Restoration of functional network state towards more physiological condition as the correlate of clinical effects of pallidal deep brain stimulation in dystonia

BackgroundDeep brain stimulation of the internal globus pallidus (GPi DBS) is an invasive therapeutic modality intended to retune abnormal central nervous system patterns and relieve the patient of dystonic or other motor symptoms.ObjectivesThe aim of the presented research was to determine the neuroanatomical signature of GPi DBS modulation and its association with the clinical outcome.MethodsThis open-label fixed-order study with cross-sectional validation against healthy controls analysed the resting-state functional MRI activity changes induced by GPi DBS in 18 dystonia patients of heterogeneous aetiology, focusing on both global (full brain) and local connectivity (local signal homogeneity).ResultsCompared to the switched-off state, the activation of GPi DBS led to the restoration of global subcortical connectivity patterns (in both putamina, diencephalon and brainstem) towards those of healthy controls, with positive direct correlation over large-scale cortico-basal ganglia-thalamo-cortical and cerebellar networks with the clinical improvement. Nonetheless, on average, GPi DBS also seemed to bring local connectivity both in the cortical and subcortical regions farther away from the state detected in healthy controls. Interestingly, its correlation with clinical outcome showed that in better DBS responders, local connectivity defied this effect and approached healthy controls.ConclusionsAll in all, the extent of restoration of both these main metrics of interest towards the levels found in healthy controls clearly correlated with the clinical improvement, indicating that the restoration of network state towards more physiological condition may be a precondition for successful GPi DBS outcome in dystonia.     

钢板增强内固定治疗肱骨近端粉碎性骨折的研究进展

肱骨近端骨折是老年人群最常见的损伤之一,随着社会人口老龄化,肱骨近端骨折发生率日益上升[1-3].肱骨近端骨折中约20%为移位明显的不稳定骨折.切开复位内固定是治疗肱骨近端不稳定骨折的主要方法,以肱骨近端锁定内固定系统(proximal humerus internal locking system,PHILOS)为代表的锁定钢板具有成角稳定、解剖设计等优点,是目前首选的固定材料[4-11].但临床研究发现手术治疗的并发症高达50%,包括肱骨头缺血坏死、骨折不愈合或畸形愈合、螺钉切出等[12-14].骨折严重粉碎、骨质疏松和内侧支撑不足是并发症的主要危险因素[15-18],增强肱骨近端骨内支撑有助于提高手术治疗稳定和防止并发症.肱骨距螺钉、骨水泥填充、异体骨支撑、可膨胀钛网以及特殊钢板等都是目前最常用的肱骨近端骨折增强内固定手段.笔者拟对该方面的研究进展做一综述.     

Endurance Behavior of Cemented Tibial Tray Fixation Under Anterior Shear and Internal-External Torsional Shear Testing: A New Methodological Approach

BackgroundEarly total knee arthroplasty failures continue to surface in the literature. Cementation technique and implant design are two of the most important scenarios that can affect implant survivorship. Our objectives were to develop a more suitable preclinical test to evaluate the endurance of the implant-cement-bone interface under anterior shear and internal-external (I/E) torsional shear testing condition in a biomechanical sawbones.MethodsImplants tested included the AS VEGA System PS and the AS Columbus CR/PS (Aesculap AG, Germany), with zirconium nitride (ZrN) coating. Tibial implants were evaluated under anterior shear and I/E torsional shear conditions with 6 samples in 4 test groups. For the evaluation of the I/E torsional shear endurance behavior, a test setup was created allowing for clinically relevant I/E rotation with simultaneous high axial/tibio-femoral load. The test was performed with an I/E displacement of ±17.2°, for 1 million cycles with an axial preload of 3,000 N.ResultsAfter the anterior shear test an implant-cement-bone fixation strength for the AS VEGA System tibial tray of 2,674 ± 754 N and for the AS Columbus CR/PS tibial tray of 2,177 ± 429 N was determined (P = .191). After I/E rotational shear testing an implant-cement-bone fixation strength for the AS VEGA System PS tray of 2,561 ± 519 N and for the AS Columbus CR/PS tray of 2,824 ± 515 N was resulted (P = .39).ConclusionBoth methods had varying degrees of failure modes from debonding to failure of the sawbones foam. These two intense biomechanical loading tests are more strenuous and more representative of clinical activity.     

Ankle fracture follow up using the Chertsey Outcome score for Trauma. Floor and ceiling effect of the scale

BackgroundPatient reported outcome measures (PROMs) are increasingly used by orthopaedic surgeons in order to measure their results. The Chertsey Outcome Score for Trauma (COST) is a recently validated PROM, which treats trauma as pathology, is not site or pathology specific. It measures the rehabilitation of the patients after an injury, using the pre-injury status as the default state of the patients. The aim of the present study was to focus on a narrow group of patients with similar ankle fracture injuries, investigate if there is any floor or ceiling effect of the scale and examine its use during the ankle fracture at the immediate post-injury rehabilitation period.Materials and methodsAll patients who had isolated ankle fractures treated either operatively or conservatively between March 2018 and December 2019, were included in the study. A COST and a FADI questionnaire was completed prior to their follow-up at 2, 6 and 12 weeks post injury/operation. Demographic data were also collected.ResultsA total of 527 COST questionnaires from 314 different patients (aged 51.4 ± 18.4 years) were included in the study. The average COST score was 40.28 ± 18 and the average FADI score was 60.1 ± 21.8. The VAS score reached 3.57 ± 2.2. There was no significant floor and ceiling effect for the COST score. The COST score had good correlation with the FADI score (Spearman’s Rho=0.69) and good internal consistency (Cronbach’s Alpha=0.85).ConclusionNo significant floor or ceiling effect was identified for the COST score, during the short and medium term follow up period following an ankle fracture, treated with either conservative or operative management. The scale was found to be valid and with good internal consistency.     

解剖锁定钢板联合同种异体腓骨治疗肱骨近端骨折疗效的Meta分析

文题释义：肱骨近端骨折：肱骨近端包括肱骨头及大结节、小结节，中老年人骨质疏松及低能量损伤可导致肱骨近端骨折。 同种异体腓骨：取自于人体异体，经过加工处理，去除其免疫原性，保留其骨性结构，可用于移植修复骨缺损，起到支撑作用。 背景：肱骨近端骨折是临床常见骨折，但对肱骨近端内侧柱缺乏支撑的骨折目前仍是治疗难点，并发症常见，失败率较高。 目的：比较解剖锁定钢板联合同种异体腓骨与单纯解剖锁定钢板治疗肱骨近端骨折的疗效。 方法：使用计算机检索PubMed、Embase、Cochrane Library、Google Scholar、中国知网、万方、维普数据库，检索时间均从建库到2020年2月。检索国内外关于对比研究解剖锁定钢板联合同种异体腓骨与单纯解剖锁定钢板治疗肱骨近端骨折疗效的文献。2名研究员根据纳入和排除标准分别独立筛选文献，提取数据，评估文献中的偏倚风险。纳入12篇相关文献使用RevMan 5.2软件将以下指标进行Meta分析，包括影像学数据、功能评分和并发症。结果与结论：①通过文献检索、根据纳入和排除标准，12篇文献纳入研究，其中11篇为回顾性队列研究，1篇为随机对照研究；纳入研究文献质量高，但GRADE证据质量级别较低。②共纳入958例患者，其中解剖锁定钢板联合同种异体腓骨组411例，单纯解剖锁定钢板组547例；③Meta分析结果显示，解剖锁定钢板联合同种异体腓骨组术后1年肱骨头高度差值(MD=-2.40，95%CI：-2.49至-2.31)、颈干角差值(MD= -6.14，95%CI：-6.62至-5.67)、目测类比评分(MD=-0.22，95%CI：-0.35至-0.08)、肩关节功能评分(MD=4.12，95%CI：2.18-6.06)，上肢伤残评分(MD=-10.32，95%CI：-13.44至-7.19)、术后2年的目测类比评分(MD=-0.37，95%CI：-0.55至-0.19)、肩关节功能评分(MD=5.07，95%CI：2.86-7.27)、总体并发症(OR=0.31，95%CI：0.20-0.48)及肱骨头螺钉切出(OR=0.25，95%CI：0.11-0.55)均明显优于单纯解剖锁定钢板组(P < 0.05)，肱骨头坏死(OR=0.94，95%CI：0.47-1.88)，两组间差异无显著性意义(P > 0.05)；④因此，较弱的证据提示，肱骨近端解剖锁定钢板联合同种异体腓骨治疗肱骨近端骨折的短期疗效优于解剖锁定钢板，可减少并发症的发生，促进功能恢复。ORCID: 0000-0002-8486-3932(阳运康) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程     

Biodegradable versus titanium osteosynthesis in maxillofacial traumatology: a systematic review with meta-analysis and trial sequential analysis

Titanium osteosynthesis is currently the fixation system of choice in maxillofacial traumatology. Biodegradable osteosynthesis systems have the ability to degrade in the human body. The aim of this study was to conduct a systematic review, with meta- and trial sequential analyses, to assess the efficacy and morbidity of biodegradable versus titanium osteosynthesis after maxillofacial trauma. MEDLINE, Embase, and CENTRAL were searched for randomized controlled trials and prospective and retrospective controlled studies. Five time periods were studied: perioperative, short-term (0–4 weeks), intermediate (6–12 weeks), long-term (>12 weeks), and overall follow-up. After screening 3542 records, 24 were included. All had a high risk of performance and detection bias due to the nature of the interventions. Meta-analysis showed no differences in efficacy or morbidity between biodegradable and titanium osteosynthesis. The risk of perioperative screw breakage was significantly higher (risk ratio 17.13, 95% confidence interval 2.19–34.18) and the symptomatic plate removal rate lower in the biodegradable group (risk ratio 0.11, 95% confidence interval 0.02–0.57), which was confirmed by the trial sequential analysis. The quality of evidence ranged from very low to moderate. Based on the narrative review and meta-analyses, current evidence shows that biodegradable osteosynthesis is a viable alternative to titanium osteosynthesis when applied in the treatment of maxillofacial trauma, with similar efficacy but significantly lower symptomatic plate removal rates. Perioperative screw breakage occurred significantly more often in the biodegradable group compared to the titanium group.     

单侧外固定治疗重度Pilon骨折的临床疗效探究

目的探讨单侧外固定治疗重度Pilon骨折的临床疗效。方法回顾性分析2017年6月-2018年12月南京中大医院江北院区骨科收治的重度Pilon骨折患者100例,男性54例,女性46例;年龄18~65岁,平均35.5岁;Ruedi-AllgowerⅡ型39例,Ⅲ型61例。按照不同固定方法分为常规固定组和单侧外固定组,各50例,比较两组患者住院时间、完全负重下地时间、骨折愈合时间,评价治疗前及治疗后3个月踝关节活动度、踝关节功能恢复情况、疼痛程度,并统计患者的治疗效果及并发症发生情况。结果单侧外固定组住院时间、完全负重下地时间、骨折愈合时间分别为(16.50±1.50)d、(132.56±10.25)d、(14.16±0.69)周,均短于常规固定组(19.25±2.35)d、(198.65±16.58)d、(17.58±1.50)周(t/P=6.975/0.001、23.970/0.001、14.650/0.001)。治疗后3个月,单侧外固定组踝关节Mazur评分为(85.67±6.59)分,显著高于常规固定组(62.78±3.45)分,VAS评分为(2.23±0.36)分,低于常规固定组(4.59±0.89)分(t/P=21.760/0.001、17.380/0.001);单侧外固定组患者踝关节活动度分别为(17.29±0.16)°、(28.36±1.23)°、(19.68±0.16)°、(16.89±2.12)°,均高于常规固定组(10.62±1.25)°、(21.57±2.58)°、(14.36±1.62)°、(14.25±0.57)°(t/P=37.430/0.001、16.800/0.001、23.110/0.001、8.503/0.001)。单侧外固定组治疗优良率为90.00%,显著高于常规固定组74.00%(χ^2/P=4.336/0.037)。单侧外固定组总并发症发生率为4.00%,显著低于常规固定组的18.00%(χ^2/P=5.005/0.025)。结论单侧外固定支架治疗重度Pilon骨折可有效减轻患者疼痛症状,提高患者踝关节活动度,恢复患者功能,治疗效果显著,安全性较高。