BACKGROUND:Forceful fixation and enough blood supply in fracture site are the fundament for treating bone nonunion. OBJECTIVE:To investigate the outcome of autologous lilac bone-grafting and plate fixation in treatment of the ununited distal ulnar fracture with osseous defects. DESIGN,TIME AND SETTING:The own control study was performed at the Department of Orthopaedics,Sixth People's Hospital,Shanghai Jiao Tong University from August 2002 to May 2006. PARTICIPANTS:Of 21 cases of the ununited distal ulnar fracture with osseous defects,13 cases were induced by ulnar and radial fracture,and 8 cases were induced by ulnar fracture. There were 15 cases of open fracture and 6 cases of closed fracture of first onset. Bone defects were 1.5 cm-5.0 cm,averagely 3.1 cm. METHODS:Bone defects were filled with intercalary lilac grafts. Length and axial ray of ulna were controlled. Ulna was fixed utilizing 5-8 wells 1/3 tubular plate,reconstruction plate or locking compression plate. At least two screws were used at the distal end,and 3 or 4 screws were fixed in the proximal end,FoUow-up was conducted once per month to observe clinical appearances and radiograph in each patient. MAIN OUTCOME MEASURES:Fracture nonunion,dorsal extension and palmer flexion of wrist joint,pronation and supination of the forearm were measured. RESULTS:All 21 cases were followed up for a mean time of 14.7 months. All the patients obtained bony union,and a mean time of 4.6 months (ranged 3 to 7 months). The distal ulnar healed with < 10° of angular deformity in a coronal plane in one patient and with 15° of angulation in a sagittal plane in another one,while others (19 patients) obtained satisfactory alignment. The excellent and good rate was 90.5％. CONCLUSION:Intercalary bone-grafting with autologous lilac and secure fixation for treating the ununited distal ulnar fracture with osseous defects can reconstruct ulnar length,correct deformities,and obtain good bone healing and functional recovery.

BACKGROUND: Forceful fixation and enough blood supply in fracture site are the fundament for treating bone nonunion. OBJECTIVE: To investigate the outcome of autologous iliac bone-grafting and plate fixation in treatment of the ununited distal ulnar fracture with osseous defects. DESIGN, TIME AND SETTING: The own control study was performed at the Department of Orthopaedics, Sixth People’s Hospital, Shanghai Jiao Tong University from August 2002 to May 2006. PARTICIPANTS: Of 21 cases of the ununited distal ulnar fracture with osseous defects, 13 cases were induced by ulnar and radial fracture, and 8 cases were induced by ulnar fracture. There were 15 cases of open fracture and 6 cases of closed fractureof first onset. Bone defects were 1.5 cm-5.0 cm, averagely 3.1 cm. METHODS: Bone defects were filled with intercalary iliac grafts. Length and axial ray of ulna were controlled. Ulna was fixed utilizing 5-8 wells 1/3 tubular plate, reconstruction plate or locking compression plate. At least two screws were used at the distaend, and 3 or 4 screws were fixed in the proximal end. Follow-up was conducted once per month to observe clinical appearanceand radiograph in each patient. MAIN OUTCOME MEASURES: Fracture nonunion, dorsal extension and palmer flexion of wrist joint, pronation and supination othe forearm were measured. RESULTS: All 21 cases were followed up for a mean time of 14.7 months. All the patients obtained bony union, and a mean timof 4.6 months (ranged 3 to 7 months). The distal ulnar healed with

Background:Mediastinoscopy is an effective method for the treatment of early esophageal cancer with minimal invasiveness and lower risk. Preoperative accurate staging of esophageal cancer is the key for the choice of mediastinoscopic operation as the treatment modality. Aims:To evaluate the value of combination of endoscopic ultrasonography(EUS)with CT for the treatment of esophageal cancer under mediastinoscopy. Methods:Sixty patients with esophageal cancer were enrolled. The TN staging results of esophageal cancer by EUS and CT examination were compared with the results of postoperative TN staging. Patients were divided into mediastinoscopic operation group and conventional operation group, and the operation time,intraoperative bleeding volume,postoperative pleural drainage flow and postoperative hospitalization time of the two groups were compared. Results:The accuracy rates of preoperative EUS examination in assessing T and N stage were 81. 7% and 83. 3% ,respectively;accuracy rates of preoperative CT examination were 60. 0% and 53. 3% , respectively;and accuracy rates of EUS combined with CT were 85. 0% and 86. 7% ,respectively. Compared with conventional operation group,intraoperative bleeding volume[(178. 2 ± 30. 1)mL vs.(232. 0 ± 48. 2)mL,P ﹤ 0. 05], postoperative pleural drainage flow[( 142. 8 ± 22. 5 ) mL vs. ( 256. 0 ± 42. 3 ) mL,P ﹤ 0. 01 ],postoperative hospitalization time[(12. 1 ± 2. 5)days vs. (14. 3 ± 3. 6)days,P ﹤ 0. 05]in mediastinoscopic operation group were significantly decreased,and no significant difference in operation time was found between the two groups[(152. 4 ± 13. 2) minutes vs.(163. 3 ± 25. 5)minutes,P ﹥ 0. 05]. Conclusions:Combination of EUS with CT examination can improve the accuracy of preoperative staging,thus provides an important reference for the choice of treating esophageal cancer by mediastinoscopic operation.

Objective To investigate the surgical treatment and outcome of distal humeral shear fractures in adults through Kaplan approach.Methods Nine patients with closed shear fracture of the distal humerus were surgically treated through Kaplan approach from September 2005 to September 2009.The lateral collateral ligament was released only in 1 case.All the fractures were classified into type 1A (3 cases),type 1B (1 case),type 2A (1 case),type 3A (1 case) and type 3B (3 cases) according to Dubberley classification.Under the direct vision,cannulated screw was used after anatomic reduction was confirmed by fluoroscopy.Results All fractures were reduced anatomically without any neural or vascular injury.Only 1 case of grade 1 heterotopic ossification was found 12-24 months postoperatively.There were excellent in 4 cases,and good in 5 cases.The average Broberg-Morrey score was 94.2.The average arc of flexion-extension was 116°.As to the 4 cases with posterior comminution,the averaged score and the arc of flexion-extension was 92.8 and 104°,respectively.Conclusion Through Kaplan approach,the reduction and internal fixation of distal humeral shear fractures can be manipulated successfully with lateral collateral ligament intact,and the short-term outcome is satisfactory.Dubberley classification which focused on the severity and prognosis is helpful to make a surgical plan.

Objective To discuss factors influencing the heterotopic ossifications (HO) after treatment of bi-column acetabular fractures. Methods One hundred and ninety-three cases of bi-column acetabular fractures were followed up, including 147 males and 46 females with an average age of 34. 4 years. Thirty-one cases were associated with craniocerebral trauma. The interval between injury and surgery was less than 1 week in 15 cases, 1 to 2 weeks in 121 cases, 2 to 3 weeks in 34 cases, and over 3 weeks in 23 cases. Factors that might have influenced HO, including surgical method, associated injury, and interval between injury and surgery, were analyzed retrospectively. Results All the cases were followed up for an average of 44. 2 (14 to 84) months. The mean operation time was 238 (150 to 330) minutes, and the average blood loss was 1453 (450 to 4400) mL. The incidence rate of HO was 39. 9% (77 in 193 cases), including 39 cases of degree one, 23 cases of degree two, and 15 cases of degree three. Of the 77 cases associated with HO, 14 had craniocerebral trauma and 63 did not (χ~2 = 0. 019, P = 0. 891) . HO was found in 2 cases that had been operated on in less than 1 week, 38 cases in 1 to 2 weeks, 21 cases in 2 to 3 weeks, and 16 cases in over 3 weeks. The Spearman correlation analysis between HO degree and clinical result showed no correlation ( R = 0. 041, P =0. 722). Only 15 cases (7. 8% ) were associated with HO after the debridement of the necrotic gluteus minimus. Conclusions HO after surgery for bi-column acetabular fractures may not be correlated with craniocerebral trauma, but highly correlated with the interval between injury and surgery. Debridement of necrotic gluteus minimus and other muscles can reduce the incidence of HO.

Objective To discuss the value of preoperative C-reactive protein (CRP) and eryth-rocyte sedimentation rate (ESR) in predicting postoperative infections following multiple fractures. Methods A study was conducted in 78 patients with multiple fractures (complicated with pelvic frac-ture, ISS > 18) treated in our department from December 2006 to March 2009. CRP and ESR levels be-fore second damage control operation as well as postoperative infections were recorded. Meanwhile, the optimal cut-off value was determined by receiver operating characteristic curve and analyzed. Results There were 11 patients with postoperative infection. The preoperative optimal cut-off value of CRP was 50 mg/L, with a sensitivity of 0.909 and a specificity of 0.821. The preoperative optimal cut-off value of ESR was 27.5 mm/h, with a sensitivity of 0.818 and a specificity of 0.791. The combination tests showed the sensitivity and specificity of 0.875 and 0.900 respectively. Conclusion CRP (50 mg/L) can be a sensitive predictive index for postoperative infection in the multiple fractures (complicated with pelvic fractures). Combination test of CRP and ESR can benefit diagnosis of postoperative infection.

Objective To identify the practical microsurgical procedure for repairing in site of skin avulsion injury in hand, and evaluate the long-term following-up results. Methods From January 2001 to May 2005, 21 cases of skin avulsion injury in hand were treated in our department. The surgical procedures thumb skin was revascularized with vein graft from forearm, and the other part of injuried hand was resuffaced by the thickness skin graft taken from the original degloved skin, which was suitable for degloving injury in-graft, the dorsum and palm of hand was skin grafted by the original skin thinned, which was suitable for complete degloved injury at the proximal interphalangeal level. Results All the repaired skin were survival in 16 patients, partial necrosis occurred in 4 cases, which was severely crushed, required debridement and skin graft on the residual defect. Whole failure in 1 case, which underwent secondary amputation. Follow-up at 10-28 months shows acceptable cosmetic and sensible results, slight scarring was present on the volar as-pects of hand. The range of motion of the thumb and fingers was almost complete. All patients regained new jobs. Conclusion Individualization of mierosurgical methods for repairing in site of skin avulsion injury in hand does represent the best solution.

Objective To discuss the surgical technique of delayed acetabular fractures and its possible prognosis factors.Methods From April 2001 to November 2008,61 patients with delayed acetabular fractures were surgically treated.There were 47 males and 14 males,with an average age of 38 years.According to Letourael classification,16 simple fractures included 7 cases of posterior wall fractures,2 of posterior column fractures,1 of anterior column fractures and 6 of transverse fractures.Forty-five patients with mixed fractures included 3 cases with both fractures posterior column and wall,7 of transverse and posterior wall fractures,4 of T-shape fractures,6 of posteriorly semi-transverse fractures and 25 of both-columns fractures.Fifty-two patients suffered from traffic accident;6 patients were caused by falling from height and 3 suffered from crush injuries.Brain injuries occurred in 11 cases,thorax-abdominal injuries in 15,urinary tract injuries in 7,multiple fractures in 25.The injury of sciatic nerve was found in 3 patients preoperatively.The average interval form injury to surgery was 39 days.A single approach was employed in 13 cases,and combined antero-posterior approaches were employed in 48.The operation time was (248±45) min with a blood loss of (2160±100) ml averagely.Results The average follow-up was (61±8) months.The clinical result was evaluated by Matta reduction criteria,modified Merle d'Aubingne and Postel scoring system.Anatomical reduction was achieved in 45 cases;however,13 were unsatisfactory and 3 were poor.For clinical results,38 were graded as excellent,13 as good,6 as fair and 4 as poor.Osteonecrosis of the femoral head occurred in 3 cases (4.9%),and heterotopic ossification developed in 28 cases (45.9%).Additionally,4patients (6.6%) had a transient sciatic nerve paralysis.Conclusion Open reduction and internal fixation is a liable method for delayed acetabular fractures.Single approach is suitable for simple fractures;in principle and combined approaches are for compound delayed acetabular fractures.The reduction quality is closely related to surgeon's experience.

A total of 12 cases with Achilles tendon rupture were repaired by modified Kessler's methods.The sutured tendons were then strengthened with Mitek anchor system with 2 anchors inserted into the calcaneus lateral and medial to insertion of Achilles tendon and the sutures passed through the repaired tendon using Bunnel methods.The healing of skin incision,time to weight bearing,range of motion of the ankles,calcaneal pain and re-ruptures were recorded.The results were evaluated according to Amer-Lindholm criteria.All the patients were followed up with mean 17 months (range from 14 to 25 months).There were no calcaneeal pain or re-rupture cases,neither deep nor superficial wound infection or skin necrosis cases.According to Arner-Lindholm criteria for curative result,the result was excellent in 4 cases and good in 8 cases.The Mitek anchor system can be used successfully to treat Achilles tendon rupture and decrease postoperative complications.Thus,the technique is an ideal option for Achilles tendon rupture repair.

Objective To study the effects of nerocutneous vessels on perforator flap blood supply and survival area. Methods Thirty SD rats were randomly divided into 3 groups. The study of the vasculature and nerve disposition of rat dorsum was performed with 10 rats of one group. According to the study,a distal rectangle neurocutaneous flap based on deep circumflex iliac artery perforator, 10 cm long and 3 cm in the width, was elevated on the rest rats, and sutured back to the original situation. The axis of the experimental group's flap paralleles the posterior median line,while the control group flap's angulated about 30° with it. The blood flow of the flap was assessed by fluorescein angiography on the 1st and 7th day after surgery. The surviving rate and the capillary density of flap were assessed on the 7th day after surgery. Results The rat deep circumflex iliac perforator artery was a constant perforator artery, with an nutrition area about 4 cm× 3 cm. The dorsal cutaneous nerves run along the dorsomedian line, nourished by rich vessels. The blood perfusion 1st day after surgery was 42.85% in the experimental group, 37.94% in the control group(P ＞ 0.01 ).On the 7th day, it was 84.07% in the experimental group, 58.55% in the control group (P＜ 0.01). The mean survival rate of the experimental group was 83.93%, higher than control group's 59.95% (P＜0.01),and the density of the blood vessels was higher in experimental group than control group's. Conclusion The neurocutaneous vessels can improve the flap survival condition, which make the perforator flap bigger and safer.