[Related factors of revision of distal femoral fractures treated with lateral locking plate].

OBJECTIVE: To analyze the factors related to the need for revision surgery due to nonunion or internal fixation failure after the treatment of distal femoral fracture with lateral locking plate (LLP). METHODS: Retrospective analysis was made of the clinical data of 130 cases with distal femoral fracture treated in our hospital from March 2005 to March 2019. SPSS 17.0 software (univariate analysis and Logistic regression analysis) was used to analyze the general condition [gender, age, body mass index (BMI), comorbidities, smoking history], injury related factors (energy of injury, open or closed injury, AO/OTA classification of fracture, fracture area distribution), operation related factors (operation time, reduction quality, postoperative infection) and construct characteristics of internal fixation. RESULTS: Twelve of 130 patients who were included in the study underwent revisional surgery, with a revision rate 9.2%. Univariate analysis showed that there were significant differences in age, BMI, AO/OTA classification, fracture area distribution, operation time, reduction quality, length of plate/fracture area, length of plate/fracture area above condylar between the two groups (P < 0.05). Logistic regression analysis showed that AO/OTA classification (A3), supracondylar involved fracture, operation time, reduction quality and the length of the plate/fracture area above the condylar were the possible related factors (P < 0.05). Destruction of the medial support ability of the femur in comminuted type A3 fracture, supra-condylar cortex area fracture involvement, increase of the bending stress of the LLP due to poor fracture reduction quality, damage of the blood supply of fracture end due to long-time operation, and stress concentration caused by insufficient length of plate might be risk factors of revisional operation after the treatment of distal femoral fracture with LLP. For the patients who needed revision after LLP treatment, additional use of medial minimally invasive plate fixation and autologous bone transplantation, change to intramedullary nail fixation were commonly used clinical treatment strategies. CONCLUSION: AO/OTA classification (A3), supracondylar involved fracture, long operation time, poor reduction quality and the length of the plate/fracture area above the condylar were the possible predictive factors of the revision in distal femoral fractures treated with lateral locking plate. The appropriate application of the locking plate and operation strategy are the key to reduce the revision rate in distal femoral fractures.

[Analysis of risk factors for necrosis of femoral head after internal fixation surgery in young and mid-aged patients with femoral neck fracture].

OBJECTIVE: To retrospectively analyze the risk factors of avascular necrosis of femoral head (ANFH) after internal fixation in young and mid-aged adults. METHODS: From January 2007 to December 2017, femoral neck fracture patients (18-60 years old) treated by reduction and internal fixation were retrospectively studied in Peking University Third Hospital. We recorded their gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) grade, reason of injury, fracture side, interval between injury and surgery, location of fracture line, Garden classification, Pauwels classification, reduction method (open or closed), internal fixation and reduction quality. The diagnosis of ANFH was confirmed based on X-ray and MRI images during the follow-up. The internal fixation method included cannulated compression screw (CCS) or dynamic hip screw (DHS, with or without anti-rotation screw). χ2 test and Logistic regression analysis were used to analyze the relationship between the various factors and postoperative ANFH. RESULTS: A total of 113 patients were included in this study, including 63 males and 50 females with an average age of (43.17 ± 12.34) years. They were followed up by (25.08 ± 16.17) months. ASA grade included grade I (21 cases), grade II (55 cases) and grade III (37 cases). The reasons of injury included low-energy trauma (76 cases) and high-energy (37 cases). The fracture line included subcapital type (37 cases), transverse type (74 cases) and basal type (2 cases). Garden classification included type I (3 cases), type II (46 cases), type III (39 cases) and type IV (25 cases). Pauwels classification included type I (21 cases), type II (55 cases) and type III (37 cases). Interval between injury and surgery was (3.88 ± 3.66) days, 108 patients and 5 patients performed closed and open reduction respectively. 63 patients performed CCS, and 50 patients performed DHS. The reduction quality included grade A (91 cases), grade B (18 cases) and grade C (4 cases). 18 patients developed ANFH after surgery, the incidence rate was 15.93% (18/113). The result of χ2 test showed the reason of injury (OR=0.19, P < 0.01), Garden classification (OR=0.13, P < 0.01), Pauwels classification (OR=0.12, P = 0.02), internal fixation method (OR=3.29, P = 0.04) and reduction quality (OR=0.33, P < 0.01) were significantly associated with ANFH. These five factors were further included into the Logistic regression analysis, and its results showed that the reason of injury (OR=4.11, P = 0.03) and Garden classification (OR=4.85, P = 0.04) were statistically significant. CONCLUSION: The reason of injury, Garden classification, Pauwels classification, internal fixation and reduction quality may increase the risk of ANFH after surgery, and the reason of injury and Garden classification were much more significant.

[Risk factors of recurrent kyphosis in thoracolumbar burst fracture patients treated by short segmental pedicle screw fixation].

OBJECTIVE: To analyze the risk factors of recurrent kyphosis after removal of short segmental pedicle screw fixation in patients with thoracolumbar burst fractures. METHODS: Retrospective analysis was conducted of 144 cases of thoracolumbar burst fractures without neurological impairment treated in Peking University Third Hospital from January 2010 to December 2017. There were 74 males and 70 females, with an average age of (39.1±13.2) years. The distribution of the injured vertebrae was T12: 42, L1: 72 and L2: 30, with fracture types of A3: 90, B1: 25 and B2: 29. The patients were divided into two groups: Recurrent kyphosis group (n=92) and non-recurrent kyphosis group (n=52). SPSS 26.0 software was used for univariate analysis and Logistic regression analysis. RESULTS: The average follow-up time was 28 (20-113) months. The imaging indexes of pre-operation, 3 days post-operation, 12 months post-operation and the last follow-up were measured and compared. Anterior vertebral body height, segmental kyphosis, vertebral wadge angle and Gardner deformity were significantly improved after operation (P < 0.05), and there were some degrees of loss in the 1-year follow-up; anterior vertebral body height and vertebral wadge angle were no longer changed after the removal of the screws; however, segmental kyphosis and Gardner deformity were still aggravated after the removal of the screws (P < 0.05). There were some degrees of collapse of the height of the upper and lower discs during the follow-up. Univariate analysis showed that there were statistically significant differences (P < 0.05) between the two groups in gender, age (36.9 years vs. 43.0 years), upper disc injury, CT value (174 vs. 160), segmental kyphosis (16.6° vs. 13.3°), vertebral wadge angle (16.7° vs. 13.6°), Gardner deformity (19.1° vs. 15.2°) and ratio of anterior vertebral body height (0.65 vs. 0.71). Logistic regression analysis showed that male (OR: 2.88, 95%CI: 1.196-6.933), upper disc injury (OR: 2.962, 95%CI: 1.062-8.258) and injured vertebral wedge angle were risk factors of recurrent kyphosis after removal of internal fixation for thoracolumbar burst fracture (P < 0.05). CONCLUSION: The patients with thoracolumbar burst fracture can obtain satisfactory effect immediately after posterior short segmental pedicle screw fixation, however, there may be some degree of loss during the follow-up. Male, upper disc injury and injured vertebral wedge angle are the risk factors of recurrent kyphosis after removal of internal fixation for thoracolumbar burst fracture.

[Diagnosis and treatment for the basicervical fractures of the trochanteric region].

OBJECTIVE: To evaluate the rate of basicervical fractures and document their diagnosis and treatment. METHODS: From January 2005 to May 2016, 28 basicervical fractures of the 832 trochanteric fractures were collected and evaluated. The patients were treated with multiple screws, dynamic hip screw (DHS), intramedullary nail. Via the operation time, postoperative hospitalization, loss of blood duration the operation, hidden blood loss, total blood loss, mean union time and the final follow-up Harris hip score, the characteristics of different internal fixations were compared and analyzed. RESULTS: The incidence of basicervical fractures was 3.37% (28/832) in our study. In the intramedullary nail group (16 patients), the operation time was 55 (20,120) min, the postoperative hospitalization was 3(2, 7) d, the intraoperative blood loss was 50 (5,100) mL, the hidden blood loss was 533.37 (376.19, 987.15) mL, and the total blood loss 627.35 (406.19, 1037.16) mL. The union time and final follow-up Harris score were 6 (3, 9) months and 90.25 (74,100) min. In the DHS group (8 patients), the operation time was 87.5 (65,115) min, the postoperative hospitalization was 5.5 (2, 17) d, the intraoperative blood loss was 100 (50,300) mL, the hidden blood loss was 278.11 (202.43, 849.97) mL, and the total blood loss 580.19 (368.55, 899.97) mL . The union time and final follow-up Harris score were 5.5 (4, 12) months and 85.5 (84, 87) min. In the multiple screws group (4 patients), the operation time was 47.5 (35, 75) min, the postoperative hospitalization was 5 (2, 12) d, the intraoperative blood loss was 20 (2, 70) mL, the hidden blood loss was 150 (100.00, 412.01) mL, and the total blood loss 195.00 (120.00, 414.01) mL. The union time and final follow-up Harris score were 4 (4, 6) months and 80 (61, 97) min. The patients treated with multiple screws and intramedullary nail had a shorter operation time than the DNS group, but no obvious difference was found between the other two groups (P=0.367). Postoperative hospitalization had no significant difference among the three groups. The intraoperative bleeding was more in the DHS group, the other two groups had no significant difference (P=0.100). However, the hidden blood loss was more in the intramedullary nail group, the other two groups had no significant difference (P=0.134). The total blood loss in the intramedullary nail group was more than multiple screw group, similar to the DHS group (P=0.483). One patient treated with multiple screws underwent internal fixation failure three months after operation. The mean union time and final follow-up Harris scores had no significant difference among the three groups (P>0.05). CONCLUSION: Through this study, we found that the incidence of basicervical fractures is low. Fractures with no shift can be confirmed by preoperative X-ray. For displaced fractures, preoperative CT+3D reconstruction is recommended. Surgical treatment by closed reduction and internal fixation with DHS or intramedullary nail is shown to be very effective.

[One of the pitfalls in the surgical treatment of maisonneuve fractures: a case report].

There exist controversies in the surgical treatment of maisonneuve injury with regard to reduction and fixation of syndesmosis and management of proximal fibular fracture. It is very important for the orthopaedic surgeons to learn more techniques and avoid pitfalls from clinical practice. We summarized the clinical data of 1 failed case, a 20-year-old girl with big body weight who underwent a primary surgery for the treatment of maisonneuve fracture with minimally invasive reduction and fixation of ankle syndesmosis and posterior malleolus and open reduction and internal fixation of medial malleolus, then a revision surgery for the treatment of iatrogenic syndesmotic malreduction with open reduction and re-stabilization of ankle syndesmosis supplemented with open reduction and internal fixation of proximal fibular facture. The malreduction of distal fibula was not found until finishing the postoperative computed tomography (CT) scan 2 weeks after the primary surgery, then the patient experienced an revision surgery including removal of the screws installed primarily for fixation of ankle syndesmosis, and open reduction and internal fixation of proximal fibular fracture, and limited open reduction and re-stabilization of ankle syndesmosis. Then the patient rehabilitated regularly under the direction of the surgeon who performed these two operations, and the postoperative recovery was smooth, then the hardwares for fixation of ankle syndesmosis and fracture of proximal fibula and medial malleolus were removed at different postoperative time. The patient experienced an excellent outcome at the end of the 3-year follow-up. The reasons for the failure in this case might include the overemphasized minimally invasive technique in the process of reduction, inaccurate assessment of intraoperative fluoroscopy and postoperative radiographs, and inappropriate utilization of the reduction clamp. Attention should be paid to the fact that an obliquely placed clamp for closed reduction of diastasis of ankle syndesmosis could result in syndesmotic malreduction. The worsened alignment of the fracture end of proximal fibula observed by intraoperative fluoroscopy may alert surgeons to syndesmotic malreduction. Partial exposure of syndesmosis and anatomical reduction and fixation of proximal fibular fracture may be useful measurres to avoid malreduction of ankle syndesmosis in the surgical treatment of maisonneuve injury in some patient, especially the patient with critically destabilized ankle.

Effect of estradiol and bisphenol A on human hepatoblastoma cell viability and telomerase activity

Sex hormones from environmental and physiological sources might play a major role in the pathogenesis of hepatoblastoma in children. This study investigated the effects of estradiol and bisphenol A on the proliferation and telomerase activity of human hepatoblastoma HepG2 cells. The cells were divided into 6 treatment groups: control, bisphenol A, estradiol, anti-estrogen ICI 182,780 (hereinafter ICI), bisphenol A+ICI, and estradiol+ICI. Cell proliferation was measured based on average absorbance using the Cell Counting-8 assay. The cell cycle distribution and apoptotic index were determined by flow cytometry. Telomerase activity was detected by polymerase chain reaction and a telomeric repeat amplification protocol assay. A higher cell density was observed in bisphenol A (P<0.01) and estradiol (P<0.05) groups compared with the control group. Cell numbers in S and G2/M phases after treatment for 48 h were higher (P<0.05), while the apoptotic index was lower (P<0.05) and telomerase activities at 48 and 72 h (P<0.05) were higher in these groups than in the control group. The cell density was also higher in bisphenol A+ICI (P<0.01) and estradiol+ICI (P<0.05) groups compared with the ICI group. Furthermore, cell numbers were increased in S and G2/M phases (P<0.05), while the apoptotic index was lower (P<0.05) and telomerase activities at 48 and 72 h were higher (P<0.05) in these groups than in the ICI group. Therefore, bisphenol A and estradiol promote HepG2 cell proliferation in vitro by inhibition of apoptosis and stimulation of telomerase activity via an estrogen receptor-dependent pathway.

Effect of estradiol and bisphenol A on human hepatoblastoma cell viability and telomerase activity.

Sex hormones from environmental and physiological sources might play a major role in the pathogenesis of hepatoblastoma in children. This study investigated the effects of estradiol and bisphenol A on the proliferation and telomerase activity of human hepatoblastoma HepG2 cells. The cells were divided into 6 treatment groups: control, bisphenol A, estradiol, anti-estrogen ICI 182,780 (hereinafter ICI), bisphenol A+ICI, and estradiol+ICI. Cell proliferation was measured based on average absorbance using the Cell Counting-8 assay. The cell cycle distribution and apoptotic index were determined by flow cytometry. Telomerase activity was detected by polymerase chain reaction and a telomeric repeat amplification protocol assay. A higher cell density was observed in bisphenol A (P<0.01) and estradiol (P<0.05) groups compared with the control group. Cell numbers in S and G2/M phases after treatment for 48 h were higher (P<0.05), while the apoptotic index was lower (P<0.05) and telomerase activities at 48 and 72 h (P<0.05) were higher in these groups than in the control group. The cell density was also higher in bisphenol A+ICI (P<0.01) and estradiol+ICI (P<0.05) groups compared with the ICI group. Furthermore, cell numbers were increased in S and G2/M phases (P<0.05), while the apoptotic index was lower (P<0.05) and telomerase activities at 48 and 72 h were higher (P<0.05) in these groups than in the ICI group. Therefore, bisphenol A and estradiol promote HepG2 cell proliferation in vitro by inhibition of apoptosis and stimulation of telomerase activity via an estrogen receptor-dependent pathway.