Objective:To explore the interrelationship among three simplified hand and wrist bone age assessment methods and to establish corresponding bone ages for each substage in male children.Methods:This retrospective case series study included 169 left hand and wrist X-rays from 152 male children who underwent bone age assessments at the Pediatric Orthopedics and Pediatrics Departments,Beijing Jishuitan Hospital,Capital Medical University from January 2019 to December 2023. The age at the time of X-ray was (13.7±2.0) years (range:9.1 to 17.9 years). Reasons for bone age assessment included evaluating the progress of adolescent idiopathic scoliosis in 36 cases, predicting limb length discrepancies in 28 cases, and predicting the height of healthy adolescents in 88 cases. Bone age was first graded using the Chinese hand-wrist bone age assessment method. Three simplified hand and wrist bone age assessment methods were then applied:Sanders simplified skeletal maturity staging system(Sanders stage), the distal radius and ulna classification (DRU), and e thumb ossification composite index (TOCI). Somers′delta correlation test was used to analyze the relationship among the results of the three simplified methods. The bone age and standard deviation for each sub-stage were calculated, and gender differences in bone age for the same sub-stage were compared with previous study.Results:The DRU, TOCI and Sanders stages showed a strong correlation when assessing bone age in male children, with Somers′delta correlation coefficients ranging from 0.881 to 0.876 (all P<0.01). The sub-stages with the smallest standard deviations (shorter duration) in each of the three classifications can serve as a quick reference for determining precise bone age, included proximal thumb epiphysis covered, without sesamoid (12.0 years);proximal thumb epiphysis covered with sesamoid or distal radial covered (13.0 years), early capping of the thumb epiphysis, radial epiphysis medial side capping(13.5 years), all phalangeal epiphyses capping (14.0 years), distal phalangeal physes beginning to close (14.5 years), all distal phalangeal physes closed (15.0 years), middle or proximal phalangeal physes beginning to close (15.5 years), all digital epiphyses closed (16.5 years), and nearly complete distal radius fusion with a notch (17.5 years). On average, the bone ages of males were 2 years behind those of females in the same substage. Conclusions:The DRU, TOCI, and Sanders stages can be applied to male children, and it is showed good correlation between them. The subtypes with shorter duration can be used as a quick assessment method to determine the bone age.

Objective:To explore the interrelationship among three simplified hand and wrist bone age assessment methods and to establish corresponding bone ages for each substage in male children.Methods:This retrospective case series study included 169 left hand and wrist X-rays from 152 male children who underwent bone age assessments at the Pediatric Orthopedics and Pediatrics Departments,Beijing Jishuitan Hospital,Capital Medical University from January 2019 to December 2023. The age at the time of X-ray was (13.7±2.0) years (range:9.1 to 17.9 years). Reasons for bone age assessment included evaluating the progress of adolescent idiopathic scoliosis in 36 cases, predicting limb length discrepancies in 28 cases, and predicting the height of healthy adolescents in 88 cases. Bone age was first graded using the Chinese hand-wrist bone age assessment method. Three simplified hand and wrist bone age assessment methods were then applied:Sanders simplified skeletal maturity staging system(Sanders stage), the distal radius and ulna classification (DRU), and e thumb ossification composite index (TOCI). Somers′delta correlation test was used to analyze the relationship among the results of the three simplified methods. The bone age and standard deviation for each sub-stage were calculated, and gender differences in bone age for the same sub-stage were compared with previous study.Results:The DRU, TOCI and Sanders stages showed a strong correlation when assessing bone age in male children, with Somers′delta correlation coefficients ranging from 0.881 to 0.876 (all P<0.01). The sub-stages with the smallest standard deviations (shorter duration) in each of the three classifications can serve as a quick reference for determining precise bone age, included proximal thumb epiphysis covered, without sesamoid (12.0 years);proximal thumb epiphysis covered with sesamoid or distal radial covered (13.0 years), early capping of the thumb epiphysis, radial epiphysis medial side capping(13.5 years), all phalangeal epiphyses capping (14.0 years), distal phalangeal physes beginning to close (14.5 years), all distal phalangeal physes closed (15.0 years), middle or proximal phalangeal physes beginning to close (15.5 years), all digital epiphyses closed (16.5 years), and nearly complete distal radius fusion with a notch (17.5 years). On average, the bone ages of males were 2 years behind those of females in the same substage. Conclusions:The DRU, TOCI, and Sanders stages can be applied to male children, and it is showed good correlation between them. The subtypes with shorter duration can be used as a quick assessment method to determine the bone age.

Objective:To compare the clinical efficacy between arthroscopically assisted reduction versus open reduction in the treatment of paediatric humeral lateral condylar fractures with Kirschner wire fixation.Methods:A retrospective study was conducted to analyze the data of 28 children with humeral lateral condylar fracture who had undergone surgery at Department of Pediatric Orthopedics, Beijing Jishuitan Hospital from August 2023 to September 2023. There were 24 males and 4 females with an age of (6.5±1.6) years, 24 cases of type Ⅱ and 4 cases of type Ⅲ fractures according to the Jacob classification, and 1 case of type Ⅰ and 27 cases of type Ⅱ fractures according to the Milch classification. The time from injury to surgery averaged (71.6±21.3) hours. The children were divided into 2 groups according to their reduction methods: an arthroscopic group of 16 cases treated by arthroscopically assisted reduction and K-wire fixation and an open reduction group of 12 cases treated by open reduction and K-wire fixation. The operation time, incision length, Kirschner wire removal time, Mayo elbow performance score (MEPS) and the incidence of lateral bony spur on the X ray at the last follow-up were compared between the 2 groups; the flexion-extension and carrying angle of the elbow were compared between the healthy side and the affected side within each group at the last follow-up.Results:There was no significant difference in the preoperative general data between the 2 groups, indicating comparability ( P>0.05). The 28 pediatric patients were followed up for (4.9±0.4) months after surgery. The incision length [(1.3±0.4) cm] and Kirschner wire removal time [(42.8±3.5) d] in the arthroscopic group were significantly shorter than those in the open reduction group [(4.8±0.5) cm and (95.5±16.4) d] ( P<0.05). There was no significant difference in the operation time between the 2 groups [(70.6±15.5) min versus (61.7±14.5) min] ( P>0.05). There was no significant difference in the flexion-extension or in the carrying angle between the healthy and affected sides within each group at the last follow-up ( P>0.05). There was no significant difference either in the MEPS score or in the incidence of lateral bony spur between the 2 groups at the last follow-up ( P>0.05). Follow-up revealed pin infection in 1 patient in the arthroscopic group, and exposure of Kirschner wire tail in 1 patient in the open reduction group. Conclusions:In the treatment of humeral lateral condylar fractures, arthroscopically assisted reduction and Kirschner wire fixation can allow for debridement of the fracture ends in a minimally invasive way, visual fracture evaluation and reduction. Compared with open reduction, arthroscopically assisted reduction can reduce operative trauma without significantly increasing operation time.

Objective:To analyze the feasibility and safety of laparoscopic radical resection of hilar cholangiocarcinoma (HCCA).Methods:Clinical data of 72 patients with HCCA undergoing radical resection at the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2019 to January 2022 were retrospectively analyzed, including 36 males and 36 females, aged 57(47, 63) years old. According to surgical approach, patients were divided into the laparoscopic group ( n=39) and open group ( n=33). The surgical safety, tumor radicality, postoperative recovery, complications and survival time were compared between the two groups. Results:Operative time was comparable between the two groups [(6.4±2.6) h vs. (6.3±2.4) h, P>0.05], while the intraoperative blood loss was lower in the laparoscopic group [(531.9±273.3) ml vs. (674.6±330.0) ml]. Data were also comparable between the two groups in terms of R0 resection rate [92.3% (36/39) vs. 93.9% (31/33)], the number of lymph node dissection (7.7±2.6 vs. 7.6±2.4), and the incidence of postoperative complications [20.5% (8/39) vs. 18.2% (6/33)] (all P>0.05). However, the laparoscopic group was superior to the open group in terms of postoperative analgesia time [(2.0±0.7)d vs. (2.8±0.9)d], postoperative resumption of feeding time [(1.6±0.5)d vs. (3.9±0.9)d], and postoperative hospitalization time [(8.6±1.5)d vs. (12.8±2.2)d] ( t=4.04, 8.23, 9.47, respectively, all P<0.001). Postoperative cumulative survival was comparable between the two groups ( χ2=0.50, P=0.480). Conclusion:Laparoscopic radical resection of HCCA has similar efficacy to open surgery and has the advantage of less invasiveness and enhanced recovery.

Objective:To explore the characteristics of biliary stricture after liver transplantation (LT) under SpyGlass peroral choledochoscopy and to investigate its treatment value for difficult stricture.Method:A total of 24 patients of biliary stricture after LT at the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University underwent SpyGlass examination from January 2019 to December 2020, 15.5 months (2-58 months) after surgery. The characteristics of different types of strictures and the selective guidewire placement results by SpyGlass were recorded and analyzed.Results:Of the 24 patients, 9 were anastomostic strictures (AS) and 15 others were non-anastomostic strictures (NAS). The main characteristic of 5 initial AS patients was scar constriction. Whether treated or not, all of the 15 NAS patients showed evident inflammatory hyperplasia in hilar bile duct under SpyGlass, 80% (12/15) of which were accompanied with intrahepatic biliary stones. The strictures disappeared with mild hyperplasia in 8 patients (4 AS and 4 NAS) whose biliary stents were extracted. Eleven patients (5 AS and 6 NAS) needed guidwire placement under SpyGlass, six (54.5%) of whom succeeded. The successful rate in AS patients was higher than that of NAS (4/5 VS 2/6).Conclusion:The main characteristic of AS is scar constriction and that of NAS is inflammatory hyperplasia. Selective guidewire placement can be achieved by SpyGlass peroral choledochoscopy with a satisfactory successful rate in the difficult AS.

Objective:To explore the effectiveness of medial malleolus screw epiphyseodesis for pediatric ankle valgus correction and calculate the correction rate, and analyse the influence factors on deformity correction and the risk factors of deformity recurrence after screw removal.Methods:Medical records and radiographs of patients undergoing screw hemiepiphyseodesis of the medial physis of the distal tibia for ankle valgus between Jan 2011 and Dec 2020, at a single pediatric orthopedic department were retrospectively analyzed. A total of 41 patients (49 ankles) were included in following study, including 28 male patients and 13 female patients; with 24 left sides and 25 right sides. Median age at surgery was 10.75 (4.5, 13.9) years, and median follow-up time was 27 (12, 64) months. According to the clinical diagnosis: hereditary multiple exostoses were 23 ankles, fibula hemimelia were 5 ankles, tibia hemimelia were 2 ankles, endochondromatosis were 5 ankles, neurofibromatosis were 5 ankles, traumatic fracture were 6 ankles, and fibrous dysplasia were 3 ankles. The lateral distal tibial angle (LDTA) was measured on ankle weight-bearing X-ray to evaluate the deformity correction. Malhotra classification was used to describe shortening of the fibula at the ankle.Results:Eventually effective correction were obtained in 36 ankles, with an overall effective rate of 73.5%. Screw type (partial-thread or full-thread), screw length (whether to the contralateral cortex), washer used, clinical diagnosis, and age are not independent risk factors for effective correction. Multiple linear regression analysis ( R 2=0.67) was applied for postoperative correction amplitude in effective correction cases, and the length of correction time ( P<0.001), clinical diagnosis ( P=0.013) and preoperative LDTA ( P=0.002) were significant predictive factors after adjusting for age differences. One-way ANOVA were used to compare data between different clinical diagnosis, showed a significant difference in the mean postoperative correction rate ( F=5.05, P=0.003). Conclusion:Medial malleolus screw epiphyseodesis is an effective and reliable method for the treatment of ankle valgus deformity in children; different clinical diagnosis can produce significant differences in the correction rate of ankle valgus deformity.

Objective To evaluate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-based comprehensive minimally invasive treatment for biliary anastomotic stenosis (BAS) after liver transplantation. Methods Clinical data of 60 BAS recipients after liver transplantation were retrospectively analyzed, 54 male and 6 female, aged (48±10) years. ERCP was initially carried out. If it succeeded, plastic or metallic stents were placed into the biliary tract. If it failed, percutaneous transhepatic cholangial drainage (PTCD) or single-operator cholangioscopy (SpyGlass) was adopted to pass through the stenosis. If all these procedures failed, magnetic anastomosis or other special methods were delivered. The incidence and treatment of BAS after liver transplantation were summarized. The efficacy, stent removal and recurrence were observed. Results The median time of incidence of BAS after liver transplantation was 8 (4, 13) months. Within postoperative 1 year, 1-2 years and over 2 years, 39, 16 and 5 recipients were diagnosed with BAS, respectively. All 60 BAS recipients after liver transplantation were successfully treated, including 56 cases initially receiving ERCP, and 41 completing BAS treatment, with a success rate of 73%. The failure of guide wire was the main cause of ERCP failure. The success rates of PTCD, SpyGlass and magnetic anastomosis were 5/9, 5/7 and 7/8, respectively. Two recipients were successfully treated by percutaneous choledochoscope-assisted blunt guide wire technique and stent placement in the biliary and duodenal fistula. After 3 (3, 4) cycles of ERCP and 13 (8, 18) months of stent indwelling, 38 recipients reached the stent removal criteria, including 25 plastic stents and 13 metallic stents. The indwelling time of plastic stents was longer than that of metallic stents (P < 0.05). Six cases suffered from stenosis recurrence at 12 (8, 33) months after stent removal, and the recurrence rate was 16%. Six patients were treated with ERCP, and 5 of them did not recur after the stents were successfully removed. Multivariate analysis showed that delayed diagnosis of stenosis and frequent ERCP before stent removal were the independent risk factors for BAS recurrence (both P < 0.05). Conclusions ERCP-based comprehensive minimally invasive treatment may improve the success rate of BAS treatment after liver transplantation and yield satisfactory long-term efficacy. Delayed diagnosis of BAS and high frequent ERCP required for stent removal are the independent risk factors for BAS recurrence.

Objective:To investigate the surgical treatment, clinical effect and revision reasons of children with proximal femoral fibrous dysplasia(FD).Methods:The clinical data of 26 children with polyostotic FD of proximal femur who underwent surgery at Department of Pediatric Orthopaedics, Beijing Jishuitan Hospital from June 2016 to June 2018 were retrospectively analyzed. There were 18 males and 8 females with a mean age of 9.2 years (range:5 to 16 years).One of them was McCune Albright syndrome. Fifteen cases were in first operation and 11 cases were in revision operation. The operation methods and results were reviewed,and the causes of revision were analyzed.Results:Among the 15 children who underwent the first operation,13 cases underwent osteotomy or fracture reduction and interlocking intramedullary nail(IMN) fixation;One case underwent valgus osteotomy and pediatric hip plate(PHP)internal fixation;One case underwent valgus osteotomy+lesion curettage+allogeneic bone graft+PHP fixation. Among the 11 children who underwent revision surgery,9 cases were treated with IMN fixation,1 case with PHP fixation,and 1 case with PHP fixation+allogeneic bone graft. The causes of revision included distal fixation failed in 6 cases,proximal fixation failed in 3 cases,plate fixation failed in 5 cases,and recurrence occurred after curettage and artificial bone graft in 2 cases. Patients were followed up for 1.4 years(range:1.0 to 3.5 years) after recent operation. The osteotomy or fracture healed well with good deformity correction. Postoperative complications included infection in 1 case and local bone partial resorption in 1 case.Conclusions:Osteotomy combined with rigid internal fixation is an effective surgical treatment for fibrous dysplasia of proximal femur in children. Internal fixation should cover the whole length of lesion. Intramedullary nail is the most common choice. Because the growth of height and the progress of the disease itself,this deformity is prone to recur in children,needing closely follow-up after operation.

Objective:To identify whether splenectomy for treatment of hypersplenism has any impact on development of hepatocellular carcinoma(HCC) among patients with liver cirrhosis and hepatitis.Methods:Patients who underwent splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension between January 2008 and December 2012 were included from seven hospitals in China, whereas patients receiving medication treatments for liver cirrhosis and portal hypertension (non-splenectomy) at the same time period among the seven hospitals were included as control groups. In the splenectomy group, all the patients received open or laparoscopic splenectomy with or without pericardial devascularization. In contrast, patients in the control group were treated conservatively for liver cirrhosis and portal hypertension with medicines (non-splenectomy) with no invasive treatments, such as transjugular intrahepatic portosystemic shunt, splenectomy or liver transplantation before HCC development. All the patients were routinely screened for HCC development with abdominal ultrasound, liver function and alpha-fetoprotein every 3 to 6 months. To minimize the selection bias, propensity score matching (PSM) was used to match the baseline data of patients among splenectomy versus non-splenectomy groups. The Kaplan-Meier method was used to calculate the overall survival and cumulative incidence of HCC development, and the Log-rank test was used to compare the survival or disease rates between the two groups. Univariate and Cox proportional hazard regression models were used to analyze the potential risk factors associated with development of HCC.Results:A total of 871 patients with liver cirrhosis and hypertension were included synchronously from 7 tertiary hospitals. Among them, 407 patients had a history of splenectomy for hypersplenism (splenectomy group), whereas 464 patients who received medical treatment but not splenectomy (non-splenectomy group). After PSM,233 pairs of patients were matched in adjusted cohorts. The cumulative incidence of HCC diagnosis at 1,3,5 and 7 years were 1%,6%,7% and 15% in the splenectomy group, which was significantly lower than 1%,6%,15% and 23% in the non-splenectomy group ( HR=0.53,95% CI:0.31 to 0.91, P=0.028). On multivariable analysis, splenectomy was independently associated with decreased risk of HCC development ( HR=0.55, 95%CI:0.32 to 0.95, P=0.031). The cumulative survival rates of all the patients at 1,3,5,and 7 years were 100%,97%,91%,86% in the splenectomy group,which was similar with that of 100%,97%,92%,84% in the non-splenectomy group ( P=0.899). In total,49 patients (12.0%) among splenectomy group and 75 patients (16.2%) in non-splenectomy group developed HCC during the study period, respectively. Compared to patients in non-splenectomy group, patients who developed HCC after splenectomy were unlikely to receive curative resection for HCC (12.2% vs. 33.3%,χ2=7.029, P=0.008). Conclusion:Splenectomy for treatment of hypersplenism may decrease the risk of HCC development among patients with liver cirrhosis and portal hypertension.

Objective:To investigate the surgical treatment, clinical effect and revision reasons of children with proximal femoral fibrous dysplasia(FD).Methods:The clinical data of 26 children with polyostotic FD of proximal femur who underwent surgery at Department of Pediatric Orthopaedics, Beijing Jishuitan Hospital from June 2016 to June 2018 were retrospectively analyzed. There were 18 males and 8 females with a mean age of 9.2 years (range:5 to 16 years).One of them was McCune Albright syndrome. Fifteen cases were in first operation and 11 cases were in revision operation. The operation methods and results were reviewed,and the causes of revision were analyzed.Results:Among the 15 children who underwent the first operation,13 cases underwent osteotomy or fracture reduction and interlocking intramedullary nail(IMN) fixation;One case underwent valgus osteotomy and pediatric hip plate(PHP)internal fixation;One case underwent valgus osteotomy+lesion curettage+allogeneic bone graft+PHP fixation. Among the 11 children who underwent revision surgery,9 cases were treated with IMN fixation,1 case with PHP fixation,and 1 case with PHP fixation+allogeneic bone graft. The causes of revision included distal fixation failed in 6 cases,proximal fixation failed in 3 cases,plate fixation failed in 5 cases,and recurrence occurred after curettage and artificial bone graft in 2 cases. Patients were followed up for 1.4 years(range:1.0 to 3.5 years) after recent operation. The osteotomy or fracture healed well with good deformity correction. Postoperative complications included infection in 1 case and local bone partial resorption in 1 case.Conclusions:Osteotomy combined with rigid internal fixation is an effective surgical treatment for fibrous dysplasia of proximal femur in children. Internal fixation should cover the whole length of lesion. Intramedullary nail is the most common choice. Because the growth of height and the progress of the disease itself,this deformity is prone to recur in children,needing closely follow-up after operation.