Axis pedicle screwing assisted by intraoperative 3-D navigation versus freehand axis pedicle screwing in treatment of Hangman fracture / 中华创伤骨科杂志

Objective:To compare the therapeutic results between axis pedicle screwing assisted by intraoperative 3-D navigation and freehand axis pedicle screwing in the treatment of Hangman fracture.Methods:A retrospective analysis was performed of the 64 patients with Hangman fracture who had received posterior axis pedicle screwing at Department of Spinal Surgery, The Sixth Hospital of Ningbo from May 2014 to December 2019. According to the placement methods of axis pedicle screws, they were divided into a navigation group ( n=34, subjected to axis pedicle screwing assisted by intraoperative 3-D navigation) and a freehand group ( n=30, subjected to freehand axis pedicle screwing). Pedicle screw placement time, operation time, intraoperative bleeding, fluoroscopy time, hospital stay, total hospitalization cost and complications were recorded and compared between the 2 groups. The accuracy of axis pedicle screw placement was evaluated according to the postoperative cervical CT and screw grading criteria proposed by Park et al. At admission, 3 months postoperation, and the last follow-up, neurological function of the patients was evaluated by modified Japanese Orthopedic Association (mJOA) score, neck pain was evaluated by visual analogue scale (VAS), and C2/3 vertebral body angulation and C2 forward displacement were measured. The clinical efficacy was evaluated by Moon grading at the last follow-up. Results:The navigation group and the freehand group were comparable due to insignificant differences between them in the preoperative general data ( P>0.05). The accuracy of screw placement in the navigation group (98.2%, 54/55) was significantly higher than that in the freehand group (85.2%, 46/54) ( P<0.05). The screw placement time, operation time, fluoroscopy time and total hospitalization cost in the navigation group were significantly more than those in the freehand group ( P<0.05). Vertebral artery injury occurred in 3 cases in the freehand group. Screw loosening, screw breakage or rod breakage occurred in none of the patients after operation. There was no significant difference between the 2 groups in the intraoperative bleeding, hospital stay or follow-up time ( P>0.05). In both groups, the VAS score, mJOA score, C2/3 vertebral body angulation and C2 forward displacement were significantly improved at 3 months postoperation and the last follow-up compared with those at admission ( P<0.05), but there was no significant difference between the 2 groups in the contemporary comparisons ( P>0.05). At the last follow-up, Moon grading in the navigation group was significantly better than that in the freehand group ( P<0.05). Conclusion:In the treatment of Hangman fracture, compared with freehand screw placement, axis pedicle screwing assisted by intraoperative 3-D navigation can improve accuracy and safety of screw placement and reduce postoperative complications, leading to better clinical efficacy.

Assessment of rapid on-line evaluation of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses (with video) / 中华消化内镜杂志

Objective:To assess rapid on-line evaluation (ROLE) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic masses.Methods:Data of patients with solid pancreatic masses who underwent EUS-FNA in Peking University First Hospital from October 2017 to October 2019 were retrospectively analyzed. Patients were divided into the ROLE group and the control group. The number of FNA passes in ROLE group was decided by the cytopathologist based on the number of pancreatic tissue cells or heteromorphic cells obtained, while that in the control group was decided by the endoscopy physician according to the visual observation of tissue strips. The cytological and histological diagnosis of EUS-FNA specimen were made by another cytopathologist. The gold standard for final diagnosis was based on the histological diagnosis of surgically resected specimens. For patients who did not undergo surgical treatment, the final diagnosis was made based on the clinical course, imaging, tumor markers and feedback on treatment. The diagnostic yield, the accuracy, the sensitivity, the specificity, FNA passes, puncture time and adverse events were compared between the two groups.Results:A total of 87 patients were enrolled, 51 in the ROLE group and 36 in the control group. The diagnostic yield of the ROLE group was higher than that of the control group without significant difference [98.0% (50/51) VS 86.1%(31/36), P=0.078]. The number of FNA passes in the ROLE group was significantly less than that in the control group (median 2 VS 3, P<0.001). No significant difference in mean FNA puncture time was found between the ROLE group and the control group (19.4 min VS 18.5 min, P=0.089). There were no significant differences between the two groups with regard to the diagnostic yield, the sensitivity, the specificity, the positive predictive value, the negative predictive value or the incidence of adverse events. Conclusion:ROLE of EUS-FNA for pancreatic solid tumor may improve tissue acquisition for puncture, reduce the number of FNA passes, and may not significantly increase the procedure time and risk of puncture.

Effectiveness and safety of endoscopic submucosal dissection for Siewert type Ⅱ early esophagogastric junction cancer and precancerous lesion / 中华消化内镜杂志

Objective:To assess the effectiveness and safety of endoscopic submucosal dissection (ESD) in the treatment of early esophagogastric junction (EGJ) cancer and precancerous lesion.Methods:Clinical data of 67 patients with Siewert type Ⅱ early EGJ cancer or precancerous lesion who underwent ESD at Endoscopy Center of Peking University First Hospital from July 2012 to June 2019 were retrospectively analyzed. Clinical and pathological features, technical data and complication rate were reviewed. The factors that may affect the curative resection were analyzed.Results:Among the 67 cases, 5 were protruding type, 59 flat type, and 3 depressed type. The median lesion diameter was 1.6 ( QR: 1.8) cm, the median operation time was 60.0 ( QR: 56.0) min. The en bloc resection rate was 97.0% (65/67), the complete resection rate was 91.0% (61/67), and the curative resection rate was 82.1% (55/67). Factors related to non-curative resection were tumor size ( OR=8.457, 95% CI: 1.227-58.302, P=0.030) and pathological type ( OR=15.133, 95% CI: 1.518-150.870, P=0.021). ESD-related complications occurred in 3 cases (4.5%), including 1 case of delayed hemorrhage who received endoscopic hemostasis therapy, and 2 cases of post-operative cicatricial stricture who then received endoscopic dilation. Fifty-eight patients were followed up, and recurrence was found in 1 patient during follow-up with positive vertical margin who refused subsequent therapy.Metachronous early gastric cancer was found in another patient during follow-up, who was treated with a second ESD. Conclusion:ESD is a safe, effective and less invasive technique for early EGJ cancer and precancerous lesion. Tumor size, boundary and infiltration depth of the lesion should be accurately evaluated before operation to formulate appropriate treatment strategies.

Application of rubber band and clip facilitated endoscopic submucosal dissection for colorectal neoplasms (with video) / 中华消化内镜杂志

Objective:To evaluate the safety and efficacy of rubber band and clip facilitated endoscopic submucosal dissection (RAC-ESD) for colorectal neoplasms.Methods:A retrospective cohort study was performed. Clinical data of 115 patients with colorectal neoplasm receiving ESD from September 2018 to August 2019 were retrospectively analyzed. Thirty-four patients received RAC-ESD treatment (RAC-ESD group) and 81 received conventional ESD treatment (conventional ESD group). The procedure time, the dissected area per minute during ESD, en bloc resection rate, complete resection rate, curative resection rate, complication occurence and recurrence rate were compared between the two groups.Results:The median specimen area of RAC-ESD group was 6.32 (7.53) cm 2, and the median procedure time was 40.0 (55.0) min. The mean dissected area per minute was 0.14 (0.20) cm 2/min. While in conventional ESD group, the median specimen area was 4.71 (5.02) cm 2, the median procedure time was 50.0 (50.0) min and the mean dissected area per minute was 0.09 (0.07) cm 2/min. The median specimen area of RAC-ESD group was slightly larger and the median procedure time was slightly shorter than those of conventional ESD group, but neither was significantly different(both P>0.05). The median dissected area per minute of RAC-ESD group was significantly larger than that of the conventional ESD group ( P=0.008). The en bloc resection rate, complete resection rate and curative resection rate of RAC-ESD group were 100.0% (34/34), 100.0% (34/34) and 97.1% (33/34), while those of the conventional ESD group were 100.0%(81/81), 96.3%(78/81) and 91.4%(74/81), respectively. There was no ESD-related complication in either group. After 10.0±5.5 months of follow-up, there was no local recurrence in both groups. Conclusion:RAC-ESD may increase resection efficacy with safety.

Effect of spatial location of the screw at the injured vertebra on the vertebral height in AO type A thoracolumbar fracture / 中华创伤骨科杂志

Objective:To compare the effects of 3 spatial locations of the screw at the injured vertebra on the vertebral height in AO type A thoracolumbar fracture.Methods:A retrospective analysis was performed of the 156 patients with type A thoracolumbar fracture who had been hospitalized at Department of Spine Surgery, The Sixth Hospital of Ningbo from January 2016 to June 2019. They were divided into 3 groups according to the spatial location of the screw at the injured vertebra. In group A of 55 cases, the screws were located in the vertebral body between the longitudinal axis bisector of the vertebral pedicle and the upper endplate; in group B of 52 cases, the screws were located in the vertebral body between the vertical axis bisector of the vertebral pedicle and the horizontal line of the apex of the inferior pedicle notch; in group C of 49 cases, the screws were located in the vertebral body between the horizontal line at the apex of the inferior pedicle notch and the inferior endplate. The anterior, middle and posterior heights of the injured vertebra, Beck index and angulation of the injured vertebra at preoperation, one week postoperation and the last follow-up were compared between the 3 groups and within the same group.Results:There was no significant difference in preoperative general data between the 3 groups, showing comparability ( P>0.05). In all the 3 groups, the anterior and middle heights of the injured vertebra and Beck indexes at one week postoperation and at the last follow-up were significantly larger than those before operation while the angulations of the injured vertebra at one week postoperation and at the last follow-up were significantly smaller than the preoperative values (all P<0.05), but there was no significant difference between one week postoperation and the last follow-up in any of the above indexes ( P>0.05). In all the patients, the posterior height of the injured vertebra at one week postoperation was significantly larger than those before operation and at the last follow-up ( P<0.05), but there was no such a significant difference in comparison between preoperation and the last follow-up ( P>0.05). At the last follow-up, groups A and B had significantly larger anterior and middle heights of the injured vertebra and Beck indexes but significantly smaller angulations of the injured vertebra than group C, but such significant differences did not exist when the above indexes were compared between groups A and B ( P>0.05). Conclusions:In insertion into an injured vertebra, the screw should be parallel and close to the upper endplate, and located in the middle and upper part of the vertebra corresponding to the longitudinal axis of the vertebral pedicle, because this spatial position is conducive to intraoperative reduction, maintaining the postoperative height of the injured vertebra, and decreasing loss of the vertebral height.

Biomechanical stability of atlantoaxial and occipitocervical fixations with unilateral spinous process screw plus contralateral pedicle screw: a finite element analysis / 中华创伤骨科杂志

Objective:To determine the biomechanical stability of atlantoaxial and occipitocervical fixations with unilateral spinous process screw plus contralateral pedicle screw.Methods:After nonlinear finite element models of the intact upper cervical spine (C0-3) were constructed and validated, they were processed into 3 kinds with normal axis anatomy, a high-riding vertebral artery and a thin axis lamina, re-spectively.In the models, the odontoid fracture stabilized by atlantoaxial fixation and the atlas fracture sta-bilized by occipitocervical fixation were simulated.In the atlantoaxial fixation, the group of unilateral spinous process screw+contralateral pedicle screw+bilateral atlas lateral mass screws (spinous process screw group) was compared with that of bilateral axis pedicle screws+bilateral atlas lateral mass screws (pedicle screw group); in the occipitocervical fixation, the group of unilateral spinous process screw+contralateral pedicle screw+occipital screws (spinous process screw group) was compared with that of bilateral axis pedicle screws+occipital screws (pedicle screw group).Three different techniques in insertion of spinous process screws (horizontal, oblique and vertical) were applied.The range of motion (ROM) was measured in extension-flexion, lateral flexion and rotation of occipitocervical bodies (C0-C3) after internal fixation.Results:Compared with the intact models, the ROMs of extension-flexion, lateral flexion and rotation of C1-C2 were obviously reduced in the spinous process screw group and the pedicle screw group in the models with atlantoaxial and occipitocervical fixations.In the atlantoaxial fixation, the ROMs of extension-flexion, lateral flexion and rotation of C1-C2 were greater in the spinous process screw group than in the pedicle screw group; in the occipitocervical fixation, the spinous process screw group had greater ROM of lateral flexion of C1-C2 and greater ROM of rotation of C0-C2 than the pedicle screw group.There were unobvious differences in insertion of spinous process screws between the horizontal, oblique and vertical techniques.Conclusions:In the atlantoaxial and occipitocervical fixations, the unilateral spinous process screw plus contralateral pedicle screw can provide as fine stability as the bilateral axis pedicle screws.In the atlantoaxial fixation, the bilateral axis pedicle screws may lead to better stability of C1-C2 than the unilateral spinous process screw plus contralateral pedicle screw.In the occipitocervical fixation, the bilateral axis pedicle screws may lead to better stability of C1-C2 in lateral flexion and rotation than the unilateral spinous process screw plus contralateral pedicle screw. The 3 different techniques in insertion of spinous process screws lead to an unobvious difference in the stability of C1-C2.

Clinical short-term and long-term efficacy of endoscopic submucosal dissection in the treatment of early low rectal cancer and precancerous lesions / 中华胃肠外科杂志

Objective@#To evaluate the short-term and long-term efficacy of endoscopic submucosal dissection (ESD) in the treatment of early low rectal cancer and precancerous lesions.@*Methods@#Inclusion criteria: (1) Distance from the lower margin of tumor to the anal was ≤ 5 cm. (2) Early low rectal cancers were any size rectal epithelial tumors with infiltration depth limited to the mucosa and submucosa, which were diagnosed by postoperative pathology as high-grade intraepithelial neoplasia or adenocarcinoma of the rectum with infiltration depth of intramucosal or submucosal cancer (M or SM stage). (3) Precancerous lesions included adenoma and low-grade intraepithelial neoplasia of the rectum. (4) Patients received ESD treatment. Patients with tumor invasion depth over submucosa by pathology were excluded. From January 2008 to January 2018, 63 patients meeting the above criteria in Peking University First Hospital were enrolled in this descriptive cohort study. The disease characteristics, clinical manifestations, pathological types, treatment time, hospitalization time, en bloc resection rate (resection of the whole lesion), complete resection rate (both the horizontal and vertical incision margins were negative), postoperative complications and follow-up results were analyzed. Cummulative survival rate was calculated by Kaplan-Meier.@*Results@#The diameter of the lesion was (29.0±23.4) mm and the distance from the lesion to the anus was (2.7±1.8) cm. The median operation time was 45.0 (range, 10.0 to 360.0) minutes, the median hospitalization time was 3.0 (range, 2.0 to 12.0) days, en bloc resection rate was 100%, complete resection rate was 96.8% (61/63), and 1 case (1.6%) had postoperative bleeding. The follow-up rate was 87.3% (55/63) and the median follow-up time was 57.9 (range, 15.6 to 121.1) months. No local recurrence was found during the follow-up period and the 5-year survival rate was 100%.@*Conclusion@#Short- and long-term efficacy of ESD are quite good in the treatment of patients with early low rectal cancer and precancerous lesions.

Modified drilling template for placement of cervical anterior transpedicular screws / 中华创伤骨科杂志

Objective To evaluate the accuracy in placement of cervical anterior transpedicular screws (ATPS) under the guidance of our modified drilling template.Methods Eight wet cadaveric specimens of adult cervical spine,4 male and 4 female ones,were used for this experiment.Data of CT thin layer scanning of the cervical specimens in DICOM format were imported into software Mimics 17.0.After 3D models of the cervical vertebrae were reconstructed,the optimal trajectory was designed for ATPS placement in the transparent mode of the 3D models.Normal and our modified drilling templates for ATPS placement were designed and manufactured by 3D printing.The 2 kinds of drilling templates were used to assist ATPS placement onto one cervical vertebra,with laterality randomized.Altogether 64 pieces of ATPS were placed,with 32 ones for each drilling template.Postoperative CT scanning was conducted to evaluate the accuracy in ATPS placement.The 2 kinds of ATPS template were compared in terms of the deviations between actual and ideal trajectories in direction (caudal-angle and extroversive-angle) and position (X and Y axes) of the entry point.Results Our modified drilling template led to one screw penetrating the pedicle cortical bone while the normal drilling template led to 4 screws penetrating the pedicle cortical bone,yielding an accuracy rate of 96.9％ and of 87.5％ respectively.The extroversive-angle deviation (0.72°±0.69°),caudal-angle deviation (0.91°±0.70°),X axis shift (0.53 ±0.40 mm) and Y axis shift (0.54 ±0.42 mm) related to the modified template were all significantly smaller than those related to the normal template (1.16° ± 0.70°,1.49°±0.68°,0.88±0.40mm,1.22±0.42mm,respectively) (P ＜0.05).Conclusion Compared with a normal ATPS template,our modified drilling template for ATPS may be advantageous in better fitness,greater stability,increased accuracy in screw placement,and protection of adjacent discs.

Efficacy analysis of endoscopic therapy for early colorectal carcinoma: a retrospective study of 113 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the clinical efficacy of endoscopic therapy for early colorectal cancer.</p><p><b>METHODS</b>Clinical data of 113 early colorectal mucosal carcinoma or submucosal carcinoma receiving endoscopic therapy were retrospectively analyzed and compared with 39 early colorectal cancer cases receiving surgery during the same time.</p><p><b>RESULTS</b>All the cases were well-moderately differentiated adenocarcinoma. Size of tumors in endoscopic group was (26.2±21.5) mm, and that was (30.9±24.3) mm in surgery group (P=0.257). Baseline data between the two groups were not significantly different (all P>0.05). Significantly shorter median operating time [15.0 minutes vs. 203.0 minutes, χ=69.322, P=0.000] and median hospital stay [3.0 days vs. 17.0 days, χ=76.180, P=0.000] were observed in endoscopic group compared with surgery group. The en bloc resection rate, curative resection rate, lymph node metastatic rate and complication rate were not significantly different between two groups (all P>0.05). Ten patients in endoscopic group were referred to additional surgery for deep invasion and/or incomplete resection, of whom 7 received radical surgery, and the other 3 cases without radical surgery did not develop recurrence during follow-up of (20.5±0.9) months. After follow-up for (17.5±15.8) months, the local recurrence rate was 5.3% (6/113) in endoscopic group and 0 (0/39) in surgery group without significant difference (χ=0.983, P=0.321). There was no significant difference in 5-year tumor-free survival rate between two groups (91.8% vs. 97.0%, χ=1.533, P=0.216).</p><p><b>CONCLUSION</b>Endoscopic therapy possesses shorter operating time, shorter hospital stay and similar efficacy as compared to surgery in the treatment of early colorectal cancer.</p>

Surgical treatment for the terrible triad injury of the elbow complicated with fracture of the anteromedial facet of coronoid process / 中华创伤骨科杂志

Objective To report the clinical results of surgical treatment of fracture of the anteromedial facet of the coronoid process in terrible triad injury.Methods Of the 59 patients with terrible triad injury of the elbow,17 were surgically treated for fracture of the anteromedial facet of the coronoid process from July 2010 to July 2014.They were 12 men and 5 women,from 29 to 70 years of age (average,50 years).By the Mason classification for the radial head fractures,2 cases were type Ⅰ,13 type Ⅱ and 2 type Ⅲ;by the O'Driscoll classification for coronoid process fractures,one was type Ⅰ,14 were type Ⅱ and 2 type Ⅲ.All patients were treated through combined approaches.The lateral Kocher approach was used to fixate or replace the radial head and to repair the lateral ligament complex;the anteromedial approach was used to fixate the coronoid process fracture and to explore and repair the medial collateral ligament if necessary.Fracture union,implant loosening,ectopic ossification,regression and articular alignment were assessed on the postoperative X-rays.At final follow-ups,the elbow function was evaluated using Mayo elbow performance score (MEPS) and Broberg & Morrey grading system for traumatic arthritis.Results The average follow-up duration for the 17 patients was 32 months (range,from 24 to 60 months).Final follow-ups showed that the mean arc of flexion-extension was 97° (from 70° to 120°),the mean extension limitation 23° (from 0 to 40°),the mean arc of forearm rotation 139° (from 90° to 145°),the mean pronation 71° (from 60° to 90°)and the mean supination 67° (from 60° to 85°).The MEPT scores averaged 87 points (from 80 to 100 points),yielding 7 excellent,8 good and 2 fair cases.By the Broberg & Morrey grading,there were 4 cases of grade 1 and one of grade 2.No evidence of elbow instability,nonunion or implant failure was found.Ectopic ossification around the elbow happened in 4 cases,transient ulnar nerve palsy was found in one,and the Kirschner wire was removed operatively in 2 because it had loosened after fracture union.Conclusion The treatment of anteromedial coronoid fractures in terrible triad injury should be anatomically reduced through direct exposure and fixated rigidly.

Clinical analysis of endoscopic submucosal dissection on treatment of colorectal lesions / 中华消化内镜杂志

Objective To assess the efficiency and safety of endoscopic submucosal dissection (ESD)on treatment of colorectal lesions. Methods Clinical data of 163 patients with colorectal lesions, who underwent ESD at Endoscopy Center of Peking University First Hospital from June 2012 to June 2016, were retrospectively analyzed. The clinicopathologic features, the rate of en bloc resection, complete resection,complication and recurrence were reviewed. Results Among the 163 colorectal lesions,118 were mucosal lesions and 45 were submucosal ones. The mucosal lesions included 31 cases of protruding type,22 of flat type and 65 of laterally spreading tumor(LST). The submucosal lesions were all protruding type. The median lesion diameter was 2.2(2.0)cm, median operation time was 42(53)min. En bloc resection rate was 92.6%(151/163),and complete resection rate was 86.5%(141/163). The risk factor related to en bloc resection rate and complete resection rate was tumor size(P<0.05).Complications occurred in 4 cases, including 2 cases of intraoperative bleeding and 1 case of delayed bleeding who received endoscopic hemostasis therapy,and 1 patient with delayed perforation,which was managed by emergency surgery. Four recurrences were observed in 135 cases during follow-up, of which 3 were cured by additional endoscopic treatment,and 1 by surgery. Conclusion ESD is a safe and effective, but less invasive technique for colorectal lesions. Favorable long-term clinical outcomes can be achieved when en bloc curative resection is performed.

Operative treatment and classification system of terrible triad of the elbow / 中华骨科杂志

Objective To explore the classification system and outcomes of surgical treatment for terrible triad of the elbow.Methods Data of 42 patients with terrible triad elbow injuries who were surgically treated between 2009 and 2015 were retrospectively analyzed.There were 29 males and 13 females with a mean age of 47 years at the time of injury.42 patients of terrible triad injuries were classified into four types:type ⅠA,ⅠB,Ⅱ,Ⅲ,and Ⅳ injuries.Type ⅠA and Ⅱ injuries were treated through an isolated lateral approach,while type ⅠB,Ⅲ and Ⅳ injuries were treated by a combined lateral and anteromedial approach.Operative treatment consisted of repair or replacement of the radial head,repair of the lateral collateral ligament (LCL) and coronoid fracture fixation.Type ⅠA injuries were treated with radial head and LCL repair without coronoid fixation.Type Ⅳ elbow injuries were treated with medial collateral ligament (MCL) repair.Elbow functional status was evaluated using the Mayo elbow performance score (MEPS).Results There were three patients with type ⅠA injuries,7 patients type ⅠB injuries,15 type Ⅱ injuries,10 type Ⅲ injuries,and 7 type Ⅳ injuries.The average follow-up period was 30 months (range,24-56 months).All fractures of coronoid got union at average 11.5 months except for type ⅠA injuries.40 patients with fractures of radial head got union at average 12.4 months and two patients underwent radial head replacement without loosening.The mean flexion-extension arc was 107°±22°,the mean flexion contracture was 20°±10° and the mean flexion was 127°±14°.The average forearm rotation arc was 145°±14°,which included an average pronation of 73°±8° and an average supination of 71°±9°.The mean MEPS was 89±9 points (range,55-100 points),with excellent results in 24 elbows,good result in 17 and poor result in one;the excellence rate was 97％ (41/42).Thirteen patients had radiographic signs of arthrosis according to the Broberg-Morrey system (9 elbows were grade 1 and 4 were grade 2).5 patients had evidence of heterotopic ossification,of which four had minimal periarticular ossification and did not require additional surgery.The remaining patient showed significant heterotopic ossification and required an elbow release.1 patient with type Ⅲ injury developed transient median nerve paralysis and got full recovery after conservative treatment for 8 weeks.1 patient with type Ⅲ injury developed ulnar neuropathy and required an anterior ulnar nerve transposition.2 patients,who had shifting hardware but still achieved union,required a second surgery to remove the implant:one patient had a Kirschner wire shift from the radial head at 6 months after surgery,and the other had a loose screw in the coronoid process at one year after surgery.Conclusion Our classification system of terrible triad of the elbow may provide a guide for the selection of an ideal surgical approach and treatment modality.

Safety and efficacy of endoscopy therapy for early colorectal carcinoma / 中华消化内镜杂志

Objective To evaluate safety and efficacy of endoscopy therapy for early colorectal carcinoma of different types. Methods Clinical data of 113 patients with early colorectal carcinoma who were treated with different endoscopic therapies including polypectomy,EMR and ESD(ESD with snare and standard ESD)were retrospectively analyzed. The size, en bloc resection rate, curative resection rate, procedure time,associated complications and recurrence rate were compared among groups. Results Eleven pedunculated lesions were treated with polypectomy or EMR, which were en bloc resected and curative resected with no complication or local recurrence. Nineteen semi-pedunculated lesions were treated with EMR or ESD with no complications. Lesions treated with EMR were smaller than those of ESD(P=0.026), and had a lower en bloc resection rate[77.8%(14/18)VS 1/1,P=1.000]. The difference of curative resection rate and recurrence rate between groups was not significant(P>0.05). Eighty-three sessile lesions were treated with all three procedures.Lesions treated with ESD were larger than EMR(P=0.000),with a higher curative resection rate than EMR[95.5%(42/44)VS 77.8%(28/36),P=0.041]and a longer procedure time than EMR(P=0.000). There were no significant difference in severe complications[9.1%(4/44)VS 0],en bloc resection rates and recurrence rates(P>0.05). Ten lesions treated with ESD-S had a medium size between EMR and standard ESD group, with a significant shorter procedure time than standard ESD group(36.9 ± 24.7 min VS 120.4 ± 152.3 min, P=0.004).They were en bloc resected and complete resected. Conclusion Endoscopic treatment is safe and effective for early stage colorectal carcinoma. In order to get en bloc curative resection,endoscopists should carefully choose a suitable technique based on the macroscopic morphology of lesions. ESD-S can be used as a transitional method from EMR to ESD.

Comparison of postoperative hidden blood loss and deep venous thrombosis between dynamic hip screw,InterTan and proximal femoral nail antirotation-Ⅱ in treatment of femoral intertrochanteric fracture / 中华创伤骨科杂志

Objective To compare dynamic hip screw (DHS),InterTan and proximal femoral nail antirotation-Ⅱ (PFNA-Ⅱ) in the treatment of femoral intertrochanteric fracture in terms of their effects on postoperative hidden blood loss (HBL) and deep venous thrombosis (DVT).Methods We retrospectively analyzed the 133 patients with femoral intertrochanteric fracture who had been treated in our hospital from November 2011 to November 2015.Of them,42 received DHS treatment,including 22 males and 20 females;43 underwent InterTan fixation,including 21 males and 22 females;48 had PFNA-]Ⅱtreatment,including 25 males and 23 females.At preoperation,1,3 and 7 days postoperation,all of them had tests of hemoglobin (Hb),hematocrit value (Hct),blood platelet (PLT),thrombin time (TT),activated partial thromboplastin time (APTT),prothrombin time (PT),human fibrinogen (FIB) and D-dimer.DVT was detected using color Doppler ultrasound at 7 days postoperation.Results At 1,3 and 7 days postoperation,the DHS patients had the smallest values of Hb,Hct,TT,PT and APTT while the PFNA-Ⅱ patients the largest.The DHS patients had the largest values of intraoperative bleeding,PLT,FIB and D-dimer while the PFNA-Ⅱ patients the smallest.There were significant differences between the 3 groups in all the indexes (P ＜ 0.05) except in TT at 7 days postoperation and APTT at 1 and 7 days postoperation between the InterTan and PFNA-Ⅱ groups (P ＞ 0.05).The incidence of DVT in the InterTan group (2.3％,1/43) and in the PFNA-Ⅱ group (0) was significantly lower than in the DHS group(7.1％,3/42) (P ＜ 0.05).Conclusion In the treatment of femoral intertrochanteric fracture,PFNA-Ⅱ may be superior to InterTan and DHS in reducing postoperative HBL and control of DVT.

Preliminary clinical study of anterior pedicle screw fixation for lower cervical spine injuries / 中华创伤杂志

Objective To investigate the preliminary clinical application of anterior pedicle screws in treatment of the lower cervical spine injuries. Methods The study involved 22 patients with lower cervical spine injuries treated with anterior pedicle screw technique from January 2009 to December 2011.X-ray and CT images of the patients were taken postoperatively to evaluate whether the position,orientation and length of the screws were appropriate and whether there involved pedicle cortex perforation,transverse foramen or spinal canal invasion.MRI was also performed to ascertain the situation of decompression,the formation of epidural hematoma and the degeneration of cervical spinal cord.The improvement of JOA score was compared statistically. Results All the patients were followed up for 3-36 months ( mean,15.5 months).A total of 44 anterior lower cervical screws were implanted and all screws were inserted smoothly.All the patients had bone healing after average 4.5 months,which showed no loosening,prolapse or breakage of the screws or no loosening of the plate.One patient showed hoarseness postoperatively,which was probably due to the long-term distraction of recurrent laryngeal nerve.The symptom disappeared at around three weeks after neurotrophic support.Two patients complained of dysphagia postoperatively,and were informed of keeping a soft diet.The symptom was remarkably alleviated after three months or so.The X-ray films indicated satisfactory position of the implanted screws.Before discharge,the transaxial CT images showed that two screws perforated the medial pedicle cortex ( 1 ° ) and that two screws perforated the lateral cortex (1 °) and affected the medial margin of the transverse foramen.Before discharge,the MRI indicated obvious alleviation of the anterior spinal cord compression in all patients and a small amount of anterior epidural hematoma in four patients,with no obvious spinal cord compression.At 12 months after operation,the MRI showed significant improvement of spinal cord degeneration in three patients.JOA score was increased from preoperative (8.5 ± 0.7) to ( 14.5 ± 0.8 ) before discharge (P ＜0.01 ).JOA score was (15.7 ±0.7) at six months postoperatively,which was significantly improved as compared with that before discharge. Conclusions Anterior pedicle screw fixation is a reliable and safe method for reconstruction of the anterior lower cervical injuries.Surgical indications should be strictly controlled in its clinical application.

Unstable atlas fractures treated by anterior plate fixation through transoral approach / 中华骨科杂志

Objective To explore the clinical outcomes of anterior plate fixation through transoral approach in the treatment of unstable atlas fractures.Methods From March 2004 to May 2010,20 patients with unstable atlas fractures were treated by anterior plate fixation through transoral approach,including 12 males and 8 females,aged from 23 to 68 years (average,47.7±13.9 years).Of the 20 cases of unstable atlas fractures,4 cases were classified as anterior 1/2 Jefferson fracture,8 cases as 1/2 ring Jefferson fracture,and 8 cases as anterior 3/4 ring Jefferson fracture.The preoperative average VAS scores were 6.0±1.3 points,ranged from 4 to 8 points.Clinical and imaging examinations were performed during follow-up period to evaluate the outcomes.Results All patients were followed up for 12 to 81 months,with an average of 48.5±20.0 months.There were no screw loosing and breakage,no plate displacement,and no spinal cord and vertebral artery injury during operation.A total of 20 plates were placed and all 40 screws were inserted into atlas lateral mass.Computed tomography scans demonstrated 2 screws were placed too close to the vertebral artery canal,but without clinical consequences.The postoperative VAS scores were from 0 to 3 points with an average of 1.3±1.0 points.Static and dynamic films 6 months after surgery demonstrated that fusion was achieved in all cases.Atlantoaxial rotational function was restored satisfactorily.No plate-related complication was observed in all patients in the whole follow-up period.Conclusion Anterior plate fixation through transoral approach is an effective method for management of unstable atlas fractures,which has advantages such as solid bony fusion and low incidence of complication.

A study of the feasibility of posterior thoracic transarticular pedicle screw fixation / 中华骨科杂志

Objective To identify the feasibility and the anatomical parameters of posterior transarticular pedicle screw fixation in the thoracic spine, provide a reference for clinical applications. Methods Twenty human cadaveric thoracic spine segments were dissected posteriorly and anteriorly, with care taken to expose the laminas and pedicles. The entrance point of transarticular pedicle screws was located in the 7 mm away from the above at the inferior margin of the lamina and the inside at the exterior margin, respectively. Posterior transarticular pedicle screws implantation was performed under direct visualization into T1,2,T5,6 and T9,10 Under direct abservation, the feasibility of posterior transarticular pedicle screw fixation was assessed. Then a CT was done. On the morphologic CT scan, the angle and length of the transarticular pedicle crew trajectory were measured. Results The thoracic transarticular pedicle screw trajectory were caudal tilting in the sagittal plane and lateral tilting in the axial plane with successful placement. Screws were placed across the facet joint, and from the inferior articular process of upper thoracic vertebra into the pedicle of lower thoracic vertebra. There was little difference between different number of thoracic vertebrae of the angle, but without significance. The average angles of the screws were 41.4°+3.2°caudal tilting in the sagittal plane and 2.1°±0.7° lateral tilting in the axial plane. The average trajectory lengths were (40.6±4.9)mm, and the lengths increased gradually from upper thoracic vertebra to middle and lower. There were significant differences statistically among T1,2, T5,6 and T9.10 (F=74.09, P＜0.01 ). Conclusion Posterior transarticular pedicle screw fixation is feasible, and there are some directions for implantating the screws. Transarticular pedicle fixation in the thoracic spine affords an alternative to standard pedicle screw placement for thoracic stabilization.

Minimally invasive transforaminal lumbar interbody fusion or posterior lumbar interbody fusion in treatment of lumbar degenerative disorder disease / 中华骨科杂志

ObjectiveTo evaluate the clinical effects of transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion(PLIF) using microendoscopic discectomy under X-Tube system in treatment of lumbar degenerative disc diseases.MethodsFrom December 2007 to April 2008,32 patients with low back disorders were treated by microendoscopic discectomy TLIF or PLIF under X-Tube system,including 19 cases in TLIF and 13 in PLIF.Etiologies including lumbar disc herniation combined with segmental instability in 21 cases,and spondylolisthesis in 11 cases.All patients were under regular postoperative follow-up and radiological examination.The clinical functional outcomes were evaluated according to Oswestry disability questionnaire.ResultsThe mean operation time was 120 min(range,90-180),and the average blood loss was 190 ml (range,100-400).There were no complications,such as infection and internal fixation failure.Bony fusion was achieved in all patients.The follow-up was from 14 months to 41 months with 21 months in the average.The average 0swestry scores decreased from preoperative 40.1％±4.1％ to 9.5％±3.7％ three months after the operation.The outcomes of this operation were rated as excellent.ConclusionMicroendoscopic discectomy TLIF or PLIF under X-Tube system in treatment of lumbar degenerative disc diseases has the characteristics of less blood loss,tissue trauma and quick recovery.

Treatment strategies for lower cervical distractive flexion injuries / 中华创伤杂志

Objective To discuss the strategies for treatment of lower cervical distractive flexion injuries. Methods Sixty-eight patients including 43 males and 25 females at age range of 18-72 years (average 43 years) suffered from lower cervical distractive flexion injuries were operated from January 2002 to June 2007. According to Allen's classification, there were 7 patients at grade Ⅰ, 19 at grade Ⅱ,29 at grade Ⅲ and 13 at grade Ⅳ. Temporary skull traction was used for each subject before surgery. Only posterior approach was performed in 26 patients who were fixated by pedicle screw system,lateral mass screw system or transarticular screw system. Combined anterior and posterior approach was applied for the other 42 patients at one stage. The curative effect was followed up for all patients after the procedures. Results All patients were followed up for 6-65 months ( average 34 months), which showed posterior incision infection in 2 patients who were cured after debridement or change dressing. Two patients with aggravated neural symptome were cured following treatment with methylprednisolone. Neural function was improved at least for one level in all patients except for 18 patients (Frankel A). Of 11 patients at grade B, there were 4 patients improved to grade C and 5 to grade D. Of 10 patients at grade C, there were 6 patients recovered to grade D and 4 to grade E. All 15 patients at grade D reached grade E. It was not found loosening, breakage or defuxion. The graft bone was fused within 3-4 months, with no any complications related to surgical fixation. Conclusions The strategies for lower cervical distractive flexion injuries should be taken according to Allen' s classification. Single posterior procedure is suitable for grade Ⅰ and Ⅱ injuries. While combined posterior and anterior procedure can be used for grade Ⅲ and Ⅳ injuries.