Objective To evaluate the effect of posteromedial combined with lateral surgical approach in treatment of trimalleolar factures.Methods The clinical data of 37 patients with trimalleolar factures underwent open reduction and internal fixation through posteromedial combined with lateral surgical approach were retrospectively ana-lyzed.There were 21 males and 16 females with average age of 55.0 years (ranged 35 -80).Complications such as infection,nonunion,fixation failures were observed.All patients were followed up at 6 months and 12 months after sur-gery and assessed functionally with American Orthopaedic Foot and Ankle Society Scores (AOFAS).After the 12 month follow up,the patients were also called for a radiological examination.Results Average follow -up time was 18.8 months (12 -27 months).All cases had no complications such as incision infection,skin necrosis,internal fixator loosening or rupture and bone nonunion.Using AOFAS,the scores were 82.9 and 89.7 respectively at the 6 month and 12 month follow up.The degree of arthrosis was grades Ⅰ in 2 ankles,Ⅱ in 1 ankle,and Ⅲ in 1 ankle according to Kellgren&Lawrence.Conclusion Posteromedial combined with lateral surgical approach for the treat-ment of trimalleolar factures has leaded to an satisfactory clinic outcomes.It is minimally invasive and has less compli-cations and cost.

Objective To investigate the correlation of heme oxygenase-1 (HO-1) expression and autophagy in mice with liver ischemia reperfusion (IR) injury,and to study the influence of HO-1 on the hepatic function.Methods Control group,IR group,Hemin + IR group and Znpp + IR group were constructed.Mice in the Hemin + IR group and the Znpp + IR group were pretreated by Hemin (HO-1 inducer) and Znpp (HO-1 inhibitor) before IR.According to different reperfusion time,the IR group was divided into the 0,2,6,12,24,48 and 72 hours groups,and the Hemin + IR group and the Znpp + IR group were divided into the 0,2,6,12,24 hours groups.The levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were detected to evaluate the hepatic function.The autophagosome and pathological changes of liver were observed under electron microscope and hematoxylin and eosin (HE) staining,respectively.The expressions of HO-1 and autophagyassociated protein (LC3Ⅱ) in the protein level were detected by Western blot.All data were analyzed using the analysis of variance,t test and q test,respectively.Results The levels of ALT and AST of the IR group,Hemin + IR group and Znpp + IR group were significantly higher than those of the control group (F =96.17,85.53,P ＜0.05).The levels of ALT and AST of the IR 12 hours group and 24 hours group were significantly higher than those of the Hemin + IR 12 hours group and 24 hours group (qALT=--14.46,-7.85 ; qAST=-12.98,-5.26,P ＜0.05),but significantly lower than those of the Znpp + IR 12 hours group and 24 hours group (qALT=4.25,4.94;qAST=4.98,3.53,P ＜ 0.05).The results of HE staining showed that hepatic IR injury was significalty alleviated in the Hemin + IR group when compared with the IR group and the Znpp + IR group.The Suzuki degrees of hepatic IR injury in the control group,IR 12 hours group,Hemin + IR 12 hours group and the Znpp + IR 12 hours group were 0.5 ± 0.3,2.6 ± 0.5,1.1 ± 0.3,3.0 ± 0.4,respectively,with significant differences among the 4 groups (F =53.62,P ＜0.05).There were significant difference in the Suzuki degrees of hepatic IR injury between the IR 12 hours group and the Hemin + IR 12 hours group,and between the IR 12 hours group and the Znpp + IR 12 hours group (q =10.67,14.02,P ＜ 0.05).The results of electron microscopy showed that the number of autophagosome in the IR group was greater than the control group and Znpp + IR group,but lesser than the Hemin + IR group.The numbers of autophagosome in every 10 high power fields of the control group,IR 12 hours group,Hemin + IR 12 hours group and the Znpp + IR 12 hours group were 0.4 ±0.2,1.8 ±0.6,4.0 ± 1.8,0.7 ±0.5,respectively,with significant difference among the 4 groups (F =21.35,P ＜ 0.05).There were significant differences in the number of autophagosome between the IR 12 hours group and the Hemin + IR 12 hours group,and between the IR 12 hours group and the Znpp + IR 12 hours group (q =6.05,-3.03,P ＜ 0.05).The expressions of HO-1 and LC3Ⅱ in the IR group and the Hemin + IR group were significantly increased.The relative expressions of HO-1 protein in the Hemin + IR 6 hours group and the 12 hours group were 0.64 ±0.17 and 0.51 ±0.12,which were significantly higher than 0.45 ± 0.08 and 0.17 ± 0.03 of the IR 6 hours group and 12 hours group (t =4.03,4.69,P ＜ 0.05).The relative expressions of LC3Ⅱ protein in the Hemin + IR 6 hours group and the 12 hours group were 1.04 ± 0.20 and 1.20 ± 0.23,which were significantly higher than 0.58 ± 0.04 and 0.95 ±0.14 of the IR 6 hours group and 12 hours group (t =4.29,6.69,P＜0.05).The relative expressions of HO-1 protein in the Znpp + IR 6 hours group and 12 hours group were 0.23 ± 0.03,0.14 ± 0.02,respectively,and the relative expressions of LC3Ⅱ protein were 0.35 ± 0.04 and 0.49 ± 0.14,which were significantly lower than the HO-1 and LC3Ⅱ protein expressions in the IR 6 hours group and 12 hours group (tHO-1 =13.82,7.04; tLC3Ⅱ =7.21,4.03,P ＜0.05).Conclusion HO-1 is positively related to the amelioration of hepatic function,and it may be achieved by induction of autophagy.

Objective To explore clinical effect of double plates in the treatment of com-minuted fracture of tibial plateau.Methods Patients with double plates in the treatment of com-minuted fracture of tibial plateau were systematically analyzed.Bone grafting was applied to the area of cancellous bone defect under cartilage surface.The T-shaped supported plate was placed in medial tibial condyle after pre-bending and the lateral was fixed by the small anti-slip plate.And functional exercise of knees after operation was taken.Results All patients were healed and there were no knee valgus deformity,break of plate and screw,deep infection,internal and external fix-ation failures after the operation.The excellence rate reached to 84.2%.Conclusion From the clinical perspective,double plates could effectively treat comminuted fracture of tibial plateau.

Objective To explore clinical effect of double plates in the treatment of com-minuted fracture of tibial plateau.Methods Patients with double plates in the treatment of com-minuted fracture of tibial plateau were systematically analyzed.Bone grafting was applied to the area of cancellous bone defect under cartilage surface.The T-shaped supported plate was placed in medial tibial condyle after pre-bending and the lateral was fixed by the small anti-slip plate.And functional exercise of knees after operation was taken.Results All patients were healed and there were no knee valgus deformity,break of plate and screw,deep infection,internal and external fix-ation failures after the operation.The excellence rate reached to 84.2%.Conclusion From the clinical perspective,double plates could effectively treat comminuted fracture of tibial plateau.

Objective:To explore mechanical stability of Proximal Humeral Internal Locking Plate System (PHILOS) in the treatment of Vancouver B1 femoral periprosthetic fractures by three-dimensional finite element analysis.Methods:A three-dimensional finite element model of the femur was established by digital medical software (Mimics 21.0, 3-matic12.0, Geomagic12.0 and Hypermesh 2017.0) using the CT data of a femur from a volunteer (male, 34 years old, 173 cm in height and 65 kg in weight). After the femoral trochanter was cut in the femoral models, a femoral stem was implanted. PHILOS fixation (PHILOS group) and Cable-Ready GTR fixation (Cable group) were applied respectively. Loads of 700 N, 1,400 N and 2,100 N were applied to the 2 groups of finite element models. Distributions of Von Mises stress and deformation were investigated in the finite element models of 2 internal fixations; the mechanical stability was compared between the 2 groups of models.Results:The maximum deformation occurred on the femoral ball head in the 2 groups of models. At the load of 2,100 N, the maximum deformation was 3.77 mm in the PHILOS group, larger than 3.58 mm in the Cable group, and the maximum stress peak value in the PHILOS group was 491.54 MPa, about 49.2% lower than that in the Cable group (733.61 MPa). The peak stress in the PHILOS group was mainly distributed on the 4th and 5th fixation ends at the bone plate while the peak stress in the Cable group was mainly distributed on the second titanium cable under the fracture line.Conclusions:Under various loads, both PHILOS fixation and Cable-Ready GTR fixation can provide sufficient mechanical stability. As the peak stress of PHILOS fixation is much lower than that of Cable-Ready GTR fixation, PHILOS can be used as an effective fixation method for Vancouver B1 femoral periprosthetic fractures.

Objective:To evaluate the clinical efficacy of high tibial osteotomy(HTO) plus arthroscopic surgery in the treatment of medial gonarthrosis.Methods:From January 2017 to May 2018, 40 patients were treated at Department of Joint Orthopaedics, Wujin Hospital Affiliated to Jiangsu University and at Department of Joint Orthopaedics, The First Affiliated Hospital to China Medical University for medial gonarthrosis. They were divided into 2 groups according to their different treatment methods. Group A was treated by HTO plus arthroscopic surgery; there were 20 cases, 8 males and 12 females with an age of 59.7 years ± 5.5 years. Group B was treated by only HTO; there were also 20 cases, 10 males and 10 females with an age of 58.2 years ± 4.3 years. The 2 groups were compared in terms of Hospital for Special Surgery (HSS) knee score, visual analogue scale (VAS), hip knee ankle angle (HKA), medial proximal tibia angle (MPTA) and posterior tibial slope angle (PTSA) at 6, 12 and 24 months postoperatively and at the last follow-up.Results:The 2 groups were comparable because there were no significant differences between them in the preoperative general data ( P>0.05). The HSS and VAS scores at 6 months after operation in group A (82.7±2.4 and 1.7±0.7) were significantly better than those in group B (78.4±2.6 and 2.2±0.8) ( P<0.05); the HSS score at 12 months after operation in group A (88.1±1.8) was significantly better than that in group B (82.9±1.7) ( P<0.05). There were no significant differences between the 2 group in the VAS score at 12 months after operation, or in the HSS or VAS scores at 24 months or at the last follow-up ( P>0.05). There were no significant differences either in the HKA, MPTA or PTSA scores between postoperative 6, 12, 24 months and the last follow-up ( P>0.05). Conclusion:In the treatment of medial gonarthrosis, high tibial osteotomy plus arthroscopic surgery may lead to better short-term outcomes than high tibial osteotomy alone, but the 2 methods may result in similar curative efficacy by 24 months after surgery.

Objective:To analyze the clinical characteristics of adult Chinese patients with syncope.Methods:This is a cross-sectional survey study. Patients with preliminary diagnosis of syncope in the Emergency Department, Geriatrics and Cardiology Outpatient Department, or Syncope Unit of 37 hospitals in 19 provinces, autonomous regions and the Hong Kong Special Administrative Region from June 2018 to March 2021 were included in this study. The clinical features of these patients with syncope were analyzed.Results:A total of 4 950 consecutive patients with syncope were included in this study. The age was (56.3±16.8)years, and 2 604 cases (52.6%) were male. The most common type of syncope was neurally mediated syncope (2 345 (47.4%)), followed by cardiac syncope (1 085 (21.9%)), orthostatic hypotensive syncope (311 (6.3%)), and unexplained syncope accounted for nearly one third (1 155 (23.3%)). Predisposing syncope was more common in patients under 65 years of age(2 066(72.4%) vs. 786(27.6%),χ 2=136.5, P<0.001). Presyncope was more common in patients with neurally mediated syncope (1 972(79.0%) vs.1 908(73.9%), χ 2=17.756, P<0.001). Premonitory symptoms were more common in women(1 837(80.0%) vs. 1 863(73.0%),χ 2=33.432, P<0.001). Presyncope syndrome was more common in patients under 65 years of age (2 482(77.8%) vs. 1 218(73.4%),χ 2=17.523, P=0.001). Cyanosis was more common in ≥65 years old patients (271(18.2%) vs. 369(12.7%), χ 2=23.235, P<0.001). Urinary incontinence was more common in old patients aged ≥65 years(252(15.2%) vs. 345(10.8%), χ 2=19.313, P<0.001). Family history was more common in patients with cardiogenic syncope compared with other types of syncope (264(24.3%) vs. 754(19.5%), χ 2=11.899, P=0.001). Hypertention(1 480(30.5%)), coronary heart disease(1 057(21.4%)), atrial flutter and atrial fibrillation(359(7.2%)), second degree atrioventricular block(236(4.8%)) were common complications of syncope. The proportion of patients with coronary heart disease was significantly higher in cardiac syncope than that of other types of syncope(417(38.4%) vs. 640(16.6%), χ 2=241.376, P<0.001). Other common complications included cerebrovascular diseases (551 (11.1%)) and diabetes mellitus (632(12.8%)). Conclusions:Neurally mediated syncope is the most common syncope in adult Chinese population. Patients with predisposing conditions and premonitory conditions are younger. Presyncope is more common in women. The proportion of family history and coronary heart disease is higher in patients with cardiogenic syncope.