Objective:To investigate the clinical efficacy of 3D printed metal augment or tibial prosthesis for reconstruction of large bone defects in total knee arthroplasty (TKA) and knee revision surgery.Methods:A total of 7 patients (7 knees) with TKA or knee revision who were admitted to the Department of Orthopaedics of the Second Affiliated Hospital of Zhejiang University School of Medicine with large bone defects from July 2018 to December 2023 were retrospectively analyzed, including 4 patients with TKA and 3 patients with knee revision. There were 3 males and 4 females, aged 58.7±7.6 years (range, 54-68 years), 3 patients with left knee and 4 patients with right knee. All the patients had bone defects in the knee joint (AORI type III), 2 cases had bone defects only in the femur, 4 cases had bone defects only in the tibia, and 1 case had bone defects in both the tibia and femur, which were treated with personalized reconstruction using 3D printing. Hip-knee-ankle angles, American Knee Society score (KSS) before and after surgery were compared, and postoperative complications were observed.Results:All patients successfully completed the operation, and the operation time was 189.3±35.5 min (range, 125-240 min). Complex TKA was performed in 4 cases with surgical times of 175, 195, 210, and 240 min, and revision surgery was performed in 3 cases with surgical times of 125, 180, and 200 min, respectively. Intraoperative blood loss was 114±24.4 ml (range, 100-150 ml). Five cases used 3D printed metal augment, and two used 3D printed one-piece tibial components. All patients were followed up for 2, 2, 5, 6, 7, 20, 57 months, respectively. The KSS of the five patients at 3 months postoperatively were 56, 61, 66, 56, and 56 points, respectively, greater than the preoperative scores of 35, 44, 36, 27, and 41 points. The KSS functional scores of the five patients at 3 months postoperatively were 45, 45, 45, 30, and 45 points, respectively, which were greater than the preoperative scores of 30, 30, 15, 20, and 20 points. The hip-knee-ankle angle was 181.8°±3.4° (range, 177.9° to 188.0°) at the final follow-up and 175.8°±12.4° (range, 153.3° to 192.1°) before surgery, with no significant difference ( t=-1.230, P=0.242). At the final follow-up, the 3D printed component was well integrated with the bone surface, the prosthesis was securely positioned, and the force lines of the lower limbs were normal. There were no postoperative complications such as poor wound healing, infection, fat liquefaction, nerve injury, deep vein thrombosis of lower limbs, knee joint stiffness, periprosthesis infection and loosening. Conclusion:Using 3D printed metal augment or tibial prosthesis to reconstruct the huge bone defect in TKA and revision has a satisfactory early clinical effect, satisfactory joint function and good surgical safety.

BACKGROUND:Stem cell transplantation is a new way to prevent and cure intervertebral disc degeneration.However,whether the transplanted stem cells can survive,proliferate,differentiate,and restore the function of nucleus pulposus cells after transplantation,is the key and difficult point to overcome. OBJECTIVE:To explore the effects of Bushenhuoxue decoction on survival,proliferation,and nucleus pulposus-like differentiation of adipose-derived stem cells. METHODS:A Transwell chamber was used to construct a co-culture model of human adipose-derived stem cells and human degenerative nucleus pulposus cells.The experiment was divided into control group,model group,drug-containing serum group,and drug-free serum group.Except for the control group,the co-culture system of other groups was treated with 50 μmol/L tert-butyl hydrogen peroxide for 24 hours.The drug-containing serum group and drug-free serum group were treated with DMEM low-glucose complete culture medium containing drug-containing serum of Bushenhuoxue decoction or drug-free serum with 20％volume fraction for 48 hours.The sublayer adipose-derived stem cells were taken.Toluidine blue staining was used to detect proteoglycan synthesis levels.Real-time PCR method was used to detect mRNA expression of type Ⅱ collagen,proteoglycan and SRY-box transcription factor 9.The protein expression of SOX9 was detected by western blot assay.Lactate dehydrogenase assay was used to detect cytotoxicity.Flow cytometry was used to detect reactive oxygen species,and β-galactosidase staining was used to detect cell senescence. RESULTS AND CONCLUSION:(1)Compared with the control group,the proportion of necrotic cells in the model group increased;toluidine blue staining became lighter,and the expression levels of type Ⅱ collagen,proteoglycan,SOX9 mRNA and SOX9 protein decreased(P<0.05).Compared with the model group,the drug-containing serum of Bushenhuoxue decoction could significantly reduce cell injury and promote the expression of type Ⅱ collagen,proteoglycan,SOX9 mRNA,and SOX9 protein(P<0.05),but the improvement in the drug-free serum group was not significant(P>0.05).(2)Compared with the control group,the contents of cytotoxicity,reactive oxygen species,and cell senescence in the model group were significantly increased.Compared with the model group,the microenvironment of the coculture system was significantly improved by drug-containing serum of Bushenhuoxue decoction(P<0.05),while drug-free serum had no significant effect on the microenvironment of the co-culture system(P>0.05).(3)The results show that Bushenhuoxue decoction can promote the survival,proliferation,and nucleus pulposus-like differentiation of adipose-derived stem cells.

Deficiency, stasis, water and toxin are of great significance in the pathogenesis and pathologic evolution of chronic heart failure (CHF). Based on "deficiency, blood stasis, water and toxin", the pathogenesis and treatment of CHF were discussed in this article. It was found that in the pathogenesis, deficiency--deficiency of heart qi and deficiency of heart yang were the origin of the disease, and blood stasis, water and toxin were the markers of the disease. Among them, blood stasis was the central pathological link, and also an important mechanism that could aggravate the disease and cause a vicious cycle; water-phlegm and water dampness were the basic pathological products; toxin-heat toxin, water toxin, and stasis toxin were the final results of disease progress and product accumulation. In terms of treatment, CHF can be divided into four stages: early, middle, late and end. In the early stage, tonifying qi and regulating heart can be used for the treatment of root cause, and promoting blood circulation and water can be used for the treatment of symptoms; tonifying qi and yin and reinforcing the healthy qi, reducing blood stasis, purging turbid, and eliminating pathogenic factors can be used in the middle stage; reducing blood stasis and removing toxic materials should be used in the late stage, supplemented with warming yang and increasing urine excretion; astringing yang,generating body fluids, tonifying qi and yang should be used in the end stage. At the same time of treating by stages, attention should be paid to adhering to a holistic concept and dialectical treatment; pay attention to timing and flexible medication; adopting a combination of Chinese and Western approaches and integrating them.

Objective: To investigate the promotional effect of the new teaching method of goal orientation combined with plan-do-check-act (PDCA) cyclic improvement on specialized medical knowledge and operation skills among physicians in critical care medicine. Methods: A total of 84 physicians who received critical care medicine training in Department of Critical Care Medicine in Foshan Hospital of Traditional Chinese Medicine from January 2013 to December 2015 were selected, and according to the time of admission, they were divided into control group with 41 physicians and experimental group with 43 physicians. The physicians in the experimental group received the new teaching method of goal orientation combined with PDCA cyclic improvement, i.e., the physicians started systematic learning according to the learning goals sent out by the teaching secretary, summarized problems during learning and looked for optimal solutions every week, and then continued learning in the next week through PDCA cyclic improvement. The physicians in the control group received traditional teaching combined with bedside teaching, but no learning goals were set for them. The two groups were compared in terms of theoretical examination scores, clinical operation skills, and results of the questionnaire survey. The t-test and Wilcoxon ranksum test were used for comparison of scores between the two groups by SPSS 18.0. Results: Compared with the control group, the experimental group had significant increases in the scores of theoretical examination (91.50±4.18 vs. 87.80±3.63) and operation skills (88.80±3.34 vs. 85.40±2.88). The questionnaire survey showed that compared with the control group, the experimental group had a significantly higher degree of satisfaction, significantly greater learning interests, and significantly greater improvements in operation skills, clinical thinking ability, and self-confidence. Conclusion The new teaching method of goal orientation combined with PDCA cyclic improvement can stimulate learning interests, clarify learning goals, help physicians to master important and difficult issues, and thus improve their learning outcomes and scores in Department of Critical Care Medicine.

Objective To investigate the three-dimensional morphological characteristics of tibial plateau based on CT image post-processing technique and analyze its significance in preoperative planning of tibial plateau fractures.Methods Multi-slice spiral CT data of 98 humans (56 males and 42 females) with normal tibial plateau and 30 patients (15 males and 15 females) with tibial plateau fractures were extracted.Morphological measurements of the tibial plateau were achieved by means of a three-dimensional measurement method based on points,lines and surfaces.Differences in threedimensional parameters between genders in normal tibial plateau and differences between normal tibial plateau and tibial plateau fractures were analyzed.Results Differences of males and females were significant in width of tibial plateau [(73.2 ± 3.7) mm,(65.5 ± 3.7) mm],anteroposterior dimension of medial tibial plateau [(39.8 ± 3.5) mm,(34.8 ± 2.6) mm] and anteroposterior dimension of lateral tibial plateau [(34.0 ± 3.3) mm,(29.8 ± 3 5) mm] (P ＜ 0.05),but not in varus inclination of tibial plateau [(3.19 ± 1.98) °,(3.16 ± 1.89) °],medial plateau posterior slope [(7.31 ± 3.04) °,(8.16 ± 2.46)°] and lateral plateau posterior slope [(5.23 ±2.35)°,(5.60 ±2.55)°] (P ＞0.05).Above parameters in three-dimensional morphological measurements of tibibial plateau fractures varied compared to the normal reference value (P ＜ 0.05).Intraclass correlation coefficient (ICC) for intra-observe and inter-observer agreement in normal tibial plateau measurement was excellent.Conclusions Present research provides a series of scientific and objective data for preoperative planning of tibial plateau fractures.Measurements of tibial plateau can assist the evaluation of reduction of tibial plateau fractures.

Objective To discuss the curative effect of computer assisted pre-operation plan (CAPP) in treating the geriatric intertrochanteric femoral fracture.Methods The data of intertrochanteric fractures treated with PFNA-Ⅱ between March 2012 and June 2015 were retrospectively analyzed.They were divided into two groups by preoperative design.One group was the CAPP group consisting of 53 patients with a mean age of 75.3 years (range,60-92 years).According to the Evans Classification,there were 12 Evans type Ⅰb,9 Evans type Ⅰc,15 Evans type Ⅰd and 17 Evans type Ⅱ fractures.The other group was the non-CAPP group consisting of 74 patients with a mean age of 76.6 years (range,62-95 years).There were 18 Evans type Ⅰb,15 Evans type Ⅰc,20 Evans type Ⅰd and 21 Evans type Ⅱ fractures.Operation time,intraoperative blood loss,times of fluoroscopy during operation and days of hospital stay were compared.The hip joint function was evaluated by Harris score at the final follow-up.Results The CAPP meanly cost 24.7 min.The consistency of the surgery and CAPP was up to 100％.In the CAPP group,the average operation time was 46.8±6.5 min;the average times of fluoroscopy during operation were 12.0±2.3 times;and the average blood loss was 154.4±27.6 ml.In the non-CAPP group,the average operation time was 57.8±10.3 min;the average times of fluoroscopy during operation was 20.9±3.2;and the average blood loss was 235.0±65.8 ml.All above data in the CAPP group were significantly lower than those in the non-CAPP group.The mean days of hospital stay were 13.9±1.3 days in the CAPP group and 14.3±1.4 days in non-CAPP group.The days of hospital stay had no significant difference between the two groups.Forty-five patients with an average follow-up period of 18.3 months were reviewed in the CAPP group.Fifty patients were followed up with an average period of 19.2 months in the non-CAPP group.At the final follow-up,the average Harris score was 88.6±2.8 points (range,84-96 points) in the CAPP group and 87.5±3.2 points (range,80-95 points) in the non-CAPP group.Conclusion CAPP system is convenient and efficient.It can facilitate the treatment of intertrochanteric fracture effectively.

Objective To study effect of Xuebijing injection on coagulation function and prevention of deep venous thrombosis in elderly fracture patients with mechanical ventilation.Methods 60 patients were randomly divided into control group(30 cases) and Xuebijing group(30 cases).Xuebijing group received Xuebijing injection, besides physical therapy for prevention of deep venous thrombosis received by control group.Coagulation parameters and Lac at different time points,thrombosis incidence,hemorrhage incidence APACHE II score and 28 -day mortality were compared between the two groups.Results In Xuebijing group,PT,APTT,DD on d3 and Fg 48 on d5 had statistically significant differences compared with before treatment.PT,APTT on d3,d5 and DD on d5 were statistical-ly different compared with the control group(P <0.05).PLT,Lac,hemorrhage incidence and 28 -day mortality had no significant differences between the two groups.Thrombosis incidence in Xuebijing group was significantly lower than the control group(20.00% vs 3.33%) (χ2 =4.043,P =0.044,P <0.05).Both of APACHE II score were lower than before treatment,but the Xuebijing group was significantly decreased(t =5.48,P =0.000,P <0.05). Conclusion Xuebijing injection could improve coagulation function,and decrease thrombosis incidence in elderly fracture patients with mechanical ventilation.

Objective To provide references for anatomical reduction and correct implantation in treatment of distal fibular fracture by analyzing morphological characteristics of distal fibula on three-dimensional (3D) modes.Methods 16-row spiral CT scans of 126 normal ankle structures from May 2009 to June 2014 were collected.Surface shaded display technique was used to reconstruct 3-D images of bones around the ankle.The distal fibula was extracted using 3D segmentation technique.The parameters of distal fibula were measured by selecting points,lines and surfaces on the 3D models.Results The morphological characteristics of distal fibula were complicated.Significant differences were observed between males and females in most parameters (P ＜ 0.05),but not in the length between the plane of the most lateral point of the tibial anterior node and the most distal point of the fibula,the length between the midpoint of lateral border of the fibula and its opposite cortex on the plane of the most proximal border of the fibular fossa or the mean angle of posterior crest of the fibula (P ＞ 0.05).The intra and interclass correlation coefficients (ICC) were excellent.Conclusions When a lateral plate is used for internal fixation of distal fibula,the plate should be placed as proximally as possible.When a posterior-lateral plate is used,the screws to be inserted on the plane proximal to the initial point of anterior node of the tibia can be fixed bi-cortically.When a posterior plate is used,pre-contour of the plate before insertion is required.

Objective To establish a way to measure the injury severity of articular surface due to posterior malleolus fracture and investigate its clinical significance based on three-dimensional reconstruction technique.Methods Between May 2009 and March 2014,138 cases of peri-ankle injury combined with posterior malleolus fracture were treated.Lateral radiographs were reviewed to measure the ratio of posterior fragment area to distal tibial plafond area using the common method.Three-dimensional CT images were examined to measure ratio of the area of injury using the three-dimensional measuring method.Statistical comparison was made using the t-test and intraclass correlation coefficient (ICC).Results Measurement failed on 33 lateral radiographs and 13 three-dimensional CT images.Six cases cannot be measured by both imaging technology,so results of 98 cases were compared.Ratio of posterior fragment area to tibial plafond area was (16.2 ± 7.2) ％ measured by radiographs and was (29.6 ±10.1) ％ by three-dimensional CT scans (P ＜ 0.05).Three-dimensional CT measurements showed higher intra and inter-observer agreement (ICC of 0.973 to 0.942) than that in radiographic measurements (ICC of 0.875 to 0.860).Conclusion Three-dimension CT assessment of the extent of injury to articular surface because of posterior malleolus fracture is reliable and reproducible,but radiographic assessment may underestimate the injury and influence the choice of surgical indications.

Objective To study the effect of Xuebijing injection on transfusion and systemic inflammation in traumatic coagulopathy patients. Methods Seventy-nine patients were randomly divided into Xuebijing Group (36 cases) and Control Group (43 cases). Xuebijing group received Xuebijing injection in addition to the regular treatment received by control group. Levels of TNF-α, IL-6, IL-8 and transfusion amount between two groups were compared. Results Coagulation abnormality was almost corrected in all patients after treatment. In Xuebijing Group, transfusion of RBC, FFP and cryoprecipitate were significantly less than that in control group (P<0.05). At 72 h after admission, TNFα, IL-6 and IL-8 were significantly lower in Xuebijing Group (P < 0.05). Conclusion Xuebijing injection could reduce transfusion in traumatic coagulopathy patients , possibly resulting from its antagonism against systemic inflammation.