2018年 · 第21卷第04期

The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical management of these complex injuries includes debridement & lavage of the open wound with combined bony and soft tissue reconstruction. Good results depend on early high quality definitive surgery usually with early stable internal fixation and associated soft tissue repair. While all elements of the surgical principles are very important and depend on each other for overall success the most critical element appears to be achieving very early healthy soft tissue cover. As the injuries become more complex this involves progressively more complex soft tissue reconstruction and may even requiring urgent free tissue transfer requiring close co-operative care between orthopaedic and plastic surgeons. Data suggests that the best results are obtained when the whole surgical reconstruction is completed within 48-72 h.

Purpose: To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice. Methods: This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded. Results: All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases). Conclusion: In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials.

Purpose: To express the versatility of a variety of non-microsurgical skin flaps used for coverage of difficult wounds in the lower third of the leg and the foot over 4 years period. Five kinds of flaps were used. Each flap was presented with detailed information regarding indication, blood supply, skin territory and technique. Methods: Altogether 26 patients underwent lower leg reconstruction were included in this study. The reconstructive procedures applied five flaps, respectively distally based posterior tibial artery perforator flap (n = 8), distally based peroneal artery perforator flap (n = 4), distally based sural flap (n = 6), medial planter artery flap (n = 2) and cross leg flaps (n = 6). Results: In all cases, there were no signs of osteomyelitis of underlying bones or discharge from the undersurface of the flaps. Fat necrosis occurred at the distal end of posterior tibial artery perforator flap in one female patient. The two cases of medial planter artery flap showed excellent healing with closure of donor site primarily. One cross leg flap had distal necrosis. Conclusion: Would at lower third of leg can be efficiently covered by posterior tibial, peroneal artery and sural flaps. Heel can be best covered by nearby tissues such as medial planter flap. In presence of vascular compromise of the affected limb or exposure of dorsum of foot, cross leg flap can be used.

Purpose: Wrist has a complex anatomy and undergoes complex injuries. Scaphoid fracture is one of such injuries. It is the most common fracture in carpal bone. Most of the scaphoid fractures are missed on initial X-rays. Magnetic resonance imaging (MRI) is considered as a gold standard for diagnosing scaphoid fractures. Ultrasonography (USG) is emerging as a good alternative to make an early diagnosis of scaphoid fractures. Our aim is to throw light upon the role of USG in detection of scaphoid fractures. Methods: The study was centered upon 114 patients in the age range 10-65 years, with traumatic wrist injury and were clinically suspected to have scaphoid fractures. Patient with non-traumatic history, bilateral wrist injury and late presentation were excluded. X-rays, USG using high frequency probe and MRI were done for all patients. MRI was considered to be the gold standard test. Patients were followed up at 6 weeks. Results: Of the 114 patients, X-ray could diagnose scaphoid fractures in 48 patients, 30 of which were confirmed by MRI. USG results were positive in 74 patients, of which MRI was positive in 67 patients. The accuracy of scaphoid fracture detection with USG was 98.04% in comparison to X-ray (20.58%), which was statistically significant. Conclusion: USG provides a more accurate and reliable method of making an early diagnosis of scaphoid fracture than X-rays. It is non-invasive, non-expensive and allows better visualisation of cortical disruption.

Purpose: To evaluate the quality of life among survivors after sepsis in 2 years, comparing with critical patients without sepsis and the general people, analyze the changes and the predictors of quality of life among septic survivors. Methods: This prospective case-control study screened the intensive care unit (ICU) patients in Tianjin Third Central Hospital from January 2014 to October 2017, and the Chinese general population in the previous studies was also included. According to inclusion criteria and exclusion criteria, 306 patients with sepsis were enrolled as the observation group, and another 306 patients without sepsis in ICU during the same period, whose ages, gender and Charlson Comorbidity Index matched with observation group, were enrolled as the control group. At 3 mo, 12 mo, and 24 mo after discharge, the Mos 36-item Short Form Health Survey (SF-36), the Euroqol-5 dimension (EQ-5D), and the activities of daily living (ADL) were evaluated in face-to-face for the quality of life among survivors. Results: There were 210 (68.6%) septic patients and 236 (77.1%) non-septic critically ill patients surviving. At 3 months after discharge, the observation and control groups had the similar demographic characteristics (age: 58.8 ± 18.1 years vs. 57.5 ± 17.6 years, p = 0.542; male: 52.0% vs. 51.4%, p = 0.926). However, the observation group had higher acute physiology and chronic health evaluation II (APACHEII) scores, higher sequential organ failure assessment (SOFA) scores, longer hospital stay, and longer ICU stay than the control group did (p < 0.05). There were no significant differences in the eight dimensions of the SF36 scale, the EQ-5D health utility scores, and the activities of daily life scores between septic survivors and non-septic survivors (p > 0.05). In addition, compared with the quality of life of the Chinese general population (aged 55-64 years), the quality of life of septic patients were significantly lower at 3 months after discharge (p < 0.05). Comparing the quality of life of the ill patients who had been discharged at 3 mo and 24 mo, the general health improved statistically (p = 0.000) and clinically (score improvement > 5 points). Older age (OR, 1.050; 95% CI, 1.022-1.078, p = 0.000), female (OR, 3.375; 95% CI, 1.434-7.941, p = 0.005) and longer mechanical ventilation time (OR, 3.412; 95% CI, 1.413, 8.244, p = 0.006) were the risk factors for the quality of life of septic survivors. Conclusion: The long-term quality of life of septic survivors was similar to that of non-sepsis critically ill survivors. After discharge, the general health of sepsis improved overtime. Age, female and mechanical ventilation time (>5 days) were the predictors of the quality of life after sepsis.

Purpose: To investigate the effects of estrogen G protein-coupled receptor 30 (GPR30) agonist G1 on hippocampal neuronal apoptosis and microglial polarization in rat traumatic brain injury (TBI). Methods: Male SD rats were randomly divided into sham group, TBI ＋vehicle group, TBI ＋G1 group. Experimental moderate TBI was induced using Feeney's weigh-drop method. G1 (100μg/kg) or vehicle was intravenously injected from femoral vein at 30 min post-injury. Rats were sacrificed at 24 h after injury for detection of neuronal apoptosis and microglia polarization. Neuronal apoptosis was assayed by immunofluorescent staining of active caspase-3. M1 type microglia markers (iNOS and IL-1β) and M2 type markers (Arg1 and IL-4) were examined by immunoblotting or ELISA. Total protein level of Akt and phosphorylated Akt were assayed by immunoblotting. Results: G1 significantly reduced active caspase-3 positive neurons in hippocampus. Meanwhile G1 increased the ratio of Arg1/iNOS. IL-1β production was decreased but IL-4 was increased after G1 treatment. G1 treatment also increased the active form of Akt. Conclusions: GPR30 agonist G1 inhibited neuronal apoptosis and favored microglia polarization to M2 type.

Purpose: Microgravity is known to cause endothelium dysfunction in astronauts returning from spaceflight. We aimed to reveal the regulatory mechanism in alterations of human endothelial cells after simulated microgravity (SMG). Methods: We utilized the rotary cell culture system (RCCS-1) to explore the subsequent effects of SMG on human umbilical vein endothelial cells (HUVECs). Results: SMG-treated HUVECs appeared obvious growth inhibition after return to normal gravity, which might be attributed to a set of responses including alteration of cytoskeleton, decreased cell adhesion capacity and increased apoptosis. Expression levels of mTOR and its downstream Apaf-1 were increased during subsequent culturing after SMG. miR-22 was up-regulated and its target genes SRF and LAMC1 were down-regulated at mRNA levels. LAMC1 siRNAs reduced cell adhesion rate and inhibited stress fiber formation while SRF siRNAs caused apoptosis. Conclusion: SMG has the subsequent biological effects on HUVECs, resulting in growth inhibition through mTOR signaling and miR-22-mediated mechanism.

The most commonly accepted system of classification for tibia plateau fractures is that of Schatzker. Increasingly, both high energy injuries and atypical osteoporotic fragility failures have led to more complex, unusual and previously undescribed fracture patterns being recognized. We present a case of a patient with a previously unreported pattern of tibia plateau fracture and knee dislocation. We highlight the challenges confronted and present the management and the outcomes of his injury. A 28-year old male motorcyclist was involved in a head on collision with a truck and was transferred by helicopter to our level 1 major trauma centre emergency department. His injuries were a circumferential degloving injury to his left leg and a right lateral tibial plateau fracture/knee dislocation. The pattern of the lateral tibial plateau fracture was unique and did not fit any recognised classification system. The patient received a spanning external fixator initially and after latency of 12 days for soft tissue resuscitation he underwent definite fixation through an antero-lateral approach to the proximal tibia with two cannu- lated 6.5 mm partially threaded screws and an additional lateral proximal tibia plate in buttress mode. A hinged knee brace was applied with unrestricted range of motion post-operatively and free weight bearing were permitted post operatively. At the 6 months follow up, the patient walks without aids and with no limp. Examination revealed a stable joint and full range of motion. Plain radiographs revealed that the fracture healed with good alignment and the fixation remained stable. High energy injuries can lead to more complicated fracture patterns, which challenge the orthopaedic surgeons in their management. It is crucial to understand the individual fracture pattern and the possible challenges that may occur. This study reports a lateral tibia plateau fracture/dislocation which perhaps is best described as a reverse Schatzker IV type fracture.

Developmental dysplasia of the hip (DDH) is one of the most common congenital disorders in childhood. Its diverse pathological changes require different treatments and result in different outcomes. Although many studies have been conducted on DDH, some special pathology is still unrecognized. We here presented a rare case of a one-year and eleven-month old girl with DDH; a half-free intra-articular osteocartilaginous tissue was found in her right hip joint. X-ray, computer assisted tomography (CT) and magnetic resonance imaging (MRI) were performed to evaluate the pathological changes. MRI revealed some positive findings. The patient experienced open reduction and histopathological examination of the small tissue. Through gross anatomy it is a half-free intra-articular osteocartilaginous tissue, which can fully match a fossa observed at the femoral head. Histopathological examination found that the tissue was composed of collagenous fiber and cartilage-like tissue. Interestingly, we found the expression of type I collagen according to immunohistochemical analysis, which indicated that the cartilage-like tissue was formed due to laceration of the articular cartilage. This kind of disorder should be included as one of the pathologies of DDH. The most possible origin of this tissue is the femoral head which we speculate may have been fractured before.

It is estimated that 15% of traffic accidents cause trauma to large vessels. In about 70%-95% of cases, aortic rupture took place in the distal ligament of the left subclavian artery, whereas in the remaining cases rupture occurred in the ascending aorta above the aortic valve. Trauma to the aortic sinus and coronary arteries is rarely found in traffic accident victims. Therefore, coronary artery trauma is often misdiagnosed as coronary atherosclerotic heart disease. The present case is a 42 years old male who survived from a traffic accident. He presented with aortic sinus and left coronary artery trauma. He was misdiagnosed as having coronary atherosclerotic heart disease, and therefore wrongly given antiplatelet medicine, such as aspirin, in another hospital. Definite diagnosis was achieved in our hospital, and the patient underwent Bentall and mitral valve replacement, as well as tricuspid valvuloplasty. The aortic occlusion time during surgery was 47 min, and the total cardiopulmonary bypass time was 63 min. After surgery, transthoracic echocardiography confirmed that all the artificial valves worked sufficiently. The patient felt good and symptoms such as asthma and decreased exercise tolerance disappeared. This case taught us that acute aortic syndrome cannot be ignored when patients present with pectoralgia; antiplatelet medication should not be given before definite diagnosis.

This case report reveals the implementation of sensorimotor adaptation and learning process for rehabilitation in a patient with traumatic brain injury to achieve optimum recovery which is permanent in nature in compliance to the disability rating scale. A twenty two year old gentleman who had a history of fall was diagnosed as having subarachnoid hemorrhage along with diffuse axonal injury of the brain and bilateral lung contusion with pneumothorax. He underwent a total of ten months of sensorimotor adaptation and learning process for rehabilitation, which achieved functional mobility with a walker.