Comparative investigation of transport and deposition of nebulized particles in nasal airways following various middle turbinectomy.

BACKGROUND: Topical intranasal medication is required following functional endoscopic sinus surgery (FESS). The optimal particle size of transnasal nebulization aimed at the sinonasal cavities is not conclusive. The current study aims to evaluate the effect of particle size and various surgery scope of middle turbinectomy (MT) on post-full FESS drug delivery to the sinonasal cavities. METHODS: Sinonasal reconstructions were performed from post-full FESS CT scans in 6 chronic rhinosinusitis with nasal polyps (CRSwNP) patients. Four additional models representing alternative surgery scopes of MT were established from each post-FESS reconstruction for simulation data comparison. Airflow and particle deposition of nebulized delivery were simulated via computational fluid dynamics (CFD) and validated through in vitro experiments. The optimal particle sizes reaching a deposition of at least 75% of the maximum in the targeted regions were identified. RESULTS: The drug deposition rate onto the targeted regions increased following MT, with the greatest deposition following posterior MT (P-MT). Droplets in the range of 18-26 λm reached a deposition of larger than 75% of the maximum onto the targeted regions. Drug delivery rate in the sinonasal cavities varied significantly among individuals and across different types of MT with varying surgical scopes. CONCLUSIONS: This study is the first to investigate the effect of various surgery scope on drug delivery by transnasal nebulization to the sinonasal cavities. The findings strongly affirm the vast potential of transnasal nebulization as an effective post-FESS treatment option. Moreover, it emphasizes that the drug delivery process via atomizers to the nasal cavity and paranasal sinuses is highly sensitive to the particle size.

Threshold of 25(OH)D and consequently adjusted parathyroid hormone reference intervals: data mining for relationship between vitamin D and parathyroid hormone.

PURPOSE: By recruiting reference population, we aimed to (1): estimate the 25(OH)D threshold that maximally inhibits the PTH, which can be defined as the cutoff value for vitamin D sufficiency; (2) establish the PTH reference interval (RI) in population with sufficient vitamin D. METHODS: Study data were retrieved from LIS (Laboratory Information Management System) under literature suggested criteria, and outliers were excluded using Tukey fence method. Locally weighted regression (LOESS) and segmented regression (SR) were conducted to estimate the threshold of 25(OH)D. Multivariate linear regression was performed to evaluate the associations between PTH concentration and variables including 25(OH)D, gender, age, estimated glomerular filtration rate (EGFR), body mass index (BMI), albumin-adjusted serum calcium (aCa), serum phosphate(P), serum magnesium(Mg), and blood collection season. Z test was adopted to evaluate whether the reference interval should be stratified by determinants such as age and gender. RESULTS: A total of 64,979 apparently healthy subjects were recruited in this study, with median (Q1, Q3) 25(OH)D of 45.33 (36.15, 57.50) nmol/L and median (Q1, Q3) PTH of 42.19 (34.24, 52.20) ng/L. The segmented regression determined the 25(OH)D threshold of 55 nmol/L above which PTH would somewhat plateau and of 22 nmol/L below which PTH would rise steeply. Multivariate linear regression suggested that gender, EGFR, and BMI were independently associated with PTH concentrations. The PTH RI was calculated as 22.17-72.72 ng/L for subjects with 25(OH)D ≥ 55 nmol/L with no necessity of stratification according to gender, age, menopausal status nor season. CONCLUSION: This study reported 25(OH)D thresholds of vitamin D sufficiency at 55 nmol/L and vitamin D deficiency at 22 nmol/L, and consequently established PTH RIs in subjects with sufficient vitamin D for northern China population for the first time.

[Clinical efficacy of femoral neck screw system combined with supported hollow screw in treatment of femoral neck fractures with posterometral comminution in young and middle-aged patients].

Objective: To investigate the clinical efficacy of dynamic cross screw system (FNS) for femoral neck fractures in young and middle-aged patients with posterior medial comminution. Methods: A retrospective cohort study. Clinical data of 197 young and middle-aged patients with femoral neck fractures accompanied by posterior medial comminution treated with closed reduction FNS and internal fixation with anti-rotation cannulated screws in Beijing Luhe Hospital, Beijing Jishuitan Hospital and Beijing Tongren Hospital from October 2019 to October 2021 were analyzed retrospectively. According to different surgical methods, the patients were divided into two groups. There were 102 patients in the FNS group, included 55 males and 47 females with a mean age of (40.49±19.79) years; and there were 95 patients in the FNS plus anti-rotation hollow screw group (combined group), included 51 males and 44 females with an average age of (40.03±18.82) years. All patients were followed-up for at least 1 year after surgery. The general clinical data, surgical conditions and Harris score of the hip joint at the last follow-up of the two groups were compared. And the clinical efficacy of the two surgical schemes were evaluated and compared. After surgery, routine X-ray and CT examinations were performed to evaluate the fracture reduction and internal fixation, and the shortening of the femoral neck on the affected side was compared to that of healthy side according to the Zlowodzki method. Results: At the last follow-up, the incidence of fracture reduction loss, screw resection and coxa vara in the combined group were all significantly lower than those in the FNS group [10 (10.5%) vs 28 (27.4%), 1 (1.0%) vs 7 (6.8%) and 9 (9.4%) vs 21 (20.5%), respectively, all P<0.05]. The incidence of nonunion and necrosis of the femoral head in the combined group were both lower than those in the FNS group, but there was no significant difference between two groups (both P>0.05). The postoperative mild, moderate and severe femoral neck shortening in the combined group were all lower than those in the FNS group, and the difference were not statistically significant (all P>0.05). At the last follow-up, the Harris score in the combined group was 84.60±2.08, and it was higher than that in the FNS group (79.57±4.31), but the difference was not statistically significant (P=0.403). Conclusion: FNS plus supporting hollow screw has a good clinical effect on femoral neck fractures in young and middle-aged adults with posterior medial comminution.

Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome.

BACKGROUND: The benefits of early continuous neuromuscular blockade in patients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation remain unclear. METHODS: We randomly assigned patients with moderate-to-severe ARDS (defined by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure [PEEP] of ≥8 cm of water) to a 48-hour continuous infusion of cisatracurium with concomitant deep sedation (intervention group) or to a usual-care approach without routine neuromuscular blockade and with lighter sedation targets (control group). The same mechanical-ventilation strategies were used in both groups, including a strategy involving a high PEEP. The primary end point was in-hospital death from any cause at 90 days. RESULTS: The trial was stopped at the second interim analysis for futility. We enrolled 1006 patients early after the onset of moderate-to-severe ARDS (median, 7.6 hours after onset). During the first 48 hours after randomization, 488 of the 501 patients (97.4%) in the intervention group started a continuous infusion of cisatracurium (median duration of infusion, 47.8 hours; median dose, 1807 mg), and 86 of the 505 patients (17.0%) in the control group received a neuromuscular blocking agent (median dose, 38 mg). At 90 days, 213 patients (42.5%) in the intervention group and 216 (42.8%) in the control group had died before hospital discharge (between-group difference, -0.3 percentage points; 95% confidence interval, -6.4 to 5.9; P = 0.93). While in the hospital, patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group. There were no consistent between-group differences in end points assessed at 3, 6, and 12 months. CONCLUSIONS: Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets. (Funded by the National Heart, Lung, and Blood Institute; ROSE ClinicalTrials.gov number, NCT02509078.).

Ruling Out Real-Valued Standard Formalism of Quantum Theory.

Standard quantum theory was formulated with complex-valued Schrödinger equations, wave functions, operators, and Hilbert spaces. Previous work attempted to simulate quantum systems using only real numbers by exploiting an enlarged Hilbert space. A fundamental question arises: are the complex numbers really necessary in the standard formalism of quantum theory? To answer this question, a quantum game has been developed to distinguish standard quantum theory from its real-number analog, by revealing a contradiction between a high-fidelity multiqubit quantum experiment and players using only real-number quantum theory. Here, using superconducting qubits, we faithfully realize the quantum game based on deterministic entanglement swapping with a state-of-the-art fidelity of 0.952. Our experimental results violate the real-number bound of 7.66 by 43 standard deviations. Our results disprove the real-number formulation and establish the indispensable role of complex numbers in the standard quantum theory.

Toward Frameworks with Multiple Aligned and Interactive Fe(CO)3 Rotators: Syntheses and Structures of Diiron Complexes Linked by Two trans-Diaxial α,ω-Diphosphine Ligands Ar2P(CH2)nPAr2.

Reactions of (η4-benzylideneacetone)Fe(CO)3 and the α,ω-diphosphines Ar2P(CH2)nPAr2 afford the trigonal bipyramidal diiron tetraphosphorus complexes trans,trans-(CO)3Fe[Ar2P(CH2)nPAr2]2Fe(CO)3 (n/Ar = 3/Ph 3, 4/Ph 4a, 4/p-tol 4b; 56-19%). Crystal structures establish essentially parallel P-Fe-P axes, iron-iron distances of 5.894(9)-5.782(1) Å (3) and 6.403(1)-6.466(1) Å (4a,b), and van der Waals radii of 4.45 Å for the Fe(CO)3 rotators, the planes of which are offset by 0.029-1.665 Å. Analogous reactions of Ph2P(CH2)6PPh2 yield the square pyramidal monoiron complex trans-(CO)3Fe[Ph2P(CH2)6PPh2] (6', 31%), a rare case where a diphosphine spans trans basal positions (∠P-Fe-P 147.4(2)°). Both 3 and 6' exhibit two CO 13C NMR signals at room temperature, indicating slow exchange on the NMR time scale, which in the former could entail Fe(CO)3/Fe(CO)3 gearing. Under analogous conditions, 4a,b exhibit one signal. Previously reported adducts of Fe(CO)3 and Ph2P(CH2)nPPh2 are surveyed (1:1, n = 1-5; 2:2, n = 5), and the IR νC≡O band patterns and energies of all complexes analyzed with the aid of DFT calculations. The diiron complexes are preferred thermodynamically. Attention is given to limiting types of Fe(CO)3/Fe(CO)3 interactions in the diiron complexes.

[Incidence and risk factors of ulnar nerve dysfunction after open reduction and internal fixation of humeral intercondylar fractures].

Objective: To investigate the incidence and related risk factors of ulnar nerve dysfunction after open reduction and internal fixation of humeral intercondylar fractures. Methods: A total of 168 patients who underwent open reduction and plate and screw fixation of a humeral intercondylar fracture between January 2013 and May 2017 were retrospectively analyzed. There were 85 males and 83 females, aged from 14 to 77 years with a mean age of (43±17) years. Diagnosis of ulnar neuropathy was defined as documentation of sensory and motor dysfunction of the ulnar nerve in the medical record. The explanatory (independent) variables included age, gender, injury type, AO typing, time from injury to surgery, surgery approach, plates fixation methods and whether the nerve was transposed. Univariate and multivariate analyses were performed to determine risk factors associated with postoperative ulnar nerve dysfunction. Results: Acute injury-related ulnar nerve neuropathy was diagnosed in 12(7.1%) of 168 patients. Among the other 156 patients without preoperative ulnar nerve neuropathy,the total postoperative ulnar neuropathy was found in 52 patients (33.3%), and in 26(16.7%) at the final follow-up, according to the McGowan grades system; 23(88.5%) of 26 patients were clinically graded as grade 1, and 3(11.5%) were graded as grade 2. Multivariate logistic analysis showed that triceps sparing approach (OR=2.639, P=0.039) and parallel double plate fixation (OR=3.089, P=0.046) were associated with a risk of postoperative ulnar nerve dysfunction. Conclusion: There is a substantial incidence of postoperative ulnar nerve dysfunction after open reduction and plate and screw fixation of humeral intercondylar fracture, postoperative ulnar neuropathy may occur from the time of injury through the long-term follow-up period, triceps sparing approach and parallel double plate fixation are the risk factors for ulnar neuropathy.

[Stent placement for filter-related chronic occlusion of the inferior vena cava].

Objective: To assess the technical success rate, stent patency, clinical efficacy and complications of stent placement for filter-related chronic occlusion of the inferior vena cava. Methods: A retrospective analysis was carried out for 12 patients with filter-related chronic occlusion of the inferior vena cava associated with severe post-thrombotic syndrome, who underwent stent placement after ineffective conservative therapy at Nanjing First Hospital from March 2016 to December 2018,9 males and 3 females, aged from 48 to 77 years, mean age 60 years, six had bilateral lower extremity symptoms and six had unilateral lower extremity symptoms.Technical success rate, stent patency, clinical efficacy and complications of stent placement were recorded. Clinical success was defined as relief of symptoms and a decrease in clinical, etiology, anatomy, and pathophysiology (CEAP) score for at least grade 1. Results: Stent placement in the unilateral or bilateral iliocaval occlusion was successful in 11 patients. The cause of technical failure in the single patient with failed stent placement was an inability to cross the occluded left iliacvein and the patient was treated with stent placement in the right iliocaval vein.There were 7 patients with inferior vena cava and unilateral iliocaval stent placement; 5 patients with inferior vena cava and bilateral iliocaval stent placement. Acute stent thrombosis occlusion occurred in 1 case after the operation, the blood flow recanalized after catheter-directed thrombolysis and re-stenting. All patients were followed up for 6 to 24 months, with an average of (13±6) months. During the follow-up period, CTV or venography of lower limbs showed that the blood flow in the stent was unobstructed. At the last follow-up, 12 patients were evaluated as clinically effective. Three patients had transient treatment of lateral lumbar pain during operation, which alleviated by themselves.No significant abdominal pain, severe hemorrhage, symptomatic pulmonary embolism and other complications related to treatment occurred in all patients during perioperative period and follow-up. Conclusion: Stent placement is safe and feasible in the treatment of filter-related chronic occlusion of the inferior vena cava, which can alleviate the clinical symptoms of severe post-thrombotic syndrome.

miR-506 suppresses cervical cancer cell proliferation both in vitro and in vivo.

Cervical cancer (CC) is one of the most common gynecological malignancies in women worldwide. Recently increasing evidences indicate aberrant expression of miR-506 was reported to be associated with a variety of tumors. The aimof this study was to evaluate the potential role of miR-506 in CC and verify its effect on the regulation of ABCC4. The expression of miR-506 in cervical cancer tissues and HeLa and C33A cell lines was examined using quantitative Real-time PCR. MTT assay and animals studies were use to examine the effects of miR-506 on cervical cancer proliferation. Luciferase reporter and western blot were used to confirm miR-506 could regulate ABCC4. We found that miR-506 was significantly downregulated in human CC cell lines (HeLa and C33A) and clinical CC specimens as compared with matched cell lines and adjacent normal tissues, while the expression level of ABCC4 was higher in tumor tissues than it in adjacent normal tissues. We also revealed that up-regulated expression of miR-506 could inhibit CC cells proliferation both in vitro and in vivo. Moreover, ABCC4 was identified as a direct target of miR-506 and the inverse relationship between them was also observed. In summary, our finding suggests that miR-506 acts an important role in suppressing CC cell proliferation and suppresses the expression of ABCC4 by directly targeting its 3'-UTR. miR-506 may represent a novel therapeutic target of microRNA-mediated suppression of cell proliferation in CC, but the role of the miR-506/ABCC4 axis in CC progression needs further study.

Review of the role of leptin in the regulation of male reproductive function.

Since discovered in 1994, leptin has been thought to be a pleiotropic hormone that regulates food intake, controls energy balance in the body and influences multiple tissues in the body. Leptin plays an important mediating role in the regulation of neuroendocrine and can transmit the nutritional status signals to the reproductive-related central nervous system. Many studies have shown that leptin may play an important role in the control of reproductive function. Leptin can act on all levels of the hypothalamus-pituitary-gonadal (HPG) axis and may have local effects on the function of testis and spermatogenesis. Leptin is critical for puberty initiation and can also modulate testosterone synthesis by downregulating cAMP-dependent activation of steroidogenic genes expressions. Leptin is found to be higher in infertile men than in normal subjects. Yet, the exact role of leptin in the regulation of male reproductive function remains incomplete. The purpose of this review was to summarise the recent research about the biological effects of leptin on male reproductive system. In-depth study of leptin in reproductive system will help to reveal the pathogenesis of infertility and provide new treatment ideas for human assisted reproductive technology.

Roles of Fas/FasL-mediated apoptosis and inhibin B in the testicular dysfunction of rats with left-side varicocele.

We investigated the role of the Fas/FasL signalling pathway and inhibin B expression in rats with an experimentally induced left-side varicocele. Forty-five Sprague Dawley (SD) male rats were randomly divided into three groups in average: control group, sham group and experimental group. The expression of inhibin B in the rat left testis was analysed at the mRNA and protein levels by reverse transcription-polymerase chain reaction (RT-PCR) and Western blotting respectively. The expressions of Fas, FasL and caspase-3 in the left testis were measured by RT-PCR and immunofluorescence. The apoptosis index (AI) was measured by terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL). Both the mRNA and protein of inhibin B were significantly reduced in the experimental group compared with that in the control group or the sham group. The expression of Fas, FasL and caspase-3 in the experimental group was significantly increased compared to that in the control group or the sham group. The concentration of serum inhibin B was also inversely related to circulating FSH concentrations and positively correlated with sperm count. It is concluded that Fas/FasL system may play an important role in apoptosis of rats with experimental varicocele and inhibin B could reflect spermatogenesis function.

Bidirectional pumped high power Raman fiber laser.

This paper presents a 3.89 kW 1123 nm Raman all-fiber laser with an overall optical-to-optical efficiency of 70.9%. The system consists of a single-wavelength (1070nm) seed and one-stage bidirectional 976 nm non-wavelength-stabilized laser diodes (LDs) pumped Yb-doped fiber amplifier. The unique part of this system is the application of non-wavelength-stabilized LDs in high power bidirectional pumping configuration fiber amplifier via refractive index valley fiber combiners. This approach not only increases the pump power, but also shortens the length of fiber by avoiding the usage of multi-stage amplifier. Through both theoretical research and experiment, the bidirectional pumping configuration presented in this paper proves to be able to convert 976 nm pump laser to 1070 nm laser via Yb3+ transfer, which is then converted into 1123 nm Raman laser via the first-order Raman effect without the appearance of any higher-order Raman laser.

Remote Control by π-Conjugation of the Emissive Properties of Fischer Carbene-BODIPY Dyads.

The synthesis, structure, and complete characterization of mono- and bimetallic dyads joining Fischer carbene complexes and BODIPY chromophores are reported. In these organometallic species, the Fischer carbene complex is attached to the BODIPY moiety through a p-aminophenyl group linked at the C8 carbon atom of the BODIPY core. The photophysical properties, namely the corresponding UV/vis absorption and emission spectra of these new metal-carbene complexes, are analyzed and discussed. It is found that whereas the absorption of the considered dyads strongly resembles that of the parent 4-anilinyl-substituted BODIPY, the fluorescence emission is significantly reduced in these species, very likely as a result of a Förster-type energy transfer mechanism. At variance, the replacement of the pentacarbonyl-metal(0) fragment by a carbonyl group leads to high fluorescence emission intensity. In addition, the emissive properties of the BODIPY core in these organometallic dyads can be tuned by remote groups by means of π-conjugation, as supported by density functional theory calculations.

Understanding and controlling airborne organic compounds in the indoor environment: mass transfer analysis and applications.

Mass transfer is key to understanding and controlling indoor airborne organic chemical contaminants (e.g., VVOCs, VOCs, and SVOCs). In this study, we first introduce the fundamentals of mass transfer and then present a series of representative works from the past two decades, focusing on the most recent years. These works cover: (i) predicting and controlling emissions from indoor sources, (ii) determining concentrations of indoor air pollutants, (iii) estimating dermal exposure for some indoor gas-phase SVOCs, and (iv) optimizing air-purifying approaches. The mass transfer analysis spans the micro-, meso-, and macroscales and includes normal mass transfer modeling, inverse problem solving, and dimensionless analysis. These representative works have reported some novel approaches to mass transfer. Additionally, new dimensionless parameters such as the Little number and the normalized volume of clean air being completely cleaned in a given time period were proposed to better describe the general process characteristics in emissions and control of airborne organic compounds in the indoor environment. Finally, important problems that need further study are presented, reflecting the authors' perspective on the research opportunities in this area.

Experimental reconstruction of cervical esophageal defect with artificial esophagus made of polyurethane in a dog model.

The defect of esophagus after surgical excision in patients is usually replaced by autologous stomach, jejunum, or colon. The operation brings severe trauma and complications. Using artificial esophagus to replace the defect in situ can reduce the operative trauma, simplify the operative procedures, and decrease the influence to digestive function. A variety of experiments have been designed for developing a practical artificial esophagus. Nevertheless, a safe and reliable artificial esophagus is not yet available. The objective is to evaluate the possibility of the artificial esophagus made of non-degradable polyurethane materials being used in reconstruction of the segmental defect of cervical esophagus in beagles, observe the regeneration of esophageal tissue, and gather experience for future study. The cervical esophageal defects in 13 beagles were designed to 2-cm long and were constructed by the artificial esophagus made of non-degradable polyurethane materials. Nutrition supports were given after the operation. The operative mortality, anastomotic leakage, migration of artificial esophagus, and dysphagia were followed up. The regeneration of the esophageal tissues was evaluated by histopathology and immunohistochemical labeled streptavidin-biotin method. The surgical procedures were successfully completed in all beagles, and 12-month follow-ups were done. Only one beagle died of severe infection, and all others survived until being killed. The anastomotic leakage occurred in nine beagles, most of them (8/9) were cured after supportive therapy. The migration of artificial esophagus occurred in all 12 surviving beagles, and one artificial esophagus stayed in situ after migration. All 12 surviving beagles showed dysphagia with taking only fluid or soft food. No beagle died of malnutrition. The neo-esophagus was composed of granulation tissue, and the inner surface was covered by epithelium in 2-3 months completely. But the inner surface of neo-esophagus with artificial esophagus staying in situ after migration was not covered by epithelium, and the granulation tissue was infiltrated by a great deal of inflammatory cells. Antibodies against cytokeratin were positively expressed in epithelium of neo-esophagus. Up to 12 months after operation, antibodies against smooth muscle actin and desmin were both negatively expressed in neo-esophagus. The artificial esophagus made of non-degradable polyurethane reconstructing cervical esophageal defect is practicable. Although there are some problems, including anastomotic leakage, migration, and dysphagia, they are not lethal following good supportive therapy. The esophageal epithelium can regenerate with the supporting role of artificial esophagus. In the future, deformable artificial esophagus should be improved, and a much longer follow-up will be performed to evaluate whether the esophageal gland and skeletal muscle can regenerate.

[Treatment of the old terrible triad of the elbow without operative history].

OBJECTIVE: To introduce the surgical techniques and treating results of the old "terrible triad" of the elbow. METHODS: A retrospective analysis of 11 cases of old "terrible triad" of the elbow treated by the author from March 2009 to February 2014 were performed, with 9 males and 2 females; mean age was (31.82±8.66) years (17-45 years). The average time after injury was (6.36±2.50) weeks (4-12 weeks), with 7 cases on the left and 4 right. The combined injury included 2 cases with distal radius fractures, 1 with ankle fractures, fractures of the distal radius and the head injury (minor epidural hematoma, no surgery), and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation, and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures: 2 cases were type I, 5 were type II, 4 were type III. Classification of the coronoid process: Regan & Morrey: 1 was type I, 10 were type II; according to O'Driscoll classification, all the fractures were tip fracture, one was the first subtype, 10 were the second subtype. The elbow were released, the coronoid process were fixed by lasso suture combined with Kirschner wires. Radial head fractures were resected in 1 case, and replaced in 1 case, 3 cases with no treatment, 6 cases with osteotomy and 3.0 mm headless compression screw (HCS) fixation. The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicondyles, No.2 Ethibon was used in 2 cases through bone holes, and suture anchorsin the other 9 cases. All the patients were fixed by Stryker DJD II hinged external fixator to protect the bone and soft tissue. RESULTS: The average follow-up time was (38.36±21.92) months (19-77 months). All the patients had no obvious pain, instability and ulnar nerve symptoms in the last follow-up. The average elbow flexion was 134.09°±12.41° (100°-140°), average extension was -15.91°±14.46 ° (-40°-0°), range of flexion and extension was 118.18°±23.80° (70°-140°). Average pronation was 70.91°±26.63° (20°-90°), supination was 70.91°±26.63° (20°-100 °). The range of motion (ROM) of forearm rotation was 150.91°±43.00° (40°-180°). Average Mayo elbow performance score (MEPS) was 96.36±5.04 (85- 100).X-ray showed that no degenerative changes. Five patients had heterotopic ossifications, according to Hastings and Graham grading: 1 case was grade I, 3 cases were grade IIA, 1 case was IIB. CONCLUSION: The old "terrible triad" of elbow with no operative history is difficult to treat. The elbow's functions and stabilization can be recovered by thorough elbow release, repair of coronoid process and anterior capsule, radial head fractures, lateral collateral ligament and the common extensor tendon insertion, combined with hinged external fixator. Joint stiffness and heterotopic ossification are common complications.

[Diagnosis and treatment of adult capitellar fractures].

OBJECTIVE: To discuss the diagnosis, differential diagnosis, classification methods and treatment of the capitellar fractures of the distal humerus. METHODS: In the study, 28 adult patients with the capitellar fractures were treated in Beijing Jishuitan Hospital from Sep. 2008 to Jan. 2014. There were 10 females and 18 males with an average age of 34 years (range: 14-66 years). According to Dubberley classification: IA type in 6 cases, IB type in 2 cases, IIA type in 8 cases, IIB type in 4 cases, IIIA type in 4 cases, and IIIB type in 4 cases. Sixteen patients were treated with a single Kochr approach, 1 with a lateral approach combined with a medial approach, 2 combined with anterior elbow approach and 9 combined with posterior median approach. All of the fractures were fixed with Herbert screws, 7 cases with support plates, and 4 cases with the hinged elbow external fixator. All of the patients were followed up for clinical examination and radiograph check. They were evaluated with Broberg-Morrey score system. RESULTS: The average follow-up time was 28.5 months (range 12-72 months). The average bone union time was 8 weeks. The average ulnohumeral motion was 112°(60°-150°) and forearm rotation was 145°(100°-170°). The average Broberg-Morrey score was 92.5 points (range: 62-100 points). The excellent and good rate was 91.8%. The complications of traumatic arthritis was in 2 cases and elbow stiffness was in 2 cases. CONCLUSION: Attention should be paid to the diagnosis and differential diagnosis of capitellar fractures without missing the combined injury. According to Dubberley classification, appropriate surgical approach and the internal and external fixed methods could be chosen. Early postoperative, reasonable and effective exercise is helpful to the recovery of elbow joint function.

[Analysis of anterolateral approach and lateral approach for the treatment of coronal shear fracture of the distal humeral].

OBJECTIVE: To treat the coronal shear fracture of the distal humeral during open reduction and internal fixation by anterolateral approach and lateral approach, and to analyze the advantage and disadvantage of each approach. METHODS: From September 2006 to July 2014, 10 patients with coronal fracture of the distal humeral were analyzed, who were all treated with Open Reduction and Internal Fixation (ORIF), 5 with anterolateral approach (group A) and 5 with lateral approach (group B). For the anterior-lateral approach, the radial nerve and brachioradialis were retracted laterally and the brachialis was retracted medially, the capsule was incised and the fracture line was exposed, usually the capitellum and the lateral part of the trochlear could be exposed clearly but the exposure was limited. For the lateral approach, the brachioradialis was retracted anteriorly, the lateral collateral ligament (LCL) was protected or released from the starting point on the lateral condyle of the humeral, the elbow could be dislocated and the capitellum and part of the trochlear could be exposed. The fractures were classified with the system of Dubberley, the complications were analyzed and the ultimate results were evaluated according to the Mayo elbow performance index (MEPI). RESULTS: For group A, 4 re-operations were performed, 2 for the irritation of the screws,1 for stiff elbow and 1 for failure of the internal fixation. One radial nerve injury happened but recovered later. The mean MEPI was 82 points. For group B, 1 failure of the internal fixation and instability of the elbow happened. The revision operation was performed for this patient. The mean MEPI was 91 points. CONCLUSION: Lateral approach is better,it gives more exposure for the joint and the radial nerve is safe, but the trochlear is difficult to be exposed, and the LCL must be protected or repaired during the operation. Anterolateral approach can be used to expose the capitellum and the radial side of the trochlear, but the radial nerve is dangerous and more complications may happen.

[Effect of radiotherapy and indomethacin together in the prevention of recurrence of ectopic ossification around the elbow after resection].

OBJECTIVE: To discuss the effect of single low dose local radiotherapy and indomethacin together in the prevention of recurrence of ectopic ossification around the elbow after resection. METHODS: From Jun. 2009 to Dec. 2011, we performed excision of ectopic ossification around the elbow in 78 stiff elbows. For each case, we used both medial and lateral approaches, and we performed both anterior and posterior capsulectomies and removal of ectopic ossification. In the lateral approach, we started proximally, the lateral supracondylar ridge of the humerus was exposed from the interval between extensor carpi radialis longus (ECRL) and triceps, and then distally passed the interval between ECRL and extensor carpi radialis brevis (ECRB). With the medial approach, after releasing the ulnar nerve, the pronator teres muscle origin was reflected from the medial epicondyle, and then the common flexor-pronator tendon was split longitudinally distally and the brachalis and the anterior portion of the flexor-pronator group were dissected off the anterior humerus. If there was forearm rotation dysfunction, we used extensive lateral approach, the anconeus muscle was reflected from the ulna and the scar tissue and ectopic ossification around the proximal radioulnar joint were resected. The important structures, such as the lateral ulnar collateral ligament (LUCL) and the anterior part of the medial collateral ligament (AMCL), should be carefully protected, because they were important for the elbow stability. Anterior transposition of the ulnar nerve depended on the patients' condition. We performed low dose radiotherapy 4 hours before operation, and we used indomethacin for 6 weeks after operation. In these patients, there were 46 males and 32 females, whose age averaged (35.8±7.9) years (16-65 years). According to Hastings-Graham classification, there were 56 IIA, 5 IIB, 6 IIC and 11 III before operation. RESULTS: We followed up these patients for 26 months with an average of 24-36 months, all the patients improved their elbow function, and no recurrence of ectopic ossification appeared except for 1 patient. For this patient, his elbow function was excellent, and according to Hastings-Graham classification, his ectopic ossification was of type I. CONCLUSION: Single low dose local radiotherapy and indomethacin together are effective in the prevention of recurrence of ectopic ossification around the elbow after excision.