Comparison of three surgical fixation methods for fracture of distal radial metaphyseal diaphyseal junction in children / 中华创伤骨科杂志

Objective:To compare the effects of anterograde elastic stable intramedullary nailing (ESIN-A), retrograde K-wires fixation (KW-R) and retrograde precision shaping of elastic stable intramedullary nailing (ESIN-RPS) in the treatment of fractures of distal radial metaphyseal diaphyseal junction (DRMDJ) in children.Methods:A retrospective study was conducted to analyze the data of 112 eligible children with DRMDJ fracture who had been treated at Department of Orthopedics, Children's Hospital, Anhui Medical University and Department of Orthopedics, The People's Hospital of Fuyang City,Anhui Medical University, from January 2016 to May 2022. There were 64 males and 48 females, with an age of (8.4±2.3) years. The children were divided into 3 groups according to different surgical fixation methods: group ESIN-A of 36 cases, group KW-R of 52 cases, and group ESIN-RPS of 24 cases. The operation time, intraoperative bleeding, fluoroscopy times, alignment rates and residual angulations by the anteroposterior and lateral X-ray films immediately after reduction were compared among the 3 groups. The Gartland-Werley evaluation of wrist function and complications were compared at the last follow-up.Results:There was no statistically significant difference in the preoperative general data among the 3 groups, indicating comparability ( P>0.05). In the operation time, group KW-R [(71.2±9.2) min] > group ESIN-A [(65.1±13.1) min] > group ESIN-RPS [(51.7±17.1) min]; in the fluoroscopy times, group KW-R [(13.9±6.3) times] > group ESIN-A [(9.0±2.8) times] > group ESIN-RPS [(6.4±2.0) times]; in the alignment rates by the anteroposterior and lateral X-ray films immediately after reduction, group ESIN-RPS (93.1%±4.6% and 95.2%±3.3%) > group KW-R (82.1%±11.0% and 88.1%±7.4%) > group ESIN-A (80.4%±9.9% and 86.7%±6.9%); in the residual angulations by the anteroposterior and lateral X-ray films immediately after reduction, group ESIN-RPS (3.3°±1.8° and 2.9°±2.1°) < group ESIN-A (5.2°±1.0° and 5.0°±3.2°) < group KW-R (6.6°±1.6°and 7.5°±2.7°). Pairwise comparisons in the above items were statistically significant ( P<0.05). In group ESIN-A, the incision length [(1.8±0.3) cm] was significantlylonger than that in group ESIN-RPS [(1.4±0.2) cm], and the intraoperative blood loss [(8.3±2.2) mL] significantly larger than that in group ESIN-RPS [(5.5±1.6) mL] ( P<0.05). One year after operation, the excellent and good rate by the Gartland-Werley evaluation of wrist function in groups ESIN-RPS, ESIN-A and KW-R, respectively, were 95.8% (23/24), 86.5% (31/36) and 86.1% (46/52), showing no statistically significant difference between the 3 group ( P>0.05), and the major incidence of complications in group KW-R (25.0%, 13/52) and in group ESIN-A (25.0%, 9/36) were significantly higher than that in group ESIN-RPS (4.2%, 1/24) ( P<0.05). Conclusion:In the treatment of DRMDJ fractures in children, compared with ESIN-A and KW-R, ESIN-RPS is an effective choice due to its advantages of shorter operation time, less intraoperative blood loss, less radiation, better alignment, and fewer complications.

Risk factors for failure in closed reduction of flexed supracondylar humerus fractures in children / 中华创伤骨科杂志

Objective:To identify the risk factors for failure in closed reduction of flexed supracondylar humerus fractures of Wilkins type Ⅲ in children.Methods:The data of 171 children were retrospectively analyzed who had been treated for flexed supracondylar humerus fractures of Wilkins type Ⅲ from January 2013 to December 2021 at Department of Orthopaedics, Children's Hospital of Jiangxi Province and Children's Hospital of Fudan University Anhui Hospital. They were divided into a reduction failure group (35 cases) and a reduction success group (136 cases). Factors such as fracture height, age, body mass index, ulnar-radial offset direction, obvious axial rotation of the distal fracture fragment, combined ulnar nerve injury, and time from injury to operation were listed as risk factors. The independent risk factors for failure in closed reduction of flexed supracondylar humerus fractures were identified by univariate analysis of variance and multi-variate logistic regression analysis.Results:The average age of 171 children was (7.8±2.6) years. There were 151 cases of radial deviation and 20 cases of ulnar deviation, 120 high type fractures and 51 low type fractures, and 20 cases of combined ulnar nerve injury and 115 cases of obvious rotation of the distal fracture fragment. The one-way ANOVA showed statistically significant differences between the reduction failure group and the reduction success group in terms of age, obvious rotation of the distal fracture fragment, and ulnar nerve injury ( P<0.05), but no significant differences in fracture height, body mass index, ulnar-radial offset direction, or time from injury to operation ( P>0.05). Multivariate logistic regression analysis showed that obvious rotation of the distal fracture fragment ( OR=3.287, 95% CI: 1.136 to 9.513, P=0.028) and combined ulnar nerve injury ( OR=6.439, 95% CI: 2.262 to 18.327, P=0.001) were risk factors for failure in closed reduction. Conclusion:As obvious rotation of the distal fracture fragment and combined ulnar nerve injury may be independent risk factors for failure in closed reduction of flexed supracondylar humerus fractures of Wilkins type Ⅲ in children, they should arouse more attention in the treatment of such fractures.

Induction of Anxiety-Like Phenotypes by Knockdown of Cannabinoid Type-1 Receptors in the Amygdala of Marmosets / 神经科学通报·英文版

The amygdala is an important hub for regulating emotions and is involved in the pathophysiology of many mental diseases, such as depression and anxiety. Meanwhile, the endocannabinoid system plays a crucial role in regulating emotions and mainly functions through the cannabinoid type-1 receptor (CB1R), which is strongly expressed in the amygdala of non-human primates (NHPs). However, it remains largely unknown how the CB1Rs in the amygdala of NHPs regulate mental diseases. Here, we investigated the role of CB1R by knocking down the cannabinoid receptor 1 (CNR1) gene encoding CB1R in the amygdala of adult marmosets through regional delivery of AAV-SaCas9-gRNA. We found that CB1R knockdown in the amygdala induced anxiety-like behaviors, including disrupted night sleep, agitated psychomotor activity in new environments, and reduced social desire. Moreover, marmosets with CB1R-knockdown had up-regulated plasma cortisol levels. These results indicate that the knockdown of CB1Rs in the amygdala induces anxiety-like behaviors in marmosets, and this may be the mechanism underlying the regulation of anxiety by CB1Rs in the amygdala of NHPs.

Short-term effectiveness of ultrasound-guided Kirschner wire provocation technique in treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of ultrasound-guided closed reduction by Kirschner wire provocation technique in the treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents.@*METHODS@#Between May 2019 and May 2022, 41 patients with Salter Harris types Ⅰ and Ⅱ distal tibial epiphyseal fractures were admitted, all of whom had periosteal entrapment on preoperative MRI, and 38 cases (92.7%) were confirmed to have periosteal entrapment by intraoperative ultrasound. There were 24 males and 14 females, the age ranged from 6.8 to 15.7 years, with an average of 10.7 years; and there were 20 cases of Salter Harris type Ⅰ and 18 cases of type Ⅱ. The time from injury to operation was 22-76 hours, with an average of 28.4 hours. The preoperative imaging examination showed excellent alignment in 4 cases, good in 20 cases, and poor in 14 cases. The ultrasound guided Kirschner wire provocation technique for closed reduction and percutaneous Kirschner wire internal fixation were performed. The operation time, intraoperative fluoroscopy frequency, fracture healing time, and complications were recorded. Anteroposterior and lateral X-ray films of the affected ankle joint were taken before operation, at 3 months after operation, and at last follow-up to observe the healing of the fracture, and anteroposterior X-ray films of the whole length of both lower limbs were taken to evaluate the alignment of the force lines of the affected limbs. The range of motion (ROM), visual analogue scale (VAS) score, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used to evaluate ankle function. The mechanical lateral distal tibia angle (mLDTA) and the anatomic anterior distal tibia angle (aADTA) were measured.@*RESULTS@#The operation time ranged from 17 to 52 minutes, with an average of 22.6 minutes, and the intraoperative fluoroscopy frequency ranged from 3 to 11 times, with an average of 4.2 times. X-ray examination during operation and at 2 days after operation showed that anatomical reduction was achieved. All patients were followed up 10-24 months, with an average of 16.4 months. All fractures healed in 6.1-7.2 weeks, with an average of 6.3 weeks; no fracture displacement occurred, and the patients recovered to their pre-injury level of motion at 6 months after operation. Needle tail irritation occurred in 2 cases at 4 weeks after operation, and they recovered after symptomatic treatment. During the follow-up, there was no serious complication such as incision deep infection, bone nonunion, delayed union, and malunion. At last follow-up, the patients' alignment were all excellent, and the difference was significant when compared with preoperative one ( Z=-7.471, P<0.001). The VAS score, AOFAS ankle-hindfoot score, dorsiflexion-plantar flexion ROM, varus-valgus ROM, mLDTA, and aADTA significantly improved at 3 months after operation and last follow-up when compared with preoperative ones ( P<0.05).@*CONCLUSION@#Ultrasound-guided closed reduction by Kirschner wire provocation technique for treating Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents is minimally invasive and safe.

Reconstruction of medial and lateral column periosteal hinge using Kirschner wire to assist in closed reduction of multi-directional unstable humeral supracondylar fractures in children / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of medial and lateral column periosteal hinge reconstruction using Kirschner wire in the closed reduction of multi-directional unstable humeral supracondylar fractures in children.@*METHODS@#A clinical data of 43 children with multi-direction unstable humeral supracondylar fractures, who met the selection criteria and were admitted between August 2020 and August 2022, was retrospectively analyzed. Twenty-one cases of fractures were treated wuth closed reduction after medial and lateral column periosteal hinge reconstruction using Kirschner wire and percutaneous Kirschner wires fixation (study group), while 22 cases of fractures were treated by traditional closed reduction technique and percutaneous Kirschner wire fixation (control group). There was no significant difference in gender, age, cause of injury, fracture side, and interval from injury to operation between the two groups ( P>0.05). The operation time, intraoperative fluoroscopy times, the number of children who were changed to open reduction after closed reduction failure, fracture healing time, complications within 2 months after operation, and the Flynn score of elbow joint function at last follow-up were compared between the two groups.@*RESULTS@#All the fractures in the study group were successfully closed reduction, and 4 cases in the control group were changed to open reduction and completed the operation, the difference between the two groups was significant ( P=0.040). The operation time and intraoperative fluoroscopy times of the study group were significantly less than those of the control group ( P<0.05). All children in both groups were followed up 6-18 months with an average of 9.0 months in the study group and 9.8 months in the control group. Imaging review showed that the fractures of both groups healed, and the difference in the healing time between the two groups was not significant ( P=0.373). According to Flynn score at last follow-up, the excellent and good rate of elbow joint function was 95.2% (20/21) in the study group and 86.4% (19/22) in the control group, with no significant difference ( P=0.317). There was no complication such as infection or irritation at the end of Kirchner wire within 2 months after operation.@*CONCLUSION@#For children with multi-directional unstable humeral supracondylar fractures, the use of Kirschner wires to reconstruct the medial and lateral column periosteal hinge to assist in closed reduction has the advantages of shortening operation time, reducing intraoperative fluoroscopy times, and effectively reducing the incidence of open reduction, and can achieve similar postoperative elbow joint function when compared with traditional closed reduction technique.

Research progress in the diagnosis and treatment of transitional fracture of the distal tibia / 中华创伤杂志

Transitional fracture of the distal tibia includes triplane fracture and Tillaux fracture and may combine with tibial shaft fracture or proximal fibular fracture. The fracture type is based on the mechanism of ankle injury and closure degree of the distal tibial epiphysis. Delayed or improper treatment may cause premature closure of the epiphysis in transitional fracture of the distal tibia, which may lead to ankle deformity or even disability, so it is necessary to pay attention to timely and correct diagnosis. Three-dimensional CT can show the fracture line of epiphysis of the distal tibia during the transitional period, which can improve the diagnostic rate and facilitate the effective placement for internal fixation. At present, there are various treatment methods for transitional fracture, including closed reduction with plaster fixation, closed or open reduction with percutaneous Kirschner wire or screw fixation, but a general consensus has not been reached. Improper treatment is likely to cause joint dysfunction, osteoarthritis and other adverse consequences. Therefore, the authors review the characteristics, diagnosis and treatment of transitional fracture of the distal tibia, in order to provide a reference for clinical treatment.

The optimal means for measuring the abduction angle before Spica cast in developmental dysplasia of the hip / 中华骨科杂志

Objective:Comparison of four methods in intraoperative abduction angles (AA) measurements of human cast immobilization in developmental dysplasia of the hip (DDH) by visual inspection and electronic software according to different body surface markers.Methods:Data were retrospectively collected from January 2019 to November 2021 in a total of 27 patients (54 hips) who underwent closed or simple open reduction. There were 6 males and 21 females with an average age of 13.2 months. Five doctors used visual inspection and mobile phone software to measure the AA of the hip joint immediately during the operation, and compared with the postoperative MRI measurement results (AA-MRI). The four methods of intraoperative measurement were: Junior visualization (AA-JV), the intersection angle between the line connecting the center of the popliteal fossa and the contact center of the plaster frame and the line connecting the two ischial tuberosities; the same methods as method one by Senior visualization (AA-SV); the intersection angle between the line connecting the center of the popliteal fossa and the center of the anus and the line connecting the ischial tubercle (anus-popliteal, AA-AP); the intersection of the vertical line between the center of the popliteal fossa and the groin and the horizontal line of the center of the anus and the vertical line connecting the two ischial tuberosities intersect (anus-groin crease-popliteal, AA-AGCP). The t-test, correlation coefficient, linear regression and Bland-Altman test were used to evaluate the measurements. Results:Comparing the four intraoperative and postoperative AA-MRI measurement methods, AA-JV (42.69°±4.13°) < AA-SV (44.80°±4.08°) < AA-AGCP (46.25°±5.15°) < AA-MRI (47.68°±4.21°) < AA-AP (51.77°±5.30°), and the difference between AA-JV and AA-SV, AA-AP and AA-AGCP was statistically significant ( t=2.53, P=0.013; t=5.47, P=0.001), there was no significant difference between AA-AGCP and AA-MRI ( t=1.57, P=0.118). The inter-group agreement of the five methods ICC test ranged from 0.807 to 0.892, and the intra-group average agreement of AA-MRI was 0.948. All ICC results were greater than 0.75 with good agreement. Linear regression results showed that the four intraoperative measurement methods had a good or moderate linear relationship with AA-MRI, AA-AGCP ( R 2=0.499)>AA-AP ( R 2=0.318)>AA-SV ( R 2=0.253)>AA-JV ( R 2=0.217), AA-AGCP was the best measurement method. The results of Bland-Altman scatterplot of AA-AGCP and AA-MRI were in good agreement, the mean and standard deviation of bias were -0.796±3.247, and the limit of agreement was 95% LoA (-7.16, -5.57). Conclusion:The AA method of visualization before Spica casting was smaller than truth. The method AA-AGCP objectively by landmarks was the advocated means measuring abduction angle during operation with highly consistency, agreement and easily performed.

Characteristics and reliability of a novel sub-classification of Wilkins type III lateral-flexion supracondylar fracture of the humerus in children / 中华创伤杂志

Objective:To investigate the characteristics and reliability of a novel sub-classification of Wilkins type III lateral-flexion supracondylar fracture of the humerus in children.Methods:A retrospective cohort study was used to analyze the clinical data of 92 children with supracondylar fracture of the humerus admitted to Provincial Children′s Hospital of Anhui Medical University from January 2013 to August 2021, including 38 males and 54 females, aged 2-13 years [(8.5±2.4)years]. Lateral-flexion Wilkins type III supracondylar humeral fractures were classified into two subtypes according to the fracture features: type IIIA ( n=14), complete fracture with the distal fragment displaced anteriorly and laterally, with no obvious anterior or posterior inclination (<10°) or rotation; type IIIB ( n=78), complete fracture with the distal fragment displaced anteriorly and laterally, with significant anterior or posterior inclination (>10°) or rotation. The incidence and risk ratio of ulnar nerve injury and open reduction were compared between the two subtypes of the fracture. The weighted Kappa method was used to test the inter- and intra-observer agreement of the two new subtypes. Results:Of all, 15 children had ulnar nerve injury, among which 1(6.7%) was type IIIA and 14(93.3%) were type IIIB; while other 77 children had no ulnar nerve injury. The risk of ulnar nerve injury in children with type IIIB was 3-fold higher than that in children with type IIIA ( OR=2.84, 95% CI 0.34- 25.56, P>0.05). The open reduction was performed in 11(73.3%) out of the 15 children with ulnar nerve injury, but in 18(23.4%) out of the 77 children with no ulnar nerve injury. The risk of open reduction in children with ulnar nerve injury was 9-fold higher than that in children without ulnar nerve injury ( OR=9.01, 95% CI 2.28- 33.17, P<0.01). Open reduction was performed in 29 children, among which 2(6.9%) were type IIIA and 27(93.1%) were type IIIB. The risk of open reduction in children with type IIIB was 3-fold higher than that in children with type IIIA ( OR=3.17, 95% CI 0.66-15.24, P>0.05). The intra-observer Kappa value was 0.49±0.09(95% CI 0.31-0.66), indicating a moderate agreement. The inter-observer Kappa value was 0.80±0.06(95% CI 0.68-0.91), indicating a strong or very strong agreement. Conclusions:Wilkins type IIIB lateral-flexion supracondylar fracture of the humerus in children is more likely to be accompanied by ulnar nerve injury and to be opt to open reduction in comparion with type IIIA. The new subtyping has reliable inter-observer and intra-observer consistency, and is able to facilitate the prediction of surgical plans.

Diagnosis and treatment of slipped capital femoral epiphysis in children / 国际儿科学杂志

Slipped capital femoral epiphysis is a hip disease with an unclear etiology,characterized with displacement and rotation of the femoral neck relative to the femoral epiphysis.Currently,the treatment methods vary according to clinical classification,including non-surgical treatment,in situ fixation,subcapital re-alignment osteotomy,base-of-neck osteotomy and intertrochanteric osteotomy.Postoperative complications such as avascular necrosis of femoral head,instability of hip joint,and chondrolysis are common and extremely challenging to treatment,which seriously affect the quality of life in children.Therefore,it is of great significance to clarify the treatment of different types of slipped capital femoral epiphysis and to reduce complications.At present,arthroscopic adjuvant therapy is mininally invasive and effective.This article reviews the progress of treatment of the slipped capital femoral epiphysis and the reduction of complications in children.

Magnetic resonance imaging of the femoral head morphology of the hip after normal children and DDH with closed and open reduction / 国际儿科学杂志

Objective To investigate the shaping rules of the femoral heads in the morphological perspective.The research objects are hips of normal children and children who have developmental dysplasia of the hip(DDH) and after closed reduction or limited open reduction.At the same time measuring and analyzing normal hip femoral head form changing with the children's age.Methods Collecting the DDH cases that after closed reduction and limited open reduction from June 2013 to December 2015.The follow-up period was more than 1 year.MRI images were collected before surgery,6 months after surgery,1 year after surgery,and 2 years after surgery.In addition,normal hip joint MRI images from 0 to 18 years old were collected for controlled study.Descriptive data on the affected side,healthy side and normal hip joint morphology of the hip dislocation were statistically analyzed.Results (1) The mean eccentricity of femoral head in normal hip decreased from (0.362 ±0.069) at 1-2 years to(0.141 ±0.028) at 18-19 years.(2) The eccentricity of femoral head before closed reduction and limited open reduction were both greater than those of healthy side.There was no significant difference in the eccentricity of the femoral head between the healthy side and the affected side at 1 year after closed reduction (P =0.211).There was no significant difference in the diameter of the bilateral femoral heads (P =0.871).The eccentricity of the bilateral femoral heads remained different at 2 years after limited open reduction (P =0.028),and the diameter of the affected femoral head exceeded the healthy side 1 year after surgery (P =0.001).Conclusion The shape of the femoral head of normal children gradually approaches the spherical shape with age.One year after closed reduction of DDH,the shape and size of the affected femoral head are close to the healthy side,and the femoral head of the affected side increases more than the healthy side in 1 ～ 2 years after open reduction and the morphology is still different.

The clinical pathological analysis of 23 patients with renal damage caused by microscopic polyangiitis / 中华风湿病学杂志

Objective To study the clinical features and pathology of renal damage in patients with MPA. Method The clinical pathological changes of 23 MPA patients were analyzed and the patients with positive ANCA were compared with those with negative ANCA. Results Most MPA patients were senile and male with the symptoms of lung damage, pleuritis, arthritis and myalgia as well as extrarenal symptoms such as fever, weight-loss, and anorexia. 65.2% of the patients were ANCA (+). Symptoms of renal function damage were hematuria and proteinuria, which could be found in all the patients. Different degree of renal damage could be detected. Glomerular cresent formation, which were mostly fibrous, could be found in all of the 23 patients. Half of the patients have tuft necrosis and interstitial vessel vasculitis. Conclusion MPA patients often have extrarenal symptoms besides renal function damage. Patients with positive ANCA differs from patients with negative ANCA in both clinical manifestation and kidney pathology.