Pregnancy complicated by aortic root aneurysm in patients with Marfan syndrome is one of the main causes of termination of pregnancy or even death in pregnant women. A very small number of pregnant women require cardiac surgery to preserve pregnancy under extracorporeal circulation, and all surgeries use aortic root replacement. We reported a 30-year-old patient with severe aortic regurgitation combined with giant aortic root aneurysm and Marfan syndrome in mid-pregnancy. Valve-sparing root replacement using reimplantation technology was performed via a multidisciplinary cooperation model. This not only achieved the patient’s desire to continue pregnancy but also avoided the anticoagulation and bleeding complications brought by mechanical valve replacement, reduced pregnancy risks and improved long-term quality of life. Postoperative echocardiography showed a small amount of aortic valve regurgitation, aortic valve coaptation height of 0.6 cm, effective height of 1.1 cm, maximum aortic flow velocity of 1.4 m/s, mean transvalvular pressure gradient of 4.4 mm Hg, and satisfactory clinical results.

Objective:To evaluate the various wire tension belt ventral compression wiring technologiesfor treating several types of femoral greater trochanter fractures in total hip replacement, according to the different types of greater trochanter of femur fractures.Methods:From March 2013 to June 2019, a total of 1 280 cases of primary total hip arthroplasty were completed in our hospital, 21 patients with greater trochanter fractures were identified in total hip replacement. There were 11 males and 10 females with an average age of 65.81±6.45 years (range 42-76 years). All of them were unilateral. There were 11 cases on the left and 10 cases on the right. There were 11 cases of osteoarthritis secondary to hip dysplasia, 4 cases of hip osteoarthritis, 4 cases of aseptic necrosis of femoral head and 2 cases of femoral neck fracture. Different wire tension belt ventral compression wiring technologies were used for each fracture type. Harris hip function score, Parker activity score, and visual analogue scale (VAS) score of hip pain were evaluated during follow-up. X-ray films were taken to evaluate the fracture healing, prosthesis position, loosening and dislocation.Results:Three new fracture types were proposed: A transverse fracture from the greater trochanter tip to the base (4 cases); B oblique fracture from the greater trochanter tip to the base (according to the fracture line direction, type B was further divided into types B1 (4 cases) and B2 (6 cases); and C fracture line from the greater trochanter to subtrochanteric plane (7 cases). Among the 21 patients, one died at an early stage, two were lost during follow-up, and 18 were followed up for an average of 30.7±7.6 months. In 18 patients, the mean operation time was 110.0±20.0 min, and the mean intraoperative blood loss was 356.9±115.7 ml. The patients' Harris score was 35.26±5.52 at the preoperative, 65.7±6.42 at the 3 months after operation, and 87.75±6.21 at the final follow-up. The difference was statistically significant ( F=377.23, P<0.001). The patients' Parker score was 2.17±0.98 at the preoperative, 5.94±1.11 at the 3 months after operation,and 8.01±0.77 at the final follow-up. The difference was statistically significant ( F=170.96, P<0.001). The patients' VAS score was 6.22±1.11 at the preoperative, 2.61±0.92 at the 3 months after operation, and 1.28±0.67 at the final follow-up. The difference was statistically significant ( F=139.71, P<0.001). Deep vein embolism, heterotopic ossification was noted in one and another patient, respectively. The patient with non-union refused reoperation and had a broken steel wire, lower-limb limp, and no notable pain at the 12-month follow-up examination. Radiographs of 17 patients showed good location of the femoral prosthesis and no chronic pain. Conclusion:Different types of greater trochanter fractures in total hip arthroplasty were proposed, using different wire tension belt ventral compression wiring technologies for the various types of femoral greater trochanter fractures during total hip replacement can improve clinical outcomes.

Objective:To investigate the effectiveness and safety of middle-column preserved pedicle subtraction closing-opening wedge osteotomy for the treatment of stiff kyphosis.Methods:From January 2016 to April 2018, 12 patients with stiff kyphosis in our department were treated with middle-column preserved pedicle subtraction closing-opening wedge osteotomy. The patients' operative time, intraoperative blood loss, postoperative drainage, surgical complications, low back pain and leg pain visual analogue scale (VAS), Oswestry dysfunction index (ODI) score, and SF-36 were recorded.These parameters were compared at preoperative, postoperative, and at the final follow-up. Coronal parameters included lumbar scoliosis Cobb angle, C 7 vertebral body center to humeral vertical line distance (C 7PL-CSVL), whilesagittal parameters includedlumbar Lordosis (LL), sacral slope (SS), pelvic tilt (PT), and sagittalvertical axis (SVA). Results:All of 12 patients successfully completed the operation.The mean operation time was 238.20±65.95 min, the mean intraoperative blood loss was 440.50±133.60 ml.The patients’ODI score was 65.92%±6.96% at the preoperative, and 21.00%±3.19% at the final follow-up. The difference was statistically significant ( t=20.32, P<0.0001).The VAS score of back pain was 6.00±0.95 at preoperative, 2.33±0.89 at 3 months postoperatively, and 1.42±0.51 at the final follow-up. The VAS score of leg pain was 6.91±1.24 at preoperative, 2.50±1.00 at 3 months postoperatively, and1.50±0.52 at the final follow-up. There was significant difference in SF-36 at preoperative and at final follow-up ( P<0.05). The differences in LL, SS, PT and SVA at the preoperative and at final follow-up were statistically significant ( F=17.47, P<0.001; F=5.015, P=0.0125; F=14.66, P<0.001; F=81.11, P<0.001) . There was significant difference in lumbar scoliosis Cobb angle and C 7PL-CSVL at the preoperative and at final follow-up ( F=87.19, P<0.001; F=100.9, P<0.001) . Conclusion:The advantages of this surgical procedure includesimple operation, reducedsurgery time, and shorten intraoperative bleeding, which can effectively relief clinical symptoms, improve the quality of life, correctkyphosis, and maintain the patient's spinal-pelvic balance.

Objective:To investigate the effect of middle-column preserved pedicle subtraction closing-opening wedge osteotomy for the treatment of old thoracolumbar compression fractures combined with kyphosis deformity.Methods:A retrospective case series study was performed to analyze data of 27 patients with old thoracolumbar compression fractures combined with kyphosis deformity admitted in Taizhou Hospital from January 2010 to January 2017. There were 10 males and 17 females, with age range of 45-75 years (mean, 61.7 years). The injured segments and osteotomy segments included T 11 in 5 patients, T 12 in 10, L 1in 8 and L 2 in 4. Time from initial fracture to surgery was 9-120 months (mean, 23.2 months). According to the American Spinal Injury Association (ASIA) classification, neurological impairment symptoms were detected in 9 patients, including grade C in 1 and grade D in 8. All patients underwent one-level middle-column preserved pedicle subtraction osteotomy. Operation time, blood loss, and perioperative complications were recorded. Before operation, at 3 months after operation and at latest follow-up, kyphosis Cobb angle, sagittal vertical axis (SVA) and height of anterior column (AC) as well as posterior column (PC) were measured. Visual analogue scale (VAS) and Oswestry disability index (ODI) score were used to evaluate the clinical efficacy. American Spinal Injury Association (ASIA) score was used to assess neurological function. Results:All patients were followed up for average 18.1 months (range, 12-34 months). Operation time was (155.2±35.4)minutes (range, 130-250 minutes). Blood loss was (338.1±101.4)ml (range, 150-550 ml). No serious neurological or vascular complications occurred during perioperative period. Kyphosis Cobb angle was (6.0±3.1)° at postoperative 3 months compared to preoperative (46.5±8.5)°( P<0.05), and showed no significant loss at latest follow-up [(7.9±3.8)°] ( P>0.05). SVA was improved significantly from preoperative [42.7(25.5, 78.2)]mm to [5.5(1.2, 7.3)]mm at postoperative 3 months ( P<0.05). AC height was increased by average 16.3 mm at postoperative 3 months compared to the preoperative level ( P<0.05), with no significant change in PC height ( P>0.05). There was no significant difference in SVA, AC height and PC height at postoperative 3 months and latest follow-up ( P>0.05). There were significant differences in VAS [(1.7±0.8)points, (2.3±1.4)points] and ODI (17.3±7.5, 19.4±4.3) at postoperative 3 months and at latest follow-up compared to these before operation [(7.7±1.3)points, 61.4±6.2] ( P<0.05), with no significant differences in VAS and ODI at postoperative 3 months and latest follow-up ( P>0.05). No implant failure was noted during follow-up. The osteotomy surface was fused in all patients at postoperative 6 months. At latest follow-up, ASIA grade was improved from grade C to grade D in 1 patient and from grade D to grade E in 8 patients. Conclusion:Middle-column preserved pedicle subtraction closing-opening wedge osteotomy can effectively correct old thoracolumbar fractures with kyphosis, relieve pain and improve nerve function.

Objective: To explore the clinical effect of reduction and reconstruction of the removed bony structure after one-stage posterior resection of high cervical tumors. Methods: From October 2009 to March 2018, 17 patients including 10 males and 7 females of high cervical tumors who underwent one-stage posterior resection with an average age of 57 years (26~84 years) were reviewed. There were 11 shwannomas, 3 meningiomas and 3 concurrent shwannoma and meningioma arising in the same level, respectively. Reduction with (14 cases) or without internal fixation (3 cases) were performed for the removed C1 posterior arch or C2 laminar and spinous process. The clinical effects were compared with Visual analogue score (VAS), Japanese Orthopaedic Association scores (JOA) and American Spinal Injury Association (ASIA) grade. The cervical lordosis and range of motion were measured with the X-ray before the operation and at the last follow-up. Results: There were no vertebral artery injury or massive hemorrhage during the surgeries. The operation time was 184±43 min, blood loss was 203±223 ml, and mean follow-up period was 29.1±28.2 months. No recurrence was found during the follow-up, and the motor and sensory were significant recovered in all patients after surgery. VAS score and JOA score were significantly improved at the last follow-up. ASIA grade was C for 1 case, D for 11 cases and E for 5 cases before surgery. After surgeries, C improved to D, 8 cases of D improved to E and 3 cases of D failed improved to E. Although the cervical lordosis and range of motion was decreased significantly in the last follow-up in X-ray, no patients complained stiffness and discomfort in rotation or flexion and extension of the neck. Cardiac arrest during operation was occurred in 1 case, and heartbeat recovered after stopping the manipulation. CSF leakage was found in 9 cases and no surgical site infection was occurred. Conclusion Resection of high cervical dumbbell-shape tumors is a demanding surgery with high incidence of complications. The reduction and reconstruction of removed bony structure without fusion could rebuild the stability of high cervical spine and preserve the cervical range of motion as much as possible which improves clinical effect.

OBJECTIVE: To investigate the expression of Toll-like receptor 4 (TLR4)/myeloid differentiation factor (MyD88)/nuclear factor-κB (NF-κB) pathway genes and related inflammatory factors tumor necrosis factor-α (TNF-α), interleukin (IL)-12, IL-6 in patients with secondary spinal cord injury (SSCI) and the correlations with prognosis. METHODS: The clinical data of 105 SSCI patients and 40 healthy subjects were reviewed. According to Frankel's classification of spinal cord injury, the patients were divided into complete injury group and incomplete injury group, and according to the improvement of Japanese Orthopedic Association (JOA) scores, the patients were divided into good prognosis group and poor prognosis group. The expression of TLR4, MyD88, NF-κB in peripheral blood mononuclear cells (PBMC) and serum TNF-α, IL-12, IL-6 levels were compared between SSCI patients and healthy controls, between patients with complete and incomplete injury, between patients with poor and good prognosis. Logistic regression analysis was used to analyze the risk factors leading to poor prognosis of SSCI, and Pearson's correlation analysis was used to analyze the correlation between JOA score and the above indicators. RESULTS The expressions of TLR4, MyD88, NF-κB in PBMC and serum TNF-α, IL-12, IL-6 levels in SSCI patients were significantly higher than those in healthy subjects (all P<0.01), those in complete injury group were higher than those in incomplete injury group, and those in poor prognosis group were higher than those in good prognosis group (all P<0.01). The proportions of patients with Frankel grade A, spinal cord edema or hemorrhage, spinal cord injury length longer than 4 cm in poor prognosis group was significantly higher than those in good prognosis group (all P<0.01). Logistic regression analysis showed that Frankel grade, spinal cord edema or hemorrhage, length of spinal cord injury, relative expressions of TLR4, MyD88, NF-κB in PBMC, serum levels of TNF-α, IL-12 and IL-6 were risk factors for poor prognosis in SSCI patients (P<0.05 or P<0.01). Pearson's correlation analysis showed that JOA improvement rate was negatively correlated with the relative expressions of TLR4, MyD88, NF-κB mRNA in PBMC and serum TNF-α, IL-12, IL-6 levels (P<0.05 or P<0.01). CONCLUSIONS The activation of TLR4/MyD88/NF-κB pathway and the up-regulation of the expression of related inflammatory factors TNF-α, IL-12 and IL-6 are involved in the progression of SSCI, which are closely related to the neuroinflammatory injury, and can be used as reference indexes for evaluating prognosis in SSCI patients.

Objective To investigate the correlations of distribution and grading of deep medullary veins (DMVs) with clinical prognoses of patients with acute anterior circulation infarction by using susceptibility-weighted imaging (SWI).Methods Fifty patients with acute anterior circulation infarction,admitted to our hospital from August 2016 to December 2017,were enrolled in our study.SWI was performed to evaluate the DMVs.Univariate and multivariate Logistic regression models were used to determine the correlation between distribution of DMVs and clinical prognoses of patients.DMVs on the ipsilateral side of the lesions were further graded and analyzed;boxplot was used to describe its relation with modified Rankin scale (mRS) scores of the patients.Results DMVs were observed in 36 patients (72％),with 19 ipsilateral DMVs and 17 contralateral DMVs.The ipsilateral DMVs were independently associated with poor outcome (odds ratio=3.380,95％CI:1.006-11.393,P=0.049).The contralateral DMVs were not independent predictors for outcomes,but appeared commonly in patients with good outcome (44.8％).In patients with ipsilateral DMVs,grading 1,grading 2,and grading 3 were noted in 7,two and three patients,respectively;boxplot analysis showed that DMVs patients of grading 3 had higher mRS scores,with an average of 4.Conclusion The ipsilateral DMVs on SWI are independent predictive biomarkers for poor clinical outcome after stroke,and contralateral DMVs often indicate good prognosis.

Objective Based on MRI m-Dixon-Quant technique to quickly quantify bone marrow fat content in the vertebral body of middle-aged and elderly patients,and provide a scientific basis for the diagnosis of osteoporosis(OP).Methods A total of 74 middle-aged and elderly patients who were admitted to our hospital from July 2016 to July 2017 were collected.The age,sex and body mass index (BMI)of the patients were collected.All subjects were evaluated for bone mineral density (BMD)and fat fraction (FF)and other indicators of measurement.According to the guidelines for bone mineral density measurement by the American College of Radiology(ACR),the subject was classified by the bone mineral density value,and receiver operating characteristic(ROC)curve was used for the diagnosis and analysis of FF.Results The average age of the subjects was (59.50±8.72)years.There was a positive correlation between MRI m-Dixon-Quant FF and age(r=0.436),which was highly negatively correlated with the average bone density(r=-0.739).By ROC analysis,the sensitivity and specificity were 74.2% and 83.3% for normal and low bone mass groups,92.0% and 88.9% for the normal and OP groups,and 72.0% and 87.1% for the low bone mass and OP groups.FF could be used for the evaluation of OP.If FF<54.60,normal bone mass was considered.If 54.60≤FF≤65.20,low bone mass was considered,if FF>65.20,OP was considered.Conclusion The MRI m-Dixon-Quant FF index can be rapidly and quantitatively used for the diagnosis of OP,which provides a new reference for the diagnosis of OP.

Objective To investigate the effectiveness and safety of middle-column preserved pedicle subtraction closingopening wedge osteotomy for the treatment of ankylosing spondylitis (AS)-related thoracolumbar kyphosis.Methods From January 2010 to December 2016,eleven patients (9 males and 2 females) who underwent one-level middle-column preserved pedicle subtraction osteotomy with an average age of 40.8 years (21-68 years) were reviewed.The average thoracolumbar kyphosis angle (TLK) was 50.5°±9.6° and the average lumbar lordosis angle was-2.5°±24.1°.The thoracolumbar kyphosis,sagittal vertical axis (SVA),lumbar lordosis,pelvic tilt,sacral slope,thoracic kyphosis,Scoliosis Research Society (SIRS) 22,Oswestry disability index (ODI) score,the length of anterior column and posterior column at the pre-and post-operation,operation time,perioperative blood loss and complications were recorded.Results The osteotomy sites of 11 cases included 7 in L2,2 in L3 and 2 in T12.Theaverage operation time was 156.8 min (120-220 min).The average blood loss was 604.5 ml (350-900 ml).The average time of followup was 24 months (12-42 months).Complications were encountered in 2 patients.There were 1 casewith transient neurological deficits,another case with incision infection.No serious neurological or vascular complications occurred in all cases.The thoracolumbar kyphosis (TLK),lumbar lordosis,pelvic tilt,sacral slope,thoracic kyphosis,SRS 22 and ODI score were improved significantly.The preoperative TLK cobb was 50.5° (36°-66°),which improved to 5.1 ° (1 °-11°) at the final follow-up with a mean correction rate of 89.9％.Sagittal migrationwas improved from 184.6 mm preoperatively to 79.2 mm atthe final follow-up with an average correctionrate of 49.3％.The differences of the length of posterior column of osteotomy site after operation showed no statistical significance.All patients had solid fusion at osteotomy site and no instrumentational failure and loosening were found over the follow up.Conclusion Middle-column preserved pedicle subtraction closing-openingwedge osteotomy is safe and effective for correction of the thoracolumbar kyphosis deformity occurring in ankylosing spondylitis,resulting in satisfactory out comes with acceptable complications.

Objective To investigate the clinical efficacy and prognostic factors for M4/M5subtypes in chil-dren with acute myeloid leukemia(AML).Methods A retrospective analysis of the clinical data of M4/M5subtypes in Shanghai Children′s Hospital Affiliated to Shanghai Jiaotong University,from January 2009 to December 2014 was carried out.The long-term efficacy,prognosis and relapse factors were analyzed.Results The clinical data of 46 ca-ses were collected,among which 38 cases were treated with more than 2 courses,including 22 male,16 female,19 cases M4and 19 cases M5.The median age was 5 years.5-year overall survival(OS)rate and 5-year event-free survival (EFS)rate were(57.7 ± 9.3)% and(47.2 ± 8.9)%,and 5-year EFS of M4and M5were(52.4 ± 12.7)% and (45.4 ± 11. 9)%. Compared with the international risk stratification:5-year EFS rate of favorable-risk, intermediate-risk and poor-risk were(77.2 ± 12.4)%,(49.5 ± 14.9)% and(25.0 ± 19.8)%(χ2=6.305,P=0.043).Single factor analysis showed that extramedullary infiltration(χ2=4.828,P=0.028),Chromosome karyotype (χ2=10.178,P=0.017),the eighth day assessment(χ2=5.382,P=0.020)and course of treatment(χ2=4.771, P=0.029)were prognostic factors;multivariate analysis showed extramedullary infiltration(HR =5.323,95%CI:1.620-17.490,P=0.006)and less-than-6 courses of treatment(HR=6.186,95%CI:1.726-22.176,P=0.005)were the independent risk factors of affecting survival.Conclusions (1)Strengthening treatment and ade-quate courses of treatment are the critical to improve the overall curative effect in children with M4/M5subtypes.(2) Extramedullary infiltration was the risk factor for survival and recurrence in M4/M5subtypes.(3)It is suggested that the children who have the initial symptoms and molecular biology with poor prognostic factors choose hematopoietic stem cell transplantation as early as possible.