Does a novel 3D printed individualized guiding template based on cutaneous fiducial markers contribute to accurate percutaneous insertion of pelvic screws? A preliminary phantom and cadaver study.

BACKGROUND: Most 3D-printed guiding templates require dissection of soft tissues to match the corresponding surfaces of the guiding templates. This study sought to explore the accuracy and acceptability of the novel 3D printed individualized guiding templates based on cutaneous fiducial markers in minimally invasive screw placement for pelvic fractures. METHODS: The printed template was tested on five high-fidelity biomimetic phantom models of the bony pelvis and its surrounding soft tissues as well as on two fresh frozen cadavers. Four cutaneous fiducial markers were transfixed on each phantom model prior to performing CT scans to reconstruct their 3D models. Personalized templates for guiding screw insertion were designed based on the positions of the fiducial markers and virtually planned target screw channels after scanning, followed by 3D printing of the guide. Phase 1 consisted of five expert surgeons inserting one anterograde supra-pubic screw and one sacroiliac screw percutaneously into each phantom model using the 3D-printed guide. The deviation of screw positions between the pre-operative planned and post-operative actual ones was measured after registering their 3D modelling. A Likert scale questionnaire was completed by the expert surgeons to assess their satisfaction and acceptability with the guiding template. Phase 2 consisted of repeating the same procedures on the fresh frozen cadavers in order to demonstrate face, content and concurrent validity. RESULTS: In Phase 1, all ten screws were successfully implanted with the assistance of the guiding template. Postoperative CT scans confirmed that all screws were safely positioned within the bony pelvic channels without breaching the far cortex. The mean longitudinal deviation at the bony entry point and screw tip between the pre-operative planned and post-operative actual screw paths were 2.83 ± 0.60 mm and 3.12 ± 0.81 mm respectively, with a mean angular deviation of 1.25 ± 0.41°. Results from the Likert questionnaire indicated a high level of satisfaction for using the guiding template among surgeons. In Phase 2, results were similar to those in Phase 1. CONCLUSIONS: The 3D-printed guiding template based on cutaneous fiducial markers shows potential for assisting in the accurate insertion of percutaneous screws in the pelvis.

Use of minimally invasive cerclage wiring for displaced major fragments of femoral shaft fractures after intramedullary nailing promotes bone union and a functional outcome.

BACKGROUND: Femoral shaft fractures caused by high energy trauma can be very challenging due to the large variability in fracture morphology and poor functional outcomes. Displaced major fragments of femoral shaft fractures are difficult to manage after closed reduction and intramedullary nailing (IMN). The minimally invasive cerclage wiring (CW) procedure has become an optimal tool for major fragment resetting and stabilization after IMN. However, arguments continue for the potential risk of arterial injury, blood supply disruption, and delayed bone union or non-union with the CW procedure. The surgical algorithm for treating femoral shaft fractures with displaced major fragments remains controversial. Thus, emphasis is placed on whether the CW procedure can promote the bone union rate and improve functional outcomes without significant complications. METHODS: We performed a retrospective study on all patients of femoral shaft fractures with displaced major fragments between June 2015 and August 2019 in our trauma centre. Eligible patients were included and stratified into the CW group and IMN group. Demographics, radiological data, callus formation, union time, and functional outcomes were critically compared between the two groups. RESULTS: Thirty-seven patients were included in the present study according to our inclusion/exclusion criteria, of whom 16 (43.2%) were stratified into the CW group, and 21 (56.8%) into the IMN group. The modified radiographic union score for femorae (mRUSH) in the CW group and IMN group was significantly different (11.94 ± 1.29 vs. 7.95 ± 0.74, 6 months; 15.88 ± 0.50 vs. 10.33 ± 0.91, 12 months) (p < 0.0001). The mean union time was significantly different between the CW and IMN groups (7.9 ± 3.2 months vs. 20.1 ± 8.48 months) (p < 0.0001). Bone union at 12 months differed significantly between the CW and IMN groups (15 vs. 5) (p < 0.05). The Harris Hip Score in the CW group was significantly higher than that in the IMN group (88.19 ± 4.69 vs. 76.81 ± 5.26, 12 months; 93.19 ± 4.68 vs. 87.57 ± 5.38, 24 months) (p < 0.01). The Hospital for Special Surgery Knee Score was significantly different between the CW and IMN groups (78.50 ± 5.65 vs. 67.71 ± 4.65, 12 months; 89.50 ± 5.05 vs. 75.81 ± 8.90, 24 months) (p < 0.0001). CONCLUSIONS: Minimally invasive CW is an optimal supplement for IMN in the treatment of femoral shaft fractures with displaced major fragments. As illustrated, the benefits of CW potentially include promotion of the bone union rate and improvement in functional outcomes.

A novel Patient-Specific Three-Dimensional Printing Template Based on External Fixation for Pelvic Screw Insertion.

PURPOSE: To investigate the clinical effect of novel patient-specific 3D printing templates based on external fixation for pelvic screw insertion compared with the fluoro-navigation technique. MATERIALS AND METHODS: We retrospectively studied 18 pelvic fracture patients from July 2017 to July 2018. For analysis, patients were divided into two groups: the template group (15 screws in 8 patients) and the fluoro-navigation group (22 screws in 10 patients). The screw insertion time, radiation exposure time, and accuracy of the screw insertion as evaluated by postoperative CT scans were analyzed. RESULTS: In the template group, the average screw insertion time (11.5 ± 2.3 min/screw) was significantly 50.6% less than that in the fluoro-navigation group (23.3 ± 3.1 min/screw; P < 0.05). The average time of X-ray exposure in the template group (11.5 ± 3.9 s/screw) was also significantly 39.8% less than in the fluoro-navigation group (19.1 ± 2.5 s/screw; P < 0.05). In the template group, the mean deviation distance and angle between the actual and planned screw position was 2.6 ± 0.2 mm and 2 ± 0.3°. CONCLUSIONS: The patient-specific template based on external fixation can guide the insertion of the pelvic screw accurately and safely while significantly reducing operation and radiation exposure time.

Human umbilical cord mesenchymal stem cell-derived exosomes inhibit migration and invasion of breast cancer cells via miR-21-5p/ZNF367 pathway.

BACKGROUND: Human umbilical cord mesenchymal stem cell-derived exosomes (hucMSC-exos) exhibit various roles in breast cancer development. The molecular mechanisms underlying hucMSC-exos in breast cancer cells are not fully clear. In the current study, we set out to investigate the downstream signaling pathways of hucMSC-exos in MCF-7 cells, a commonly used cell line to study breast cancer. METHODS: hucMSC-exos' effects on MCF-7 cells were examined using immunocytochemistry. An inhibitor and a mimic of miR-21-5p were administered. The mRNA and protein levels of ZNF367 were analyzed using real-time quantitative reverse transcription PCR (qRT-PCR)and western blotting. Transwell assays were used to measure invasion and migration. Dual-luciferase assays were performed to investigate the binding sites between miR-21-5p and ZNF367. To manipulate expression, an overexpressing of ZNF367 approach was utilized. RESULTS: We confirmed that hucMSC-exos can be internalized by MCF-7 cells. hucMSC-exos dramatically inhibited migration and invasion behaviors through downregulation of ZNF367 and upregulation of miR-21-5p. miR-21-5p directly binds on 3'UTR of ZNF367. miR-21-5p mimic partially abolished overexpressed ZNF367-induced migration and invasion. In breast cancer tissues, there was a negative correlation between miR-21-5p and ZNF367 levels. The similar results were also obtained in human breast cancer MDA-MB-231 cells. CONCLUSION: husMSC-exos are anti-oncogenic in MCS-7 cells. husMSC-exos suppress ZNF367 expression and promote miR-21-5p expression. miR-21-5p opposes ZNF367's actions during breast cancer development. miR-21-5p direct binds ZNF367 3'UTR to inhibit ZNF367 expression. The interaction between miR-21-5p and ZNF367 may serve as a future therapeutic approach to improve breast cancer prognosis.

A biomechanical matched-pair comparison of two different locking plates for tibial diaphyseal comminuted fracture: carbon fiber-reinforced poly-ether-ether-ketone (CF-PEEK) versus titanium plates.

BACKGROUND: Several methods have been proposed to reduce plate construct stiffness and promote secondary bone healing. In this study, we explored the stiffness and strength of the new carbon fiber-reinforced poly-ether-ether-ketone (CF 50) plate compared with the titanium alloy plate (Ti6Al4V). METHODS: Titanium and CF-PEEK locking plates were tested in a tibial non-osteoporotic diaphyseal comminuted fracture model to determine construct stiffness in axial compression, torsion, and bending. Subsequently, constructs were loaded until construct failure to determine construct strength. RESULTS: Relative to the titanium locking plate, the stiffness of the CF-PEEK locking plate was 6.8% and 30.8% lower in 200 N and 700 N axial compression, respectively (P < 0.05), 64.9% lower in torsion (P < 0.05), and 48.9% lower in bending (P < 0.05). The strength of the CF-PEEK locking plate was only 2.6% lower under axial compression, 7.8% lower in torsion, and 4.8% lower in bending than the titanium locking plate (P > 0.05). CONCLUSIONS: The CF-PEEK locking plate significantly reduced axial, torsion, and bending stiffness compared with the titanium locking plate. Nonetheless, axial, torsional, and bending strength showed only a modest reduction. Considering its other advantages, which include radiolucency and artifact-free imaging, the CF-PEEK locking plate therefore deserves further clinical investigation.

Clinical outcomes of blood transfusion to patients with pelvic fracture in the initial 6 h from injury.

As part of the treatment of pelvic fracture, major hemorrhage poses a challenge for trauma surgeons. The aim of the present study was to evaluate the clinical outcomes of blood transfusion in the initial 6 h after pelvic fracture, and to define the blood transfusion volume required for each pelvic fracture type. A retrospective cohort study was performed on patients with pelvic fracture at a single Level I Trauma Centre over a 3-year period. A total of 1,297 patients were transported to our trauma centre within 2 h of injury and blood transfusion was administered in the initial 6 h after pelvic fracture. Review of the patients' medical records provided the initial pelvic radiographs and data from emergency department care. Clinical outcomes, including frequency of blood transfusion, blood transfusion volume, injury severity scores and mortality, were evaluated. All pelvic fractures were defined as closed fractures and patients were categorized according to the Arbeit fuer Osteosynthese (AO) classification system. Statistical methods were used to identify trends to provide guidance for clinical prediction. Complete data were available for 497 patients with pelvic fracture, 104 (20.9%) of which received blood transfusion. The blood transfusion volume in the initial 6 h ranged from 0 to 10,000 ml, with a mean of 1,213.94±1354.11 ml. The total mortality rate was 1.8%. Among the patients with C-type pelvic fractures, the frequency of blood transfusion was 59.0% and the mean volume was 2,191.30±1,740.93 ml. The mortality rate for C-type pelvic fractures was 11.43%. The B3 subtype of pelvic fractures had the highest transfusion frequency (53.6%), while the C3 subtype had the largest blood transfusion volume (5,700.00±4,666.90 ml). Patients with type A-C pelvic fractures had a progressively larger mean transfusion volume, transfusion frequency and mortality in the initial 6 h after pelvic fracture. The AO classification system was demonstrated to be a useful tool for the identification of pelvic fracture risk in the present study.

External fixation combined with delayed internal fixation in treatment of tibial plateau fractures with dislocation.

The aim of this study was to evaluate the clinical efficacy of external fixation, delayed open reduction, and internal fixation in treating tibial plateau fracture with dislocation.Clinical data of 34 patients diagnosed with tibial plateau fracture complicated with dislocation between January 2009 and May 2015 were retrospectively analyzed. Fifteen patients in group A underwent early calcaneus traction combined with open reduction and internal fixation and 19 in group B received early external fixation combined with delayed open reduction and internal fixation. Operation time, postoperative complication, bone healing time, knee joint range of motion, initial weight-bearing time, Rasmussen tibial plateau score, and knee function score (HSS) were statistically compared between 2 groups.The mean follow-up time was 18.6 months (range: 5-24 months). The mean operation time in group A was 96 minutes, significantly longer than 71 minutes in group B (P < .05). In group A, 5 cases had postoperative complications and 1 in group B (P < .05). The mean bone healing time in group A was 6.9 months (range: 5-9 months) and 6.0 months (range: 5-8 months) in group B (P > .05). In group A, initial weight-bearing time in group A was (14.0 ±â€Š3.6) weeks, significantly differing from (12.9 ±â€Š2.8) weeks in group B (P < 0.05). In group A, the mean knee joint range of motion was 122° (range: 95°-150°) and 135° (range: 100°-160°) in group B (P > 0.05). Rasmussen tibial plateau score in group A was slightly lower than that in group B (P > .05). The excellent rate of knee joint function in group A was 80% and 84.21% in group B (P > .05).External fixation combined with delayed open reduction and internal fixation is a safer and more efficacious therapy of tibial plateau fracture complicated with dislocation compared with early calcaneus traction and open reduction and internal fixation.