Objective To study the clinical effects of delayed surgery for Maisonneuve fractures.Methods Between January 2006 to June 2011,we treated 21 patients with Maisonneuve fracture by delayed surgery.They were 18 men and 3 women,aged from 17 to 63 years (average,36.8 years).Rupture of inferior tibiofibular ligaments was complicated in all,lateral malleolus fracture in 17 cases,medial malleolus fracture in 14 cases,rupture of deltoid ligament in 7 cases,and posterior malleolus fracture in 15 cases.None of them got timely surgery due to complicated injuries,poor skin condition or missed diagnosis.Six patients had surgery after 2 weeks,11 after 3 weeks and 4 after 4 weeks.The interval from injury to surgery ranged from 14 to 32 days,averaging 21.3 days.Fractures of lateral,medial and posterior malleolus were treated with open reduction and internal fixation.Ruptures of deltoid ligament and anterior ligament of inferior tibiofibula were repaired and reconstructed.Functional recovery of the ankle joint was assessed using American Orthopaedic Foot and Ankle Society (AOFAS) scoring system.Results The patients were followed up for 10 to 18 months (average,12.3 months).All the fractures healed after an average time of 12.4 weeks (from 10 to 22 weeks).No infection or implant failure was observed in this group.The affected ankle restored inflexion basically to the range of the contralateral 6 months post-surgery,but was limited in the ranges of varus and valgus.Pain was extensively experienced.At the last follow-up,10 patients (47.6％) showed obvious disparity between the 2 sides,and 5 ones had lateral displacement of the talus and widened ankle mortise.AOFAS results were excellent in 5 cases,good in 9,fair in 4 and poor in 3,yielding a good to excellent rate of 66.7％.Conclusion Because delayed surgery increases the difficulties in surgery and functional recovery,early diagnosis and early surgery are crucial for treatment of Maisonneuve fractures to achieve satisfactory outcomes.

Objective To investigate the effects of long-and mid-term indwelling AO clavicular hook plate (CHP) on the shoulder function following surgery for acromioclavicular dislocation(from grade Ⅲ to grade Ⅴ by Rockwood's classification).Methods A retrospective study was done of 95 patients with acromioclavicular dislocation who had been fixed with AO CHP from December 2002 to May 2011.They were 80 men and 15 women,aged from 20 to 63 years (average,45.0 years).By the Rockwood's classification,there were 40 cases of type Ⅲ,35 ones of type Ⅳ and 20 ones of type Ⅴ.Time from injury to surgery ranged from 2 to 7 days (average,4.6 days).The CHP was indwelling in 70 patients but removed in 25 patients from 12 to 23 mouths post-surgery (average,16.5 months).The University of California (UCLA) shoulder scoring system was used to compare the shoulder functions between those with an indwelling CHP and those without,as well as between the healthy and affected shoulders among those with an indwelling plate.Results The follow-up time for all the 95 cases ranged from 7.5 months to 9 years,with an average of 38 months.Of those with an indwelling CHP,subacromial bone erosion occurred in 45,internal implant failure in 3,impingement in 13,screw loosening in 2 and frozen shoulder in 5,giving a complication rate of 97.1％ (68/70).Of those without an indwelling CHP,subacromial bone erosion occurred in 3 and no redislocation was found in this group,giving a complication rate of 12.0％ (3/25).The UCLA score for the affected shoulder among those with an indwelling CHP(27.0 ± 11.0 points) was lower than that for the healthy one (34.0 ± 1.0 points) and lower than that for the affected shoulder among those without an indwelling CHP(32.0 ± 6.5 points).Conclusion Long-and mid-term indwelling AO CHP can have a significant adverse impact on shoulder function,leading to a very high rate of postoperative complications.

Objective To investigate the outcomes of infection mauagement after patellar fracture surgery using vacuum sealing drainage (VSD) combined with closed irrigation-suction within the articular cavity.Methods We treated 7 patients who had been inflicted by infection after patellar fracture surgery from June 2008 to March 2012.They were 5 men and 2 women,aged from 19 to 52 years (average,40.5years).There were one open aud 6 close patellar fractures.Their infections occurred 14 to 21 days (average,17.7 days) after internal fixation.One infection was superficial and 6 were deep,resulting in pyogenous arthritis of the knee.All cases were given debridement and VSD treatment and immobilized with braces.The 6 cases of deep infection were irrigated continuously with 4000 mL 0.9％ NaCl every day within the articular cavity.Direct skin suture or transplantation of local skin graft was performed after growth of fresh granulation tissue.Neer system was used to evaluate the knee functions at the last follow-up.Results After the VSD was applied for 7 to 12 days,the wound surface and knee cavity were very clean and fresh granulation tissue emerged.The wound was closed by direct suture for one superficial and one deep infection.Local skin grafts were transplanted for 5 deep infections.The infections were effectively controlled without pain,swelling or local fistula.The patients were followed up from 3 to 48 months (average,21 months).The functional outcome according to Neer' s criteria at the last follow-up was excellent in 2 cases,good in 3 and fair in 2.Conclusion In management of infection after patellar fracture surgery,VSD combined with closed irrigation-suction within the articular cavity can drain sufficiently,control infection effectively and stimulate fresh granulation growth,facilitating wound closure by direct suture or transplantation of a local skin flap.

Objective To investigate effect of hypertonic-hyperoncotic solution (HHS,namely 4.5 g/ml NaCl plus 6.0 g/ml hydroxyethyl starch) on brain protection in rabbits with pulmonary trauma combined with hemorrhagic shock and the possible mechanism.Methods Thirty New Zealand white rabbits were randomly divided into control group (Group A),lactated Ringer' s solution (LRS) treatment group (Group B) and HHS treatment group (Group C),with 10 rabbits per group.Models of pulmonary trauma with hemorrhagic shock were established in Groups B and C.Later,fluid resuscitation,including LRS at 3-fold the volume of blood loss and HHS at dose of 5 mL/kg,was respectively given for Groups B and C at 60 minutes after shock.Rabbits in each group were sacrificed at 4 hours after resuscitation for brain tissue harvest.Evan blue exudation in the parietal cortex of rabbit brain in each group was observed by fluorescence microscope.Brain water content was weighed and calculated.Neuron apoptosis was tested by TUNEL method.Expressions of Bcl-2 and Bax proteins were detected by Western blot.Resalts Group B showed massive exudation of Evan blue,notable increase of brain water content,large apoptosis of neurons,up-regulation of Bcl-2 and Bax proteins,but a decline of Bcl-2 to Bax ratio,as compared with Group A (P ＜ 0.01).However,Group C showed significant decrease regarding Evan blue exudation,brain water content and apoptotic neurons,and significant increase of ratio of Bcl-2 and Bax,as compared with Group B (P ＜ 0.05).Conclusion HHS improves blood brain barrier,inhibits neuron apoptosis and thus protects brain function.

Objective To investigate effect of monosialotetrahexosy-1 ganglioside (GM1) on the autophagic neuronal death induced by spinal cord injury.Methods Ninety SD rats were randomly divided into sham group,isotonic saline group and GM1 group,with 30 rats per group.Spinal cord injury at T10 segment was induced by Allen method in the isotonic saline group and GM1 group.Expression of endogenous LC3 was detected by florescence microscope.Ratio of LC3-Ⅱ and LC3-Ⅰ,and expression of Beclin-1 were detected by Western blot.Results LC3 was significantly up-regulated in the isotonic saline group,as compared to the sham group (P ＜0.05).Also,an up-regulation of LC3 and a decline of autophagic body formation were observed in GM1 group,as compared to isotonic saline group (P ＜0.05).Expressions of LC3-Ⅱ and Beclin-1 and ratio of LC3-Ⅱ to LC3-Ⅰ were significantly increased in the isotonic saline group,as compared to the sham group (P ＜ 0.05).Expressions of LC3-Ⅱ and Beclin1 and ratio of LC3-Ⅱ to LC3-Ⅰ significantly were decreased in the GM1 group,when compared to the isotonic saline group (P ＜ 0.05).Conclusion GM1 inhibits autophagic neuronal death after spinal cord injury and hence exerts protective effect on the neurons.

Objective To analyze the pathophysiological variation in patients with penetrating cardiac trauma (PCT) and discuss the classified treatment strategies.Methods A retrospective analysis was conducted on pathogenetic condition,medical interventions and other clinical information of 133 PCT patients.The patients were divided into four groups in accordance with their symptom classification on arrival at emergency department,including sub-clinic type,cardiac tamponade type,hemorrhagic shock type and agonal type.Meanwhile,the patients were classified into three groups according to their pathogenesis phase,including sub-clinical phase,clinical phase and agonal phase.Development characteristic of patients' condition in each group was investigated in each time point by survival analysis.Impacts of medical interventions on prognosis of those patients were analyzed,such as pericardial space exploration,emergency room thoracotomy (ERT),operating room thoracotomy (ORT).Results Some patients at sub-clinical phase were aggravated into clinical phase or agonal phase,as well as some patients at clinical phase were aggravated into agonal phase during in-hospital treatment.There were significance differences of posttraumatic suvival course among the four groups,namely sub-clinical type,cardiac tamponade type,hemorrhagic shock type and agonal type (P ＜ 0.01).The differences of posttraumatic survival course were also significant among the three groups,namely sub-clinical phase,clinical phase and agonal phase (P ＜ 0.01).Conclusion Clinical symptom classification (or pathogenesis phase) of PCT may not be always unchangeable,thus it is recommended that PCT patients should be treated based on their clinical symptom classification or patbogenesis phase at consultation.

Objective To investigate technical points,risks and advantages of primary total knee arthroplasty (TKA) through subvastus approach.Methods The study involved 68 patients of similar basic conditions who were treated by TKA between September 2008 and August 2010,including 34 patients treated through subvastus approach (Group A) and 34 patients treated through traditional medial parapatella approach (Group B).Clinical parameters between groups were comparatively studied after operation.Results All patients were followed up for 6-25 months (mean 8.7 months).Alignment of lower extremities in both groups was restored.Group A showed significant differences from Group B in aspects of postoperative drainage volume [(124 ± 32.4) ml vs (182 ± 41.3) ml,P ＜ 0.05],requirement of lateral retinacular release (7％ vs 23％,P ＜0.01),time before patients being capable of having active straight-leg-raising movement [(1.3 ± 0.7) d vs (3.2 ± 0.6) d,P ＜ 0.05],and time away from patients being able to bend their leg up to 90° [(3.1 ± 0.6) d vs (5.3 ± 0.5) d,P ＜ 0.05].Conclusion Primary total knee arthroplasty through subvastus approach can hardly intervene in extension knee apparatus and in blood circulation around patellas,promote rapid recovery of knee function and achieve satisfactory early outcomes.

Objective To discuss imaging classification of blunt traumatic thoracic aortic injury (BTTAI) and weigh guideline value of its imaging classification to surgical options.Methods BTTAI in 12 patients were divided into three types in accordance with outline of aortic injury revealed by CT imaging,i.e.,type A of normal outline of aortic blood vessel but free endothelium in aortic cavity,type B of abnormal aortic outline and contrast extravasation to aortic lumen exterior but only confining to mediastina,and type C of abnormal aortic outline and contrast leakage to thoracic cavity.Significance of BTTAI morphological classification was analyzed according to data,such as systemic injury severity score (ISS),local injury sites,surgical approaches and patients' outcome.Results Multiple injuries combined with BTTAI were observed in all patients whose aortic lesion image could be all generalized by above-mentioned classification.BTTAI image showed type A in three patients,type B in seven and type C in two.Pseudoaneurysm was confirmed as the foremost common BTTAI.There were no significant differences in ISS,hypotension morbidity,treatment methods or mortality between each type of BTTAI.Conclusions BTTAI occurs mostly in multiple injuries and thus overall injury severity assessment is not only depended on aortic lesion classification.BTTAI classification in this study reflects injury severity of vessel wall,takes account to location of lesion and adjacent relations (especially length of landing zone) and hence has accurate referential value for surgical decisions.

Objective To evaluate feasibility of flap fenestration in management of the condition that a stent-graft is wrongly deployed in false lumen of aortic dissection.Methods A retrospective analysis was conducted on a case of Stanford type B aortic dissection who was confirmed that the stent-graft had been wrongly deployed in false lumen of aortic dissection by CT angiography (CTA) after endovascular repair.Thereafter,an additional surgical management was carried out.At length,flap fenestration at 2 cm below pre-deployed stent-graft was performed using an Outback catheter so as to link false and true lumens.Successively,another stent-graft was placed via the access to draw blood flow from false lumen back to true lumen and then coil embolization was performed for distal breach of the dissection.Results Surgery was carried out under local anesthesia,with operation duration of 170 minutes and intraoperative blood loss of 350 ml.The chest and back pain disappeared after operation.The patient commenced to take food and take off-bed activity at the very day of operation in absence of paraplegia,visceral ischemia,or other complications.Aortic CTA at postoperative one week showed ideal positioning of stent-graft,fluent blood flow of aorta and major visceral artery,and vanishing of false lumen.Conclusions Flap fenestration at far-end of pre-deployed stent-graft so as to draw blood flow back to true lumen by connecting the new placed stent graft to pre-deployed stent-graft is an effective treatment for mis-deployment of stentgraft in false lumen of aortic dissection.Outback catheter for flap fenestration is characterized by accurate location and high safety.

Objective To investigate feasibility and validity of endovascular aortic repair (EVAR) of traumatic thoracic aortic injuries (TTAI).Methods A retrospective analysis was conducted on data of 13 patients with TTAI.Pathological changes were evaluated by spinal CT angiography (CTA) preoperatively and re-evaluated by digital subtraction angiography (DSA) in EVAR.CTA was performed again to confirm therapeutic effects at postoperative 3,6,12 months and annually thereafter.Results All patients had successful EVAR.Complete or partial cover of left subclavian artery was observed in four patients.Endoleak in angiography shortly after stent delivery was noticed in three patients.However,endoleak disappeared in one patient after short stent placement for twice; endoleak was evidently decreased in one patient after balloon dilation.Follow-up was performed for another patient with slight endoleak.A total of 12 patients were followed up,which showed no complications,such as endoleak,ischemia of left upper extremity,paralysis or stent-graft migration.Conclusion EVR is safe and effective in treatment of TTAI.