Objective To introduce the diagnosis and treatment of the missed adolescent humeral capitellar fracture malunion.Methods Retrospectively analyzed 6 cases with missed adolescent capitellar fracture malunion treated by the author from Jul.2010 to Mar.2015 and their follow-up results.Among them, 5 were male and 1 was female.The average age is (14.33 ± 1.86) years, 4 were left-side and 2 were right.Results The average time from injury to the operation is (8.67 ± 3.88) months.Before operation, the average elbow flexion was (91.67° ±7.53°), the average elbow extension was (40.0° ± 8.94°), the average range of flexion and extension activities was (51.67° ±11.69°).Forearm rotation was not limited.Average M EPS score was (80.83 ± 4.92).Released the elbow in 3 cases with additional medial incision.The fragment was fixed by HCS.The lateral collateral ligament was repaired by suture anchors (2 cases) or by trans-os suture(4 cases).Three cases were fixed by DJDⅡ Stryker hinged external fixatorswhich were removed after 8 weeks.The average postoperative follow-up time was (39.33 ± 20.42) months.Postoperatively, the average elbow flexion was (138.33° ±7.528°), the average elbow extension was (5.0° ± 4.472°), the average range of flexion and extension activities was (133.33° ±9.832°).Forearm rotation is not limited.The average MEPS score was 100.Conclusions The adolescent capitellar fracture is prone to be missed and cause malunion, elbow stiffness or other complications which is very difficult to deal with.By complete elbow release, osteotomy and internal fixation, the lateral collateral ligament repair, and hinged external fixator if necessary, the final elbow function can be improved.

Objective To compare the posterior midline approach and the combined lateral and medial approach usually used in elbow arthrolysis. Methods From January to December in 2009, 41 cases of elbow stiffness were treated and fully followed up by the same team in our hospital. The posterior midline approach was used in 21 cases, 15 males and 6 females, with an average age of 35.8 years (16 to 70 years). In this group, the total flexion-extension arc was ＜ 30° in 12 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Eight cases had ulnar symptoms. The combined lateral and medial approach was applied in 20 cases, 8 males and 12 females, with an average age of 38. 8 years (16 to 51 years). In this group, the total flexion-extension arc was ＜ 30° in 11 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Five cases had ulnar symptoms. Results The 41 cases were followed up for 4 to 15 months (average, 7.9 months). In the posterior approach group, the mean preoperative flexion-extension ROM (27.6°± 25.7°) was improved to the postoperative 111.4°± 25.6°, the mean preoperative rotation ROM ( 152.9°± 46. 9°) to the postoperative 168.1°± 19. 1°, and the mean preoperative MEPS score (65.5 ± 11.5) to the postoperative 95.7 ±6.4. In the combined approach group, the mean flexion-extension ROM was improved from 35.5°± 25.0° preoperatively to 116. 5°± 19.1° postoperatively, the mean rotation ROM from 138.0°±55.7° preoperatively to 148.5°± 45.6° postoperatively, and the mean MEPS score from 66. 3 ± 13.0 preoperatively to 97.3 ± 7.0 postoperatively. The differences were statistically significant between preoperation and postoperation in both groups ( P ＜ 0. 05), but not statistically different between the 2 groups in the preoperative or postoperative values ( P ＞ 0. 05). In the posterior approach group, 5 patients had huge hematoma, 3 had wound dehiscence at the posterior elbow, and the others all had mild hematoma. But in the combined approach group, no wound complications were noted. Conclusion The combined lateral and medial approach should be used as far as possible in the elbow arthrolysis to avoid the likely complications when the posterior midline approach is used.

Objective:To introduce the surgical techniques and treating results of the old “terrible triad”of the elbow.Methods:A retrospective analysis of 1 1 cases of old “terrible triad”of the elbow treated by the author from March 2009 to February 2014 were performed,with 9 males and 2 females;mean age was (31.82 ±8.66)years (17-45 years).The average time after injury was (6.36 ±2.50) weeks (4-12 weeks),with 7 cases on the left and 4 right.The combined injury included 2 cases with distal radius fractures,1 with ankle fractures,fractures of the distal radius and the head injury (minor epidural hematoma,no surgery),and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation,and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures:2 cases were type Ⅰ,5 were type Ⅱ,4 were type Ⅲ. Classification of the coronoid process:Regan &Morrey:1 was type Ⅰ,10 were type Ⅱ;according to O’Driscoll classification,all the fractures were tip fracture,one was the first subtype,10 were the second subtype.The elbow were released,the coronoid process were fixed by lasso suture combined with Kirschner wires.Radial head fractures were resected in 1 case,and replaced in 1 case,3 cases with no
treatment,6 cases with osteotomy and 3.0 mm headless compression screw (HCS)fixation.The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicon-dyles,No.2 Ethibon was used in 2 cases through bone holes,and suture anchorsin the other 9 cases.All the patients were fixed by Stryker DJDⅡhinged external fixator to protect the bone and soft tissue.Re-sults:The average follow-up time was (38.36 ±21.92)months (19-77 months).All the patients had no obvious pain,instability and ulnar nerve symptoms in the last follow-up.The average elbow flexion was 134.09°±12.41°(100°-140°),average extension was -15.91°±14.46°(-40°-0°),range of flexion and extension was 118.18°±23.80°(70°-140°).Average pronation was 70.91°±26.63° (20°-90°),supination was 70.91°±26.63°(20°-100°).The range of motion (ROM)of forearm rotation was 150.91°±43.00°(40°-180°).Average Mayo elbow performance score (MEPS)was 96.36 ±5.04 (85 -100).X-ray showed that no degenerative changes.Five patients had heterotopic os-sifications,according to Hastings and Graham grading:1 case was grade Ⅰ,3 cases were grade ⅡA, 1 case was ⅡB.Conclusion:The old “terrible triad”of elbow with no operative history is difficult to treat.The elbow’s functions and stabilization can be recovered by thorough elbow release,repair of coro-noid process and anterior capsule,radial head fractures,lateral collateral ligament and the common ex-tensor tendon insertion,combined with hinged external fixator.Joint stiffness and heterotopic ossification are common complications.

Objective To investigate the causes and treatment of postoperative nonunion of the intercondylar fracture of humerus. Methods Twenty-six patients suffering from postoperative nonunion of the intercondylar fracture of humerus, 14 males and 12 females, were analyzed in this study. Four cases underwent total elbow arthroplasty(TEA), and the other 22 received refixation and autografting, 4 of whom healed only after 2 operations. The causes of postoperative nonunion were analyzed. Results This group had 28 unstable fixations, 16 postoperative plaster external fixations and 21 significant bone defects. On average, they had a follow-up of 11.4 months (4 to 41 months). In the 4 TEA cases, the average flexion was 112° (90° to 130°) and the extension 18° (0 to 35°). Their average MEPS score was 85(80 to 90 points). The other 22 cases achieved bone union ultimately, with an average flexion of 97.7°± 10. 0° (70° to 110°),an average extension of 30. 9°± 12.8°(0 to 60°), and an average motion arc of 66. 8°± 10. 5° (50° to 90°).Their average MEPS score was 81.4 ± 11. 1 points (65 to 100 points). Conclusions Inadequate internal fixation, elbow stiffness due to plaster external fixation and significant bone defects are the main causes for postoperative nonunion of the intercondylar fracture of humerus. 90-90 plate fixation and parallel plate fixation, together with constructive bone grafting, can achieve bone union in most cases, though the motion arc of the elbow is still unsatisfactory.

Objective:To discuss the effect of single low dose local radiotherapy and indomethacin to-gether in the prevention of recurrence of ectopic ossification around the elbow after resection.Methods:From Jun.2009 to Dec.2011,we performed excision of ectopic ossification around the elbow in 78 stiff elbows.For each case,we used both medial and lateral approaches,and we performed both anterior and posterior capsulectomies and removal of ectopic ossification.In the lateral approach,we started proximal-ly,the lateral supracondylar ridge of the humerus was exposed from the interval between extensor carpi radialis longus (ECRL)and triceps,and then distally passed the interval between ECRL and extensor carpi radialis brevis (ECRB).With the medial approach,after releasing the ulnar nerve,the pronator teres muscle origin was reflected from the medial epicondyle,and then the common flexor-pronator tendon was split longitudinally distally and the brachalis and the anterior portion of the flexor-pronator group were dissected off the anterior humerus.If there was forearm rotation dysfunction,we used extensive lateral ap-proach,the anconeus muscle was reflected from the ulna and the scar tissue and ectopic ossification around the proximal radioulnar joint were resected.The important structures,such as the lateral ulnar collateral ligament (LUCL)and the anterior part of the medial collateral ligament (AMCL),should be carefully protected,because they were important for the elbow stability.Anterior transposition of the ulnar nerve depended on the patients’condition.We performed low dose radiotherapy 4 hours before opera-tion,and we used indomethacin for 6 weeks after operation.In these patients,there were 46 males and 32 females,whose age averaged (35.8 ±7.9)years (16 -65 years).According to Hastings-Graham classification,there were 56 ⅡA,5 ⅡB,6 ⅡC and 1 1 Ⅲ before operation.Results:We followed up these patients for 26 months with an average of 24-36 months,all the patients improved their elbow func-tion,and no recurrence of ectopic ossification appeared except for 1 patient.For this patient,his elbow function was excellent,and according to Hastings-Graham classification,his ectopic ossification was of typeⅠ.Conclusion:Single low dose local radiotherapy and indomethacin together are effective in the prevention of recurrence of ectopic ossification around the elbow after excision.

[Objective] To study the inhibition effect of berberine on cell proliferation in acute T lymphocytic leukemia cell line Molt-4,and its mechanisms.[Methods] The logarithmic growing cell lines were incubated with 0,10,100 μg/ml berberine for various hours.The apoptosis induced by berberine was detected by flow cytometry,eletrophoresis and microscopy.The protein pro-Caspase-3 and p65 were determined by Western bolt assay.[Results]Treated with berberine,Molt-4 cells were found with apoptosis bodies by microscopy.By flow cytometry,it was found that number of G2/M cells was increased and number of S cells was reduced.Necrosis band was found in DNA ladder electrophoresis.The expression of pro Caspase-3 was activated partly and p65 was down-regulated in Molt-4 cells treated with berberine.[Conclusion]Berberine can induce Molt-4 cells apoptosis, and NF-κB、Caspase-3 have been shown to regulate the apoptosis programme.

Objective To discuss causes and treatment outcomes of radial nerve injury related to hinged external fixators applied to the elbow,enhance understanding of the injury and thereby reduce its clinical incidence.Methods The study involved five cases who experienced radial nerve injury in the wake of application of unilateral hinged external fixators to the elbow.Exploration and neurolysis was perfomed at 3-12 weeks after injury since no signs of nerve recovery.Afterwards,follow-up was made for all cases.Results Causes of radial nerve injury were as follows:proximal humerus Schanz screws stretched and compressed radial nerve by tethering soft tissues into cicatricial bands in two cases; distal humerus Schanz screws compressed radial nerve by tethering soft tissues adjacent to radial nerve to cicatricial bands in one case; distal humerus Schanz screws compressed radial nerve in motion of the elbow by tethering thickened intermuscular septa and further forcing the enlargement of muscle force in two cases.Forces of muscles supplied by radius nerve reached fourth or fifth rank at postoperative one-year follow-up.Conclusions Radial nerve is vulnerable in the application of unilateral hinged external fixators to the elbow due to its special path and relative stability.Accordingly,injury to radial nerve can be reduced and even avoided by knowing its anatomy features and standardizing the operation in use of external fixators.Exploration and treatment immediately after the confirmation of radial nerve injury can achieve good prognosis.

Objective To compare the effect of coronoid fixation combined with lateral collateral ligament repair versus hinged external fixator in treatment of elbow varus posteromedial rotational instability.Methods This retrospective cohort research included 34 patients with elbow varus posteromedial rotational instability operated between January 2011 and June 2015.All patients had coronoid process fractures of O'Driscoll type Ⅱ[(six with subtype 1,24 with subtype 2 and four with subtype 3).Fifteen of the 34 patients were operated by coronoid fixation combined with lateral collateral ligament repair (Group A) and other 19 patients were operated by coronoid fixation combined with placing hinged external fixator (Group B).Interval between injury and operation,operation time and blood loss were recorded.At final follow-up,elbow range of motion,Mayo elbow performance score (MEPS) and Hastings and Graham heterotopic ossification classification were measured.Results There were no significant differences in the interval between injury and operation,operation time and blood loss between the two groups (P ＞0.05).Median period of follow-up was 30 months in Group A and 40 months in Group B.Last follow-up showed flexion of the affected elbow in Group B [145° (135°-150°)] was better than that in Group A [140° (130°-145°)] (P ＜ 0.05),while between-group differences were insignificant in elbow extension,elbow extension-flexion,forearm pronation-supination and heterotopic ossification classification (P ＞ 0.05).MEPS in Group A scored 100 in 10 patients,90 in three,85 in one and 70 in one;MEPS in Group B scored 100 in 13 patients,90 in one,85 in four and 80 in one.There was no significant difference in MEPS between the two groups (P ＞ 0.05).Conclusion For treating elbow varus posteromedial rotational instability,either lateral collateral ligament repair or hinged external fixation after anatomic reduction and coronoid fixation can achieve good results.

Objective To investigate the clinical outcomes of terrible triad of the elbow treated with single lateral incision versus combined lateral and medial incisions.Methods This retrospective cohort research involved 57 patients with terrible triad of the elbow operated between July 2010 and June 2013.According to the surgical approaches,the patients were assigned to single lateral incision (Group A,n =32) and combined lateral and medial incisions (Group B,n =25).Group A consisted of 21 males and 11 females,with a mean age of (40.2 ± 3.3) years.Group B consisted of 18 males and seven females,with a mean age of (39.1 ± 2.6) years.Operation time,blood loss,postoperative complications,elbow range of motion,Mayo elbow performance score (MEPS) and Hastings and Graham heterotopic ossification classification were compared between groups.Results There were no significant differences in operation time and blood loss between Group A and B (P ＞ 0.05).Incidence of ulnar nerve injury and strength decrease were higher in Group A than Group B (P＜0.05).Mter a mean follow-up of 25.9 months,elbow extension-flexion and forearm pronation-supination in Group A [(123.4 ± 6.5) ~,(167.5 ± 6.0) °] were better than those in group B [(84.9 ± 27.2) °,(136.5 ± 8.5)°] (P ＜ 0.01),and MEPS in Group A [(95.8 ± 1.2) points] was also better than that in Group B [(84.9 ± 3.1) points] (P ＜ 0.01).Heterotopic ossification was more serious in Group B than Group A (P ＜ 0.01).Conclusion Single lateral incision is associated with better function and lower rate of heterotopic ossification than combined lateral and medial incisions in treating terrible triad of the elbow.

Objective To report the early surgical outcomes of treating elbow varus posteromedialrotational instability (EVPRI),a pattern of traumatic elbow instability which has been recently described but incompletely understood. MethodsFrom December 2009 to April 2011,11 male patients with an EVPRI pattern were surgically treated in our hospital.Their average age was 33.8(from 22 to 40) years.They had 4 left and 7 right elbows affected.All had tenderness at the medial and lateral sides of the elbow and varus angulation of the elbow without dislocation.Their preoperative stress view X-rays and CT scans showed widened humeroradial joint space and fracture of the anteromedial facet of the coronoid process.We confirmed the diagnosis by applying yarus,pronated and axial stresses onto the forearm to evoke elbow dislocation,under fluoroscopy after anesthesia.In the initial operative treatment,the coronoid was repaired with a plate and K-wires applied to the medial surface of the coronoid,and a hinged external fixator was applied at the lateral side without repairing the lateral collateral ligament.Early rehabilitation was encouraged. Results All were followed up for an average of 14.4 (from 6 to 26) months.Each obtained an excellent result according to the Mayo Elbow Performance Index and recovered excellent elbow function.The average flexion was 137.8° ± 4.4° (from 130°to 140°), average extension 5.6°±7.3° (from 0 to 20°), average range of extension-flexion 132.2°±9.7°(from 120° to 140°),average pronation 87.8°±6.7°(from 70° to 90°),average supination 88.9° ± 3.3° (from 80° to 90°),and average range of rotation 176.7° ± 10.0° (from 150° to 180°).No complications such as varus subluxation of the elbow,infection and arthrosis occurred in this group. Conclusions Since EVPRI is a distinct type of elbow fracture-dislocation that must be recognized and adequately treated to restore good elbow function,inadequate or conservative treatment may cause subluxation,arthrosis or a poor outcome.Surgical treatment can achieve an excellent early outcome and avoid severe complications.