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INTRODUCTION: To describe the clinical outcomes of arthroscopic fixation of displaced posterior cruciate ligament (PCL) avulsion fractures with/without associated tibia plateau fractures using an adjustable loop suspensory fixation device. METHODS: Four male patients who have sustained PCL tibia avulsion fractures with/without associated tibia plateau fractures were operated on in a single centre using an arthroscopic adjustable loop suspensory device technique. After arthroscopic evaluation and reduction of the fracture using a probe and PCL drill guide, a proximal medial tibial mini incision was used to drill a bone tunnel through the fracture fragment. An adjustable loop suspensory device was relayed through the bone tunnel via a transtibial manner, and the button device was flipped onto the bony fragment for fixation. The associated tibial plateau fractures were then fixed if present. Knee function at the last follow-up was evaluated by International Knee Documentation Committee (IKDC), Knee Injury And Osteoarthritis Outcome Score (KOOS), Lysholm scores. Range of motion and knee stability were assessed, and fracture union was evaluated by plain radiographs. RESULTS: All patients underwent the operation successfully with no major complications encountered. All were followed up for a minimum of 6 months. There was no instability reported by the patients or found during objective evaluation using posterior drawer test and reverse pivot shift test. All fractures achieved union. Mean post-operative Lysholm score was 91.5 (range 85-95), IKDC score was 85.1 (range 74.7-89.7) and KOOS was 89.3 (range 81.5-94.6). All patients returned to their pre-injury activities of daily living and work. Radiographic evaluation showed union at the fracture site in all four patients at the last follow-up. CONCLUSION: This arthroscopic procedure is a viable minimally invasive technique that is appropriate in minimally displaced avulsion fractures of the PCL with associated tibia plateau fractures. LEVEL OF EVIDENCE: Case Series, IV.

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INTRODUCTION: The superior articular capsule complements the rotator cuff's function in shoulder stability. With irreparable rotator cuff tears, superior capsular reconstruction (SCR) improves dynamic glenohumeral (GH) joint kinematics. We present a novel method of SCR in cadaveric shoulders using the long head of bicep (LHB) tendon instead of previously explored fascia lata autograft, thereby reducing harvest site and suture anchor associated complications. HYPOTHESIS: This novel method of SCR using the LHB is feasible biomechanically in restoring shoulder stability in irreparable supraspinatus tendon tear. MATERIALS AND METHODS: Seven cadaveric shoulders were tested in a custom shoulder testing system. Superior translation of the humerus, subacromial contact pressure and area, and glenohumeral range of motion were tested at 0°, 30°, and 60° of glenohumeral abduction in the following conditions: (1) intact shoulder, (2) simulated complete supraspinatus tendon tear, (3) modified SCR using LHB, (4) and modified SCR using LHB and side-to-side repair augmentation. RESULTS: The complete cuff tear shifted the humeral head superiorly as compared to the intact shoulder. Subacromial peak contact pressure was also increased at 30° and 60° while contact area was increased at 0° and 30°. The modified SCR both with and without side-to-side repair shifted the humeral head inferiorly at 30° and 60°, with contact area further reduced at 60°. Both techniques had comparable results for contact pressure and total rotational range of motion. CONCLUSION: The LHB with appropriate distal insertion on the greater tuberosity restores shoulder stability in irreparable rotator cuff tears by re-centering the humeral head on the glenoid. LEVEL OF EVIDENCE: Basic science study, biomechanical testing.

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INTRODUCTION: Engaging Hill-Sachs lesions in recurrent anterior shoulder dislocation have been managed with the remplissage procedure. Clinical and cadaveric studies have reported limitation of rotation after this procedure. We introduce the reverse McLaughlin procedure where the infraspinatus and the underlying capsule are detached and approximated into the Hill-Sachs defect with transosseous sutures. This is a preliminary report using this technique. METHODS: Seventeen patients with recurrent anterior shoulder dislocations and an engaging Hill-Sachs lesion underwent a Bankart repair and remplissage procedure (n = 9) or the reverse McLaughlin procedure ( n = 8). Patients were evaluated using the SF-36, American Shoulder and Elbow Surgeons (ASES), and Constant scores. Clinical assessment of the shoulders was also performed. RESULTS: At the final follow-up, all patients in both groups achieved comparable clinical outcome scores. No significant differences were reported in the range of motion of the shoulders between the two groups. There was one dislocation of the operated shoulder in each group after an injury. CONCLUSION: The reverse McLaughlin procedure for engaging Hill-Sachs lesions is simple, easy to perform, and associated with functional outcomes and range of motion at least equivalent to those obtained via the remplissage technique. It may be an alternative to the latter procedure. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

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RATIONALE: In clinical work, neuroendocrine synchronous multiplicity carcinoma was relatively rare. Most were confirmed by the pathological diagnosis of a certain part of the body combined with the imaging of the whole body, while cases that had both pathological and immunohistochemistry diagnosis were few. PATIENT CONCERNS: A patient who presented with abdominal pain visited our hospital, and was diagnosed with lesions in both the small intestine and lung. DIAGNOSES: Both were considered primary tumors by imaging, and diagnosed as neuroendocrine carcinomas by pathology. INTERVENTIONS: The intestinal lesion was surgically resected, and the lung tumor treated by chemoradiotherapy. OUTCOMES: The survival time of this patient exceeded 24 months. LESSONS: The diagnosis relied on clinical, imaging, pathological, and immunohistochemical features, which confirmed a synchronous multiple carcinoma. Treatment was based on the pathological types. Through this case report, the clinical and pathological data of neuroendocrine synchronous multiplicity carcinoma could be enriched.

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Traumatic dislocation of the subtalar joint is an infrequently occurring injury, with open true posterior dislocation an even rarer injury. We describe our treatment of a young motorcyclist who was brought into hospital after a road traffic accident, having sustained an open posterior subtalar dislocation. After initial reduction and resuscitation in the emergency department, he was taken to the operating theater for emergent wound debridement and external fixation of his ankle using a unilateral external fixator device. After 2 subsequent repeat debridements, this was changed to a ring external fixator device, followed by split-thickness skin grafting of his wound. He was allowed full weightbearing and was discharged from hospital 10 days after his last operation. He continued to improve clinically at his outpatient appointments to the 1-year follow-up point, with his external fixator removed at 6 weeks postoperatively. At the last follow-up appointment, he had successfully returned to his previous employment. To the best of our knowledge, only 1 other description of an open posterior dislocation has been reported, which was managed nonoperatively after wound debridement. Ours is the first reported case of an open posterior dislocation managed surgically using a ring external fixator. We believe the ability to allow immediate weightbearing resulting from the additional stability provided by this type of fixation is advantageous, with a theoretical reduction in the risk of periarticular osteoporosis and calf muscle atrophy. The early mobilization afforded by this treatment is hoped to improve the typically poor long-term outcomes for these patients.

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INTRODUCTION: Tension-band wire fixation of patellar fractures is associated with significant hardware-related complications and infection. Braided polyester suture fixation is an alternative option. However, these suture fixations have higher failure rates due to the difficulty in achieving rigid suture knot fixation. The Arthrex syndesmotic TightRope, which is a double-button adjustable loop fixation device utilizing a 4-point locking system using FibreWire, may not only offer stiff rigid fixation using a knotless system, but may also obviate the need for implant removal due to hardware related problems. The aim of our study is to compare the fixation rigidity of patella fractures using Tightrope versus conventional tension-band wiring (TBW) in a cadaveric model. MATERIALS AND METHODS: TBW fixation was compared to TightRope fixation of transverse patella fractures in 5 matched pairs of cadaveric knees. The knees were cyclically brought through 0-90° of motion for a total of 500 cycles. Fracture gapping was measured before the start of the cycling, and at 50, 100, 200 and 500 cycles using an extensometer. The mean maximum fracture gapping was derived. Failure of the construct was defined as a displacement of more than 3mm, patella fracture or implant breakage. RESULTS: All but one knee from each group survived 500 cycles. The two failures were due to a fracture gap of more than 3mm during cycling. There was no significant difference in the mean number of cycles tolerated. There was no implant breakage. There was no statistical significant difference in mean maximum fracture gap between the TBW and TightRope group at all cyclical milestones after 500 cycles (0.3026±0.4091mm vs 0.3558±0.7173mm, p=0.388). CONCLUSIONS: We found no difference between the TBW and Tightrope fixation in terms of fracture gapping and failure. With possible lower risk of complications such as implant migration and soft tissue irritation, we believe tightrope fixation is a feasible alternative in fracture management of transverse patella fractures.

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BACKGROUND: Surgery on the radial head is usually performed via the Kocher interval. Iatrogenic injury to the posterior interosseous nerve (PIN) and lateral ligamentous complex are known complications of lateral elbow approaches. The extensor digitorum communis (EDC) splitting approach for lateral elbow exposure is known to provide better access to the anterior half of the radial head while reducing the risk of injury to the lateral ligaments. The aim of this study was to provide clinical outcome data for the EDC splitting approach. METHODS: Thirteen patients with closed radial head fractures underwent internal fixation or replacement via the EDC splitting approach. Patients were evaluated using the Mayo Elbow Performance, American Shoulder and Elbow Surgeons (ASES), and Disabilities of Arm, Shoulder and Hand scores. Clinical assessments of the elbows were also performed. RESULTS: Ten patients underwent open reduction and internal fixation of their radial heads, and 3 underwent radial head replacements. At final follow-up, all patients achieved good to excellent Mayo Elbow Performance scores, with a mean score of 90 (range 80-100). They had a mean ASES elbow score of 89.6 (range 77-97) and a mean Disabilities of Arm, Shoulder and Hand score of 12.8 (range 6.67-25.8). Patients reported a mean overall ASES satisfaction score of 8.5 (range 6-10). There were no significant surgical complications, including iatrogenic damage to the PIN or the lateral ligaments. CONCLUSION: The EDC splitting approach is a feasible method of exposing the lateral elbow, providing safe and reliable access to the radial head.

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INTRODUCTION: Autologous bone grafting has been accepted as the gold standard in the treatment of non-unions and in definitive filling of segmental bone defects. However, there have been well-recognised complications associated with their harvest. The Reamer Irrigator Aspirator (RIA) system is an alternative technique of autologous bone graft harvesting. Studies have been published in the Western population showing the efficacy and outcome of this technique. No prior studies were done in the Asian population, who has smaller average canals, different femoral geometry as compared to Caucasians and weaker bone density in both genders. We aim to present the findings and discuss its suitability in the Asian population when dealing with segmental bone loss and non-unions requiring reconstruction. METHODS: We conducted a retrospective analysis of all trauma patients with segmental bone loss and non-unions treated with RIA bone grafting over a 4.5 year period. A total of 57 cases of RIA bone grafting were conducted on 53 patients. The amount of bone graft harvested, blood loss and post-operative pain were measured. Patients were followed up for union rate as well as complications of the procedure. RESULTS: Union was achieved in 86.8% of patients. The mean time to union was 17.64 weeks. Seven patients did not achieve union after the first RIA surgery, in which six of seven were open fractures initially and six were smokers. One major intra-operative complication was recorded, that being a fractured femoral shaft due to thinning of the cortex by the RIA harvester. There were two patients who developed donor site superficial soft tissue infection that resolved after a course of antibiotics. There were no long-term complications seen in all patients. CONCLUSIONS: The safety and efficacy of RIA bone graft harvesting for the management of non-union in the Asian population is promising, with adequate graft quantities, high success and low complication rates that are comparable to the Caucasian population. The diameter of the medullary canal in our population is suitable for this procedure. We believe that RIA bone graft harvesting provides a reliable and safe alternative source of autologous bone grafts for bone grafting of non-union sites.

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Proximal ulna fractures account for 20% of all proximal forearm fractures. Many treatment options are available for such fractures, such as cast immobilisation, plate and screw fixation, tension band wiring and intramedullary screw fixation, depending on the fracture pattern. Due to the subcutaneous nature of the proximal forearm, it is vulnerable to open injuries over the dorsal aspect of the proximal ulna. This may in turn prove challenging, as it is critical to obtain adequate soft tissue coverage to reduce the risk of implant exposure and bony infections. We herein describe a patient with a Gustillo III-B open fracture of the proximal ulna, treated with minimally invasive intramedullary screw fixation using a 6.0-mm cannulated headless titanium compression screw (FusiFIX, Péronnas, France).

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BACKGROUND: Successful return to sport is an important outcome measure after anterior cruciate ligament (ACL) reconstruction and a reason for patients' decisions to elect surgery. Rehabilitation programs supervised by physical therapists are routinely prescribed after ACL reconstruction surgery. However, the added advantage of supervised physical therapy after ACL reconstruction is still debatable. HYPOTHESIS: Attending more supervised physical therapy sessions after arthroscopic ACL reconstruction in recreational athletes increases their chance of successful return to sport. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors analyzed 93 recreational athletes who underwent arthroscopic ACL reconstruction. After arthroscopic single-bundle ACL reconstruction, patients were advised to attend 20 supervised physical therapy sessions. Patients' demographics, surgical details, and outcome measures (Knee injury and Osteoarthritis Outcome Score [KOOS], Lysholm scale, and Short Form-36 Health Survey [SF-36]) were recorded presurgery and at 1-year follow-up. Ability to return to sports was documented through patients' self-report. The attendance at physical therapy by each patient was obtained by examining database records and assessed as fully compliant (>15 sessions), moderately compliant (6-15 sessions), or noncompliant (<6 sessions). RESULTS: Patients in the fully compliant group had significantly greater odds (odds ratio [OR], 18.5; 95% CI, 1.9-184.5; P = .013) of a successful return to sport as compared with the noncompliant group. Patients in the moderately compliant group also had greater odds of returning to sport as compared with the noncompliant group (OR, 4.2; 95% CI, 1.0-16.6; P = .043). Patients in the fully compliant group had significantly greater scores on the Lysholm (P < .001), KOOS Sports and Recreation subscale (P = .021), KOOS Symptoms subscale (P = .040), and SF-36 physical component summary (PCS) (P = .012) as compared with the noncompliant group. Moderately compliant patients had significantly greater scores on the Lysholm (P = .004), KOOS Sports and Recreation (P = .026), KOOS Symptoms (P = .041), KOOS Quality of Life (P = .022), and SF-36 PCS (P = .004) as compared with noncompliant patients. CONCLUSION: In recreational athletes, moderate to full compliance with a supervised physical therapy program predicts improved knee function and a greater chance of returning to sport 1 year after ACL reconstruction.

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The purpose of the present prospective study was to analyze the predictors of outcome and review the quality of life of patients who underwent emergency fasciotomy for foot compartment syndrome after blunt trauma. A total of 14 patients were identified and followed for an average of 24 (range 14 to 33) months. The mean interval from initial presentation to decompressive fasciotomy was 5.8 (range 3 to 11) hours. The follow-up data from our patients revealed satisfactory functional and quality of life outcomes, with 11 of 14 (78.6%) able to return to work. Two (14.3%) patients developed claw-toe deformities and 3 (21.4%) patients had sensory deficits directly attributed to compartment syndrome. Finally, 4 (28.6%) patients required modified shoes or shoe inserts for comfortable ambulation. Our findings suggest that earlier fasciotomy results in better quality of life scores, American Orthopaedic Foot and Ankle Society scale scores, and visual analog scale pain scores and a greater likelihood of being able to wear all shoes comfortably, ambulate independently, and return to work. A shorter interval to fasciotomy, younger age, the absence of bony injury, the absence of other concomitant injuries, and a low velocity crush injury all tended to be predictors of good outcomes at the final review.

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The X-ray repair cross-complementation group 1 (XRCC1) protein plays an important role in base excision repair, and the genetic polymorphisms in the XRCC1 gene influence its function. XRCC1 codon 280 polymorphism is an Arg-His change in the XRCC1 gene. Many studies were published to investigate the association between XRCC1 codon 280 polymorphism and risk of lung cancer, but the results were inconsistent. We performed a meta-analysis of 16 studies with a total of 18,660 subjects (8,736 cases and 9,924 controls). The pooled odds ratios (OR) and corresponding 95 % confidence intervals (95 % CI) for the gene-disease association were calculated. Overall, there was a significant association between XRCC1 codon 280 polymorphism and increased risk of lung cancer (HisHis vs. ArgArg: OR = 1.53, 95 % CI 1.08-2.16, P = 0.016; HisHis vs. ArgArg/ArgHis: OR = 1.55, 95 % CI 1.10-2.19, P = 0.012). However, subgroup analysis by race failed to confirm the obvious association in Europeans and Asians. Therefore, there is a significant association between XRCC1 codon 280 polymorphism and increased risk of lung cancer. More studies with a large sample are needed to further evaluate the possible race-specific effect in the association above.

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BACKGROUND AND OBJECTIVE: NKG2D-expressing CD8+NKT cells and soluble major histocompatibility complex class I-related chain A (sMICA) is one of recently emerged general interests in tumor research area. The aim of this study is to investigate the levels of NKG2D-expressing CD8+NKT cells in peripheral blood of lung cancer patients, which are remarkably related to clinical significance, and to analyze the correlation between NKG2D-expressing CD8+NKT cells and sMICA levels, and to explore the role of NKG2D and sMICA in immune surveillance. METHODS: Flow cytometry was used to determine the percentage of NKG2D-expressing CD8+NKT cells, and ELISA was used to measure the levels of sMICA in peripheral blood of 82 untreated lung cancer patients and 45 healthy controls. The association of NKG2D levels with clinical features was analyzed. RESULTS: The expression of NKG2D on CD8+NKT cells in lung cancer group was significantly lower than that in healthy group, with statistically significant difference (P < 0.001). And with the increase of TNM stage, NKG2D expression rate reduced gradually. NKG2D expression in stage IV disease was significantly lower than which stage I-II and III disease (P < 0.001). The expression of NKG2D on CD8+NKT cells was remarkably lower in that in smokers than that in non-smokers, with statistically significant difference (P < 0.05). NKG2D exhibited negative correlation with sMICA (r=-0.598, P < 0.001). CONCLUSIONS: Lung cancer has low expression of NKG2D in CD8+NKT cells which correlate with pathological stage. Detection of NKG2D and sMICA might be helpful to understand immune functions and provide evaluation of combined treatment for clinical cancer.

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BACKGROUND: NKG2D-expressing NK cells and soluble major histocompatibility complex class I-related chain A (sMICA) is one of aroused general interests in tumor research area recently. The aim of the study is to investigate the levels of NKG2D-expressing NK cells and sMICA in peripheral blood of advanced lung cancer which are remarkably related to clinical significance and analyse the role of NKG2D-expressing NK cells and sMICA in immune surveillance. METHODS: Flow cytometry was used to determine the percentage of NKG2D-expressing NK cells, T cell subsets, NK cells, and ELISA was used to mesure the levels of sMICA in peripheral blood of 115 advanced lung cancer patients and 50 healthy controls. RESULTS: Compared with control group, the levels of sMICA, CD8+T cells, NK cells increased, while the levels of NKG2D-expressing NK cells, CD3+ T cells, CD4+ T cells, CD4+ T/CD8+ T in experimental group decreased. NKG2D-expressing NK cells had a perfect negative correlation with sMICA (r =-0.319, P <0.05). NKG2D-expressing NK cells had positive correlation with CD4+ T cells, CD4+ T/CD8+ T and negative correlation with CD8+ T cells (P <0.05), sMICA had negative correlation with CD4+ T cells, CD4+ T/CD8+ T and positive correlation with CD8+ T cells (P <0.05), they had no significant correlation with CD3+ T cells, NK cells respectively (P <0.05). CONCLUSIONS: Accumulation of sMICA in serum may lead to the down-modulation of NKG2D-expressing NK which has been proposed to be a novel mechanism used by cancer cells to evade the tumor immunosurveillance. They may be potential indicators investigating immune functions and helpful in the evaluation of their happening and proceeding.

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OBJECTIVE: The purpose of this phase I/II study is to investigate the safety/toxicity profile of weekly administration of docetaxel in combination with cisplatin for the chemo-naive patients with advanced non-small cell lung cancer (NSCLC), and to evaluate the efficacy of this regime. METHODS: In phase I trial, 15 patients were included. IV infusion of escalating doses of docetaxel consisting of four levels from 25 to 40 mg/m2 (25, 30, 35, 40 mg/m2) on D1, 8, 15 and cisplatin of 75 mg/m2 on D1 was administered. The regime was repeated every 4 weeks. Blood samples were obtained on D1, 15 in the first cycle to measure the PK. Dose limiting toxicity (DLT) was determined in cycle 1 and defined as any grade 3 non-hematologic toxicity which could not be reverted into grade less than grade 2 within 4 days or any grade 4 hematologic toxicity. Eighty-three patients completed their phase II study with administration of docetaxel at a dose of 35 mg/m2 based on the data of phase I trial. RESULTS: In the phase I trial, grade 3/4 neutropenia was mainly observed in patients who received docetaxel of 40 mg/m2 (level 4) with one patient suffering from an infection signifying dose limiting toxicity (DLT). Non-hematological toxicities including nausea/vomiting, alopecia, fluid retension and asthenia were tolerable. Based on these data, the maximum tolerence dose (MTD) did not reach the level of weekly giving docetaxel at a dose of 40 mg/m2 in combination with cisplatin 75 mg/m2 every 4 weeks. The pharmacokinetic/dynamics results There was no statistically significant difference between clearance value among the 4 dose levels of docetaxel from 25 to 40 mg/m2 when measured by Cmax and AUC. The pharmacokinetics of docetaxel was not influenced by the presence of co-administration of cisplatin when compared D1 with D15 as based on CmaxN, AUCN and CL. In the phase II trial, totally 83 patients received 216 cycles of chemotherapy. One CR (complete response) and 22 PR (partial response) were achieved with an objective response rate of 27.7% in this series and 30.7% in the evaluable patients. The 1-year survival was 48.6% with a median survival of 10.7 months (range: 3-34 months). Hematologic toxicities were the major side effects, though most were mild; grade III/IV neutropenia developed in 15%. The common non-hematologic toxicities were nausea, vomiting and asthenia. CONCLUSION: Weekly consecutive administration of docetaxel on D1, 8, 15 for 3 weeks plus cisplatin on D1 is tolerable and effective with minimal myelosuppression in chemo-naive patients with advanced NSCLC.

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OBJECTIVE: To evaluate the efficacy and adverse events of irinotecan (CPT-11) combined with cisplatin (DDP) in the treatment of patients with advanced non-small cell lung cancer (NSCLC). METHODS: Of 36 NSCLC patients consisting of 23 males and 13 females with a medium age of 52 years included, there were 26 adenocarcinomas, 7 squamous cell carcinomas, 1 adeno-squamous cell carcinoma and 2 unclassified types; 13 stage III B and 23 stage IV; 24 chemonaive and 12 previously treated by chemotherapy with a medium Karnofsky status of 90. All patients had measurable or evaluable parameters. The regimen was administered as following: CPT-11 60 mg/m2, IV, D1, 8 and 15; DDP 80 mg/m2, IV, D1; every 28 days as a cycle. RESULTS: Totally, 97 cycles were carried out in these 36 patients with a medium cycles of 3. Of 35 evaluable patients, 22.9% (8/35) achieved partial response, 60.0% (21/35) had stable disease and 17.1% (6/35) progressive disease. The response rate was 29.2% (7/24) for chemonaive patients and 9.1% (1/11) for these previously treated. The 1-year survival rate was 45.4% with a medium time to tumor progression (TTP) of 199 days for the responders. The incidence rate of grade III/IV adverse events were: 16.7% for neutropenia, 13.9% alopecia, 5.6% diarrhea, 2.8% nausea and vomiting, respectively. CONCLUSION: Irinotecan plus cisplatin is effective with tolerable adverse events in treating patients with advanced non-small cell lung cancer, but further investigation trials are needed.

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BACKGROUND: To evaluate the efficacy and toxicity of ifosfamide and cisplatin in the treatment of advanced non-small cell lung cancer. METHODS: Fifty-six patients with advanced non-small cell lung cancer were treated by combination chemotherapy of ifosfamide and cisplatin for two cycles: ifosfamide 1.5-2.0g/m² iv drip on day 1-4, mesna 400mg iv at 0,4,8 hours after using ifosfamide; DDP 25-30mg/m² iv drip on day 5-7. The response, toxicity, relievable period and survival period were evaluated. RESULTS: The total response rate was 50.0%. The response rate of patients in primary treatment was 52.8% and that of return cases was 45.0% (P > 0.05). The median relievable period was five months. The median duration of survival (MDS) was nine months. The major toxicity was inhibition of bone marrow, especially of leukocyte and platelet. CONCLUSIONS: Combination chemotherapy of ifosfamide and cisplatin is effective in the treatment of advanced non-small cell lung cancer including the return cases, and the toxicity is tolerable. If G-CSF is used as a complementary therapy, this regimen could be quite clinically valuable.