Bony Hypertrophy in Vascularized Fibular Grafts

Background: Vascularized fibula graft (VFG) transfer is an established method of repairing large skeletal defects resulting from trauma, tumor resection, or infection. It obviates the process of creeping substitution that conventional bone grafts undergo and therefore exhibits better healing and improved strength. The aim of this study is to evaluate hypertrophy in VFG. Methods: We retrospectively reviewed patients undergoing VFG and studied immediate and late postoperative radiographs. Orthogonal views were measured for width of graft cortex and intramedullary canal, as well as adjacent recipient bone. Changes were measured for total cross sectional area, cortical area, intramedullary area, and graft width. Results: Thirty patients were included in the analysis, with recipient sites including 3 forearm, 4 humerus, 12 tibia, and 11 femur. Mean follow-up was 7.6 years (0.5-24.9 years). Patients' mean age was 31 (16-59 years). Average hypertrophy was 254% in early postoperative period and 340% in the late postoperative period. There was rapid graft hypertrophy in early postoperative period that plateaued with time. The width of the graft increased over time but didn't exceed the width of the adjacent recipient bone. In the later postoperative period, the size of graft intramedullary canal increased. Upper and lower extremity grafts showed similar hypertrophy. Conclusions: Using VFG to treat large skeletal defects is an attractive option in part due to the graft's ability to hypertrophy. We describe an early period of periosteal hypertrophy, followed by endosteal hypertrophy. These processes have relevance to function, mechanical strength, and surgical decision-making.

Naringin inhibits titanium particles-induced up-regulation of TNF-α and IL-6 via the p38 MAPK pathway in fibroblasts from hip periprosthetic membrane

AIMS

Inflammatory responses to wear debris cause osteolysis that leads to aseptic loosening and hip arthroplasty failure. Wear debris stimulate macrophages and fibroblasts to secret proinflammatory cytokines, including TNF-α and IL-6, which have been specifically implicated in periprosthetic osteolysis and osteoclast differentiation. Naringin has anti-inflammatory effect in macrophages. Moreover, naringin inhibited osteoclastogenesis and wear particles-induced osteolysis. In this study, we examined the potential inhibitory effects of naringin on titanium (Ti) particle-induced proinflammatory cytokines secretion in fibroblasts and the possible underlying molecular mechanisms.

MATERIALS AND METHODS

Fibroblasts were isolated from periprosthetic membrane at the time of revision surgery performed due to aseptic loosening after hip arthroplasty and were cultured in the presence or absence of Ti particles, naringin and mitogen-activated protein kinase (MAPK) inhibitors, PD98059 (a selective inhibitor of ERK), SP600125 (a selective inhibitor of JNK), and SB203580 (a selective inhibitor of p38). TNF-α and IL-6 assays were performed using enzyme-linked immunosorbent assay kits. The phosphorylation levels of p38 and nuclear factor kappa B p65 (NF-κB p65) were examined by western blot.

RESULTS

Naringin or SB203580 pretreatment significantly suppressed the secretion of TNF-α and IL-6 induced by titanium particles in fibroblasts, while inhibition of ERK or JNK pathways showed no effect on production of TNF-α and IL-6. Moreover, naringin inhibited Ti particle-induced phosphorylation of p38 and p65.

CONCLUSIONS

These results indicated that naringin could inhibit Ti particle-induced inflammation in fibroblasts by inhibiting p38 MAPK/NF-κB p65 activity and might be a potential drug for the treatment of inflammatory periprosthetic osteolysis after arthroplasty.

Naringin increases osteoprotegerin expression in fibroblasts from periprosthetic membrane by the Wnt/β-catenin signaling pathway

Background

The osteoclast bone resorption is critical in aseptic loosening after joint replacement. The balance between activator of nuclear factor kappa B ligand (RANKL) and osteoprotegerin (OPG) is considered to play a central role in osteoclast maturation. Fibroblasts from the periprosthetic membrane express RANKL and promote osteoclast formation. Studies have demonstrated that naringin inhibited osteoclastogenesis and wear particle-induced osteolysis. In this study, the naringin-induced OPG/RANKL effects and its underlying mechanism were studied in fibroblasts from periprosthetic membrane.

Methods

Fibroblasts were isolated from the periprosthetic membrane during hip arthroplasty for revision due to aseptic loosening. Fibroblasts were cultured and treated with or without naringin and DKK-1 (the classical inhibitor of Wnt/β-catenin signaling pathway). OPG and RANKL mRNA and protein levels, gene expression of β-catenin, and cyclin D1, which participate in the Wnt signaling pathway, were examined by real-time polymerase chain reaction and enzyme-linked immunosorbent assay.

Results

The mRNA and protein levels of OPG were enhanced by naringin in a dose-dependent manner compared to that of the non-treated control. In contrast, naringin did not affect the expression of RANKL. Importantly, DKK-1 attenuated OPG expression in fibroblasts under naringin treatment. Moreover, naringin stimulated the gene expression of β-catenin and cyclin D1 in fibroblasts, and the effect could be inhibited by DKK-1.

Conclusion

The results indicated that naringin enhanced OPG expression through Wnt/β-catenin signaling pathway in fibroblasts from periprosthetic membrane, which may be useful to inhibit periprosthetic osteolysis during aseptic loosening after total joint arthroplasty.

Limb salvage for malignant bone tumours of distal tibia with dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array with ankle arthrodesis and preserving subtalar joint

BACKGROUND

The treatment of malignant tumours of the distal tibia is a challenging surgical problem due to the scarce soft tissue coverage and the instability of the ankle joint that often occurs after resection. However, there is no consensus on the ideal treatment for malignant tumours of the distal tibia.

METHODS

We report a new reconstruction for five patients with high-grade osteosarcoma of distal tibia, using dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and external fixator, with ankle arthrodesis and preserving subtalar joints. The patients were examined clinically and radiographically.

RESULTS

The average follow-up duration was 88 months. The mean wound healing time was 14 days. Bone healing was achieved for all the five patients at an average time of 7 months. There were no complications of mal-union, skin necrosis, post-operative infection, loss of internal fixation, peroneal nerve injury. One patient had a local recurrence, which required amputation 15 months postoperatively. The remaining four patients were able to walk with an average functional score of 81.25% according to MSTS.

CONCLUSIONS

Our study shows that this technique is safe and effective to perform implantation of dual ipsilateral vascularized autogenous fibular graft in a trapezoid-shaped array and preserving subtalar joints in terms of the distal tibial reconstruction for malignant bone tumour of the distal tibia. This reconstruction represents a biological alternative protocol for limb salvage in cases of malignant bone tumour of the distal tibia, with encouraging results and with the advantages of lower complications and accelerating recovery.

LEVEL OF EVIDENCE

Level IV.

A prospective study of coracoclavicular ligament reconstruction with autogenous peroneus longus tendon for acromioclavicular joint dislocations

BACKGROUND

Anatomic coracoclavicular (CC) ligament reconstruction (ACCR) provides good outcomes for Rockwood type III and VI acromioclavicular (AC) joint dislocations. Various grafts have been used, but complications from graft harvesting are not uncommon. This study examined the clinical and radiographic outcomes of patients with AC joint dislocations repaired with the autogenous anterior half of the peroneus longus tendon (AHPLT) to achieve ACCR.

METHODS

Patients with a Rockwood type III to V AC joint dislocation and magnetic resonance imaging of the disruption of the CC ligaments, as well as the AC capsule, were prospectively recruited. Patients received ACCR using an autogenous AHPLT graft and were evaluated clinically and radiographically preoperatively and at 1, 3, 6, and 12 months postoperatively.

RESULTS

A total of 18 patients (mean age, 51 years) were prospectively recruited and received an autogenous AHPLT graft ACCR. Fifteen patients completed clinical and radiographic follow-up examinations at 12 months. The mean Constant score (CS) was 51 preoperatively and 93 at 12 months (P <.005). No significant difference was noted at 12 months between the CS of the injured and contralateral shoulder. The mean American Orthopedic Foot and Ankle Society score at 12 months was 99, and this was not different from the value at any other time point. Loss of reduction occurred in 10 patients (56%), and tunnel widening was observed in 9 (50%), but neither was significantly correlated with functional outcome.

CONCLUSION

Autogenous AHPLT appears to be a reliable tendon graft source for CC ligament reconstruction.

Titanium Elastic Nail (TEN) versus Reconstruction Plate Repair of Midshaft Clavicular Fractures: A Finite Element Study

BACKGROUND

The biomechanical characteristics of midshaft clavicular fractures treated with titanium elastic nail (TEN) is unclear. This study aimed to present a biomechanical finite element analysis of biomechanical characteristics involved in TEN fixation and reconstruction plate fixation for midshaft clavicular fractures.

METHODS

Finite element models of the intact clavicle and of midshaft clavicular fractures fixed with TEN and with a reconstruction plate were built. The distal clavicle displacement, peak stress, and stress distribution on the 3 finite element models were calculated under the axial compression and cantilever bending.

RESULTS

In both loading configurations, TEN generated the highest displacement of the distal clavicle, followed by the intact clavicle and the reconstruction plate. TEN showed higher peak bone and implant stresses, and is more likely to fail in both loading configurations compared with the reconstruction plate. TEN led to a stress distribution similar to that of the intact clavicle in both loading configurations, whereas the stress distribution with the reconstruction plate was nonphysiological in cantilever bending.

CONCLUSIONS

TEN is generally preferable for treating simple displaced fractures of the midshaft clavicle, because it showed a stress distribution similar to the intact clavicle. However, TEN provides less stability, and excessive exercise of and weight bearing on the ipsilateral shoulder should be avoided in the early postoperative period. Fixation with a reconstruction plate was more stable but showed obvious stress shielding. Therefore, for patients with a demand for early return to activity, reconstruction plate fixation may be preferred.

The mechanical benefit of medial support screws in locking plating of proximal humerus fractures

Background

The purpose of this study was to evaluate the biomechanical advantages of medial support screws (MSSs) in the locking proximal humeral plate for treating proximal humerus fractures.

Methods

Thirty synthetic left humeri were randomly divided into 3 subgroups to establish two-part surgical neck fracture models of proximal humerus. All fractures were fixed with a locking proximal humerus plate. Group A was fixed with medial cortical support and no MSSs; Group B was fixed with 3 MSSs but without medial cortical support; Group C was fixed with neither medial cortical support nor MSSs. Axial compression, torsional stiffness, shear stiffness, and failure tests were performed.

Results

Constructs with medial support from cortical bone showed statistically higher axial and shear stiffness than other subgroups examined (P<0.0001). When the proximal humerus was not supported by medial cortical bone, locking plating with medial support screws exhibited higher axial and torsional stiffness than locking plating without medial support screws (P≤0.0207). Specimens with medial cortical bone failed primarily by fracture of the humeral shaft or humeral head. Specimens without medial cortical bone support failed primarily by significant plate bending at the fracture site followed by humeral head collapse or humeral head fracture.

Conclusions

Anatomic reduction with medial cortical support was the stiffest construct after a simulated two-part fracture. Significant biomechanical benefits of MSSs in locking plating of proximal humerus fractures were identified. The reconstruction of the medial column support for proximal humerus fractures helps to enhance mechanical stability of the humeral head and prevent implant failure.

A prospective, randomised trial comparing the use of absorbable and metallic screws in the fixation of distal tibiofibular syndesmosis injuries: mid-term follow-up

Our aim was to compare polylevolactic acid screws with titanium screws when used for fixation of the distal tibiofibular syndesmosis at mid-term follow-up. A total of 168 patients, with a mean age of 38.5 years (18 to 72) who were randomly allocated to receive either polylevolactic acid (n = 86) or metallic (n = 82) screws were included. The Baird scoring system was used to assess the overall satisfaction and functional recovery post-operatively. The demographic details and characteristics of the injury were similar in the two groups. The mean follow-up was 55.8 months (48 to 66). The Baird scores were similar in the two groups at the final follow-up. Patients in the polylevolactic acid group had a greater mean dorsiflexion (p = 0.011) and plantar-flexion of the injured ankles (p < 0.001). In the same group, 18 patients had a mild and eight patients had a moderate foreign body reaction. In the metallic groups eight had mild and none had a moderate foreign body reaction (p < 0.001). In total, three patients in the polylevolactic acid group and none in the metallic group had heterotopic ossification (p = 0.246). We conclude that both screws provide adequate fixation and functional recovery, but polylevolactic acid screws are associated with a higher incidence of foreign body reactions.

Identification of duplication downstream of BMP2 in a Chinese family with brachydactyly type A2 (BDA2)

Brachydactyly type A2 (BDA2, MIM 112600) is characterized by the deviation and shortening of the middle phalange of the index finger and the second toe. Using genome-wide linkage analysis in a Chinese BDA2 family, we mapped the maximum candidate interval of BDA2 to a ∼1.5 Mb region between D20S194 and D20S115 within chromosome 20p12.3 and found that the pairwise logarithm of the odds score was highest for marker D20S156 (Zmax = 6.09 at θ = 0). Based on functional and positional perspectives, the bone morphogenetic protein 2 (BMP2) gene was identified as the causal gene for BDA2 in this region, even though no point mutation was detected in BMP2. Through further investigation, we identified a 4,671 bp (Chr20: 6,809,218-6,813,888) genomic duplication downstream of BMP2. This duplication was located within the linked region, co-segregated with the BDA2 phenotype in this family, and was not found in the unaffected family members and the unrelated control individuals. Compared with the previously reported duplications, the duplication in this family has a different breakpoint flanked by the microhomologous sequence GATCA and a slightly different length. Some other microhomologous nucleotides were also found in the duplicated region. In summary, our findings support the conclusions that BMP2 is the causing gene for BDA2, that the genomic location corresponding to the duplication region is prone to structural changes associated with malformation of the digits, and that this tendency is probably caused by the abundance of microhomologous sequences in the region.

Fibrohistiocytoma combined with an aneurysmal bone cyst at T7 in a 63-year-old woman

We present a case of spinal tumor, with fibrohistiocytoma combined with aneurysmal bone cyst (ABC) at the pedicle and transverse process of T7 in a 63-year-old female. ABC is a rare skeletal tumor and spinal ABC is extremely rare. Fibrohistiocytoma is a type of primary benign bone tumor. ABC is also a rare bone tumor that most often occurs in the pelvis. The combined lesion of two primary bone benign tumors is relatively rare in clinic. In addition, fibrohistiocytoma and ABC are widely confused with other giant cell containing tumors of the bone. X-rays, magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) scans were performed and assessed. Finally, the diagnosis was confirmed by pathological tests. The patient underwent surgery and had an extremely good recovery. The correct diagnosis of a spine tumor is important when determining the surgical procedure.

An implantable electrical stimulator used for peripheral nerve rehabilitation in rats

This study evaluated an implantable electrical stimulator using a sciatic nerve injury animal model, and ethological, electrophysiological and histological assessments. Forty Sprague-Dawley rats were used in the study, and were subjected to crushing of the right sciatic nerve with a micro-vessel clamp. Electrical stimulators were implanted in twenty of the rats (the implantation group), while the remaining twenty rats were assigned to the control group. At three and six weeks following the surgery, the sciatic nerve function index (SFI) and the motor nerve conduction velocity (MCV) were demonstrated to be significantly higher in the implantation group compared with the control group (P<0.05). Histological analysis, using hematoxylin and eosin (H&E) staining, showed the typical pathological atrophy, and an assessment of the nerve that had been crushed revealed distal axonal breakdown in the control group. These results suggest that the implantable electrical stimulator was effective, and was suitable for implantation in a Sprague-Dawley rat model.

Partial wrist arthrodesis versus arthroplasty for distal radius giant cell tumours

PURPOSE

The purpose of this study was to evaluate the clinical efficacy of using the proximal fibular graft for partial wrist arthrodesis or arthroplasty after the resection of giant cell tumours of the distal radius.

METHODS

Between February 2006 and August 2010, 14 patients (seven males, seven females; average age, 35.7 years) with grade II and III giant cell tumours of the distal radius were treated by tumour resection and autologous proximal fibular grafts to reconstruct the wrist in our hospital. Seven patients each were treated by wrist arthroplasty and partial wrist arthrodesis, and were followed up for 2.2-6.8 years (average, 3.9 years).

RESULTS

All patients achieved primary healing. No tumour recurrence was observed during follow-up in any of the patients. No statistically significant difference in forearm rotation was observed between patients undergoing the two different treatments. However, wrist flexion-extension activities were significantly better and the wrist grip strengths were significantly worse in the arthroplasty group than in the arthrodesis group. The Musculoskeletal Tumour Society score did not significantly differ between the groups.

CONCLUSIONS

Overall, joint arthroplasty remains a favourable treatment with regard to the functional outcome for giant cell tumours of the distal radius; however, some of these patients may have a weaker grip strength. In comparison, partial wrist fusion appears to provide a durable and stable wrist with good long-term functional outcome.

Is the lag screw sliding effective in the intramedullary nailing in A1 and A2 AO-OTA intertrochanteric fractures? A prospective study of Sliding and None-sliding lag screw in Gamma-III nail

OBJECT

To compare the Sliding with Non-sliding lag screw of a gamma nail in the treatment of A1 and A2 AO-OTA intertrochanteric fractures.

MATERIALS AND METHODS

80 patients were prospectively collected. In each group, AO/OTA 31-A were classified into group A. AO/OTA 31-A2.1 was classified as group B. We classified the A2.2 and A2.3 as group C. According to the set-screw locking formation of Gamma-III, the cases were randomly allocated to Sliding subgroup and Non-sliding subgroup in A, B and C groups. Follow-ups were performed 1, 3, 6 and 12 months postoperatively.

RESULTS

In the Sliding group, the bone healing rate 3, 6, 12 months postoperatively reached 85.00%, 97.50%, 100% in group A, B and C. Meanwhile, in Non-sliding group, postoperatively, bone healing rate were 90.00%, 95.00% and 97.50% in group A, B and C, respectively. Both differences were not significant. Lower limb discrepancy between Sliding and Non-sliding pattern was significantly different in group C which represent fracture types of AO/OTA 31-A2.2 and A2.3 (0.573 ± 0.019 mm in Non-sliding group, 0.955 mm ± 0.024 mm in Sliding group, P < 0.001 ). Difference of sliding distance among the three groups was significant among group A, B and C: 0.48 mm ± 0.04 mm, 0.62 mm ± 0.07 mm and 0.92 mm ± 0.04 mm (P < 0.001). Differences in average healing time and Harris scores also presented no significance in the three groups.

CONCLUSIONS

As a result, we can conclude that the sliding distance is minimal in Gamma nails and it is related to the comminuted extent of the intertrochanteric area in A1 and A2 AO-OTA intertrochanteric fractures. For treating these kinds of fractures, the sliding of the lag screw of an Gamma nail does not improve any clinical results and in certain cases, such as highly comminuted A1 and A2 fractures, can therefore even benefit from a locked lag screw by tightening the set-screw.

[Effect of extracorporeal shock wave therapy on diabetic chronic wound healing and its histological features]

OBJECTIVE

Extracorporeal shock wave (ESW) can promote angiogenesis and tissue repair. To investigate the influence of ESW therapy on the histological features of diabetic chronic wounds and wound healing.

METHODS

Ninety-six male Sprague Dawley rats with weight (220 +/- 20) g were divided into 3 groups (n = 32): diabetic control group, ESW treatment group, and normal control group. The diabetic rats were prepared in diabetic control group and ESW treatment group by intraperitoneal injection of Streptozotocin (60 mg/kg). Then a circular full-thickness skin wound of 1.8 cm in diameter was made at the back of diabetic rats to establish the diabetic chronic wound model, and the same wound was made in normal control group. In ESW treatment group, ESW (0.11 mJ/mm2, 1.5 Hz energy, and 500 pulses) was applied to treat the wound at 1 day after wounding; in two control groups, no ESW treatment was given. The wound healing and histological changes were observed by HE and Masson staining at 3, 7, and 14 days after treatment; and the cell proliferation, angiogenesis, and collagen deposition were observed by CD31 and proliferating cell nuclear antigen (PCNA) immunohistochemical staining.

RESULTS

The wound closure rate in diabetic control group was lower, and the healing time was significantly longer than those in normal control group (P < 0.05); at 3, 7, and 14 days after treatment, the inflammatory cell infiltration in wound tissue was obvious, and the relative area density of collagen fibers, wound microvessel density (MVD), and the relative density of PCNA-positive cells were significantly lower than those in normal control group (P < 0.05). The wound healing time was significantly shorter and the wound closure rate was significantly higher in ESW treatment group than those in the diabetic control group (P < 0.05). At different time points in ESW treatment group, the inflammatory cells signficantly reduced, while the relative area density of collagen fibers, MVD, and relative density of PCNA-positive cells significantly increased when compared with those in diabetic control group (P < 0.05). No significant difference in MVD and relative density of PCNA-positive cells was found between ESW treatment group and normal control group (P > 0.05).

CONCLUSION

Low-energy ESW treatment can inhibit the local inflammatory response, promote cell proliferation, increase angiogenesis and collagen deposition, and enhance granulation tissue formation, and so it can promote chronic wound healing in diabetic rats.

[Reconstruction of the knee stability after resection of tumors of the proximal fibula]

OBJECTIVE

To investigate the method and the clinical outcomes of reconstruction of the knee stability after resection of tumors of the proximal fibula.

METHODS

The clinical data were retrospectively analyzed, from 16 patients with tumors of the proximal fibula undergoing proximal fibular resections and reconstructions of the lateral collateral ligament and the tendon of the biceps femoris with anchors between January 2008 and December 2009 (test group). Five patients underwent proximal fibular resection but were not given reconstruction surgery at the same period as the control group. There was no significant difference in gender, ages, disease duration, and tumor site between 2 groups (P > 0.05). Lateral stress test was performed after operation; X-ray films were taken to measure the joint space. Musculoskeletal Tumor Society (MSTS) functional score system was used to evaluate the joint function.

RESULTS

All incisions healed by first intention in 2 groups. Iatrogenic complete peroneal nerve function loss occurred in patients undergoing Malawer type II surgical resection. The patients in both groups were followed up 12 to 36 months, with an average of 30 months. One patient with osteosarcoma of the test group developed local recurrence, and died of lung and systemic metastases after 12 months; the other patients had no recurrence. At last follow-up, the results of knee lateral stress test were negative in the test group, and the joint space increased and was classified as grade A; the results of knee lateral stress test were positive in the control group, and the joint space was classified as grade D. The MSTS score was 97.5 +/- 3.5 in the test group and 87.5 +/- 3.5 in the control group, showing significant difference (t = 2.85, P = 0.01).

CONCLUSION

The reconstruction of the bony attachment of the lateral collateral ligament and the tendon of the biceps femoris with anchors after resection of the proximal fibula is a safe, reliable, and simple technique to reconstruct knee stability after resection of tumors of the proximal fibula.

Treatment of aseptic nonunion after intramedullary nailing fixation with locking plate

OBJECTIVE

To evaluate the safety and efficacy of locking plate combined with bone grafting in the treatment of aseptic nonunion following intramedullary nailing fixation of fractures of the long bones.

METHODS

Thirty-eight consecutive patients treated in our hospital between January 2004 and December 2006 were included in this retrospective study. The nonunions included 20 femurs, 15 tibias, and 3 humeri. The duration of non-union ranged from 6 to 84 months and 21 (55.3%) of them were located around the metaphysis of the affected long bones. There were 12 women and 26 men with a mean age of 39.2 years (range, 9-70 years). Locking plate combined with bone grafting was the procedure chosen to treat every case of nonunion in this series. The clinical outcomes were evaluated.

RESULTS

All patients were followed up for 6-20 months (average 11.6 months). After locking plate fixation combined with bone grafting, union was achieved in all cases, the average healing time being 5.3 months (range, 4-8 months). Infection of the superficial incision occurred in three cases (7.9%) and delayed healing of the incision in one case, all of which healed with no further complications. The function of the adjacent joints was excellent to good in 30 patients (78.9%), fair in 7 (18.4%) and poor in 1 (2.6%) after follow-up.

CONCLUSION

Locking plate fixation combined with bone grafting is a highly effective treatment for aseptic nonunions of the long bones after intramedullary nailing fixation, especially in the case of metaphyseal nonunion.

Recurrence analysis in 66 cases with grade I and grade II chondrosarcomas in the extremities

OBJECTIVE

We analyzed chondrosarcomas in long bones to assess whether Grade I and II chondrosarcomas should both be grouped as low grade malignant tumors (musculoskeletal Tumor Society Stage I or Stage II), and to explore rational surgical treatment for Grade I and II chondrosarcomas.

METHODS

We retrospectively reviewed 66 patients from January 1996 to December 2007 with Grade I and II chondrosarcoma of the extremities without metastases at the Department of Orthopaedics of Shanghai Sixth People's Hospital. Thirty-eight patients had undergone intralesional or marginal resection, and 28 patients had undergone wide marginal or radical excision based on imaging findings. The mean age of the patients was 43 years (range, 5-85) and the minimum follow-up was 31 months (mean, 48; range, 5-141). We analyzed grade diagnosis, therapeutic options, and local recurrence rate of the two grades of chondrosarcoma.

RESULTS

Of all patients, 22 experienced local recurrence, making the local recurrence rate 33.3%. A statistically significant difference in outcome between patients with Grade I and Grade II tumors undergoing intralesional resection was identified. No significant difference according to surgical method was found between the two groups in total.

CONCLUSION

Grade II chondrosarcomas should be grouped as high stage malignant tumors (Stage II) and grade I chondrosarcomas assigned to the low stage malignant tumor group (Stage I). Our experience suggests the surgical method should be related to radiographic margin status and oncologic classification. Wide resection should be considered for Grade II, while intralesional resection is suitable for Grade I.

Effect of celecoxib on proliferation, collagen expression, ERK1/2 and SMAD2/3 phosphorylation in NIH/3T3 fibroblasts

In the present study, the effects of celecoxib on proliferation, collagen expression, ERK1/2 and SMAD2/3 phosphorylation in NIH/3T3 fibroblasts were investigated. NIH/3T3 fibroblasts stimulated with fibroblast growth factor-2 (FGF-2) or transforming growth factor-β1 (TGF-β1) were examined in the presence of celecoxib. Proliferation was assessed by MTT assays; ERK1/2 expression and SMAD2/3 expression were assessed by quantitative RT-PCR and western blotting; ERK1/2 phosphorylation and SMAD2/3 phosphorylation were assessed by western blot analysis. The results indicated that celecoxib could suppress cell proliferation stimulated by FGF-2 (IC(50) FGF+group, 75±1.9μmol/l) and TGF-β1 (IC(50) TGF+group, 48±1.4μmol/l), by inhibiting ERK1/2 phosphorylation but not ERK1/2 expression. Celecoxib also suppressed collagen expression (0.35-fold COL3 and 0.43-fold COL1 at 320μmol/l celecoxib relative to the untreated control after stimulation with TGF-β1 for 3h, P<0.01), by inhibiting SMAD2/3 phosphorylation but not SMAD2/3 expression. The suppression of NIH/3T3 fibroblast proliferation and collagen expression upon stimulation by FGF-2 and TGF-β1 is likely a result of the inhibition of ERK1/2 and SMAD2/3 phosphorylation by celecoxib.

Celecoxib suppresses fibroblast proliferation and collagen expression by inhibiting ERK1/2 and SMAD2/3 phosphorylation

This study aimed to investigate whether celecoxib suppresses fibroblast proliferation and collagen expression by inhibiting extracellular signal-regulated kinase 1/2 (ERK1/2) and SMAD2/3 phosphorylation. Celecoxib was added to NIH/3T3 fibroblasts stimulated by fibroblast growth factor-2 (FGF-2) or transforming growth factor-β1 (TGF‑β1). NIH/3T3 fibroblast proliferation and viability were assessed by MTT assays; ERK1/2 expression and SMAD2/3 expression were assessed by quantitative RT-PCR and Western blot analysis. The results indicated that celecoxib suppressed cell proliferation (IC50 FGF+ group, 75 ± 1.9 µmol/l) stimulated by FGF-2, and also inhibited cell viability (IC50 FGF- group, 252 ± 2.3 µmol/l) by inhibiting ERK1/2 phosphorylation but not ERK1/2 expression. In addition, celecoxib treatment led to the apoptosis of NIH/3T3 fibroblasts (IC50 FGF- group, 35 ± 1.4 µmol/l). Celecoxib also suppressed collagen expression (0.35-fold COL3 and 0.43-fold COL1 with 320 µmol/l celecoxib relative to the untreated group following stimulation for 3 h, p<0.01) when stimulated by TGF‑β1, by inhibiting SMAD2/3 phosphorylation but not SMAD2/3 expression. Celecoxib is capable of inhibiting ERK1/2 and SMAD2/3 phosphorylation, which is responsible for NIH/3T3 fibroblast proliferation and collagen expression.

Free vascularised fibular graft for post-traumatic osteonecrosis of the femoral head in teenage patients

Free vascularised fibular grafting has been reported to be successful for adult patients with osteonecrosis of the femoral head (ONFH). However, its benefit in teenage patients with post-traumatic ONFH has not been determined. We evaluated the effectiveness of free vascularised fibular grafting in the treatment of this condition in children and adolescents. We retrospectively analysed 28 hips in 28 patients in whom an osteonecrotic femoral head had been treated with free vascularised fibular grafting between 2002 and 2008. Their mean age was 16.3 years (13 to 19). The stage of the disease at time of surgery, and results of treatment including pre- and post-operative Harris hip scores, were studied. We defined clinical failure as conversion to total hip replacement. All patients were followed up for a mean of four years (2 to 7). The mean Harris hip score improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100) at final follow-up. At the latest follow-up we found improved or unchanged radiographs in all four initially stage II hips and in 23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated. No patient underwent total hip replacement. Free vascularised fibular grafting is indicated for the treatment of post-traumatic ONFH in teenage patients.

Hidden blood loss after total hip arthroplasty

A prospective study was carried out to analyze the characteristics of hidden blood loss after total hip arthroplasty (THA) in a series of 1232 patients. The method of deducting the observed perioperative blood loss from the calculated total blood loss based on hematocrit changes was used to calculate the hidden blood loss of each patient. The reinfused and transfused bloods were also considered. We found that the amount of hidden blood loss after THA was much larger than we observed perioperatively and significantly different between differently diagnosed patients. We concluded that THA can cause a large amount of hidden blood loss, which should be monitored carefully. Retaining and repairing the articular capsule is recommended during the operation, which can significantly decrease hidden blood loss.

[Repair of radial segmental bone defects by combined angiopoietin 1 gene transfected bone marrow mesenchymal stem cells and platelet-rich plasma tissue engineered bone in rabbits]

OBJECTIVE

To investigate the osteogenesis effects of angiopoietin 1 (Ang-1) gene transfected bone marrow mesenchymal stem cells (BMSCs) seeded on beta tricalcium phosphate (beta-TCP) scaffolds (tissue engineered bone) with platelet-rich plasma (PRP).

METHODS

BMSCs were isolated from bone marrow tissue of rabbits. The Ang-1 gene was transfected into the BMSCs at passage 2 by lentivector, which were seeded on beta-TCP scaffolds with PRP (0.5 mL) after 48 hours of transfection. Bilateral radial segmental bone defects (15 mm in length) were created in 20 3-month-old New Zealand rabbits. Then the tissue engineered bone with the Ang-1 gene transfected BMSCs (experimental group) and untransfected BMSCs (control group) were implanted into the defects in the right and left radius, respectively. X-ray, histology, immunohistochemistry, and biomechanics observations were done at 2, 4, 8, and 12 weeks after operation.

RESULTS

In vitro, the transfected rate was over 90% and RT-PCR showed that the Ang-1 expression were significantly increased after transfection. The X-ray films showed that some callus formed at 4 weeks, partial bony union was observed at 8 weeks, and complete union at 12 weeks in experimental group; and bone union was not observed at 12 weeks in control group. HE staining showed that capillary appeared at 8 weeks and more capillaries were observed in new bone at 12 weeks in experimental group; only a few capillaries were observed at 12 weeks in control group. At 8 and 12 weeks, the microvascular density were (50.1 +/- 7.8) /mm2 and (66.1 +/- 3.5)/mm2 in experimental group and were 0 and (30.3 +/- 7.2)/mm2 in control group, showing significant differences between 2 groups at 12 weeks (Z = -2.107, P = 0.031). Immunohistochemistry examination showed that the positive cells can be found at 8 weeks in experimental group. And the biomechanical analysis showed that maximum loads of experimental group were significantly higher than those of control group in three-point bending test and compression test at 12 weeks (P < 0.05).

CONCLUSION

The tissue engineered bone with PRP and Ang-1 can increase the osteogenic properties by enhancing capillary regeneration, thus it can be used to repair radial segmental bone defects of rabbit.

Intraoperative three-dimensional imaging in tibial plateau fractures with complex depressions

INTRODUCTION

The aim of the study was to investigate the role of the intra-operative three-dimensional imaging in the tibial plateau fractures with complex depressions.

MATERIAL AND METHODS

Thirty tibial plateau fracture patients with complex depression were treated with the use of intra-operative three-dimensional imaging (Arcadis 3D). The image quality as well as the clinical benefit was evaluated.

RESULTS

In total 74 plates were used in these 30 patients. Six Kirschner wires and 50 screws were used outside the plate as raft technique in 4 and 21 patients. The additional critical imaging information which was unachievable in plain fluoroscopy was gain in 12 patients. Four patients among these 12 patients were revised because of the depression. Two patients were revised due to the misplacement of screws.

CONCLUSION

The intra-operative three-dimensional imaging (Arcadis) is necessary when the two-dimensional fluoroscopy was unsatisfactory in the depressed tibial plateau fracture.

[Ankle arthrodesis by lateral malleolus osteotomy and internal fixation with locking proximal humeral plate]

OBJECTIVE

To summarize the surgical technique of ankle arthrodesis using lateral malleolus osteotomy and locking proximal humeral plate internal fixation, and to evaluate the clinical effectiveness.

METHODS

Between March 2009 and June 2010, 18 patients with ankle joint disease were treated, including 8 cases of post-traumatic arthritis, 3 cases of rheumatoid arthritis, 5 cases of osteoarthritis, and 2 cases of post-traumatic necrosis of talus. There were 10 males and 8 females with an average age of 48 years (range, 36-67 years). The average disease duration was 3 years (range, 1-6 years). The main symptoms included swelling, pain, and a limited range of motion of the ankle. Four patients accompanied with ankle varus deformity and 2 patients with valgus deformity. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system, the preoperative score was 43.5 +/- 10.2. An ankle arthrodesis using lateral malleolus osteotomy and locking proximal humeral plate internal fixation was performed in all patients.

RESULTS

Superficial wound infection and partial skin necrosis occurred in 1 case respectively, and were cured after symptomatic treatment; the other incisions healed by first intention without complications. Sixteen patients were followed up 16 months on average (range, 1-2 years). The X-ray films showed that bone fusion was obtained at 8-16 weeks (mean, 12 weeks) after operation. The symptom was relieved completely in all patients at last follow-up without complication of implant failure, nonunion, and malunion. The postoperative AOFAS ankle and hindfoot score was 83.0 +/- 6.3, showing significant difference when compared with the preoperative score (t=26.20, P=0.00).

CONCLUSION

Ankle arthrodesis using lateral malleolus osteotomy and locking proximal humeral plate internal fixation has the advantages of feasible technique, the rigid fixation, and high fusion rate, so it may obtain a good clinical effectiveness.

[Repair of soft tissue defects of lower extremity by using cross-bridge contralateral distally based posterior tibial artery perforator flaps or peroneal artery perforator flaps]

OBJECTIVE

To discuss the feasibility of repairing soft tissue defects of lower extremity with a distally based posterior tibial artery perforator cross-bridge flap or a distally based peroneal artery perforator cross-bridge flap.

METHODS

Between August 2007 and February 2010, 15 patients with soft tissue defect of the legs or feet were treated. There were 14 males and 1 female with a mean age of 33.9 years (range, 25-48 years). The injury causes included traffic accident in 8 cases, crush injury by machine in 4 cases, and crush injury by heavy weights in 3 cases. There was a scar (22 cm x 8 cm at size) left on the ankle after the skin graft in 1 patient (after 35 months of traffic accident). And in the other 14 patients, the defect locations were the ankle in 1 case, the upper part of the lower leg in 1 case, and the lower part of the lower leg in 12 cases; the defect sizes ranged from 8 cm x 6 cm to 26 cm x 15 cm; the mean interval from injury to admission was 14.8 days (range, 4-28 days). Defects were repaired with distally based posterior tibial artery perforator cross-bridge flaps in 9 cases and distally based peroneal artery perforator cross-bridge flaps in 6 cases, and the flap sizes ranged from 10 cm x 8 cm to 28 cm x 17 cm. The donor sites were sutured directly, but a split-thickness skin graft was used in the middle part. The pedicles of all flaps were cut at 5-6 weeks postoperatively.

RESULTS

Distal mild congestion and partial necrosis at the edge of the skin flap occurred in 2 cases and were cured after dressing change, and the other flaps survived. After cutting the pedicles, all flaps survived, and wounds of recipient sites healed by first intention. Incisions of the donor sites healed by first intention, and skin graft survived. Fifteen patients were followed up 7-35 months with an average of 19.5 months. The color and texture of the flaps were similar to these of the recipient site. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system, the mean score was 87.3 (range, 81-92).

CONCLUSION

A distally based posterior tibial artery perforator cross-bridge flap or a distally based peroneal artery perforator cross-bridge flap is an optimal alternative for the reconstruction of the serious tissue defect of contralateral leg or foot because of no microvascular anastomosis necessary, low vascular crisis risk, and high survival rate.

Osteogenic and angiogenic effects of mesenchymal stromal cells with co-transfected human Ang-1 gene and BMP2 gene

To increase the osteogenic and angiogenic effects of marrow-derived mesenchymal stromal cells (MSCs), we co-transfected (by means of lentivirus) the human angiopoietin-1 gene (hAng-1) and human bone morphogenetic protein 2 gene (hBMP2) into MSCs. Real-time PCR and ELISA showed that both genes were successfully co-expressed in the MSCs with expression sustained until the eighth week. The alkaline phosphatase activity of the MSCs was more significantly augmented by the co-transfection with both genes than by any single gene transfection. These results demonstrate that the combined gene therapy with hAng-1 and hBMP2 using lentivirally co-transfected MSCs is feasible.

[Effect of local basic fibroblast growth factor and 5-fluorouracil on accelerating healing and preventing tendon adhesion after flexor tendon repair]

OBJECTIVE

To assess the effect of basic fibroblast growth factor (bFGF) and 5-fluorouracil (5-FU) applied topically on the tendon adhesion and the healing process after the flexor tendon repair in Leghorn chickens.

METHODS

Ninety male Leghorn chickens (weighing 3.0-3.5 kg) were randomly divided into 3 groups, with 30 chickens in each group. The flexor digitorum profundus tendons of the third right toes were transected and sutured directly. The repair site in group A was given 0.6 microL fibrin sealant (FS). In group B, the repair site was given 0.6 microL FS containing 500 ng bFGF. In group C, before the tendons were transected, they had been soaked in 5-FU solution, and then the same treatment as group B was given. Six specimens of the third toe were harvested to perform the macroscopical and histological examinations at 1, 2, 4, and 8 weeks, respectively, and to perform the biomechanical test at 8 weeks.

RESULTS

All animals survived until the experiment was completed. All incisions healed smoothly. No rupture occurred in the repaired tendon. At 8 weeks, the adhesion degree was lighter in group C than in group B (P < 0.05), but there was no significant difference in the adhesion degree between group A and groups B, C (P > 0.05). At 1, 2, and 4 weeks after operation, the number of fibroblast cells of group A was significantly less than that of group B (P < 0.05), and the number of fibroblast cells of group C was significantly less than that of group A and group B in the tendon sheath and epitenon (P < 0.05); however, it was significantly more than that of group A in the tendon parenchyma (P < 0.05), and no significant difference was observed when compared with that of group B (P > 0.05). At 8 weeks, no difference was found among 3 groups (P > 0.05). The collagen fiber content of group A was significantly less than that of group B at 4 and 8 weeks (P < 0.05). In the sheath and epitenon, the collagen fiber content of group A was significantly more than that of group C at 4 weeks (P < 0.05); however, no significant difference was found between 2 groups at 8 weeks (P > 0.05). The collagen fiber content of group A was significantly less than that of group C in the parenchyma at 4 and 8 weeks (P < 0.05). At all time points, the collagen fiber content of group B was significantly more than that of group C in the sheath and epitenon (P < 0.05), but no significant difference in the parenchyma was observed between 2 groups (P > 0.05). The biomechanical tests showed that the gliding excursion of the tendon in groups A, B, and C was (3.51 +/- 0.56), (2.84 +/- 0.42), and (4.56 +/- 0.59) mm, respectively; the work of flexion was (14.08 +/- 1.85), (20.62 +/- 3.52), and (10.91 +/- 1.53) N x mm, respectively; and the ultimate tensile strength of the tendon was (11.26 +/- 1.83), (15.02 +/-2.20), and (14.40 +/- 1.57) N, respectively. There were significant differences in the gliding excursion of the tendon and the work of flexion among 3 groups (P < 0.05) and in the ultimate tensile strength of the tendon between group A and groups B, C (P < 0.05), but there was no significant difference in the ultimate tensile strength of the tendon between group B and group C (P > 0.05).

CONCLUSION

Local single-use bFGF and 5-FU can not only effectively promote the healing of flexor tendon, but also significantly reduce tendon adhesion.

[Minimal invasive fixation for acetabular fracture with three dimensional fluoro-images based on navigation]

OBJECTIVE

To evaluate the security and effectiveness of minimal invasive fixation with three dimensional (3D) fluoro-images based on navigation system in the management of acetabular fractures.

METHODS

Between August 2008 and January 2010, 12 patients with acetabular fractures were treated with percutaneous screw fixation under the guidance of 3D fluoro-images based on navigation system after closed reduction. There were 7 males and 5 females, aged 28-57 years (mean, 38.1 years). Fractures were caused by traffic accident in 9 cases, and falling from height in 3 cases. According to AO classification, there were 1 case of A2.2 type, 3 cases of A2.3 type, 2 cases of A3.2 type, 2 cases of A3.3 type, 1 case of B2.2 type, 1 case of B3.2 type, 1 case of C2.1 type, and 1 case of C2.3 type. The interval from injury to hospitalization was 4 hours to 3 days (mean, 1.2 days).

RESULTS

Totally 28 screws were implanted. The average time to implant 1 screw was 24.8 minutes. Twenty-seven screws were placed correctly with a successful rate of 96.4%, only 1 screw was reinserted for deviation. All the screws were checked by the 3D fluoro-images, which showed they were not in the joint space after fixation. The results were the same as that by CT scanning. Incisions healed by first intention, and no implant failure occurred. All 12 patients were followed up 7 to 24 months with an average of 16.8 months. At last follow-up, fracture union was achieved in all patients with satisfactory screw fixation.

CONCLUSION

The minimal invasive fixation with 3D fluoro-images based on navigation system makes the surgery for the nondisplaced acetabular fracture more precise and time-saving, minimizes the surgery injury, and improves the clinical results with less complications.

Clinical outcomes of midclavicular fractures treated with titanium elastic nails

BACKGROUND

Midclavicular fractures are common clinically, accounting for about 76% of all clavicular fractures. Recent studies have revealed a previously unrecognized incidence of nonunion and malunion after conservative treatment of more severe midclavicular fractures. Our aim was to evaluate the clinical outcomes of midclavicular fractures treated with titanium elastic nails.

METHODS

From February 2005 to February 2007, 41 patients with displaced midclavicular fractures received open reduction and internal fixation with a titanium elastic nail inserted through the sternal end of the clavicle. We evaluated the visual analogue scale (VAS), the Constant score and the Disabilities of the Arm, Shoulder and Hand (DASH) scale to determine outcomes.

RESULTS

A mean follow-up of 14.5 months (range 7-24 mo) revealed radiographic fracture union in all patients with an average clinical healing time of 2.2 months. Mean subjective pain 3 days after surgery was significantly lower than the day before surgery (p < 0.001). The mean range of motion 3 days after surgery was significantly improved compared with the day before surgery (p < 0.001). The nails were removed in all patients a mean of 7.2 months (range 5.4-9.5 mo) after surgery, and no fractures recurred. The mean postoperative DASH score was 2.5 (range 0.5-8.0) and the mean postoperative Constant score was 95.2 (range 86.5-97.0).

CONCLUSION

Limited open reduction and internal fixation with titanium elastic nails is a safe and minimally invasive surgical procedure for the treatment of displaced midclavicular fractures in adults and achieves good functional results and high patient satisfaction.

Beneficial effect of autologous transplantation of endothelial progenitor cells on steroid-induced femoral head osteonecrosis in rabbits

Femoral head osteonecrosis (ON) is a serious complication of steroid administration. We examined whether implantation of autologous bone marrow-derived endothelial progenitor cells (EPCs) can augment neovascularization and bone regeneration in steroid-induced osteonecrosis of the femoral head. Forty 12-week-old male New-Zealand white rabbits were divided into group I (left untreated, n=12), group II (core decompression, n=12), and group III (core decompression + autologous EPCs implantation, n=16) after receiving an established inductive protocol for inducing steroid-associated ON. Four weeks later, these rabbits were euthanized, bilateral femora were dissected for Micro-CT-based microangiography to assess vascularization, and then the osteonecrotic changes and repair processes were examined histopathologically. Quantitative analysis showed that new vessel formation in group III was significantly greater compared with other groups at 4 weeks after treatment. The histologic and histomorphometric analyses revealed that the new bone volume was significantly higher in group III than in groups I and II 4 weeks after treatment. A combination of EPCs and core decompression enhances the neovascularization and bone regeneration in rabbit steroid-induced femoral head ON. Local implantation of EPCs may provide a novel and effective therapeutic option for early corticosteroid-induced ON.

Reverse LISS plating for intertrochanteric hip fractures in elderly patients

Background

Fractures of the intertrochanteric hip are common and the treatment of unstable fractures generally requires an operative approach. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. We have attempted to apply the Less Invasive Stabilization System (LISS) in reverse position for the repair of intertrochanteric hip fractures in elderly patients with osteoporotic bones. A retrospective review is presented of the cases of 28 elderly patients with stable and unstable fractures of the intertrochanteric hip treated using the reverse LISS.

Methods

We treated 28 elderly patients with a mean age of 82.3 years. According to the Evens classification, there were 2 Type I fractures, 2 Type II fractures, 3 Type III fractures, 13 Type IV fractures, 6 Type V fractures and 2 Type R fractures. All fractures were treated using the reverse LISS. Radiographic and clinical evidence of functional outcome and complications were evaluated.

Results

Mean perioperative blood loss was 92.4 milliliters (range 35 to 245 milliliters), and the mean postoperative hospital stay was 8.7 days (range 3 to 14 days).

Complications included one minor wound hematoma. Radiographically, no collapses, screw cutouts, or head penetrations were seen. All surviving patients (28 of 28; 100 percent) had uneventful fracture healing with union achieved by six months in all patients.

Conclusions

Use of the Reverse LISS plating for intertrochanteric hip fractures resulted in event-free fracture healing.

Changes in Femoral Head Blood Supply and Vascular Endothelial Growth Factor in Rabbits with Steroid-induced Osteonecrosis

The molecular aetiology of steroid-induced osteonecrosis (ON) is unclear. The aim of this study was to investigate changes in the femoral head blood supply and vascular endothelial growth factor (VEGF) protein levels following steroid-induced ON of rabbit femoral heads in the early stage of the disease, and to investigate a possible mechanism for ON. Using a classic protocol, ON was induced in 30 male 28-week old New Zealand white rabbits. An additional 15 untreated rabbits served as controls. Change of blood supply in the proximal femur was assessed by dynamic magnetic resonance imaging and microangiography. The VEGF protein and mRNA levels were assessed by immunohistochemistry and quantitative real-time polymerase chain reaction, respectively. After 6 weeks, the results indicated that VEGF protein and mRNA levels were significantly lower and femoral head blood supply had also decreased significantly in ON+ rabbits compared with controls. The down-regulation of VEGF may play a critical role in the disease process of ON.

[Surgical treatment of tarsometatarsal joint complex injury]

OBJECTIVE

To report the outcome of surgical treatment of tarsometatarsal joint complex injury.

METHODS

In the period from January 2003 to December 2008, 167 cases of closed tarsometatarsal joint injury were treated, including 35 cases of tarsometatarsal joint complex injury. Diagnosis was made by X-ray examination or/and CT scan. Either close or open reduction was performed and followed by internal fixation with screw or/and plate. X-ray examination was done in the regular follow-up and functional evaluation was carried out by AOFAS midfoot score system.

RESULTS

In this series 135 cases got a mean follow-up of 48 months, ranging from 12 to 75 months. Therein the 26 cases of tarsometatarsal joint complex injury had a mean postoperative AOFAS midfoot score of 67 (ranging from 48 to 75), and secondary post-traumatic arthritis in 16 cases, 12 of which had arthrodesis as a result of severe pain. The 109 cases of pure tarsometatarsal joint injury had a mean postoperative AOFAS midfoot score of 82 (ranging from 70 to 95), and secondary post-traumatic arthritis in 17 cases, only 5 of which had arthrodesis finally. Those cases of pure tarsometatarsal joint injury treated by close reduction and internal fixation with percutaneous screw got a mean postoperative AOFAS midfoot score of 87 (ranging from 82 to 95), demonstrating a significant deference (t = 2.651, P < 0.05) when compared with that of metatarsal joint complex injury.

CONCLUSION

The tarsometatarsal joint complex injury has a prognosis inferior to that of the pure tarsometatarsal joint injury, and the keys to its successful treatment are appropriate diagnosis, anatomical reduction and secure fixation of all the components of the complex.

Treatment for large skeletal defects by free vascularized fibular graft combined with locking plate

BACKGROUND

Reconstruction of large skeletal defects secondary to osteomyelitis or open fracture is a challenging problem. The purpose of this study was to evaluate the results of using free vascularized fibular graft (FVFG) combined with locking plate in the treatment of large skeletal defects from open fracture and infection.

METHODS

Ten patients with a mean age of 34 years (ranged 13-57 years) and a mean length of 8.7 cm (range 6-17 cm) skeletal defect were treated with FVFG and locking plate. The mean follow-up time was 26 months.

RESULTS

Grafting union occurred in all patients, with a mean healing time of 4.5 months. No recurrence of osteomyelitis and stress fractures was observed. The mean time to full weight-bearing was 10 months, and all patients were pain-free and able to walk without supportive devices.

CONCLUSIONS

FVFG combined with locking plate is a viable option for the management of large skeletal defects from open fracture and infection.

Treatment of femoral head osteonecrosis in patients with systemic lupus erythematosus by free vascularised fibular grafting

The purpose of this study was to review the radiographs of symptomatic femoral head osteonecrosis in patients with systemic lupus erythematosus (SLE) and to assess the results of treatment using free vascularised fibular grafting. We retrospectively reviewed 50 patients (80 hips) with SLE who underwent free vascularised fibular grafting for osteonecrosis of the femoral head. All patients were followed up for at least 2 or more years (average, 4.3 years). The mean Harris hip score improved from 72 to 88. At the latest follow-up, we found improved or unchanged radiographs in 12 of initially Stage II hips and in 60 of 64 Stage III or IV hips. No hips failed treatment and underwent total hip arthroplasty. The data suggest that free vascularised fibular grafting was successful in maintaining joint function and in delaying the need for joint replacement procedure.

Risk factors for articular cartilage lesions in symptomatic discoid lateral meniscus

PURPOSE

To investigate risk factors related to articular cartilage lesions in discoid lateral meniscus (DLM) and to analyze the possible mechanisms associated with articular cartilage lesions.

METHODS

From October 2004 to April 2008, 103 knees in 97 patients with DLM confirmed by arthroscopy were operated on at our clinical center. Among them, 16 knees were accompanied by articular cartilage injury. Data on risk factors, including patient age, traumatic history, DLM type, presence or absence of tear, symptomatic duration, and meniscal shape, were analyzed to investigate the relation with articular cartilage lesion by logistic regression analysis.

RESULTS

Only symptomatic duration and meniscal shape had a significant relation with articular cartilage lesion. Symptomatic duration and meniscal shape can be regarded as risk factors, and their odds ratios were 4.983 (P < .01) and 5.356 (P < .05), respectively.

CONCLUSIONS

Long symptomatic duration (>6 months) and asymmetrical shape of DLM were more frequently related to articular cartilage lesions than other factors.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Curative effect and safety of vascularized fibula grafting in renal transplant recipients with osteonecrosis of the femoral head: three case reports

Osteonecrosis of the femoral head is a common and severe complication after renal transplantation. It is characterized by deterioration of hip joint function, which impairs quality of life. We present 3 renal transplant case reports of patients with osteonecrosis of the femoral head who underwent free vascularized fibular grafting at our hospital. Follow-up was from 1(1/2) to 2 years. All 3 patients exhibited good recovery with substantial improvement in joint function. Intraoperative and postoperative findings demonstrated the safety of this surgical procedure.

[Clinical application of the reverse neurocutaneous flap with anterior cutaneous branch of the femoral nerve supplied by the perforator of saphenous artery]

OBJECTIVE

To report the operative technique and clinical application of the neurocutaneous flap with anterior cutaneous branch of the femoral nerve supplied by the perforator of saphenous artery.

METHODS

The reverse neurocutaneous flap with anterior cutaneous branch of the femoral nerve supplied by the perforator of saphenous artery was used for repairing the defect around knee or at the upper pad of leg. Since Oct. 2005, 16 cases were treated. The flap size ranged from 15 cm x 7 cm to 30 cm x 15 cm. Flap rotation angle ranged from l00 degrees to 180 degrees.

RESULTS

13 flaps survived completely. Flap necrosis happened at the 1/7 - 1/5 distal end of the 3 flaps, which healed with dressing or local flap advancement. The patients were followed up for 6 to 24 months with satisfactory functional and cosmetic results. There was no morbidity at the donor site.

CONCLUSION

The flap has the advantages of both the perforator flap and the neurocutaneous flap. The size of the neurocutaneous flap with the anterior cutaneous branch of the femoral nerve can be enlarged for the large defect at lower extremity.

[Analysis of the donor-site complications of the anterolateral thigh flap]

OBJECTIVE

To investigate the donor-site complications of the anterolateral thigh flap and its influencing factors.

METHODS

Between July 1988 and July 2007, 427 patients were treated with anterolateral thigh flap. Among them, 33 patients had postoperative donor-site complications and their clinical data were analyzed retrospectively. There were 21 males and 12 females aged 14-47 years old (average 32.7 years old). The size of the wound defect ranged from 16 cm x 7 cm to 28 cm x 13 cm. The area of the flap harvested during operation ranged from 16 cm x 7 cm to 30 cm x 13 cm. The donor sites were treated by direct suture in 7 cases; free split-thickness skin graft in 23 cases, and reverse superficial epigastric artery flap repair in 3 cases. The size of graft in the donor site ranged from 10 cm x 5 cm to 18 cm x 8 cm. The occurrence of short-term (within 4 weeks) and long-term (over 6 months) complications were analyzed.

RESULTS

All patients were followed up for 8-54 months (average 21 months). There were 26 patients (78.8%) with short-term and long-term complications and 7 patients (21.2%) with long-term complications. The short-term complications included skin graft necrosis in 23 cases (69.7%), wound infection in 17 cases (51.5%), and muscle necrosis in 2 cases (6.1%). The long-term complications included non-healing wounds in 21 cases (63.6%), serious scar in 28 cases (84.8%), discomfort in 25 cases (75.8%), and dysfunction of the quadriceps femoris in 16 cases (48.5%).

CONCLUSION

The occurrence of anterolateral thigh flap donor-site complications is related to the anatomical structure of the anterolateral thigh region, the surgical procedure, and the patient's physique.

Construction of a recombinant eukaryotic expression plasmid containing human calcitonin gene and its expression in NIH3T3 cells

AIM

To construct a recombinant eukaryotic expression plasmid containing human calcitonin (hCT) gene and express the gene in murine fibroblast NIH3T3 cells.

MATERIALS AND METHODS

A murine Igkappa-chain leader sequence and hCT gene were synthesized and cloned into pCDNA3.0 to form the pCDNA3.0-Igkappa-hCT eukaryotic expression vector, which was transfected into NIH3T3 cells. The mRNA and protein expressions and secretion of hCT were detected. Primarily cultured osteoclasts were incubated with the supernatant of pCDNA3.0-Igk-hCT-transfected NIH3T3 cells, and their numbers were counted and morphology observed.

RESULTS

The expression and secretion of hCT were successfully detected in pCDNA3.0-Igk-hCT-transfected NIH3T3 cells. The number of osteoclasts was decreased and the cells became crumpled when they were incubated with the supernatant of pCDNA3.0-Igk-hCT-transfected NIH3T3 cells.

CONCLUSION

A recombinant eukaryotic expression vector containing hCT gene was successfully constructed and expressed in NIH3T3 cells. The secreted recombinant hCT inhibited the growth and morphology of osteoclasts.

[Effect of various concentrations of platelet-rich plasma on osteogenic differentiation of skeletal muscle-derived stem cells]

OBJECTIVE

To investigate the effect of various concentration of platelet-rich plasma (PRP) on osteogenic differentiation of rabbit skeletal muscle-derived stem cells (SMSCs) cultured in vitro.

METHODS

Blood drawn from the central ear arteries of 9 one-year-old New Zealand white rabbits weighing 2.5-3.0 kg (male and female) was used to prepare PRP (Landesberg method). Full blood count and platelet count in PRP were tested. Soleus muscle of right hindlimb in rabbit was obtained and used to culture SMSCs in vitro. The cells at passage 3 were randomly divided into different groups: the experimental groups in which the cells were treated by conditioned culture media with various concentrations of autologous PRP (6.25%, 12.50%, 25.00%, 50.00%), and the control group in which the cells were treated with the media without PRP. At different time points after intervention, osteogenetic activity of the cells was detected by ALP staining observation, ALP activity detection was conducted, alizarin red staining for calcium nodules and immunofluorescence staining for osteocalcin were performed, and core binding factor alpha1 (Cbfalpha1) of osteogenic gene expression was tested by RT-PCR.

RESULTS

The full blood PRP count and the platelet count in PRP was (3.06 +/- 0.46) x 10(5)/microL and (18.08 +/- 2.10) x 10(5)/microL, respectively. ALP staining: the cells in all the experimental groups were positive for the staining with many black sediment particles in cytoplasm; the cells in the control group were negative staining. ALP activity: all the experimental groups were higher than the control group (P < 0.05), the experimental group at 12.50% was superior to other experimental groups at each time point (P < 0.05). Alizarin red staining: at 14 days after culture, orange-red calcium nodules were evident in all the experimental groups; no orange-red calcium nodules were observed in the control group with a mineralization rate of zero; there were significant difference between the experimental groups and the control group in terms of mineralization rate (P < 0.05), the experimental group at 12.50% had a higher mineralization rate than other experimental groups (P < 0.05). Immunofluorescence staining for osteocalcin: at 7 days after culture, the experimental groups were positive for the staining with yellow fluorescence in cytoplasm, and the result of the control group was negative. RT-PCR detection: no obvious changes of the gene expression were noted at 4, 12, and 24 hours after culture in the control group; the gene expression in all the experimental groups was significant superior to that of control group, especially at 12 hours, and the expression in the experimental group at 12.50% was the highest.

CONCLUSION

PRP can obviously promote the osteogenic differentiation of SMSCs cultured in vitro in a concentration-dependent manner, and the 12.50% is proved to be the ideal concentration.