Tranexamic acid in patients with post-traumatic elbow stiffness: protocol for a randomised, double-blind, placebo-controlled trial investigating the effectiveness of tranexamic acid at reducing the recurrence of heterotopic ossification after open elbow arthrolysis.

INTRODUCTION: Exaggerated inflammatory response is one of the main mechanisms underlying heterotopic ossification (HO). It has been suggested that the antifibrinolytic drug tranexamic acid (TXA) can exert a significant anti-inflammatory effect during orthopaedic surgery. However, no prospective studies have yet investigated the effects of TXA on HO recurrence in patients following open elbow arthrolysis (OEA). METHODS AND ANALYSIS: Here, we present a protocol for a single-centre, randomised, double-blind, placebo-controlled trial to investigate the effectiveness of TXA on HO recurrence after OEA in a single hospital. A minimum sample size of 138 eligible and consenting participants randomised into treatment and control groups in a 1:1 manner will be included. Patients will receive 2 g of intravenous TXA (experimental group) or placebo (normal saline, control group) administered before skin incision. The primary outcome is HO recurrence rate within 12 months after surgery. The secondary outcomes are the serum immune-inflammatory cytokines including erythrocyte sedimentation rate, C reactive protein, interleukin (IL)-6, IL-1ß, IL-13 at the first and third day postoperatively, and elbow range of motion and functional score at 1.5, 6, 9 and 12 months after surgery. After completion of the trial, the results will be reported in accordance with the extensions of the Consolidated Standards of Reporting Trials Statement for trials. The results of this study should determine whether TXA can reduce the rates of HO occurrence after OEA. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Medical Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (reference number 2022-123-(1)). The results of this study will be disseminated through presentations at academic conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ChiCTR2300068106.

Association Between Tranexamic Acid Use and Heterotopic Ossification Prevalence After Elbow Trauma Surgery: A Propensity-Score-Matched Cohort Study.

BACKGROUND: Heterotopic ossification (HO) is a common complication of elbow trauma that can affect limb mobility. Inflammation is an initiating factor for HO formation. Tranexamic acid (TXA) can reduce the inflammatory response after orthopaedic surgery. However, evidence regarding the effectiveness of TXA use for HO prevention after elbow trauma surgery is lacking. METHODS: This retrospective observational propensity-score-matched (PSM) cohort study was conducted from July 1, 2019, to June 30, 2021, at the National Orthopedics Clinical Medical Center, Shanghai, People's Republic of China. A total of 640 patients who underwent surgery following elbow trauma were evaluated. The present study excluded patients with an age of <18 years; those with a history of elbow fracture; those with a central nervous system injury, spinal cord injury, burn injury, or destructive injury; and those who had been lost to follow-up. After 1:1 matching on the basis of sex, age, dominant arm, injury type, open injury, comminuted fracture, ipsilateral trauma, time from injury to surgery, and nonsteroidal anti-inflammatory drug use, the TXA group and the no-TXA group comprised 241 patients each. RESULTS: In the PSM population, the prevalence of HO was 8.71% in the TXA group and 16.18% in the no-TXA group (with rates of 2.07% and 5.80% for clinically important HO, respectively). Logistic regression analyses showed that TXA use was associated with a lower rate of HO (odds ratio [OR], 0.49; 95% CI, 0.28 to 0.86; p = 0.014) than no TXA use, as well as with a lower rate of clinically important HO (OR, 0.34; 95% CI, 0.11 to 0.91; p = 0.044). None of the baseline covariates significantly affected the relationship between TXA use and HO rate (p > 0.05 for all). Sensitivity analyses supported these findings. CONCLUSIONS: TXA prophylaxis may be an appropriate method for the prevention of HO following elbow trauma. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique.

OBJECTIVE: To describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method. METHODS: A pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty-five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo-Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5-8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley's criteria. RESULTS: Twenty-five patients were followed up for an average of 28.96 (Range, 15-48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5-9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection. CONCLUSIONS: The combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.

Celecoxib-Loaded Electrospun Fibrous Antiadhesion Membranes Reduce COX-2/PGE2 Induced Inflammation and Epidural Fibrosis in a Rat Failed Back Surgery Syndrome Model.

To date, failed back surgery syndrome (FBSS) remains a therapy-refractory clinical condition after spinal surgery. The antiadhesion membrane is applied to prevent FBSS by isolating fibrosis; however, the inflammation stimulated by the foreign body and surgical trauma needs to be further resolved simultaneously. Therefore, we developed new electrospun polycaprolactone (PCL) fibrous membranes loaded with celecoxib (CEL) to prevent fibrosis and inflammation associated with FBSS. The CEL-loaded PCL fibers were randomly distributed, and the drug was released over two weeks. Fluorescence micrographs revealed that the fibroblasts proliferated less on the PCL-CEL fibrous membranes than in the PCL group and the blank control. In the rat laminectomy model after 4 weeks, magnetic resonance imaging of epidural fibrosis was least in the PCL-CEL group. Expression of COX-2 and PGE2 was lower in the PCL-CEL group. It concluded that the CEL-loaded PCL membrane could reduce fibrosis and inflammation in a rat model of FBSS via COX-2/PGE2 signaling pathways.

Full recovery of elective orthopedic surgery in the age of COVID-19: an 8-month retrospective cohort study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to dramatic disruptions to orthopedic services. The purpose of this study is to quantify the reinstatement of elective orthopedic surgeries of our institution in Shanghai, China, and share our first-hand experiences of how this region is managing the post-outbreak period. METHODS: The number of patients receiving elective orthopedic surgeries was analyzed in the timeframe of 8 months since the start of the pandemic (from January 20 to September 16) and compared with the patients receiving the same treatment during the same period in 2019. And a detailed workflow for handling patients about to receive elective surgeries in the COVID-19 post-outbreak period was described. RESULTS: The number of the selective surgeries in the first 3 months only accounted for 31.72% of the same period in 2019 (p = 0.0031), and the ratio reached 97.47% when it came to the last 5 months (p > 0.9999). The selective surgeries even surpassed the pre-epidemic level in months 7 and 8. And the difference of the surgeries was not significant in the whole eight observed months between 2019 and 2020 (p = 0.1526). No health care providers or hospitalized patients in orthopedic departments in Shanghai have been infected nosocomially. CONCLUSIONS: Elective orthopedic surgeries have been fully recovered from the COVID-19 pandemic in our institution, and the new normalcy established during the post-outbreak period helped this region co-exist with the impact of the virus well. TRIAL REGISTRATION: Retrospectively registered, registration number: ChiCTR2000039711 , date of registration: November 6, 2020.

Postconditioning With Red-Blue Light Therapy Improves Survival of Random Skin Flaps in a Rat Model.

BACKGROUND: Random skin flap ischemic necrosis is a serious challenge in reconstructive surgery. Photobiomodulation is a noninvasive effective technique to improve microcirculation and neovascularization. Photobiomodulation with red or blue light has been separately proven to partially prevent skin flap necrosis, but the synergistic effect of red and blue light not been elucidated. Our experiment evaluated the impact of postconditioning with red-blue light therapy on the viability of random flaps. METHODS: Thirty Sprague-Dawley male rats (male, 12 weeks) with a cranially based random pattern skin flap (3 × 8 cm) were divided into 3 groups: control group, red light group, and red-blue light group. On postoperative day 7, flap survival was observed and recorded using transparent graph paper, flaps were obtained and stained with hematoxylin and eosin, and microvessel density was measured. Micro-computed tomography was used to measure vascular volume and vascular length. On days 0, 3, and 7 after surgery, blood flow was measured by laser Doppler. To investigate the underlying mechanisms, the amount of nitric oxide (NO) metabolites in the flap tissue was assessed on days 3, 5, and 7 after surgery. RESULTS: The mean percentage of skin flap survival was 59 ± 10% for the control group, 69 ± 7% for the red light group, and 79 ± 9% for the red-blue light group (P < 0.01). The microvessel density was 12.3 ± 1.2/mm2 for the control group, 31.3 ± 1.3/mm2 for the red light group, and 36.5 ± 1.4/mm2 for the red-blue light group (P < 0.01). Both vascular volume and total length in the red-blue light group showed significantly increased compared with the red light and control group (P < 0.01). Blood flow in the red-blue light treated flap showed significantly increased at postsurgery days 3 and 7 compared with the red light and control group (P < 0.01). The level of the NO metabolites was significantly increased in flap tissues belonging to the red-blue light group compared with the other 2 groups (P < 0.01). CONCLUSIONS: This study showed that postconditioning with red-blue light therapy can enhance the survival of random skin flap by improving angiogenesis and NO releasing.

High-purity magnesium pin enhances bone consolidation in distraction osteogenesis model through activation of the VHL/HIF-1α/VEGF signaling.

Distraction osteogenesis has widespread clinical use in the treatment of large bone defects. Nonetheless, the prolonged consolidation period carries the risk of complications. Magnesium-based materials have been shown to promote bone regeneration in fracture healing both in vitro and in vivo. Here, we investigated whether high-purity magnesium could enhance bone formation in distraction osteogenesis. High-purity magnesium pins were placed into the medullary cavity in the rat distraction osteogenesis model. Results showed that the bone volume/total tissue volume, bone mineral density, and mechanical properties of new callus were significantly higher in the high-purity magnesium group compared to stainless steel and control group (p < 0.01). Histological analyses confirmed improved bone consolidation and vascularization in high-purity magnesium group. Further, polymerase chain reaction-array investigation, Western blot, and immunohistochemical results found that vascular endothelial growth factor and hypoxia inducible factor-1α were highly expressed in the high-purity magnesium group, while Von Hippel-Lindau protein was the opposite (p < 0.01). In conclusion, high-purity magnesium implants have the potential to enhance angiogenesis and bone consolidation in the distraction osteogenesis application, and this process might be via the regulation of Von Hippel-Lindau/hypoxia inducible factor-1α/vascular endothelial growth factor signaling.

L-shaped corticotomy with bone flap sliding in the management of chronic tibial osteomyelitis: surgical technique and clinical results.

BACKGROUND: We described the use of the technique of L-shaped corticotomy with bone flap sliding to treat chronic osteomyelitis of the tibia in eight patients and presented the preliminary results. METHODS: L-shaped corticotomy with bone flap sliding was performed in eight patients between 2007 and 2014. All patients had chronic tibial osteomyelitis involving the anterior tibial cortex with intact and healthy posterior cortex. The size of bone defects following sequestrectomy and radical debridement was 8.1 cm on average. One patient required a latissimus dorsi flap. The mean follow-up period was 34.1 months. The functional and bone results were evaluated at the time of the latest follow-up. RESULTS: Complete eradication of infection and union of docking sites were achieved in all patients. Functional results were judged excellent in five patients and good in the rest three patients. Bone results were graded as excellent in all cases. The mean external fixation time was 169.9 days and external fixation index was 21.2 days/cm. Pain was the most common complaint that we faced during lengthening. Pin tract infections were observed in four patients, and mild transient stiffness of ankle joint was observed in three patients. CONCLUSIONS: We have found this technique to be safe and effective, significantly diminishing the external fixation index. The earlier removal of the external fixator may result in increased patient comfort, a reduced complication rate, and a rapid and convenient rehabilitation.

Resection arthrodesis using distraction osteogenesis then plating as a hybrid surgical technique for the management of bone sarcomas of the distal tibia.

PURPOSE: We report the oncological and functional results of limb salvage for bone sarcomas involving the distal tibia using hybrid surgical technique of resection arthrodesis by bone transport then plating. METHODS: Five patients (mean age 18.6 years) with primary distal tibial sarcomas (two Ewing's sarcomas and three osteosarcomas) were treated by this method. The average duration of follow-up is 53 months. All patients accepted distraction osteogenesis with a standard technique using external fixator after wide (four cases) or marginal (one case) resection in the first operation. They were re-admitted for the second surgical treatment (plate insertion and removal of the external fixator) one to two months after they achieved the necessary limb length and desired alignment. RESULTS: Solid union of the lengthening site and sound fusion of the ankle were achieved in all five patients with full and unassisted weight bearing. The mean lengthening was 11.8 cm (range 8-14 cm) and the external fixation index (EFI) was 29.3 days/cm (range 22.8-36.3 days/cm). The mean functional score according to the rating system of the Musculoskeletal Tumour Society was 88% (83-90%). One patient showed poor response to chemotherapy, had local recurrence of sarcoma one year after plating, and was treated with above-knee amputation. CONCLUSIONS: In carefully selected patients with primary distal tibial sarcomas, this hybrid method can effectively eliminate tumor lesion, reconstruct function, and shorten the length of wearing an external fixator by a meticulous conversion to internal fixator.