[Transcriptomic characteristics analysis of bone from chronic osteomyelitis].

OBJECTIVE: To explore the molecular mechanism of chronic osteomyelitis and to clarify the role of MAPK signal pathway in the pathogenesis of chronic osteomyelitis, by collecting and analyzing the transcriptional information of bone tissue in patients with chronic osteomyelitis. METHODS: Four cases of traumatic osteomyelitis in limbs from June 2019 to June 2020 were selected, and the samples of necrotic osteonecrosis from chronic osteomyelitis (necrotic group), and normal bone tissue (control group) were collected. Transcriptome information was collected by Illumina Hiseq Xten high throughput sequencing platform, and the gene expression in bone tissue was calculated by FPKM. The differentially expressed genes were screened by comparing the transcripts of the Necrotic group and control group. Genes were enriched by GO and KEGG. MAP3K7 and NFATC1 were selected as differential targets in the verification experiments, by using rat osteomyelitis animal model and immunohistochemical analysis. RESULTS: A total of 5548 differentially expressed genes were obtained by high throughput sequencing by comparing the necrotic group and control group, including 2701 up-regulated and 2847 down-regulated genes. The genes enriched in MAPK pathway and osteoclast differentiation pathway were screened, the common genes expressed in both MAPK and osteoclast differentiation pathway were (inhibitor of nuclear factor κ subunit Beta, IκBKß), (mitogen-activated protein kinase 7, MAP3K7), (nuclear factor of activated t cells 1, NFATC1) and (nuclear factor Kappa B subunit 2, NFκB2). In rat osteomyelitis model, MAP3K7 and NFATC1 were highly expressed in bone marrow and injured bone tissue. CONCLUSION: Based on the transcriptome analysis, the MAPK signaling and osteoclast differentiation pathways were closely related to chronic osteomyelitis, and the key genes IκBKß, MAP3K7, NFATC1, NFκB2 might be new targets for clinical diagnosis and therapy of chronic osteomyelitis.

[Progress on complications of chronic osteomyelitis with bone defect treated by bone transportation].

Bone transportation technology (Ilizarov technique) effectively solves the clinical problem of chronic osteomyelitis with structural bone defect. The paper combined with own clinical experience and a large number of literatures, the results showed that this method had some complications related to severe bone healing, such as non union of the joint ends and poor mineralization of the extended gap. Maintenance of force line during operation, protection of osteotomy end tissues, appropriate transporting velocity and stress stimulation after operation, and application of "accordion technology" are the keys to reduce such complications. At present, there is still much controversy about the timing of removal of external fixator. Once the re fracture is caused by early removal, it must be treated actively as soon as possible. In addition, it is necessary to reduce the local thermal injury of nail canal during operation and strengthen the nursing of nail canal after operation in order to prevent nail canal infection. Reasonable analgesic regimen combined with active functional exercise is an important method to avoid the occurrence of adjacent joint dysfunction.

[Surgical treatment of deep infection around the spine].

OBJECTIVE: To study the surgical method and clinical effect of deep infection around the spine. METHODS: The clinical data of 7 patients with deep infections around the spine treated from January 2015 to January 2018 were retrospectively analyzed. All patients were acute infection within 3 weeks after spinal surgery. There were 5 males and 2 females, aged from 29 to 67 years old with an average of 42 years old. Four of them had implants and the other three didn't. After infection was diagnosed, they accepted aggressive debridement with assistance of vacuum sealing drainage(VSD). The antibiotic artificial bones were put in wounds, combined with intravenous antibiotics. Blood-rich adjacent tissue flaps were used to reconstruct defect of wounds. The tissue flaps included 4 paraspinal muscle flaps, 1 thoracolumbar fascial flap, 1 latissimus dorsi flap and 1 paraspinal muscle combined with thoracolumbar fascial flap. RESULTS: All 7 patients were followed up from 6 to 24 months with an average of 13.28 months. During the follow-up period, among the 4 patients with instrument, except one patient of lumbar fusion removed internal fixation due to postoperative infection, the other 3 patients successfully kept the implants. One case of cervical fracture and dislocation was repaired by latissimus dorsi transposition. Its wound healed but hydrops accumulated under the flap. This patient was cured by puncture drainage and local pressure bandaging. The other 5 wounds' healing were first intention and no postoperative complications such as infection recurrence, hematoma, effusion or wound dehiscence occurred. CONCLUSIONS: Deep infection around the spine is a serious complication and should be treated aggressively once diagnosed. Thorough debridement with the help of negative pressure closed drainage, local application of antibiotic artificial bone combined with systemic intravenous antibiotics and repairing wounds with adjacent tissue flaps are effective procedures for the treatment of deep infection around the spine.

[Transfer of gastrocnemius muscle flap for postoperative infection with patellar internal fixation].

OBJECTIVE: To investigate clinical effect of gastrocnemius muscle flap for repairing postoperative infection of patellar internal fixation. METHODS: From January 2011 to January 2017, 15 patients with postoperative infection of patellar internal fixation were treated, including 9 males and 6 females ranged from 31 to 66 years old with an average age of (42.5±11.2) years old. The courses of disease ranged from 2 to 8 months with an average of (4.3±1.5) months. All wounds were repaired by gastrocnemius muscle flap after debridement. The coverage of muscle flap was performed by free skin graft and donor site was closed directly. Survival of muscle flap, healing of incision were observed. HUANG Yong-xin clinical criteria and KSS score criteria were used to evaluate knee joint function 9 after operation. RESULTS: All muscle flaps were survived without necrosis. Incision of 13 patients were healed at stageI, and 2 patients had wound dehiscence after operation and healed after symptomatic treatment. All patients were followed up from 9 months to 30 months with an average of(20.6±8.3) months. No recurrence of infection was observed, and texture of muscle flap, skin color, appearance were good. According to HUANG Yong-xin clinical criteria, 13 excellent and 2 moderate. The clinical score of KSS score was 83.3±7.8, and functional score of KSS score was 86.3±10.4. CONCLUSIONS: Gastrocnemius muscle flap is an effective method in repairing postoperative infection of patellar internal fixation with stable curative effect and low recurrence rate, which is worthy popularizing.

[Causes and strategies for postoperative bone nonunion after bone transport of lower limb bone of chronic osteomyelitis with bone defect].

OBJECTIVE: To explore causes and strategies for postoperative bone nonunion after bone transport of lower limb bone of chronic osteomyelitis with bone defect. METHODS: From June 2012 to December 2015, clinical data of 38 patients with lower limb bone of chronic osteomyelitis with bone defect were retrospectively analyzed, including 23 males and 15 females aged from 20 to 56 years old with an average of 36.5 years old; 5 cases occurred on 5 femoral osteomyelitis and 33 cases were tibial;the time from injury to bone transport ranged from 2 to 19 months with an average of 7.4 months; the distance of bone defect ranged from 4 to 12 cm with an average of 7.3 cm. Bone transport were performed at 1 week later after operations, and transport directions were from near-end to far-end for 30 cases, from far-end to near-end for 3 cases and bidirectional transport for another 5 cases. The alignment and transport speed were adjusted and weight-bearing was encouraged. Regular follow-up was performed and X-ray films were taken to observe complications such as poor mineralization in transport gaps, nonunion of docking sites, and recurrent fracture. Paley scoring was used to evaluate clinical effects. RESULTS: All patients were followed up for 12 to 36 months with an average of 23.1 months. No recurrence of osteomyelitis, but multiple complications associated with poor bony healing occurred. In the process of bone transport, 3 cases occurred poor mineralization in transport gaps, 17 cases occurred ununion of docking sites, 5 cases suffered fracture gap, 1 case occurred fracture without remove of external fixation, and 4 cases occurred facture after remove of external fixation. The time of taken fixation ranged from 9 to 27 months with an average of 16.3 months; index of external fixation ranged from 1.7 to 2.7 months/cm with an average of 2.24 months/cm. According to Paley's scoring, bony results showed 12 cases excellent, 16 good, 3 moderate and 7 poor;and functional results showed 14 cases excellent, 18 good, 3 moderate and 3 poor. CONCLUSIONS: Bone transport technique could effectively solve clinical problems of long bone osteomyelitis with bone defect. However, long treatment period influence prognosis. Therefore, indications should be chosen strict, and operations should be precise and accurate, also monitored across whole process and followed up in time. Doctors should be actively guide corresponding prevention strategies.

[Modified one-stage revision procedure for treating proximal femoral infected nonunion after intramedullary nail fixation].

OBJECTIVE: To explore the methods and results of modified one-stage revision procedure for treating proximal femoral infected nonunion after intramedullary nail fixation. METHODS: From June 2010 to June 2015, 10 patients of proximal femoral infected nonunion after intramedullary nail fixation were treated with modified one-stage revision procedure, including 9 males and 1 female, ranging in age from 35 to 77 years old. There were 3 cases of intertrochanteric fractures, 2 cases of intertrochanteric fractures accompanied with proximal femoral fractures and 5 cases of subtrochaneric fracures. The fractures ware fixed by LISS plate after radically debridement. The bone defects were repaired by free vascularized fibular graft and autogenous cancellous bone graft mixed artificial bone containing antibiotics. Postoperatively, ambulation without weight bearing was encouraged as early as possible. RESULTS: Ten patients were followed up from 9 to 30 months and all nonunions healed smoothly without wound infection recurrence or internal fixation failure at the final follow-up. The time for full weight bearing was from 12 to 28 weeks. The hip joint function was evaluated by Sanders Traumatic Hip Rating Scale, the result was excellent in 7 cases, good in 2, and fair in 1 at the final follow-up. CONCLUSIONS: Modified one-stage revision procedure is an effective treatment with a good functional result for proximal femoral infected nonunion after intramedullary nail fixation. On the basis of radical debridement, the combination of infection control and bone healing therapeutic techniques is key for success.

Efficient induction of antimicrobial activity with vancomycin nanoparticle-loaded poly(trimethylene carbonate) localized drug delivery system.

Surgery and the local placement of an antibiotic are the predominant therapies to treat chronic osteomyelitis. Vancomycin-loaded N-trimethyl chitosan nanoparticles (VCM/TMC NPs) as a potential drug delivery system have high intracellular penetration and effective intracellular antibacterial activity. This study investigated the effects of a biocompatible material, poly(trimethylene carbonate) (PTMC), to increase the sustained effectiveness of an intracellular antibiotic and its potential application in antibiotic delivery. VCM/TMC NP-PTMC was characterized using scanning electron microscopy and Fourier transform infrared spectroscopy to determine the morphology, stability and chemical interaction of the drug with the polymer. Further, the biodegradation, antibacterial activity, protein adsorption, cell proliferation and drug release characteristics were evaluated. In addition, a Staphylococcus aureus-induced osteomyelitis rabbit model was used to investigate the antibiotic activity and bone repair capability of VCM/TMC NP-PTMC. The results showed that the composite beads of VCM/TMC NPs followed a sustained and slow release pattern and had excellent antibacterial activity and a higher protein adsorption and cell proliferation rate than the VCM-PTMC in vitro. Furthermore, VCM/TMC NP-PTMC inhibits bacteria and promotes bone repair in vivo. Thus, VCM/TMC NP-PTMC might be beneficial in periodontal management to reduce the bacterial load at the infection site and promote bone repair.

[Total thigh musculocutaneous flap in reconstruction of refractory pressure ulcers around hips in patients with spinal cord injury].

OBJECTIVE: To discuss the treatment of life-threatening refractory pressure ulcers around hips in patients with spinal cord injuries(SCI)and evaluate its clinical outcomes. METHODS: From March 2012 to June 2015, eight paraplegic patients with life-threatening refractory pressure ulcers around hips were treated with total thigh musculocutaneous flaps following amputation of proximal femurs or hips, including 7 males and 1 female with an average age of (52.0±2.6) years old ranging from 35 to 68. The coures of disease was from 10 months to 7 years with a mean of(2.9±0.2) years. All the 8 patients had compound ulcers of more than two parts, 7 cases had hip infection on the same side. The area of superficial wounds ranged from 3.0 cm×3.0 cm to 12.0 cm×15.0 cm. The clinical effects were evaluated according to infection controlling, wound healing, improving of nutrition and life quality of patients. RESULTS: All patient were followed up for 3 months to 2 years with an average of 1.3 years. All flaps survived, 5 cases obtained wound healing at one-stage, 2 cases had wound dehiscence and the wounds were closed after a second operation, 1 case had partial flap necrosis which was healed by dressing change, 1 case had urethral injury that was repaired in operation. All wounds were cured successfully without infection and ulcer recurrence during the follow-up period. The nutrition and quality of life of all cases improved observably after operation. CONCLUSIONS: The total thigh musculocutaneous flap is effective to reconstruct the refractory pressure ulcers around hip of patient with SCI. It can rescue life at the cost of losing one lower limb. It is an operation of last resort for the patients.

[Surgical treatment for the fractures and dislocations of the elbow in old patients].

OBJECTIVE: To introduce and report the preliminary results of 7 old patients with fractures and dislocations of the elbow. METHODS: From July 2011 to August 2015, 7 old patients suffered from fractures and dislocations of the elbow(5 of which were terrible triad). One patient had type Iradial head fracture, 3 type IIand 1 type III according to the Mason classification, and 1 type I, 5 type IIand 1 type III according to the Regan-Morrey classification. All the 7 patients received operation and then were treated with external fixation. Fractures of the radial head were fixed with Herbert screws or locking plates and screws. Fractures of ulnar coronoid were reduced and fixed with lag screws or K-wires or PDS sutures or locking screws according to the types. The lateral and medial collateral ligaments were also repaired. Plaster external fixation was applied for 3 weeks after operation, in the position with elbow flexion in 90 degrees and forearm rotation in neutral. External fixation braces were used for each patient after the plasters were removed, and at the same time rehabilitation programs were carried out. RESULTS: All the 7 patients were followed up, and the during ranged from 13 to 48 months(averaged, 20 months), with healed fractures, stable elbow and no pain movement. The functional outcome was excellent in 3 patients, good in 3 and fair in 1 according to the Mayo Elbow Performance Score(MEPS). CONCLUSIONS: It is not easy to get stable fixation for fractures and dislocations of the elbow in old patients with osteoporosis and low density of bone, but the operation can achieve satisfied clinical outcomes after external fixation.

[Repairing ankle and foot injuries with perforator-based propeller flaps].

OBJECTIVE: To evaluate clinical effects of repairing ankle and foot injuries with perforator-based propeller flaps. METHODS: From June 2012 to April 2014, 20 patients with soft tissue defects on the foot and ankle were treated by perforator-based propeller flaps, including 14 males and 6 females with an average age of (36.2±4.6) years old ranging from 8 to 64 years. Area of soft tissue defect varied from 5 cm×2 cm to 22 cm×7 cm. The time from injury to operation ranged from 8 to 90 days, with an average of(38.2±6.2) days. AOFAS scoring were applied to evaluate therapeutic effects. RESULTS: All patients were followed up from 6 to 24 months with an average of(13.5±2.2) months. Appearance and quality of flap were good. Operation time was 90 to 210 min, with an average of(120±32) min. Nineteen flaps were survived successfully, the flap edge of 1 case was necrosis and healed after free skin grafting. A good contour was confirmed on the recipient area. The total AOFAS score was(93.1±10.0) at the final following-up, 14 cases obtained excellent results and 6 cases were good. CONCLUSIONS: Perforator-based propeller flaps for ankle and foot injuries has advantages of safe, effectivity and could receive good results.

[Treatment of osteomyelitis and bone defect of femoral shaft by external fixation and bone transport].

OBJECTIVE: To discuss the clinical effects and superiority of applying external fixation and bone transport to treat osteomyelitis and bone defect of femoral bone. METHODS: From August 2008 to December 2013,16 patients with osteomyelitis and bone defect of femoral bone were treated including 11 males and 5 females with an average age of 42 years old ranging from 13 to 62 years old. The average course of disease was 18 months ranging from 2 months to 4.5 years, and the average length of bone defect was 7.8 cm ranging from 4.5 to 15 cm. The bone defect of all cases were treated by external fixation and bone transport, the bone transport began at 1 week after operation, 1 mm per day and 4 times per day. RESULTS: All patients were followed up for 10 to 36 months (means 22.5 months). One patient did not cooperate with treatment leads to the failure, then took the amputation. The remaining 15 cases of osteomyelitis were under control, including 12 cases of bone transport achieved one stage bone union, 3 cases achieved bone union via bone graft from iliac bone. The bone union time was 5 to 13 months(means 7.9 months). Thirteen patients almost obtained the same length of two lower extremities,2 patients had shortening of 1.5 to 2 cm. The time of moving the external fixation was from 6 to 16 months (means 9.3 months). CONCLUSION: Application of external fixation and bone transport is an effective method in treating the osteomyelitis and bone defect that can control the infection, eradicate wounds, and be the equalization of limb length.

[Application of vancomycin-loaded calcium sulphate in treatment of osteomyelitis].

OBJECTIVE: To investigate the role of vancomycin-loaded calcium sulphate in the treatment of osteomyelitis. METHODS: We implanted vancomycin-loaded calcium sulphate into 24 patients with traumatic osteomyelitis who were treated in our hospital from February 2008 to February 2010,and then the antibiotic concentrations in the lesions were measured.Bacterial culture results,inflammatory markers,as well as wound healing were observed.X-ray was performed in the location where the vancomycin-loaded calcium sulphate was implanted.The blood vancomycin level as well as liver and kidney functions were determined. RESULTS: The vancomycin concentration in the lesion exceeded the effective therapeutic concentrations and the minimum inhibitory concentration,while the blood concentration was low.The liver and renal function remained normal.The safety profile was good,and the cure rate of osteomyelitis reached 100%. CONCLUSIONS: The vancomycin-loaded calcium sulphate can release high-concentration vancomycin in the diseased sites without causing high blood concentration.Also,it can guide the regeneration of bones.Therefore,it is effective and safe in treating osteomyelitis.

[Study of feature extraction methods for maize's near infrared spectra in biomimetic pattern recognition].

Near infrared spectrum is an important step in near infrared spectrum qualitative analysis, which influences the qualitative analysis results directly. Diffuse transmittance measurements mode was used to collect spectral data of eight maize varieties. PCA, ICA, PLS-DA and wavelet transformation were used to extract features of pretreated data. Finally, we used the test set data to test the recognition models of eight maize varieties which were built based on biomimetic pattern recognition (BPR). We draw a conclusion that PLS-DA can make models get higher average correct recognition rate than PCA, ICA and Wavelet transformation.

[Application of damage control in severe traumatic limb salvage].

OBJECTIVE: To investigate the importance of damage control in limb salvage in severe trauma. METHODS: A retrospective analysis of 14 patients with severe limb trauma was performed from June 2007 to December 2009. There are 13 males and 1 female,ranging in age from 6 to 62 years with an average of 38.4 years. According to the Tscherne's classification about soft tissue injury, 10 cases were type Fr.O III, 2 cases were type Fr.O IV, and 2 cases were type Fr.C II. All the patients received the first operation in our hospital. In the first stage, all the patients received debridemen directed by damage control after the situation was evaluated. The broken arteries were anastomosed, bone fractures were fixed with external fixation, wound were covered with the application of VSD. In the second stage, the soft tissue defect was reconstructed, and the plate fixation of unstable fracture was performed. RESULTS: The patients were followed up, and the duration ranged from 6 to 19 months. All limbs were salvaged successfully with two-stage operations,except one Fr.O IV fracture reveived the third operation. No osteomyelitis occurred, and the functions of the salvaged limbs were satisfied. Two patients had non-union at 9 month later, and were cured after re-debridement and bone replantation. The time of fracture union ranged from 5 to 15 months. CONCLUSION: Severe traumatic limbs always have high rate of infection and extremity disability because the severe injury of soft tissue. The application of damage control can reduce the further injury of soft tissue, which is better for the success of limb salvage.