Modified Masquelet Technique Assisting 3D Printed Elbow Prosthesis for Open Elbow Fracture with Severe Bone Defect: A Case Report and Technique Note.

BACKGROUND: Internal fixation for severe open articular bone defects is sometimes ineffective or dangerous. In the emergency stage, radical debridement and infection prevention are demanded to provide a good tissue base and the space-occupying effect to provide enough necessary space to avoid soft-tissue contraction for the reconstruction. In addition, the 3D printing technology makes individual limb reconstruction a reality. CASE PRESENTATION: Here, we present a 31-year-old patient with an open fracture and severe bone defect of his left elbow caused by traffic accident, classified as Gustilo-Anderson IIIB. We adopted aggressive debridement and insertion of polymethyl methacrylate (PMMA) to prevent the infection and temporarily construct the bone defect in the emergency stage. Secondly, the total elbow arthroplasty was performed using a unique three-dimensional (3D) printed prosthesis to reconstruct the elbow joint. During the follow-up, the elbow movement function was satisfactory. CONCLUSIONS: The modified Masquelet technique assisting 3D printing of personalized elbow joint makes the satisfactory functional reconstruction for open high-energy injuries come true. It could be promoted for the similar surgery of other open joints fractures with severe bone defects.

Retracted: Management of Infected Bone Defects of the Lower Extremities by Three-Stage Induced Membrane Technique.

Retraction requested by the author due to an admission of research fraud. Reference: Chong Zhang, Chunquan Zhu, Guorong Yu, Kai Deng, Li Yu. Management of Infected Bone Defects of the Lower Extremities by Three-Stage Induced Membrane Technique. Med Sci Monit 2020; 26: e919925. 10.12659/MSM.919925.

Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites.

BACKGROUND The purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity. MATERIAL AND METHODS From January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed. RESULTS External iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery. CONCLUSIONS Although limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon's best efforts.

A New Feature Descriptor for Multimodal Image Registration Using Phase Congruency.

Images captured by different sensors with different spectral bands cause non-linear intensity changes between image pairs. Classic feature descriptors cannot handle this problem and are prone to yielding unsatisfactory results. Inspired by the illumination and contrast invariant properties of phase congruency, here, we propose a new descriptor to tackle this problem. The proposed descriptor generation mainly involves three steps. (1) Images are convolved with a bank of log-Gabor filters with different scales and orientations. (2) A window of fixed size is selected and divided into several blocks for each keypoint, and an oriented magnitude histogram and the orientation of the minimum moment of a phase congruency-based histogram are calculated in each block. (3) These two histograms are normalized respectively and concatenated to form the proposed descriptor. Performance evaluation experiments on three datasets were carried out to validate the superiority of the proposed method. Experimental results indicated that the proposed descriptor outperformed most of the classic and state-of-art descriptors in terms of precision and recall within an acceptable computational time.

Repair of Massive Bone Defects of the Proximal Femur Using Iliac Bone Flaps of the Ascending Branch of the Lateral Circumflex Femoral Artery: A Retrospective Report.

BACKGROUND AND OBJECTIVE: The management of bone defects is still a difficult problem. Local vascularized bone grafts represent an efficient and widely used method. In this retrospective report, iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were used for the management of proximal femur bone defects. PATIENTS AND METHODS: The hospital information system and clinical data collected by surgeons were retrospectively reviewed. Patients with massive bone defects of the proximal femur reconstructed with iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were included. Relevant data, including general information, perioperative treatment, and imaging data during follow-up, were retrieved for analysis. Five patients (4 males and 1 female) aged 18 to 42 years were included in this report. All patients were diagnosed with proximal femoral bone defects. The sizes of the bone defects ranged from 5 ×4 cm to 8 × 5 cm. Harris hip score was adopted to evaluate the functional outcomes. The adverse events were recorded. The mean follow-up time was 6.3 years. RESULTS: Iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were transferred locally for the 5 patients. Bone flaps were fixed with plates in 4 cases and Kirschner wires in 1 case. The hospital stay was 12 to 27 days, with an average of 19.4 days. All cases achieved bony healing after 3 to 6 months postoperatively. The Harris hip scores ranged from 87 to 95 at final follow-up. All patients achieved good to excellent functional outcomes. One superficial infection occurred. No other adverse events or serious adverse events were noted. CONCLUSIONS: Local transfer of iliac bone flaps of the ascending branch of the lateral circumflex femoral artery represents a safe and effective method for the reconstruction of massive bone defects of the proximal femur.

Management of Infected Bone Defects of the Lower Extremities by Three-Stage Induced Membrane Technique.

BACKGROUND Infected bone defects are therapeutic challenges. Although the induced membrane technique has been used for this problem, there is a 3% to 20.7% failure to eradicate infection, and there have been few reports about its use in tuberculous infection. We present our three-stage induced membrane technique (TSIMT) for treating infected bone defects of the lower extremity. MATERIAL AND METHODS Forty-one adult patients with infected bone defects of the lower extremities treated by TSIMT were included in a retrospective case-series study between January 2013 and June 2018. The clinical, imaging and laboratory assessment outcomes were analyzed. RESULTS In the first stage, 3 patients had ankle tuberculous bone defects and 17 patients underwent 2-4 debridements. In the second stage, the average bone defect was 6.0 cm; 1 patient needed an anterolateral thigh flap to cover the wound. In the third stage, 10 patients underwent autograft mixed allograft, and 18 cases used internal fixation. The mean follow-up period was 23.3 months. All patients achieved bone union and clinical eradication of infection. Changes in Lower Extremity Functional Scale (LEFS) scores after 1 year of TSIMT and bone union time are associated with advanced age, longer duration of infected bone defects, active smoking, and external fixation (p<0.05), but are not dependent on bone defect size, debridement times, type of bone graft, or spacer-placing time (p>0.05). CONCLUSIONS TSIMT is effective in treating infected bone defects of the lower extremities. Advanced age, longer duration of infected bone defects, active smoking, and external fixation adversely affect bone union and recovery of infected extremities in a limited time span.

Asymmetric limb lengthening in the treatment of tibial hemimelia caused by osteomyelitis: A case report.

RATIONALE: Tibial hemimelia is known as a rare congenital lower limb deficiency. It has been classified into different types based on Jones classification, and the traditional treatment of tibial hemimelia is amputation. Here we present a variant and unclassified case of tibial hemimelia, which was caused by osteomyelitis. And the lower limb with tibial hemimelia was salvaged by asymmetric limb lengthening. PATIENT CONCERNS: 19-year-old girl had the shortened and curved left lower extremity with walking abnormalities. DIAGNOSIS: The patient's deformity was caused by osteomyelitis of tibia occurred when she was 18 month old. The tibial shaft was absent, while the proximal and distal tibia was present but was hypoplastic with radiographic analysis. The fibula was hypertrophied and curved like the capital letter C. The leg length discrepancy (LLD), mostly coming from the left lower leg, was 22 cm. INTERVENTIONS: We were able to salvage the limb successfully by 5 operations, including releasing soft tissue, fusing the proximal tibiofibular joint, fibular osteotomy, femur lengthening, and fibular lengthening. OUTCOMES: The whole treatment time for the patient was 3 years and 2 months, and she was followed up for 5 years afterward. The length of femur lengthening and fibula lengthening during the reconstruction were 7.8 cm and 11 cm, respectively. Most of the deformities were corrected, except that the left lower limb was still 2 cm shorter than the contralateral limb, and the 34 mm of mechanical axis deviation (MAD) of left lower limb remained. The reason why the patient's lower limbs were asymmetric was that the femur and fibular lengthening were performed within the affected limb only. Overall, the patient was very satisfied with her asymmetric limbs and its function after surgeries. LESSONS: The LLD in this case mainly came from tibial hemimelia. However, the fibula was unable to be lengthened to 22 cm during the lower leg distraction process because of blood flow disturbance. We could only lengthen the femur to salvage the limb in this situation. Even though the patient still had a few residual deformities and a pair of asymmetric lower limbs, she was satisfied with the function and appearance of the reconstructed limb. Therefore, the lower limb with tibial hemimelia can be salvaged by asymmetric limb lengthening in special cases.

Mincle in the innate immune response of mice fungal keratitis.

AIM: To investigate how macrophage inducible C-type lectin (Mincle) influences inflammation in mice fungal keratitis induced by Aspergillus fumigatus (A. fumigatus). METHODS: C57BL/6 mice were infected with A. fumigatus after pretreated with Mincle agonist TDB or Mincle neutralizing antibody (MincleAb), taking DMSO or IgG as control group respectively. The cornea lesions were monitored with slit-lamp microscope and evaluated by clinical score. Mincle expression was assessed using reverse transcription-ploymerase chain reaction (RT-PCR) and immunostaining. The expression of cytokines (IL-1ß, TNF-α and IL-6) chemokines (CXCL-1 and MIP-2) was determined by RT-PCR and ELISA. Neutrophil infiltration was observed by immunostaining. The levels of nitric oxide (NO) generated by corneas were tested by Griess reaction. RESULTS: Mincle mRNA and protein levels were higher in infected corneas than normal corneas of C57BL/6 mice, saving clinical scores revealed differences. When pretreated with Mincle agonist TDB, the mRNA and protein levels of IL-1ß, TNF-α and IL-6 in infected corneas were significantly increased compared with the control group (P<0.01). Results of the counterpart in corneas pretreated with Mincle neutralizing antibody was decreased consistently (P<0.01). Expression of CXCL1 and MIP-2 mRNA levels were up-regulated in TDB group and down-regulated in MincleAb group (P<0.01), coincide with neutrophil aggregation degree in corneas showed by immunostaining. As for the concentration of NO, it was promoted in TDB group compared with DMSO control group, and decreased in MincleAb group compared with IgG control group. CONCLUSION: Mincle plays a dual role in mice fungal keratitis. It participates in the innate immune system by enhancing inflammation. What's more, Mincle can mediate cytotoxic effects by regulating the formation of NO.

[Research progress of correlation between traumatic brain injury and fracture healing].

Objective: To review the current status and advances of the correlation between traumatic brain injury (TBI) and fracture healing. Methods: The related domestic and abroad literature about the correlation between TBI and fracture healing was extensively reviewed and analyzed. Results: There are a variety of studies on the correlation between TBI and fracture healing, which can be divided into two major aspects: revascularization and osteogenesis; the local and systemic changes of the neuropeptide and hormone after TBI. Conclusion: TBI facilitates callus formation, the further research is needed to clarify the exact mechanism.

Repair of severe composite tissue defects in the lower leg using two different cross-leg free composite tissue flaps.

This article reports 2 cross-leg free composite tissue flaps for repairing the severe composite tissue defects in lower leg without suitable adjacent recipient vasculature for microvascular anastomosis. The osseous myocutaneous flap of ilium and tensor fascia lata pedicled with ascending branch of lateral femoral circumflex vessels and the osseous muscle flap of scapula and latissimus dorsi pedicled with subscapular vessels were performed, respectively, to reconstruct the bone and soft-tissue defects in the lower leg of 2 patients. Both donor vessels were the posterior tibial artery and great saphenous vein from the contralateral lower leg. The legs and the bone flaps were immobilized by an external fixator. The periods of pedicle division were 43 and 67 days, respectively, after transplantation. Both flaps survived after pedicle division and the patients regained the ability to walk. There were no such complications as joint stiffness or donor site morbidity except for a linear scar. The 2 cross-leg free composite tissue flaps were optional methods for salvaging limbs that were otherwise nonreconstructable. But the indication for cross-leg free-tissue flap should be limited strictly.

Distally-based sural neurocutaneous flap for repair of a defect in the ankle tissue.

The Achilles tendon and the bones around the foot and ankle are often exposed after trauma and infection because of the thinness of the soft tissue. Many surgeons consider the distally-based neurocutaneous flap as the first choice for reconstructing soft tissue defects around the ankle, as it provides robust axial perfusion for flaps and is easier to transpose than random pattern local flaps or free flaps. We report here a series of 23 cases of reconstruction of the foot and ankle using a distally-based sural neurocutaneous flap. This flap, which measured from 5 × 4 cm(2) to 15 × 10 cm(2), was transferred to cover defects in the soft tissues of the foot and ankle. The short saphenous veins were ligated in 12 cases and retained in the remaining 11 cases. All flaps survived, but two cases with retained short saphenous veins developed venous congestion, including one that progressed to distal necrosis. In conclusion, the distally-based sural neurocutaneous vascular flap provides a valuable tool for the repair of defects in tissues around the ankle.

Solitary giant hemangioma of the humerus.

Osseous hemangiomas are mainly seen in the skull or spine and rarely occur in other bones. They are small lesions usually localized in the metaphyseal and diaphyseal regions. This article describes a rare case of a giant intraosseous hemangioma occupying nearly the whole humerus for 28 years. Initially, the patient, a 36-year-old woman, had been misdiagnosed with fibrous hyperplasia of the left humerus. We intended to curette the lesions and transplant fibula to fill the bone defect, but the initial surgical attempt could not be completed due to massive intraoperative bleeding. In the second surgery, she was treated by blocking the blood flow of the subclavian artery temporarily through a balloon catheter, curetting lesions, and filling the defect of bone with bone cement and K-wires. At 12-month follow-up, there was no evidence of local recurrence of hemangioma or loosening of bone cement. However, longer-term follow-up is needed to confirm the success of the surgery. Although hemangiomas of long bone are rare, they should be considered in the differential diagnosis of bone tumors.

[Anatomic study and clinical application of sural neuro-myocutaneous compound flap transposition].

OBJECTIVE: To investigate the anatomical study and clinical applications of sural neuron-myocutaneous flap transposition for repairing the special patients with soft tissue defect in foot and ankle. METHODS: The branches, distributions and anastomoses of the vessels and nerves lie in superficial layer of the posterior crural region were observed on 30 sides of adult cadaver lower limb specimens perfused with red latex. Since February 2004, distally based sural neuron-myocutaneous flap was applied for repairing 7 cases of soft tissue defect in foot and ankle. RESULTS: The nutrient vessels of sural nerve, small saphenous vein and posterior femoral cutaneous nerve anastomosed permanently with the musculocutaneous perforators of medial and lateral head of gastrocnemius. There were 2 - 3 anastomoses found respectively. The musculocutaneous perforators pierced the two heads of gastrocnemius muscle (1.8 +/- 0.5) cm medially and (3.7 +/- 0.9) cm laterally away from the groove of the muscle. The medial anastomoses more closed to the middle groove and their diameters were found larger than the lateral ones. In operation, we routinely observed the compound flap for 15 to 20 minutes and found actively errhysis on the muscle, so the fine blood circulation in the flap was demonstrated. All flap survived after operation and the cases were followed up 2 to 6 months with cured osteomyelitis and satisfied flap outline. CONCLUSIONS: Distally based sural neuro-myocutaneous flap can live. The operative method is simple. The flap offers an excellent donor site for repairing the soft tissue defect in foot and ankle in special cases.

The treatment of displaced femoral neck fractures with vascularized great trochanter periosteal flap transposition in children.

In this study, we investigated the clinical outcome of the treatment of displaced femoral neck fractures with vascularized great trochanter periosteal flap transposition in children. There were 23 children with displaced femoral neck fractures. Using Delbet classification, there were 2 type I (transepiphyseal), 12 type II (transcervical), and 9 type III (cervicotrochanteric). All the treatments were carried out with vascularized great trochanter periosteal flap transposition, and fixed by Kirschner needle or hollow screws. Both methods achieved healing and patients were followed from 9 months to 5 years, with average follow-up of 3 years. Avascular necrosis (AVN) of the femoral head occurred in three children; early closure of epiphysis occurred in one child; and restricted movement was seen in three children. According to Ratliff function assessment and Harris hip score, the results were: 17 excellent, 3 good, and 3 poor. The excellent and good rates reached 87.1%. The vascularized greater trochanter periosteal flap transposition may accelerate the union of fractures, improve blood supply to the femoral head, and reduce the incidence rate of AVN. This flap is therefore an effective method for the treatment of displaced femoral neck fractures in children.