Objective: To investigate the distribution of pupil diameter and its association with myopia in school age children, providing ideas into the mechanisms of the role of pupil diameter in the onset and development of myopia. Methods: Adopting a combination of stratified cluster random sampling and convenience sampling method, 3 839 children from six schools in Shandong Province were included in September 2021. Pupil diameters distribution was analyzed by age, sex, and myopic status. Pearson correlation analysis was used to assess the relationship between pupil diameter and cycloplegic spherical equivalent (SE), as well as axial length (AL) and other variables. Propensity score matching (PSM) was applied to match myopic and non myopic children at a 1∶1 ratio based on age and sex. A generalized linear model (GLM) was constructed with pupil diameter as the dependent variable to identify independent factors influencing pupil size and its association with myopia. Results: The mean pupil diameter of school age children was (5.77±0.80)mm. Pupil diameter exhibited a significant increasing trend with age ( F =49.34， P trend ＜ 0.01). Myopic children had a significantly larger mean pupil diameter [(6.10±0.73)mm] compared to non myopic children [(5.62±0.79)mm] with a statistically significant difference( t=18.10, P <0.01). Multivariable GLM analysis, adjusted for age, amplitude of accommodation, and uncorrected visual acuity, revealed a negative correlation between pupil diameter and cycloplegic SE (before PSM: β =-0.089, after PSM: β =-0.063, both P ＜0.01). Conclusions Myopic school age children exhibite larger pupil diameters than their non myopic counterparts. Pupil diameter may serve as a potential indicator for monitoring myopia development in school age children.

The incidence of osteoporotic thoracolumbar vertebral fracture (OTLVF) in the elderly is gradually increasing. The kyphotic deformity caused by various factors has become an important characteristic of OTLVF and has received increasing attention. Its clinical manifestations include pain, delayed nerve damage, sagittal imbalance, etc. Currently, the definition and diagnosis of OTLVF with kyphotic deformity in the elderly are still unclear. Although there are many treatment options, they are controversial. Existing guidelines or consensuses pay little attention to this type of fracture with kyphotic deformity. To this end, the Lumbar Education Working Group of the Spine Branch of the Chinese Medicine Education Association and Editorial Committee of Chinese Journal of Trauma organized the experts in the relevant fields to jointly develop Clinical guidelines for the diagnosis and treatment of osteoporotic thoracolumbar vertebral fractures with kyphotic deformity in the elderly ( version 2024), based on evidence-based medical advancements and the principles of scientificity, practicality, and advanced nature, which provided 18 recommendations to standardize the clinical diagnosis and treatment.

Objective:To evaluate the impact of orthopedic robotic assistance and conventional freehand methods on surgical strategies, the safety of pedicle screw placement, and clinical efficacy in patients with upper cervical spine diseases.Methods:From January 2017 to March 2023, a total of 63 cases with upper cervical spine disease, were divided into two groups based on the screw placement technique: the robot-assisted pedicle screw placement (RA) group (41 cases) and the conventional freehand pedicle screw placement (CF) group (22 cases), were retrospectively included. These patients in the RA and CF groups underwent two types of posterior cervical surgery, including occipitocervical fusion (9 cases and 8 cases) and fixation and fusion of atlantoaxial and distal vertebrae (32 cases and 14 cases). The outcome parameters, including the disease course, surgical time, intraoperative blood loss, fluoroscopy frequency, radiation dose, hospital stay, treatment costs, complications, the rate of the pedicle screw placement, accuracy of upper cervical pedicle screw placement, and the risk factors that possibly affected the accuracy were recorded and analyzed. Postoperative follow-up was conducted for at least 6 months, and the efficacy of patients was assessed using imaging parameters, ASIS classification, VAS, and JOA scores.Results:Both groups had no screw-related complications and no spinal cord or vertebral artery injuries. In the RA group, the pedicle screw placement rates for the patients with occipitocervical fusion, and fixation and fusion of atlantoaxial and distal vertebrae were 100% (48/48) and 89.6% (138/154), respectively, far exceeding the placement rate in the CF group 42.9% (18/42) and 78.3% (54/69) (χ 2=37.403, P<0.001; χ 2=5.128, P=0.024). The fluoroscopic exposure dose and operation time of the two types of surgical patients in the RA group were both higher than those in the CF group ( P<0.05). Compared with the CF group, the accuracy of C 1 screws in the RA group increased from 42% (11/26) to 80% (51/64), with statistical significance (χ 2=13.342, P=0.004); while the accuracy of C 2 screws improved from 77% (33/43) to 88% (63/72) with no statistical difference (χ 2=2.863, P=0.413). Non-parametric correlation analysis found a significant correlation between the accuracy of C 1 and C 2 pedicle screw placement and the order of guide wire insertion in the RA group ( r=0.580, P<0.001; r=0.369, P=0.001). Postoperatively, both groups showed significant differences in cervicomedullary angle (CMA), Chamberlain angle (CL), McGregor angle, Boogard angle, Bull angle, clivus-canal angle (CCA), occipitocervical (C 0-C 2) angle, posterior occipitocervical angle (POCA), C 2-C 7 angle, and anterior atlantodental interval (ADI) ( P<0.05). The ASIA classification improved to varying degrees for both groups postoperatively, but there were no statistically significant differences between preoperative, postoperative, and last follow-up evaluations. VAS and JOA scores significantly improved for both groups postoperatively and at the last follow-up ( P<0.05). Conclusion:Both orthopedic robotic-assisted and conventional freehand pedicle screw placement techniques achieved satisfactory therapeutic effects in the treatment of upper cervical spine diseases. The orthopedic robot can effectively ensure the accuracy of upper cervical pedicle screw placement, the increase placement rate of pedicle screws in the upper cervical spine, and reduce fluoroscopy exposure. However, it is necessary to avoid the vertebral displacement caused by the priority insertion of the guide needle, which may affect the accuracy of subsequent planning.

Objective:To compare the clinical efficacy of robotic-assisted and fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).Methods:A total of 27 patients with lumbar degenerative disease receiving robot-assisted MIS-TLIF (robot-assisted group) treatment in the First Affiliated Hospital of Nanjing Medical University from May 2020 to September 2021 were retrospectively analyzed, including 9 males and 18 females, aged 61.00±9.11 years (range, 41-71 years). Twenty-seven patients who received fluoroscopic-assisted MIS-TLIF (fluoroscopic-assisted group) during the same period were selected as controls, including 16 males and 11 females, aged 56.70±11.97 years (range, 32-76 years). Operation time, intraoperative bleeding, radiation exposure time, postoperative drainage, hospitalization time, visual analogue scale (VAS) for pain, Oswestry disability index (ODI), accuracy of pedicle screw placement, and postoperative complications were recorded. The learning curve of the robot-assisted group was drawn based on the amount of surgery and the operation time by fitting the logarithmic curve.Results:All patients successfully completed the operation and were followed up for 15.44±3.89 months (range, 12-24 months). The operation time, drainage volume, and hospitalization time in the robot-assisted group were 181.44±36.43 min, 43.70±22.04 ml, and 5.04±1.40 d, respectively, which were smaller than 223.22±59.40 min, 74.63±71.86 ml, 6.59±3.04 d in the fluoroscopy-assisted group, and the differences were statistically significant ( P<0.05). The radiation exposure time in robot-assisted group was 77.78±9.81 s, which was larger than fluoroscopy-assisted group (63.78±17.70 s). There were statistically significant differences in lumbar VAS scores between the two groups before and after surgery ( P<0.05), 3 days after operation and the last follow-up was smaller than those before operation. The VAS score on postoperative day 3 in the robot-assisted group was 2.52±0.98, which was less than 3.07±0.87 in the fluoroscopically-assisted group ( t=0.294, P=0.032). In both groups, 108 pedicle screws were placed, and the accuracy of nail placement in the robot-assisted group was 93.5% (101/108), which was greater than that in the fluoroscopically-assisted group 77.8% (84/108), and the difference was statistically significant (χ 2=11.821, P=0.008). By fitting a logarithmic curve to describe the relationship between the number of operations and the operation time of the robotic-assisted group of operators, the results showed that the operation time decreased with the increase of the number of operations, and the operation time fluctuated greatly in the first 10 cases, and then gradually shortened and stabilized after 10 operations. Conclusion:Robot-assisted MIS-TLIF can improve the accuracy of pedicle screw placement, improve the early postoperative pain and shorten the learning curve.

OBJECTIVE: To explore the genetic basis for 4 patients with globozoospermia. METHODS: Semen and blood samples were collected from the patients for the determination of sperm concentration, viability, survival rate, morphology and acrosome antigen CD46. Meanwhile, DNA was extracted for whole exome sequencing (WES), and candidate variants were validated by Sanger sequencing. RESULTS: All of the four patients were found to harbor variants of the DPY19L2 gene. Patients 1 ~ 3 had homozygous deletions of the DPY19L2 gene. Sanger sequencing confirmed that the DPY19L2 gene in patient 3 was disrupted at a recombination breakpoint area BP2, resulting in nonallelic homologous recombination and complete deletion of the DPY19L2 gene. Patients 2 and 3 respectively harbored novel homozygous deletions of exons 2 ~ 22 and exons 14 ~ 15. Patient 4 harbored heterozygous deletion of the DPY19L2 gene, in addition with a rare homozygous deletion of the 3' UTR region. CONCLUSION DPY19L2 gene variants probably underlay the globozoospermia in the four patients, which has fit an autosomal recessive pattern of inheritance and the characteristics of genomic diseases.
Male ; Humans ; Teratozoospermia/genetics* ; Homozygote ; Semen ; Sequence Deletion ; 3' Untranslated Regions ; Membrane Proteins

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is still a refractory disease in children’s orthopedics. With the introduction of the concept of ‘‘osteoimmunology’’, the immune-inflammatory mechanisms between bone and immune system have become a research focus of LCPD. However, few studies have reported on the pathological role of inflammation-related receptors such as toll-like receptors (TLRs) as well as immune cells such as macrophages in LCPD. This study was for investigating the mechanism of TLR4 signaling pathway on the direction of macrophage polarization and the repair of avascular necrosis of femoral epiphysis in LCPD. METHODS: With GSE57614 and GSE74089, differentially expressed genes were screened. Through enrichment analysis and protein–protein interaction network, the functions of TLR4 were explored. Furthermore, immunohistochemistry, enzyme-linked immunosorbent assay (ELISA), hematoxylin & eosin (H&E) staining, micro-CT, tartrate-resistant acid phosphatase (TRAP) dyeing and western blotting were performed for determining the influences of TAK-242 (a TLR4 inhibitor) on the repair of avascular necrosis of femoral epiphysis in rat models. RESULTS: Totally 40 co-expression genes were screened as well as enriched in TLR4 signaling pathway. Immunohistochemistry and ELISA analyses certified that TLR4 facilitated macrophage polarization toward the M1 phenotype and prevented macrophage polarization toward the M2 phenotype. Besides, the results of H&E and TRAP staining, micro-CT, and western blotting showed that TAK-242 can inhibit osteoclastogenesis and promote osteogenesis. CONCLUSION Inhibition of TLR4 signaling pathway accelerated the repair of avascular necrosis of femoral epiphysis by regulating macrophage polarization in LCPD.

Objective:To analyse the clinical efficacy and outcome of early abdominal paracentesis drainage (APD) in the treatment of severe acute pancreatitis (SAP).Methods:The clinical data of 107 SAP patients with massive abdominal fluid in Shanghai General People Hospital from May 2017 to December 2021 were collected and analyzed. Patients were divided into APD group ( n=56) and NO-APD group ( n=51) according to whether they underwent APD or not within 3 days after admission. The APD group was then divided into abdominal compartment syndrome (ACS) subgroup ( n=29) and NO-ACS subgroup ( n=27) according to whether ACS had occurred or not at the time of puncture. Patients' general data, the duration of systemic inflammatory response (SIRS), length of ICU stay, the trends of intra-abdominal pressure and inflammatory indicators (white blood cell count and the content of C-reactive protein) within 1-3 days after admission, incidence of infection complication, step-up therapy, discharge or death were recorded. Results:The intra-abdominal pressure were 18.6±5.6mmHg , 13.7±4.2mmHg (1 mmHg=0.133 kpa) in APD group and NO-APD group, respectively. The intra-abdominal pressure of APD group was significantly higher than that of NO-APD group, and the difference was statistically significant ( P=0.000). Compared with NO-APD group, the duration of SIRS was significantly shortened in APD group [3(2, 4) days vs 4(3, 6) days, P=0.029]. On day 1, 2 and 3 after admission, the intra-abdominal pressure was 18.6±5.6 mmHg, 16.4±4.7 mmHg and 13.5±3.9 mmHg in APD group, and was 13.7±4.2 mmHg, 12.3±3.6 mmHg and 11.0±2.6 mmHg in NO-APD group, respectively. The intra-abdominal pressure of the APD group dropped faster than the NO-APD group ( P=0.004). The white blood cell count was (14.8±4.8), (10.5±4.5) and (9.0±3.8)×10 9/L in APD group, and was (14.2±5.4), (12.3±7.3), (11.7±5.3)×10 9/L in NO-APD group, respectively. Compared with the NO-APD group, the decrease rate of white blood cell count was faster in APD group ( P=0.006). The C-reactive protein content was (153.6±47.1), (150.4±10.5) and (108.8±49.4)mg/L in APD group, and were (174.8±31.1), (191.6±29.4) and (186.8±45.5)mg/L in NO-APD group . The content of C-reactive protein in APD group decreased significantly, while that in NO-APD group did not decrease. There was a significant difference between the two groups ( P=0.009). In the subgroup comparisons, the duration of SIRS in the ACS subgroup was significant longer than that in the NO-ACS subgroup [4(3, 5) days vs 2(1, 3)days, P=0.000]. Compared between the two groups and two subgroups respectively, there were no statistically significant differences on length of ICU stay, infection complication rate, advanced treatment rate and mortality. Conclusions:For SAP patients with abdominal fluid, APD in the early stage could shorten the duration of SIRS, decrease intra-abdominal pressure rapidly, improve inflammatory indicators, but could not improve the clinical outcome.

Bone defects caused by different causes such as trauma, severe bone infection and other factors are common in clinic and difficult to treat. Usually, bone substitutes are required for repair. Current bone grafting materials used clinically include autologous bones, allogeneic bones, xenografts, and synthetic materials, etc. Other than autologous bones, the major hurdles of rest bone grafts have various degrees of poor biological activity and lack of active ingredients to provide osteogenic impetus. Bone marrow contains various components such as stem cells and bioactive factors, which are contributive to osteogenesis. In response, the technique of bone marrow enrichment, based on the efficient utilization of components within bone marrow, has been risen, aiming to extract osteogenic cells and factors from bone marrow of patients and incorporate them into 3D scaffolds for fabricating bone grafts with high osteoinductivity. However, the scientific guidance and application specification are lacked with regard to the clinical scope, approach, safety and effectiveness. In this context, under the organization of Chinese Orthopedic Association, the Expert consensus for the clinical application of autologous bone marrow enrichment technique for bone repair ( version 2023) is formulated based on the evidence-based medicine. The consensus covers the topics of the characteristics, range of application, safety and application notes of the technique of autologous bone marrow enrichment and proposes corresponding recommendations, hoping to provide better guidance for clinical practice of the technique.

Objective:To compare Jack dilator-kyphoplasty (DKP) and balloon-kyphoplasty (BKP) for osteoporotic vertebral compression fracture (OVCF) in postoperative vertebral height loss and adjacent intervertebral disc degeneration.Methods:A total of 94 OVCF patients were treated and fully followed up at Department of Orthopaedic Surgery, The First Hospital Affiliated to Nanjing Medical University from May 2007 to October 2016. Of them, 30 were subjected to DKP and 64 to BKP. In DKP group, there were 18 males and 12 females, with an age of (72.4±9.2) years, a bone density of (-3.99±0.88) SD and a disease course of (0.7±0.4) months; in BKP group, there were 28 males and 36 females, with an age of (71.6±14.3) years, a bone density of (-4.08±0.63) SD and a disease course of (0.6±0.3) months. The 2 groups were compared in terms of change in the height of injured vertebrae, disc height index percentage (DHIP) and Pfirrmann grading of adjacent disc degeneration at preoperation, 2 days and 36 months after operation.Results:The 2 groups were comparable due to insignificant differences in their preoperative general data ( P>0.05). The anterior and middle heights of injured vertebrae and DHIP at postoperative 36 months were significantly lower than those at postoperative 2 days in both groups ( P<0.05). There was no significant difference between the 2 groups in DHIP at 36 months after operation (79.86%±4.48% versus 80.24%±6.85%) ( t=0.277, P=0.782). By the Pfirrmann grading, 36 and 84 patients had intervertebral disc degeneration in DKP and BKP groups respectively. There was no significant difference in the incidence of intervertebral disc degeneration between the 2 groups (60.0% versus 65.6%) (χ 2=0.560, P=0.454). Conclusions:In the OVCF treatment, DKP and BKP may potentially cause height loss of the injured vertebrae and degeneration of adjacent intervertebral disc, but no difference was found in disc degeneration between the 2 modes.

Objective:To evaluate the accuracy and safety of cervical pedicle screw (CPS) placement under orthopaedic robot navigation system guidance.Methods:From March 2019 to February 2021, the data of 33 patients (19 males and 14 females, aged from 26 to 75 years, with an average age of 50.5 years) treated with pedicle screw fixation with the assistance of orthopaedic surgery robot through the posterior cervical spine were retrospectively analyzed. In clinical diagnosis, there was upper cervical fracture with instability in 14 patients (fracture nonunion in 2 patients), upper & subaxial cervical fracture in 1 patient, cervical spinal cord injury with spinal stenosis in 2 patients, cervical spinal stenosis in 9 patients, occipitocervical deformity in 2 patients, post-operative revision of cervical spondylosis in 2 patients, cervical intraspinal tumor in 3 patients. A total of 151 CPSs were inserted in C 1-C 7 using robot navigation system based on intraoperative three-dimensional C-arm fluoroscopy to assist in screw placement in posterior cervical surgery. Among them, 74 screws were implanted into upper cervical spine; 77 screws were implanted in the lower cervical spine. CT was used to obtain image data within 7 days after operation, and Neo classification was used to evaluate the accuracy of cervical pedicle screw placement. The patients were followed up for 2 weeks to observe the clinical symptoms and signs, and to determine whether there were surgical complications such as nerve and blood vessel injury and incision infection. Results:According to Neo classification, 91.4% (138/151) screws were completely contained in the pedicle without breaking through the pedicle cortex (grade 0). Among them, the accuracy of C 1 screws was 97.1% (34/35), C 2 screws was 92.3% (36/39), C 3 screws was 88.2% (15/17), C 4 screws was 71.4% (10/14), C 5 screws was 85.7% (12/14), C 6 screws was 93.3% (14/15), C 7 screws was 100.0% (17/17). The screw accuracy was highest in C 7, the lowest in C 4. The Kruskal-Wallis H test was performed on the accuracy of screw placement in different cervical level, and the results showed that there was no statistical difference (χ 2=1.31, P=0.971). However, a total of 13 screws were found to perforate the cortex of pedicle, although any neural or vascular complications associated with CPS placement were not encountered. Among them, 9 screws were found to perforate laterally, and 4 screws were found to perforate medially. No postoperative incision infection occurred in all cases. Conclusion:The safety of CPS placement can be effectively guaranteed with the assistance of the orthopaedic robot system.