Objective:To investigate the clinical characters and prognostic value of PSA flare and bone flare in metastatic castration resistant prostate cancer(mCRPC) patients received Abiterone acetate(AA) therapy.Methods:A retrospective study was conducted for 93 mCRPC patients treated with AA from Jul.2016 to Dec.2020. Mean age was (75.4±8.9)years, median PSA was 58.2 (16.4, 148.6)ng/ml. Patients received at least 6 months of AA treatment. PSA flare was defined as an increase of PSA after AA therapy followed by a decrease. Bone flare was defined as disease progression after 3 months of therapy, typically based on increased lesion intensity or number, and reevaluation 6-9 months later showed improvement in the scan. The clinical characters and prognostic value of the flare phenomenon was evaluated and analyzed respectively.Results:The median follow up time was 16 months(6, 54 months), fourteen patients showed PSA flare at first month after AA treatment, and median time of duration was 2 months(1, 7 months). The serum alkaline phosphatase (ALP) had a similar rising trend along with PSA flare[115.5(98.0, 198.5)U/L vs. 119.0(97.0, 288.8)U/L, P=0.016]. Seven patients showed bone flare and 3 cases co-existed with PSA flare. Multivariate Cox regression analysis indicated bone flare was an independent protective factor for progression free survival(PFS)( HR=0.117, 95% CI 0.015-0.895, P=0.039), PSA flare had no significant influence on PFS ( HR=1.314, 95% CI 0.554-3.121, P=0.536)and overall survival(OS)( HR=1.348, 95% CI 0.393-4.263, P=0.635). Log-rank test showed patients with bone flare had a longer PFS( P=0.016) and OS( P=0.047) compared with patients without bone flare. Conclusions:PSA flare always faded away after 2 months AA therapy and had no influence on PFS and OS. Bone flare maybe an indication for better prognosis.

Objective:To report our experience in using the Ilizarov technique to treat bone defects secondary to Gustilo Ⅲb open tibial fractures with negative clinical signs and serological inflammatory markers.Methods:A retrospective study was performed to analyze the 19 patients with bone defects secondary to Gustilo Ⅲb open tibial fracture who had been treated at Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital between January of 2010 and June of 2021. They were 15 males and 4 females with an age of (41±11) years. Their inclusion criteria: undergoing treatment with Ilizarov technique (consecutive compression-distraction or bone transport), soft tissue coverage procedures resulting in wound closure and negative clinical infection signs for at least 3 months and normal serological inflammatory markers, and follow-up for more than 3 months after frame removal. Three-phase bone scan was performed for the patients before the present surgery. Debridement, sampling of deep tissues for bacterial culture, and external stabilization with a fixator were performed in the present surgery. Osteotomy for compression-distraction or bone transport technique was carried out at 1 stage or 2 stages. Systemic antibiotic therapy for 6 weeks was continued for those with positive microbiological analysis guided by antibiogram. Recorded were results of intra-operative pus detection around defects, microbiological findings, length of bone defect reconstructed, rate and time of infection recurrence during treatment, fracture union rate, bone healing index, bony and functional results.Results:The interval between primary injury to the present surgery was (10±8) months. The preoperative three-phase bone scan showed infection free in 8 cases, chronic osteomyelitis in 7 cases, and suspicious infection in 4 cases. No pus was found during intra-operative debridement in all. The intra-operative microbiological detection was positive in 1 sample in 1 patient (infection free indicated by bone scan), and in ≥2 samples in 3 patients (bone scan indicating non-infection, infection not excluded and osteomyelitis in 1 case each). The length of bone defect reconstructed was (8±3) cm. The follow-up after the present surgery was (37±15) months. Fracture union was achieved in all cases, with a bone healing index of (1.7±0.5) months/cm. Clinical infection signs were observed 1 (1, 1) month after the present surgery in 6 patients whose microbiological results were all negative. All the 6 patients ended up with no clinical recurrence after empirical use of systemic antibiotics in 5 and radical debridement in one. The bony results showed 16 excellent and 3 good cases while the functional results showed 10 excellent and 9 good cases.Conclusions:In treatment of bone defects secondary to Gustilo Ⅲb open tibial fractures with negative clinical signs and serological inflammatory markers, constant vigilance is needed against low-grade infection. Intra-operative multiple sampling of deep tissues with a standardized protocol and microbiological testing are extremely valuable for diagnosis of fracture-related infections.

Objective:To analyze the clinical characteristics and prognostic value of prostate-specific antigen (PSA) dynamic features in patients with metastatic castration resistant prostate cancer (mCRPC) received abiraterone acetate (AA) therapy.Methods:The data of 89 patients with mCRPC who received AA therapy from January 2017 to June 2021 in Shanghai Tongji Hospital were retrospectively reviewed. The age of patients was (75.7 ± 8.3) years old, median PSA before AA was 56.88 (19.31, 143.75) ng/ml. The PSA dynamic features included PSA nadir (PSAN) and PSAN time. PSAN was defined as the lowest value of PSA after treatment, and PSAN time was defined as time to PSAN after AA treatment. PSAN was divided into 3 groups: PSAN1 (<0.1 ng/ml), PSAN2 (0.1- 4.0 ng/ml) and PSAN3 (>4.0 ng/ml) groups. PSA response was defined as a maximum PSA decline rate ≥50%, and no PSA decline after treatment was defined as primary resistance. Cox regressions adjusted to clinical factors were performed to evaluate the influence of PSA dynamic features on patients' radiographic progression-free survival (rPFS) and overall survival (OS). Log-rank test was used to evaluate the survival time of patients in different PSAN groups. Receiver operator characteristic (ROC) curve and area under the curve (AUC) were performed to analyze the predictive value of PSA dynamic features on survival outcomes of patients.Results:The follow-up time was 17 (12, 23) months, and 75 (84.3%) patients showed PSA responses. The median PSAN was 1.82 (0.01, 11.70) ng/ml, median PSAN time was 5.0(3.0, 9.5)months. Multivariate Cox regression indicated that PSAN was an independent risk factor for rPFS ( PSAN2: HR=5.308, P=0.017; PSAN3: HR=13.209, P<0.001), and PSAN time ≥ 5 months( HR=0.309, P<0.001)was an independent protective factor for rPFS. Also, the PSAN3 was an independent risk factor for OS( HR=9.459, P=0.048). Log-rank test indicated that the rPFS of PSAN1 group (median not reached) was significantly longer than PSAN2 [median 13.0(95% CI 8.2-17.8) months, P=0.001] and PSAN3 [8.0 (95% CI 4.1-11.9) months, P<0.001] groups. ROC curve and AUC showed that PSAN had a higher predictive value in rPFS outcomes compared with T stage, metastatic disease volume, and Eastern Cooperative Oncology Group (ECOG) score (0.82 vs. 0.69, 0.68, 0.53, P<0.05). PSAN had a higher predictive value in OS outcomes than metastatic disease volume and ECOG(0.83 vs. 0.63, 0.58, P<0.05). Conclusions:Lower PSAN needs longer PSAN time. PSAN is an independent risk factor for rPFS and OS, and PSAN time is an independent protective factor for rPFS.

Objective:To study the outcome of realignment for genu varum with tibial bone defect managed with antegrade bone transport.Methods:To retrospectively study 11 patients with tibial bone defect and genu varum treated with antegrade bone transport from January 2012 to December 2020. All the patients were males, aged 42±16 years, left in 8 cases and right in 3. The segmental bone defect was secondary to fractures with amount of 7.9±2.1 cm. 10 cases were congenital genu varus, and 1 case was genu varus caused by malunion of proximal tibial fracture. The anatomical lateral tibio-femoral angle (aLTFA) was 179°(178°, 180°), the anatomical lateral distal femoral angle (aLDFA) was 82°(81°, 83°), joint line convergence angle (JLCA) was 0°(0°, 1°) and the anatomical medial proximal tibial angle (aMPTA) was 83.1°±3.9° before treatment. 7 cases were treated with unilateral external fixators, 3 cases with circular external fixators, and 1 case with hybrid external fixator. Antegrade bone transport surgeries were performed to treat bone defects and varus deformities. Among them, 3 cases using unilateral external fixators were additionally corrected for varus using swinging clamps, while 1 case using a circular external fixator was corrected for varus by installing hinges on the lateral side of the proximal tibia and distracting the medial-positioned threaded rod. The data including the angles between proximal pins in monorail fixators or proximal ring orientation in ring fixators and knee joint line, post-operative mechanic axis deviation (MAD) of lower extremity, the position of the mechanical axis relative to the width of the tibial plateau, mechanic medial proximal tibial angle (mMPTA), the amount of deformity correction in radiographic AP view, bone healing time, bone healing index (BHI), functional score and complications according to Paley's criteria were studied.Results:All 11 patients were followed up, and the follow-up time after removing the external fixators was 11(3, 25) months. The angles between pins in proximal clamp in monorail frame of 7 cases and hybrid frame of 1 case and joint line were 0° (-1°, 1°), while those between proximal ring orientation in circular fixators of 3 cases and joint line were 0°, 0° and 2° respectively. The MAD were -6±6 mm, mMPTA was 90°(89°, 92°), the amount of correction was 7.2°±3.9° in the last follow-up. The final mechanic axis passed through the lateral plateau at 58%±9% of its width (counting from medial knee edge). Well consolidation was achieved for all patients with 12±4 months (range, 7-20 months) of bone healing time. BHI was 1.6±0.6 months/cm (range, 1.2-2.9 months/cm). Functional score according to Paley's criteria was excellent in 7 cases and good in 4. Complications were 5 problems (3 of pin site infections and 2 of soft tissue infections) and 1 obstacle (soft tissue invagination). All the cases with problems were resolved with oral antibiotics. In the one with the obstacle of soft tissue invagination, the skin and docking site bone healing were noticed after invaginated tissue resection and refreshment procedure.Conclusion:It is advisable for genu varum with tibial bone defect to be realigned while managed with antegrade bone transport.

Prostate cancer with metastasis to the kidney is rare. Here, we report a case of prostate cancer metastasizing to renal cell carcinoma. A 67-year-old male presented with low back pain for 3 months, aggravated with persistent fever for 2 weeks in June 2018.Histopathological diagnosis of prostate adenocarcinoma was established. Meanwhile, contrasted CT of the abdomen showed a 3.0 cm×2.5 cm×2.5 cm enhanced solid mass on the lower pole of the right kidney. Nephron-sparing surgery was performed for the renal mass. Histopathology revealed a Grade 2 renal clear cell carcinoma with focal prostate carcinoma metastasis to the tumor. Then the patient received abiraterone acetate (AA) therapy. The patient did not encounter tumor recurrence in right kidney 18 months after surgery. However, PSA progression occurred 6 months later after AA therapy, then docetaxel chemotherapy and Sr 89 therapy were performed with limited efficacy. The patient died after 30 months.

Objective To introduce the technique we invented to treat hypertrophic and oligotrophic nonunion of femoral shaft fracture after dynamization of intramedullary nail (IMN) and to report its preliminary results.Methods The data of 2 cases with hypertrophic nonunions of femoral shaft fracture and 1 case with oligotrophic nonunion following IMN dynamization who had been treated by the technique from March 2006 to July 2017 in Beijing Jishuitan hospital were retrospectively studied.There were 2 females and 1 male,aged 50,66 and 24 years old.2 parallel half pins were inserted from anterior to posterior at the trochanteric and condylar zones of the femur for antegrade intramedullary nailing patients,and from lateral to medial sides for retrograde intramedullary nailing patient respectively,then the pins were connected with monolateral limb reconstruction fixator.The fracture nonunion site was compressed by the fixator up to 10-15 mm.The holes at the end of intramedullary nail where their screws were removed for dynamization were locked again with 2 locking screws,and then the frame was removed.The patients are allowed to start their rehabilitation and fully bear their body weight 1 day after the operation.Results The three patients were followed up for 25,22,and 7 months after the surgery,respectively.The X-ray films showed the fracture healed at 7 months in two case,and at 12 months in one.One patient got her nail removed 25 months after the operation,feeling good 37 months after the removal.Conclusion This technique is an option to manage the hypertrophic and oligotrophic fracture nonunion of the femur after dynamization of IMN.It is mini-invasive to the nonunion site,easy to practice and allows early rehabilitation.

Objective: To discuss the result of treating tibia deformity with fixator assisted nailing technique (FAN). Methods: A total of 5 patients with 7 limbs of tibial deformity-were treated with FAN technique. Etiology: 2 patients with bilateral tibial deformity suffered from Ricket's disease, 2 patients were malunion after tibial fracture, 1 patient was congenital pseudoarthrosis of tibia. This is a retrospective study. The unilateral external fixator was mounted on the medial side of tibia, and thenthe minimal invasive osteotomy was performed. After the deformity was corrected, the intramedullary nail was inserted to fix the tibia. None of the patients need bone autograft. The pre-operation and post-operation medial proximal tibia angle (MPTA), mechanical axis deviation (MAD) and range of motion (ROM) were measured and analyzed. Results: All the 5 patients were followed-up for 12-60 months (average 32 months). The osteotomy site united in 3-5 months (average 4.5 months) post-operatively. According to Paley’s imaging scores, 4 patients were excellent and 1 patient was good. According to Paley's functional result scores, 5 patients were excellent; according to Paley’s bone results evaluation, 4 patients were excellent and 1 patient was good. We achieved desired post-operative MAD (from medial 15 mm-lateral 10 mm) in 6 limbs. The MPTA in 7 limbs was corrected to normal (84°-90°). The ROM was not significantly changed before and after operation. The average ROM of knee before operation was 125°(120°-135°), and average postoperative ROM was 120°(115°-130°), No deep infection or neurovascular injury occurred. All patients were satisfied with the method and results of the operation. Conclusion FAN technique combines the advantage of external fixation and intramedullary nail, and it is a good method to treat tibial deformity, the patient should be carefully evaluated and selected for applying this technique.

Objective To evaluate the medial submuscular plating of the femur after limb lengthening and correction with frame in patients with limb length discrepancy and/or angular deformity.Methods A retrospective study was conducted involving 12 patients who had been referred to Department of Orthopaedic Trauma,Beijing Jishuitan Hospital from December 2009 to November 2016 for limb length discrepancy and/or angular deformity.They were 3 males and 9 females,with an average age of 23 years (from 14 to 32 years).Altogether 4 left and 8 right sides were involved.Of them,11 got their length discrepancy and/or angular deformity secondary to injury to distal femoral epiphyseal plate caused by trauma in their childhood and one had length discrepancy and angular deformity following unsuccessful conservative treatment of superior condylar fracture of the femur.The femoral shortening ranged from 3 to 11 cm (average,6.7 cm),and the varus or valgus deformity of the knee ranged from 8° to 18° (average,12°).First,a monolateral fixator was installed on the lateral femur.The limb was lengthened from 7 to 14 days after diaphysis osteotomy.Femoral supracondylar osteotomy was conducted again in patients with knee angular deformity after the lengthening reached the expected length and the deformity was corrected with the aid of external fixator.After medial submuscular plating via the femoral lateral approach using minimally invasive techniques,the external frames were removed.The time for plate removal,limb lengthening and correction of the varus or valgus deformity were documented.Results The mean follow-up was 31 months (from 23 to 43 months) for the 9 patients who had their plates still in situ,and 6.5 months (from 2 to 14 months) for the 3 patients who had subsequently their plates removed.None had blood transfusion.All underwent distraction osteogenesis of the femur to their preoperatively expected length,ranging from 3 to 9 cm (mean,6.2 cm).Both varus and valgus deformities were corrected.None developed a deep infection.The range of motion of the knee joint was similar to that before operation in all but one patient who had a range of motion 40° less than the pre-operative one.The time for external fixation averaged 91 days (from 46 to 113 days),with an external index of 22 d/cm.All patients were satisfied with their outcomes.Conclusion Medial femoral submuscular plating after limb lengthening and angular deformity correction with the external fixator on the lateral side is a useful technique for patients with femoral limb length discrepancy and/or angular deformity,significantly shortening the time for external fixation.

Objective:To discuss the result of treating valgus or varus knee deformity with fixator assist nailing (FAN)technique and distal femur osteotomy(DFO).Methods:In this retrospective study,14 patients with 17 limbs,12 valgus and 5 varus knee deformity were treated with DFO and FAN.The aver-age age of the patients was 23 (17-44)years .The unilateral external fixator was mounted on the lateral side of femur,the minimal invasive distal femoral osteotomy was performed.After the deformity was cor-rected,the intramedully nail was inserted to fix the femur.None of the patients need bone autograft.The preoperation and postoperation lateral distal femur angle (LDFA ),mechanical axis deviation (MAD ) and range of motion (ROM)were measured and analyzed.Results:All the 14 patients were followed-up for 12 -72 months (average 34 months).The osteotomy site united in 3 -5 months (average 3.5 months)post-operatively.According to Paley’s functional scores,12 patients were excellent,2 patients were good.We achieved desired postoperative MAD (from medial 15 mm to lateral 10 mm)in 15 limbs of 12 patients.The LDFA in 1 1 limbs was corrected to normal (84°-90°).The ROM was not signifi-cantly changed before and after operation in the both groups.No infection or neuro-vascular injury oc-curred.Conclusion:The FAN technique is an effective method to treat valgus knee or varus knee de-formity in young patients with DFO.

OBJECTIVETo evaluate the results of managing the infected nonunions of distal tibial fractures combined with talar fracture and calcaneal fracture with tibial bone transport, tibiotalar or tibiocalcaneal arthrodesis using the hybrid external fixator.

METHODSA retrospective review of 26 patients who underwent either tibiotalar arthodesis or tibiocalcaneal arthodesis using an hybrid external fixator for infected nonunions of distal tibial fractures, talar and calcaneal fractures after tibial bone distraction was made. Each patient had a debridement of all infected and nonviable bones, the wound area were 2 cm×4 cm-4 cm×8 cm. The bony surfaces of distal tibia and talus were prepared for the fusion followed by application of an Orthofix's hybrid external fixator.

RESULTSThe remaining 18 patients undertook debridement at the docking sites, and 14 of them had autogenous bone grafting. There was a mean follow-up of 32 months (22-38 months). All the patients had successful fusions. There were no recurrent deep infections or amputations. Two patients had 6° of varus deformity at the docking site.

CONCLUSIONTibiotalar or tibiocalcaneal arthrodesis using the Ilizarov technique is viable alternative to amputation in patients with infected nonunions,especially if there is a large bone loss of the tibias, talus and calcaneus.

Amputation ; Ankle Injuries ; Ankle Joint ; Arthrodesis ; Bone Transplantation ; Calcaneus ; External Fixators ; Follow-Up Studies ; Foot Injuries ; Fractures, Bone ; Humans ; Ilizarov Technique ; Joint Dislocations ; Retrospective Studies ; Talus ; Tibia ; Tibial Fractures