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.

Objective:To investigate the characteristics of postoperative internal fixation failures of femoral intertrochanteric fractures and analyze the related reasons using the leverage-balance-reconstruction theory.Methods:A retrospective case series study was performed for 40 patients suffering from implant failure after internal fixation of femoral intertrochanteric fractures admitted to Peking University People's Hospital from January 1999 to December 2019. There were 20 males and 20 females, aged from 43 to 92 years [(74.1±11.5)years]. The patients were assigned to extramedullary fixation (extramedullary fixation group, 17 patients) and intramedullary fixation (intramedullary fixation group, 23 patients). Complications associated with internal fixation were recorded, including internal fixation cutout, coxa vara deformity of hip joint, internal fixation withdrawal, femoral heck shortening and internal fixation breakage. Based on the lever-balance-reconstruction theory, the failure reasons of internal fixation were analyzed in combination with the change of arm length and outward shift of fulcrum measured before operation, after internal fixation and after fixation failure.Results:Among 40 patients, internal fixation cutout occurred in 18 patients, coxa vara deformity of hip joint in 37, internal fixation withdrawal in 29, femoral neck shortening in 37 and internal fixation breakage in 3. In extramedullary fixation group, the lengths of primary power arm and resistance arm were (8.0±1.0)mm and (59.4±10.9)mm, the lengths of power arm and resistance arm after fixation were (72.7±21.7)mm and (8.9±7.4)mm, the lengths of power arm and resistance arm after fixation failure were (50.3±14.9)mm and (33.6±17.6)mm. In intramedullary fixation group, the lengths of primary power arm and resistance arm were (6.7±0.6)mm and (49.8±9.9)mm, the lengths of power arm and resistance arm after fixation were (51.5±7.0)mm and (19.8±5.9)mm, the lengths of power arm and resistance arm after fixation failure were (41.6±9.6)mm and (32.4±7.7)mm. In each group, the lengths of power arm and resistance arm after internal fixation showed significant differences from that of normal ones and from that after fixation failure ( P<0.05). The length of power arm in extramedullary fixation group was larger than that in intramedullary fixation group ( P<0.05). The shortening of power arm in extramedullary fixation group was larger than that in intramedullary fixation group after fixation failure ( P<0.05). Conclusions:The extramedullary and intramedullary fixation of femoral intertrochanteric fractures result in the displacement of reconstruction fulcrum. The shortening of power arm is observed after fixation failure. The leverage-balance-reconstruction theory is helpful to analyze the cause of complications. The power arm after extramedullary fixation is longer than that after intramedullary fixation and is therefore more prone to fixation failure. The primary cause of postoperative internal fixation complications is to achieve a new balance of leverage.

肱二头肌远端肌腱损伤常见于中年男性的优势侧肘关节[1].常见的损伤机制为前臂持重肘关节负重由屈曲位向伸直位活动,肱二头肌腱突然受力所致[2],发生率为2.5/100000人次.危险因素包括吸烟及BMI过大(超过30％).患者的平均年龄 47岁,超过90％的患者为男性[3].

Intertrochanteric femoral fractures are common in clinical practice and the key to treatment is timely stable fixation and early rehabilitation to prevent bedridden complications. At present, the failure of common internal fixation system in the treatment of unstable intertrochanteric femoral fractures is not rare. The authors think that for the normal anatomical type of leverage structure of human proximal femur, pivot can bear weight and complete multidirectional activities because its pivot is close to the center of the body. The intertrochanteric femoral fractures destroyed the trabecular structure on the tension side and pressure side. At the same time, the physiological lever of the proximal femur was destroyed. The cause for the failure of the existing internal fixation is the inability to reconstruct the physiological pivot. Based on the anatomical and biomechanical characteristics of the proximal femur, the author reviewed the previous literatures and analyzed the problems in the treatment of intertrochanteric femoral fractures, and for the first time raised the " lever-pivot balance" theory for the treatment of intertrochanteric femoral fractures. This theory opens a new way for solving the problems in treatment of intertrochanteric femoral fractures.

目的探究半胱氨酸蛋白酶抑制剂C（cystain C,Cys C）含量对老年妇女髋部骨折风险的影响。方法选取2013年1月至2017年1月于我院进行就诊的老年女性髋部骨折65例为实验组,选同期于我院进行体格检查的70例老年健康女性为对照组。比较两组治疗前血清Cys C水平及骨密度,比较实验组治疗前及治疗30d后血清Cys C水平及骨密度,并对血清Cys C水平与骨密度的相关性进行分析。结果实验组患者血清Cys C水平低于对照组（P＜0.05）,骨密度低于对照组（P＜0.05）;实验组治疗后血清Cys C水平上升（P＜0.05）,骨密度上升（P＜0.05）;实验组患者血清Cys C水平与其骨密度之间存在正相关关系（P＜0.05）。结论血清Cys C水平与老年女性髋部骨折之间存在相关性,通过对血清Cys C水平的监测能够对是否存在髋部骨折进行风险预测。

Background The common symptoms of shoulder impingement syndrome include shoulder pain and shoulder activity limitation,and shoulder pain is the chief complaint of majority of patients.There are many causes for shoulder pain,and the common causes include bursitis and tendon degeneration which are resulted from the impingement between subacromial bursa/rotator cuff and humerus/ acromion in the abduction activity of shoulder.The abnormal activity of humeral head and scapula which is resulted from rotator cuff injury may also cause shoulder impingement and generate symptoms.To alleviate pain and increase joint range of motion,such methods as no-load rest,cold compress,physical therapy,oral administration of nonsteroidalanti-inflammatory drugs (NSAID)and injection of cortical hormone are adopted for non-operational treatment of shoulder impingement.An international multicenter study shows that,injection of cortical hormone is an effective means for the patients for whom the other methods such as rest are ineffective without exception.However,the mechanism of its significant effect has not been made clear,and an widely accepted interpretation to its mechanism is that hormone can relieve sterile inflammatory reaction.However,the adverse effects of application of hormone for many times are obvious, and the common adverse effects include&nbsp;spontaneous rupture of supraspinatus tendon, skin atrophy on local injection site and cartilage degeneration at humeral head etc.The reason why local injection of hormone is effective in treatment of shoulder impingement syndrome is that hormone can relieve local inflammatory reaction.Then, whether local injection of NSAID can also avoid the adverse effects resulted from hormone in the mean time of achieving good curative effects thanks to its anti-inflammatory action? It is the objective of this study to know the effects of local injection of parecoxib sodium in reducing shoulder impingement syndrome as well as the advantages and disadvantages of hormone.Methods Ⅰ.Inclusion and exclusion criteria:The patients with shoulder impingement syndrome confirmed in Outpatient department of our hospital were selected.The inclusion criteria:(1 )there exists painful arc when shoulder is abduced by 60°-120°;(2 )Neer′s disease positive;(3 )Hawkin′s disease positive;(4) subacromial bursitis confirmed through B ultrasound or MRI.Exclusion criteria:(1)Age <18 years;(2)course of disease <1 month;(3)has history of shoulder joint injection in the past 3 weeks;(4) has past history of rotator cuff tear;(5)Has past history of shoulder osteoarthritis;(6)Has systemic inflammatory reaction disease;(7 )Has past history of shoulder operation;(8 )has past history of shoulder infection;(9)has past history of shoulder joint adhesion or instability;(10)has past history of alimentary tract ulcer and hematopathy.For each patient included in this study,our hospital described the objective and method of this study,the personal information to be acquired,the probable problems and signed informed consent.This study was performed upon approval by the Ethics Committee of Tianjin No.5 Central Hospital.Ⅱ.Study design:This study is a randomized control test.To ensure double blind trial,after the clinic doctor has issued medical advice for local injection, the patients included in study should take medicine from pharmaceutist;one fixed pharmaceutist should issue and prepare the drug for injection,and randomized evelop method is adopted (envelops randomly drawn by patients).Two kinds of drugs are prepared:(1 )Hormone group:To 40mg Triamcinolone acetonide(provided by Kunming Jida Pharmacy Co.,Ltd),add 2% lidocaine (China Otsuka Pharmaceutical Co.,Ltd),prepare the solution to 5 ml;(2 ) NSAID group:Add 2%lidocaine to Parecoxib sodium (Pfizer Pharmaceuticals Limited),and prepare the solution to 5ml.The drug is sucked into a 5 ml syringe.After the pharmacist has made numbering and recording (the content cannot be seen since envelope is added),the doctor who issued the medical device should complete local injection.Each patient is injected according to standard injection method.The "soft spot" on posterior-lateral side serves as the needle insertion point, and needle is inserted from posterior angle of acromion and inserted downwards by 2 cm and outwards by 1cm,pointing to the direction of coracoid.After completion of injection,pain relief in the abduction of shoulder joint is used as the mark of correct injection position.Ⅲ.Evaluation indicators:For each patient,the first author and the second author of this article respectively make evaluation and recording for the shoulder joint range of motion(abduction),HSS score and ache (VAS score)at 30 min prior to injection,30 min after injection and 3 weeks after injection;After completion of evaluation and recording,for each patient,take the mean value evaluated and recorded by two physicians.Ⅳ.Statistical analysis:For the comparison on the results between two groups,two sided t test is performed.If P <0.05,it is meant that the different has statistical significance.According to the Equation for sample size,calculate the required number of patients in each group.Two groups need to respectively include 14 patients.Results During the period from October 2012 to September 2014,59 patients with confirmed shoulder impingement syndrome entered the study;After evaluation based on inclusion/exclusion criteria,48 patients were incorporated into the study groups.Every 24 cases were randomly divided into hormone injection group and NASID injection group,4 cases lost to follow up (2 cases in hormone group and 2 cases in NSAID group);2 cases failed to receive follow-up visit on schedule (1 case in hormone group and 1 case in NSAID group).Through MRI at 2 weeks after injection,7 case were confirmed as rotator cuff tear (2 cases in hormone group and 3 cases in NSAID group).Finally,37 cases obtained complete follow-up visit (1 9 cases in hormone group and 18 cases in NSAID)and received MRI or ultrasonic examination,and it was made clear that they did not suffer from rotator cuff tear.Both&nbsp;drug injection groups received follow-up visit at 3 week after injection,when both drugs shown obvious ache relief (NSAID group:1.12±2.1 1,P =0.04;hormone group:1.48±2.97,P =0.05). However,there was no difference in ache relief when two kinds of drugs were compared (P =0.1 70).In the 3-week follow-up visit,the difference of shoulder joint HSS score of NSAID injection group in comparison with the value prior to injection has statistical significance (P =0.143 ).Both NSAID group and hormone group shown obvious improvement in abduction function in comparison with the abduction function prior to operation,with both differences having statistical significance (NSAID group:P =0.03;hormone group P =0.04).In the 3-week follow-up visit,the shoulder joint abduction range of NSAID group is greater than that of hormone group,with P =0.03.Conclusion Injection of hormone and NSAID drug under acromion can help relieve the pain of patient with shoulder impingement syndrome.The shoulder joint range of motion and HSS score of NSAID injection group are superior to those of hormone group.

Essex-Lopresti 损伤是指桡骨头骨折合并下尺桡关节脱位及骨间膜撕裂，是一种少见的前臂、腕及肘关节同时受累的损伤。常引起长期腕关节疼痛、握力下降及前臂旋转功能受限，严重影响生活质量。Curr 等[1]在1946年首先报道了1例急性桡骨头骨折合并下尺桡关节损伤、桡骨向近端移位的病例。Essex-Lopresti [2]在1951年报道了2例下尺桡关节脱位的病例，该类患者同时有桡骨头骨折、骨间膜撕裂所致前臂纵向不稳定。此后，此类急慢性损伤被命名为 Essex-Lopresti 损伤，也有学者称为前臂纵向不稳定。