Development of a risk-predicting score for hip preservation with bone grafting therapy for osteonecrosis.

Identification and differentiation of appropriate indications on hip preserving with bone grafting therapy remains a crucial challenge in the treatment of osteonecrosis of the femoral head (ONFH). A prospective cohort study on bone grafting therapy for ONFH aimed to evaluate hip survival rates, and to establish a risk scoring derived from potential risk factors (multivariable model) for hip preservation. Eight variables were identified to be strongly correlated with a decreased rate of hip survival post-therapy, and a comprehensive risk scoring was developed for predicting hip-preservation outcomes. The C-index stood at 0.72, and the areas under the receiver operating characteristics for the risk score's 5- and 10-year hip failure event predictions were 0.74 and 0.72, respectively. This risk score outperforms conventional methods in forecasting hip preservation. Bone grafting shows sustained benefits in treating ONFH when applied under the right indications. Furthermore, the risk scoring proves valuable as a decision-making tool, facilitating risk stratification for ONFH treatments in future.

Autologous Costal Cartilage Grafting for a Large Osteochondral Lesion of the Femoral Head: A 1-Year Single-Arm Study with 2 Additional Years of Follow-up.

BACKGROUND: There is currently no ideal treatment for osteochondral lesions of the femoral head (OLFH) in young patients. METHODS: We performed a 1-year single-arm study and 2 additional years of follow-up of patients with a large (defined as >3 cm 2 ) OLFH treated with insertion of autologous costal cartilage graft (ACCG) to restore femoral head congruity after lesion debridement. Twenty patients ≤40 years old who had substantial hip pain and/or dysfunction after nonoperative treatment were enrolled at a single center. The primary outcome was the change in Harris hip score (HHS) from baseline to 12 months postoperatively. Secondary outcomes included the EuroQol visual analogue scale (EQ VAS), hip joint space width, subchondral integrity on computed tomography scanning, repair tissue status evaluated with the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and evaluation of cartilage biochemistry by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping. RESULTS: All 20 enrolled patients (31.02 ± 7.19 years old, 8 female and 12 male) completed the initial study and the 2 years of additional follow-up. The HHS improved from 61.89 ± 6.47 at baseline to 89.23 ± 2.62 at 12 months and 94.79 ± 2.72 at 36 months. The EQ VAS increased by 17.00 ± 8.77 at 12 months and by 21.70 ± 7.99 at 36 months (p < 0.001 for both). Complete integration of the ACCG with the bone was observed by 12 months in all 20 patients. The median MOCART score was 85 (interquartile range [IQR], 75 to 95) at 12 months and 75 (IQR, 65 to 85) at the last follow-up (range, 24 to 38 months). The ACCG demonstrated magnetic resonance properties very similar to hyaline cartilage; the median ratio between the relaxation times of the ACCG and recipient cartilage was 0.95 (IQR, 0.90 to 0.99) at 12 months and 0.97 (IQR, 0.92 to 1.00) at the last follow-up. CONCLUSIONS: ACCG is a feasible method for improving hip function and quality of life for at least 3 years in young patients who were unsatisfied with nonoperative treatment of an OLFH. Promising long-term outcomes may be possible because of the good integration between the recipient femoral head and the implanted ACCG. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Clinical and biochemical characteristics of 12 Chinese primary hypertrophic osteoarthropathy patients with HPGD mutations.

Primary hypertrophic osteoarthropathy (PHO) is a rare genetic disease mainly affecting the skeletal and skin. Two genes involved in prostaglandin degradation are known to be responsible for PHO: HPGD and SLCO2A1. HPGD gene mutation can cause PHO autosomal recessive 1 (PHOAR1). The purpose of the present study is to analyze the clinical and biochemical characteristics and HPGD gene mutations of 12 Chinese PHOAR1 patients. Twelve PHOAR1 patients from eleven families, including eleven males and one female, were enrolled in this study. Digital clubbing and periostosis came out to be the most common features, which always occur in the early childhood. We performed HPGD gene analysis and identified six novel (c.1A>G, c.34G>T, c.317T>A, c.475G>T, c.548C>T and c.421+1G>T) and one known (c.310_311delCT) HPGD mutations. The recurrent mutation c.310_311delCT were found in all eleven patients, suggesting it is a hotspot mutation. PHOAR1 patients are considered to have an autosomal recessive inheritance pattern. Here, in addition to nine compound heterozygous patients and two homozygous patients, we found one heterozygous patient and reviewed two heterozygous patients reported in other studies. In terms of biochemical characteristics, our PHOAR1 patients have elevated urinary prostaglandin E2 (PGE2) levels (P<0.001) and decreased urinary prostaglandin E metabolite (PGE-M) levels (P=0.04) compared with healthy controls. The patients' PGE2/PGE-M (E/M) ratio came out to be lower than normal subjects (P<0.001). This study provides a comprehensive description of the clinical phenotypes of Chinese PHOAR1 patients and expands the genotypic spectrum of the disease.

How can medial support for proximal humeral fractures be achieved when positioning of regular calcar screws is challenging? Slotting and off-axis fixation strategies.

BACKGROUND: Achieving medial support for proximal humeral fractures (PHFs) by regular calcar screw positioning is challenging when the humeral head is small or locking plates are placed distally, as there are unable inserted calcar screws into the humeral head. We aimed to investigate the suitability of the 2 strategies, slotting calcar screw (SCS) and off-axis calcar screw (OCS), to achieve medial support for PHFs. METHODS: Regular calcar screw (RCS), SCS, OCS, and noncalcar screw (NCS) were tested via mechanical experiments and finite element analysis (FEA), using synthetic bones for biomechanical comparisons. All PHFs treated in our hospital from March 2017 to March 2019 were reviewed. The patients were divided into 3 groups based on the calcar screw fixation: RCS, SCS, and OCS. The postoperative varus collapse (neck-shaft angle changed to less than 120°) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded. RESULTS: The properties of RCS, SCS, and OCS against the torsion and varus force were superior to those of NCS, whereas the stiffness of SCS, OCS, and RCS were similar. FEA predicted lower peri-screw strains in the OCS and SCS than in the RCS, indicating a lower risk of cut-out. Patients (n = 125; 75 female, 50 male) aged 55.9 ± 13.0 years were evaluated. Compared with the RCS (5/55), varus collapse incidences were not significantly higher following SCS (0/29, P = .094) or OCS (3/41, P = .756), and neither were DASH scores (P = .867 and .736, respectively). CONCLUSIONS: This study is a preliminary study demonstrating that the SCS and OCS fixation strategies could be useful alternatives when regular calcar fixation is not possible using the plate at hand.

Treatment of Advanced Kienböck's Disease Using 3D Printing Assisted Autologous Costochondral Transplantation: A Case Report.

CASE: We describe a patient with advanced Kienböck's disease, treated with 3-dimensional (3D) printing assisted costochondral transplantation. Cartilage shaping was achieved according to a biomimetic 3D-printed prosthesis designed by mirror symmetry of the healthy wrist. The inserted cartilage spacer was fixed using the autologous palmar longus tendon. After 14 months of follow-up, the patient had significant pain relief and had recovered nearly the full range of wrist motion. No significant absorption or osseous metaplasia of the cartilage was seen on the radiographic and magnetic resonance images. CONCLUSION: This costochondral transplantation strategy may offer a feasible treatment option for patients with severe Kienböck's disease.

Low Back Pain Caused by Iliopsoas Tendinopathy Treated with Ultrasound-Guided Local Injection of Anesthetic and Steroid: A Retrospective Study.

BACKGROUND: Low back pain is a prevalent symptom that occurs in all age of people, whereas the pathogenesis is unknown. Iliopsoas tendinopathy is an increasingly recognized hip disorder that may contribute to low back pain. Our purpose is to evaluate the effect of ultrasound-guided local injection of anesthetic and steroid into the trigger point of iliopsoas tendon in treating low back pain caused by iliopsoas tendinopathy. MATERIALS AND METHODS: This retrospective study reviewed 45 patients diagnosed with iliopsoas tendinopathy treated by B-ultrasound guided injection of 2 mL 2% lidocaine and 1 mL (5 mg) triamcinolone acetonide into the trigger point of iliopsoas tendon from March 2016 to June 2016. Medical records were collected to analyze the clinical presentation. Numerical Rating Scale (NRS) measuring low back pain and Harris Hip score (HHS) measuring hip pain and function were administered to determine patient outcomes. Telephone follow-up was conducted, and the mean follow-up was 11 months. RESULTS: We observed that most patients with iliopsoas tendinopathy also complain about chronic low back pain except for groin pain. After injection of anesthetic and corticosteroid into the iliopsoas tendon, the NRS of patients with low back pain fell from 7.68±1.31 to 2.58±1.16 immediately after the injection and 0.75±0.73 at follow-up. The HHS improved from 43.02±16.81 to 98.15±2.56 at follow-up. Statistically significant difference (P<0.001) was observed. All patients returned to their original level of function, and only five patients presented with mild low back pain at the follow-up. CONCLUSION: Low back pain is a prevalent presentation for iliopsoas tendinopathy. Diagnosis of iliopsoas tendinopathy should be considered in patients with low back pain with tenderness over the iliopsoas tendon. Ultrasound-guided local injection of anesthetic and steroid lead to satisfactory effect in relieving low back and groin pain and improving joint function.

Biomechanical analysis of fibular graft techniques for nontraumatic osteonecrosis of the femoral head: a finite element analysis.

BACKGROUND: Free vascularized fibula graft (FVFG) techniques have most consistently demonstrated beneficial effects in young patients diagnosed with nontraumatic osteonecrosis of the femoral head (NONFH), and the core track technique (CTT) in particular is the most commonly used technique. As an alternative to CTT, the modified light bulb technique (LBT) has been reported to have a higher success rate. However, its biomechanical outcomes are poorly understood. This study aimed to compare the biomechanical properties of modified LBT with those of CTT in treating NONFH. METHODS: Two types (C1 and C2) of NONFH finite element models were established on the basis of a healthy subject and the Japanese Investigation Committee (JIC) classification system, and the CTT and LBT procedures were simulated in each type of model. The average von Mises stresses and stiffness of the proximal femur were calculated by applying a load of 250% of the body weight on the femoral head to simulate walking conditions. In addition, two patient-specific models were built and simulated under the same boundary conditions to further validate the LBT. RESULTS: In the healthy subject-derived models, both the LBT and CTT resulted in reduced stresses in the weight-bearing area, central femoral head, femoral neck, and trochanteric and subtrochanteric regions and increased structural stiffness after surgery. In the weight-bearing area, the CTT reduced the stress more than the LBT did (36.19% vs 31.45%) for type C1 NONFH and less than the LBT did (23.63% vs 26.76%) for type C2 NONFH. In the patient-specific models, the stiffness and stresses also increased and decreased, respectively, from before to after surgery, which is consistent with the results of healthy subject-derived models. CONCLUSION: The biomechanical effects of the LBT and CTT differ by the JIC type of NONFH. In terms of preventing the collapse of the femoral head, the LBT may be more effective for JIC type C2 NONFH and may be a suitable alternative to the CTT, while for JIC type C1 NONFH, the CTT is still a better choice. Both techniques can improve the biomechanical properties of NONFH by reducing the proximal femoral stress and increasing the structural stiffness.

Bone marrow lesion on magnetic resonance imaging indicates the last chance for hip osteonecrosis treated with vascularized fibular grafting before collapse.

PURPOSE: Timing of surgery is the most critical prognostic factor for hip osteonecrosis treated with free vascularized fibular grafting (FVFG). Bone marrow lesion (BML) on MRI usually occurs immediately before femoral head collapse. We conducted a retrospective cohort study to evaluate whether the noncollapsed hips with BML can benefit from FVFG. METHODS: Consecutive patients undergoing modified FVFG were identified from our clinical repository between January 2014 and December 2014. Based on whether BML was pre-operatively detected, the four year radiographic and clinical outcomes were compared. RESULTS: In the BML cohort, 22 of 53 hips (42%) showed radiographic signs of osteonecrosis progression, which was significantly higher than that in the control cohort (8 of 49, 16%; P = 0.005). The BML hips showed a significantly lower pre-operative Harris Hip Score (HHS) than those without BML (77.8 vs. 85.5, P = 0.046), whereas no such difference was observed in the final HHS or its post-operative improvement (HHS 90 vs. 94, P = 0.397; HHS improvement 12 vs. 8, P = 0.067). In the subgroup of patients with a pre-operative HHS lower than 80, BML hips were associated with a slightly lower final HHS than hips without BML. Four of 5 (80%) failed hips with BML had a poor pre-operative hip function. CONCLUSION: BML indicates the last chance for a reproducible improvement in the treatment of hip osteonecrosis with FVFG before collapse. However, the concomitant lower pre-operative HHS (< 80) is a poor prognostic factor for BML-positive hips.

A 3D-printed, personalized, biomechanics-specific beta-tricalcium phosphate bioceramic rod system: personalized treatment strategy for patients with femoral shaft non-union based on finite element analysis.

BACKGROUND: Although double-plate fixation (DP), i.e., fixation with a combination of a main lateral plate (LP) and a support medial plate (MP), is a relatively mature method for treating femoral shaft non-union with bone defect causes complications. The purpose of this study was to evaluate LP fixation with a 3D-printed, personalized, biomechanics-specific ß-TCP bioceramic rod system (LP + 3DpbsBRS) as an alternative with less collateral damage. METHODS: Structure-specific finite element modelling was used to simulate femoral shaft non-union with bone defects and treatment with an LP only as the blank control. Then, the peak von Mises stress (VMS), the VMS distribution, and the plate displacement were determined to compare the effectiveness of LP + CBG (cancellous bone grafting), DP + CBG, and LP + 3DpbsBRS under 850 N of axial force. RESULTS: Our results indicated that the peak VMS was 260.2 MPa (LP + 3DpbsBRS), 249.6 MPa (MP in DP + CBG), 249.3 MPa (LP in DP + CBG), and 502.4 MPa (LP + CBG). The bending angle of the plate was 1.2° versus 1.0° versus 1.1° versus 2.3° (LP + 3DpbsBRS versus MP in DP + CBG versus LP in DP + CBG versus LP + CBG). CONCLUSION: The 3DpbsBRS in the LP + 3DpbsBRS group could replace the MP in the DP + CBG group by providing similar medial mechanical support. Furthermore, avoiding the use of an MP provides better protection of the soft tissue and vasculature.

J-bone graft with double locking plate: a symphony of mechanics and biology for atrophic distal femoral non-union with bone defect.

OBJECTIVE: Atrophic distal femur non-union with bone defect (ADFNBD) has been a worldwide challenge to treat due to the associated biological and mechanical problems. The purpose of this study was to introduce a new solution involving the use of a J-shaped iliac crest bone graft (J-bone) combined with double-plate (DP) in the treatment of femoral non-union. METHODS: Clinically, 18 patients with ADFNBD were included in this retrospective study and were treated with a combination of J-bone graft and DP. The average follow-up time was 22.1 ± 5.5 months (range, 14 to 34 months). The imaging information and knee joint activity tests and scores were used to evaluate the time to weight-bearing, the time to non-union healing, and the knee joint mobility. A finite element analysis was used to evaluate the differences between the following: (1) the use of a lateral locking plate (LLP) only group (LLP-only), (2) a DP only group (DP-only), (3) a DP with a J-bone group (DP+J-bone), and (4) an LLP with a J-bone group (LLP+J-bone) in the treatment of ADFNBD. A finite element analysis ABAQUS 6.14 (Dassault systems, USA) was used to simulate the von Mises stress distribution and model displacement of the plate during standing and normal walking. RESULT: All patients with non-union and bone defect in the distal femur achieved bone healing at an average of 22.1 ± 5.5 months (range, 14 to 34 months) postoperatively. The average healing time was 6.72 ± 2.80 months. The knee Lysholm score was significantly improved compared with that before surgery. Under both 750 N and 1800 N axial stress, the maximum stress with the DP+J-bone structure was less than that of the LLP+J-bone and DP-only structures, and the maximum stress of J-bone in the DP+J-bone was significantly less than that of the LLP+J-bone+on structure. The fracture displacement of the DP+J-bone structure was also smaller than that of the LLP+J-bone and DP-only structures. CONCLUSION: J-bone combined with DP resulted in less maximum stress and less displacement than did a J-bone combined with an LLP or a DP-only graft for the treatment of ADFNBD. This procedure was associated with less surgical trauma, early rehabilitation exercise after surgery, a high bone healing rate, and a satisfactory rate of functional recovery. Therefore, a combination of J-bone and DP is an effective and important choice for the treatment of ADFNBD.

Exosomes in the Repair of Bone Defects: Next-Generation Therapeutic Tools for the Treatment of Nonunion.

Nonunion with bone defects, a common complication after long bone fracture, is a major challenge for orthopaedic surgeons worldwide because of the high incidence rate and difficulties in achieving successful treatment. Bone defects are the main complications of nonunion. The conventional biological treatments for nonunion with bone defects involve the use of autologous bone grafts or bone graft substitutes and cell-based therapy. Traditional nonunion treatments have always been associated with safety issues and various other complications. Bone grafts have limited autologous cancellous bone and there is a risk of infection. Additionally, problems with bone graft substitutes, including rejection and stimulation of bone formation, have been noted, and the health of the stem cell niche is a major consideration in cell-based therapy. In recent years, researchers have found that exosomes can be used to deliver functional RNA and mediate cell-to-cell communication, suggesting that exosomes may repair bone defects by regulating cells and cytokines involved in bone metabolism. In this review, we highlight the possible relationships between risk factors for nonunion and exosomes. Additionally, we discuss the roles of exosomes in bone metabolism and bone regeneration.

[Mid-term effectiveness of surgical hip dislocation for femoroacetabular impingement].

OBJECTIVE: To assess the mid-term effecitveness of femoroacetabular impingement (FAI) treated by surgical hip dislocation. METHODS: Between April 2014 and August 2015, 15 patients (16 hips) with FAI were enrolled in the study and treated with surgical hip dislocation. There were 12 males and 3 females with an average age of 36.6 years (range, 22-59 years). Among them, 14 cases involved in unilateral hip and 1 in bilateral hips. The mean disease duration was 28 months (range, 4-120 months). Preoperative visual analogue scale (VAS) score and Harris hip score were 7.9±1.0 and 44.1±9.3, respectively. RESULTS: All incisions healed by first intention. There was no main complication, such as vessel and nerve injuries and infection. All 15 patients were followed up 30-46 months (mean, 39.5 months). The VAS score was 2.5±1.6 at 3 months and 0.5±0.7 at last follow-up. The Harris score was 85.5±4.4 at 3 months and 95.6±3.9 at last follow-up. There were significant differences in two scores between pre- and post-operation and between 3 months and last follow-up ( P<0.05). The satisfaction rate of hip function was 93.8% (15/16) at last follow-up. X-ray examination showed that there was no sign of impingment at the femoral head and neck and acetabulum forming site of the affected hip joint, and no complication such as loosening of internal fixator, nonunion of osteotomy, avascular necrosis of femoral head, and heterotopic ossification occurred during follow-up. CONCLUSION: The surgical hip dislocation is a safe and effective way to treat FAI in the mid-term follow-up, which can repair torn labrum and trim acetabulum and femoral neck.

Erythrocyte sedimentation rate and fibrinogen concentration of whole blood influences the cellular composition of platelet-rich plasma obtained from centrifugation methods.

Erythrocyte sedimentation rate (ESR), which reflects the sedimentation rate of platelets, leukocytes and erythrocytes in response to centrifugal force, may influence the cellular composition of platelet-rich plasma (PRP) obtained via centrifugation methods. However, no relevant studies have substantiated this. In the present study, blood was collected from 40 healthy volunteers and used to prepare PRP with two plasma-based preparation systems [YinPRP and Plasma Rich in Growth Factor (PRGF) systems] and two buffy coat-based systems (RegenPRP and WEGOPRP systems) in a single-donor model. Volumes of PRP and platelet-poor plasma (PPP) that were removed in the preparation process were recorded. Analyses of ESR, haematocrit, C-reaction protein, coagulation, serum glucose and serum lipid of the whole blood used for PRP preparation were performed to evaluate the levels of ESR and the factors known to influence it. Whole blood analysis was performed to evaluate the cellular composition of PRP. Results demonstrated that there were marked positive correlations between the ESR of the whole blood used for PRP preparation and PPP removal efficiencies, platelet concentrations, platelet capture efficiencies and platelet enrichment factors of PRP formulations obtained from plasma-based systems, and PRP yield efficiency of RegenPRP and PPP removal efficiency of WEGOPRP. Furthermore, there were marked negative correlations between ESR and concentrations and enrichment factors of platelets, leukocytes and erythrocytes of RegenPRP. Fibrinogen concentration of the whole blood, which had a marked positive correlation with ESR, also influenced the cellular composition of PRP. These findings may increase the understanding of PRP preparation and provide substantial evidence for the individualised optimisation of PRP preparation systems used in clinical practice.

Optimization of pure platelet-rich plasma preparation: A comparative study of pure platelet-rich plasma obtained using different centrifugal conditions in a single-donor model.

While it has been proved that centrifugal conditions for pure platelet-rich plasma (P-PRP) preparation influence the cellular composition of P-PRP obtained, the optimal centrifugal conditions to prepare P-PRP have not yet been identified. In the present study, platelet-containing plasma (PCP) was prepared with the first-spin of different double-spin methods and P-PRP was prepared with different double-spin methods. Whole-blood analysis was performed to evaluate the cellular composition of PCP and P-PRP. The basal and ADP-induced CD62P expression rates of platelets were assessed by flow cytometry to evaluate the function of platelets in PCP and P-PRP. Enzyme-linked immune sorbent assay was performed to quantify interleukin-1ß, tumor necrosis factor-α, platelet-derived growth factor AB and transforming growth factor ß1 concentrations of PCP and P-PRP. Correlations between the cellular characteristics and cytokine concentrations of P-PRP were analyzed by Pearson correlation analysis. Effects of P-PRP on the proliferation, survival and migration of human bone marrow-derived mesenchymal stem cells and human articular chondrocytes were evaluated by a Cell Counting Kit-8 assay, live/dead staining and Transwell assay, respectively. The results showed that centrifugation at 160 × g for 10 min and 250 × g for 15 min successively captured and concentrated platelets and growth factors significantly more efficiently with preservation of platelet function compared with other conditions (P<0.05). The correlation analysis showed that the similar leukocyte concentrations and leukocyte-reducing efficiencies resulted in similar pro-inflammatory cytokine concentrations in P-PRP (P>0.05) and the maximization of platelet concentration, platelet enrichment factor, platelet capture efficiency and platelet function resulted in the maximization of growth factor concentrations in P-PRP obtained using the optimal conditions (P<0.05). Compared with P-PRP obtained under other conditions, P-PRP obtained under the optimal conditions significantly promoted the proliferation and migration of cells (P<0.05) and did not alter cell survival (P>0.05). Therefore, centrifugation at 160 × g for 10 min and 250 × g for 15 min successively with removal of the buffy coat as a crucial step may provide an optimal preparation system of P-PRP for clinical application.

Comparative evaluation of the effects of platelet­rich plasma formulations on extracellular matrix formation and the NF­κB signaling pathway in human articular chondrocytes.

Concentrated leukocytes in leukocyte and platelet­rich plasma (L­PRP) may deliver increased levels of pro­inflammatory cytokines to activate the nuclear factor (NF)­κB signaling pathway, to counter or overwhelm the beneficial effects of growth factors on cartilage regeneration. However, to date, no relevant studies have substantiated this. In the present study, L­PRP and pure platelet­rich plasma (P­PRP) were prepared, and leukocytes, platelets, pro­inflammatory cytokines and growth factor concentrations were quantified; they were then used to treat human articular chondrocytes (HACs). Pyrrolidine dithiocarbamate (PDTC; 50 µM) was used to inhibit the activation of NF­κB. The nuclear translocation of NF­κB p65 and the protein expression of cartilaginous markers (collagen II, aggrecan and sex­determining region Y­box 9) were determined using western blot analysis. The mRNA expression of NF­κB­dependent inflammatory mediators, including inducible nitric oxide synthase and cyclooxygenase­2, and cartilaginous markers were determined using reverse transcription­quantitative polymerase chain reaction analysis. The production of prostaglandin E2, nitric oxide and glycosaminoglycan (GAG) were quantified using enzyme­linked immunosorbent assays, the Griess reaction and a 1,9­dimethylmethylene blue assay, respectively. The results demonstrated that L­PRP induced the nuclear translocation of NF­κB p65, upregulated the mRNA expression of NF­κB­dependent inflammatory mediators and upregulated the production of their products, whereas P­PRP, which had similar growth factor concentrations but significantly lower pro­inflammatory cytokine concentrations than L­PRP, did not. P­PRP promoted the mRNA and protein expression levels of cartilaginous markers and the production of GAG more effectively, compared with L­PRP. Furthermore, inhibition of the activation of NF­κB by PDTC enhanced the effects of L­PRP on extracellular matrix formation in the HACs to a level similar to that of P­PRP. These findings suggested that leukocytes in L­PRP activated the NF­κB signaling pathway via the delivery of interleukin­1ß and tumor necrosis factor­α to counter the beneficial effects of growth factors on extracellular matrix formation in HACs. Therefore, P­PRP may be more suitable for the treatment of osteoarthritis.

[Surgical techniques and effectiveness of volar locking plates for senile delayed distal radius fractures].

Objective: To investigate the surgical technique and effectiveness of volar locking plates for senile delayed distal radius fractures. Methods: Between October 2014 and September 2015, 25 cases of delayed distal radius fractures were treated by volar locking plates. There were 3 males and 22 females with an average age of 73 years (range, 65-87 years). Injury was caused by tumble in 19 cases and by traffic accident in 6 cases. All the cases had closed fracture. According to the AO classification, 10 cases were rated as type A2, 7 cases as type A3, 3 cases as type B3, and 5 cases as type C1. The manual reduction and plaster immobilization were performed in 18 cases first, but reduction failed; no treatment was given in 7 cases before surgery. The time from injury to surgery was from 33 to 126 days (mean, 61 days). Preoperatively, the volar tilting angle was (-16.0±3.1)°; the ulnar inclining angle was (10.8±7.0)°; the radial shortening was (11.2±3.6) mm; the wrist range of motion was (41.0±7.5)° in flexion and was (42.0±6.3)° in extension; and the grip strength was 33.0%±3.1% of normal side. Results: All incisions healed primarily, and no postoperative complication occurred. The patients were followed up 1-1.5 years (mean, 1.3 years). The X-ray films showed that fracture union was achieved in all the patients, with the mean healing time of 9.2 weeks (range, 8-12 weeks); the displacement of the articular surface was less than 1 mm. At last follow-up, the volar tilting angle was (13.1±3.2)°; the ulnar inclining angle was (21.9±4.6)°; the radial shortening was (2.0±1.1) mm; the wrist range of motion was (52.0±11.7)° in flexion and was (65.0±4.8)° in extension; and the grip strength was 84.0%±4.2% of normal side; all showed significant difference when compared with preoperative ones ( P<0.05). According to the Gartland and Werley score, the results were excellent in 15 cases, good in 6 cases, fair in 2 cases, and poor in 2 cases at last follow-up; the excellent and good rate was 84%. Conclusion: By the good design of the volar locking plate and the command of surgical techniques, good effectiveness can be achieved in the treatment of senile delayed distal radius fracture.

Free Medial Plantar Flap Connection with a Posterior Tibial Artery Flap in Reconstruction of Fore-Mid Foot Skin Defect.

BACKGROUND: Although there are many surgical treatments for covering the skin defect of the fore-mid foot, how to reconstruct the weight-bearing region remains a challenge. The weight-bearing region of the sole needs to withstand the pressure and shearing stresses of walking, so the plantar skin is anatomically different from other skins in the areas of texture, thickness, subcutaneous tissue, etc. Medial plantar flaps that are harvested from the instep region are regarded as the first choice for weight-bearing region reconstruction because of their excellent functional and aesthetic long-term result. However, when facing an extensive skin defect on a weight-bearing area such as a fore-mid foot avulsion, the application of this flap is limited because if we put the flap in a weight-bearing area of the forefoot, the set of vessels will be exposed to outside. METHODS: We suggest 2 connected free flaps (posterior tibial artery flap and medial plantar flap) pedicled with 1 set of vessels. The medial plantar flap was used to cover the skin defect of the weight-bearing area in the forefoot. The dorsal skin defect of the injured foot was covered with a posterior tibial artery flap and supplied the medial plantar flap with the posterior tibial vessel. The midfoot skin defect was repaired by a full-skin grafting. RESULTS: Long-term follow-up results showed that the shape and function of the injured limbs recovered almost entirely. CONCLUSION: This method of connected flaps is suitable for repairing large skin defects of the fore-mid foot.

Exosomes from Human Synovial-Derived Mesenchymal Stem Cells Prevent Glucocorticoid-Induced Osteonecrosis of the Femoral Head in the Rat.

Osteonecrosis of the femoral head (ONFH) represents a debilitating complication following glucocorticoid (GC)-based therapy. Synovial-derived mesenchymal stem cells (SMSCs) can exert protective effect in the animal model of GC-induced ONFH by inducing cell proliferation and preventing cell apoptosis. Recent studies indicate the transplanted cells exert therapeutic effects primarily via a paracrine mechanism and exosomes are an important paracrine factor that can be directly used as therapeutic agents for tissue engineering. Herein, we provided the first demonstration that the early treatment of exosomes secreted by human synovial-derived mesenchymal stem cells (SMSC-Exos) could prevent GC-induced ONFH in the rat model. Using a series of in vitro functional assays, we found that SMSC-Exos could be internalized into bone marrow derived stromal cells (BMSCs) and enhance their proliferation and have anti-apoptotic abilities. Finally, SMSC-Exos may be promising for preventing GC-induced ONFH.

A Novel Guidewire Aiming Device to Improve the Accuracy of Guidewire Insertion in Femoral Neck Fracture Surgery Using Cannulated Screw Fixation.

BACKGROUND The aim of this study was to improve the accuracy of guidewire insertion in the femoral neck fracture surgery using cannulated screw fixation. MATERIAL AND METHODS A novel aiming device was designed and manufactured. Between January 2010 and June 2012, 64 femoral neck fracture patients were included into the study. All 64 patients were divided into 2 groups randomly. The aiming device was used during the operation for patients in the experimental group, but not in the control group. RESULTS There were no statistically significant differences in operative time or bleed volume between the groups (P>0.05). The frequency of guidewire drilling was significantly lower in the experimental group than in the control group (P<0.05). The angle between the first cannulated screw and the central axis of the femoral neck in coronal plane and sagittal plane, and the distance between the bottom cannulated screw and the medial calcar femorale rim, were significantly smaller in the experimental group than in the control group (P<0.05). CONCLUSIONS The aiming device is simple in structure and easy to use. It could help surgeons to accurately insert cannulated screw guidewires. The aiming device is suitable for broad clinical use.

Improve the Efficiency of Surgery for Femoral Shaft Fractures with A Novel Instrument: A Randomized Controlled Trial.

OBJECTIVE: To improve the efficacy of closed reduction and wire guiding during intramedullary nail internal fixation in femoral shaft fractures. METHODS: A novel instrument was designed and manufactured. Sixty-eight patients were enrolled from February 2011 to December 2013. The instrument designed was used during the operation in the experimental group, but not in the control group. RESULTS: All patients exhibited fracture union, excluding 1 patient in the experimental group and 2 in the control group who had non-union; all of whom achieved fracture union with reoperation. There were no statistically significant differences in operative blood loss or duration of hospital stay between the groups (P > 0.05). The operative time, frequency of wire drilling, and number of open reduction cases, were significantly smaller in the experimental group than in the control group (P < 0.05). CONCLUSION: Femoral shaft fractures are difficult to reduce using general methods; the novel instrument showed high clinical value and proved effective and safe in assisting with closed reduction and intramedullary nail fixation for femoral shaft fractures. TRIAL REGISTRATION: ChiCTR ChiCTR-ICR-15007335.