Enhanced recovery after surgery (ERAS) has been proven to reduce surgical injuries, promote recovery, and improve postoperative outcomes in different types of surgeries. A core principle of ERAS is to provide programmatic evidence-based perioperative interventions. An international multidisciplinary expert group provided a statement on clinical practice in each thematic area of ERAS by obtaining a list of potential ERAS elements, and reviewing literature. The version 2024 of "Perioperative care in cardiac surgery: A joint consensus statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and the Society of Thoracic Surgeons (STS)" is developed from the version 2019 of "Guidelines for perioperative care in cardiac surgery: Enhanced Recovery after Surgery Society recommendations". The consensus statement group was composed of multidisciplinary experts such as cardiac surgeons, anesthesiologists, intensive care physicians, and nurses, based on personal ERAS knowledge and experience. This article interprets the changes and new statements in the 2024 consensus, which can provide a foundation for the best perioperative practices for adult cardiac surgery patients.

【Objective】 Until now, most clinical and basic studies on Kashin-Beck disease (KBD) have focused on the visible deformed extremities, and there is a lack of reports concerning their spinal features, especially for the atlantoaxial joint. The purpose of this study was to determine the prevalence and radiographic features of atlantoaxial dislocation (AAD) in KBD in adult patients. 【Methods】 The prevalence and radiographic features of AAD were determined by the basic information collected, clinical symptoms, and lateral and dynamic plain radiography in 111 KBD patient and 120 non-KBD participants. In the KBD group, AAD and non-AAD patients were compared in age, gender, height, weight, BMI, smoking history, chronic history, disease duration and grade of disease so as to identify the related factors of the occurrence of AAD. 【Results】 Symptoms at the neck or neurological manifestations were present in 17.5% (21/120) in the non-KBD population and 39.6% (44/111) patients with KBD. AAD case was not detected in the non-KBD population, while in 16.2% (18/111) of KBD patients in the endemic area. The prevalence was higher in the KBD patients than in the non-KBD population, and there was a significant difference in the detection rate of AAD between the two groups (χ²=21.10, P<0.001). Plain radiography demonstrated that there were 10 (55.6%) cases with separation of the odontoid process and the other 8 (44.4%) cases with hypoplasia of odontoid process. Anterior AAD was noted in 12 (66.7%) patients and posterior AAD in 6 (33.3%) cases based on the displacement direction, while 16 (88.9%) cases were reducible and 2 (11.1%) cases were irreducible on the basis of the reducibility. Comparing the 93 patients with non-AAD KBD patients and 18 patients with AAD patients, there was no significant difference in age, sex, BMI, history of medical disease or smoking (all P>0.05). There were significant differences in height, weight, disease duration and grade of disease between AAD and non-AAD patients (all P<0.05). 【Conclusion】 KBD can cause the occurrence of atlantoaxial dislocation by inducing separation or hypoplasia of the odontoid process. This research may provide clinical evidence for screening, earlier prevention and treatment of atlantoaxial dislocation in adult KBD patients.

Objective:To investigate the characteristics and significance of insulin-like growth factor 1(IGF- 1) and insulin-like growth factor binding protein 2 (IGFBP2) expressions in ankle cartilage of patients with Kashin-Beck disease (KBD).Methods:In this case-control study, 10 KBD patients who were hospitalized in the Department of Orthopedics of Shaanxi Provincial People's Hospital from January 2010 to December 2016 were selected as KBD group, and 10 patients with ankle fracture caused by trauma but without talus injury during the same period were selected as control group, the cartilage tissues of the two groups were collected. IGF-1, IGFBP2 positive cells, the mRNA and protein expressions of IGF-1, IGFBP2 in the cartilage tissues were detected by immunohistochemistry, real-time fluorescent quantitative PCR and Western blotting, respectively. According to the expressions of IGF-1 and IGFBP2 in ankle cartilage of KBD patients, a patient with amputation caused by trauma was selected in Shaanxi Provincial People's Hospital, and ankle joint cartilage was taken to prepare chondrocytes for in vitro cell verification experiments. The chondrocyte were divided into control group (0 ng/ml T-2 toxin), T-2 treatment group (20 ng/ml T-2 toxin) and T-2+ IGFBP2 silenced group (20 ng/ml T-2 toxin+ 50 nmol/L IGFBP2 siRNA), the MTT method and dimethyl methylene blue staining were used to detect the activity of chondrocyte and the secretion of sulfated glycosaminoglycan (sGAG). Results:In the control group and the KBD group, the number of IGF-1[(47.26 ± 8.97), (68.15 ± 7.42) cells] and IGFBP2 positive cells [(27.56 ± 5.40), (71.85 ± 7.62) cells] in the cartilage tissues were significantly different ( t = 4.487, 9.402, P < 0.01). Compared with the control group, the IGF-1, IGFBP2 mRNA and protein expression levels in KBD group were significantly higher, the differences were significantly different ( t = 3.340, 20.700, 4.684, 8.699, P < 0.05 or < 0.01). In cell experiment, the chondrocyte activitives and sGAG contents of the control group, T-2 treatment group, and T-2+ IGFBP2 silenced group were significantly different ( F = 226.70, 80.66, P < 0.01); among them, the cell activitives and sGAG contents of the T-2 treatment group and T-2+ IGFBP2 silenced group were lower than those of control group ( P < 0.05), and the T-2+ IGFBP2 silenced group were higher than those of the T-2 treatment group ( P < 0.05). Conclusions:The expressions of IGF-1 and IGFBP2 in the ankle cartilage of KBD patients are significantly higher. Silencing IGFBP2 gene can reduce the inhibitory effect of T-2 toxin on chondrocyte activity and the secretion of sGAG.

Objective    To explore the association between preoperative, perioperative parameters, especially estimated glomerular filtration rate (eGFR) and postoperative atrial fibrillation (POAF) after modified extended Morrow procedure. Methods    A total of 300 hypertrophic obstructive cardiomyopathy (HOCM) patients who underwent modified extended Morrow procedure in our hospital from January 2012 to March 2018 were collected. There were 197 (65.67%) males and 103 (34.33%) females with an average age of 43.54±13.81 years. Heart rhythm was continuously monitored during hospitalization. The patients were divided into a POAF group (n=68) and a non-POAF group (n=232). The general data, perioperative parameters and echocardiographic results were collected by consulting medical records for statistical analysis. Univariate and multivariate logistic regression models were used to analyze the risk factors for POAF. Results    Overall incidence of POAF during hospitalization was 22.67% (68/300). Compared with patients without POAF, patients with POAF were older, had higher incidence of chest pain and syncope, lower level of preoperative eGFR, higher body mass index and heart function classification (NYHA), larger preoperative left atrial diameter and left ventricular end diastolic diameter, and longer ventilator-assisted time, ICU stay and postoperative hospital stay. Age, heart function classification (NYHA)≥Ⅲ, hypertension, syncope history and eGFR were independent risk factors for POAF. Receiver operating characteristic curve analysis showed that the area under the curve of eGFR was 0.731 (95%CI 0.677-0.780, P<0.001), and the sensitivity and specificity were 82.4% and 57.8%, respectively. Conclusion    Increased age, high preoperative heart function classification (NYHA), hypertension, preoperative syncope history and decreased eGFR are independent risk factors for POAF in HOCM patients who underwent surgical septal myectomy. Preoperative decreased eGFR can moderately predict the occurrence of POAF after modified extended Morrow procedure.

Objective:To detect the expression levels of interleukin (IL)-1β, insulin-like growth factors (IGF)-1 in serum and synovial fluid of patients with Kaschin-Beck disease (KBD) and osteoarthritis (OA) and analyze the relationship between IL-1β, IGF-1 levels and visual analogue scale (VAS) score.Methods:From January 2010 to December 2016, 60 patients visited the department of orthopedics of Shaanxi Provincial People's Hospital were selected, included 20 patients with KBD (arthroscopic debridement of ankle), 20 patients with OA (arthroscopic debridement of ankle), and 20 patients with ankle fracture (no talus injury) as control group. The peripheral blood and synovial fluid samples from the patients were collected. Enzyme-linked immunosorbent assay was used to detect the expression levels of IL-1β, IGF-1 in serum and synovial fluid. In each group, VAS score was calculated pre-operative and post-operative at 3, 7, 14 and 28 d. The relationship between IL-1β, IGF-1 levels and VAS score was evaluated by correlation analysis.Results:Synovial fluid IL-1β and IGF-1 levels in the KBD and OA groups were (67.32 ± 6.22), (56.46 ± 5.43) and (24.36 ± 6.22), (21.45 ± 4.35) pg/ml, respectively, which were higher than those in the control group [(27.01 ± 3.15), (10.21 ± 2.50) pg/ml, P < 0.05]. Meanwhile, serum IL-1β and IGF-1 levels in the KBD and OA groups were higher than those in the control group ( P < 0.05). Pearson correlation analysis showed that the expression levels of IL-1β and IGF-1 in serum pre-operative and post-operative at 3, 7, 14 and 28 d were positively correlated with VAS score in KBD and OA groups, respectively ( r = 0.427, 0.502, 0.562, 0.628, P < 0.05). Conclusion:The levels of IL-1β and IGF-1 in synovial fluid from ankle joints and serum are significantly increased in KBD group and OA group, and the levels of IL-1β and IGF-1 in serum are positively correlated with VAS score, respectively.

Objective    To evaluate the clinical outcomes of  pulmonary valve replacement (PVR) in patients with tetralogy of Fallot (TOF) after re-PVR surgery. Methods    PubMed, EMbase, the Cochrane Controlled Trials Register databases, CNKI, CBM disc and VIP datebases were searched, and study eligibility and data abstraction were determined independently and in duplicate. Literature searches from database establishment to December 2018. The heterogeneity and data were analyzed by the software of Stata 11.0. Results    Of 4 831 studies identified, 26 studies met eligibility criteria, and invovled with a total of 3 613 patients. The combined 30-day mortality for PVR was 2.2% (95% CI 1.5%-3.1%) and follow-up mortality was 3.4% (95% CI 2.4%-4.9%), re-PVR rate was 6.8% (95% CI 5.1%-9.2%), and the rate of intervention was 11.4% (95% CI 8.0%-16.4%). Subgroup analysis showed that the patient's age range may be a heterogeneous source of mortality during the follow-up period, and there was no statistical heterogeneity for adult patients (P=0.63, I2=0%), with a lower incidence than those including adolescents patients. The type of valve was likely to be a source of retrospective PVR. There was no statistical heterogeneity in bioprosthetic valves and allograft lobes (P=0.24, I2=25%). And the incidence of re-PVR was lower than that of the mechanical valve patients. Heart function classification (NYHA) of patients with TOF after PVR was statistically improved (P<0.05). Electrocardiogram QRS change was not statistically differently (P>0.05). Postoperative MRI findings showed a decrease in RVEDV, an increase in RVEF, a decrease in RV/LV ratio, and a decrease in pulmonary valve (all P<0.05). Funnel map monitoring, Begg test and Egger's test both indicated that there was no publication bias. Conclusions    According to the results of the analysis, PVR after TOF surgery is a more mature surgery, the clinical effect was significant, with lower early and long-term mortality. The long-term mortality rate of adolescent patients undergoing PVR is higher than that of adult patients. Long-term outocme of re-PVR or re-intervention is still the main problem affecting the effect of the operation. Indications for surgery and choice of valve need further investigation.

Objective To evaluate the quality of life of patients with Kaschin-Beck disease (KBD)receiving total knee arthroplasty (TKA) before and after the operation.Methods Clinical efficacy of 25 patients with KBD who underwent TKA in Department of Orthopaedics,Shaanxi Provincial People's Hospital from January 2015 to January 2017 was prospectively analyzed.A questionnaire survey on KBD quality of life (KBDQOL)was carried out to evaluate the quality of life of the patients before,6 months and 1 year after the surgery.Results The scores of physical function,activity limit,social support,mental status and total health scores of KBDQOL in 6 months after the surgery (30.60 ± 3.73,23.24 ± 2.03,15.16 ± 1.62,18.92 ± 2.89,12.80 ± 2.57) and 1 year after the surgery (32.00 ± 3.19,23.76 ± 1.59,15.60 ± 1.29,20.16 ± 2.67,17.28 ± 3.88) were significantly higher than those of before the surgery (18.84 ± 4.94,21.04 ± 2.72,12.80 ± 2.06,13.68 ± 3.42,7.92 ± 1.93,P ＜ 0.05).However,there was no significant difference in economic scores before,6 months and 1 year after the surgery (10.68 ± 2.98,10.60 ± 2.78,10.48 ± 2.80,P ＞ 0.05).Conclusions The quality of life after TKA in patients with KBD severe knee osteoarthritis is significantly better than that before the surgery.The KBDQOL questionnaire is an appropriate tool for evaluating the quality of life in KBD patients.

Objective To study the therapeutic effects of arthroscopic debridement combined with sodium hyaluronate injection in treatment of Kashin-Beck disease with ankle arthritis.Methods Using prospective study,Kashin-Beck disease patients with ankle arthritis,who had underwent arthroscopic debridement combined with sodium hyaluronate injection,were selected as study subjects.X-ray stratification was performed based on Kellgren-Lawrence grading method,grade 1,2,3 were studied,if there were fewer patients at grade 1,then merge with grade 2.Visual analogue scale (VAS),anterior and posterior ankle activity and ankle hindfoot score were used to evaluate the effects before and 3,6,12 months after the treatment.Results Totally 33 patients were collected,VAS scores (6.9 ± 0.2,2.9 ± 0.2,2.1 ± 0.1,1.9 ± 0.1),anterior and posterior ankle activities (20.9 ± 0.6,31.5 ± 0.6,32.1 ± 0.6,34.1 ± 0.4),and ankle hindfoot scores (51.3 ± 0.5,70.8 ± 1.1,76.0 ± 0.9,77.0 ± 0.9) before and 3,6,12 months after the treatment,were compared,and the differences were statistically significant (F =267.47,703.09,756.49,P ＜ 0.01).VAS scores (7.0 ± 0.2,2.8 ± 0.2,1.7 ± 0.1,1.7 ± 0.1;7.0 ± 0.3,3.2 ± 0.3,2.8 ± 0.2,2.2 ± 0.2),anterior and posterior ankle activities (22.4 ± 0.7,32.5 ± 0.6,33.1 ± 0.6,51.3 ± 0.5;18.1 ± 0.9,29.6 ± 1.0,30.2 ± 1.0,31.4 ± 0.9),and ankle hindfoot scores (51.6 ± 0.9,70.9 ± 0.5,77.7 ± 0.9,79.1 ± 1.0;50.6 ± 0.5,65.5 ± 1.8,72.8 ± 1.4,72.9 ± 1.4) in grade 1 + grade 2,and grade 3 patients before and 3,6,12 months after the treatment,were compared,and the differences were statistically significant (F =244.80,64.04;379.94,498.83;1 393.07,159.70,P ＜ 0.01).Compared with those before the treatment,VAS scores of all,grade 1 + grade 2,and grade 3 patients in 3,6,12 months after the treatment significantly decreased,anterior and posterior ankle activities and ankle hindfoot scores significantly increased (P ＜ 0.05).Conclusion Arthroscopic debridement combined with sodium hyaluronate injection is effective in the treatment of Kashin-Beck with disease ankle arthritis.

OBJECTIVETo evaluate the effect of demineralized cancellous bone (DCB) seeded with allogeneic chondrocytes for repairing articular osteochondral defects in rabbits.

METHODSArticular chondrocytes were isolated from a 1-month-old male New Zealand rabbit for primary culture. The passage 1 chondrocytes were seeded onto prepared rabbit DCB scaffold to construct tissue-engineered cartilage and cultured for 2 weeks. Full-thickness articular osteochondral defects (3 mm both in diameter and depth) were created on both sides of the femoral medial condyles in 30 New Zealand white rabbits (age 4- 5 months). In 20 of the rabbits, the defects were filled with the tissue-engineered cartilage on the right side (group A) and with DCB only on the left side (group B); the remaining 10 rabbits did not receive any implantation in the defects to serve as the control (group C). At 1, 3, and 6 months after the implantation, tissue samples were collected from the defects for macroscopic observation and histological examination with Toluidine blue (TB) and collagen type Ⅱ staining. The effect of defect repair using the tissue-engineered cartilage was assessed at 6 months based on the histological scores.

RESULTSThe prepared DCB had a spongy 3D structure with open and interconnected micropores of various sizes and showed good plasticity and mechanical strength. DCB began to degrade within 1 month after implantation and was totally absorbed at 3 months. At 6 months after implantation, the defects filled with the chondrocyte-seeded DCB were repaired mainly by hyaline-like cartilage tissues, which were well integrated to the adjacent cartilage without clear boundaries and difficult to recognize. The chondrocytes were located in the lacunate and arranged in vertical columns in the deep repaired tissue, where matrix proteoglycans and collagen type Ⅱ were distributed homogeneously close to the normal cartilage. The subchondral bone plate was reconstructed completely. The defects implanted with DCB only were filled with fibrocartilage tissue, as compared with fibrous tissue in the control defects. The histological scores in group A were significantly superior to those in group B and C ( < 0.05), but the scores for subchondral bone plate reconstruction were comparable between groups A and B at 6 months.

CONCLUSIONSDCB is a good scaffold material for preparing tissue-engineered cartilage, and chondrocyte- seeded DCB can repair articular osteochondral defects by inducing the generation of hayline-like cartilage.

Objective To evaluate the clinical effects of total knee arthroplasty (TKA) in treatment of severe adults Kashin-Beck disease (KBD). Methods Sixteen cases of KBD patients underwent TKA in Shaanxi Provincial People's Hospital, including 2 males (2 knees) and 14 females (17 knees), aged 41 to 56 years, mean (56.38 ± 6.40) years, left knee in 8 cases and right knee in 11 cases, knee varus in 15 cases and valgus knees in 4 cases. Visual Analogue Scale/Score (VAS), Hospital for Special Surgery (HSS) scores, knee range of motion, varus deformity and postoperative complications were observed before and after TKA. Results In this group of TKA patients, the levels of VAS scores in pre-total knee arthroplasty (pre-TKA), 2 weeks post-total knee arthroplasty (post-TKA), 3 months post-TKA, and at the end of the follow-up were 7.51 ± 1.00, 3.56 ± 1.29, 1.83 ± 1.40 and 1.10 ± 0.87, respectively. The level of VAS scores in 2 weeks post-TKA was significantly lower than that in pre-TKA (P<0.01), and the VAS levels were continued to decrease in post-TKA (all P< 0.01). Total HSS score at the end of the follow-up post-TKA was 78.60 ± 5.30, which was significantly higher than that in pre-TKA (43.59 ± 10.08, t=19.21, P< 0.01). At the end of the follow-up post-TKA, in addition to the muscle strength, the levels of pain, knee function, activity, flexion deformity and stability (25.94 ± 4.17, 15.88 ± 3.70, 14.09 ± 1.03, 6.79 ± 2.25, 8.58 ± 1.30) were significantly higher than those in pre-TKA (11.56 ± 5.39, 7.56 ± 1.75, 9.86 ± 3.85, 3.05 ± 3.22, 5.00 ± 3.07, t= 16.00, 8.32, 6.43, 7.07, 6.95, all P< 0.01). At the end of follow-up post-TKA, the knee degree of extension [(3.05 ± 2.71)°] was significantly lower than that in pre-TKA [(15.11 ± 11.30)°, t= -5.40, P< 0.01], the knee degree of flexion [(115.79 ± 9.65)°] was significantly higher than that in pre-TKA [(93.95 ± 22.40)°, t=6.02, P< 0.01), the degree of varus [(2.40 ± 2.40)° ] and valgus [(3.75 ± 2.50)° ] deformity was significantly lower than those in pre-TKA [(11.33 ± 10.43)°, (18.00 ± 5.72)°, t = - 4.15, - 3.61, all P< 0.05]. One patient was diagnosed as knee tuberculosis in 6 months post-TKA. There was no complication in this group of patients. Conclusion The TKA in severe adults knee of KBD can significantly reduce knee pain, improve knee function, correct joint deformities and improve quality of life in patients, and shows good clinical results.