Treatment of Partial Traumatic Hemipelvectomy: A Study of 21 Cases.

BACKGROUND: Partial traumatic hemipelvectomy (THP) is a catastrophic and life-threatening injury caused by high-energy impact. With advances in prehospital resuscitative techniques, more patients now survive this disastrous injury; however, the management of partial THP still lacks well-established therapeutic protocols. The purpose of this study was to present our experience in managing partial THP in a level-I trauma center. METHODS: We retrospectively reviewed the medical records of 21 consecutive patients with partial THP. The key points of successful treatment are hemorrhage control, proper decision-making regarding amputation, treatment of associated injuries, and infection control. Data on patient demographics, injury characteristics, surgical management, and outcomes were recorded and analyzed. RESULTS: Eight female and 13 male patients with a mean age of 31.3 years met the diagnostic criteria. The mean follow-up was 51.9 months. Of 17 surviving patients, 7 underwent primary amputation; limbs were successfully preserved in 4; and 6 patients underwent secondary amputation because of infection, organ dysfunction, and limb necrosis. Two patients died during resuscitation, and 2 patients died after amputation. Phantom limb pain, infection, and skin flap necrosis were the major postoperative complications. CONCLUSIONS: THP requires cooperative multidisciplinary emergency diagnosis and treatment, early surgical intervention, and definitive treatment. Rapid resuscitation, adequate hemostasis, early amputation, and repeated debridement may improve survival. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Exosomes derived from platelet-rich plasma present a novel potential in alleviating knee osteoarthritis by promoting proliferation and inhibiting apoptosis of chondrocyte via Wnt/ß-catenin signaling pathway.

BACKGROUND: Platelet-rich plasma (PRP) provides a nonsurgical approach for treating osteoarthritis (OA). Exosomes that play vital roles in intercellular communication have been studied extensively. Here, we investigated the therapeutic potential and molecular mechanism of exosomes derived from PRP (PRP-Exos) in alleviating OA. METHODS: Exosomes derived from PRP(PRP-Exos) were isolated and purified using the exoEasy Maxi Kit and then identified and analyzed. Primary rabbit chondrocytes were isolated and treated with interleukin 1 beta (IL-1ß) to establish the OA model in vitro. Proliferation, migration, and apoptosis assays were measured and compared between PRP-Exos and activated PRP (PRP-As) to evaluate the therapeutic effects on OA. The mechanism involving the Wnt/ß-catenin signaling pathway was investigated by Western blot analysis. In vivo, we established animal knee OA model by surgery to compare the therapeutic effect of PRP-Exos and PRP-As. RESULTS: We successfully isolated and purified exosomes from PRP using the exoEasy Maxi Kit. We also isolated and identified chondrocytes from the New Zealand white rabbit and established the IL-1ß-induced OA model; meanwhile, PRP-Exos and PRP-As both inhibited the release of tumor necrosis factor-α(TNF-α) and there was no statistically significant difference between the two. In proliferation, migration, scratch assay, the promoting effect of PRP-Exos was significantly more better than PRP-As. Furthermore, PRP-Exos could significantly decreased apoptotic rate of OA chondrocyte compared with PRP-As. In Western blot analysis, the expression of ß-catenin, and RUNX2, Wnt5a were increased in IL-1ß-treated chondrocytes, but PRP-Exos and PRP-As could both reverse these changes, and the reversal effect of the former was better than the latter. In vivo, we found that both PRP-Exos and PRP-As displayed the progression of OA, and the effect of PRP-Exos was obviously better than PRP-As by chondrocyte count and Osteoarthritis Research Society International (OARSI) scoring system. CONCLUSION: The therapeutic effects of PRP-Exos on OA were similar or better compared with those of PRP-As in vitro or in vivo. PRP-Exos acting as carriers containing growth factors derived from PRP present a novel therapy for OA by activating the Wnt/ß-catenin signaling pathway.

Modified ilioinguinal approach in combined surgical exposures for displaced acetabular fractures involving two columns.

The purpose of this study is to assess the advantages of modified ilioinguinal approach in combined surgical exposures for displaced acetabular fractures involving two columns management. 73 patients with displaced acetabular fractures involving two columns underwent open reduction and internal fixation through combined surgical approaches between 2006 and 2014 in our hospital. The modified ilioinguinal approach combined with Kocher-Langenbeck approach group (group A) included 46 patients. The standard ilioinguinal approach combined with Kocher-Langenbeck approach group (group B) included 27 patients. Outcome was assessed in operative time, blood loss, function outcomes and complications. In group A, the average operative time was 123.2 min, and the average blood loss was 586.2 ml. Anatomic reduction was achieved in 39 patients (84.8 %). The functional recovery was good in 37 patients (80.4 %). Complications related to the approach were observed in 10 patients (21.7 %). In group B, the average operative time was 161.5 min, and the average blood loss was 830 ml. Anatomic reduction was achieved in 24 patients (88.9 %). The functional recovery was good in 22 patients (81.5 %). Complications related to the approach were observed in 9 patients (33.3 %). This study demonstrates that both combined approaches permits good postoperative function results for treatment of acetabular fractures involving two columns. However, the modified ilioinguinal approach combined with Kocher-Langenbeck approach provides less operative time, blood loss and complications.

Three-dimensionally-navigated cross-cannulated screw fixation for traumatic pubic symphysis diastasis: an anatomical study.

OBJECTIVE: The aim of this study was to design and optimize the secure corridor of cross-cannulated screw implantation in pubic symphysis through Orbic 3D (Siemens Medical Solutions, Erlangen, Germany) computerized navigation and to provide an anatomic basis through the study of regional anatomy. METHODS: Fifteen embalmed adult cadavers (8 males, 7 females) were used in this study. All pelvic specimens were placed in the supine position on a radiolucent carbon fiber table. The ideal angle of screw placement, appropriate screw diameter, and perfect attachment point were determined by the computerized navigation system. According to the above data, cross-cannulated screws 6.5 mm in diameter were implanted by the guide pins. Based on detailed local dissection, the entry-exit points of double screws were exposed in the pelvis. The distances were measured between the entry-exit points and the major structures. Radiographs and computed tomography (CT) scans of the pelvis were performed to reassess the position of screws. RESULTS: The trajectory of the first screw originated from the trailing edge of the pubic tubercula to the anterior-lower corner of the contralateral pubic tubercula. The second screw was directed from the base of the pubic tubercula to the junctional zone between the pubic tubercula and inferior ramus of the pubis of the opposite side of the body. Both screws maintained a safe distance from the surrounding major structures. All screw corridors were found intact without any damage under X-ray and CT images. CONCLUSION: The Orbic 3D computer navigation system is a reliable and new method of achieving a secure corridor for screw implantation in the pubic symphysis.

Management and outcome of pelvic fractures in elderly patients: a retrospective study of 40 cases.

BACKGROUND: Pelvic fractures are uncommon in elderly patients and so are infrequently addressed in the literature. The purpose of this study was to investigate the management and outcome of pelvic fractures in elderly patients. METHODS: We retrospectively reviewed the records of pelvic fractures in elderly patients (age ≥55 years) who were treated in our department from September 1997 to May 2010. RESULTS: A total of 40 elderly patients with pelvic fractures were identified. Their mean age was 65.8 years (range 55-87 years). About 68% (n = 27) were men. The average Injury Severity Score (ISS) was 17.8 (range 6-45). Twelve (30%) patients required blood transfusion (mean 10 units) during the first 24 hours. The fractures were most frequently due to falling from a standing position (48%). Almost half (48%) were grade I breaks. Associated injuries were present in 70% (n = 28) of patients, and 65% (n = 26) had medical co-morbidities. Altogether, 29 patients (73%) underwent non-surgical management of their pelvic fracture. The average hospital stay was 25 days. There were five in-hospital deaths and one death 10 months after discharge. High ISSs (>25) were associated with increased in-hospital mortality (P = 0.018). At the final assessment (mean follow-up 15 months), 52% of the surviving patients had experienced decreased self-sufficiency. CONCLUSIONS: Pelvic fractures in elderly patients result in high morbidity and mortality rates. A high ISS (>25) can be used to identify a patient at high risk. We recommend aggressive resuscitation and intensive care for that patient. For patients with an unstable pelvic or displaced acetabular fracture (≥2 mm) who can endure surgery, open reduction and internal fixation can provide adequate fixation for early weight-bearing and restoration of the bone stock.

An evaluation of three-dimensional image-guided technologies in percutaneous pelvic and acetabular lag screw placement.

BACKGROUND: Percutaneous stabilization using three-dimensional (3D) navigation system is a promising treatment for pelvic and acetabular fractures. However, there are still some controversies regarding the use of 3D navigation to treat pelvic and acetabular fractures. The purpose of this study was to compare the Iso-C(3D) fluoroscopic navigation, standard fluoroscopy, and two-dimensional (2D) fluoroscopic navigation in placing percutaneous lag screws in pelvic specimens to better understand the merits of 3D navigation techniques. METHODS: Fifty-four instrumentation procedures were performed in this study using six cadaveric pelvic specimens. Three groups were designated for different procedures and tests: group I, standard fluoroscopy; group II, 2D fluoroscopic navigation; and group III, Iso-C(3D) fluoroscopic navigation. Nine screws were placed in each pelvis, including four screws placed bilaterally through the ilium into S1 and S2 vertebrae, four screws placed bilaterally through anterior and posterior columns of acetabulum, and one screw placed through the pubic symphysis. 3D fluoroscopic techniques were evaluated to determine the accuracy of screw position, instrumentation time, and fluoroscopic time. The data were statistically analyzed using SPSS 13.0. RESULTS: The malposition rate was 38.89%, 22.22%, and 0% in standard fluoroscopy, 2D fluoroscopic navigation, and Iso-C(3D) fluoroscopic navigation groups, respectively. There was no significant difference between standard fluoroscopy and 2D fluoroscopic navigation. Compared with Iso-C(3D) fluoroscopic navigation, there were significant differences (analysis of variance [ANOVA], P < 0.05). The mean instrumentation operating time using Iso-C(3D) fluoroscopic navigation technique was 15.4 ± 4.5 min. There were significant differences compared with standard fluoroscopy (31.5 ± 6.2 min) and 2D fluoroscopic navigation (26.3 ± 7.5 min; ANOVA, post hoc Scheffe, P < 0.01). The mean fluoroscopic time of Iso-C(3D) fluoroscopic navigation was 66 ± 4.8 min. Compared with standard fluoroscopy (132.8 ± 7.3 min) and 2D fluoroscopic navigation (47.7 ± 5.6 min), there were significant differences (ANOVA, post hoc least significant difference, P < 0.01). CONCLUSIONS: In the present study, we compared Iso-C(3D) fluoroscopic navigation, 2D fluoroscopic navigation, and standard fluoroscopy. Iso-C(3D) fluoroscopic navigation showed a higher accuracy rate in positioning and a shorter instrumentation operating time. The fluoroscopic time was longer in Iso-C(3D) fluoroscopic navigation than that in standard fluoroscopy, indicating that radiation exposure can be moderately reduced in Iso-C(3D) fluoroscopic navigation operation, although the fluoroscopic time was the shortest in 2D fluoroscopic navigation.

[Operative treatment of the scapular fractures through modified Judet approach].

OBJECTIVE: To investigate the effect of operative treatment of scapular fractures through modified Judet approach. METHODS: From January 1997 to October 2005, 21 patients (15 females, 6 males; mean age 34 years) of scapular fractures were treated by open reduction and internal fixation through the modified Judet approach. According to Hardegger classification system, there were 11 patients of scapular body fractures, 10 patients of scapular neck fractures, 8 patients of glenoid rim fractures, 7 patients of glenoid fossa fractures, 9 patients of scapular spine fractures, and 6 patients of scapular acromion fractures. RESULTS: Eighteen patients were followed up with an average of 21 months (range 6 months-4 years). According to Rowe scores system, 12 patients showed excellent, 3 showed good, 2 showed fair, and 1 showed poor. CONCLUSIONS: The modified Judet approaches have the advantages of wide exploration, safety, and easy fixation. It is a good choice to the operation for most types of scapular fractures through the modified Judet approach.

[Treatment of soft tissue defects of palm and proximal fingers with double vascular pedicle flaps].

OBJECTIVE: To establish a new operative method to repair defects of palm and proximal fingers with double vascular pedicle flaps. METHODS: From August 1992 to June 2000, 20 cases of soft tissue defects of palm and fingers were repaired with double vascular pedicle flaps. Twenty patients included 9 males and 11 females, aged 17-35 years. The causes were crush, avulsion, and so on. The interval between injury and operation was 3-11 hours. The wound area ranged from 8 cm x 12 cm to 10 cm x 20 cm. We devised the two side flaps on pectoral-umbilical place with well-known blood vessel to cover flexion and extension regions of palm and the multi-lobes skin flap to cover defect of fingers simultaneously. RESULTS: Out of 20 patients, 19 were followed up 8-12 months with an average of 9.8 months. All the flaps survived completely. The skin colour and the contour of the palm and digits were good. CONCLUSION: The double vascular pedicle flap is one of the best choices to repair soft tissue defect of the palm and proximal fingers; the procedure is simple and the operation is extended easily.

The diagnosis and treatment of severe cerebral fat embolism.

OBJECTIVE: To improve the diagnosis and treatment of severe cerebral fat embolism (SCFE). METHODS: The data of nine patients with SCFE were retrospectively analyzed. The manifestations of the central nerve system, respiratory system and hemorrhage were recorded, at the same time, accessory examination including arterial oxygen, fat macroglobules in venous blood and image examination was adapted. The patients were treated with exopexy, pharmocotherapy and oxygentherapy. RESULTS: Two of the nine patients died of severe complications, the other seven recovered without severe sequela. CONCLUSIONS: Gurd standard should be improved for early diagnosis of SCFE. If svere complications can be prevented, patients who receive early treatment will have favourable prognosis.