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Objective:To analyze the risk factors of acute kidney injury (AKI) in hip fracture patients with serious underlying diseases and establish a prediction nomogram.Methods:Clinical information of hip fracture patients admitted to the intensive care unit (ICU) of Beth Israel Deaconess Medical Center (BIDMC) was analyzed using the Medical Information Mart for Intensive Care (MIMIC)-IV. Patient comorbidities, disease scores, vital signs and laboratory tests, surgical modalities, invasive procedures, and drug use were recorded. According to the diagnostic criteria of AKI in the Kidney Disease Improving Global Outcome (KDIGO) guideline, the enrolled patients were randomly divided into training set and validation set. Based on logistic regression analysis, least absolute shrinkage and selection operator (LASSO) logistic regression algorithm was used to analyze the risk factors of AKI after admission, and the corresponding prediction model was calculated.Results:A total of 474 patients were enrolled, including 331 in the training set and 143 in the validation set. According to the diagnostic criteria of AKI of KDIGO guidelines, the patients were divided into AKI group (159 cases) and non-AKI group (172 cases). Univariate analysis showed that age ( t=2.61, P=0.009), coronary heart disease (χ 2=2.08, P=0.038), heart failure (χ 2=2.60, P=0.009), hemoglobin ( t=1.89, P=0.059), platelets ( t=1.81, P=0.070), urea nitrogen ( t=2.83, P=0.005), blood creatinine ( t=3.65, P<0.001), blood sodium ( t=2.55, P=0.011), blood glucose ( t=2.52, P=0.012), anion gap ( t=3.44, P=0.001), diastolic blood pressure ( t=2.72, P=0.007), mean arterial pressure ( t=2.16, P=0.031), SOFA score ( t=3.69, P<0.001), simplified acute physiological function score II (SAPSII) score ( t=2.95, P=0.003), as well as furosemide (χ 2=2.03, P=0.042), vancomycin (χ 2=1.70, P=0.089), vasoactive medications (χ 2=3.74, P<0.001) and use of invasive mechanical ventilation (χ 2=4.81, P<0.001) were risk factors associated with the development of AKI in hip fracture patients. Multivariate logistic regression analysis showed that age ( OR=1.03, P<0.001), coronary heart disease ( OR=2.05, P=0.069), hemoglobin ( OR=0.88, P=0.050), blood creatinine ( OR=1.37, P=0.009), blood sodium ( OR=1.07, P=0.026), anion gap ( OR=1.09, P=0.028) and vasoactive medications ( OR=3.83, P=0.018) and the use of invasive mechanical ventilation ( OR=6.56, P<0.001) were independent predictors of the development of AKI in hip fracture patients with serious underlying diseases. The area under the curve of the nomogram prediction model constructed by the above 8 predictors was 0.789, and the calibration curve of the nomogram was close to the ideal diagonal. Decision curve analysis showed that the net benefit of the model was significant. Conclusion:The incidence of AKI is high in hip fracture patients with serious underlying diseases. Age, coronary heart disease, hemoglobin, serum creatinine, serum sodium, anion gap, vasoactive drugs, and invasive mechanical ventilation can predict the occurrence of AKI to a certain extent. Combined with the risk factors, the construction of the corresponding prediction model can predict and manage the diagnosis and treatment of AKI in patients with hip fracture complicated with severe underlying diseases.
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Objective:To investigate the early effects of cup in cup technique in reconstructing paprosky III acetabular bone defect in revision hip arthroplasty.Methods:From January 2017 to December 2019, a total of 20 cases (20 hips) with paprosky III acetabular bone defect were reconstructed by Cup-in-Cup technique, including 9 males and 11 females. The age ranged from 45 to 76 years, with an average of 64.6 years. The causes of revision were aseptic loosening of prosthesis in 17 cases and loosening of prosthesis caused by periprosthetic infection in 3 cases. There were 13 hips with acetabular bone defect of paprosky IIIA and 7 hips with paprosky IIIB. The acetabular side was repaired in 13 cases, and the acetabulum and femoral side were repaired in 7 cases at the same time. Harris hip score was used to evaluate hip function during postoperative follow-up. The occurrence of serious complications such as intraoperative vascular and nerve injury, postoperative prosthesis dislocation, periprosthetic infection and fracture were counted. The height and horizontal position of hip rotation center were measured by X-ray film.Results:The operation duration was 110±25 min (range 80-180 min) and intraoperative bleeding was 700±180 ml. All cases were followed up for 12-36 months, with an average of 18 months. At the last follow-up, the Harris hip score of 16 cases was more than 80, with excellen in 2 cases, good in 14 cases and fair in 4 cases. The Harris score was 84.3±7.5, which was significantly higher than that before operation 40.1±16.6 ( t=15.34, P<0.001). The height of hip joint rotation center on the affected side decreased from 34.2± 3.3 mm before operation to 18.6±2.8 mm after operation with significant difference ( t=15.11, P<0.001). The horizontal distance increased from 18.1±5.5 mm before operation to 26.2±7.3 mm after operation with significant difference ( t=-5.95, P<0.001). After operation, the height of hip joint rotation center on the affected side was slightly higher than that on the opposite side, with a significant difference between the affected side 18.6±2.8 mm and the opposite side 12.2±3.3 mm ( t=6.73, P=0.018). The horizontal position was 26.2±7.3 mm, which had no significant difference compared with the contralateral 30.1±5.5 mm ( t=-3.29, P=0.381). There was no vascular and nerve injury, periprosthetic infection or incision related complications. During the following-up, the prosthesis was in satisfied position without prosthesis or screw loosening and fracture. Conclusion:The reconstruction of paprosky III acetabular bone defect with Cup-in-Cup technique in revision hip arthroplasty can obtain satisfied early effects, with achieving relatively normal hip rotation center and initial stability.
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Bisphosphonates have become the first-line drugs for the treatment of osteoporosis,which can reduce the risk of brittle fracture by inhibiting osteoclast activity and increasing bone density.Bisphosphonates bring benefits to osteoporosis patients,while some side effects can occur.In recent years,bisphosphonate related femoral atypical fractures (AFF) have been gradually recognized and become the focus of researches.AFF has typical clinical features and X-ray findings:Patients with long-term usage of bisphosphonate drug.AFF were defined as atraumatic or low-trauma fractures located in the subtrochanteric region or femoral shaft.X-ray showed transverse or short oblique fracture of the medial cortex which shaped like a "spike",and the bone cortex at the fracture area becomes thicker because of localized or diffuse periosteal reaction.AFF pathological mechanism is not clear,mainly with long-term use of bisphosphonates which seriously inhibit bone turnover,other theories including the theory of syndrome like collagen abnormal theory,mineral abnormal theory,hypophosphatasia,precise pathological mechanism still needs further study.Although the absolute incidence of AFF is very low,the number of AFF will inevitably increase with the increasing number of aging osteoporosis patients and the widespread application of bisphosphonates,which should be paid more attention to.AFF risk factors included long-term usage history of bisphosphonate,glucocorticoid treatment history,female patients,fracture prodromal symptoms including pain,discomfort or weakness in the thighs or groin and the bowing of the femoral shaft was associated with the location of AFF fracture.At present,the point of view of AFF treatment is:complete fracture of femoral length,reamed intramedullary nail fixation.Even for incomplete fractures,preventive intramedullary nailing should also be considered.The healing time of AFF fracture increases obviously.The most common complications are delayed union and nonunion.The rate of delayed union can be as high as 26％.How to improve the curative effect of this kind of fracture needs further study.In this paper,the latest literature on the clinical features,diagnostic criteria,morbidity,risk factors,pathological mechanisms,treatment and complications of atypical fractures of the femur were reviewed.
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Objective To investigate the clinical effects of high restrictive anti-dislocation prosthesis total hip arthroplasty(THA)in treating elderly femoral neck fracture patients with hemiplegia.Methods From June 2015 to January 2017,Fortythree elderly femoral neck fracture patients with hemiplegia were treated with CombiCup THA system.There were 15 males and 28 females with an average age of 71.5±5.6 years (60-84 years).The left side was involved in 20 cases,while the right side in 23 cases.There were 15 cases with Garden Ⅲ type and 28 cases with type Ⅳ.Lower limb muscle strength grade were 20 cases in grade 3,19 cases in grade 4,and 5 cases in grade 5.Sixteen cases walked independently before injury,while 27 of them walked with the aid of crutches.The duration between injuries to operation ranged from 2 days to 5 days.The size of the prosthesis and offset distance were recorded by template technique pre-operation.The appropriate type of prosthesis was selected to restore the offset and to reconstruct the abductor muscle arm,according to the actual measurement in the operation and the preoperative plan.Based on the bone mineral density and medullary cavity morphology,biological or cemented femoral stem prosthesis was selected.The quality of the implant and the length of both lower limbs were evaluated by pelvic X-ray immediately after operation.The patients were followed-up at 2 weeks,1 months,2 months,3 months,6 months,1 and 2 years.Functional exercise guidance and complications were recorded at the follow-up duration.At the last follow-up,the hip function and limb function were evaluated according to the Harris score and Fugl-Meyer motor function assessment respectively.Results Based on pelvic X-ray evaluation after operation,all prosthesis position were favorable with the average angle of acetabular abduction 45.1±2.3 degrees and the length difference of both limbs less than 5 mm (average 2.2±0.8 mm).The follow-up duration ranged from 6 to 24 months with an average of 11.2±3.5 months.There was no complication such as prosthesis dislocation and infection.Deep venous thrombosis in calf occurred in 3 patients at 2 days after operation,who underwent recanalization after thrombolysis.At the last follow-up,the average score of Harris hip function and Fugl-Meyer were 90.2±3.8 (77 to 96) and 97.1±2.5 (83 to 100),respectively.No dislocation,infection,loosening,subsidence and osteolysis phenomenon was found during the follow-up.Conclusion The elderly patients with Garden type Ⅲ or Ⅳ femoral neck fractures accompanied with hemiplegia can be treated with anti-dislocation prosthesis THA.It does have the advantages of low dislocation rate and imoroved hemiolegic limb function.
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Objective To investigate the mechanism,injury characteristics,and early interventions of bilateral femoral shaft fracture.Methods Twenty-five cases of bilateral femoral shaft fracture treated between December 2009 and June 2012 were enrolled in the study.Eighteen patients were males and 7 were females with mean age of 31.2 years (range,17-40 years).Nineteen cases were injured due to traffic accidents and 6 due to the hit by heavy objects.There were 47 sides with closed fracture and 3 sides with open fracture.Intramedullary nailing was performed at 32 sides and plate fixation was used at 18 sides.ISS,blood routine,some blood biochemical items,blood or plasma use,and hospitalization days were measured.Results ISS was (14.6 ± 5.2) points.Preoperative readiness time and hospital stay were (10.1 ± 3.7) days and (28.9 ± 8.4) days respectively.After hospitalization,measured values were (3.0 ± 0.4) × l012/L for red blood cells,(86.0 ± 13.5) g/L for hemogIobin,(47.0 ± 10.6) g/L for total protein,(31.4 ± 6.5) g/L for albumin,(124.1 ± 95.1) U/L for aspartate aminotransferase,(114.2 ± 107.1) U/L for alanine aminotransferase,and (1 848.7 ± 1 044.8) U/L for creatine kinase with significant differences from the reference ranges (P ＜ 0.05 or 0.01).Amount of blood transfused for 23 cases was (1 444.4 t 726.5) ml and plasma transfused for 19 cases was (305.6 ± 98.3) ml before operation.Volume of intra-and post-operative blood transfusion was (2 005.7 ± 1 153.1) ml.Conclusions Stabilization of vital signs predominates the early treatment of bilateral femoral shaft fracture.After the condition is stable,intramedulary nailing or plating can be performed concurrently.
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Objective To investigate the possibility of establishing a Modic changes (MCs) animal model,and explore the pathogenesis of MCs through imaging,histology and molecular biology experiments.Methods Fifty four New Zealand rabbits (weight 2.5-3.0 kg,half male and half female) were randomly divided into 3 groups:sham group (n=l8),muscle embedment group (n=18) and NP embedment group (n=18).In NP embedment group,the L4-5 and L5-6 discs were exposed by the lumbar anterolateral surgical approach.A 16 G needle was used to puncture the L5-6 vertebral body close to the epiphyseal plate.The depth of the drilling was approximately 3 mm.A 5 ml syringe was then put into the L4-5 intervertebral disc and extracted the NP,which was injected into the drilled hole of the vertebral body.The muscle embedment group and sham group shared the same operating procedures and drilling methods with the NP embedment group.Some pieces of muscle acquired from paraspinal muscles were put into the drilled hole in muscle embedment group,while nothing was put into the drilled hole in sham group.After that,the bleeding stopping,tissue washing and suture were done in all groups.12 weeks,16 weeks and 20 weeks after the surgery,MRI scan was applied to each group.All the specimens were tested by HE staining,real-time fluorescence quantitative PCR and Western blot to observe the expression of inflammatory cytokines.Results After modeling for 12 weeks,16 weeks and 20 weeks,MRI showed low signal changes on T1WI and mixed high signal in the context of low signal changes on T2WI in the NP embedment group.However,the muscle embedment and sham group showed no significant signal changes.Gross observation and HE staining confirmed that there was abnormal tissue proliferation in the imbed site of the NP embedment group.RT-PCR and Western blot showed high expression of IL-4,IL-17 and IFN-γin the NP embedment group,which were positively correlated with the length of the postoperative period.There was no significant difference between the muscle embedment group and sham group.Conclusion The puncturing of vertebral body close to endplate and putting nucleus into it can create an animal model of MCs.Autoimmune factors may play an important role in MCs.
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Objective To screen and validate differentially expressed microRNAs in human degenerative nucleus pulposus cells (NPCs) and to predict their target genes,and to investigate the role of JNK pathway in degenerative intervertebral disc disease.Methods Eight degenerative nucleus pulposus tissues were harvested from 8 patients (6 males and 2 females) with lumbar degenerative disease,and three normal nucleus pulposus tissues were harvested from 3 patients (3 males) with lumbar fracture,intraoperatively.Differentially expressed microRNAs were screened by microRNA microarray analysis and validated by real-time qPCR.Target genes of highly expressed microRNAs were predicted by analyzing information from data bases:MicroCosm v5,TargetScan 5.1 and microRNA.org.Signal pathways associated with the target genes were analyzed,and qPCR was used to validate the screening results.Results Twenty differentially expressed microRNAs were identified.The microRNA-513a-5p and microRNA-494 were highly expressed in degenerative nucleus pulposus tissue,which was corresponding to the verification results,and the ratio was 2.222 2 and 2.948 5,respectively.Target genes of microRNA-513a-5p and microRNA-494 were MKK4 and JunD,respectively.MKK4 and JunD were both involved in JNK signaling pathway and located in upstream and downstream of this pathway,respectively.Conclusion In human degenerative nucleus pulposus cells,microRNA-513a-5p and microRNA-494 are highly expressed microRNAs,whose target genes are MKK4 and JunD,respectively.Both MKK4 and JunD are involved in JNK signaling pathway.These results indicate that JNK pathway may play important role in the pathogenesis of degenerative intervertebral disc disease.
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Objective To observe the expression of Interleukin-17 (IL-17) in different types of herniated disc tissue,and to investigate Modic changes in corresponding injured segment and relationship between Modic changes and herniated types.Methods Fifty patients with single level disc herniation were enrolled in this study.According to clinical diagnosis criteria,imaging (CT and MR) examination results,and the view in surgery process the patients were divided into 2 groups:herniation group(35 patients),degeneration group(15 patients).According to MRI,patients were divided into 2 groups:Modic changes group(14 patients),non-Modic changes group (36 patients).The disc tissues were observed by HE staining and immunohistochemical staining,and the expression of IL-17 was detected by using real-time quantitative PCR.Results Pathological examination revealed that there were more granulation tissue and neovascularization in herniation group than in degeneration group.Immunohistochemical result showed that there were more IL-17-positive cells in herniation group than in degeneration group; there were more IL-17-postive cells in Modic changes group than in non-Modic changes group.The expression of IL-17 mRNA in herniation group was 6.7701 times more than that in degeneration group.The expression of IL-17mRNA in Modic changes group was 4.2836 times more than that in non-Modic changes group. Conclusion The herniated disc nucleus pulposus can cause more prominent local inflammation.Autoimmune responses maybe play an important role in pathophysiological mechanisms of Modic changes.
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Objective To investigate the effect of tension stress on the changes of mRNA expression of interleukin-17B (IL-17) and inducible nitric oxide synthase (iNOS) in rat discs.Methods Sixty-four female Sprague-Dawley rats were randomly divided into 4 groups:sham (S),tail-suspended (TS),tail-suspended with needle puncture (TSNP) and single needle puncture (SNP) groups.Tail-suspension device made rats of TS group and TSNP group hindlimb suspended,which exerted tension force on the coccygeal vertebrae disc;and aseptic needle puncture on the tail disc between the seventh and eighth coccygeal vertebrae (Co7/Co8)of TSNP,SNP group induced the inflammatory environment.The discs were harvested 4 weeks later.Measurements included gross observation,histological observation and real-time quantitative reverse transcription-polymerase chain reaction (RT-qPCR) analysis.Results Gross and histological examination found that varying degrees of degenerative changes in the annulus and nucleus in TS,SNP and TSNP groups,but not in the S group.RT-qPCR results showed that the mRNA of IL-17B and iNOS were significantly higher in the TSNP and SNP groups than that in the S group.The values of 2-△△Q were 12.99 and 8.12 in TSNP groups,and the 2-△△Q values of SNP group demonstrated 22.49 and 14.98 compared to S groups.Sole application of tension stress brought by the tail-suspension slightly enhanced the expression of IL-17B and iNOS,the values of 2-△△Q were 1.22 and 1.49,which didn't reach a statistically significant change.Compared with SNP group,the mRNA expression of IL-17B and iNOS in TSNP groups were shapely decreased,the values of 2-△△Q were-9.50 and -6.86 respectively.Conclusion Relatively low magnitude tension stress might play a key role in anti-inflammatory process and the relief of discogenic pain.