Evaluation of basic laparoscopic training under 5A teaching mode / 中华胃肠外科杂志

Objective: To evaluate the rationality and effectiveness of basic laparoscopic training under 5A teaching mode. Methods: A prospective randomized controlled study was conducted. The teaching records of 70 trainees who received basic laparoscopic traning at the Laparoscopic Surgical Training Base in Chinese PLA General Hospital from July to December 2019 were analyzed. All the trainees participating in the laparoscopy training had obtained the national practicing physician certificates, including 12 junior physicians of our center, 9 intermediate physicians of our center, 19 advanced physicians, 13 postgraduate students, 8 doctoral students, and 9 surgical standardized training physicians. A random number table method was used to divide all the trainees into two groups: the traditional teaching group or the 5A teaching group (35 people in each group). In the traditional teaching group, the training of 4 modules of " precise beans, quincuncial piles, ring positioning and knot-tying suture" modules according to a fixed sequence and schedule was carried out. Each module had a learning time of 8 hours. In the 5A teaching group, the training started from five dimensions of analysis, aim, accomplishment, appraise and advance. Before conducting each stage of training, the actual operation ability of the trainees was tested, each class hour was designed individually, accurate teaching was conducted to the trainees, the ability of the trainees was evaluated dynamically, and the previous steps were cycled periodically based on class hours. The operating time and pass rate of trainees of two groups in the basic operation module of laparoscopy were statistically analyzed, and a hierarchical analysis of related influencing factors was conducted. Results: The time of above modules before training in the 5A teaching group and the traditional teaching group was similar (all P>0.05). After definitive training, the time required for trainees in 5A teaching group and traditional teaching group to complete the 4 modules was shortened to varying degrees. Compared to traditional teaching group, 5A teaching group spent less time in completing each project [precise beans: (63.2±10.1) seconds vs. (83.6±18.7) seconds, quincuncial piles: (56.2±7.3) seconds vs. (101.4±31.7) seconds, ring positioning: (84.2±13.7) seconds vs. (127.3±28.5) seconds, knot-tying suture: (263.2±41.8) seconds vs.(428.8±95.2) seconds, all P<0.05], and had higher pass rates [precise beans: 97.1% (34/35) vs. 80.0% (28/35), quincuncial piles: 91.4% (32/35) vs.71.4% (25/35), ring positioning: 100.0% (35/35) vs. 82.9% (29/35), knot-tying suture: 77.1% (27/35) vs. 60.0% (21/35), all P<0.05]. Among the junior trainees (junior physicians of our center, postgraduate students, doctoral students, and standardized surgical training physicians) and intermediate trainees (intermediate physicians of our center and advanced physicians), the 5A teaching group completed 3 modules (quincuncial piles, ring positioning and knot-tying suture) faster than the traditional teaching group [junior trainees: quincuncial piles (76.4±12.4) seconds vs. (139.8±41.6) seconds, ring positioning (92.2±20.5) seconds vs. (131.3±28.4) seconds, knot-tying suture (293.8±66.7) seconds vs. (444.3±103.3) seconds; intermediate trainees: quincuncial piles (51.4±5.9) seconds vs. (94.7±8.6) seconds, ring positioning (63.9±13.5) seconds vs. (87.5±18.6) seconds, knot-tying suture (210.1±35.6) seconds vs. (367.5±54.9) seconds, all P<0.05]. Conclusion: 5A teaching mode can acheive better training results compared with the traditional teaching mode in basic laparoscopic training, and is worthy of further popularization and application.

Prevention and treatment of complications in the treatment of femoral shaft closed fracture with core drilling intramedullary nail / 中国骨伤

OBJECTIVE@#To summarize the complications of core drilling intramedullary nail in the treatment of femoral shaft closed fracture and explore the treatment strategy.@*METHODS@#From August 2014 to June 2018, a total of 215 patients with closed femoral shaft fractures were treated with closed reduction core drill intramedullary nail, including 129 males and 86 females, aged from 18 to 62 years, with an average of (44.2±10.6) years old. The time from injury to operation was 3 to 21 days. There were 102 cases of AO type A fracture, 82 cases of AO type B fracture and 31 cases of AO type C fracture. The time of operation, the amount of blood loss during operation, the duration of hospitalization, the time of fracture healing and the HSS score of knee joint function at the last follow-up were recorded. The observation of complications included:iatrogenic fracture, core drill broken, core drill twist, postoperative infection, and fracture nonunion.@*RESULTS@#The average operation time was (63.2± 15.6) min and intraoperative blood loss was (150.0±34.5) ml. All the incisions reached grade A healing. Patients were follow up for a mean of (18.5±3.2) months, the average hospital stay was (4.3±1.2) days, and the average fracture healing time was (5.6±2.3) months. At the final follow-up, the average HSS score of knee joint was 90.3±4.7. Related complications occurred in 37 cases (17.2%). The core drill related complications occurred in 13 cases (6.0%), including core drill broken in 5 cases (2.3%), core removal in 1 case and slotting in 4 cases;core drill twist in 8 cases (3.7%). After the core was cut, the core was removed. Similar complicationsof conventional intramedullary nail:iatrogenic fracture was performed in 12 cases (5.6%), including 10 cases of fracture end split and 2 cases of distal perimedullary fracture of intramedullary nail. The patients with cleavage at the fracture end were not treated after judging their stability, and the patients with fracture around the distal end of the intramedullary nail were fixed with auxiliary steel plate during operation;1 case(0.4%) with delayed infection after operation, debridement and external fixation was replaced and healed after bone transfer; fracture nonunion occurred in 11 cases (5.1%), of which 7 cases (3.3%) were hypertrophic nonunion and healed with additional plate. Atrophic nonunion occurred in 4 cases (1.9%), which healed after additional steel plate and bone graft.@*CONCLUSION@#Core drilling intramedullary nail is an effective method for the treatment of closed femoral shaft fracture, and the complications include core drill related complications and conventional intramedullary nail similar complications. Accurate preoperative evaluation, careful operation during operation and early postoperative symptomatic treatment can effectively reduce the occurrence of related complications.

Effect of Early Weight-bearing on Appropriate Population with Intertrochanteric Fracture after Surgery / 中国康复理论与实践

Objective:To observe the effect of early weight-bearing on the appropriate population with intertrochanteric fracture after surgery. Methods:From April, 2017 to December, 2018, a total of 45 patients with Evans-Jensen type II intertrochanteric fracture and fracture reduction as positive medial cortex support (PMCS) after proximal femoral nail anti-rotation (PFNA) fixation were randomly divided into control group (n = 22) and experimental group (n = 23). Weight-bearing as tolerated (WBAT) was initiated from six weeks after surgery in the control group, and within 48 h after surgery in the experimental group. The frequency of WBAT in two groups increased gradually from three times a day for ten minutes a time to five times a day for 20 minutes a time until clinical healing of fracture. The length of stay, hospital cost, the fracture healing time and the complication incidence were compared between two groups, as well as the scores of Visual Analogue Scale (VAS) and Harris Hip Score at six weeks, three months and six months after surgery. Results:Compared with the control group, the length of stay was shorter (t = 3.716, P < 0.01), the hospital cost was lower, but no significant difference was found (t = 1.540, P > 0.05), and the fracture healing time was shorter (t = 6.248, P < 0.001) in the experimental group. The complication incidence was lower in the experimental group, but there was no significant difference (χ2= 2.198, P > 0.05). Six weeks, three months and six months after surgery, there was no significant difference in the score of VAS between two groups (t < 1.330, P > 0.05). The score of Harris Hip Score was significantly higher in the experimental group than in the control group six weeks after surgery (t = -5.115, P < 0.001), however, no significant difference was found in other time points (|t| < 1.799, P > 0.05). Conclusion:Early weight-bearing within 48 h after PFNA fixation for Evans-Jensen type II intertrochanteric fractures and reduction with PMCS could shorten the length of stay, shorten the bony healing time and promote early recovery of hip function.

A new type of adjustable weight bearing rehabilitation brace for lower limbs in postoperative rehabilitation of proximal femoral nail anti-rotation / 中国骨伤

OBJECTIVE@#To study and analyze the clinical effect of the self-developed new adjustable weight-bearing rehabilitation brace in the rehabilitation of the femoral intertrochanteric fracture after the operation of PFNA.@*METHODS@#From July 2015 to June 2017, 62 patients with typeⅡ (Evans-Jensen classification) intertrochanteric fracture of femur were treated with PFNA internal fixation. There were 11 males and 19 females in the routine rehabilitation group, with an average age of (70.73± 6.09) years;17 males and 15 females in the brace rehabilitation group, with an average age of (71.25±6.60) years. Among them, the patients in the routine rehabilitation group recovered according to the routine method, and the patients in the support rehabilitation group used the self-developed new adjustable weight-bearing rehabilitation support of lower limbs to assist the early rehabilitation. The pain intensity(VAS score), weight-bearing of affected limb, clinical healing time of fracture, Harris score and complications were recorded and analyzed.@*RESULTS@#Nine patients lost their visit half a year later, the other 53 patients were followed up for 9 to 18 months. The VAS score at 1, 3, 6 months after operation of brace rehabilitation group was lower than that of routine rehabilitation group(<0.05). The weight bearing of the limbs in the rehabilitation group was significantly higher than that in the conventional rehabilitation group(<0.05), but the clinical healing time of fracture in the brace rehabilitation group was shorter than that in the routine rehabilitation group(<0.05). In addition, the Harris score of the postoperativebrace rehabilitation group was better than that of the conventional rehabilitation group(<0.05). The incidence of complications was lower than that of the conventional rehabilitation group(=0.048).@*CONCLUSION@#In the rehabilitation of Evans Jensen typeⅡintertrochanteric fracture after PFNA internal fixation, the new self-developed adjustable weight-bearing rehabilitation brace can significantly relieve postoperative pain, regulate and moderately increase the stress stimulation at the fracture end, so as to promote fracture healing, accelerate the recovery of hip joint function, reduce the incidence of complications, and its clinical effect is safe and reliable.

Comparision of clinical effects between one-stage anterior and posterior approach in treating thoracolumbar tuberculosis with debridement and internal fixation / 中国骨伤

<p><b>OBJECTIVE</b>To compare the outcomes of surgical operation by posterior or anterior approach only for thoracolumbar tuberculosis.</p><p><b>METHODS</b>The clinical data of 97 patients with thoracolumbar tuberculosis underwent debridement and internal fixation from January 2005 to December 2014 were retrospectively analyzed. The study included 59 males and 38 females, with a mean age of 53.7 years ranged from 20 to 68 years. The course of disease was from 1 to 13 months with an average of (6.9±2.3) months. Among these patients, 43 cases were treated through one-stage anterior approach (anterior approach group) and 54 cases were treated through posterior approach (posterior approach group). The clinical data and imaging data of 97 cases were analyzed, including the operation time, intraoperative and postoperative blood loss, postoperative hospitalization time, complications, visual analogue scale(VAS), Oswestry Disability Index(ODI), Frankle grade, bone fusion time, and corrective rate of Cobb angle.</p><p><b>RESULTS</b>Operation time, intraoperative and postoperative blood loss, postoperative hospitalization time, complication rate, and corrective rate of Cobb angle were(174.4±9.9) min, (885.0±95.7) ml, (103.2±11.5) ml, (15.1±0.7) d, 9.3%, (73.4±3.2)% in posterior group respectively, while in anterior approach group were(229.5±15.2) min, (1326.0±113.5) ml, (153.2±16.7) ml, (19.0±0.8) d, 16.3%, (62.3±2.5)%, respectively, and there was significant difference between two groups. There was no significant difference in graft bone fusion between two groups. Postoperative VAS, ODI, Frankel grade of all patients were obviously improved, but there was no significant difference between two groups.</p><p><b>CONCLUSIONS</b>Thoracolumbar tuberculosis could be cured by one-stage anterior or posterior approach with debridement, bone grafting and internal fixation, but posterior approach has advantages of less trauma and better deformity correction.</p>