Clinical Comparison of the “Windowing” Technique and the “Open Book” Technique in Schatzker Type II Tibial Plateau Fracture

ObjectiveSurgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high‐quality research. The aim of the study is to compare the “windowing” and “open book” techniques for the treatment of Schatzker type II tibial plateau fractures.MethodsIn this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. “Windowing” group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the “windowing” technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The “open book” group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post‐traumatic arthritis. The radiographic outcome (x‐ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient‐reported outcome was visual analogue scale (VAS) scores.ResultsThe mean follow‐up time for the158 patients was 32 months (range, 24–42 months). The time elapsed from injury to surgery in “windowing” group and “open book” group were 3.7 ± 1.2 (range, 1–10 days) and 3.5 ± 1.4 days (range, 1–11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the “windowing” group (61.0 ± 8.3 min, range, 45–120 min) and the “open book” group (61.2 ± 10.4 min, range, 40–123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the “windowing” and “open book” groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow‐up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post‐traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05).ConclusionsThe “windowing” and “open book” techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the “windowing” technique provides better reduction quality, leading to a satisfactory prognosis.     

Design of a New “U”‐shaped Staple and Its Clinical Application in Postoperative Ankle Valgus of Congenital Pseudarthrosis of the Tibia in Children

ObjectiveThere has been a lack of suitable epiphysis blocking materials due to the characteristics of less tissue coverage and narrow epiphysis in children''s distal tibial medial malleolus. Therefore, this study is to investigate the clinical efficacy and safety of a new “U”‐shaped staple in the treatment of postoperative ankle valgus of congenital pseudarthrosis of the tibia (CPT).MethodAccording to the inclusion and exclusion criteria, 33 patients with postoperative ankle valgus of CPT were treated with new “U”‐shaped staples from May 2013 to September 2019. The deformity of ankle valgus was gradually corrected by implanting a new “U”‐shaped staple on the medial side of the distal tibia. Clinical indexes such as the operation time, intraoperative bleeding and hospital stay were observed. Tibiotalar angle was selected as the evaluation index of ankle valgus. American Orthopedic Foot & Ankle Society (AOFAS) scale was used for clinical evaluation of ankle function. The tibiotalar angle, deformity correction rate and complications were evaluated by preoperative, postoperative and last follow‐up imaging data. Student''s t‐test was used for statistical analysis.ResultsThirty‐three patients, including 12 males and 21 females were included. All the patients were followed up for at least 14 months, with an average of 35 months. The average operation time was 23 (15–40) min, the average amount of intraoperative bleeding was 7.5 (4–10) mL, and the average hospital stay was 4.2 (3–6) days. The intraoperative tibiotalar angles of all patients were 74.2° ± 4.6°, the tibiotalar angle were 86.8° ± 4.9° when internal fixation was removed, and the tibiotalar angles at the last follow‐up were 84.3° ± 5.9°. The average orthopedic rate was 0.68° per month. No patients suffered from serious complications such as screw prolapse, osteomyelitis, wound infection, etc. Postoperative wound pain complications occurred in two patients, which were relieved after conservative treatment. The AOFAS score improved from 46.2 ± 9.4 before the operation to 74.6 ± 5.7 at the last follow‐up (P < 0.01). The ankle movement was good without joint stiffness. There was no epiphyseal plate injury after the removal of internal fixation.ConclusionThe new “U”‐shaped staple is characterized by simple implantation, low notch, lower risk of fixation failure and close fitting with cortical bone. It is a safe and effective internal fixation system for the treatment of ankle valgus in children.     

Transvaginal subfascial synthetic sling – “A novel technique” versus trans-obturator mid-urethral sling in female stress urinary incontinence: A comparative study

Background:To assess the treatment outcome and overall efficacy of the novel technique of a transvaginal subfascial synthetic sling (TVSS) in comparison to the standard trans-obturator tape (TOT-O) mid-urethral sling for female stress urinary incontinence (SUI).Materials and methods:The study included 206 female SUI patients managed at our institution between March 2015 and December 2019. The patients were randomly distributed into 2 comparable groups (Group A as TOT-O and Group B as TVSS) with respect to age, trouble due to SUI assessed with respect to degree of incontinence (number of episodes and diapers used per day), and body mass index (≤40 kg/m²), with 100 patients in the TOT-O group as group A and 106 patients in TVSS as group B. Preoperative variables related to the number of incontinent episodes and diapers usage were equal in both groups. The procedure was done under spinal anesthesia and results were assessed in terms of improvement in SUI as the primary outcome, any sexual dysfunction, complications, and overall satisfaction as secondary outcomes.Results:Symptomatic improvement after the procedure was seen in all patients with complete resolution of symptoms in 91 patients (91.%) in the TOT-O group (group A) versus 96 patients (90.56%) in the TVSS (group B). Postoperative complications included urinary retention in 6% versus 5.6%, increased day time urinary frequency in 8% versus 6.6%, urge incontinence in 4% versus 2.8%, and groin/thigh pain in 12% versus 0.9%, respectively. Mesh incision was done in 1 (1%) versus none (0%), and local mesh excision for mesh erosion in 2 (2%) versus 1 (0.9%) at 3 months after the procedure in the TOT-O group and the TVSS group, respectively. The p value and Chi-Square test with respect to the clinical profile and satisfaction with respect to complete resolution of symptoms was calculated using Open EPI software which were insignificant. Sexual function (SF) was assessed using the Brief Index of SF for Women questionnaire. All the patients were satisfied with respect to SF at 6 months of follow-up.Conclusions:The TVSS as a novel technique for female SUI is less invasive, simpler to learn, with less postoperative pain with resolution of SUI, rapid recovery, and good personal satisfaction compared to the standard TOT-O in procedure.     

“Inside Disc Out” Discectomy for the Treatment of Discogenic Lumbar Spinal Canal Stenosis under the Intervertebral Foramen Endoscope

ObjectiveConventional posterior‐approach decompression surgeries have a higher risk of nerve root injury and dura laceration. We explore the therapeutic strategy and effect of “inside disc out” discectomy under intervertebral foramen endoscope technique for discogenic lumbar spinal canal stenosis (DLSS) treatment.MethodsTwenty‐nine patients with DLSS in the responsible segment were treated with “inside disc out” discectomy under intervertebral foramen endoscope technique between October 2017 to October 2019. Lower limb and back pain were recorded before operation, and visual analogue scale (VAS) score and Oswestry disability index (ODI) were recorded for lower limb and back pain at 1, 3, 6, and 12 months postoperatively. The postoperative effects were evaluated using the modified MacNab method for all the patients.ResultsAll 29 patients successfully completed the operation. The operation time was 75–120 min, with an average of 90 ± 17 min. Postoperative lumbar CT examinations of all the patients showed full decompression of the spinal cord with no residual pressure. The average follow‐up time for all the patients was 13 ± 3.5 months (12–18 months). The VAS score for lower back and lower limb pain was 7.52 ± 1.25 before the operation, and 1.80 ± 0.63, 1.33 ± 0.88, 1.07 ± 0.89, and 0.81 ± 0.51 at 1, 3, 6, and 12 months after the surgery, respectively. The Oswestry dysfunction index was 59.43 ± 10.04 before surgery and 29.67 ± 10.35, 21.13 ± 9.32, 14.52 ± 5.98, and 9.84 ± 4.68 at 1, 3, 6, and 12 months after the surgery, respectively. The VAS score and ODI index of low back and lower limb pain at different time points after the surgery were significantly improved compared to those before the surgery (P < 0.01). The effect of the modified MacNab was excellent in 26 patients, good in two patients, and fair in one patient. The excellent and good rates were 91.4%. Among them, one patient had symptoms of hyperesthesia in the anterior aspect of the thigh and decreased quadriceps muscle strength after lumbar 4/5 segment endoscopic surgery. After symptomatic and conservative treatment, the symptoms disappeared 4 weeks postoperatively, and there were no other serious surgical complications.ConclusionsFollowing the “inside disc out” discectomy under intervertebral foramen endoscope protocols, the risk of nerve injury can greatly be reduced, with good postoperative efficacy. Overall, the procedure is safe and feasible for DLSS treatment.     

锁定加压钢板与克氏针结合外固定支架治疗老年绝经期骨质疏松性桡骨远端复杂关节内骨折疗效分析

目的探讨锁定加压钢板与克氏针结合外固定支架治疗老年绝经期骨质疏松性桡骨远端复杂关节内骨折的疗效。方法 80例骨质疏松性桡骨远端复杂关节内骨折患者按手术方式分为两组,各40例:Ⅰ组骨折AO/ASIF分型:C1型11例,C2型15例,C3型14例,采用锁定加压钢板固定治疗,Ⅱ组骨折AO/ASIP分型:C1型12例,C2型13例,C3型15例,采用克氏针结合支架外固定治疗。术后比较两组患者骨折愈合情况、腕关节功能恢复情况和并发症发生率。结果两组患者均获随访,随访时间8~10个月,平均(8.3±1.4)个月。术后Ⅰ组愈合率为97.5(39/40),Ⅱ组愈合率为95.0%(38/40),两组愈合率比较差异无统计学意义(χ2=0.866,P=0.352)。两组患者骨折愈合时间、术后桡骨短缩距离比较差异亦无统计学意义(P0.05)。两组C1型、C2型骨折患者术后腕关节功能恢复情况比较差异无统计学意义(P0.05),而Ⅰ组C3型骨折患者术后Gartland-Werly评分显著高于Ⅱ组,差异具有统计学意义(P0.05)。Ⅰ组术后出现并发症3例(7.5%):碎骨片畸形愈合1例,手术切除后愈合;切口感染2例,予抗生素后得到控制;Ⅱ组术后并发症4例(10%):骨折延迟愈合2例,针道感染2例,予常规抗生素治疗后痊愈。结论对于C1型、C2型桡骨远端复杂关节内骨折患者,可以选择锁定加压钢板或克氏针联合外固定支架固定治疗;而对于严重的C3型骨折患者,克氏针联合外固定支架治疗效果更佳。     

“手风琴”技术在牵张成骨区新生骨矿化中的作用

目的探讨“手风琴”技术对大鼠牵张区骨再生的作用、刺激时机以及可能机制。方法取 12 周龄雄性 SD 大鼠 54 只，制备右侧胫骨牵张成骨模型。术后经 5 d 潜伏期、7 d 牵张期后进入为期 6 周的矿化期。根据在矿化期实施“手风琴”操作的时间不同，将大鼠随机分为 4 组：对照组（n=18）为观察组，不行“手风琴”操作；早期组（n=18）、中期组（n=12）及晚期组（n=6）分别于矿化第 1、3、5 周行“手风琴”操作，操作时间为 7 d，其中 3.5 d 压缩、3.5 d 牵张。对照组和早期组分别于矿化第 2、4、6 周结束时，中期组于矿化第 4、6 周结束时，晚期组于矿化第 6 周结束时，各取 6 只大鼠处死，取双侧胫骨进行相关观测。矿化期间每周对各组大鼠右侧胫骨摄正侧位 X 线片，观察骨再生与矿化进展；各组每次取材时对右侧胫骨行 Micro-CT 扫描三维重建观察，评估牵张区新生骨结构改变，并计算矿化第 6 周各组 158～211、211～1 000 及 158～1 000 阈值范围的骨体积（bone volume，BV）和组织体积（tissue volume，TV），计算两者比值 BV/TV，同时计算骨密度（bone mineral density，BMD）。矿化第 6 周，对所取胫骨行四点弯曲生物力学检测最大压力、弹性模量、折断能量；行 Von Kossa、番红 O、HE 染色及成骨相关转录因子（osterix，OSX）、骨钙蛋白（osteocalcin，OCN）、VEGF 免疫组织化学染色观察。 结果X 线片显示牵张区骨痂在矿化中期组行“手风琴”刺激后矿化速度最快。Micro-CT 三维重建可见中期组骨重建最快，牵张后 6 周皮质获得连续。矿化第 6 周，中期组 BMD 及 158～1 000、211～1 000 阈值范围的 BV/TV 均高于其余各组。生物力学检测示，中期组胫骨标本的最大压力、弹性模量、折断能量均显著高于其余 3 组（P<0.05）。组织学染色示中期组骨重建速度最快，且至牵张后第 6 周髓腔基本获得再通。免疫组织化学染色结果进一步提示，中期组新生骨组织内成骨指标（OCN、OSX）及成血管指标（VEGF）随着骨重建的进程明显升高后又恢复正常。 结论“手风琴”技术有利于牵张成骨区新骨形成，其中矿化中期进行“手风琴”操作能更快速、有效地促进大鼠骨矿化与重建。     

The “self‐treatment of wounds for venous leg ulcers checklist” (STOW‐V Checklist V1.0): Part 2—The reliability of the Checklist

The “Self‐Treatment of Wounds for Venous Leg Ulcers Checklist” (STOW‐V Checklist V1.0) is an evidence‐based, standardised tool designed to assist nurses to appraise the conduct of wound treatment when undertaken by patients who have venous leg ulcers. A prospective reliability study was conducted to determine the reliability of the STOW‐V Checklist V1.0. Video‐recordings of patients who self‐treated their leg ulcer were obtained (n = 5) and nurses (n = 15) viewed each video‐recording three times and concurrently completed the Checklist. Internal consistency, inter‐rater reliability and intra‐rater reliability were evaluated. Cronbach''s alpha for items in the Checklist was 0.792, 0.791 and 0.783 for Occasions 1, 2 and 3, respectively, indicating good reliability. Inter‐rater reliability was 0.938, 0.958 and 0.927 for Occasions 1, 2 and 3, respectively; these results were statistically significant and indicative of excellent reliability. Intra‐rater reliability was 0.403 to 0.999; these results were statistically significant and meeting or exceed adequacy in the case of all except two raters. The study provides preliminary evidence that the Checklist is measuring the concepts that it intends to measure and that there is a high level of agreement among raters. It is recommended that the STOW‐V Checklist V1.0 is utilised with patients in a shared‐care model, with nurses and other healthcare professionals providing supervision and oversight of self‐treatment practices whenever this is feasible and acceptable to the patient.     

肱桡关节“接吻骨折”特点及治疗研究

目的 探讨肱桡关节“接吻骨折”临床特点以及治疗方法。方法 回顾分析2016年1月—2021年6月收治的12例肱桡关节“接吻骨折”患者临床资料。男8例，女4例；年龄15～75岁，平均41.9岁。致伤原因：跌倒伤7例，高处坠落伤3例，运动伤2例。受伤至入院时间2～72 h，中位时间2 h。桡骨头骨折根据Mason分型标准：Ⅰ型2例，Ⅱ型8例，Ⅲ型2例。肱骨小头骨折根据Grantham分型标准：Ⅰ型10例，Ⅱ型2例；其中4例GranthamⅠ型X线片检查漏诊，经CT和/或MRI检查确诊。合并肘关节其他损伤4例。桡骨头骨折采用螺钉或微型钢板内固定11例，保守治疗1例；肱骨小头骨折采用螺钉或钢板内固定9例，摘除1例，保守治疗2例。术后X线片复查骨折愈合情况；采用Mayo肘关节功能评分标准（MEPS）评价患肢功能恢复情况，检测肘关节活动度。结果 术后切口均Ⅰ期愈合，无早期相关并发症发生。患者均获随访，随访时间10～24个月，平均15.2个月。X线片复查示骨折均愈合，愈合时间2～3个月，平均2.3个月。末次随访时，肘关节屈伸活动度达65°～161°，平均136.9°；旋转活动度达70°～180°，平均149.2°。MEPS评分为70～100分，平均87.4分；获优8例、良2例、可2例，优良率83.3%。结论 肱桡关节“接吻骨折”临床少见，肱骨小头骨折程度一般较桡骨头骨折轻，GranthamⅠ型肱骨小头骨折单纯X线片检查易漏诊。此类型骨折按照关节内骨折处理原则治疗，可获得较好疗效。     

胸腰椎骨折后路复位术后椎体“空壳”现象的影像学研究

目的分析胸腰椎骨折后路复位术后椎体“空壳”影像学特征，探讨椎体“空壳”与骨折愈合间的关系。方法回顾分析 2013 年 1 月—2015 年 12 月，采用经后路椎弓根钉棒系统复位内固定术治疗的 116 例胸腰椎骨折患者临床资料。男 72 例，女 44 例；年龄 22～66 岁，平均 43 岁。致伤原因：交通事故伤 24 例，高处坠落伤 54 例，重物砸伤 38 例。骨折节段：T₁₁ 5 例，T₁₂ 38 例，L₁ 52 例，L₂ 21 例。压缩性骨折 51 例，爆裂性骨折 65 例。矢状面 Cobb 角 8～27°，平均 15°；伤椎前缘压缩程度 20%～75%，平均 44%。骨密度测量显示：骨量正常 30 例，骨量减少 40 例，骨质疏松 41 例，严重骨质疏松 5 例。观察术后椎体“空壳”现象发生例数、病理特点及影像学规律，并进行多因素 logistic 回归分析。 结果术后患者均获随访，随访时间 11～18 个月，平均 13 个月。共 72 例出现椎体“空壳”现象，主要集中于椎体前柱及上终板薄弱区附近（54/72，75.0%），以不规则形为主（50/72，69.5%）。椎体骨折线走行与椎体“空壳”形态和复位后椎体骨折块移位有关；“空壳”形态转归可分为消失型、缩小型和塌陷型，椎体“空壳”体积和转归类型是影响椎体骨折愈合的危险因素。结论胸腰椎骨折后路复位术后椎体“空壳”发生率及骨折不愈合率均较高，椎体“空壳”转归类型及体积是其主要影响因素。     

The “self‐treatment of wounds for venous leg ulcers checklist” (STOW‐V Checklist V1.0): Part 1—Development,pilot and refinement of the checklist

Patients who have chronic wounds such as leg ulcers should be active participants in their treatment and care. This participation may include self‐treatment of the wound which involves the patient cleaning the wound, applying and removing wound dressings, and/or applying and removing compression therapy. The aim of the study was to develop a Checklist to assist nurses to appraise the conduct of wound treatment when undertaken by the patient. A three‐phase mixed methods study was conducted. A systematic and evidence‐based approach to developing and using structured observations for the study of health behaviour guided the process of developing, piloting and refining the Checklist. The resulting “Self‐Treatment of Wounds for Venous Leg Ulcers Checklist” (STOW‐V Checklist V1.0) can assist the nurse to evaluate the conduct of key self‐treatment behaviours in the areas of equipment and workspace, hand hygiene, wound dressing removal, skin care, wound cleansing and debridement, wound assessment, wound dressing application, and compression therapy application. The growing recognition that patients can benefit when involved in care, the need to enact self‐management because of COVID‐19, and the ever present competition for healthcare funding and resources are compelling reasons for patients, care providers, and healthcare services to afford the self‐management approach, and associated interventions such as self‐treatment, greater consideration. It is recommended that the STOW‐V Checklist is used with patients in a shared‐care model, with nurses and other healthcare professionals providing supervision and oversight of self‐treatment practices whenever this is feasible and acceptable to the patient.     

Minimally Invasive Full‐endoscopic Posterior Cervical Foraminotomy and Discectomy: Introducing a Simple and Useful Localization Technique of the “V” Point

ObjectiveConventional localization technique of V point for full‐endoscopic posterior cervical foraminotomy and discectomy (FPCD) required repeated fluoroscopies, especially in patients with short and thick necks. To address this issue, the present study aimed to introduce a new localization technique of V point, and further evaluate its efficacy.MethodsA K‐wire was inserted and fixed at the pedicle eye under A/P fluoroscopy, then a working channel was established quickly along with it. Thirty‐four patients who underwent minimally invasive FPCD assisted by the new technique were included in this study. The clinical and radiological data were collected and analyzed, including radiation dose, operative time, positioning time, visual analog scale (VAS) for neck and arm pain, neck disability index (NDI) scores, Cobb angle of operative level and range of motion of the cervical spine.ResultsAll operations were performed successfully, and no iatrogenic nerve or vascular injury occurred. None of the patients needed to be transferred to open surgery or revision surgery. The mean radiation dose was found to be1.68 ± 0.36 mSv. The mean positioning time observed was 10.68 ± 5.42 min and the average operation time was 81.18 ± 10.87 min. The operation time significantly declined as the number of patients increased. A significant difference in operation time between the first (96.22 ± 10.36 min) and last quartile (75.00 ± 3.84 min) of cases was observed (t = 4.82, P < 0.001). The VAS scores for neck and arm pain, and NDI scores were significantly improved after surgery (P _VAS−Neck<0.0001, P _VAS−Arm<0.0001, P _NDI<0.0001). Based on MacNab criteria, the excellent plus good rate was 91.17%. The Cobb angle of operative level and range of motion of the cervical spine were significantly improved postoperatively (t = 2.846, P _OA = 0.015; t = 2.232, P _ROM−CA = 0.026).ConclusionThe new image‐assisted V point localization technique is simple and useful with little radiation exposure and short positioning time. FPCD assisted by the new technique could be a safe and effective alternative on properly selected patients.     

Open Reduction and Internal Fixation by Volar Locking Plates and the “Poking Reduction” Technique in Distal Radius Fractures with Displaced Dorsal Ulnar Fragments: A Retrospective Study

ObjectiveTo investigate the clinical and radiological outcomes of distal radius fractures (DRFs) with displaced dorsal ulnar fragments treated with volar locking plate (VLP) and the “poking reduction” technique.MethodsBetween January 2014 and January 2019, 78 unilateral DRFs with displaced dorsal ulnar fragment (AO type C3) treated with VLP were conducted. According to the reduction technique of the dorsal ulnar fragment, the patients were divided into the conventional reduction (CRG) group (33 patients, 14 males and 19 females, mean age 57.2 ± 12.1 years old) and the “poking reduction” (PRG) group (45 patients, 11 males and 34 females, mean age 60.1 ± 12.4 years old). According to the AO classification, there were 21 cases of C3.1 and 12 of C3.2 in the CPG group, 27 cases of C3.1 and 18 of C3.2 in the PRG group. Clinical and radiographic data were extracted from the electronic medical record system. These data were reviewed for clinical outcomes (range of motion, grip strength), radiological outcomes (volar tilt, radial inclination, radial height, step of articular surface), and postoperative complications. The final functional recovery was evaluated by the disabilities of the arm, shoulder, and hand (DASH) score.ResultsThe mean duration of follow‐up was 27 months (range from 12 to 56). The average operation time and intraoperative blood loss did not significantly differ between groups (p > 0.05). Postoperative CT examination showed that the step of articular surface in CPG group (0.8 ± 0.3 mm) was larger than that in PRG group (0.5 ± 0.2 mm) (p < 0.001). The DASH score did not significantly differ between groups (26.1 ± 4.6 in CRG and 24.7 ± 4.0 in PRG, p > 0.05) at 3 months postoperatively. At 6 months and 12 months postoperatively, the DASH score was better in PRG group (11.8 ± 2.5 and 10.4 ± 2.0) than in CRG group (13.6 ± 2.7 and 12.2 ± 2.5) (p = 0.004, p = 0.001, respectively). At 12 months postoperatively, wrist range of motion did not significantly differ between groups (p > 0.05). There was no significant difference in radiological parameters between the two groups (p > 0.05). The incidence of complications was higher in the CRG group (7/33) than in the PRG group (2/45) (p = 0.009).ConclusionThe “poking reduction” technique is a wise option for reduction of dorsal ulnar fragment in DRFs. This innovative technique could restore smoothness of the radiocarpal joint effectively, and the dorsal ulnar fragment could be fixed effectively combined with the volar plate.     

胸腰椎骨折后椎体“空壳”现象的手术治疗策略

目的探讨胸腰椎骨折后椎体“空壳”的手术治疗策略，为“空壳”的干预及治疗提供临床参考。方法2015 年 6 月—2017 年 1 月，根据选择标准纳入 53 例胸腰椎骨折术后有椎体“空壳”高危发生风险的患者进行前瞻性研究。全部患者根据就诊顺序按随机表法分为两组：治疗组 27 例，采用短节段钉棒固定联合伤椎重建；对照组 26 例，采用单纯短节段钉棒固定。两组患者性别、年龄、致伤原因、骨折 Denis 分型、骨折节段、伤椎前缘压缩程度、骨密度、美国脊髓损伤协会（ASIA）分级等一般资料比较差异均无统计学意义（P>0.05），具有可比性。计算并比较两组患者术前、术后即刻及末次随访时伤椎前缘压缩程度、疼痛视觉模拟评分（VAS）和 Oswestry 功能障碍指数（ODI），同时观察术后椎体“空壳”及手术并发症情况。 结果所有患者均获随访，随访时间 12～18 个月，平均 14.4 个月。术后治疗组有 5 例发生“空壳”，末次随访时不愈合 4 例；对照组有 23 例发生“空壳”，末次随访时不愈合 19 例；两组比较差异有统计学意义（P<0.05）。治疗组 1 例发生切口脂肪液化、4 例发生骨水泥渗漏，对照组发现 2 例螺钉松动、1 例单侧连接棒断裂，两组并发症发生率比较差异无统计学意义（χ²=0.504，P=0.478）。术后即刻及末次随访时两组患者伤椎前缘压缩程度、VAS 评分和 ODI 评分均较术前显著改善（P<0.05）。术后即刻两组伤椎前缘压缩程度比较差异无统计学意义（P>0.05），但末次随访时对照组显著高于治疗组（P<0.05）；除末次随访时对照组 ODI 评分显著高于治疗组外（P<0.05），其余时间点两组 VAS 评分及 ODI 评分比较差异均无统计学意义（P>0.05）。 结论采用短节段钉棒固定联合伤椎重建治疗胸腰椎骨折能有效预防椎体“空壳”，有利于伤椎高度的维持和远期功能的改善，临床治疗效果满意。     

微小 RNA 在 MSCs 成骨分化中的调控作用及在骨科疾病中作为治疗靶点和诊断工具的研究进展

目的对微小 RNA（microRNA，miRNA）调控 MSCs 成骨分化及在骨科疾病中的研究进展作一综述。方法广泛查阅近年来 miRNAs 调控 MSCs 成骨分化的相关文献，对其调控机制及在骨科疾病中作为治疗靶点和诊断工具的应用研究进展进行综述。结果miRNA 是内源性非编码长度为 20～22 个核苷酸的小 RNAs，其在 MSCs 成骨分化中起着重要作用。成骨作用始于 MSCs 分化为成熟的成骨细胞，同时骨代谢动态平衡的各阶段都与不同的 miRNAs 调控作用相关。miRNAs 通过对 mRNAs 切割、降解，翻译抑制或甲基化靶基因，从基因转录后水平进行调控。此外，目前研究还提示 miRNAs 可成为一种新型的骨科疾病诊断工具和治疗靶点。结论对 miRNAs 调控机制的深入研究，将为找到新的骨科疾病治疗靶点和诊断工具提供更多思路。     

“When nothing happens,nobody is afraid!” beliefs and perceptions around self‐care and health‐seeking behaviours: Voices of patients living with diabetic lower extremity amputation in primary care

Self‐management and self‐care are the cornerstone of diabetes care and an essential part of successfully preventing or delaying diabetes complications. Yet, despite being armed with the required information and guidance for self‐management, self‐care and adherence to foot self‐care recommendations and compliance to medication among patients with diabetic foot ulcer and diabetic lower extremity amputations remain low and suboptimal. This study reveals in‐depth account of nine such patients'' beliefs and perceptions around their illness, their self‐care, and their health‐seeking behaviours. Patients living with diabetic lower extremity amputation displayed profound lack of knowledge of self‐care of diabetes and foot and passive health‐related behaviours. The overarching sense that "when nothing happens, nobody is afraid," points to a lack of motivation in taking charge of one''s own health, whether this is with reference to treatment or care adherence, following recommended self‐care advice, or seeking timely treatment. The Health Beliefs Model provides the theoretical framework for probing into the factors for the participants'' suboptimal self‐care and passive health‐seeking behaviours. Two themes emerged from data analysis: profound knowledge deficit and passive health‐related behaviours. The beliefs and perceptions around self‐care and health‐seeking behaviours for patients with lower extremity amputation are interpreted as the “ignorant self” with passive health‐seeking behaviours. Patients with diabetes and diabetic foot diseases may benefit from personalized education, motivational interviewing, and family support.     

TCDD 致胎鼠腭裂模型中 miR-381-3p 下调抑制腭间充质细胞成骨分化的实验研究

目的探讨 2, 3, 7, 8-四氯二苯二英（2，3，7，8-tetrachlorodibenzo-p-dioxin，TCDD）致胎鼠腭裂模型中 miR-381-3p 下调与胎鼠腭间充质（mouse embryonic palatal mesenchymal，MEPM）细胞成骨分化抑制的相关性。方法32 只 6～8 周龄 SPF 级建康 C57BL/6J 孕鼠随机分为 TCDD 组与对照组，每组 16 只。于胚胎日第 10.5 天（embryonic day 10.5，E10.5）时，TCDD 组一次性灌胃 TCDD（28 μg/kg）、对照组给予等量玉米油。于 E13.5 和 E14.5 取出两组胎鼠大体观察腭突组织后，取 E13.5 和 E14.5 腭突组织行实时荧光定量 PCR 检测 miR-381-3p 表达；E14.5 腭突组织 Western blot 检测成骨特异性转录因子 RUNX2 和骨桥蛋白（osteopontin，OPN）的表达。取对照组 E14.5 胎鼠腭突分离培养 MEPM 细胞，取第 3 代细胞以含 10 nmol/L TCDD 的完全培养基培养，于 0、0.5、1、2、3 d 检测 miR-381-3p 表达，0、1、2、3 d 检测 RUNX2 和 OPN 蛋白表达。另取第 3 代 MEPM 细胞随机分为 4 组，沉默表达组及对照组分别转染 miR-381-3p 抑制物及抑制物对照，过表达组及对照组分别转染 miR-381-3p 模拟物及模拟物对照。转染 48 h 后，检测各组 miR-381-3p 及 RUNX2 和 OPN 蛋白表达。结果E13.5 和 E14.5 时对照组获得活胎鼠 96 只、TCDD 组 92 只；其中，E14.5 对照组活胎鼠可见双侧腭突接触，TCDD 组双侧腭突中间有间隙。TCDD 组胎鼠腭突组织 miR-381-3p 以及 RUNX2、OPN 蛋白相对表达量均明显低于对照组（P<0.05）。TCDD 处理 MEPM 细胞 0.5 和 1 d 后 miR-381-3p 相对表达量较 0 d 时明显下降（P<0.05），2、3 d 时表达量明显上升，与 0 d 时比较差异无统计学意义（P>0.05）；1、2、3 d 时 RUNX2 及 OPN 蛋白相对表达量均较 0 d 时显著降低（P<0.05）。MEPM 细胞转染 48 h 后，沉默表达组 miR-381-3p 及 RUNX2、OPN 蛋白相对表达量均较其对照组下降，过表达组均较其对照组升高，差异有统计学意义（P<0.05）。 结论在 TCDD 致胎鼠腭裂模型中，miR-381-3p 表达下调可能抑制胎鼠 MEPM 细胞成骨分化。     

锌指蛋白 A20 对兔腰椎间盘退变影响的实验研究

目的探讨锌指蛋白 A20 对兔腰椎间盘退变的影响。方法取 3 月龄新西兰大白兔 26 只，体质量 2.0～2.5 kg，经腹细针穿刺法制备 L_3、4、L_4、5、L_5、6 椎间盘退变模型，其中 24 只术后 4 周 MRI 检查明确造模成功，随机分为 4 组（n=6），于目标椎间盘中分别注射锌指蛋白 A20 过表达腺病毒（过表达 A20 组）、空载体腺病毒（空载体组）、PBS 液（对照组）、锌指蛋白 A20干扰腺病毒（干扰 A20 组）。于注射前 1 d 及注射后 1、2、3、6 d 行生物反应综合评分；注射后 2、4、8 周，各组行 MRI 检查并测量 T2 弛豫时间（T2 信号值）后，取材行阿利辛蓝染色观察椎间盘髓核细胞退变情况，免疫组织化学染色检测锌指蛋白 A20 以及椎间盘退变相关指标（Ⅱ型胶原、蛋白聚糖）的表达，Western blot 检测锌指蛋白 A20、NF-κB 结合蛋白［P65、磷酸化 P65（phosphate P65，P-P65）、Ⅱ型胶原、蛋白聚糖］、自噬相关蛋白［LC3 （LC3Ⅱ/LC3Ⅰ）、P62］以及炎症因子（TNF-α、IL-1β）的表达。 结果各组注射后各时间点生物反应综合评分均明显低于注射前 1 d（P<0.05）；注射后 6 d 干扰 A20 组评分明显低于其他组（P<0.05），其他组间比较差异均无统计学意义（P>0.05）。MRI 检测提示，注射后 2、4、8 周过表达 A20 组 T2 信号值均最高（P<0.05），2、4 周时干扰 A20 组最低（P<0.05），其余组间差异均无统计学意义（P>0.05）。阿利辛蓝染色显示，注射后 4 周过表达 A20 组蛋白聚糖含量最高（P<0.05）、干扰 A20 组最低（P<0.05）；8 周时过表达 A20 组蛋白聚糖含量显著高于其他组（P<0.05），其他组间比较差异无统计学意义（P>0.05）。免疫组织化学染色示，锌指蛋白 A20、Ⅱ型胶原、蛋白聚糖表达过表达 A20 组最高（P<0.05），干扰 A20 组上述蛋白表达最低（P<0.05）。Western blot 检测示锌指蛋白 A20、蛋白聚糖、Ⅱ型胶原、LC3 （LC3Ⅱ/LC3Ⅰ）蛋白相对表达量过表达 A20 组最高、干扰 A20 组最低，而 P-P65、TNF-α、IL-1β、P62 蛋白相对表达量过表达 A20 组最低、干扰 A20 组最高，与其他组比较差异均有统计学意义（P<0.05）；各组 P65 蛋白相对表达量差异均无统计学意义（P>0.05）。 结论锌指蛋白 A20 能通过抑制炎症反应，有效延缓兔腰椎间盘退变的进程。