Combination of granulocyte colony-stimulating factor and CXCR4 antagonist AMD3100 for effective harvest of endothelial progenitor cells from peripheral blood and in vitro formation of primitive endothelial networks.

Endothelial progenitor cells (EPC) derived from the circulation may be used to enhance neovascularization. Since the combination of granulocyte colony-stimulating factor (GCSF) and CXCR4 antagonist AMD3100 efficiently mobilizes hematopoietic stem cells into peripheral circulation, it may increase the pool of endogenously circulating EPC. We tested this hypothesis by administering GCSF and AMD3100 to adult rabbits and rats, isolating mononuclear cells from peripheral blood by Ficoll density gradient centrifugation, and characterizing the blood-derived EPC based on morphology, immunophenotyping, gene expression and other functional analyses. These EPC showed clonal growth similar to that of human umbilical vein endothelial cells when cultured in complete EGM-2 medium on collagen I-precoated culture plates. The EPC exhibited a typical cobblestone-like morphology and were relatively homogeneous by the third passage. The cells expressed the typical endothelial marker CD31 based on flow cytometry and fluorescence microscopy, formed capillary-like structures when cultured in Matrigel, internalized DiI-acetylated low-density lipoprotein, bound Ulex europaeus agglutinin-1, and expressed CD31 and several other endothelial markers (VEGFR2, VE-cadherin, Tie-2, eNOS, vWF) at significantly higher levels than bone marrow-derived mesenchymal stem cells. These results suggest that the combination of GCSF and AMD3100 can efficiently release stem cells into peripheral circulation and generate EPC that show the desired morphological, immunophenotypic and functional characteristics. This minimally invasive approach may be useful for autologous cell transplantation for postnatal neovasculogenesis and tissue repair.

Combined Medial and Lateral Approach Versus Paratricipital Approach in Open Reduction and Internal Fixation for Type C Distal Humerus Fracture: A Randomized Controlled Study.

OBJECTIVE: Olecranon osteotomy and paratricipital approaches were widely used in the treatment of type C distal humerus fracture but some disadvantages exist, so a combined medial and lateral approach was designed. The objective of this study was to investigate and compare the clinical outcomes of combined medial and lateral approach with the paratricipital approach in open reduction and internal fixation of type C distal humerus fractures. METHODS: From May 2018 to April 2020, 37 patients with type C distal humerus fracture who accepted open reduction and internal fixation in our hospital were enrolled in this study. All cases were randomly divided into two groups according to the surgical approach: combined medial and lateral approach group (19 cases), paratricipital approach group (18 cases). All of the patients received open reduction and double vertical plates fixation. The operation and follow-up indexes, including operation time, blood loss, incision length, triceps muscle strength, flexion-extension arc of elbow and forearm rotation arc, were recorded and compared. Caja score was used to assess the quality of fractures reduction. Mayo Elbow Performance Score (MEPS) was used to evaluate the elbow function in the follow-up. Complications such as incision infection, ulnar nerve injury, degenerative osteoarthritis, and heterotopic ossification were analyzed. RESULTS: The differences in age, gender, and AO classification of fractures between two groups were not statistically significant (p > 0.05). The sum of medial and lateral incision length of combined approach group was longer than the midline incision of paratricipital approach group (15.4 ± 0.8 vs. 14.6 ± 0.8, p < 0.05), but there was no significant difference in operation time (103.5 ± 10.2 vs. 106.0 ± 8.8, p > 0.05), blood loss (71.3 ± 24.5 vs. 72.8 ± 24.6, p > 0.05), and Caja score (16.05 ± 5.67 vs. 15.56 ± 5.66, p > 0.05). During the follow-up, the MEPS of combined approach group was higher than that of paratricipital approach group at 3 months postoperatively (80.5 ± 5.7 vs. 68.9 ± 8.1, p < 0.05), but there was no significant difference in MEPS at 6 months postoperatively (83.9 ± 6.6 vs. 79.7 ± 7.0, p > 0.05) and at the last follow-up (86.8 ± 7.1 vs. 86.9 ± 7.7, p > 0.05) between the two groups. There was no significant difference in triceps muscle strength (p > 0.05), flexion-extension arc (126.8 ± 5.3 vs. 128.9 ± 6.0, p > 0.05), and forearm rotation arc (163.2 ± 5.3 vs. 163.6 ± 4.8, p > 0.05) at the last follow-up. Although the incidence of complication of combined approach group (15.8%) was lower than that of paratricipital approach group (22.2%), the difference was not statistically significant (p > 0.05). CONCLUSIONS: The combined medial and lateral approach was an effective and safe way of open reduction and internal fixation for type C distal humerus fractures. Compared with the paratricipital approach, the combined medial and lateral approach could restore the elbow function more quickly postoperatively, and the long-term results were comparable.

[Managements of open wounds from an earthquake].

OBJECTIVE: To explore the surgical managements of open wounds from 5·12 Wenchuan Earthquake. METHODS: In this report, fifty one patients with open wounds were treated after transported into West China Hospital from May 12 to 26 in 2008 after 5·12 Wenchuan Earthquake. Among 51 cases, open wounds were due to open fractures (n = 8), fasciotomy (n = 6), exposed bone (n = 8) and defects of skin and soft tissue (n = 29). All cases had wound infections. Sixty operations were performed, including muscle and myocutaneous flap (n = 4), skin grafting (n = 30), NPWT (negative pressure wound therapy) (n = 2) and debridement (n = 24). RESULTS: Four cases of muscle and myocutaneous flaps survived with an excellent blood circulation. And 30 cases of skin grafting had a survival rate of over 90%, 2 cases of NPWT and 24 cases of debridement required further treatment. CONCLUSION: With adequate surgical managements, open wound healing from an earthquake may be accelerated and the functions maximally preserved.

[Surgical treatment of sinus tract in diabetic foot with adjacent pedicle fascia flap and arthrodesis].

OBJECTIVE: To study the therapeutic effect of adjacent pedicle fascia flap filling and arthrodesis in the regional management of sinus tract in diabetic foot. METHODS: From February 2007 to August 2010, 6 patients suffering diabetic foot with sinus tract were included. There were 4 male and 2 female patients, aged 47 to 68 (averaging 58.3 +/- 6.7). One case had the entrance of sinus tract in the heel, and its base located deep in the calcaneus. Three cases had the sinus tract in the vola or dorsum of the foot, in which 1 with a perforating tract connecting the vola and the dorsum. Another 2 cases were in the toes, both located around joints. Under the effective treatments of anti-infection, anti-coagulation and control of blood sugar, blood pressure as well as blood lipid level, the patients were subjected to surgical treatments of sinus tract, the sinuses in the heel, sole and dorsum of the feet were filled up with facial flap, and those in the toes were eliminated using arthrodesis. RESULTS: All the 6 patients received rational debridement. Four patients were treated with adjacent fascia flap filling, the other two were treated with arthrodesis. The sinus tracts healed 14-20 d after surgery in all patients. One patient developed skin necrosis at the edge of the incision in the dorsum of the foot and another whose sinus located in the toe suffered inflammation and exudation. Both patients recovered after dressing replacement, antiseptic therapy and blood sugar regulation for a period of time. CONCLUSION: Appropriately designed pedicle fascia flap can provide satisfactory healing for sinus in the heel, vola and dorsum, and arthrodesis is a safe and effective way for that in the toes. Rational debridement is the key prerequisite for healing of sinus tract in diabetic foot.

Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials.

HYPOTHESIS: Clavicular fractures account for 2% to 2.6% of all fractures. Plating has been considered the gold standard for treating midshaft clavicular fracture. Intramedullary pinning and conservative treatments have also been commonly used. We hypothesized that intramedullary pinning and conservative treatments have the same treatment results compared with plating. METHODS: To evaluate the effect of plating vs intramedullary pinning or conservative treatment for midshaft clavicular fracture, the Cochrane Central Register of Controlled Trials (CENTRAL; Wiley Online Library, October 2010), PubMed (1950 to October 2010), and EMBASE (1980 to October 2010) were searched. Randomized and quasi-randomized controlled clinical studies evaluating plating vs intramedullary pinning or plating vs conservative treatment for midshaft clavicular fracture in adults were collected. After independent study selection by 2 authors, data were collected and extracted independently. The methodologic quality of the studies was assessed. Pooling of data was undertaken. RESULTS: Four studies involving 305 clavicular fractures were included. There were no significant differences between plating and intramedullary pinning with regard to outcome for Oxford Shoulder Score, Constant Shoulder Score, nonunion, infection, fixation failure, and hardware removal. More symptomatic hardware events occurred with plating compared with intramedullary pinning. Reduced nonunion, malunion, and neurologic symptoms, as well as more satisfaction with ultimate appearance, were associated with plating than with conservative treatment. DISCUSSION: This meta-analysis supports the treatment effects reported previously with plating for midshaft clavicular fractures. The outcome of this meta-analysis contradicted the findings reported previously with conservative treatment for midshaft clavicular fractures. CONCLUSION: The available evidence suggests that there are no differences in treatment effects between plating and intramedullary pinning, but plating is associated with more side effects. Plating is associated with improved treatment effects when compared with conservative treatment.

Cross-arm replantation for traumatic bilateral upper extremity amputations: a case report.

A 40-year-old woman had her right extremity avulsed at the proximal upper arm level and the wrist and hand of her left extremity irretrievably injured in a traffic accident. The right distal forearm was surgically amputated and replanted onto the stump of the left distal forearm. New strategy for nerve repair was applied and the function recovery of the cross-replanted hand was favorable. We thought that cross-extremity replantation was indicated when the patient suffered from bilateral total or subtotal amputation at different levels and orthotopic replantation was impossible.

FOXO3 is targeted by miR-223-3p and promotes osteogenic differentiation of bone marrow mesenchymal stem cells by enhancing autophagy.

Mesenchymal stem cells (MSCs) are a promising regenerative medicine. The roles of miRNAs in osteogenic differentiation of bone marrow MSCs (BM-MSCs) remained less reported. Forkhead Box O3 (FOXO3) and alkaline phosphatase (ALP) levels in the BM-MSCs were measured on 3, 7, and 14 days after osteogenic differentiation. After transfection of FOXO3 overexpression plasmids or siFOXO3 into BM-MSCs, factors related to osteogenic differentiation or cell autophagy were determined. Besides, 3-methyladenine or rapamycin, as well as miR-223-3p mimic or inhibitor were applied to further determine the effect of FOXO3 in BM-MSCs. FOXO3 and ALP levels were increased in a time-dependent manner with osteogenic differentiation, supported by Alizarin Red Staining. Furthermore, up-regulated FOXO3 increased levels of ALP and factors related to osteogenic differentiation by increasing levels of autophagy-related factors. FOXO3, targeted by miR-223-3p, reversed the effects of miR-223-3p on factors related to BM-MSC autophagy and osteogenic differentiation. Down-regulated miR-223-3p expression promoted osteogenic differentiation of BM-MSCs by enhancing autophagy via targeting FOXO3, suggesting the potential of miR-223-3p as a therapeutic target for enhancing bone functions.

Surgical Treatment of Internal Fixation Failure of Femoral Peritrochanteric Fracture.

OBJECTIVE: To investigate the factors, surgical treatment methods and clinical effect of internal fixation failure of intertrochanteric and subtrochanteric fractures. METHODS: From June 2015 to May 2019, arthroplasty and internal fixation revision were used to treat 18 cases of internal fixation failure of intertrochanteric and subtrochanteric fractures. There were 10 males and eight females, with an average age of 67.3 years (38-92 years). The 16 cases of initial intertrochanteric fractures were classified according to AO/OTA:13 cases of A2 and 3 cases of A3, the other 2 cases were subtrochanteric fractures (Seinsheimer type IV). The internal fixation failure was treated with total hip arthroplasty (6 cases), bipolar hemiarthroplasty (4 cases), revision with proximal femoral lockingplate (4 cases) and extend intramedullary nail (4 cases). RESULTS: All patients were followed up for an average of 24.7 months (range, 12 to 36 months). The average operative time was 111.4 min (range, 72 to 146 min) and the average intraoperative blood loss was 403.6 mL (range, 200 to 650 mL). The average time of fracture union was 6.9 months (range, 5 to 9 months) for cases of internal fixation revision. The operative time of the arthroplasty group was shorter than the revision group (P < 0.001), and the intraoperative blood loss of the arthroplasty group was less than the revision group (P = 0.001). The affected limb shortening of postoperative (0.21 ± 0.19 cm) was better than preoperative (2.01 ± 0.60 cm) (P < 0.001), while the limb shortening of the arthroplasty group (0.11 ± 0.21 cm) was less than the revision group (0.33 ± 0.09 cm) (P = 0.015). At the last follow-up, all injured limbs regained walking function, and the Harris hip score was 81.3 ± 9.4 points. The Harris score of postoperative was better than preoperative (33.4 ± 5.9 points) (P < 0.001), while there were no significant differences between the arthroplasty group and the revision group at 3 months (76.5 ± 8.5 vs 71.1 ± 10.6, P = 0.249), 6 months (80.9 ± 7.9 vs 78.9 ± 12.9,P = 0.687) postoperative and the last follow-up (80.5 ± 8.3 vs 82.3 ± 11.7, P = 0.716) respectively. CONCLUSION: For internal fixation failure of peritrochanteric fractures, young patients could accept internal fixation revision to restore normal anatomical structure, correct varus deformity and autograft; while elderly patients and patients with damaged femoral head could be treated with arthroplasty to restore walking function.

[Effectiveness of open reduction and locking compression hook plate in treatment of isolated humeral greater tuberosity fractures].

OBJECTIVE: To observe the effectiveness of locking compression hook plate in treatment of humeral greater tuberosity fractures. METHODS: Between March 2014 and September 2017, 16 patients with isolated humeral greater tuberosity fractures were terated with open reduction and internal fixation with locking compression hook plates. There were 11 males and 5 females, with an average age of 38.4 years (range, 22-67 years). The cause of injury was falling injury in 13 cases and sport injury in 3 cases. All patients were closed fractures. Of all patients, 14 patients accompanied with shoulder joint dislocations. CT scan showed the average displacement of fragment was 12.6 mm (range, 8-21 mm) after reduction. All patients began passive functional exercise at 3 days after operation. RESULTS: Primary healing of the incisons achieved in all patients, without complications such as infection and nerve injury. All patients were followed up 12-20 months (mean, 15.3 months). At 3 months after operation, X-ray film showed that all fractures achieved bone union, all of which met the imaging anatomical reduction standard. According to the Neer scoring criteria, 11 cases were excellent and 5 cases were good at last follow-up. One patint presented slight pain of shoulder joint and mild activity limitation, which relieved after 1 year. CONCLUSION: The method of open reduction and locking compression hook plate internal fixation for isolated humeral greater tuberosity fractures has advantages, such as less intraoperative hemorrhage, mild postoperative pain, firm fixation, and allowing patients to perform functional exercise earlier, which is conducive to shoulder functional recovery and obtain satisfactory effectiveness.

[Analysis of patients with bone injury in Wenchuan earthquake].

OBJECTIVE: To evaluate the patients with bone injury in Wenchuan earthquake. METHODS: From May 12th to June 15th 2008 the data of 1410 patients with bone injury in Wenchuan earthquake were analyzed to evaluate clinical intervention and remedy-managing experience. RESULTS: The 1410 patients average age was from 4 to 103 years old. And 744 cases (52.7%) suffered from blunt injuries, 379 cases (26.9%) from buried injuries, 287 cases (20.4%) from falling injuries; And 1317 cases were with fracture, 93 with limbs soft tissue injuries; 261 patients combined with other parts of injuries including 45 cases with paralysis; 66 cases were with crush syndrome, 25 with gas gangrene, 76 with acute kidney failure, 26 with multiple organ failure. And 912 operations were performed including 402 fracture fixation, 224 debridement, 152 debridement and suture, 85 amputation, 29 implant skin, 8 fixation of joint dislocation, 5 surgical flaps transplantation, 4 nerve and tendon suture, 2 arthroscopes, 1 joint replacement. Among the 66 crush syndrome patients, 49 accepted continuous renal replacement therapy, in which 9 cases were bleeding from named arteries and 20 blood vessels were getting embolism. Among the 1410 cases, 1 died from multiple organ failure. CONCLUSIONS: Among the patients with bone injury in Wenchuan earthquake, the elderly patients are more than the youth; The injuries are always combined with other complications; Opened injuries are polluted severely; It is difficult to deal with the crush syndrome; Paraplegia cases are less, but the amputees are more.

Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: A systematic review and meta-analysis.

BACKGROUND: Though several systematic reviews concerned have been published, controversy still exists. The current systematic review was designed to clarify the detailed advantages and disadvantages of the negative pressure wound therapy (NPWT) in treatment of open fractures in comparison with the conventional wound dressings. METHODS: A systematic search was performed in Pubmed, Cochrane Library, Embase, and Google Scholar for the published relevant clinical studies. Unpublished studies were searched in Clinicaltrials, ICTRP and ISRCTN. The outcome measures included presence of infection, wound healing process, length of the patient hospital stay, flap issues, frequency of amputation, and patient life quality. RESULTS: In the 8 randomized controlled trials (RCTs) (421 patients) and the 6 retrospective cohort studies (488 patients), NPWT resulted in a significantly lower infection rate, significantly shorter wound coverage time, wound healing time and hospital stay length, and the lower amputation rate. However, no statistically significant difference was found in the need for flap surgery, the proportion of free flaps, the flap failure rate or the fracture non-union rate. Only 1 RCT was reported to have a higher physical component score of short form 36 in the infected patients. CONCLUSION: NPWT can significantly reduce the risk of infection in treatment of open fractures and accelerate their wound healing process. Some but not much evidence suggests that NPWT may possibly help reduce the severity of the limb injury and therefore provide a chance for the limb to avoid amputation. Use of NPWT in the flap area is probably safe, but should be carried out with caution. The advantage of NPWT over the conventional wound dressings still requires to be confirmed in the other aspects.

Appropriate excision time of heterotopic ossification in elbow caused by trauma.

OBJECTIVE: The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow. METHODS: We retrospectively reviewed 42 patients who were treated operatively for heterotopic ossification of the elbow from March 2010 to December 2014 at our institution. The patients were divided into early (before 12 months) and late (after 12 months) excision groups. In the early excision group (17 patients), the average time from the initial injury to HO excision was 7.4 (3-11) months, and in the late excision group (25 patients), the average time was 33.5 (12-240) months. Every patient was evaluated by range of motion (ROM), the Mayo Elbow Performance Score (MEPS), postoperative complications and HO recurrence. RESULTS: The preoperative mean ROM in the late excision group was greater than that of the early excision group, suggesting that the ROM is expected to increase even without surgery. Both early and late surgery increased ROM and MEPS, but early surgery improved ROM and MEPS more than late surgery did (p < .05). CONCLUSIONS: Early excision of HO can provide better elbow function, as indicated by ROM and MEPS. Considering that there were no notable differences in postoperative ROM and MEPS, HO recurrence, or postoperative complications, we concluded that early excision is safe and that the time from an elbow injury to surgery may be shortened. LEVEL OF EVIDENCE: Level III, therapeutic study.

[Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures].

Objective: To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Methods: Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P>0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group ( P=0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. Results: The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference ( χ2=0.013, P=0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference ( χ2=0.509, P=0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference ( χ2=2.168, P=0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference ( χ2=0.361, P=0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference ( χ2=1.059, P=0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conclusion: Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.

Combating Superbug Without Antibiotic on a Postamputation Wound in a Patient with Diabetic Foot.

Diabetic foot is a kind of limb- and life-threatening complication that is difficult to treat with conventional therapy, especially when accompanied with peripheral arterial insufficiency and severe infection. We present a diabetic patient with a postamputation wound infected by multidrug-resistant Acinetobacter baumannii/haemolyticus, which was resistant to almost all antibiotics. As the clinical response to antimicrobial therapy was poor, antibiotic was discontinued. Autologous platelet-rich gel with anticoagulation, negative pressure wound therapy, and improvement of microcirculation were used successfully to eradicate infection of the superbug and achieve final wound closure.

[MINIMALLY INVASIVE FIXATION UNDER COMPUTER-ASSISTED NAVIGATION FOR TREATMENT OF PERIACETABULAR FRACTURES, ANTERIOR AND POSTERIOR PELVIC RING FRACTURES].

OBJECTIVE: To investigate the application and technical essentials of computer-assisted navigation in the surgical management of periacetabular fractures and pelvic fractures. METHODS: Between May 2010 and May 2011, 39 patients with periacetabular or anterior and posterior pelvic ring fractures were treated by minimally invasive fixation under computer-assisted navigation and were followed up more than 2 years, and the clinical data were analyzed retrospectively. There were 21 males and 18 females, aged 15-64 years (mean, 36 years). Fractures were caused by traffic accident in 23 cases, crush injury in 6 cases, and falling from height in 10 cases. Of them, 6 cases had acetabular fractures; 6 cases had femoral neck fractures; 18 cases had dislocation of sacroiliac joint; and 15 cases had anterior pelvic ring injuries. All patients were treated with closed or limited open reduction and screw fixations assisted with navigation. RESULTS: Eighty-nine screws were inserted during operation, including 8 in the acetabulum, 18 in the neck of the femur, 33 in the sacroiliac joint, and 30 in the symphysis pubis and pubic rami. The mean time of screw implanted was 20 minutes (range, 11-38 minutes), and the average blood loss volume was 20 mL (range, 10-50 mL). The postoperative pelvic X-ray and three dimensional CT scan showed good reduction of fractures and good position of the screws. No incision infection, neurovascular injury, or implant failure occurred. All patients were followed up 27-33 months with an average of 29.6 months. The patients could walk with full weight loading at 6-12 weeks after operation (mean, 8 weeks); at last follow-up, the patients could walk on the flat ground, stand with one leg, and squat down, and they recovered well enough to do their job and to live a normal life. CONCLUSION: Minimally invasive fixation under computer-assisted navigation may be an excellent method to treat some specific types of periacetabular and anterior and posterior pelvic ring fractures because it has the advantages of less trauma and blood loss, lower complication incidence, and faster recovery.

Coculture of peripheral blood-derived mesenchymal stem cells and endothelial progenitor cells on strontium-doped calcium polyphosphate scaffolds to generate vascularized engineered bone.

Vascularization of engineered bone tissue is critical for ensuring its survival after implantation and it is the primary factor limiting its clinical use. A promising approach is to prevascularize bone grafts in vitro using endothelial progenitor cells (EPC) derived from peripheral blood. Typically, EPC are added together with mesenchymal stem cells (MSC) that differentiate into osteoblasts. One problem with this approach is how to promote traditional tissue engineering bone survival with a minimally invasive method. In this study, we examined the effectiveness of administering to stimulate the release of peripheral blood stem cells and their co-culturing system for generating prevascularized engineered bone. Cells were isolated by Ficoll density gradient centrifugation and identified as EPC and MSC based on morphology, surface markers, and functional analysis. EPC and MSC were cocultured in several different ratios, and cell morphology and tube formation were assessed by microscopy. Expression of osteogenesis and vascularization markers was quantified by enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction, and histochemical and immunofluorescence staining. Increasing the proportion of EPC in the coculture system led to greater tube formation and greater expression of the endothelial cell marker CD31. An EPC:MSC ratio of 75:25 gave the highest expression of osteogenesis and angiogenesis markers. Cocultures adhered to a three-dimensional scaffold of strontium-doped calcium polyphosphate and proliferated well. Our findings show that coculturing peripheral blood-derived EPC and MSC may prove useful for generating prevascularized bone tissue for clinical use.

[Application of lateral malleolus hook-plate in treatment of stage II supination-adduction type medial malleolus fracture].

OBJECTIVE: To investigate the application of lateral malleolus hook-plate for the treatment of stage II supination-adduction type medial malleolus fractures. METHODS: Between January 2011 and June 2013, 21 patients with stage II supination-adduction type ankle fractures were treated with lateral malleolus hook-plate, including 12 males and 9 females with an average age of 55.5 years (range, 27-65 years). The injury causes were sprain in 17 cases and traffic accident in 4 cases. The mean time between injury and admission was 12.4 hours (range, 2-72 hours). The tibial distal medial articular surface collapse was found in 7 cases by CT examination and in 3 cases by X-ray film. Of 21 cases, there were 12 cases of low transverse fractures of lateral malleolus, 7 cases of short oblique fractures of lateral malleolus, and 2 cases of ankle joint lateral collateral ligament injury without fractures of lateral malleolus. After operation, the clinical outcome was evaluated according to the talus-leg angle, the recovery of Coin-sign continuity, inside-outside and top ankle gap, talus slope, American Orthopedic Foot and Ankle Society (AOFAS) score, Olerud-Molander score, Kofoed evaluation standards, and patient satisfaction. RESULTS: Seventeen cases were followed up 18.7 months on average (range, 12-25 months). Primary healing was obtained in 16 cases except 1 case of delayed healing. Fracture healed at an average of 14.6 weeks (range, 12-16 weeks). All cases achieved anatomical reduction, the continuity of Coin-sign, and consistency of inside and outside joint gap; no talus tilt occurred. There was no complication of reduction loss, loosening or breakage of internal fixation, or osteoarthritis during follow-up. The talus-leg angle of the affected side was significantly improved to (83.4 ± 1.8)° at 1 week after operation from preoperative (74.8 ± 7.1)° (t = 5.370, P = 0.000), but no significant difference was found when compared with normal side (83.8 ± 2.3)° (t = 0.676, P = 0.509). The AOFAS score, Olerud-Molander score, and range of motion at 1 week, 3 months, and 1 year after operation were significantly improved when compared with preoperative ones (P < 0.05). According to Kofoed evaluation standard, the outcome was excellent in 15 cases and good in 2 cases; the excellent and good rate was 100%. According to patient satisfaction, the outcome was excellent in 13 cases, good in 3 cases, and poor in 1 case; the excellent and good rate was 94.1%. CONCLUSION: The use of lateral malleolus hook-plate for fixation of stage II supination-adduction type medial malleolus fracture not only can effectively maintain anatomical reduction and supporting function, but also can prevent re-collapsing of the reset joint surface. The surgical method can not increase soft tissue complication, so it is a safe and effective method.

Tissue engineering stratified scaffolds for articular cartilage and subchondral bone defects repair.

Due to their good biocompatibility and mechanical integrity, tissue engineering scaffolds have become a principal method of repair and regeneration of osteochondral defects. To improve their intrinsic properties, control their degenerative times, and enhance their cell adhesion and differentiation, numerous scaffold architectures and formation methods have been developed and tested, but the ideal scaffold design is still controversial. Moreover, scaffold fixation has a significant influence on repair and regeneration after implantation. The authors analyzed relative studies to address the latest scaffold designs, including biphasic scaffold, multilayered scaffold, and continuous nonstratified scaffold, and this article compares their advantages and disadvantages. In addition, the authors introduce a novel modified method for scaffold fixation known as magnetic fixation. Both stratified and nonstratified scaffolds can repair osteochondral defects, but continuous nonstratified scaffolds are more biomimetic compared with the native osteochondral structures, and they lead to a better regeneration of hyaline-like cartilage and structured bone tissue. Therefore, the authors suggest continuous nonstratified scaffolds are an effective option for treating osteochondral defects.

Repair of large osteochondral defects in a beagle model with a novel type I collagen/glycosaminoglycan-porous titanium biphasic scaffold.

The limited repair potential of articular cartilage, which hardly heals after injury or debilitating osteoarthritis, is a clinical challenge. The aim of this work was to develop a novel type I collagen (Col)/glycosaminoglycan (GAGs)-porous titanium biphasic scaffold (CGT) and verify its ability to repair osteochondral defects in an animal model with bone marrow stem cells (bMSCs) in the chondral phase. The biphasic scaffold was composed of Col/GAGs as chondral phasic and porous titanium as subchondral phasic. Twenty-four full-thickness defects through the articular cartilage and into the subchondral bone were prepared by drilling into the surface of the femoral patellar groove. Animals were assigned to one of the three groups: 1) CGT with bMSCs (CGTM), 2) only CGT, and 3) no implantation (control). The defect areas were examined grossly, histologically and by micro-CT. The most satisfied cartilage repairing result was in the CGTM group, while CGT alone was better than the control group. Abundant subchondral bone formation was observed in the CGTM and CGT groups but not the control group. Our findings demonstrate that a composite based on a novel biphasic scaffold combined with bMSCs shows a high potential to repair large osteochondral defects in a canine model.

Massive juxta-articular defects of the distal femur reconstructed by series connected double-strut free-vascularized fibular grafts.

BACKGROUND: We evaluate the clinical results of reconstructing massive juxta-articular defects of the distal femur (mean, 16.4 cm) with series-connected double-strut free-vascularized fibular grafting (FVFG) and external fixator fixation. METHODS: We retrospectively reviewed a consecutive series of 19 patients, who underwent FVFG transfer because of massive juxta-articular defects of distal femur. Sixteen cases had complete records and included in this study. Five patients underwent double-strut FVFGand 11 patients underwent series-connected double-strut FVFG. FVFG was performed from 2 months to 3 months after the clinica lsigns of the infection had subsided and erythrocyte sedimentation rates had returned to normal. Both fibulas (mean, 18.6 cm) were harvested to reconstruct the femoral defect, half-ring sulcated external fixator (Orthofix Srl, Italy), and K-wires were used to provide stabilization. RESULTS: Five fibular grafts (15.6%) had vascular complications on flap monitoring. Fifteen of the sixteen reconstructed femurs (93.8%)united primarily. Stress fracture occurred in one patient. The mean duration to achieve union was 7.1 month (range, 4­18 months).Full weight-bearing walking was allowed 3 months after the confirmation of bone union (mean, 10 months; range, 7­22 months).The external fixator was removed 12.2 months (range, 10­16 months) postoperatively. The K-wires were removed 26.4 months(range, 23­30 months) postoperatively. There was no statistically significant difference of hypertrophic change between series-connected grafts and conventional double-strut grafts (27.18 vs. 24.43%, p = 0.186) and also between the three levels of the grafted fibula. Within the series-connected group, the difference of hypertrophic change between anterograde fibular grafts and retrograde fibular grafts was also not significant (25.24 vs. 29.12%, p = 0.178). The overall rate of knee stiffness (90 degree)was as high as 68.75% (11 of 16 patients). CONCLUSIONS: Massive juxta-articular defects of the distal femur are difficult and uncommon injuries. The results of this study indicate that the huge femoral defect reconstructed by series-connected double-strut FVFG provide good results in achieving bone union, reducing stress fracture rate, and achieving leg length equality.