Background:Acromioclavicular joint dislocation is common in the clinic, mostly in young adults and people who like sports. Patients with less severe injuries, such as Rockwood I, II, and some III, can be treated with conservative therapy with satisfactory results. In contrast, Rockwood types IV, V, and VI with severe acromioclavicular dislocation require surgery. The most controversial treatment is Rockwood type III, where persistent dislocation of the acromioclavicular joint leads to persistent pain and dysfunction due to failure of conservative treatment. However, due to the obsolescence stage at the time of treatment, different clinical reports have a certain incidence of poor reduction, loss of reduction, and residual pain. We proposed the method of coracoclavicular ligament + acromioclavicular ligament reconstruction under arthroscopy, which gives full play to the advantages of minimally invasive surgery and has certain significance for improving postoperative shoulder joint function and alleviating pain.Objective:To investigate the effect of arthroscopic reconstruction of coracoclavicular and acromioclavicular ligaments in treating chronic Rockwood type III acromioclavicular joint dislocation.Methods:A total of 14 patients diagnosed with old acromioclavicular dislocation from January 2016 to December 2020 were selected, including 8 males and 6 females, with an average age of (37.2±10.1) years and an average injury time of (13.4±3.5) months, and 7 patients with dominant shoulder joint involved. All underwent arthroscopic coracoclavicular + acromioclavicular ligament reconstruction. Each patient was followed up at different postoperative time points (1, 3, 6, 12 months after surgery) , and pain (VAS score) and shoulder function (UCLA score) were evaluated.Results:Fourteen patients diagnosed with obsolete acromioclavicular dislocation (all Rockwood type III) entered the study. They completed surgery, and 12 were thoroughly followed up, with a mean follow-up of (26.3±8.6) months (12-36 months) . (1) VAS score: Preoperative, postoperative 1 month, 3 months, 6 months and 12 months scores were (5.667±0.414) point, (5.583±0.288) point, (4.583±0.229) point, (2.833±0.271) point, (0.538±0.193) point, respectively. Compared with pre-operation, all patients showed pain relief at 3, 6 and 12 months after surgery, and the degree of pain relief (changes in VAS score) at 6 and 12 months after surgery was statistically improved (P<0.001) . (2) UCLA score: Preoperative, postoperative 1 month, 3 months, 6 months and 12 months scores were (19.083±0.468) point, (18.583±0.434) point, (21.000±0.628) point, (25.750±0.579) point, (32.750±0.509) point, respectively. Compared with pre-operation, UCLA scores of all patients at the 3rd, 6th and 12th months follow-up was improved, and the UCLA scores improvement at 6- and 12-months follow-up was statistically different (P<0.001) .Conclusion:Arthroscopic reconstruction of coracoclavicular and acromioclavicular ligaments can relieve pain and improve shoulder function in patients with chronic acromioclavicular dislocation with less trauma.

全膝关节置换(TKA)术后的伸膝装置损伤是一种少见而严重的并发症.本文主要探讨伸膝装置中软组织损伤的治疗方法.伸膝装置损伤会导致伸膝受限,影响患者的日常行走,严重影响患者的生活质量.其治疗目前包括保守治疗及手术治疗,保守治疗主要包括制动、拐杖等辅助行走工具;手术治疗包括修复及重建两种类型.本文主要介绍TKA术后伸膝装置损伤的病因、伸膝结构的解剖特点及治疗方法,并对各种治疗方法的效果、并发症及相应预后进行了总结.

背景:内侧间室膝关节骨关节炎是一种常见的慢性骨科疾病,多发于中老年人,是引起膝关节疼痛的常见原因.目的:回顾性分析关节镜联合内侧开放楔形胫骨高位截骨术治疗内侧间室膝关节骨关节炎的中期临床疗效.方法:2016年3月至2018年10月,应用关节镜探查联合内侧开放胫骨高位截骨术治疗内侧间室膝关节骨关节炎并成功随访39例(41膝),其中,男6例(6膝),女33例(35膝);年龄50～69岁,平均(61.9±4.5)岁.手术前后常规拍摄双膝关节负重正侧位X线片和下肢全长X线片,记录手术前后股胫角(FTA)、胫骨近端内侧角(MPTA)和视觉模拟评分(VAS)的改变,采用美国特种外科医院(HSS)评分系统、膝关节Lysholm评分系统比较手术前后膝关节功能.记录并发症的发生情况.结果:患者随访22～36个月,平均(27.4±5.8)个月.关节镜下观察到35侧膝关节合并其他损伤,包括半月板撕裂(33膝)、关节软骨损伤(17膝)、软骨游离体(6膝)、前交叉韧带损伤(1膝)等.术后患者的膝内翻畸形均得到有效纠正.手术前后VAS评分、FTA、MPTA、Lysholm评分、HSS评分、关节活动度差异有统计学意义(P<0.01).随访期间未观察到内固定失效的病例,未发现截骨处不愈合、伤口愈合不良或术后感染的情况.结论:关节镜探查联合内侧开放楔形胫骨高位截骨术能够有效矫正患肢力线,缓解疼痛症状,并且能及时发现关节内合并其他结构损伤的情况,同时采用措施进行干预,是治疗内侧间室膝关节骨关节炎的一种安全有效的方法.

Objective To evaluate the surgical technique and clinical effect of less invasive intrame-dullary nail fixation combined with titanium cable cerclage in the treatment of subtrochanteric fractures. Methods A retrospective study was performed in 46 cases of subtrochanteric fractures in Peking University People's Hospital from January 2015 to December 2017. Among them, there were 14 males and 32 females, with an average age of (77.83±10.66) years (44-92 years); 17 cases on the left side and 29 cases on the right side. The causes of injury included crash from a height, traffic accident and accidental fall. According to Seinsheimer classification, there were 26 cases of type Ⅱ, 11 cases of type Ⅲ, 9 cases of type Ⅳ, and these cases were all closed injury. After admission, these patients underwent continuous tibial tuberosity bone traction to maintain the length and force line of the lower extremity, so as to reduce the difficulty of intraoperative fracture reduction. Anticoagulant therapy was given before operation to reduce perioperative thrombotic complications. All the patients were treated with less invasive intramedullary nail fixation combined with titanium cable cerclage. Operation time, blood loss during surgery, time of fracture healing were recorded, Harris and Sanders scoring system were used to assess hip function after operation at each follow-up time point. Results All the included patients underwent surgery successfully. Average operative time and intraoperative blood loss of these patients were (131.09 ± 20.06) min and (191.96±111.03) mL, respectively. All the patients were followed up satisfactorily, with an average follow-up time of 28 months. The fractures received bone healing within 3-6 months, average hospital stay was (10.61±2.85) days. The Sanders score was excellent in 3 cases, good in 37 cases and common in 6 cases, with an excellent and good rate of 86.96%. The Harris score was excellent in 6 cases, good in 36 cases, with an excellent and good rate of 91.30%. There were no cases of wound infection, loss of reduction, nonunion of fracture or internal fixation failure. Hip pain symptoms were effectively relieved in most patients. Conclusion Less invasive intramedullary nail fixation combined with titanium cable cerclage can obtain good alignment and stability of fracture ends, which is an effective method for the treatment of subtrochanteric fractures.

目的 调查本院创伤骨科手术部位感染(surgical site infection,SSI)患者的发病情况,并分析感染原因,为预防和控制SSI提供依据.方法 选取本院自2015年1月至2019年12月期间创伤骨科所有住院手术患者为研究对象,共计10 645例患者,依据卫生部2001年颁布的《医院感染诊断标准(试行)》进行医院感染病例诊断,并根据临床科室上报的医院感染资料信息进行病历筛选和回顾性分析.结果 10 645例创伤骨科手术患者中,31例患者发生SSI,感染发生率为0.29％.2016年至2019年感染发生率呈逐年下降趋势.感染的主要病原菌为G(+)球菌,占87.50％.感染类型主要是器官(或腔隙)感染,占61.29％.患者年龄、体重指数、手术时间、手术方式、手术部位与骨科手术患者SSI的发生有相关性(P＜0.05).结论 创伤骨科手术患者SSI是临床上不可回避的问题,应重视相关危险因素,积极采取有针对性的预防控制措施改善可变因素,以有效降低骨科手术患者SSI的发生.

OBJECTIVETo investigate the clinical effect of a modified arthroscopic outside-in suture technique in the treatment of meniscus tear using a spinal needle.METHODSFrom January 2015 to October 2017, 95 patients treated with this method were followed-up. Among these cases, there were 36 males and 59 females. The age of the patients ranged from 16 to 77 years, (46.79±18.07) years in average. Among them, there were 28 patieats aged 16-35, 53 patients aged 36-65, and 14 patients aged over 65 years old. 28 cases were diagnosed with medial meniscus tear, 43 cases with lateral meniscus tear and 24 cases with both medial and lateral meniscus tear. Causes of the injury included sports, sprain, etc. According to Barrett standard, the clinical healing of meniscus tear was judged. Lysholm score, knee range of motion, visual simulation score (VAS) and magnetic resonance imaging (MRI) were used to evaluate the postoperative knee function and recovery of the patients.RESULTSThe 95 patients were followed up for 22 to 36 months, with an average of (28.32±3.98) months. According to Barrett standard, 90 patients (94.7%) obtained meniscus clinical healing. Meniscal healing rates were 96.43%, 96.23% and 85.71% in the three age groups, respectively. The meniscal healing rate was lower in the elderly group, but there was no significant difference in statistical results (P=0.262). Five patients had deep tenderness in the joint space of the injured side, and the overstretch test was positive. The preoperative and postoperative VAS scores, Lysholm scores and knee motion were compared in each group, and the differences were statistically significant (P < 0.01). At the end of the last follow-up, there were no cases of knee joint effusion, swelling and interlocking, and the joint function was effectively improved in most patients. No surgical site infection, periarticular vascular/nerve injury or knotting reaction was found during the follow-up.CONCLUSIONThis modified arthroscopic outside-in suture technique using a spinal needle has the characteristics of simple operation, small trauma and rapid recovery, and the mid-term follow-up results were satisfactory. Therefore, we consider this method to be a safe and efficient method for the treatment of meniscus anterior horn and body tear.

Objective To observe operative outcomes of suture-button technique for acute Lisfranc injury.Methods A retrospective observation was conducted of the 11 patients who had been operatively treated with suture-button technique and plate fixation for acute Lisfranc injury from January 2015 to December 2016.They were 8 men and 3 women,aged from 22 to 54 years(mean,32.1 years).By the Myerson classification for the injury,there were 9 cases of type B2 and 2 cases of type Cl;by the Chiodo classification,there were 7 cases of middle column injury,2 cases of injury to middle and lateral columns and 2 cases of injury to medial and middle columns.Their scores on the visual analogue scale(VAS),mid-foot scores of American Orthopedic Foot and Ankle Society(AOFAS),bone union and complications were observed post-operatively.Results Follow-ups for this cohort lasted for 14 to 34 months(mean,20.5 months).Follow-ups revealed that their VAS scores for the affected foot averaged 0.6(from 0 to 2),significantly higher than those for the nomal foot(Z=2.070,P=0.038).Their AOFAS scores averaged 95.2(from 87 to 100),significantly lowerer than those for the nomal foot(Z=2.121,P=0.034).All fractures were united well.Conclusion Suture-button technique can lead to satisfactory outcomes for acute Lisfranc injury.

OBJECTIVE:To evaluate the association between rotator cuff tear and the proximal migration of humeral head.METHODS:In this research, we retrospectively selected 30 patients with unilateral rotator cuff tear in Peking University People's Hospital from September 2015 to May 2016, who received magnetic resonance imaging (MRI) and X-ray of the painful shoulder before enrollment in this study, the duration between the two examinations was no longer than 1 week, and also there was no past history of surgery in the selected shoulders. There was no other exclusion criteria. Upward migration index (UMI) was the ratio between the distance of humeral head center to the lower surface of acromion, and the radius of humeral head circle, which could help to minimize the effect of anatomy difference and imaging magnification, compared with the traditional acromiohumeral distance (AHD). Then we introduced this index to stratify the selected 30 patients into 3 groups, and each group contained 10 patients, UMI of group 1 was >1 and ≤1.2, UMI of group 2 was >1.2 and ≤1.4, UMI of group 3 was >1.4. As the supraspinatus was most commonly affected by pathological change among the four rotator cuff tendons, we took it as the research object. Then we used the Spearman correlation analysis to evaluate the relationship between UMI and fatty degeneration, rotator cuff tear size and the thickness of ruptured supraspinatus tendon from X-ray and MRI.RESULTS:In the A-P view, the average UMI was 1.33 (1.02-1.51, SD: ±0.22). UMI and the tear size had a significant negative correlation (R=-0.584, P<0.01), and also there was a negative correlation between the fatty degeneration of the supraspinatus (R=-0.312, P=0.033). However, there was no correlation between UMI and the thickness of ruptured supraspinatus (R=0.127, P=0.071).CONCLUSION:UMI is related with the fatty degeneration of supraspinatus and the tear size. The reduction of UMI is a predictable and reliable mark of rotator cuff tear and degeneration in clinic. Physicians can use physical examination and X-ray first when facing the patients with shoulder pain, which is convenient and helpful for evaluating rotator cuff tears.

Objective To explore the experience in the perioperative treatment for osteoporotic fracture complicated with chronic renal insufficiency and its influence on the prognosis of the patients. Methods Sixty-nine patients with osteoporotic fracture complicated with chronic renal insufficiency were retrospectively analyzed. All the patients received surgery and were treated by team during the perioperative period. The comprehensive evaluation for treatment, preoperative retrospective analysis of the disease and treatment, and postoperative follow-up were carried out. Follow-up guidance, and the patient's perioperative renal function, anemia, wound conditions and fracture prognosis were analyzed and followed up. Results Among the 69 patients, there were 27 males and 42 females with an average age of (72.5±14.0). And there were 9 cases of spinal compression fracture, 39 hip fracture, 3 distal radius fracture, 7 proximal humerus fracture and 11 other limb fracture. There were 66 cases of chronic nephrogenic renal insufficiency, 1 case of pre-renal chronic renal insufficiency and 2 cases of post-renal chronic renal insufficiency. The mean preoperative hemoglobin content was (102.5±20.2)g/L, total protein (65.1±7.8)g/L, albumin (36.5±5.4)g/L, serum potassium (4.5±0.8)mmol/L, creatinine (293.5±267.8)μmol/L and glomerular filtration rate (GFR) (41.5±84.0)ml/min in the 69 patients. Towards chronic kidney disease (CKD), 11 cases were in stage Ⅱ, 27 cases were in stage Ⅲ, 9 in stage Ⅳ and 22 in stage Ⅴ. All the wounds had first intention healing after the operation. Sixty-two patients were followed up for (62.3±44.8) months. Ten patients died by the end of the follow-up. Nine of them were hip fracture patients. At the end of follow-up, the mortality rate was 16.1%. Conclusions The predilection sites of osteoporotic fracture complicated with chronic renal insufficiency are the hip and spine. Hip fracture is still the main disease affecting the prognosis of the patients. The controlling primary diseases by means of medical and surgical co-management is the premise to ensure the perioperative safety of the patients, but chronic renal insufficiency may still affect the patients' rehabilitation and prognosis after discharge. DOI: 10.11855/j.issn.0577-7402.2019.02.08

背景:手术治疗是急性腕舟骨骨折的主要治疗方式之一,但对于经皮钛质空心加压螺钉内固定治疗无移位或轻微移位腕舟骨骨折是否可靠仍存在较大争议.目的:回顾性分析闭合(复位)经皮钛制空心加压螺钉内固定微创修复腕舟骨骨折的疗效.方法:回顾2010年1月至2018年7月于北京大学人民医院创伤骨科手术治疗的腕舟骨骨折患者的病历资料,其中21例行闭合(复位)钛制空心加压螺钉内固定微创修复,获取术前X射线及CT检查明确分型,经3个月以上随访,并获得术后X射线检查明确骨折愈合情况,采用改良Mayo腕关节功能评分评估患者术后疗效.结果 与结论:①患者21例腕舟骨骨折均顺利愈合,平均骨折愈合时间为(9.10±3.03)周;②患者恢复日常工作或学习的平均时间为(7.00±4.08)d;③根据改良Mayo腕关节功能评分,16例为优,4例为良,1例为一般,优良率95.2％;④Herbert分型B1型患者(n=6)较A2型(n=5)和B2型(n=10)患者术后Mayo疼痛程度评分降低(P＜0.05),即Herbert分型B1型患者术后疼痛程度更重;⑤结果证实,经皮钛质空心加压螺钉内固定微创修复急性腕舟骨骨折疗效可靠.该研究方案已经北京大学人民医院伦理委员会讨论批准.

Objective This study was performed to compare the clinical efficacy of three internal fixation methods for distal clavicle fractures (Neer type II): clavicular hook plate (Group A), anatomical plate (Group B), and arthroscopic Endobutton (Group C). Methods From 2001 to 2014, 58 patients with Neer type II distal clavicle fractures were treated at our institution. The clinical results were assessed with the visual analog scale (VAS), Constant score, and Simple Shoulder Test (SST) score. Results All patients had anatomic reduction and bone healing at the final follow-up. Groups B and C had considerably less intraoperative blood loss than Group A. The incision was significantly shorter in Group C than in Groups A and B. The mean VAS score was significantly higher in the affected than unaffected shoulder. The Constant and SST scores were significantly higher in the unaffected than affected shoulder. The VAS, Constant, and SST scores of the affected shoulders were not significantly different among the three groups. Conclusions Arthroscopic Endobutton fixation has long-term clinical results similar to those of other surgical protocols for distal clavicle fractures (Neer type II). We recommend this technique because of less blood loss, shorter incision length, and less shoulder irritation than other methods.

目的 评价解剖型股骨近端髓内钉(ZNN)治疗老年股骨转子间骨折的初步疗效.方法 回顾性分析2016年9月至2017年1月北京大学人民医院创伤骨科收治的18例老年股骨转子间骨折患者的治疗过程,Evans-Jensen分型中,Ⅱ型8例,Ⅲ型6例,Ⅳ型骨折4例;所有入组患者均采用闭合牵引复位ZNN内固定术治疗.记录分析患者的手术时间、术中出血量及骨折愈合情况,采用Harris评分系统以及Charnley髋关节功能评分标准评估患髋功能恢复情况.结果 18例患者的平均手术时间为(67±21)min,术中出血量为(75±29)ml,住院天数为(14±6)d.末次随访时,12例患者达到骨性愈合的平均时间为(16.0±1.5)w,Harris评分优8例,良4例,优良率100％;Charnley髋关节功能评分标准优6例,良5例,可1例,优良率91.7％.结论 解剖型股骨近端髓内钉操作简单,出血少,固定牢固,可作为治疗老年股骨转子间骨折的优选方案.

Background: Osteoid osteoma (OO) is a common benign bone tumour that is rarely found in the talus. Its nidus is difficult to detect on early imaging. The atypical symptoms of OO and the presence of concurrent trauma or sports injuries may lead to misdiagnosis and delayed treatment. We herein analyse a case of misdiagnosis of OO of the talus and discuss how to improve the early diagnosis of this rare lesion, thereby permitting rapid treatment.Case presentation: A 23-year-old man with a history of left ankle sprains and chronic pain was diagnosed with another ankle sprain and managed conservatively based on normal X-ray findings. After 1 year of recurring pain, he was diagnosed with ankle traumatic arthritis and underwent arthroscopic surgery. His preoperative ankle X-ray findings were still normal, and magnetic resonance imaging at that time demonstrated bone marrow oedema of the left talus. His symptoms reappeared shortly after surgery and progressively worsened. Magnetic resonance imaging performed 3 months after surgery demonstrated widespread bone marrow oedema of the talus. The patient presented to our hospital for pain assessment and was diagnosed with OO of the talus 3 years after his symptoms began. Preoperative computed tomography (CT) demonstrated a typical nidus of OO of the talus. After a second surgery, the patient's symptoms completely resolved, and pathologic examination confirmed that the lesion was OO. The patient recovered 3 months later and was able to walk normally.Conclusions: OO of the ankle joint exhibits a progressive course and is difficult to diagnose at an early stage. Patients with OO of the talus often have atypical imaging findings, no signs of ankle instability, and no anterior talofibular ligament tenderness. CT is valuable for diagnosing OO, although multiple CT scans may be required to detect the nidus. Proper imaging helps doctors to achieve the correct diagnosis early in the disease course, significantly shortening the treatment cycle and improving the patient's quality of life.

目的 探讨肱骨近端髓内钉治疗有移位肱骨近端骨折(Neer分型二部分、三部分骨折)的疗效.方法 回顾性分析2012年10月至2014年12月北京大学人民医院创伤骨科采用髓内钉治疗且获得完整随访的21例肱骨近端骨折患者,其中Neer分型二部分骨折12例,三部分骨折9例.分别记录患者手术时间、术中出血量和手术并发症,采用Constant评分评价肩关节功能.结果 随访时间最短7个月,最长37个月,平均随访时间为17.45个月.所有患者骨折均愈合.平均手术时间为71.67 min,术中平均出血量为70.48 ml.末次随访平均肩关节疼痛评分0.52分.骨折平均愈合时间为4.24个月,肩关节活动平均活动范围:前屈135.24°,外展130.24°,内旋33.33°,外旋50.71°.术后平均肩关节Constant-Murley评分为82.48分,其中优2例、良15例、可3例、差1例,优良率为80.95%.1例延迟愈合、1例术后肩痛、1例伤口渗液不愈合.结论 采用髓内钉治疗肱骨近端二部分和三部分骨折创伤小、固定牢固、可允许术后早期进行功能锻炼,关节功能恢复好,是治疗肱骨近端骨折的有效手段之一.

Background The cases of distal clavicular fracture account for 12%-1 5% of all clavicular fracture cases.Distal clavicular fracture combined with coracoclavicular ligament rupture frequently behave as unstable fracture,with the opportunity for fracture non-union in conservative therapy being as high as 21%.Although partial patients with fracture nonunion show mild clinical symptoms,the symptomatic nonunion may affect the functions of shoulder joint.Therefore,most of physicians suggest operative treatment for unstable distal clavicular fracture.The operative treatment can achieve fracture union rate up to 98%.The distal clavicular fracture is characterized by fracture combined with ligament injury, and there are also diversified clinical therapies. The frequently reported internal fixation methods include kirschner wire,tension band,coraco-clavicular screw, anchor,clavicular hook plate,anatomical locking plate as well as suture fixation,etc.After fracture union,the metallic internal implants are frequently required to be taken out through operation. Different therapies have both their advantages and disadvantages.At present,there has been no unified therapy for unstable distal clavicular fracture.Arthroscopic button plate fixation therapy for unstable distal clavicular fracture is a relatively new minimally invasive treatment method,and its technology is originated from arthroscopic button plate fixation for the treatment of dislocation of acromioclavicular joint.We made retrospective analysis on the clinical effects of arthroscopic button plate fixation on distal clavicular fracture and discussed the potential advantages and disadvantages of this therapy.Method Ⅰ.General materials:Twenty-one patients with unstable distal clavicular&nbsp;fracture who received operative treatment in our department during the period from September 2010 to December 2012 are collected,seventeen cases of these meet inclusion criteria,namely 10 male cases and 7 female cases,with an average age of 42.6 years;according to Robinson clavicular fracture classification,all fracture cases are of type 3B fracture.Inclusion criteria:(1)Diagnosed as unstable distal clavicular fracture; (2 ) Received arthroscopic button plate fixation treatment. Exclusion criteria:(1)Diagnosed as unstable distal clavicular fracture,but has not received arthroscopic button plate fixation treatment,including open reduction Clavicle hook plate fixation,anatomic locking plate fixation and open button plate fixation;(2 )Old distal clavicular fracture.Ⅱ.Operative method:operation was performed under general anesthesia.Allow the patient to take sand beach chair posture, with head leaning to the other side.Draw shoulder joint anatomic marks under shoulder arthroscopy, and perform conventional disinfection on affected shoulder and upper limbs.The arthroscope enters the joint cavity from posterior portal;Under direct vision,establish the anterior working portal located in rotator interval. perform intra-articular routine inspection, pay particular attention to inspect whether there is structural damage to glenoid labrum and rotator cuff.If intra-articular injury is discovered during operation,immerely treat it.Under direct vision,establish the anterolateral second observation portal under arthroscope through anterior supraspinatus tendon,and transfer the arthroscope to the second observation portal through exchange rod.Along the upper edge of musculus subscapularis,inward expose the lower surface of coracoid,and use a feller to determine the madial and lateral edges of coracoid.Perform C-arm X-ray machine fluoroscopy to demine the vertical projection position of coracoid on clavicular surface,namely the conical ligament attachment position;open skin by 2 cm,and expose the clavicular upper surface.Place the anterior cruciate ligament guider on the central location of coracoid lower surface,drive guide pin into coracoid through clavicle;perform fluoroscopy to validate that the position of guide pin is corret;through guide pin,use a 4.5 mm hollow drill for drilling,introduce the shuttle wire,and take out guider.Take two 4-hole button plates,remove loop spinalium,and use two No.5 Ethicon suture to perform plate connection as shown in Figure 9.By means of shuttle wire,introduce the button plates to pass through clavicle and coracoid,place one plate under coracoid,place another plate on the surface of clavicle.Perform reduction of fracture.If there are soft tissues entrapped at the fracture end,use probe for release. Maintain fracture reduction,tighten the suture for knotting and fixation,perform fluoroscopy again to validate fracture reduction;perform arthroscopy to validate that the plate under coracoid is completely attached on the lower surface of coracoid.Conventionally close incision.Ⅲ.Postoperative treatment:Use shoulder joint protector to suspend the injured shoulder for 4 weeks.In 4 weeks post operation, allow the shoulder joint to perform passive uplifting and external rotation activities;In the 2nd month after operation,perform intensive joint traction exercise,active assisted shoulder joint uplifting as well as internal and external rotation activities;2 months post operation,when preliminary fracture healing is realized and there is no local pressing pain,start active motion of shoulder joint,gradually recover daily activities as well as muscle strength and endurance training on rotator cuff and shoulder girdle.Ⅳ.Post-operative follow-up:After operation,perform re-examination once per month,take X-ray film,examine the fracture union situation until bony union of fracture.In the final follow-up,make evaluation on patient through shoulder joint constant scoring,simple shoulder joint test (SST),VAS pain scoring and examination on the range of shoulder joint motion.Results All 1 7 cases obtained follow-up,with average follow-up time of 50 months (42-66 months).1 6 cases achieved fracture union,with average union time of 3.2 months;there is 1 case of nonunion.During the operation 2 cases of combined intra-articular injury,1 case of SLAP injury and 1 case of Bankart injury are discovered and respectively repaired.Average postoperative constant score of the patients is 93.1 points (72-100 points),with health side score of 98.3 points (90-100 points).SST affected side score is 10.7 points on average (8-12 points),with health side score of 1 1.6 points (9-12 points).VAS average score is 1.9 points (0-4 points),with health side score of 1.7 points (0-5 points).1 case of fracture nonunion,male,aged 50 at the time of initial operation,right shoulder is injured by falling&nbsp;from electric bicycle in drunk driving,fracture typing is 3B distal clavicle fracture;this patient has pervious history of diabetes,with unsatisfactory blood glucose control.After hospital admission, perform arthroscopic internal fixation with button plate,and postoperative conventional bracing and rehabilitation training;According to postoperative re-examination,internal fixation failure and fracture displacement are discovered;make observation until 4 months after operation;fracture nonunion, local pressing pain and obviously limited shoulder joint functions are discovered.After readmission of the patients,take out the internal implants,take ilium for bone grafting,perform internal fixation with clavicular hook-plate;In 3 months after the operation for the second time,fracture union is realized;12 months later,take out clavicular hook-plate;the shoulder joint functions of the patients are basically recovered to normal level,with Constant score of 91 points,SST score of 1 1 points and VAS score of 1 point.Conclusion Most of unstable distal clavicular fracture cases need operative treatment,but there has been no unified therapy at present.Arthroscope-assisted button plate fixation is a new operation method which has been gradually developing in recent years,which is minimally invasive,being able to treat combined intra-articular injury at the same time,realize elastic fixation of coracoclavicular,without need for reoperation.This new operation method can realize good clinical effects,but has high technical requirements.It can be an option for treatment of distal clavicular fracture.

熟练掌握肩关节解剖特点及常见疾病的影像学检查方法，对于肩关节相关疾病的诊治至关重要。肩关节周围最重要的软组织结构就是肩袖和关节囊。肩关节常用的辅助检查包括X线、B超、C T、M RI。其中肩关节X线检查最为常用，包括肩关节创伤三位像，即腋位、肩胛骨正位、肩胛骨侧位。通过X线检查可评估肩袖有无钙化或撕裂。肩峰和冈上肌出口的形态，有无骨性畸形、关节炎、骨折、脱位或肿瘤等。“真空现象”对于诊断肩袖损伤有诊断价值。此外如果肩峰下间隙过于狭窄，一般提示有肩袖撕裂的可能。B超诊断肩袖撕裂准确度高，可以检查软组织的动态表现，在B超引导下可进行穿刺。C T可以很好的测量肩关节骨性形态，显示盂唇是否完整。M RI对于肩袖疾病的诊断有着极为重要的价值。本视频将从肩关节的解剖讲起，详细介绍肩关节疾病的发生基础及各种辅助检查阳性表现及其临床意义。

目的 探讨肩关节镜下肩关节前方松解对于原发性冻结肩的治疗效果.方法 回顾性分析2011年1月至2012年12月收治并行肩关节镜下肩关节前方松解的病例资料,共入组26例,男性7例,女性19例,平均年龄55岁(41～69岁).术前进行Constant评分、简明肩关节评分(SST)、肩关节活动范围检查和疼痛视觉模拟评分(VAS).肩关节镜下手术松解范围包括喙肱韧带、肩袖间隙、盂肱中韧带、前方关节囊及盂肱下韧带前部.术后规范康复锻炼.在最后一次随访时进行肩关节活动范围、Constant评分、SST评分和疼痛VAS评分.结果 获得随访21例,随访率80.8％.平均随访时间31个月(29～36个月).伴有糖尿病患者9例,占全部26例患者的34.6％.术前肩关节前屈上举71.3°(50°～110°),术后改善至158.9°(150°～170°).术前体侧外旋5.6°(0°～15°),改善至术后57.5°(45°～70°).术前Constant评分34.9分(13～71分),术后提高到90.4分(81～100分).术前SST评分2.4分(0～7分)术后提高到10.1分(8～12分).术前患侧肩关节疼痛VAS评分平均7.9分(5～9分),术后提高到1.4分(0～3分).结论 肩关节镜下肩关节前方松解对于原发性冻结肩治疗效果确切.

Background Calcifying tendonitis of rotator cuff is a common disease that causes pain .It frequently occurs in people at 30‐50s ,especially in women .The acute calcifying tendonitis is characterized by persistent severe pain of shoulder joint of unknow n reason .In case of severe symptoms ,emergency treatment is needed .Most patients with acute phase diseases have good efficacy for conservative treatment .However ,patients who do not respond to conservative treatment or with symptoms unrelieved that severely influence work and life ,surgery that removes the calcifying lesion under the arthroscopy is recognized as the effective treatment .Recently ,with the development of arthroscopy ,removal of calcium compounds under the arthroscopy has become a common surgery and leads to good efficacy .This study was performed to assess the efficacy of removal of calcified lesion under arthroscopy for calcifying tendonitis of rotator cuff in patients with acute and chronic phases of diseases ,and to determine the difference in shoulder joint function between acute and chronic phases after surgery .Methods General data:Cases with calcifying tendonitis who received treatment from September 2009 to June 2014 were included in this study .The inclusion criteria included :(1) who had history of severe shoulder joint pain;(2) who did not respond to conservative therapy ;(3) who received arthroscopy .The exclusion criteria included :(1) who had complicated injury of rotator cuff ;(2) who received open surgery .28 cases who met inclusion criteria were enrolled .The patients were assigned to the acute group and the chronic group by the time from the acute onset to removal of calcified lesion under arthroscopy .The acute group received removal of calcified lesion within 3 months&nbsp;after the onset of shoulder pain .The chronic group received removal of calcified lesion 3 months after the onset of shoulder pain that limited range of motion .28 cases had different degrees of pain and limited range of motion in the affected shoulder joint .All patients received imaging examinations .The size ,shape of the calcified lesion in the shoulder joint and the shape of the acromion were determined based on the radiograph .Plain radiograph of the shoulder indicated oval or bar‐shaped high‐density cloudy calcification shadow in the rotator cuff below the acromion or inside the slightly lateral mucosal bursa .There were 10 cases with acute diseases in which the patients aged 38‐68 years with a mean age of 52 .6 years .In 5 cases ,the left shoulder was affected .In 5 cases ,the right shoulder was affected .The symptom was acute pain in the last 3 months .They had no previous history of obvious pain limited range of motion .The patients had acupuncture‐similar feeling ,increased temperature on regional skin , markedly tenderness of the shoulder and limited range of motion that severely influenced daily life before surgery .The preoperative radiograph indicated high‐density calcification shadow in rotator cuff below the acromion .There were 18 chronic cases ranged from 40‐73 years with a mean age of 55 .5 years .7 cases had left shoulders affected and 11 cases had right shoulders affected .All patients had a history of severe pain .The pain relieved after persistence for a certain time but did not disappear .The shoulder pain was sometimes slight and sometimes severe .The range of motion of the shoulder joint was substantially limited ,which influenced daily life .Surgery method :All surgeries were performed by chief or senior physicians at the Peking University Peoples’ Hospital .The cases were subject to general anesthesia on beach chair position .The bony marks were made before surgery .The arthroscopy was inserted through posterior approach to examine the glenohumeral joint .Severe inflammatory synovial hyperplasia of congestion was often observed on the wall inside the joint capsule .Some patients with limited range of motion had contracture in the rotator interval and thickened middle glenohumeral ligament .The structure of rotator cuff remained complete .The synovial tissue in the articular cavity was removed .The rotator interval and middle glenohumeral ligament were released .A needle was used to puncture the supraspinatus tendon and infraspinatus tendon through the outer edge of acromion to position the location of calcified lesion .If the calcified lesion was detected with the needle ,there was calcium compound on the needle tip .After positioning of calcified lesion ,it was marked with a PDS suture placed through the needle .The arthroscopy located in the subacromial space often observed obvious hyperplasia and congestion in the synovial membrane under acromion . Sometimes calcium compound was observed on the synovial membrane .The synovial membrane under the acromion was removed using shaver .The bleeding was stopped using radiofrequency coblation .The structure of rotator cuff was clearly revealed .The locations of calcified lesion were marked using sutures .The tendons were dissected along the direction of tendon fibers using blade to expose the lesion .The calcified lesion was removed with shaver .The toothpaste shaped calcium substances were observed .After complete removal of calcified lesions ,the tendon of rotator cuff was observed for defectiveness .For big calcified lesions that involved 50% depth of the tendon or footprint bone surface of rotator cuff revealed ,a 4 .5 mm suture anchor was used to repair the rotator cuff .9 cases received repair of the rotator cuff .The osteophyte was thoroughly removed if any under the acromion .8 cases received combined acromioplasty .Postoperative rehabilitation and assessment :The affected extremity was slinged in a shoulder immobilizer .The cold pack was appropriately used within 1 week after surgery .The passive shoulder joint motion was assisted with the normal hand .The range of motion increased gradually .1 week later ,the active motion was started gradually .6 weeks later ,the resistance exercise and extension treatment were applied to the shoulder joint .3 months after surgery ,the range of motion returned to normal and daily living activities returned to normal .For patients with combined rotator cuff repair ,active exercise should start 6 weeks after the surgery to avoid loosening or another tearing on the repaired site .Each patient was assessed for Constant score ,simple shoulder test (SST ) score ,range of motion of the shoulder joint and VAS pain score before and after surgery .Statistical method:Paired data before and after surgery was analyzed with t test .SPSS 15 .0 software was used forstatisticalanalysis.P<0.05indicatedhestatisticalsignificance.Results 28caseswereincludedin&nbsp;the retrospective study .The patients were subject to follow‐up ranged from 6‐33 months (with a mean of 18 .8 months) .The regular follow‐up radiograph after surgery showed removal of calcified shadow . All patients were assessed for Constant score ,VAS pain score ,range of motion of the shoulder joint and simple shoulder test (SST) score before and after surgery .For 10 cases with acute phase diseases , the mean scores of Constant scale were 51 .36 before treatment and 88 .16 after treatment ,increased by an average of 36 .80 .The anteflexion and uplift angle increased by about 77 .00° .The external rotation increased by about 18 .50° .SST questionnaire:The mean number of answers “Yes” was 5 .02 before treatment and 9 .32 after treatment ,increased by an average of about 4 .30 .The mean scores for VAS were 9 .12 before treatment and 4 .62 after treatment ,decreased by average of about 4 .50 .For 18 cases with acute phase diseases ,the mean Constant scores were 63 .70 before treatment and 88 .03 after treatment ,increased by an average of about 24 .33 .The mean number of answers “Yes” was 6 .33 before treatment and 9 .66 after treatment ,increased by an average of about 3 .33 .The mean scores for VAS were 7 .30 before treatment and 4 .19 after treatment ,decreased by an average of about 3 .11 .In this study ,28 cases with calcifying tendonitis underwent removal of calcified lesion under arthroscopy and presented different degrees of function improvement in shoulder joint .The patients with calcifying tendonitis in the acute group had significantly better Constant score ,SST growth and anteflexion and uplift angle and pain relief than the patients in the chronic group ( P <0 .05) .In this study ,9 cases received repair of rotator cuff ,including 2 cases in the acute group ,accounting for 20% of patients with acute phase diseases ,and 7 cases in the chronic group ,accounting for 38 .9% of patients with chronic phase diseases .Discussion Calcifying tendonitis of rotator cuff is a common disease that causes acute shoulder pain .When the symptom severely influences daily life and conservative therapy is not effective ,early removal of calcified lesion under the arthroscopy is effective for calcifying tendonitis and leads to good prognosis .

OBJECTIVE:To investigate the characteristics and perioperative management of hemophilia patients with fracture.METHODS:Retrospectively, we analyzed 8 patients with hemophilia combined with fracture, who were admittted to our department from 2005 to 2013. Six patients were with hemophilia A and two with hemophilia B; Based on the severity of hemophilia, 2 cases were light, 3 moderate and 3 severe; Based on the location of fracture, 4 cases were femoral neck fractures, 1 femoral intertrochanteric fracture, 1 bilateral distal femur fractures, 1 tibiofibula fracture, and 1 humerus intercondylar fracture. Blood coagulation factor replacement therapy was conducted preoperatively, intraoperatively and postoperatively, All the patients underwent closed or open reduction and internal fixation or joint replacement. Also, we analyzed the perioperative complications and observed whether the fracture healed.RESULTS:The average age was 33.5 years (14 to 47 years); In 6 cases, fractures occurred at femur, accounting for 75% of all the fractures; Femoral neck fracture was treated by closed reduction and hollow screws fixation; Femoral intertrochanteric fracture, distal femur fracture, and tibiofibula fracture were treated by open reduction and internal fixation with plate; Humerus intercondylar fracture was treated by elbow joint replacement. Intraoperative bleeding was from 50 to 600 mL, an average of 262 mL; Perioperatively, the average use of FVIII/activated prothrombin complex concentrates (APCC) was 358 U/kg (125 to 554 U/kg). Postoperatively, poor wound healing was observed in 2 patients, and the condition improved after symptomatic treatment; In patients with internal fixation, all the fractures united, and the average healing time was 14 weeks. No complications such as fixation loosening or rupture occurred after internal fixation.CONCLUSION:Hemophilia combined with fracture mainly occurred in the young, and the site of fracture was given priority to femur. With perfect preoperative preparation, on the basis of the replacement therapy, hemophilia combined with fractures was safe for surgical treatment, and postoperative fractures healing wasgood. But the risk of poor wound healing was high.

Objective To determine the total bleeding,occult bleeding,and anticoagulant use in treatment of proximal humeral fracture combined with shoulder hemiarthroplasty in order to provide necessary data for the clinical treatment.Methods Sixty-one patients with proximal humeral fracture undergone shoulder hemiarthroplasty from July 2004 to July 2013 were retrospectively analyzed for preoperative and postoperative blood routine and intraoperative and postoperative blood loss.Results For all 61 patients,total blood loss was (981.3 ± 341.5)ml and hidden loss (525.7 ± 244.6)ml,with mean occult bleeding making up 54％.Anticoagulant was used in 20 patients,with occult blood loss of (616.0 ± 267.8) ml,accounting for 59％ of total bleeding [(1 051.3 ± 402.1) ml].Anticoagulant therapy was not initiated for 41 patients and their occult loss was (481.6 ± 222.7) ml,accounting for 51％ of total bleeding [(947.2 ± 307.4) ml].More occult bleeding was observed in patients with anticoagulant therapy than those without (P ＜ 0.05).Conclusions Occult loss predominates the total blood loss during shoulder hemiarthroplasty for patients with proximal humeral fracture,which is worthy of special attention.Moreover,further occult bleeding is observed in patients treated with anticoagulant therapy.