2022年 · 第25卷第06期

Transparency Ecosystem for Research and Journals in Medicine (TERM) working group summarized the essential recommendations that should be considered to review and publish a high-quality guideline. These recommendations from editors and reviewers included 10 components of essential requirements: systematic review of existing relevant guidelines, guideline registration, guideline protocol, stakeholders, conflicts of interest, clinical questions, systematic reviews, recommendation consensus, guideline reporting and external review. TERM working group abbreviates them as PAGE (essential requirements for Publishing clinical prActice GuidelinEs), and recommends guideline authors, editors, and peer reviewers to use them for high-quality guidelines.

Sepsis remains one of the leading causes of death globally, in spite of advanced developments in intensive care and better understandings of pathophysiology related to sepsis. There is no special treatment or drug available for sepsis, currently. Under normal circumstances, neutrophil is a major player in acute infection control. However, during sepsis, the migration abilities and antimicrobial functions of neutrophils are impaired, resulting in a dysregulated immune response. Recent studies have indeed demonstrated that blocking or reversing neutrophil migration and impaired antibacterial function can improve the outcomes in septic animal models. This article systemically synthesized information regarding related factors and signaling involved in the functions of neutrophils in sepsis. This review also discussed the possibility that neutrophils be used as a marker for specific diagnosis and/or prediction of the outcomes of sepsis.

Fractures of the acetabulum in elderly patients were often caused by low energy trauma. Fractures involving anterior column are more common and often associated with impaction and comminution. Osteoporosis further complicates the management. Percutaneous fracture fixation has low morbidity but it is a technically demanding procedure. Open reduction and fracture fixation is done with or without simultaneous total hip replacement. Delayed total hip replacement is considered in posttraumatic arthritis patients. Patients with minimal displaced fractures, associated both-column fractures with secondary congruence of joint and patients who are medically unfit for surgery can be managed non-operatively. Whatever be the method of management, these elderly patients should be mobilised as early as possible.

Purpose: Antibiotic-loaded bone cement (ALBC) was usually used to prevent periprosthetic joint infection (PJI) in primary total knee arthroplasty (PTKA), but whether to use ALBC or plain bone cement in PTKA remains unclear. We aimed to compare the occurrence rate of PJI using two different cements, and to investigate the efficacy of different antibiotic types and doses administered in preventing surgical site infection (SSI) with ALBC. Methods: The availability of ALBC for preventing PJI was evaluated by using a systematic review and meta-analysis referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Existing articles until December 2021 involving PTKA patients with both ALBC and plain bone cement cohorts were scanned by searching "total knee arthroplasty" , "antibiotic-loaded cement" , "antibiotic prophylaxis" , "antibiotic-impregnated cement" and "antibiotic-laden cement" in the database of PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library. Subgroup analysis included the effectiveness of different antibiotic types and doses in preventing SSI with ALBC. The modified Jadad scale was employed to score the qualities of included articles. Results: Eleven quantitative studies were enrolled, including 34,159 knees undergoing PTKA. The meta-analysis results demonstrated that the use of prophylactic ALBC could significantly reduce the prevalence of deep incisional SSI after PTKA, whereas there was no significant reduction in the rate of superficial incisional SSI. Moreover, gentamicin-loaded cement was effective in preventing deep incisional SSI, and the use of high-dose ALBC significantly reduced the rate of deep incisional SSI after PTKA. Besides, no significant adverse reactions and complications were stated during the use of ALBC in PTKA. Conclusion: The preventive application of ALBC during PTKA could reduce the rates of deep PJI. Furthermore, bone cement containing gentamicin and high-dose ALBC could even better prevent deep infection after PTKA. However, the existing related articles are mostly single-center and retrospective studies, and further high-quality ones are needed for confirmation.

Purpose: Olecranon fractures are particularly vulnerable to distraction and subsequent fracture dislocation due to the high tensile forces. Surgical treatment aims at reducing the fracture and restoring the anatomical joint surface condition, as well as neutralizing the strain inhibiting fracture healing. The XS nail® (Intercus GmbH, Bad Blankenberg, Germany), an intramedullary implant exerting compression across the entire fracture surface, unlike plates, leaves a minimal extra-cortical profile, and can be secured with threaded locking wires, thereby retaining the anatomical reduction without displacement or steps within the articular surface, which was often found in tension band wiring. After encouraging initial results, the long-term outcome was assessed. Methods: This retrospective study evaluated the long-term outcome of patients surgically treated at our trauma center between January 2002 and December 2005 using the XS nail®. Patients over the age of 18 years eligible for the study must have undergone surgery for isolated, recent (less than 14 days) traumatic olecranon fractures, without concomitant injuries to the ipsilateral elbow and forearm. Further exclusion criteria were pseudarthrosis, re-fractures and osteotomy for distal humerus surgery, as well as polytraumatized patients unable to aid in their own recovery. Data were retrospectively gathered by standardised questionnaire and patient records, as well as surgery and anesthesiology reports. Data analysis was performed using Microsoft Office Excel® 2016. Results: There were 32 patients, 13 males (mean age 49.0 years) and 19 females (mean age 68.9 years) with 11 Schatzkers type D, 7 each type A and C, 5 type B and 2 type E at an average of 55.2 months, all showing complete consolidation. Of them, 6 patients had a loss of range of motion with more than 10° in the sagittal plane, and only 1 patient exceeded 10° reduction of supination. Twenty-five patients reported being pain-free under all circumstances, and all but 2 patients (93.75%) had returned to their previous activity level. The average disabilities of the arm, shoulder and hand score was 21.15 (range 0-88.3), and the overall Mayo elbow performance index was 91.87, without complications, such as wound infection, neurovascular impairment or premature hardware removal. Conclusion: Using the XS nail® system, all fracture types can be successfully treated and the rate of complications was lower than that treated by standard methods published in current literature. An excellent functional outcome, high range of motion as well as good retention of reduction without soft tissue irritation makes this a very suitable implant for fractures subject to tension.

Purpose: To compare the stability of the posterior anatomic self-locking plate (PASP) with two types of popular reconstruction plate fixation, i.e. double reconstruction plate (DRP) and cross reconstruction plate (CRP), and to explore the influence of sitting and turning right/left on implants. Methods: PASP, DRP and CRP were assembled on a finite element model of both-column fractures of the left acetabulum. A load of 600 N and a torque of 8 N·m were loaded on the S1 vertebral body to detect the change of stress and displacement when sitting and turning right/left. Results: The peak stress and displacement of the three kinds of fixation methods under all loading conditions were CRP > DRP > PASP. The peak stress and displacement of PASP are 313.5 MPa and 1.15 mm respectively when turning right; and the minimal was 234.0 Mpa and 0.619 mm when turning left. Conclusion: PASP can provide higher stability than DRP and CRP for both-column acetabular fractures. The rational movement after posterior DRP and PASP fixation for acetabular fracture is to turn to the ipsilateral side, which can avoid implant failure.

Purpose: Stable Weber B ankle fractures are treated by a walking boot for 6 weeks and bearing full weight through the boot as tolerated. The aim of the present study was to assess the outcome parameters of this treatment protocol, evaluate the efficacy of using the walking boot, and investigate any possible predicting factors that could affect the outcomes. Methods: All the patients with stable Weber B ankle fractures, treated in our hospital between January 2018 and December 2018, were prospectively included to the study. The patients were evaluated clinically, and the patient-reported outcome measures data were collected at the 2 and 6 weeks post-injury. Chi square, Spearman's rho test, independent samples and paired sample t-tests were used for the monovariant analysis. Results: A total of 128 consecutive patients (aged 52.2 ± 19.1 years) with supination external rotation type 2 fracture were finally included to the study. At the 2 weeks follow-up, the reported outcome measures scores were in moderate levels, but improved significantly at the 6 weeks follow-up (p < 0.0001). Multivariant analysis revealed that the ability to bear full weight without the boot at the 2 weeks after diagnosis was the only variable, which made statistically unique contribution to the foot and ankle disability index score at the 6 weeks (p = 0.005). Conclusion: Conservative treatment using a walking boot with advice to bear full weight of stable ankle Weber B fractures can bring to good functional outcomes. The ability to bear full weight without the aid of the walking boot at 2 weeks after diagnosis was the only significant predicting factor for better outcomes at 6 weeks after diagnosis.

Purpose: The treatment and outcome of tibial stress fractures concomitant with knee osteoarthritis (OA) are complicated. The aim of this study was to evaluate the functional and radiological outcome of total knee arthroplasty with long tibial stem as a treatment for patients having knee OA and tibial stress fracture. Methods: Patients who were diagnosed to have proximal tibia stress fracture along with knee OA at our institution between June 2013 and November 2018 were included in our study. All patients underwent total knee arthroplasty with long tibial stem. Preoperative and postoperative functional assessments were done according to range of movement of the knee joint, knee society score and knee injury and OA outcome score. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Results: Twelve patients were included in the study. All patients were found to have stress fractures in the proximal half of tibia and extra-arthrosis. Four patients had non-union/delayed union, and 8 patients had acute fractures. The average preoperative range of movement was 88.1°, which improved to 116.3° at 3 months following surgery. It was found that the fracture has healed in all cases. Mean knee society score improved from 32.9 preoperatively to 89.3 at 1 year follow-up. Knee injury and OA outcome score improved from a mean score of 28.3 preoperatively to 81.1 at 1 year follow-up. Conclusion: Stress fractures can occur in the proximal tibia in patients with knee OA. Total knee arthroplasty with tibial stem provides a suitable solution for both conditions. Additional plating or bone graft is unlikely to be required.

Purpose: The most popular surgical approach to manage Lisfranc fracture-dislocations is the double-incision approach, which frequently causes a variety of complications, such as skin necrosis, rotational malreduction of the first tarsometatarsal joint (TMTJ) and lateral column dorsoplantar malreduction of the TMTJ. We introduce a three-incision approach to treat Lisfranc fracture-dislocations with only minor postoperative complications and good foot function. Methods: We prospectively selected 30 previously healthy patients, ranging from 18 to 60 years of age, but only 23 patients completed the follow-up and thus were finally included, with an average age of 38.1 ± 12.9 years. All patients have sustained Lisfranc fracture-dislocations involving all three-column; 13.0% (3/23) were Myerson classification type A (medial), 47.8% (11/23) were type A (lateral), and 39.1% (9/23) were type C2. All patients were treated via a three-incision approach: a long incision made along the lateral border of the second ray was used as a working incision to visualize and reduce the first three TMTJs, as well as to apply internal fixation instrumentation; a 2 cm medial incision was made at the medial side of the first TMTJ as an inspecting incision, ensuring good reduction of the first TMTJ in medial and plantar view; another 1 cm inspecting incision was made at the dorsal side of the fourth/fifth TMTJ to prevent sagittal subluxation of the lateral column. Mean ± SD was used for quantitative data such as operation time, follow-up time and foot function scores. Postoperative complications were documented, and foot function was evaluated using the American orthopaedic foot & ankle society score, foot function index and Maryland foot score at follow-up. The foot function of the injured foot and contralateral foot of the same patient was at the end of follow-up, and independent sample t-test was used for statistical analysis. Results: The median operation time was 117.9 ± 14.6 min (range 93 - 142 min). All complications occurred within three months after the operation, and included delayed wound healing (17.4%), superficial infection (8.7%), complex regional pain syndrome (4.3%) and neuroma (4.3%). There was no case of postoperative skin necrosis or malreduction. At the end of follow-up of 14.1 ± 1.2 months (range 12-16 months), the median American orthopaedic foot & ankle society score of the operated foot was 89.7 ± 5.7, the median foot function index was 21.7 ± 9.9, and the median Maryland foot score was 88.7 ± 4.8. There were no significant differences between the operated and contralateral sides, in terms of foot function, at the end of followup (p > 0.05). Conclusion: The three-incision approach can provide adequate visualization of all TMTJs to ensure anatomical reduction and offer sufficient working space to apply internal fixation instrumentation, which is effective in treating three-column Lisfranc fracture-dislocations with minor soft tissue complications and satisfactory functional recovery.

Purpose: Venous thromboembolism (VTE) is a major health issue among hip fracture patients. This study aimed to develop an information platform based on a mobile application and then evaluate whether information platform-based nursing could improve patient's drug compliance and reduce the incidence of VTE in hip fracture patients. Methods: This study retrospectively analyzed hip fracture patients who were treated with conventional prevention and intervention methods for VTE (control group) between January 2008 and November 2012, and prospectively analyzed hip fracture patients who were treated with nursing intervention based on the information platform (study group) between January 2016 and September 2017. All the patients included in the both groups were hip fracture patients who had an age over 50 years, treated with surgery, and hospitalized ≥ 48 h. Patients were excluded if they admitted to hospital due to old fractures, had a severe bleeding after 72 h of admission, diagnosed with any type of VTE, or refused to participate in the study. The information platform was divided into medical, nursing, and patient interface. Based on the information platform, medical practitioners and nurses could perform risk assessments, monitoring management and early warnings, preventions and treatments, health educations, follow-up, and other aspects of nursing interventions for patients. This study compared essential characteristics, drug compliance, VTE occurrence, and mean length of hospitalization between the two groups. Besides, a subgroup analysis was performed in the study group according to different drug compliances. SPSS 18.0 software (IBM Corp., NY, and USA) was used for statistical analysis. Results: Altogether 1177 patients were included in the control group, and 491 patients in the study group. Regarding baseline data, patients in the study group had more morbidities than those in the control group (p < 0.05). The difference of drug compliance between the two groups was statistically significant (p < 0.001): 761 (64.7%) of the patients in the control group and only 30 (6.1%) patients in the study group had poor drug compliance. In terms of VTE, 10.7% patients (126/1177) in the control group had VTE, and the rate in the study group was 7.1% (35/491), showing a statistically significant difference (p = 0.02). Moreover, the average length of hospitalization in the study group was also significantly lower than that in the control group (10.4 days vs. 13.7 days, p < 0.001). Subgroup analyses of the study group showed that the incidence of VTE in patients with poor, partial, and good compliances were 56.7% (17/30), 5.8% (10/171), and 2.8% (8/290), respectively, revealing a significantly huge difference (p < 0.001). Conclusions: Poor drug compliance leads to higher VTE occurrence. The information platform-based nursing can effectively improve the compliance of hip fracture patients and thus considerably reduce the incidence of VTE. The mobile application may be an effective tool to prevent VTE in hip fracture patients.

Purpose: The combined use of antibiotics and anti-inflammatory medicine to manage bacterial endotoxin-induced inflammation following injuries or diseases is increasing. The cytokine level produced by macrophages plays an important role in this treatment course. Ciprofloxacin and indomethacin, two typical representatives of antibiotics and anti-inflammatory medicine, are cost-effective and has been reported to show satisfactory effect. The current study aims to investigate the effect of ciprofloxacin along with indomethacin on the secretion of inflammatory cytokines by macrophages in vitro. Methods: Primary murine peritoneal macrophages and RAW 264.7 cells were administrated with lipopolysaccharide (LPS) for 24 h. The related optimal dose and time point of ciprofloxacin or indomethacin in response to macrophage inflammatory response inflammation were determined via macrophage secretion induced by LPS. Then, the effects of ciprofloxacin and indomethacin on the secretory functions and viability of various macrophages were determined by enzyme-linked immunosorbent assay and flow cytometry analysis, especially for the levels of interleukin (IL)-1β, IL-6, IL-10, and tumor necrosis factor (TNF)-α. The optimal dose and time course of ciprofloxacin affecting macrophage inflammatory response were determined by testing the maximum inhibitory effect of the drugs on pro-inflammatory factors at each concentration or time point. Results: According to the levels of cytokines secreted by various macrophages (1.2 × 106 cells/well) after administration of 1 μg/mL LPS, the optimal dose and usage timing for ciprofloxacin alone were 80 μg/mL and 24 h, respectively, and the optimal dose for indomethacin alone was 10 μg/mL. Compared with the LPS-stimulated group, the combination of ciprofloxacin and indomethacin reduced the levels of IL-1β (p < 0.05), IL-6 (p < 0.05), IL-10 (p < 0.01)), and TNF-α (p < 0.01). Furthermore, there was greater stability in the reduction of inflammatory factor levels in the combination group compared with those in which only ciprofloxacin or indomethacin was used. Conclusion: The combination of ciprofloxacin and indomethacin suppressed the levels of inflammatory cytokines secreted by macrophages in vitro. This study illustrates the regulatory mechanism of drug combinations on innate immune cells that cause inflammatory reactions. In addition, it provides a new potential antibacterial and anti-inflammatory treatment pattern to prevent and cure various complications in the future.

Tibial plateau and distal femoral fractures are common injuries presenting a significant operative challenge. Complexity of the fracture often needs multi-planar surgical access. A combined two-staged procedure is frequently suggested both in supine and prone position to address this issue. However, this will significantly increase the operative time and eventually impact the outcome, in addition to the complications associated with prone positioning. In this study we used a standard orthopaedic table to position these patients in order to grant access to the postro-medial and a postro-lateral structures while the patient stays in supine setup, at the same time, giving the flexibility to change the alignment from valgus to varus and vice versa. This facilitates fracture reduction while addressing the anatomical structure of the knee. A further advantage is the unobstructed imaging access throughout the surgical fixation. This facilitates the reduction in operative time hence leading to a better outcome in these difficult fractures. We tested this positioning technique in more than 40 patients over a 4-year period at two different centres in the United Kingdome. We found that this approach is safe, reproducible and relatively easy to set up in the two centres.

Masquelet technique is one of the modalities for the treatment of long bone defect. Using cancellous bone graft to fill the bone defect is always a concern in children due to the small size of their iliac crest and open growth plate. We reported a case of 13-year-old male who presented with gap non-union of middle third of tibia. We applied a modified Masquelet technique by using only the cortical fibular graft instead of cancellous bone to fill the space surrounded by induced membrane. Fibula was used as a nonvascularized strut graft and matched stick graft to achieve complete union. We concluded that nonvascularized fibula grafting is an easy and effective option to fill the bone defect in children in the second stage of Masquelet technique.

Blunt traumatic tracheobronchial injury is rare, but can be potentially life-threatening. It accounts for only 0.5%-2% of all trauma cases. Patients may present with non-specific signs and symptoms, requiring a high index of suspicion with accurate diagnosis and prompt treatment. A 26-year-old female was brought into the emergency department after sustained a blunt trauma to the chest from a high impact motor vehicle accident. She presented with signs of respiratory distress and extensive subcutaneous emphysema from the chest up to the neck. Her airway was secured and chest drain was inserted for right sided pneumothorax. CT of the neck and thorax revealed a collapsed right middle lung lobe with a massive pneumothorax, raising the suspicion of a right middle lobe bronchus injury. Diagnosis was confirmed by bronchoscopy. In view of the difficulty in maintaining her ventilation and persistent pneumothorax with a massive air leak, immediate right thoracotomy via posterolateral approach was performed. The right middle lobar bronchus tear was repaired. There were no intra- or post-operative complications. She made an uneventful recovery. She was asymptomatic at her first month follow-up. A repeated chest X-ray showed expanded lungs. Details of the case including clinical presentation, imaging and management were discussed with an emphasis on the early uses of bronchoscopy in case of suspected blunt traumatic tracheobronchial injury. A review of the current literature of tracheobronchial injury management was presented.

Subcutaneous emphysema is commonly associated with infection caused by gas-producing organisms. In this case report, we describe a rare instance of traumatic subcutaneous emphysema of the hand and forearm caused by a puncture injury to the first web space of the hand. Our objective is to increase awareness of the potential for seemingly minor trauma to cause entrapment of significant air in subcutaneous tissues, thereby decreasing the likelihood that a clinically benign-appearing patient will be started down an unnecessarily aggressive treatment pathway. A 16-year-old, otherwise healthy white female, presented to the pediatric emergency room with an impressive amount of subcutaneous emphysema that developed over a 12-h period after sustaining an accidental laceration to the first web space of her right hand. She appeared nontoxic and had a clinically benign presentation. A comprehensive work-up was performed. She was splinted by the orthopedic surgery resident on call, and was admitted to the Pediatric Intensive Care Unit for overnight monitoring. She received tetanus vaccination and broad-spectrum antibiotics. The patient was discharged 2 days after admittance, with a splint applied to her right hand and forearm. She undertook home-based physical and occupational therapy. She had a pain-free range-of-motion in the right wrist, elbow and shoulder. The swelling in the right hand subsided completely. Although initially alarming, traumatic subcutaneous emphysema in an otherwise healthy patient from minor wounds (as featured in this case) does not necessarily mean one ought to proceed down an aggressive treatment algorithm. Careful evaluation of the patient's history, clinical examination findings, and determination of the Laboratory Risk Indicator for Necrotizing Fasciitis score can help guide physicians in the management of traumatic subcutaneous emphysema and potentially avoid unnecessary and costly interventions.

Corynespora cassiicola is a common plant pathogen responsible for leaf-spotting diseases in the tropical and subtropical areas. C. cassiicola seldom causes human infections. Here we describe a case of subcutaneous phaeohyphomycosis caused by C. cassiicola in a 76-year-old Chinese man, who presented to our hospital with a purulent discharge and painful sensation on his right leg. Skin biopsy revealed an abscess, and culture confirmed C. cassiicola to be the causative agent. The result was further identified by sequence analysis of the internal transcribed spacer region. The patient was successfully treated with systemic voriconazole and wound debridement: the lesion disappeared after 20 days.