Gloryren has invited Dr.Wu Liping, Extremities Joint Department, Jiangmen Central Hospital for this special interview to share the SCI paper jointly published by his team and Prof. Mayer, Founding President of German Knee Society and former President of European Sports Medicine Association in October,2021. In 2018, Jiangmen Central Hospital has invited Prof.Mayer as their international visiting professor and jointly founded the Sino-German Sports Medicine Exchange Center. This paper brings up a new three-dimensional classification of proximal tibiofibular fractures( fracture of tibial plateau) called Wu classification. And Dr.Wu has shared his suggestions to peers as a reviewer of SCI magazines and experience of publishing SCI papers in this interview.
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The bones at the upper end of human’s calf are made up of proximal tibia and proximal fibula. Though there are lots of studies on fibular fractures and fractures of fibular neck, fractures of tibial plateau combined with proximal fibular fracture are always neglected.
In 2014, Dr.Wu Liping from Extremities Joint Department, Jiangmen Central Hospital and his team have started working on these problems. It took them 7 years to collect a total of 1,358 cases of proximal tibiofibular fractures from 2010 to 2020 at 3 grade three A hospitals in Jiangmen and one grade three A hospital in Zhongshan.
Under the guidance of Director. Huang Yuanqiao, they have not only brought up a new definition of proximal tibia and fibula as well as a concept of proximal tibiofibular fracture, they have also came up with a new three-dimensional classification of proximal tibiofibular fractures(fractures of tibial plateau) after repeated analysis and verification. This new classification was named as Wu classification and published in Orthopeadic Surgery section of SCI magazine in October, 2021.
The important clinical meanings of Wu classification
It is the only one classification categorizing all the proximal tibiofibuar fractures in the world presently
Wu classification can be divided into many detailed sub-types. For example, the 1364 cases of proximal tibiofibuar fracture in this multi-center study can be divided into 45 types. Thus this classification helps doctors and researchers better understand the relations between different sub-type bone structure on anatomy and position and their subtle differences.
Currently, there isn’t any classification can categorize tiny fractures such as ACL and PCL fractures, which Wu classification can make it. Besides, Wu classification can also classify very complex fractures compared with other classification, for instance, the fracture of the medial and lateral condles of tibial plateau and the combined fracutre of the head of the fibula.
During clinical treatment, Wu classification helps medical staff choose correct internal fixation material. It not only updates the selection basis of proximal tibiofibular fractures(fracture of tibial plateau included) from X-ray and CT to three-dimensional space, but also opens a new era for the popularity of three-dimensional classification of all the fracture in the future.
1. When did you determine to be a doctor? And why did you choose Joint Surgery?
In 1999, when we chose university majors after graduation from high school, a lot of my classmates decided to major in computer science. Because it was the most popular major at that time and lots of them worked in big companies such as Huawei and Tencent after graduation. But I had a different thought since my elders were in poor health, thus I wanted to protect them from illness and extend accessible medical care to other people. To achieve these goals, I applied for medical major and attained bachelor, master and doctor degrees. I worked in Jiangmen Central Hospital after doctoral education.
I began to work in Jiangmen Central Hospital in 2010 when there was only a department of Orthopedics. In 2016, our department has classified sub-specialties such as Traumatic Joint and Sports Medicine. From 2015 to 2016, I went to Germany for academic visit and learned some diseases and surgery skills of joint surgery from a German teacher. Then I founded new projects and applied some skills such as the single condyle replacement of knee joint in our hospital after coming back from Germany, which has achieved good results and rewards.
Talking about this academic visit, I greatly appreciate Director. Huang Yuanqiao of our department for he firmly supported me to work on joint surgery. He hoped that I can benefit Jiangmen people with what I had learned from abroad and make great achievements in joint surgery.
2. What is your suggestion for doctors of joint surgery or doctors who want to work on joint surgery?
My suggestions are as followed. Firstly, laying a good foundation of surgery. Because joint surgery is a very professional specialty, you must lay a good foundation of surgery, for example, you must command some basic techniques like structure line, knot and surgical open suture.
Secondly, laying a good foundation of Orthopedics in Department of Orthopedics, including Traumatic Orthopedics and Microsurgery. A good foundation of orthopedics is a must to support your work and study of joint surgery.
Thirdly, performing operation well. A good surgery benefits patients. And you must consider about adaptation disease and the effect your surgery given to patients. Only when benefit over-weighs negative effect, can your surgery make a good effect.
Fourthly, as a joint surgery doctor, you must think outside the box of past experience and have your own innovative mind and spirit. I think this is vert important to tackle clinical problems with your own innovation.
3. Could you share the most impressive and challenging case in your career with us?
I have been very impressed with a case during my more than 10 years clinical experience. The patient is a 60-year-old local lady, and she was hospitalized because of hip pain and combined lumbar spine problems. At first, she did examination in Department of Lumbar and Spine and it turned out to be the hip joint problem, so we took her in. And I found that her hip joint was rotten as it was filled with pus and its soft tissues, bones and meat were all destroyed, in addition, its pus flowed out. With a series of liquid culture through puncturing, the case was diagnosed with coxotuberculosis, which was very difficult to treat at that time.
We decided to take step-by-step method, then we communicated with her families and attained agreement. The first time we did a simple debridement on hip joint to clean up the necrotic tissue, pus and tubercle bacillus. But the disease deteriorated after debridement as pus flew from upper leg to knee joint and even reached to lower leg at last. The disease deteriorated so quickly that the followed debridement didn’t make much effect. We have performed debridement for her 4 to 5 times, and it was at that time that a German professor visited our department, so we reported this case to him. At last, the German professor suggested to cut off her lower limb and gave her a hip dissociation surgery plus prosthetic installment. I told professor’s suggestion to patient’s families and they expressed their greatest hope was to save her leg whatever method we used.
Luckily, the old lady was saved after 8 times surgery and saved her legs. Moreover, she recovered the leg’s function well, and now she can walk to market, do some housework and even take care of children.
I want to share some inspiration from this impressive case.
Firstly, we must communicate with the team well for these complex and difficult cases.
Secondly, it is very important to gain support and understanding of patients’ family. The success our patient made after 8 times surgeries depends on her family’s support. If a case is difficult and complex without family’s support, my suggestion is better not to perform surgery or recommend this case to higher-level hospitals.
Thirdly, be persevered. Maybe there are some cases do not make good result as expected after trying all the method, but we should be persevered and keep on treating these cases with better methods or skills. Harvest may be made in the end if we are persevered. Our patient accepted 8 times surgeries but her disease recurred repeatedly for a year, and she was hospitalized a few times. However, we stuck with that and finally got a good result. And these are my experience from this impressive case.
4. From your personal experience, what do you think about the importance of academic visits to different hospitals or countries?
I think that it’s a must for doctors to have academic visits, especially visit hospitals at home and abroad to pursue further study. And its importance could be seen as follows.
Firstly, your department may restrict your exposure to new things and techniques. Academic visits help you start your career, for example, you can learn a lot of diseases that you have never known before, operations that your hospital and department have never performed before, and some specific means and measures of disease diagnosis and even some techniques about follow-up visit and rehabilitation. So academic visits are of importance in expanding your vision.
Secondly, during the visits, you have chance to meet many good teachers and learn techniques that you have never known before from them, especially some surgical procedures. Once you have command these skills, you can apply them to your department, which is not only beneficial to the hospital but also to patients.
Thirdly, academic visits matter because you would encounter many teachers and peers during visits so that you can ask for their opinions and help when you meet difficulties and this is also a good way to accumulate experience.
5. We learned that you have published more than 30 professional academic papers in domestic and foreign journals, among which 8 are SCI papers, so would you mind shiring your scientific experience with us? And how did you determine your scientific topic and research direction?
I mainly established my scientific theoretical foundation when I was a postgraduate. I have been determined to dive deep into Orthopedics ever since my undergraduate study so that I have been major in this speciality ever since then. Talking about scientific research, I think that my doctoral supervisor, Professor Zhong Shizhen, an academicians of the Chinese Academy of Engineering (CAE) inspires me the most. He has gave us very good guidance, and brought up a good theory in terms of research project, and he is still tutoring my work now.
His thoughts on determining projects are easily accessible, which are “someone needs it, no one does it, I can do it”. “someone needs it” means that your project should be applied to certain situations and resolve actual problems.
“No one does it” means that you are determined to this research direction and want to resolve this problem, and while you search a lot of materials, including domestic and foreign papers, you can’t find any previous research and experiment.
“I can do it” means that I can integrate my experiment condition, equipment and my team to work on this project.
Over the years, my thoughts on experience and scientific research from graduation to work are based on these three mottos. And I want to share with my fellow colleagues because they are very helpful.
So how to determine your scientific direction? At first, I worked in Orthopedics Department and mainly focused on Traumatology. Because I mainly study on Traumatology, a lot of my research projects are related to this field, including the lately published SCI paper I would share with you in the following interview. This paper is about the Wu Classification of proximal tibiofibular fractures, which is also some work experience of my orthopedics foundation while in Traumatology.
Now I have transformed to the Department of Joint Surgery, mainly focusing on hip and knee replacement as well as treatment on some shoulder disorders. And I do surgeries like wrist replacement and total elbow replacement. The reason why I transformed to the Department of Joint Surgery is that there are the largest surgical volume of knee joint replacement in our department. But I found that 20% of patients is not satisfied with the efficacy. So I was thinking about why they were not satisfied after surgeries. And this situation fits with the idea of “someone needs it”.
Then I went through some materials whether there was any research on it before. We found out that a lot of papers did researches on this problem but they seldom focused on the joint prosthesis itself after joint replacement surgery. And this fits for the situation of “no one does it”.
For me, I use prosthesis often in surgeries and I have my own team, so I want to do something in this field. At last, I designed 3 new types of prosthesis.
The first one is the knee joint prosthesis designed to reserve ACL and PCL. Now all the prosthesis we use for knee joint will remove PCL and preserve part of the ACL. As patients’ body feel some part missing in them, when they climb up or walk down stairs, their brains will fail to control the position of their knee well, which is a major cause to patients’ dissatisfaction with the postoperative effects. So I designed a prosthesis the PCL and ACL on my own, which has been patented.
The second one is a new type of prosthesis designed by myself. If we use the knee prosthesis available in market, we need to fix the prosthesis to the knee with bone cement, but it may cause a lot of post-op complications such as bone cement reaction, which may cause serious complications like shock or even death. And bone cement is prone to sinking or loosening, thus causing some middle to long term complications after TKA. What we design is a cement-less prosthesis that can be implanted on human body directly as prosthesis of knee and hip. This prosthesis is fixed on the knee and it can heal naturally like it is the own joint of human body. And I have applied patent for this prosthesis and will continue the research project.
6. Can you introduce the Wu Classification in your latest SCI paper? Why would you think of researching a new classification of proximal tibiofibular fractures? And what is the significance of it?
In 2013 and 2014, we were in the stage of General Orthopedics Department. I encountered then some cases of traumatic injuries, among which fracture cases accounted for the most. Fractures of the upper tibia and tibial plateau in the knee are the most common type of fracture. We have treated many patients with these fractures and have found that many patients with fractures of the tibial plateau sometimes have a fracture of the upper end of fibula, such as fibular head fracture or fibular neck fracture. However, in the course of clinical treatment, it is easy to neglect the fibular fracture and treat the fracture of the tibial plateau solely with a cast, surgery or many other methods. However, many people ignore fractures of the proximal end of the fibula and may think that a cast will be sufficed.
We did a further research and went through papers to find that 30% of tibial plateau fractures were combined with proximal fibula fracture. In the case of fracture of both medial and lateral tibial plateau, more than 60% of patients were combined with proximal fibular fracture. So we thought that we should see things with holism rather than see things separately.
Then we reviewed literature and found that few researchers brought up the concept of proximal tibiofibular fracture. There were few cases reported, such as proximal tibial fracture or combined proximal tibia and fibula fractures. And there are overall 3 papers mentioned these cases, which we have quoted in the SCI paper.
Another question is that how do we treat the proximal tibiofibular fracture with high incidence rate? Shall we take conservative treatment of plaster cast or splint or surgery? How to perform the operation? Shall we cut from the medial or lateral side? What kind of standard should we adhere to? As we know that not all the patients with fractures of tibial plateau would need to undergo operations.
The standard is the classification of fractures. We classified them into different types, such as type I, type II, type III and type IV. For type I and II, we choose conservative treatment, and we perform operations for patients diagnosed with type II and IV, so this classification is of importance to the treatment of fracture.
In the past, there wasn’t a clear definition and classification of proximal tibiofibular fracture. But the fractures of proximal tibial plateau are divided into two types according to different technologies. The first type is based on X-ray analysis. But the X-ray image is a two-dimensional (2D) plane showing front and back.
X-ray classification, including Schatzker, Arbeitsgemeinschaft für Osteosynthesefragen, is limited for it is a 2D plane, so it fails to use a three-dimensional (3D) field of view to see the fracture of tibial plateau, especially the posteromedial and posterolateral fractures. As a result, it’s hard to distinct the classification of X-ray. So we may make mistakes in surgery or treatment if based on unclear classification.
The second type of tibial plateau fracture classification is based on CT, including Luo Classification proposed the three-column classification (medial, lateral, and posterior columns) system and other researchers’ study. But this classification is based on the horizontal plane in CT, and the medial, lateral, and posterior columns are horizontal as well. If you imagine the tibial plateau, actually it is 3D. It has sagittal and frontal plane besides horizontal plane, so there lacks classification involved another two planes.
So I had a new idea in 2013 to 2014 that as human body, with bones included is 3-diamension, can we classify bones from the 3D angle? We changed them from horizontal plane, adding up sagittal and frontal plane, so we got a classification consisted of three parts and formed a completed enclosure. I think that this classification will make fractures more clear.
With this thought, I began relevant preparation with my team. We started to work on this project in 2014, collecting materials from grade three A hospitals in Jiangmen and one grade three A hospital in Zhongshan. We collected all the cases of tibial plateau fracture and proximal tibiofibular fracture from 2010 to 2020 as well as their images of X-rays, CT and 3D imaging. Then we made statistics and analysis of them and further verified our theory. We revised and checked these theories again and again.
During the whole process, Director. Huang Yuanqiao, Department of Orthopedics, Jiangmen Central Hospital, is very supportive to our study. It took us 7 years to finish this project. The results were summarized and analyzed, and we finally wrote a paper on it. After the paper was completed, we submitted it for publication and it was published in October this year. After pulication of it, many colleagues expressed their approval and wanted to learn more about this classification.
In fact, we are the first one to bring up a completed definition of proximal tibia and fibular as well as the concept of its fracture in the world.
Also we are the first one to bring up the 3D classification of proximal tibiofibular fracture. Our team decided to name it as Wu Classification, and it is very meaningful in guiding the clinical treatment. Its importance is regarded as four aspects at least as follow.
Firstly, Wu Classification categorizes all types of proximal tibiofibular fracture. Currently, Luo Classification and other systems can not classify all the fracture, but we can change it. Whatever type of proximal tibiofibular fracture you have, you can refer to Wu Classification.
Secondly, there are some avulsion fractures of ligamentous attachments, such as ACL and PCL fractures, which are not included in many classifications. These minor avulsion fractures can also be classified in the Wu Classification.
Thirdly, some complex fractures, such as the fracture of the medial and lateral condyles of the tibial plateau and the combined fracture of the head of the fibula, which I have just mentioned, cannot be classified because they involve the proximal end of the fibula, which is not included in these fractures, and which can be classified by us.
Fourthly, since it is a 3D fracture classification that we can design the plan of surgery or non-surgery treatment according to the concrete type of fracture for any specific case. For surgery, we can choose correct screws based on fracture type and fix it by internal fixation. We can be sure about the precise length, position and number of screw with Wu Classification. It is beneficial for patients that doctors perform operation well. Patients recover from fracture quickly with their joint functions back to normal, which is a good postoperative effect.
Fifthly, Wu Classification is very detailed with many types. The conventional types include Type III, IV and V. We have dozens of types and every type is explicit. If peers or experts analyze and exchange cases using our system, they will make a very clear and precise direction.
Sixthly, there’s another important meaning of Wu Classification. As the first one to categorize fractures with 3D space, it lays a foundation for the 3D classification of fractures on other parts, such as proximal humerus, proximal femur, distal femur and elbow joint, which is also our next direction.
7. As a reviewer of many SCI magazines, what suggestions do you have for peers who want to publish SCI papers?
For my peers, if you want to publish a SCI paper that you must overcome some difficulties. And my suggestions may be helpful for you to publish papers.
The first point is that it must be innovative. The reason why this article can be published is that it carries innovative ideas that may not have been done before, or you have validated the work of others, or you have negated the work of others. If your paper is very innovative, that is a very good publication element for many journals.
Second, you must overcome the difficulty of language. Since a lot of SCI magazines are published in English, for us Chinese, especially Chinese doctors, we must overcome the language difficulty. I suggest that you should write your paper in English instead of Chinese at first. It’s okay if you prefer writing in Chinese and then translating into English. But writing and revising your paper in English thinking will be better.
Third, we Chinese doctor may have troubles in native English expression while publishing SCI papers. Because many of us have never been abroad and further known about local customs, so they do not know their customary expressions very well. If you are in this condition, then you can ask some experts form Europe and the U.S. to revise your paper. And if you don’t know any expert, then you can ask professional companies to revise your paper.
8. How do you balance administration, clinical work, scientific research, teaching and your personal life?
A person’s time is limited as we only have 24 hours a day, but we have lots of work and we have to handle our life and job. So how to balance our life and work is a good topic.
I like to finish works within working hours and I think that it’s inappropriate to delay things. I follow the principle of “do what needs to be done and do it today” no matter in clinics or operation.
Generally, I usually arrange the time after work like this-I do research or write essay at nights or weekends, since I utilize the time after work, so I can make the balance between work and scientific research instead of taking up working hours.
In fact, a lot of our projects come from clinical practice. For instance, I want to compare the effect of two different knee joint replacement surgeries, so we can collect original data and material in surgeries or daily work meanwhile. We extract them during scientific research and made summary and analysis of them, then we make improvement, so it is very easy for us to form personal idea and then we can write a good article with the effect of our team. My second suggestion is that you must be clear about the boundary among work, scientific research and life, and don’t upset the balance among them.