[Progress on prevention and treatment of heterotopic ossification].

Heterotopic ossification is the formation of pathological bone in non-skeletal tissues (including muscles, tendons or other soft tissues), and the pathogenesis is not completely clear. It is often caused by musculoskeletal trauma, postoperative bone and joint surgery, or damage of the nervous system, the clinical manifestations are joint swelling, pain, and movement disorders, which often occur around the hips, knees, and elbows. At present, the prevention of heterotopic ossification mainly includes drugs, radiotherapy, molecular biological mechanism intervention, and Chinese medicine-related measures. Among them, drugs and radiotherapy are more effective methods to prevent heterotopic ossification. The intervention of molecular biology mechanism to prevent heterotopic ossification has become a new research direction and focus of attention inrecent years, and is basically at the experimental research stage. The treatment of heterotopic ossification includes various methods such as drugs, physical therapy, and surgery. Among them, surgery is recognized as the most effective treatment, however there are still some controversies and disagreements about the choice of operation time and surgical methods.

[Three-step sequential method for limb skin and soft tissue defect combined with bone or tendon exposed wound].

OBJECTIVE: To explore clinical effect of VSD technology, coverage of artificial dermis and autograft for the treatment of limb skin soft tissue defect combined with bone or tendon exposed wound. METHODS: Eighteen patients suffered from limb skin soft tissue defect combined with bone or tendon exposed wound treated by three-step sequential method from January 2013 to June 2015. Among them, including 13 males and 5 females aged from 23 to 72 years old with an average of 34.6 years old; the time from injury to operation ranged from 1.5 to 5.0 hours with an average of 2.5 h. The area of skin and soft tissue injury ranged from 4.2 cm×3.1 cm to 7.4 cm×5.2 cm. Wound recovery and taken skin wound recovery were observed to evaluate clinical results. RESULTS: All patients were followed up from 5 to 16 months, with an average of 7.6 months. Deep bone tendon tissue of wounds were effectively recovered, artificial dermis survived, and quality of healed wound was tough and shape was good. Wound transplant flap was survived, no obvious scar tissue formation, appearance was flat, skin color was a little deeper than normal skin, the overall effect was satisfactory. CONCLUSIONS: Three-step sequential method has good curative effect for patients suffered from limb skin soft tissue defect with bone or tendon exposed wound and refused to repair the flap, and has advantage of simple operation, operation risk, less invasive.

[Different mini skin flaps in repairing finger soft tissue with bone defect].

OBJECTIVE: To explore surgical methods and clinical effects of three different types of mini skin flap transplantation for repairing finger soft tissue with bone defect. METHODS: Thirty-three patients with finger soft tissue or bone defect were treated from December 2014 to October 2016, including 24 males and 9 females aged from 21 to 52 years old with an average of (36.42±5.70) years old, and soft tissue defect area ranged from 1.3 cm×1.8 cm to 2.3 cm×4.2 cm. According to damage degree, nature and patients' options, 15 finger of 15 cases were adopted retrograde dorsal metacarpal artery perforators fascia flap, 10 fingers of 9 cases were treated with free foot artery descending branch wrist skin flap, 9 fingers of 9 cases were treated with free the second toe details phalanges compound flap. Survival rate, postoperative complications and finger function assessed by Dargan functional criteria at the latest follow up were observed. RESULTS: All flaps were survived, both of donor site and recipient site were without deep infected. The donor site of one patient occurred necrotic, and the distal donor site of one patient occurred surface necrotic, then healed by active dressing change. All patients were followed up from 6 to 16 months with an average of(8.34±1.28) months. Two points of finger recognition were restored between 8 and 12 mm with an average of (8.84±0.43) mm, and the appearance, texture and sensory functions of skin flap were restored. No obvious complications were observed on the donor site. According to Dargan function evaluation of finger joints, 18 patients got excellent results, 14 moderate and 1 good. CONCLUSIONS: Three kinds of mini skin flap could receive good results in repairing soft tissue of finger or bone defect. Reverse dorsal metacarpal artery perforator fascia flap is not necessary with anastomosing blood vessels and has advantages of safe, simple and high survival rate. Descending branch of superior cutaneous branch of free ulnar artery could cut multiple other perforator flaps simultaneously, and the scar is small and hidden. Dissociated the second toe combined metatarsal phalangeal flap could repair shape and function of finger to the maximum extent and donor site is hidden.

Effect of ß­ecdysterone on glucocorticoid­induced apoptosis and autophagy in osteoblasts.

The aim of the present study was to investigate the effect of glucocorticoids in osteoblasts and to examine the role of ß­ecdysterone in the pathogenesis of glucocorticoid­induced osteoporosis. Osteoblasts were induced from bone marrow mesenchymal stem cells, which were isolated from C57BL/6 mice. Cell viability and apoptosis of osteoblasts were measured by Cell Counting Kit­8 and flow cytometry analysis, respectively. The expression of related genes and proteins was measured by reverse transcription quantitative polymerase chain reaction and western blot analysis respectively. Dose­dependent decreases in the cell proliferation and differentiation were observed in dexamethasone (Dex)­treated osteoblasts, evidenced by downregulation in the activity of alkaline phosphatasedecreased expression levels of Runt­related transcription factor 2 and osteocalcin, and upregulated expression of RANK ligand. Dex also induced apoptosis and inhibited autophagy of osteoblasts, evidenced by upregulated B­cell lymphoma 2 (Bcl­2)­associated X protein/Bcl­2 ratio and the activation of mammalian target of rapamycin (mTOR), and decreased expression levels of Beclin­1, autophagy protein 5 and microtubule­associated protein 1 light chain 3 II. The effects on cell proliferation, apoptosis and autophagy induced by Dex were reversed by ß­ecdysterone in a dose­dependent manner. Therefore, ß­ecdysterone may be a promising candidate drug for the treatment of osteoporosis through inducing osteoblast autophagic activity by inactivating mTOR.

Local influence of high molecular polyethylene particles on heterotopic ossification.

We studied the effect of molecular polyethylene particles on local heterotopic ossification. A total of 36 healthy Sprague-Dawley rats were randomly divided into the control group (n=18) and the observation group (n=18). High molecular polyethylene particles were injected to rupture Achilles tendon position in the observation group, and normal saline was injected in the control group. X-ray examinations were conducted on Achilles tendon in the 4th, 8th and 12th week after operation. The incidence rate of heterotopic ossification was evaluated, and bone trabecula morphological structure was studied under optical microscope after hematoxylin and eosin staining. Bone morphogenetic protein 2 (BMP-2), transforming growth factor-ß (TGF-ß), interleukin-1 (IL-1), tumor necrosis factor-α (TNF-α), runt-related transcription factor 2 (Runx2) and matrix metalloproteinase-9 (MMP-9) expression levels were also measured. Our results showed that heterotopic ossification incidence in the observation group was significantly lower than that in the control group. Achilles tendon structure in the control group increased in volume, and its texture was harder and cartilage-like. In the observation group, trabecular bone volume, thickness and quantity were more than those observed in the control group. BMP-2, TGF-ß, IL-1, TNF-α, Runx2 and MMP-9 levels in the observation group were significantly lower than those in the control group. We concluded that, high molecular polyethylene particles had a significant inhibiting effect on local heterotopic ossification.

[Surgical treatment for open tarsometatarsal joint injury].

OBJECTIVE: To discuss the surgical method and clinical efficacy for open tarsometatarsal joint injuries. METHODS: From March 2011 to January 2015, 21 patients with open tarsometatarsal joint injuries were treated with stage-surgery method, including 14 males and 7 females with an average age of 45.6 years old ranging from 20 to 75 years. Injury site occurred in the left foot of 13 cases and right foot of 8 cases. Traffic injury was in 5 cases, crush injury in 6 cases, heavy crushing was in 10 cases. According to Myerson to classify for tarsometatarsal joint injury, 5 cases were type B2, 9 cases were type C1, and 7 cases were type C2. And according to Gustilo to typing for soft tissue injury, 5 cases were type IIB, 10 cases were type IIIA, 6 cases were type IIIB. Fracture healingand complications were observed after operation and clinical effects were evaluated according to the midfoot score of AOFAS. RESULTS: All the patients were followed up from 11 to 40 months with an average of 16.2 months. The fracture healing time was from 10 to 16 weeks with an average of 12.3 weeks. No complications such as deep infection, nonunion and osteomyelitis were found. Midfoot score of AOFAS at last follow-up was 83.0±14.9, 9 cases got excellent results, 8 good, 2 fair, 2 poor. Two patients complicated with severe traumatic arthritis once again underwent tarsometatarsal arthrodesis. CONCLUSIONS: For the treatment of open tarsometatarsal joint injury, reasonable debridement, comprehensive assessment for the soft tissue injury, correctly grasp the surgical indications and time of internal fixation, can reduce the incidence of deep infection and osteomyelitis.

Repair of the acute deltoid ligament complex rupture associated with ankle fractures: a multicenter clinical study.

Controversy exists concerning the need for operative repair of the deltoid ligament during management of acute ankle fractures. The purpose of our report was to identify the indications for surgical intervention for deltoid ligament injury in the setting of ankle fractures. Furthermore, we aimed to elucidate the clinical outcomes after deltoid ligament repair in this setting. This was a multicenter study, involving 4 clinical institutions. From January 2006 to December 2011, 1533 ankle fractures underwent surgical intervention. Of this group, 131 deltoid ligament ruptures (8.55%) were identified and repaired operatively. Of the 131 patients, 74 were male (56.5%) and 57 were female (43.5%), with a mean age of 33.2 (range 16 to 63) years. The outcome measures included the clinical examination findings, radiographic findings, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, visual analog scale (VAS) scores, and Medical Outcomes Study Short Form 36-item questionnaire scores. All incisions healed primarily. A total of 106 patients were followed up for a minimum of 12 (range 12 to 72) months, with an average follow-up period of 27 months. The mean interval to fracture union was 14.5 (range 9 to 16) weeks. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score at the latest follow-up visit was 91.4 (range 83 to 100) points. The mean visual analog scale score was 1.2 (range 0 to 6) points. The mean Short Form-36 score was 91.2 (range 80 to 96) points. Compared with the preoperative scores, all the 3 outcome measures had improved significantly postoperatively (p < .05). The postoperative stress radiographs did not reveal any ankle instability. None had evidence of post-traumatic arthritis of the ankle from the clinical examination and radiographs. A reasonable clinical evaluation and surgical repair was executed, with an appropriate repair technique chosen according to the site of deltoid ligament rupture. The results of the present multicenter study have shown that deltoid ligament rupture can be repaired in patients with an unstable medial ankle after fracture fixation and prevent ankle stabilization-related complications.

[Surgical staging applications with antibiotic graft bone for the treatment of open calcaneal fractures].

OBJECTIVE: To discuss the effect of surgical staging and using craft bone with vancomycin for the treatment of calcaneal fractures. METHODS: From January 2006 to December 2012,13 patients with open calcaneal fractures were treated including 9 males and 4 females with an average of 35.2 years old ranging from 23 to 66. All cases were emergency cases. According to Sanders classification of calcaneal fractures, 2 cases were type II, 7 cases were type III, 4 cases were type IV. According to Gustilo-Anderson soft tissue injury classification, 8 cases were type II, 2 cases were type III A, 2 cases were type III B, 1 case were type III C. Firstly a thorough debridement or VSD procedures were applied,secondly calcaneal fracture were treated with open reduction, plate fixation and bone graft complex with antibiotics. Based on clinical examination, radiographic evaluation, and American Foot and Ankle Surgery Society (AOFAS), ankle function were evaluated after operation. RESULTS: Open wounds were headed after dressing and repairing,, lateral calcaneal wound were healed during the first period. All patients were followed up for 6 to 36 months (means 14.5 months). Fracture healing time was 14 to 20 weeks (means 16.2 weeks). Last follow-up AOFAS ankle-hindfoot score was (80.0 +/- 7.4) ranging from 55 to 95. CONCLUSION: For patients with open fractures, through reasonable clinical evaluation, staging operation, using bone graft with antibiotics can reduce the incidence of postoperative wound infection and promote fracture healing.