construction on the isometric characteristics of grafts.Method Knee specimens from ten fresh frozen cadavers were used. The attachment of medial patellofemoral ligament was observed. The distance between points from the adductor tubercle, the medial femoral epicondyle, and proximal, distal and central point of the MPFL’s femoral attachment site respectively to the middle point of its patellar attachment site were measured. Changes in length were recorded while the knee was measured by angles of knee flexion (0°, 30°, 60°, 90°, and 120°). Results The length changes in every point were compared. All of the maximal length changes of its adductor tubercle: proximal points were not greater than 3 mm. There was no significant difference between the length changes of adductor tubercle and proximal points（P>0.05）. Conclusions The position of the femoral turnel for MPFL reconstruction should be located as follows: MPFL should be at the middle point of upper edge of femoral attachment site (proximal point), and the point can appropriately be shifted to adductor tubercle.

Clinical apprehension on application of metal on metal total hip arthroplasty with large diameter heads / 中国骨伤

<p><b>OBJECTIVE</b>To approach the short-term result and clinical application of metal on metal total hip arthroplasty with large diameter heads and evaluate its safety and efficacy clinically.</p><p><b>METHODS</b>From January 2007 to March 2008, 39 hips in 37 patients (24 males and 13 females,ranging in age from 43 to 75 years, with an average of 58.5 years) were treated with metal on metal total hip arthroplasty with large diameter heads (ASRTM XL) included 14 cases of osteonecrosis (ON), 2 cases of osteoarthritis (OA), 18 cases of fresh femoral neck fracture, 3 cases of developmental dysplasia of the hip (DDH). All patients were evaluated by self assessment form, hip function examination, radiographs, preoperative and postoperative Harris hip score. Based on the short-term results, its design characteristic and clinical properties were analyzed.</p><p><b>RESULTS</b>All the incision healed well and there were not any complications such as femoral fracture, infection, dislocation and neurovascular injury. All patients obtained the follow-up and an average time was 16.5 months (12 to 19 months), all the joints had good or excellent clinical results. Radiographically, the positions of the prostheses were normal, the average limbs length and femoral eccentricity recovered as normal. The average range of motion of the hip improved remarkable, such as flexion improved from (20.1 +/- 8.2) degrees to (85.7 +/- 9.8) (t = 32.86, P < 0.01), abduction improved from (10.2 +/- 4.4) degrees to (41.5 +/- 9.1) degrees (t = 19.34, P < 0.01), adduction improved from (16.3 +/- 8.8) degrees to (40.3 +/- 10.4) (t = 11.00, P < 0.01),external rotation improved from (12.3 +/- 5.2)0 to (42.0 +/- 7.7) degrees (t = 19.96, P < 0.01), internal rotation improved from (3.4 +/- 1.1) degrees to (23.0 +/- 9.8) degrees (t = 12.41, P < 0.01). The Harris score rose from preoperative (39.3 +/- 5.6) to (91.4 +/- 10.3) at the latest follow up (t = 27.75, P < 0.01).</p><p><b>CONCLUSION</b>Short-term results show that metal on metal hip joint prosthesis with large diameter heads has advantages of small deformation of acetabular cup, lower wearing, large range of motion and few dislocation. It offers a newly valuable technology for treatment of osteonecrosis, osteoarthritis, femoral neck fracture and DDH with the higher requirement of movement after the operation.</p>

Isometry of grafts in PCL reconstruction under femoral tunnel shifting condition / 医用生物力学

Objective To explore the isometry of grafts in PCL(posterior cruciate ligament)double-bundle re-construction under femoral tunnel shifting condition.Method Knee specimens from ten fresh frozen cadavers were used.PCL were divided into anterolateral bundles(ALB)and posteromedial bundles(PMB)to the inser-tion footorint.The anterior,postedor,proximal,distal and central points of the two bundles'femoral attachment site were respectivelyanchored to the middle of the PCL's tibial attachment site by the trial wires.Changes in length of the intra-articular part of the wires were recorded while the knee was flexed from 0°to 120°.Result The length changes in every point were compared.All of the maximal length changes of ALB's proximal,pos-todor points and PMB's proximal points were not greater than 2mm.No significant difference between the length changes of ALB's proximal point and posterior(P=0.864>0.05)was found.Conclusions The femo-ral tunnel for the PCL double-bundle reconstruction should be located as follows:ALB should be at the middle point of upper edge of femoral attachment site(proximal point),while PIVIB at the middle point of femoral attachment site(proximal point).

Isometry of grafts in PCL reconstruction under femoral tunnel shifting condition / 医用生物力学

Objective To explore the isometry of grafts in PCL(posterior cruciate ligament)double-bundle re-construction under femoral tunnel shifting condition.Method Knee specimens from ten fresh frozen cadavers were used.PCL were divided into anterolateral bundles(ALB)and posteromedial bundles(PMB)to the inser-tion footorint.The anterior,postedor,proximal,distal and central points of the two bundles'femoral attachment site were respectivelyanchored to the middle of the PCL's tibial attachment site by the trial wires.Changes in length of the intra-articular part of the wires were recorded while the knee was flexed from 0°to 120°.Result The length changes in every point were compared.All of the maximal length changes of ALB's proximal,pos-todor points and PMB's proximal points were not greater than 2mm.No significant difference between the length changes of ALB's proximal point and posterior(P=0.864>0.05)was found.Conclusions The femo-ral tunnel for the PCL double-bundle reconstruction should be located as follows:ALB should be at the middle point of upper edge of femoral attachment site(proximal point),while PIVIB at the middle point of femoral attachment site(proximal point).

Prevention of prothesis dislocation after the revision of total hip arthroplasty / 中国骨伤

<p><b>OBJECTIVE</b>To explore the role of reconstruction of the posterior capsule and external rotators in prevention of postoperative dislocation in total hip arthroplasty revision following the posterolateral approach.</p><p><b>METHODS</b>Forty-five patients (47 hips) with the mean age of 65 years (55 to 78 years)of failed total hip arthroplasty were revised following the posterolateral approach. Posterior capsule was sutured to the anterosuperior portion of the capsule from where it had been detached, and the external rotators were then reattached to the soft tissue at the tip of the greater trochanter using 1.0 silk suture in surgery. The dislocation rate and risk factors were reviewed retrospectively to determine if closing the posterior capsule resulted in fewer dislocations. The femoral prosthesis and acetabular prosthesis were revised in 29 patients (31 hips), the liner was exchanged in 5 patients (5 hips), and the acetabular prosthesis or femoral components were revised in 10 patients (10 hips) and one patient (one hip) respectively. The procedure was the patient's first revision in 29 patients (30 hips), the second revision in 15 patients (16 hips), and the third revision in one patient(one hip). Radiographic evaluation included lower limb discrepancy, acetabular phase, femoral offset, anteversion angle, prosthetic loosening before and after revision. Function evaluation based on Harris score system.</p><p><b>RESULTS</b>All patients were followed up with an average of 2.7 years. None of the patients sustained dislocation or infection, except one patient felt the anterior instability but without dislocation, X-ray revealed the acetabular component was in excessively anteversion. Lower leg discrepancy, acetabular abduction, anteversion femoral offest and collodiaphyseal angle were restored to normal level after operation on the basis of X-ray. One of the acetabular components and one of the femoral components were loose without dislocation. The Harris hip score improved from (49.13 +/- 15.53) points preoperatively to (83.59 +/- 6.93) points at the final follow-up (P < 0.05). According to Harris functional evaluation, 36 hip got an excellent result, 5 good, 5 fair and 1 bad.</p><p><b>CONCLUSION</b>The historically high dislocation rate with the posterolateral approach for total hip arthroplasty revision can be reduced by careful soft tissue balancing,correction of implant alignment, meticulously closure of the posterior capsule, and reattaching the external rotators.</p>