Technical note: Intraoperative ultrasound measurement for evaluating the stability of the inferior tibiofibular joint in patients with ankle fractures.

OBJECTIVES: Injury to the tibiofibular syndesmosis is a common complication of ankle fractures. Currently, it is challenging to determine the stability of the tibiofibular joint caused by ankle fractures during surgery. This study aims to establish a standardized method for dynamically evaluating the stability of the inferior tibiofibular joint under intraoperative ultrasound and assess its utility in surgery, thereby assisting in determining the necessity for fixation of the inferior tibiofibular joint after fracture reduction and fixation. METHODS: The stability of the inferior tibiofibular joint was assessed using an intraoperative ultrasonic external rotation stress test, with a torque set at 7.2 N·m. The measured parameters included the width of the inferior tibiofibular space in neutral (N) and external rotation (E) positions, stretch ratio (E/N), and injured/healthy side stretch ratio (I/H). Patients with Weber B or C type ankle fractures were selected as participants. RESULTS: For the case with Weber C fracture, the N measurement was 4.22 mm after fracture fixation, while E measured 5.77 mm and E/N ratio was 1.37, which were larger than those on the healthy side (N: 4.17, E: 4.50, E/N:1.08), with an I/H ratio of 1.27. Intraoperative X-ray revealed instability of the inferior tibiofibular joint. After inserting a tibiofibular screw, the N measurement was 4.20 mm, while the E measurement recorded 4.32 mm, resulting in an E/N ratio of 1.03 and an I/H ratio of 0.95, indicating improved joint stability. For the Weber B fracture case, the N measurement was 3.55 mm after fracture fixation, while E measured 3.98 mm and the E/N ratio was 1.12, slightly lower than those on the healthy side (N: 3.94, E: 4.47, E/N: 1.13), with an I/H ratio of 0.99. The intraoperative X-ray revealed stability of the inferior tibiofibular joint. Therefore, no further fixation was performed on it. CONCLUSION: Standardized intraoperative ultrasound stress test allows for real-time, dynamic assessment of the stability of the inferior tibiofibular joint after ankle fracture reduction and fixation, which can help guide the fixation of the inferior tibiofibular joint, thereby reducing the risk of postoperative traumatic arthritis.

Ezetimibe attenuates functional impairment via inhibition of oxidative stress and inflammation in traumatic spinal cord injury.

Sustained inflammation after a traumatic spinal cord injury (TSCI) triggers oxidative stress and neuronal apoptosis, hindering functional recovery. Ezetimibe (EZE) has been reported to have anti-inflammatory and antioxidative properties in hepatology-related diseases, but its potential role in SCI remains unclear. In this study, we evaluated the therapeutic effect of EZE on inflammatory microglia and in an SCI model and elucidated the underlying mechanism. First, we stimulated the BV2 microglia cell line with LPS, and we also induced moderate spinal cord injuries in adult male C57BL/6 mice. Both the cells and mice were treated with EZE, and we investigated inflammation, oxidative stress, neurologic damage, and motor function in vitro and in vivo, respectively. Our findings demonstrated that EZE administration attenuates inflammation in microglia by regulating the AMPK/Nrf2 axis. Furthermore, EZE treatment reduced inflammation and oxidative stress levels in the injured spinal cord. Additionally, treatment with EZE decreased glial scarring and improved motor function recovery, indicating the protective role of EZE in SCI. EZE was found to have anti-inflammatory and antioxidative effects on SCI, and it modulated the AMPK/Nrf2 pathway in microglia. Moreover, EZE prevented histological destruction of the spinal cord tissue. In conclusion, EZE shows promise as a drug to protect neurologic integrity following post-SCI.

[Retrograde muscle release method in treatment of mild to moderate ischemic muscle contracture of forearm].

OBJECTIVE: To investigate the effectiveness of retrograde muscle release in treatment of mild to moderate type ischemic muscle contracture of forearm classified by Tsuge. METHODS: Between March 2010 and September 2018, 11 patients with mild to moderate ischemic muscle contracture of forearm were treated with retrograde muscle release. There were 6 males and 5 females with an average age of 24 years (range, 16-29 years). According to Tsuge classification, 6 cases were mild type and 5 cases were moderate type. The interval between injury and operation was 9 months to 25 years, with a median of 17 years. The scar cords in the muscle of the middle one-third of the forearm was released firstly. If the standard of sufficient release was not reached, further releasing the scar cords in the muscle and the tense tendon structure in the proximal one-third of the forearm and the origins of the flexor muscles was necessary. If the standard was still not reached, the origins of the flexor muscles can be released and slid. The effectiveness was evaluated from six aspects of the range of motion of the hand and wrist, dexterity, grip strength, sensation, subjective function scores [quick-disability of the arm, shoulder, and hand questionnaire (Quick-DASH) and the patient-related wrist/hand evaluation (PRWHE)] and satisfaction. RESULTS: All the incisions healed by first intention. Eight patients were followed up 1-106 months (median, 13 months). The range of motion of the hand and wrist was significantly improved, the results were excellent in 3 cases, good in 3 cases, and fair in 2 cases, with an excellent and good rate of 75%. The patient's dexterity evaluation scored a perfect score of 12, which was close to the normal hand dexterity. At last follow-up, the grip strength on the affected side was 37.6%-95.5% of the contralateral side, with an average of 77.6%. Seven patients had normal sensation before and after operation, and the two-point discrimination of median nerve and ulnar nerve was 4-5 mm at last follow-up; 1 patient with forearm mechanical crush injury still felt numb after operation, and the two-point discrimination of median nerve and ulnar nerve was 8 mm and 7 mm, respectively. The Quick-DASH score was 0-15.9, with an average of 4.5, and the PRWHE score was 0-23.0, with an average of 6.6. All the patients were satisfied with the surgery and the effectiveness. CONCLUSION: A targeted retrograde muscle release method for mild to moderate type ischemic contracture of forearm can achieve satisfactory effectiveness.

Comparison of oral versus intravenous tranexamic acid in total knee and hip arthroplasty: A GRADE analysis and meta-analysis.

BACKGROUND: The efficacy and safety of oral tranexamic acid (TXA) remain controversial because of the small number of clinical studies. The aim of the present study was to compare the efficacy and safety of oral TXA with intravenous TXA in patients undergoing total hip arthroplasty and total knee arthroplasty in a systematic review and meta-analysis. METHODS: We conducted a meta-analysis to identify randomized controlled trials (RCTs) involving oral and intravenous TXA in total hip arthroplasty and total knee arthroplasty up to December 2019 by searching databases including PubMed, Web of Science, Embase, the Cochrane Controlled Trials Register, the Cochrane Library China Biology Medicine, China National Knowledge Infrastructure, China Science and Technology Journal Database and Wanfang. The mean difference or standard mean difference was used to assess continuous outcomes such as hemoglobin (Hb) drop, total blood loss, drain blood loss, and length of hospital stay, with a 95% confidence interval. Relative risks with a 95% confidence interval were used to assess dichotomous outcomes such as transfusion rate and the incidence of deep venous thrombosis and calf muscular vein thrombosis. Review Manager was used for the meta-analysis. RESULTS: Ten RCTs containing 1080 participants met the inclusion criteria. We found no significant differences in terms of the average Hb drop (P = .60), total blood loss (P = .60), transfusion rate (P = .99), drain blood loss (P = .91), length of hospital stay (P = .95), and the incidence of deep venous thrombosis (P = .55) and calf muscular vein thrombosis (P = .19) between oral and IV TXA. CONCLUSIONS: Compared with the IV TXA, oral TXA has similar effects on reducing the Hb drop, total blood loss, transfusion rate, drain blood loss, and length of hospital stay without increasing the risk of calf muscular vein thrombosis and deep venous thrombosis. Furthermore, oral TXA is easy to access and administer, which decreases the workload of nurses and even delivers cost-saving benefits to the health care system. We thus conclude that oral TXA may be an optimal approach in total joint arthroplasty. However, more high-quality and multicenter RCTs are still needed to confirm our conclusions. REGISTRATION: The current meta-analysis was registered on PROSPERO (International Prospective Register of Systematic Reviews), and the registration number was CRD42018111291.

The rs6427384 and rs6692977 Single Nucleotide Polymorphisms of the Fc Receptor-Like 5 (FCRL5) Gene and the Risk of Ankylosing Spondylitis: A Case Control Study in a Single Center in China.

BACKGROUND The study aimed to explore the genetic association of Fc receptor-like 5 (FCRL5) gene variants (rs6427384 and rs6692977) with ankylosing spondylitis risk in Chinese Han population. MATERIAL AND METHODS Genotyping for FCRL5 gene variations rs6427384 and rs6692977 was implemented among 130 ankylosing spondylitis cases and 135 healthy persons, through polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) method. Frequency dissimilarity for 2 polymorphisms was compared between 2 groups using chi-square test. The association strength of FCRL5 gene polymorphism with ankylosing spondylitis risk was estimated by odds ratios with 95% confidence intervals. RESULTS The frequencies of rs6427384 CC genotype and C allele were significantly lower in the case group than that in the control group (P<0.05), which suggested that C allele of rs6427384 polymorphism might offer protection against ankylosing spondylitis onset. Whereas only 2 genotypes of rs6692977 were detected in the control group, and no significant association was found with ankylosing spondylitis susceptibility. CONCLUSIONS FCRL5 gene polymorphism rs6427384 was correlated to ankylosing spondylitis occurrence among Chinese Han population, while rs6692977 was not.

RUNX3 Polymorphisms Affect the Risk of Ankylosing Spondylitis.

BACKGROUND We aimed to assess the potential association of runt-related transcription factor 3 (RUNX3) gene variants with ankylosing spondylitis (AS) susceptibility among Chinese Han people. MATERIAL AND METHODS Genotyping for RUNX3 variants was accomplished through polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) in 115 AS patients and 102 healthy controls. Genotypes distributions of the polymorphisms in controls was assessed for their deviation from Hardy-Weinberg equilibrium (HWE). Moreover, odds ratio (OR) with 95% confidence interval (95%CI) was achieved using chi-square analysis to evaluate AS risk related to RUNX3 polymorphisms. Additionally, logistic regression analysis produced adjusted OR values. RESULTS Genotypes distribution of rs760805 and rs11249206 polymorphisms conformed to HWE in the control group (P>0.05). TT genotype of rs760805 appeared more frequently among AS cases than in controls (P=0.033), indicating its significant association with increased risk of AS onset (OR=2.309, 95%CI=1.069-4.892). The carriage of T allele in rs760805 also heightened AS incidence, in comparison to A allele (OR=1.578, 95%CI=1.075-2.316, P=0.020). Moreover, the carriage of AT+TT genotype in rs760805 and TT genotype in rs11249206 obviously increased risk of AS onset (OR=2.585, 95%CI=1.062-6.288). CONCLUSIONS RUNX3 rs760805 polymorphism can contribute to AS incidence in Chinese Han people. The interaction of the 2 polymorphisms may be a risk factor for AS.

Resorption of Iliac Bone Grafts Following Wrap-Around Flap for Thumb Reconstruction: A Follow-Up Study.

PURPOSE: To study the bone resorption pattern of iliac crest grafts after thumb reconstruction with a wrap-around flap from the hallux. METHODS: Patients who underwent thumb reconstruction with a wrap-around flap from the hallux were followed up. We measured the length, proximal, middle, and distal widths, and proximal, middle, and distal thicknesses of the iliac crest grafts on posteroanterior and lateral radiographs and used the length, width, and thickness ratios of the iliac grafts and the first metacarpal bones to calculate the amount of bone resorption. Data from 2 groups reconstructed with or without a terminal tuft were analyzed. RESULTS: Fifteen patients were followed for an average of 20 months (range, 14-72 months). Bone resorption occurred in all 3 measured dimensions in all patients and the degree of resorption increased with time. Resorption amounts of the length dimension in the group with a terminal tuft was significantly decreased compared with those in the group without a terminal tuft at 6 months, 12 months, and the last follow-up. The resorption amount of the width dimension of the distal portion was significantly less in the group with a terminal tuft at the last follow-up. The resorption amount of the thickness dimension of the distal portion was significantly lower in the group with a terminal tuft at 12 months and at the last follow-up. CONCLUSIONS: Bone resorption occurred in all dimensions of the graft after thumb reconstruction using a wrap-around flap from the hallux. Flaps including the terminal tuft had less bone resorption in the distal portion. Wrap-around toe flaps should only be used in cases of thumb amputations at the middle of the proximal phalanx and distal, and the terminal tuft should be preserved in the flap; fixation with a plate should be avoided. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Combined antibacterial and osteogenic in situ effects of a bifunctional titanium alloy with nanoscale hydroxyapatite coating.

To resolve the problems of bacterial infections and the low efficiency of osteogenesis of implanted titanium alloys in clinical dental and bone therapy, we developed a bifunctional titanium alloy (Ti) with a nano-hydroxyapatite (HA) coating (HBD + BMP/HA-Ti), which enables the sustained release of the natural antimicrobial peptide human ß-defensin 3 (HBD-3) and bone morphogenetic protein-2 (BMP-2). Due to the poriferous nano-sized structure of the HA coating with a 20-30 µm thickness, the HBD + BMP/HA-Ti material had a high encapsulation efficiency (>74%) and exhibited synchronized slow release of HBD-3 and BMP-2. In an antibacterial test, HBD + BMP/HA-Ti prevented the growth of bacteria in an inoculated medium, and its surface remained free from viable bacteria after a continuous incubation with Gram-negative and Gram-positive strains for 7 days. Furthermore, good adhesion, proliferation and osteogenic differentiation of hBMSCs in contact with HBD + BMP/HA-Ti were achieved in 7 days. Therefore, the bifunctional titanium alloy HBD + BMP/HA-Ti has a great potential for eventual applications in the protection of implants against bacteria in the orthopaedic and dental clinic.

Prone positioning for intramedullary nailing of subtrochanteric fractrures, the techniques of intraoperative fluoroscopy and reduction: A technique note.

The treatment of subtrochanteric fractures is a challenge for orthopaedic trauma surgeons. Three positions have been described previously: supine on a fracture table, supine on a flat radiolucent table, and the lateral decubitus position on a flat radiolucent table. Each one has its advantages and limitations. In this article we describe a prone position for intramedullary nailing of subtrochanteric femoral fractures. This position has the advantages including: 1) an easy approach to reduce and maintain the reduction of fracture by adjusting only the leg plate on injured side, 2) perfect intraoperation fluoroscopic imaging on both anteroposterior view and lateral view, and 3) an easy approach to establish an appropriate entry point even in obese patients.

Preservation of Devitalized Bone in Necrotic Digits Following Crush Injury With Free Tissue Transfer.

Traditional management of necrotic digits has been to allow demarcation between viable and nonviable tissues to occur, and thus to indicate the level of amputation required. In this case report, the phalangeal length of the necrotic thumb was maintained in 2 patients who had sustained crush injury. After nonviable soft tissues were debrided, the devitalized bones were covered with soft tissue flaps. All wounds healed without infection. Both cosmetic and functional results of the reconstructed thumbs were satisfactory. In one patient, radiographs of the thumb demonstrated resorption of the distal phalanx, but this did not impede daily use. This experience supports an earlier observation suggesting that devitalized bone can be covered for salvage in some cases.

Measurement of the Shift in the Distal Radioulnar Joint Using a Custom Platform.

Diagnosis of subluxation and dislocation of the distal radioulnar joint (DRUJ) is difficult. In order to measure the shift between radius and ulna, we evaluate a method with a custom platform in this study. Cadaver specimen was fixed on a custom platform, and the volar and dorsal translation of the ulnar head was measured under different stress forces. We built a subluxation model via a surgical procedure that removed components of the radioulnar joint, and the translation at varying stress levels was measured again. We find at the same stress level, the normal model results in significantly less translation than the subluxation model at the majority of the stress forces, and particularly with volar forces. Our results indicate that this measurement is a potential method to evaluate the stability of the DRUJ.

[Immunogenicity of allogeneic freezing periosteum and bone marrow].

OBJECTIVE: To investigate the immunogenicity of freezing periosteum and bone marrow during allogeneic joint transplantation, and to explore proper pretreatment of allogeneic joint. METHODS: The allogeneic periosteum and bone marrow were harvested from knee joints of 5 New Zealand white rabbits (aged, 6 months; weighing, 2.6-3.0 kg). After gradient cooling, the tissue was cryopreserved for 1 month. The freezing periosteum and bone marrow were grinded to pieces after rewarming to prepare the suspension of periosteum and bone marrow. Eighteen Chinchilla rabbits (aged, 6 months; weighing, 2.1-2.8 kg) were divided into 3 groups randomly: normal saline injection group (group A, n = 6), periosteum injection group (group B, n = 6), and bone marrow injection group (group C, n=6). The normal saline, periosteum suspension, and bone marrow suspension were injected into the peritoneal cavity in groups A, B, and C, respectively. The concentrations of interleukin 2 (IL-2), IL-6, and tumor necrosis factor alpha (TNF-alpha) in serum and the ratio of CD4' T cell/CD8+ T cell in venous blood were measured before injection, at 1 week and 2 weeks after injection. RESULTS: There was no significant difference in the concentration of IL-2 between before and after injection in the same group (P=0.241), and between groups (P = 0.055). The concentration of IL-6 after injection was significantly lower than that before injection in the same group (P = 0.040), but no significant difference was found between groups (P = 0.357). The concentration of TNF-a showed no significant difference between before and after injection in the same group (P = 0.925), but the concentration of TNF-a in group B was significantly higher than that in groups A and C (P < 0.05). The ratio of CD4+ T cell/CD8+ T cell of venous blood had no significant difference between before and after operation in the same group (P = 0.248), and between groups (P=0.646). CONCLUSION: The freezing periosteum and bone marrow are lowly immunogenic. In order to decrease the immunogenicity of the joint, preserving the periosteum and removing the marrow cavity are recommended.

[Experimental study on protective effect of early motion on articular cartilage after joint allograft].

OBJECTIVE: To investigate the protective effect of early motion on articular cartilage after joint allograft by performing a controlled trial between different post-operation strategies after joint allograft in an animal model. METHODS: Twenty hemi-knee joints were harvested from 10 6-month-old New Zealand white rabbits (male or female, weighing 2.5-3.0 kg); 10 hemi-knee joints by deep frozen treatment (donors) were transplanted to unilateral knee joints (recipients) of 10 6-month-old Chinchilla rabbits (male or female, weighing 2.5-3.0 kg), which were divided into early motion group (n = 5) and sustained fixation group (n = 5); and 10 hemi-knee joints were used as blank control (n = 5) and frozen control (n = 5). The articular cartilage of allogenic joints was detected by X-ray film, gross, and histology at 6 weeks after operation. RESULTS: Gross observation: no obvious limitation of joint movements was observed in early motion group, but obvious limitation in sustained fixation group. X-ray films: the bone ends between donor and recipient healed well with good para position and alignment on the operation day and 2 weeks after operation; at 6 weeks, angulation deformity was observed in early motion group of 3 rabbits, and para position and alignment were satisfactory in sustained fixation group. Histological observation: HE staining showed that the chondrocytes had normal quantity and morphology with few nuclear fragmentation and karyolysis in early motion group, but the quantity of chondrocytes sharply decreased with dissolved nuclei and numerous fibrous tissues in the cartilage matrix in sustained fixation group. The cell survival rate of the early motion group (49.66% +/- 2.15%) was significantly higher than that of the sustained fixation group (20.68% +/- 1.24%) (P < 0.05). Scanning electron microscopy observation: nuclear membrane was intact with chromatin condensation and edema of mitochondria and rough surfaced endoplasmic reticulum in early motion group, and that the membrane of chondrocyte vanished with blurring border between chondrocyte and matrix, rupture of nuclear membrane and the disappearance of chromatin and organelles could be found in sustained fixation group. CONCLUSION: Early motion has protective effect on articular cartilage after joint allograft, but cannot completely prevent degeneration of the allogenic articular cartilage.

[Analysis of reasons of tendon adhesion post tendon allograft].

OBJECTIVE: To explore the reasons of tendon adhesions post tendon allograft. METHODS: From May 1990 to June 2000, 85 cases receiving tendon allograft were given tenolysis because of tendon adhesions. There were 76 males and 9 females, with an average age of 24.5 years (8-46 years). Injury was caused by machine in 38 cases, electric in 32 cases, cut in 4 cases, explosion in 4 cases and extremity mutilation in 7 cases; including 66 cases of flexor tendon deficit and 19 cases of extensor tendon deficit. Six cases had 1 tendon deficit, 79 cases had tendon deficit of more than 2. The defect region ranged from I to V. The total mobility of the joint was less than 220 degrees in 73 cases. The impairment of skin, bone, nerve and vascular were treated before tendon allograft. RESULTS: Because TAM was less than 50% of TPM, the patients were given tenolysis 4-15 months after operation. And the mobilization began at the first day after operation to improve the range of active movement. Patients were followed up 7-17 years (mean 12.7 years). TAM and TPM were in accord. Mean total mobility of joint was 200 degrees. CONCLUSION: The serious of primary hurt is the important factors of tendon adhesion. Improvement of tendon selected, treatment and early mobilization can relieve the tendon adhesion.