Up to 90% of all cancer related morbidity and mortality can be attributed to metastasis. In recent years the study of tumor microenvironment, its cellular and molecular components, and how they can affect neoplastic progression toward metastasis, has become a hot focus in cancer research. Accumulated evidence shows that the formation of metastasis is a multistep sequential process, in which, the tumor cells continuously interact with the host microenvironment. Host derived factors, i-e. growth factors/inhibitors, angiogenic factors, chemokines, etc. together with different types of host cells, play important roles in the tumor progression towards metastasis. The interaction between the tumor cells and host microenvironment determines the fate of metastasis. The reveal of this interaction mechanism provides us an opportunity to find effective mode of interference and develop novel anti-metastasis drugs. In this review, we have summarized our work on a new pro-invasion factor identified in tumor microenvironment and how it affects tumor invasion and metastass. Adenosine triphosphate (ATP), the key intracellular energy currency, accumulates within the tumor microenvironment and is closely involved in cancer cell metabolism and in antitumor immunity. The established role of ATP as a growth modulator and a proinflammatory mediator endues ATP and other purines with potential players in host-tumor interaction. Our study demonstrated that extracellular ATP stimulated human cancer invasion in in vitro tests. Increased migration and invasive ability across Matrigel was observed in some human carcinoma cell lines, including the prostate, breast, colon, melanoma and lung, when stimulated with ATP or its analogues. ATP enhanced the motility of cancer cells via increasing the amount and length of lamellipodia and filopodia, which were necessary for the cell motility. Significant increase in Rac1 and Cdc42 activities was observed. Using cDNA microarray we found that the expression of a panel of invasion/metastasis-related genes was significantly changed, including the increased expression of interleukin（IL）-8 and matrix metalloproteinase-3（MMP-3） after ATP treatment. Changes of some epithelial-mesenchymal transition (EMT)-related factors were also observed, including the increase of snail, decrease of E-cadherin and claudin-1. Multiple P2Y receptors subtypes were expressed on tumor cells, but P2Y2 and P2X7 receptors were found to be mainly responsible for the proinvasive effect of ATP. Down-regulation of either P2Y2 or P2X7 abolished ATP effect on cancer invasion and expression of EMT/invasion-related genes. Further, we found that P2Y2 receptor trans-activated with epidermal growth factor receptor (EGFR) and co-activated extracellular regulated protein kinases (ERK1/2) signaling pathway, which was involved in regulating expression of EMT and other related genes. In nude mice experiment, the pro-invasive effect of ATP was further confirmed. In summary, our results reveal that ATP is a potential pro-invasive factor in tumor microenvironment. P2Y2/P2X7 receptors act as a mediator in the regulation of ATP-induced EMT and invasion of cancer cells. Given that tumor microenvironment is rich in ATP and other purines, we hypo-thesize that ATP might be a potential invasion stimulator in tumor microenvironment. Blocking ATP receptor might be a therapeutic target on cancer.

Objective： To evaluate the result of operation and gait analysis at the early stage after direct anterior approach (DAA) in total hip arthroplasty (THA). Methods: In this study, 20 patients who suffered from necrosis of femoral head or developmental dysplasia of the hip were scheduled to undergo THA. The basic information and visual analogue scale (VAS) score, Harris score before and after surgery were recorded. All of the patients finished the gait analysis before the surgery and 6 weeks and 12 weeks after the surgery, the data were compared with those of normal adult people. Results: Their hospital stay after the operation was 3.3 d, the VAS score after the operation was no more than 4 points, the positions of prosthesis were satisfactory, and there was no dislocation. The gait analysis results contained step speed, stride, the range of motion (ROM) of hip and knee. The step speed before the surgery (preoperation, Pre) was 0.64 m/s, 6 weeks after the surgery (6W) was 0.77 m/s, 12 weeks after the surgery (12W) was 1.07 m/s, and the control group was 1.19 m/s. The stride at Pre, 6W, 12W, and control group were 43.15 steps/min, 51.42 steps/min, 55.52 steps/min, and 57.15 steps/min, respectively. The ROM of hip joint at Pre, 6W, 12W, and control group were 31.00°, 39.62°, 40.40°, and 45.67°, respectively. The ROM of knee joint at Pre, 6W, 12W, and control group were 50.52°, 59.28°, 67.29°, and 70.42°, respectively. The results of the gait analysis showed that the gait recovery after the direct anterior total hip arthroplasty was very fast and at the 12th week after surgery the gait of the patients was close to the normal adult people. Conclusion: The direct anterior approach is one of the choosable approach of the THA, and this kind of surgery has a better recovery of gait after the operation, and at the end of 12 weeks after the surgery the gait is very close to the normal adult people. But we also need more studies to prove this conclusion.

Objective： To compare the efficacy and safety between direct anterior approach (DAA) and posterior approach (PA) in total hip arthroplasty. Methods: This study evaluated postoperative results of 92 consecutive total hip arthroplasties performed by a single surgeon; 44 from the DAA, and 48 from PA. The age, body mass index, operation time, blood loss, hospital stay,positioning of the artificial hip, postoperative Harris score and postoperative complications were recorded and analyzed. Results: Both the average age of the patients separately (58.0±11.9) years in DAA group and (61.0±10.4) years in PA group and the body mass index (25.1±3.7) in DAA group and (24.7±3.3) in PA group, showed no significant difference between the two groups. The DAA group had significantly reduced the hospital stay (3.8±1.7) days vs.(4.9±2.3) days for the PA group (P<0.05) and operation time was (76.0±17.4) min in DAA group, and (71.0±14.3) min in PA group (P>0.05). The amount of blood loss: in group DAA (238.0±55.3) mL, and in group PA (387.0±61.2) mL (P<0.05). There was no statistical difference in the positioning of the artificial hip: the cup anteversion in DAA group and PA group was 17.3°±5.3° vs. 18.6°±5.1°, the cup inclination was 38.5°±5.7° vs. 37.7°±5.2°. In DAA group, there was significantly less use of assistive devices ［(24.6±7.8) d vs. (31.7±10.2) d, P<0.05］， and the pain was significantly lower. Harris score at the end of 6 weeks of the follow-up: in DAA group 85.7±5.4, and in PA group 81.3±6.1 (P<0.05); at the end of the last follow-up: in DAA group 93.4±4.7, and in PA group 92.3±5.3 (P>0.05). Complications were encountered in the two groups. There were two intraoperative complications (4.4%), 1 great trochanter fracture and 1 lateral cutaneous nerve injury in DAA group. No dislocation was observed in DAA group. One dislocations and 1 groin pain were recorded in PA group. No prosthesis loosening, deep vein thrombosis, sciatic nerve injury and other complications occurred in the two groups. Conclusion: Total hip arthroplasty using the anterior approach allows for superior recovery and better stability.

Objective： To describe the surgical technique of direct anterior approach to total hip arthroplasty and to report the early clinical outcomes. Methods： A series of 100 consecutive, unselected patients who had 116 primary total hip arthroplasty surgeries (16 bilateral) done through direct anterior approach from March 11 2015 to June 21 2016 was reviewed. There were 50 male patients and 50 female patients. The average patient age was 51 years, and the average body mass index was 24.69 kg/m2. The preoperative diagnosis included avascular necrosis of femoral head, hip osteoarthritis, osteoarthritis se-condary to acetabular dysplasia, sequelae of hip old infection, ankylosing spondylitis, rheumatoid arthritis and avascular necrosis of femoral head after cannulated screws fixation of femoral neck fracture. There were 7 hips which had surgical history prior to the index hip arthroplasty, including 3 cases with bone graft treatment for avascular necrosis of femoral head through Smith-Peterson approach, 2 cases with acetabular shelf procedures for acetabular dysplasia through Smith-Peterson approach, and 2 cases with cannulated screws fixation for femoral neck fracture (internal fixation residual). All were uncemented hips. The stems used in this study included 67 Triloc stems (DePuy company, USA), 45 Corail stems (DePuy company, USA), 2 Accolade stems (Stryker company, USA), 1 Synergy stem (Smith-Nephew company, USA) and 1 Polarstem (Smith-Nephew company, USA). Results: The average follow up period was 8.5 months, the average incision scar length was 10 cm, and the average postoperative Harris score was 93.62. There was 95% postoperative leg length discrepancy within 3 mm. The average cup inclination angle was 38.7°with 94.8% in the range of 30° to 50°. The average cup anteversion angle was 14.3° with 94.2% within the target range of 5° to 25°.The were 15 (12.9%) operative complications, including two femoral perforations (changing stem from Triloc to Corail), three calcar fractures (treated with cerclage wires), four greater trochanter fractures (2 were treated wire tension band, and 2 nondisplaced fractures untreated), one deep infection (debridement and retaining of the prothesis), one superficial infection (debridement), one hematoma and three wound healing complications (debridement). All the complications were successfully treated without any sequelae at the end of the latest follow-up. There was no postoperative dislocation. There was no major nerve and vascular injuries. There were 35 cases (30.2%) reporting symptoms of lateral femoral cutaneous nerve palsy. Conclusion: Direct anterior approach to total hip arthroplasty allows accurate and reproducible cup orientation positioning and leg length restoration and decreases the risk of postoperative dislocation, which is helpful for early rapid postoperative recovery.

Objective： To compare the clinical effects of direct anterior approach (DAA) and posterolateral piriformis-sparing approach (Mis-PLA) for minimally invasive surgery of total hip arthroplasty. Methods: The patients who had total hip arthroplasty from March 2015 to February 2016 were randomly divided into 2 groups: DAA group and Mis-PLA group. In the study, 43 patients (45 hips) were performed with total hip replacement via the direct anterior approach (DAA group). As comparison，39 patients (42 hips) were performed with total hip replacement via the posterolateral piriformis-sparing approach （Mis-PLAgroup） at the same period. DAA group：27 male patients (27 hips), and 16 female patients (18 hips)，with an average age of (57.4±7.3) years, preoperative Harris score (41.4±8.7), body mass index（BMI）(24.3±2.2) kg/m2; MisPLA group： 25 male patients (26 hips)，14 female patients (16 hips), with an average age of (59.2±7.3) years, preoperative Harris score (39.6±8.4), BMI (24.7±2.5) kg/m2. The length of incision， operation time， blood loss，postoperative Harris score were observed and specially the hip functional recovery was fully assessed. Results: (1) All the incisions healed by first intention. No complications were found in both groups. The length of incision：DAA group :（9.2±0.7） cm and Mis-PLA group :（9.5±0.6） cm. No statistical significant differences were found (P=0.053). The operation time：DAA group （74.3±10.1） min and Mis-PLA group（37.5±4.3） min, which showed statistically significant differences（P＜0.01）. Blood loss：DAA group（229.6±79.2） mL and Mis-PLA group (215.7±56.0) mL. Nostatistical significant differences were found （P=0.366）. (2) The patients in both groups were followed up for 6-12 months. The Harris hip scores for 6 weeks’ follow-up：(85.5±4.1) in DAA group and (79.0±4.4) in Mis-PLA group，which indicated statistically significant differences (P＜0.01).The Harris scores for the 6-month follow-up：(94.3±2.7) in DAA group and (95.2±1.9) in Mis-PLA group. No statistically significant differences were found (P=0.125). The basic daily hip function analysis for the 6-week follow-up：walking speed: no statistically significant differences were found between the two groups（P=0.298）; Climbing stairs: Mis-PLA group’ outcome was better than DAA group’s with statistical differences (P=0.047); Circling,sitting and wearing shoes and socks: outcomes in DAA group exceeded Mis-PLA group’s with statistically significant differences （P＜0.01，P=0.016，P＜0.01）. Conclusion: Total hip arthroplasty through either DAA or Mis-PLA approaches could result in very satisfactory clinical effect. Comparing with DAA, Mis-PLA requires less operation time, shorter learning curve，which indicates that it is a relatively safer approach. The advantages of total hip arthroplasty through direct anterior approach lie in less positional limitation in the early stage of postoperative period，as well as a faster recovery of hip function.

Objective： To analyze the operation technique and the methods to avoid early complications on the learning curve for bilateral direct anterior approach (DAA) total hip arthroplasty (THA). Methods: We retrospectively studied a series of continued cases with bilateral avascular necrosis of the femoral head (AVN) or degenerative dysplastic hip and rheumatoid arthritis that were treated by DAA THA in Beijing Jishuitan Hospital. A total of 22 patients with 44 hips were analyzed from June 2014 to August 2016 in this study. There were 17 males and 5 females, and the median age was 48 years（range: 34-67 years）. All the surgery was done by DAA method by two senior surgeons. The clinic characters, early surgery treatment results and complications were analyzed. Results: We used the cementless stems in all the cases. The average operating time was (167±23) min; the average blood loss was (775±300) mL；the blood transfusion was in average (327±341) mL；the wound drainage in average was (111±73) mL Most of the patients could move out of the bed by themselves on the first day after operation, 5 patients could walk without crutches on the first operating day, and 13 patients could squat on the third days after operation. The patients were discharged averagely 4 days after operation. We followed up all the patients for averagely 16 months （range: 8-24 months）. There was no loosening or failure case in the latest follow up. In the study, 2 patients had great trochanter fracture, 2 patients had thigh pain, 4 patients had lateral femoral cutaneous nerve palsy, and 3 patients had muscle damage. The Harris scores were improved from 29±8 preoperatively to 90±3 postoperatively (P<0.01).  Conclusion: The DAA THA can achieve faster recovery and flexible hip joint after operation. However it is a kind of surgery with high technique demanding. Carefully selected patients, and skilled technique, can help the surgeon avoid the early complications. It is associated with high complication rate in the learning curve for bilateral DAA THA.

Objective： There are limited data describing the clinical characteristics and prognosis of culture negative pyogenic spondylitis. The aim of this study was to investigate the treatment, prognosis and clinical characteristics of culture negative pyogenic spondylitis. Methods: A retrospective study reviewed 74 patients who were diagnosed with spondylitis in Peking University First Hospital from January 2010 to December 2015. A total of 27 patients suffered from pyogenic spondylitis. According to the pa-thogenic culture results, the patients were divided into two groups: culture negative group and culture positive group. The clinical characteristics and treatment outcomes between the two groups were compared. Results: The elder were more vulnerable to pyogenic spondylitis, and of the 27 patients, 12 patients were female and 15 male. All patients had no history of administration of antibiotics prior to obtaining culture samples. A causative germ was identified in 14/27 patients (51.9%) with Staphylococcus aureus being the most common pathogen. There was no significant difference between the two groups in the patient’s age, gender, visual analogue score (VAS), predisposing factor, clinical symptom, sign and spinal segment (P>0.05). Erythrocyte sedimentation rate (ESR) (P=0.056) and C-reactive protein (CRP) (P=0.040) of culture negative group were lower in contrast to culture positive group. The incidence of vertebral abscess in culture negative group was higher than in culture positive group (P=0.046). After treatment, ESR dropped almost equally in both groups, and CRP dropped faster in the culture positive group (P=0.192). At last, there was no significant difference between the two groups in hospital stay, pain relief, open debridement operation rate, and recurrence rate of infection. Conclusion: ESR and CRP of the culture negative patient were lower than those of the culture positive patient, and the incidence rate of paravertebral abscess was higher than that of the culture positive patient. After administration of antibiotics, there was no significant difference between the two groups in duration of antibiotics, open debridement operation rate and recurrence rate of infection. So, culture negative may not necessarily be a negative prognostic factor for pyogenic spondylitis. However, we should watch out for the drug resistant bacteria or double infection, due to the long term use of wide-spectrum antibiotic in culture negative patients.

Objective： To analyze and summarize the causes of unscheduled suspension of knee and hip arthroplasty and to provide the method for optimizing the patient’s preoperative management and improving the efficiency of medical resources as well as the patient’s satisfaction. Methods： The data for this report was retrospectively collected from September 2013 to August 2014 in our hospital, from cases of knee and hip arthroplasty that were suspended before the scheduled operation time. Acquisition data from the collected cases including the patients’ gender, age and the surgical procedure. At the same time, the suspension reasons were recorded and analyzed. All the decisions of suspension was made by the surgeons and the anesthesiologists according to the abnormal result of preoperative examinations, after communicating with the patients and their families and obtaining their understandings. Results： In the collecting period, our department scheduled 1 146 cases of knee and hip arthroplasty, among which 1 003 were completed, 143 suspended (12.5% suspension rate). Among the causes of suspension, the top four common causes were cardiovascular disease (44/143, 31%), other infections (20/143, 14%), bacteriuria (18/143, 13%) and inappropriate surgical indication (16/143, 11%). Other causes include surgeon’s reason, Blood system abnormalities, high inflammatory index, deep vein thrombosis, other diseases uncontrolled, abnormal liver function and poor diabetes mellitus control, etc. For the rate of suspension, there was no significant difference between the patients with different genders (male: 15.0%, and female: 11.7%, P=0.149), or age (≤50 years: 13.0%; 51-65 years: 11.6%; 66-80 years 13.3%; >80 years 11.1%; P=0.864). However compared with knee arthroplasty, hip arthroplasty had a higher suspension rate (knee arthroplasry 11.1%, hip arthroplasry 16.1%, P=0.021). Conclusion： It is important to educate and manage the patients before their knee and hip arthroplasty. Through clear diagnosis, detailed medical history analysis careful physical examination, and targeted outpatient examinations and tests for which priority was focused on cardiovascular or other system diseases we could minimize the occurrence of operative suspension post hospitalization, therefore improving the efficiency of the use of medical resources.

Objective： To investigate the morphology character of sagittally unstable intertrochanteric fractures and reduction methods. Methods: A retrospective study was used to analyze the clinical data of sagittally unstable intertrochanteric fractures cases, which were treated with proximal femoral nail anti-rotation (PFNA) fixation from March 2009 to June 2016. In the study, 36 cases were followed up completely, in which 17 cases accepted open reduction, and the other 19 cases accepted minimally invasive reduction. The operation time, amount of bleeding, the fluoroscopy times, postoperative radiographic measurements, such as tip-apex distance (TAD) and sliding distance of the spiral screw, and hip Harris scores were analyzed. The morphology character of the fractures was documented and investigated. Results: The average follow-up time was 15 months. The amount of bleeding of the open reduction group was (170.5±19.7) mL, and the amount of bleeding of the minimally invasive group was (54.7±12.5) mL. The amount of bleeding of the minimally invasive group was significantly less than that of the open reduction group (P<0.001). Between the two groups, there were no significant differences in other evaluation parameter, including operation time (P=0.054), the fluoroscopy times (P=0.053), fracture healing time (P=0.305), postoperative radiographic measurements, such as TAD (P=0.317) and sliding distance of the spiral screw (P=0.206), and hip Harris scores (P=0.459). In regard to morphology character of the fractures, the proximal anterior unstable fractures with separation displacement were more common than the proximal posterior unstable fractures with impaction. The characteristic feature of the proximal anterior unstable fractures was the proximal anterior and medial long oblique fracture, and a V shape cortical defect in the distal fracture fragment on the externally rotation X-ray. Conclusion: Sagittally unstable intertrochanteric fractures can be divided into the proximal anterior unstable fractures with separation displacement, and the proximal posterior unstable fractures with impaction. The two types have their own morphology character individually. The reduction should be performed by minimally invasive techniques.

Objective： To investigate the feasibility, surgical technique and effect of osteosynthesis for proximal humerus fractures through the minimal incision anterolateral acromion. Methods: In this study, 32 patients of proximal humeral fractures were selected and treated through the minimal incision anterolateral acromion between January 2012 and October 2014. Of these patients, there were 19 males and 13 females, with mean age 46 years old (range: 22-78 years). The mechanism of injury was a trauma of simple fall for 21 patients and motor vehicle accident for 11 patients. According to Neer classification, 18 cases had two-part fractures, 12 had three-part fractures, and 2 had four-part fractures. All patients were sustained operation of open reduction and internal fixation. The average delay between trauma and surgery was 4 d (0.5-10.0 d). The operations were performed in invariable operating room with general anesthesia. The fractures were reduced and immobilized with anatomical locking plate through the minimal  incision anterolateral acromion during operation. Patients were received passive motion after operation.  Results: All the 32 cases were followed up ranging from 3 to 34 months with an average of 11 months. All the fractures were healed. There was neither failure of internal fixation nor incision infection case. The functional results of the shoulder, according to Constant-Murley score was on an average 86 (range: 69-100). Conclusion: The treatment for proximal humeral fractures through the minimal incision anterola-teral acromion approach is a feasible and effective method, which shows good results for treating proximal humerus fractures with correct indication. There are several advantages compared with conventional deltopectoral   approach. They are minimal soft tissue disruption, minimal blood loss and easily to manipulate technique. But it required selection of indication strictly and surgeon’s experience.

Objective： To evaluate the rate of basicervical fractures and document their diagnosis and treatment. Methods: From January 2005 to May 2016, 28 basicervical fractures of the 832 trochanteric fractures were collected and evaluated. The patients were treated with multiple screws, dynamic hip screw (DHS), intramedullary nail. Via the operation time, postoperative hospitalization, loss of blood duration the operation, hidden blood loss, total blood loss, mean union time and the final follow-up Harris hip score, the characteristics of different internal fixations were compared and analyzed. Results: The incidence of basicervical fractures was 3.37% (28/832) in our study. In the intramedullary nail group (16 patients), the operation time was 55 (20,120) min, the postoperative hospitalization was 3(2, 7) d, the intraoperative blood loss was 50(5,100) mL, the hidden blood loss was 533.37 (376.19, 987.15) mL, and the total blood loss 627.35 (406.19, 1037.16) mL . The union time and final follow-up Harris score were 6 (3, 9) months and 90.25 (74,100) min. In the DHS group (8 patients), the operation time was 87.5 (65,115) min, the postoperative hospitalization was 5.5 (2, 17) d, the intraoperative blood loss was 100 (50,300) mL, the hidden blood loss was 278.11 (202.43, 849.97) mL, and the total blood loss 580.19 (368.55, 899.97) mL . The union time and final followup Harris score were 5.5 (4, 12) months and 85.5 (84, 87) min. In the multiple screws group (4 patients), the operation time was 47.5 (35, 75) min, the postoperative hospitalization was 5 (2, 12) d, the intraope-rative blood loss was 20 (2, 70) mL, the hidden blood loss was 150 (100.00, 412.01) mL, and the total blood loss 195.00 (120.00, 414.01) mL. The union time and final follow-up Harris score were 4 (4, 6) months and 80 (61, 97) min. The patients treated with multiple screws and intramedullary nail had a shorter operation time than the DNS group, but no obvious difference was found between the other two groups (P=0.367). Postoperative hospitalization had no significant difference among the three groups. The intraoperative bleeding was more in the DHS group, the other two groups had no significant difference (P=0.100). However, the hidden blood loss was more in the intramedullary nail group, the other two groups had no significant difference (P=0.134). The total blood loss in the intramedullary nail group was more than multiple screw group, similar to the DHS group (P=0.483). One patient treated with multiple screws underwent internal fixation failure three months after operation. The mean union time and final follow-up Harris scores had no significant difference among the three groups (P>0.05). Conclusion: Through this study, we found that the incidence of basicervical fractures is low. Fractures with no shift can be confirmed by preoperative X-ray. For displaced fractures, preoperative CT + 3D reconstruction is recommended. Surgical treatment by closed reduction and internal fixation with DHS or intramedullary nail is shown to be very effective.

Objective： To evaluate the feasibility of transforaminal endoscopic nerve root decompression for degenerative lumbar spinal stenosis (DLSS). Methods: From July 2011 to April 2016, 96 cases of single segment DLSS were involved. All the patients had unilateral lower extremity neurological symptoms, signs, neurogenic intermittent claudication of less than 500 m. Imaging examinations (CT or MRI) or diagnostic nerve root block confirmed single segment degeneration. The mean age was (71.6±5.4) years, male: 55 cases, female: 41 cases. Their intraoperative blood loss, operation time, complications, ambulation time and discharge time were recorded. Leg pain VAS, ODI were used to evaluate the pain and lumbar function of the patients. The clinical efficacy was evaluated by Nakai evaluation. Results: All the patients were performed endoscopic decompression of the lateral recess and nerve root by removing the ventral part of the superior facet joint, the ligamentum flavum and the intervertebral disc. The decompression range was from the inferior edge of the upper pedicle to the superior edge of the lower pedicle. The nerve root was detected to have no compression and the pulse of nerve root returned to normal. The patient got ambulant on the operation day and discharged if he had no discomfort symptom. In the study, 68 cases got follow up. The mean follow-up time was 12.1 months (6－63 months). The VAS at dif-ferent follow-up time points was improved relative to the baseline, and the difference was statistically significant (F=491.60， P<0.001). The ODI at different follow-up time points was improved relative to the baseline, and the difference was statistically significant (F=189.91， P<0.001). The excellent and good rates of Nakai evaluation were 79.4% (excellent in 42 cases, good in 12 cases, fair in 10 cases and poor in 4 cases). The mean intraoperative blood loss was (49.29±11.86) mL. The mean operation time was (92.46±21.34) min. The mean ambulation time was 1.8 h. The mean discharge time was 2.3 days. Postoperative epidural hematoma was found in 1 case. Foot drop was found in 1 case. Second stage open surgery was performed in 6 cases. Conclusion: We can apply transforaminal endoscopic decompression for the patients of lumbar spinal stenosis who have unilateral nerve root irritation. Patients with transforaminal endoscopic decompression can get less surgical trauma, quick recovery and obtain good shortterm outcome.

Objective： To describe the application of polymethylmethacrylate (PMMA)  augmentation of cement-injectable cannulated pedicle screws for the treatment of degenerative lumbar scoliosis with osteoporosis. Methods: Retrospective cohort study was used to compare cement injectable cannulated pedicle screws ( CICPs) group with PMMA augmentation and control group with traditional method in the correction surgery for Lenke-silva level Ⅲ and level Ⅳ degenerative scoliosis cases with osteoporosis. Both groups were followed up for 1 year. The clinical results were assessed by visual analog scale (VAS) of pain on lumbar and lower limbers, Oswestry disability index (ODI) score and EuroQol-5 dimensions (EQ-5D) score. The coronal major curve Cobb angel in coronal plane and thoracic kyphosis Cobb angle, lumbar lordosis Cobb angle and sagittal vertical axis (SVA) in sagittal plane were tested in whole long spine X ray. The fusion rates were evaluated by lumbar X ray and dynamic X ray. Results： In this study 34 cases were enrolled, 15 cases in CICPs group and 19 cases in control group. The general characteristics including age, gender, weight, height, BMI and BMD were without statistical difference between the two groups. There were （5.7±2.2）PMMA augmentation screws in CICPs group. The operation time, blood loss and blood transfusion were higher in CICPs group than in control group, but without statistical difference. Lumbar VAS, lower limbers VAS, ODI score and EQ-5D were all better in 1 month post-operation, 6 months postoperation and 1 year postoperation than in preoperation in both groups. lumbar VAS scores of CICPs group in 6 months postoperation(CICPs group 3.1±1.3 vs. control group 4.4±1.4， P<0.01） together with lumbar VAS scores (CICPs group 3.3±1.0 vs. control group 5.2±1.4， P<0.01），ODI scores (CICPs group 22.7±17.2 vs. control group 31.4±18.5， P<0.01） and EQ-5D in 1 year postoperation (CICPs group 2.9±2.0 vs. control group 3.5±2.5， P<0.01）were lower than those of control group. The coronal major curve Cobb angels were all lower in 1 month postoperation, 6 months postoperation and 1 year postoperation than in preoperation in both groups; thoracic kyphosis Cobb angle and lumbar lordosis Cobb angle were all higher in 1 month postoperation, 6 months postoperation and 1 year postoperation than in preoperation in both groups. The coronal major curve Cobb angel was lower in CICPs group than that in control group in 1 year postoperation (CICPs group 17.6°±6.9° vs. control group 21.2°±7.2°， P<0.01）and thoracic kyphosis Cobb angle was higher in CICPs group than that in control group in 6 months postoperation (CICPs group -33.5°±8.8 °vs. control group -28.9°±8.3°， P<0.01）and 1 year postoperation(CICPs group -33.0°±8.1° vs. control group -26.3°±7.4°， P<0.01） together with lumbar lordosis Cobb angle were higher in CICPs group than that in control group in 1 year postoperation(CICPs group 26.4°±8.1° vs. control group 22.1°±7.3°， P<0.01）. Conclusion: Polymethylmethacrylate augmentation of bone cementinjectable cannulated pedicle screws for the treatment of degenerative lumbar scoliosis with osteoporosis was effective and safe, the short-term clinical result was good.

Objective： To estimate the safety and feasibility of flexible laryngeal mask airway (FLMA) for lumbar vertebral surgery in prone position. Methods: In the study, 120 adult patients scheduled for lumbar vertebral surgery under intravenous general anesthesia were divided into group FLMA and reinforced tracheal tube (RTT) group at random. Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded at the beginning of anesthesia induction (T0) and on the time of artificial airway intubation (T1), 1 min after intubation (T2), extubation (T3), 1 min after extubation (T4) as well. The number and time required for intubation were recorded. Peak airway pressure (PPEAK), airway sealing pressure (PAS) in group FLMA and fiberoptic bronchoscopy scale (FBS) were recorded after artificial airway intubation, turned over into prone position and after the operation started, as well as on the time of 1 hour after the operation started, 2 hours after operation started and when the operation stopped. Finally, respiratory complications after extubation, including hypoxemia, laryngospasm, coughing, vomiting, hoarseness, and pharyngalgia, were observed and whether there was blood or sewage inside and outside the artificial airway was recorded. Results: There was no difference in the number and time required for intubation between the two groups (P>0.05). There was no difference in PPEAK and FBS between the two groups, and also the same at the different time points in each group (P>0.05). PAS in group FLMA was the same at the diverse time points during anesthesia (P>0.05) and always higher than PPEAK in the perioperative period. In group FLMA, there was no difference in HR, SBP and DBP between the time points of T2 and T1, also of T4 and T3 (P>0.05). In group RTT, HR, SBP and DBP were significantly higher between the time points of T2 and T1 (P<0.01); SBP was significantly higher between the time points of T4 and T3 (P<0.01), DBP and HR were higher between the time points of T4 and T3 (P<0.05). SBP in group FLMA was significantly lower than in group RTT at T2 (P<0.01), HR and DBP were lower than those in group RTT simultaneously (P<0.05). On the time point of T4, SBP, DBP and HR in group FLMA were lower than those in group RTT (P<0.05). The incidence of coughing and pharyngalgia after extubation was significantly lower in group FLMA than in group RTT (P<0.01), with the incidence of hoarseness was lower in group FLMA than in group RTT (P<0.05). There was no difference in the incidence of hypoxemia, vomiting and blood seen outside the cuff between the two groups (P>0.05) while no laryngospasm and sewage seen outside the artificial airway in each group. Conclusion: For suitable patients, FLMA can be used in mechanical ventilation forlumbar vertebral surgery in prone position with more stable circulation and less respiratory complications than RTT. Further clinical validation is needed for the safety of FLMA.

Objective： To analyze the outcomes of patients with osteoporotic vertebral compression fractures treated with polymethylmethacrylate (PMMA) and GeneX bone cement in percutaneous kyphoplasty and to provide guidance in selecting the vertebral filling material for this procedure. Methods: In this study, 86 patients with osteoporotic vertebral compression fractures treated at Peking University Third Hospital between June 2012 and June 2013 were retrospectively analyzed. The patients were followed-up with questionnaires and X-ray and CT examinations after 1 month, 3 months, 6 months, and 1 year. Postoperative conditions, including recovery rate of vertebral height, recovery rate of vertebral Cobb angle, CT data, reductions in visual analogue scale (VAS) and Oswestry scores, and postoperative complications, were evaluated. The results were analyzed using SPSS 18.0. Results: According to the rank sum test, there were significant differences in the recovery rate of vertebral height, vertebral Cobb angle and vertebral volume between the two groups after 3 months, 6 months, and 1 year (P<0.05). The GeneX-group had greater losses in vertebral height, Cobb angle and volume than did the PMMA group. The PMMA group had 3 cases of cement leakage and 1 case of an adjacent vertebral fracture after percutaneous kyphoplasty. The GeneX- group had 2 cases of cement leakage. Conclusion: GeneX- bone cement is similar to PMMA in terms of postoperative pain relief. As the filling material in percuta-neous kyphoplasty, it is effective at maintaining vertebral height, quickly improves strength and stiffness of the vertebral body and has fewer complications. However, it is not satisfactory in maintaining long-term postoperative vertebral height. GeneX- bone cement can be used as the filling material for patients with osteoporotic vertebral compression fractures in percutaneous kyphoplasty. Patients with severe osteoporosis and vertebral compression should be treated with standardized osteoporosis treatment and should try to avoid early postoperative walking exercises. Sustained vertebral filling materials, such as PMMA, are more suitable for such patients. Research into better biodegradable materials is still needed.

Objective： To evaluate the security and efficiency of a surgical robotic assisted percutaneous screw fixation for the treatment of pelvic and acetabular fractures. Methods: In the study, 12 patients with pelvic and acetabular fractures who were treated in Beijing Jishuitan Hospital from January to April in 2016 were involved in this research. The research subjects were randomly divided into two groups: the experimental group and the control group. Roboticassisted percutaneous sacroiliac screw internal fixations were performed under the guidance of fluoroscopy navigation in the experimental group; in the control group, doctors operated manually guided by fluoroscopy. Statistical analysis was performed on the total operation time, the intraoperative fluoroscopy time, the adjustment numbers of intraoperative guide wires, the excellent rate of screw placement and the incidence of adverse events in order to evaluate the security and efficiency of a surgical robotic assisted percutaneous screw fixation for the treatment of pelvic and acetabular fractures. Results: Eleven screws were placed in 7 patients from the experimental group, while 7 screws were placed in 5 patients from the control group in total. All the screw placement positions were satisfactory according to postoperative CT images. The excellent rates of screw placement position were 100% in both groups. However, the P value was 0.016 based on the comparison between the screws’ distribution in the two groups which meant that the screw distribution of the experimental group was better than that of the control group. The average fluoroscopy time needed for screw insertion was (7.36±2.63) s in the experimental group while (41.80±13.99) s in the control group (P<0.001). This suggested that the difference between the two groups had statistical significances. Intra-operative fluoroscopy time of the experimental group was significantly smaller than that of the control group. The number of the average screw adjustment was (0.36±0.48) times in the experimental group while (9.00±3.06) times in the control group (P=0.003). This suggested that the difference of the number of the guide needle adjustment between the two groups had statistical significances, and the number of the experimental group was smaller than that of the control group. The average operation time was (43.86±49.06) min in the experimental group while only (29.00±12.14) min were needed in the control group (P=0.528) . This suggested that the difference between the two groups had no statistical significance. That is, the total operation time of the two groups was equal. All the screws were in satisfactory positions according to validation results of CT scans. No complications such as screw breaking out the bone cortex and entering into the knee joint cavity, wound infection occurred. Conclusion: Surgical robots are suitable for robot-assisted percutaneous screw fixation in pelvic and acetabular fractures. Robot-assisted treatment of pelvic and acetabular fractures has significant advantages over manual operations including high accuracy, small perspective radiation, safety and efficiency.

Objective： To summarize the CT features of ankle fracture and to analyze the relationship between the CT images and the most commonly used ankle fracture classification. Methods: With 369 cases of adult ankle fractures analyzed retrospectively, the CT images 1 cm above the ankle joint and its characteristics, the Danis-Weber classification of ankle fracture were studied, and so was the relationship between CT images and the fracture classification. Results: There were 8 forms of CT images. With a, b, and c referred to the fibular fracture, posterior malleolar fracture and interosseous tibiofibular ligament (IOL) rupture respectively. 369 CT imges had 40 cases of 0 degree injury (fibula, posterior malleolus, IOL all intact); 60 cases of Ⅰa degree injury (fibular fracture, posterior malleolus and IOL intact), 3 cases of Ⅰb degree injury (fibula intact, posterior malleolus fracture, IOL intact), 26 cases of Ⅰc degree injury (fibula and posterior malleolus intact, IOL rupture); 163 cases of Ⅱab degree injury (fibula and posterior malleolus fractures, IOL intact), 6 cases of Ⅱac degree injury (fibular fracture, posterior malleolus intact, IOL rupture), 61 cases of Ⅱbc degree injury (fibula intact, posterior malleollar fracture, IOL rupture); 10 cases of Ⅲ degree injury (fibular fracture, posterior malleollar fracture and IOL rupture). According to the Danis-Weber classification, there were 18 cases of type A, 238 cases of type B, 94 cases of type C, and 19 cases without fibular fracture. The prevalence of IOL rupture were 0, 5.9%, and 88.3% in types A, B, and C respectively. There was a correlation between the CT image and Danis-Weber classification, the incidence of IOL rupture was changed with the severity of Danis-Weber classification, and the difference was statistically significant after the rank correlation test (Spearman R=0.781, P<0.001). IOL rupture not determined by the fracture classification was found with the CT images and the incidence was 5.9%. Conclusion: Cross-sectional CT images 1 cm above the ankle joint can clearly determine the IOL injury pre-operatively with a good correlation with the Danis-Weber fracture classification, IOL rupture unrecognized with the fracture classification can also be noticed with the CT image.

Objective：To investigate the effect and mechanism of targeted B7-H3 gene silencing on the tumorigenesis and metastasis of human hematological malignancy xenograft tumor in nude mice. Methods: Real-time fluorogentic quantitative PCR (qPCR) and flow cytometry (FCM) were used to detect the expression of B7-H3 in 13 strains of malignant hematologic cells. Then, U937, Maver and Z138 cells which expressed high level of B7-H3 were screened out. Targeted B7H3 knockdown in U937, Ma-ver and Z138 was performed by lentivirus transduction and the effect of B7-H3 silencing in stable cell lines was tested by qPCR and FCM. Injecting the nine groups subcutaneously into the nude mice to establish xenograft models after dividing the U937, Maver and Z138 into non-infected control group (CON), B7-H3 knockdown group (KD) and negative non-targeted control infected group (NC),respectively, for detecting the tumorigenicity and metastasis in vivo. Furthermore, the expression of Ki-67 in xenograft tumors was detected by immunohistochemistry (IHC). The expression of metalloproteinase 2 (MMP-2) was detected by western blot.  Results: The stable B7-H3 silencing cell lines of U937, Maver and Z138 were successfully established. Compared with the NC group, the KD groups of U937, Maver and Z138 had an obviously slower tumor growth. The average tumor inhibition rates at the end of observation period were 61.83% (F=43.78, P<0.05), 59.12% (F=36.51, P<0.05) and 67.37% (F=40.29, P<0.05); there was no significant difference in tumor volume growth between the NC group and the CON group (P>0.05). The liver distant metastasis of all the xenograft tumor models in nude mice was the most common and the rates of distant metastasis in KD groups were significantly lower than that of the corresponding NC groups. The Ki-67 indexes of the KD groups were significantly lower than those of the relative NC groups in three cell lines (U937: 40.3%±5.2% vs. 79.1%±6.3%, q=30.31, P<0.05, Maver: 35.2%±6.4% vs. 69.6%±5.1%， q=24.82, P<0.05; Z138: 38.4%±7.1% vs. 75.7%±4.8%, q=28.07, P<0.05); there was no significant difference in the expression of Ki-67 between the NC group and the CON group (P>0.05). The expressions of MMP-2 were also significantly lower in the KD groups than in the NC groups (U937: q=14.59, P<0.05; Maver: q=9.25, P<0.05; Z138: q=11.04, P<0.05); there was no significant difference in the expression of MMP-2 between the NC group and the CON group (P>0.05).Conclusion: Targeted B7-H3 gene silencing could inhibit the tumorigenesis and metastasis of human hematological malignancy xenograft tumor in nude mice. The mechanism may be related to the down-regulation of Ki-67 and MMP2.

Objective： To investigate how urothelial carcinoma-associated 1 (UCA1) and miR-18a modulates acquired tamoxifen resistance and the relevant mechanisms in estrogen receptor (ER) positive cancer cells. Methods: qRT-PCR was performed to detect UCA1 and miR-18a expression in breast cancer cells. Dual luciferase assay was performed to detect the binding between miR-18a and UCA1 3′UTR. Tamoxifen sensitive MCF-7 cells were transfected with UCA1 expression vector or miR-18a inhi-bitors. Tamoxifen resistant LCC9 and BT474 cells were transfected with UCA1 siRNA or miR-18a mi-mics. CCK-8 assay was performed to detect cell viability. Soft agar assay was performed to assess cell colony formation. Flow cytometric analysis was performed to check cell cycle distribution. Results: UCA1 was significantly upregulated in tamoxifen resistant LCC2, LCC9, and BT474 cells than in tamoxifen sensitive MCF-7 cells. UCA1 expression was significantly upregulated in MCF-7 cells after treatment with 0.1 μmol/L tamoxifen. UCA1 overexpression enhanced cell viability of MCF-7 cells after tamoxifen treatment, while UCA1 siRNA significantly suppressed viability of LCC9 and BT474 cells after tamoxifen treatment. In MCF-7 cells, compared with vector control+tamoxifen group, the average cell colony number and colony size of the UCA1+tamoxifen group was 19.0% more and 29.0% larger respectively, while the proportions of the cells in G1 phase and in S phase were 7.3% lower and 6.7% higher respectively. In BT474 cells, compared with siRNA control+tamoxifen group, the average cell colony number and colony size of the si-UCA1+tamoxifen group were 54.0% less and 42.0% smaller respectively, while the proportions of the cells in G1 phase and in S phase were 9.0% higher and 6.2% lower respectively. UCA1 directly interacted with miR18a and reduced its expression in ER positive breast cancer cells. Knockdown of miR-18a increased viability of MCF-7 cells after tamoxifen treatment, while miR-18a overexpression significantly reduced viability of BT474 cells after tamoxifen treatment. In MCF-7 cells, compared with miRNA inhibitor control+tamoxifen group, the average cell colony number and colony size of the miR-18a inhibitor+tamoxifen group were 15.0% more and 33.0% larger respectively, while the proportions of the cells in G1 phase and in S phase were 8.8% lower and 5.3% higher respectively. In BT474 cells, compared with miRNA control+tamoxifen group, the average cell colony number and colony size of the miR-18a mimics+tamoxifen group were 47.0% less and 25.0% smaller respectively, while the proportions of the cells in G1 phase and in S phase were 13.3% higher and 7.9% lower respectively. Conclusion: UCA1 can increase tamoxifen resistance of ER positive breast cancer cells via competitively inhibiting of miR18a.

Objective：Compare the results of molecular diffusion and mass flow in the interstitial space(ISS) displayed by using optical and magnetic probes and study partitioned drainage of the brain interstitial fluid (ISF).Methods: In the study, 36 male SD rats were randomly divided into fluorescent inspection group (18), magnetic tracer group (18). Then they were divided equally into caudate nucleus (Cn), thalamus (T) and substantia nigra (Sn) subgroup, 6 rats in each subgroup. Referencing the brain stereotaxic atlas, the coronal globus pallidus as center level, Cn, T or Sn were acted as puncture positioning target. A 10 μL microsyringe was stereotaxically positioned and the lucifer yellow (LY) solution of 2 μL 10 mmol/L was infused into centric position. The coronary slices undergo cardiac perfusion and fix respectively in time point Cn 3 h, T 2 h and Sn 1 h. The rat brain was placed in rat stainless steel brain matrices and cut backward along visual intersection. The injection point of coronal slice as the center level, take 3 slices in front of the center level and 2 slices behind of it. 1 mm for each slice and 6 slices in total. Then slices were detected by laser scanning confocal microscope (LSCM). Simultaneous, in the same coordinate brain regions of another three groups, a gadolinium-diethylene triamine pentaacetic acidm (Gd-DTPA) solution of 2 μL 10 mmol/L was infused into different injection and detected by MRI tracer-based method. Then the Radiant can be used to measure distribution area of Gd-DTPA. Results: LY and Gd-DTPA have different distribution regions in Cn, T and Sn. After LY and Gd-DTPA were introduced into the Cn subgroup 3 h, compare the 1 to 6 levels distribution area of LY and Gd-DTPA as follows: (10.95±4.27) mm2 vs. (8.33±2.25) mm2, (18.16±4.74) mm2 vs. (16.42±2.88) mm2, (24.57±3.65) mm2 vs. (20.75±2.29) mm2, (34.81±3.32) mm2 vs. (28.88±1.51) mm2, (30.53±3.12) mm2 vs. (20.92±2.75) mm2, (12.15±4.92) mm2 vs. (10.00±1.89) mm2. The statistical analysis of every level was made by T test, and the difference of the distribution area between the two tracers were not statistically significant (t=0.940， P=0.400； t=0.546， P=0.614； t=1.534， P=0.200； t=2.809， P=0.480； t=2.693， P=0.055； t=0.707， P=0.518)； After LY and Gd-DTPA were introduced into the T subgroup 2 h, compare the 1－6 levels distribution area of LY and GdDTPA as follows: (5.56±4.61) mm2 vs. (3.33±2.25) mm2, (16.21±3.36) mm2 vs. (11.42±2.88) mm2, (19.00±5.21) mm2 vs. (15.75±2.29) mm2, (25.32±5.49) mm2 vs. (22.33±3.25) mm2, (17.34±5.31) mm2 vs. (15.92±2.75) mm2, (7.67±6.19) mm2 vs. (5.00±1.89) mm2. The statistical analysis of every level was made by T test, and the difference of the distribution area between the two tracers were not statistically significant (t=0.753， P=0.493； t=1.875， P=0.134； t=0.990， P=0.378； t=0.810， P=0.464； t=0.413， P=0.701； t=0.716， P=0.514)； After LY and Gd-DTPA were introduced into the Sn subgroup 1 h, compare the 1－6 levels distribution area of LY and Gd-DTPA as follows: (6.78±4.56) mm2 vs. (4.75±2.00) mm2, (12.65±5.04) mm2 vs. (10.44±1.13) mm2, (19.51±6.54) mm2 vs. (17.55±0.30) mm2, (28.72±5.45) mm2 vs. (24.48±1.32) mm2, (21.34±4.42) mm2 vs. (17.72±0.25) mm2, (13.00±5.46) mm2 vs. (12.00±2.88) mm2. The statistical analysis of every level was made by T test and the difference of the distribution area between the two tracers were not statistically significant (t=0.705， P=0.519； t=0.743， P=0.499； t=0.517， P=0.656； t=1.310， P=0.260； t=1.416， P=0.292； t=0.281， P=0.793)， but the distribution area of LY is slightly more than Gd-DTPA.Conclusion: LSCM imaging technology confirmed partitioned drainage of the brain ISF found by MRI tracer-based method and provided technology and method validation for MRI tracerbased method. LSCM imaging technology with higher contrast and resolution, therefore more sophisticated partitioned drainage of the brain interstitial fluid were got.

Objective： To investigate the influences of repeated propofol anesthesia on the hippocampal apoptosis and the long-term learning and memory abilities of neonatal rats. Methods: In the study, 45 male Sprague-Dawley rats, aged 7 days, were randomly divided into 3 group (n=15 each): control group (C group) that received intralipid 7.5 mL/kg intraperitioneal (IP) once a day×7 days; group propofol 1 (P1) that received propofol 75 mg/kg IP once a day×7 days; group propofol 2 (P2) that received intralipid 7.5 mL/kg IP once a day×6 days+propofol 75 mg/kg IP on the 7th day. In each group, 5 animals were chosen and arterial blood samples were obtained immediately after the animals were fully awake for blood gas analysis. Learning and memory abilities were assessed using Morris water maze when the other rats were 4 weeks old. The animals were decapitated after the tests. The hippocampi were isolated for detection of neuron-specific nucleoprotein (NeuN) expression by immunohistochemistry method and the expression of caspase-3 using the Western blot.  Results: There was no significant difference in the indexes of blood gas analysis among the 3 groups. Morris water maze test: compared with group C, the escape latency and the length of searching on the 5th day were significantly prolonged, and the searching time in target quadrant and platform crossing on the 6th day were significantly decreased in group P1 (P<0.05) but not in group P2. Compared with group C, NeuN-positive neurons were decreased, and the expression of caspase-3 was increased in the rats of group P1 (P<0.05) but not in group P2. Conclusion: Repeated propofol anesthesia may destroy longterm learning and memory abilities by inducing apoptosis of hippocampal neurons in neonatal rats, while single dose of propofol has no obvious effect on the hippocampal apoptosis and longterm learning and memory of neonatal rats.

Objective： To investigate changes of swallowing function and associated symptoms in Chiari malformation typeⅠ (CMⅠ) patients with and without dysphagia by the analysis of their clinical and high-resolution manometry (HRM) parameters. Methods: A total of 42 patients diagnosed with symptomatic CMI without atlantoaxial dislocations which were confirmed by clinical manifestations and magne-tic resonance imaging(MRI) findings between January 2010 and July 2015 at Peking University Third Hospital were included in this study. Twenty patients had a history of various dysphagia symptoms, or reported symptoms of choking, coughing after eating or drinking, while the other 22 patients denied symptoms of dysphagia. The data collected from the medical records of these patients included the patient’s age, sex, date of diagnosis, duration of illness, symptoms, results of MRI and HRM, and date of sur-gery. Results: (1) Dysphagia group had 14 female patients, and no-dysphagia group had 8 female patients. Dysphagia usually occurred in female patients, and in addition to dysphagia, we recorded other symptoms and signs in the CMⅠ patients, including numbness, hypoesthesia, limb weakness, neck pain, muscle atrophy, ataxia, hoarseness, symptoms caused by posterior cranial nerve damage, pharyngeal reflex, uvula deviation, and pyramidal signs. A higher percentage of the CMⅠ patients with dysphagia (15/20) had symptoms of posterior cranial nerve damage compared with the control group (5/22; P=0.01). (2)HRM showed a significant difference in upper esophageal sphincter (UES) relax ratio measurement (75.3% vs. 63.1%, P=0.023) and UES proximal margin (17.2 cm vs. 15.7 cm, P=0.005) between the two groups. (3) The percentage of syringomyelia affecting the bulbar or upper cervical region on MRI was significantly higher in the dysphagia group (17/20 vs. 7/22, P=0.001). Conclusion: CMⅠ was usually accompanied by symptoms caused by posterior cranial nerve damage, ataxia, and positive pyramidal signs. Location of the syringomyelia affecting specifically the bulbar or upper cervical region was associated with dysphagia in CMⅠ patients. These findings suggest that the mechanism of dysphagia in CMⅠ may be due to a dysfunction in the neurological pathway of pharyngeal muscle movement. Dysphagia etiology work-up should include CMⅠ in the differential diagnosis.

Objective： To investigate the anesthetic choice for patients undergoing cesarean section complicated with placenta implantation. Methods: A retrospective case review of the patients with placenta implantation between 2008 and 2013 at Peking University Third Hospital was conducted in the International Classification of Diseases (ICD)-9 codes, excluding natural birth and not first diagnosed in our hospital, a total of 96 cases were incorporated into this study. According to the degree of implantation, they were divided into three groups: accreta group, increta group and percreta group. We analyzed the time from the start of surgery to baby delivery and the anesthetic technique. Results: The accreta group included 49 cases, the increta group 33 cases, and the percreta group 14 cases. The average time from the start of surgery to fetus delivery in the three groups were (6.7±3.0) min, (7.2±4.6) min, and (11.9±4.9) min, and the percreta group was significantly different from the accreta group and the increta group (P<0.05). There were significant differences among the three groups in anesthetic choices (P<0.001): in the accreta group, 45 cases (91.8%) underwent spinal anesthesia, 2 cases (4.1%) underwent general anesthesia, and 2 cases (4.1%) were converted to general anesthesia after spinal anesthesia during the operation; in the increta group, 22 cases (66.7%) underwent spinal anesthesia, 4 cases (12.1%) underwent general anesthesia, and 7 cases(21.2%) were converted to general anesthesia after spinal anesthesia; in the percreta group, 2 cases (14.3%) underwent spinal anesthesia, 2 cases (14.3%) underwent general anesthesia, and 10 cases (71.4%) were converted to general anesthesia after spinal anesthesia. Conclusion: Spinal anesthesia can be used as the first choice of cesarean section complicated with placenta implantation and general anesthesia should be considered in placenta percreta.

Objective：Positive effects of bioactive glass (BG) on proliferation, mineralization, and differentiation of human dental pulp cells (hDPCs) was already verified in various former studies. The Arg-Gly-Asp-Ser sequence (RGDS) was confirmed of affecting cell adhesion. Before further investigation, the objective of this study is to investigate whether RGDS can affect the effects of BG on the adhesion, proliferation and mineralization of hDPCs. Methods: hDPCs were harvested from third molars of 18-25-year-old individuals after informed consent. Enzyme digestion technique was used. The 4th to 6th ge-neration of hDPCs were used for all experiments.The cells of the experimental groups were cultured in Dulbecco minimum essential medium (DMEM) containing ionic dissolution products of BG and RGDS of seve-ral concentrations (12.5 mg/L, 25.0 mg/L, 50.0 mg/L, 100.0 mg/L, 200.0 mg/L). DMEM containing ionic dissolution products of BG without RGDS was used for cell culture as control group. Cell adhesion was tested 4 h after cell seeding by MTT assay. Cell proliferation was examined at 1, 3, 5, 7, and 9 d after cell seeding by MTT assay. Cell mineralization was investigated on days 14 and 28 by alizarin red staining. After being stained and dried, mineralized nodules were dissolved by cetylpyridinium chloride (CPC) for semi-quantitative test. Results were statistically analyzed by one way ANOVA, SPSS (version 19.0) and P<0.05 was considered to be significant. Results: Cell adhesion in BG group showed no difference from that in DMEM group. Compared with BG group, hDPCs in BG+RGDS groups suggested weaker cell adhesion.When the concentration of RGDS increased, the adhered cell number decreased. hDPCs cultured with BG and RGDS showed lower proliferation activity in the early stage, while no significant difference was observed after 3 d. BG group promoted the mineralization of hDPCs compared with positive control group, negative control group and RGDS group. No significant difference was observed between BG+RGDS group and BG group or between RGDS group and positive control group. Conclusion: BG promotes proliferation and mineralization without affecting cell adhesion of hDPCs. Unbounded RGDS inhibits cell adhesion, but has no influence on the positive effects of BG on the proliferation and mineralization of hDPCs.

Objective： To investigate the proliferation, odontogenic differentiation and mineralization of human dental pulp cells (HDPCs) on bioactive glass(BG) and extracted dentin proteins(EDP). Me-thods: Primary HDPCs were isolated from third molars by enzyme digestion and were cultured in Dulbecco’s minimum essential medium (DMEM). Then the 4th generation of HDPCs was cultured with DMEM, which contained BG-EDP, BG, and EDP, respectively. Meanwhile HDPCs were cultured in DMEM as control group. Proliferation of HDPCs was evaluated by 3-（4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide(MTT) colorimetric assay. Odontogenic differentiation was determined by alkaline phosphatase (ALP) activity assay and real-time PCR. Mineralization was investigated by Alizarin red staining and cetylpyridinium chloride (CPC) assay. Results: The proliferation of HDPCs was increased significantly in BG-EDP group on 3,7,and 9 d(optical density value:1.36±0.06, 2.52±0.20, 2.72±0.29) compared with BG(optical density value: 1.20±0.26,2.33±0.26,2.50±0.30),EDP(optical density value: 1.13±0.15, 2.10±0.13, 2.38±0.22) and control group(optical density va-lue: 0.84±0.17, 1.84±0.18, 1.95±0.19), P<0.05. After 7 days, ALP activity of BG-EDP group had no statistical difference compared with EDP group and control group; the expression of odontogenic differentiation genes (DSPP, DMP-1) showed no difference among all the groups(P>0.05). After 14 days, ALP activity of BG-EDP group (56.67±1.83) was significantly upregulated compared with EDP group (41.98±9.71) and control group (30.82±6.70), P<0.05, but had no statistical difference compared with BG group (56.29±6.20)， P>0.05; DSPP gene expression was upregulated significantly in BG-EDP group (5.79±1.94) compared with the other groups (P<0.05); DMP-1 gene expression of BG-EDP group (3.87±1.87) increased but had no statistical difference compared with the other groups (P>0.05). The alizarin red staining showed more mineral nodules in  BG-EDP group, the cetylpyridinium chloride semi-quantification presented higher calcification in BG-EDP group (0.27±0.01) compared with the other groups (P<0.05). Conclusion: Compared with either BG or EDP, BG-EDP significantly promotes the proliferation, odontogenic differentiation and mineralization of HDPCs.

Objective：To examine the in vitro effects of low-level laser irradiation (LLLI) on proliferation and differentiation of human adipose-derived stromal cells（hASCs). Methods: Cultured cells were exposed to different doses of LLLI with a semiconductor diode laser (980 nm; 100 mW-12 W power output). The effects of laser on proliferation were assessed daily up to seven days of culture in cells irradiated for four consecutive days with laser doses of 2, 4, 6 or 8 J/cm2, the cells without irradiation were used as controls. Half of the cells were changed to osteogenic medium (OM) when they had grown to 70% confluence. The hASCs both with and without osteogenic supplements were divided into three groups, and each group was irradiated at doses of 0, 2 and 4 J/cm2. In order to examine the in vitro effects of LLLI on osteogenic differentiation of hASCs, the alkaline phosphatase activity was assessed on day 7, and alizarin red staining (AR-S) and quantitative detection were assessed on days 14 and 21. The expression of osteoblast master genes (ALP and Runx2) were tested on days 7 and 14.  Results: The proliferation medium(PM)+LLLI4 J/cm2 group had the highest multiplication rate. In the groups with osteogenic supplements, LLLI increased alkaline phosphatase activity and mineralized nodule formation, and stimulated the expression of ALP and Runx2. Furthermore, the effect became more obvious at high dose. Conclusion: Our data demonstrated that hASCs proliferation and osteogenic differentiation were enhanced by LLLI. With the increase of laser dose, the effect of LLLI would be enhanced at first, and then be decreased after reaching a peak.

Objective：To evaluate the malodor level and to explore the effect of mechanical self-cleaning of tongue coating in patients with halitosis originating from tongue coating. Methods: Ten patients with halitosis originating from tongue coating were enrolled and divided into two groups randomly. The patients in test group received instruction of mechanical cleaning of tongue coating while no such instruction was given to control group. Organoleptic test (OLT) score, volatile sulfide compounds (VSC) value, area of tongue coating (Ta), thickness of tongue coating (Tt) and periodontal condition were recorded at baseline and were repeated at the end of 1 week, 2 weeks, 4 weeks and 8 weeks later. The clinical outcomes were compared at different time points between the groups. Also, changes within the group were analyzed. Results: As time went by, tongue coating area and thickness tended to decrease in test group while the changes showed no statistically difference (P>0.05). The organoleptic score in test group decreased significantly (P<0.001). Changes of volatile sulfide compounds value within each group had no statistically difference (P>0.05), though they showed a tendency to decrease and fewer changes in control group were found. Compared with the baseline, average probing depth and bleeding index (P<0.05) were significantly lower in both the groups at the end of the test period, while no statistically difference was observed between test group and control group (P>0.05). Plaque index showed no difference at different time points in both the groups (P>0.05). Conclusion: Mechanical selfcleaning of tongue coating did not influence plaque index while it had tendency to reduce tongue coating area and thickness. Malodor could be released after self-cleaning of tongue coating to a certain extent, indicating necessity and importance of intervention role by dentists.

Objective： To discuss the effect of treatment of complicated intra-articular distal radius fractures with extended flexor carpi radialis approach. Methods: A retrospective analysis of 38 cases with fresh complicated intra-articular distal radius fractures treated by using extended flexor carpi radialis approach in our hospital from October 2012 to March 2015, with 25 males and 13 females. The average age was (52.76±8.62) years (32-64 years). The average time to surgery was (5.42±1.91) d (3-10 d), with left wrist 17 cases and right wrist 21 cases. All the patients were with C3 distal radius fractures according to Association for the Study of Internal Fixation (AO/ASIF) classification. The follow-up was conducted 1, 2, 3, 6, and 12 months after operation, including AP and lateral X-ray, wrist extension and flexion, radial deviation and ulnar deviation, forearm pronation and supination, and grip strength. At the end of 6 and 12 months after operation, all the patients were evaluated by using the mo-dified Garland-Werley score and patient rated wrist evaluation (PRWE). Results: All the patients got good bone union, and their follow-up time was more than 12 months. The average follow-up time was (16.37±2.85) months (12-22 months). The score of modified Garland-Werley evaluation 6 months post-operation was 5.37±2.82, excellent and good rate was 84.21%, the score of modified Garland-Werley evaluation 12 months post-operation was 5.03±2.60, excellent and good rate was 86.84%. The score of PRWE 6 months post-operation was 15.82±8.38, the score of PRWE 12 months post-operation was 12.17±7.58. Conclusion: The extended flexor carpi radialis approach is effective for the treatment of complicated intra-articular distal radius fractures and can avoid the complications of volar and dorsal combination approach.

There exist controversies in the surgical treatment of maisonneuve injury with regard to reduction and fixation of syndesmosis and management of proximal fibular fracture. It is very important for the orthopaedic surgeons to learn more techniques and avoid pitfalls from clinical practice. We summarized the clinical data of 1 failed case, a 20-year-old girl with big body weight who underwent a primary surgery for the treatment of maisonneuve fracture with minimally invasive reduction and fixation of ankle syndesmosis and posterior malleolus and open reduction and internal fixation of medial malleolus, then a revision surgery for the treatment of iatrogenic syndesmotic malreduction with open reduction and re-stabilization of ankle syndesmosis supplemented with open reduction and internal fixation of proximal fibular facture. The malreduction of distal fibula was not found until finishing the postoperative computed tomography (CT) scan 2 weeks after the primary surgery, then the patient experienced an revision surgery including removal of the screws installed primarily for fixation of ankle syndesmosis, and open reduction and internal fixation of proximal fibular fracture, and limited open reduction and re-stabilization of ankle syndesmosis. Then the patient rehabilitated regularly under the direction of the surgeon who performed these two operations, and the postoperative recovery was smooth, then the hardwares for fixation of ankle syndesmosis and fracture of proximal fibula and medial malleolus were removed at different postoperative time. The patient experienced an excellent outcome at the end of the 3-year follow-up. The reasons for the failure in this case might include the overemphasized minimally invasive technique in the process of reduction, inaccurate assessment of intraoperative fluoroscopy and postoperative radiographs, and inappropriate utilization of the reduction clamp. Attention should be paid to the fact that an obliquely placed clamp for closed reduction of diastasis of ankle syndesmosis could result in syndesmotic malreduction. The worsened alignment of the fracture end of proximal fibula observed by intraoperative fluoroscopy may alert surgeons to syndesmotic malreduction. Partial exposure of syndesmosis and anatomical reduction and fixation of proximal fibular fracture may be useful measurres to avoid malreduction of ankle syndesmosis in the surgical treatment of maisonneuve injury in some patient, especially the patient with critically destabilized ankle.