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Objective:To investigate the relationship between intracerebral high-density foci and progressive stroke (PS) morbidity by using dual-energy CT, which can quantify the intracerebral high-density foci of patients with acute ischemic stroke after endovascular treatment.Methods:Ninety-two patients with acute ischemic stroke who received interventional treatment in Gaozhou People′s Hospital from May 2019 to August 2020, and underwent dual-energy CT scan immediately after intervention, were analyzed. The patients were divided into PS group ( n=35) and non-PS group ( n=57) according to the National Institutes of Health Stroke Scale (NIHSS) score, and the patients whose NIHSS score increased≥4 points within 72 hours of stroke were included in the PS group, while the patients whose NIHSS score increased<4 points were included in the non-PS group. The clinical data, volume of high-density foci and CT values were compared between the 2 groups. Logistic regression analysis was used to adjust for confounding factors and screen for risk factors. The correlations of the admission NIHSS score, presence and volume of high-density lesions, maximum CT (CTmax) value and average CT (CTave) value with the onset of PS were analyzed, and the receiver operating characteristic curve was used to screen predictive indicators of PS. Results:In the PS group, the NIHSS score (18.80±8.50 vs 14.40±9.58, t=2.229, P=0.028), proportion of high-density foci [29/35(82.9%) vs 32/57 (56.1%), χ 2=6.928, P=0.008], high-density focal volume [13.23 (39.33) cm 3vs 0.76 (9.82) cm 3, U=1 440.000, P<0.001], CTmax value [80.00 (92.00) HU vs 65.00 (87.50) HU, U=1 337.000, P=0.005] and CTave value [53.48 (23.79) HU vs 45.94 (55.11) HU, U=1 345.000, P=0.004] were higher than those in the non-PS group. The NIHSS score ( OR=1.054, 95% CI 1.004-1.106, P=0.033; rs=0.255, 95% CI 0.051-0.447, P=0.014), presence of high-density foci ( OR=3.776, 95% CI 1.358-10.503, P=0.011; rs=0.274, 95% CI 0.093-0.460, P=0.008), high-density focal volume ( OR=1.026, 95% CI 1.003-1.049, P=0.027; rs=0.381, 95% CI 0.183-0.560, P<0.001), CTmax value ( OR=1.006, 95% CI 1.001-1.011, P=0.014; rs=0.292, 95% CI 0.088-0.475, P=0.005) and CTave value ( OR=1.021, 95% CI 1.007-1.035, P=0.004; rs=0.299, 95% CI 0.092-0.484, P=0.004) were all risk factors affecting PS morbidity and were positively correlated with PS morbidity. The area under the receiver operating characteristic curve of NIHSS score, high-density lesion volume, CTmax value, and CTave value to predict the onset of PS was 0.652, 0.722, 0.670 and 0.674, respectively. The volume of high-density lesions had moderate predictive value for the onset of PS. Conclusions:For AIS patients, CT examination should be performed immediately after interventional operation. The volume, CTmax value and CTave value of high-density lesions newly appeared in the ischemic area are positively correlated with the onset of PS. Quantifying the volume of high-density lesions can help to predict the onset of PS.
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Objective:To develop a grading system for necrosis of pedicled flaps in reconstruction of foot and ankle, and to verify its effectiveness and repeatability.Methods:A retrospective observational study was conducted. A total of 40 necroses of foot and ankle pedicled flaps were selected by 2 senior surgeons based on the flap surgery performed by the same surgical group in Department of Orthopaedic Surgery, the 920 Hospital of Joint Logistic Support Force of PLA from January 2010 to January 2022. A grading system for pedicled flap necrosis was proposed by a working group and the 40 necrotic flaps were graded. The coincidence rate was calculated to evaluate the effectiveness of the grading system through correlation studies between grading and clinical treatment. One photo of a typical postoperative necrotic flap was collected from each of the 40 flaps. Then 5 extramural surgeons were asked to grade the necroses shown on the photos according to the proposed grading system. Moreover, weighted Kappa analysis was performed on the results of proposed grading system and also on the standard grading currently in use, to evaluate the repeatability of the proposed grading system. Evaluated data were expressed by Mean±SD, and the coincidence rate was expressed by percentage. The reproducibility was studied by weighted Kappa analysis.Results:Of the 40 necrotic flaps, 7 flaps were classified in Grade I, 16 in Grade Ⅱ, 12 in Grade Ⅲ and 5 in Grade IV. In comparison with the actual treatment methods, the overall coincidence rate of the grading system was 92.5%. It indicated that the proposed grading system could effectively guide the selection of a treatment procedure. The average weighted Kappa coefficient of surgeons was at 0.628 with a 95% confidence interval (95%CI) between 0.460-0.796, which was strongly consistent with the standard of the grading system currently in use.Conclusion:The grading system for necrosis of pedicled flap in reconstruction of foot and ankle proposed in this study is simple and clear. It is able to effectively guide the treatment of flap necrosis. The preliminary validation shows that the classification system has good repeatability.
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Objective:To assess the efficacy and safety of trimethoprim/sulfamethoxazole (TMP/SMZ) combined with caspofungin for the treatment of acquired immunodeficiency syndrome (AIDS)patients with moderate to severe pneumocystis pneumonia (PCP) requiring mechanical ventilation.Methods:The clinical data of AIDS patients who admitted to Chongqing Public Health Medical Center from March 1, 2019 to March 1, 2021 with moderate to severe PCP requiring mechanical ventilation were retrospectively analyzed. Clinical characteristics and outcomes were compared between two groups receiving either combination therapy with TMP/SMZ and caspofungin (combination therapy group) or TMP/SMZ monotherapy (monotherapy group). The patients were divided into two subgroups according to the baseline arterial partial pressure of oxygen (PaO 2), patients with arterial PaO 2≥50 mmHg (1 mmHg=0.133 kPa) and PaO 2 <50 mmHg. The clinical efficacies of combination therapy and monotherapy in each subgroup were further compared. Chi-square and Fisher exact test were used for statistical analysis. The three-month survival was estimated by the Kaplan-Meier method, and the three-month survival rates were compared by Log-rank method. Results:A total of 83 patients were enrolled, including 23 in the monotherapy group and 60 in the combination therapy group. There was no significant difference in all-cause hospital mortalities between these two groups (34.8%(8/23) vs 23.3%(14/60), χ2=1.12, P=0.290). Kaplan-Meier survival curves indicated no significant difference in the three-month survival rates between the two groups ( χ2=0.51, P=0.477). There ware no significant differences observed in the positive clinical response rates and the mechanical ventilation rates after seven days of anti-PCP treatment between the two groups ( χ2=0.02 and 0.01, respectively, both P>0.05). In the 52 patients with PaO 2≥50 mmHg, no significant difference in all-cause hospital mortalities was observed between the monotherapy group and the combination therapy group (2/13 vs 25.6%(10/39), χ2=0.14, P=0.704). There was no statistical significance in the three-month survival rates between the two groups ( χ2=0.69, P=0.407). No significant difference was observed either in the clinical positive response rates or the mechanical ventilation rates after seven days of anti-PCP treatment between the two group( χ2=1.02 and 0.69, respectively, both P>0.05). In the 31 patients with PaO 2<50 mmHg, the all-cause hospital mortality in the combination therapy group was 19.0%(4/21), while six of the 10 patients in the monotherapy group died, and the difference was statistically significant (Fisher exact test, P=0.040). The three-month survival rate in the combination therapy group was significantly higher than that in the monotherapy group ( χ2=4.09, P=0.043). There were no significant differences in clinical positive response rate and the mechanical ventilation rate after seven days of anti-PCP treatment between the two group (Fisher exact test, both P>0.05). The overall adverse event rate in the monotherapy group was 87.0%(20/23), with an incidence of 56.5%(13/23) for both electrolyte disturbances and bone marrow suppression. The above incidences in the combination therapy group were 78.3%(47/60), 35.0%(21/60) and 53.3%(32/60), respectively, and all differences were not statistically significant ( χ2=0.34, 3.18 and 0.07, respectively, all P>0.05). Conclusions:The efficacy of combination therapy with TMP/SMZ and caspofungin is comparable to that of TMP/SMZ monotherapy in AIDS patients with moderate to severe PCP requiring mechanical ventilation. However, in AIDS patients with PCP requiring mechanical ventilation with the baseline PaO 2<50 mmHg, the efficacy of combination therapy is statistically superior to that of TMP/SMZ monotherapy. Combination therapy does not increase the risk of adverse events.
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Objective:To introduce the concept and procedures of precise flap surgery in construction of knee defects and to report the preliminary clinical outcomes.Methods:The data of 16 patients with knee defects at 17 sides were retrospectively analyzed who had been treated under the guidance of the concept of precise flap surgery at Department of Orthopedic Surgery, The 920th Hospital of Joint Logistic Support Force of PLA from August 2014 to March 2022. There were 12 males and 4 females, aged 44(34, 54) years. The wounds were at the left side in 8 cases, at the right side in 7 ones and at bilateral sides in one, and their sizes ranged from 5 cm×3 cm to 15 cm×11 cm. The time from injury to surgery was 8.5(6.0, 13.0) days. Optimal repair protocols were chosen after the donor and recipient sites were evaluated according to the methods of precise flap surgery: a retrograde anterolateral thigh flap in 7 sides, a descending genicular artery perforator flap in 3 ones, a saphenous artery flap in 2 ones, and a superior genicular lateral artery perforator flap, a popliteal artery perforator flap, a medial sural perforator propeller flap, a peroneal artery perforator propeller flap, and a randomized flap in one, respectively. The flap sizes ranged from 10 cm×6 cm to 15 cm×15 cm. The outcomes and complications of skin flap repair, and functional recovery of the affected limb were recorded.Results:All the flaps at 17 sides survived after surgery; 3 cases developed distal edge necrosis which responded to dressing change. The follow-ups for the 16 patients were 14.5(10.0, 28.0) months. All the flaps presented with good color, texture and contour. Flap bulking, local osteomyelitis, and scar ulcer was found in one case respectively. According to the revascularization assessments in the digital replantation criteria by Hand Surgery Society, Chinese Medical Association, all the flaps at 17 sides were excellent. Accoding to the knee functional evaluation of Hospital for Special Surgery (HSS) at the last follow-up, the 17 affected limbs scored 86(80,91) points, yielding 9 excellent, 7 good and 1 fair sides.Conclusion:Although the defects and donor sites around the knee vary greatly, precise flap surgery may lead to effective control of the variations, choice of an optimal reconstruction protocol, and precise wound repair.
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Objective:To compare the clinical value of CTA and CDU in perforator flap of peroneal artery.Methods:From February 2013 to October 2016, 47 patients who suffered with soft tissue defects and were hospitalised in the Department of Orthopaedics, the 920th Hospital of Joint Logistic Support Force of Chinese PLA were retrospectively reviewed and evaluated. All the defects were reconstructed by the perforator flap of peroneal artery. All patients received preoperative CTA and CDU scans before surgery. Appropriate perforator vessels were selected and the locating points in body surface and external diameters of the perforator vessels were recorded and compared with intraoperative findings. SPSS 22.0 statistical software was used for data analysis. P<0.05 was considered statistically significant. Results:The intraoperative coincidence rate of the proposed perforator vessels was 97.87% for CDU and 95.74% for CTA, with no significant difference between the 2 groups( P>0.05). It was found that the preoperative CTA and CDU measurements were consistent with the actual intraoperative measurements, and there was no significant difference between the 2 groups( P>0.05). For CTA combined with CDU, an intraoperative coincidence rate was 100% in the location of peroneal perforating vessels. All flaps were followed-up for 1 to 18(mean 13.5) months. All the flaps survived well with good texture and appearance without complication. Conclusion:CDU and CTA are reliable and useful in preoperative vascular evaluation of peroneal perforator flap, and both can be used in a complementary or combined manner.
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There are great variations in tissue defects and vascular anatomy. How to find the best solution for pre-repair of tissue defect is a challenge of flap surgery. "Precision flap surgery" is based on high-throughput and high-accuracy imaging information, comprehensive evaluation of recipient and potential donor sites, selection of the best repair plan, accurate implementation of precise surgical procedures, therefore to achieve precise and personalised repair of tissue defects. Precision flap surgery is the continuation and development of traditional flap surgery, and must comply with the bases of theory, surgical procedures and principles applied in current flap surgery. This paper describes the concept, connotation, thinking mode and method of "precision flap surgery" with examples.
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Objective:Childhood traumatic experiences greatly influenced the brain network activities of patients with depression,and there is an urgent need to explore the temporal dynamics for these changes.This study aims to investigate the abnormalities of resting-state electroencephalogram(EEG)microstates in eye-open state of depressed adolescents and to explore the correlations between their EEG microstates and the childhood traumatic experience. Methods:Using resting-state EEG microstate analysis,we explored the temporal dynamics of brain activity in patients with adolescent depression.This study selected 66 adolescents with depression as a patient group,and 27 healthy adolescents as a healthy control group.A modified k-means clustering algorithm was used to classify the 64-channel resting-state EEG data into different microstates.Independent sample t-tests were used to compare the microstate parameters between the 2 groups and further assciations between these parameters and childhood traumatic experience in patients were explored via using Spearman correlation. Results:In this study,significant differences were observed in the occurrence and transition probabilities of EEG microstates between the healthy control and the patient group.Notably,there was a statistically significant difference(P＜0.05)in the occurrence of microstate A across 2 groups,exhibiting a negative correlation with the emotional abuse component within the childhood trauma scores(Spearman's rho=-0.31,P=0.013).Furthermore,patient-specific,non-random transitions from microstate B to A(Spearman's rho=-0.30,P=0.015)and C to A(Spearman's rho=-0.31,P=0.013)were inversely associated with the scores of emotional abuse factors from childhood trauma in the patient group,showing statistically significant differences when comparing to the healthy controls(P＜0.05).Upon stratification into quartiles based on the emotional abuse factor scores,the occurrence of microstate A,as well as the transition rates from microstates B to A and C to A,retained statistical significance following adjustment for multiple comparisons(all P＜0.05). Conclusion:The abnormal temporal dynamics in brain networks of adolescents with depression are linked to childhood emotional abuse.Those who have suffered severe emotional abuse may show greater impairments in the brain's visual and central executive networks.EEG microstate analysis could be a potential tool for detecting adolescent depression with severe childhood trauma.
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Objective:To investigate the efficacy of digital reconstruction technology in assisted design of lobulated deep inferior epigastric perforator flap (DIEPF) for surgical reconstruction of large defect in lower extremity.Methods:From January 2017 to January 2022, a study was carried out to retrospectively analyse 8 patients who had massive soft tissue defects in lower extremities were admitted in the Department of Orthopaedic Surgery of the 920 Hospital of Joint Logistic Support Force of Chinese PLA. The size of defects varied from 16.0 cm×12.0 cm-28.0 cm×22.0 cm. CTA scans were performed over abdominal aorta and the arteries of lower extremities. Three-dimensional model of DIEPF and vascular pedicles were reconstructed by Mimics software. According to the shape and size of the wound, targeted perforators were determined on the 3D images, and precisely mapped in a digitised rectangular coordinate system. The lobulated flap was then digitally designed in the 3D coordinate system. Flaps were harvested according to preoperative digital designs for the reconstruction of large defects in the lower extremities. The donor site was sutured directly. The flaps and recovery of lower extremities were observed though postoperative follow-ups and were conducted through visits of outpatient clinics and distance interviews via telephone and WeChat. Recoveries of lower extremities were evaluated using Maryland ankle-foot function scoring system.Results:The 3D reconstructed models of the vessels in donor sites were successfully completed for all patients. The harvests of lobulated DIEPF were successfully guided by the digital designs. Fifteen lobes of lobulated DIEPF survived successfully in all 8 patients. All donor sites were closed in the stage-I. Necrosis occurred at the distal tip of a lobulated flap due to a local venous occlusion, and healed after debridement and re-suture. Four patients received further flap debulking surgery. Time of postoperative follow-ups had ranged 15-27 months, with an average of 20 months. At the last follow-up, all the flaps had satisfactory appearance with linear scars at the donor sites. All fractures were healed. Five patients achieved Maryland's ankle-foot function score in excellent, 2 in good, and 1 was acceptable.Conclusion:Digital reconstruction technology can accurately map the perforators and reasonably assist the design of lobulated flaps. A lobulated DIEPF offers a wider area for flap excision and allows a primary closure of the donor sites. Combination of the 2 advantages of a lobulated DIEPF can be effectively applied in reconstruction of a large-sized defect in lower extremity.
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Objective:To investigate the clinical outcomes of Ortho-Bridge Combination System (OBCS) to achieve precise ulna-shortening osteotomy (USO) in the treatment of ulnar impaction syndrome.Methods:A retrospective study was conducted to analyze the 25 patients with ulnar impaction syndrome who had been treated at Institute of Orthopedic Trauma Research, The 920th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army between January 2020 to March 2022. The patients all underwent USO using OBCS. They were 14 females and 11 males with an age of (43.2 ± 10.1) years. Their CT scans were retrieved for preoperative planning and design of a personalized USO. Intraoperatively, OBCS was fixated to the ulna before USO. After the bone was resected according to preoperative planning, the gap between the osteotomy sites was closed with compression, and OBCS was finally fixated with locking screws. The time for bone union after resection, complications, range of motion and grip strength were recorded. The clinical outcomes were evaluated by visual analogue scale (VAS) and Mayo wrist score.Results:All patients completed their operations successfully using OBCS. Their follow-up time was (13.5 ± 1.2) months. The ulnar variation was corrected and osteotomy ends got united in all patients, without nonunion, angulation, or rotation. The wrist VAS significantly decreased from 6.0 (5.0, 6.5) points before operation to 2.0 (1.0, 2.0) points at the last follow-up ( P<0.05). At the last follow-up, the Mayo wrist score [(85.4 ± 8.9) points], grip strength [(39.4 ± 1.2) kg], wrist flexion-extension (111.9° ± 12.6°), wrist pronation-supination (133.2° ± 15.7°), and ulnar radial deviation (35.3° ± 2.8°) were significantly increased compared with the preoperative values [(69.2 ± 13.3) points, (31.3 ± 5.2) kg, 102.0° ± 16.0°, 128.0° ± 15.5°, and 32.2° ± 2.8°] ( P<0.05). Conclusion:In the treatment of ulnar impaction syndrome, OBCS can facilitate the process of USO, correct ulnar variance, and avoid complications like rotation and angulation to improve functions of the wrist.
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Objective:To introduce the concept and procedure of CTA guided precision flap surgery and report the preliminary clinical application.Methods:The theory of CTA guided precision flap surgery is: based on CTA high-throughput data, comprehensively evaluate the wound and potential donor sites, and select the best plan for wound repair. This article reviews 177 patients treated under the guidance of CTA guided precision flap surgery from August 2014 to December 2018. Among them, 131 were males and 46 were females; they were 7-72 years old, with an average age of 39.5 years. The tissue defects were: 74 cases of foot and ankle, 64 cases of wrist, 15 cases of calf, 11 cases of forearm and upper arm, 7 cases of thigh and perineum, 5 cases of face and neck, and 1 case of abdomen. The size of the defect was 2 cm×1 cm to 65 cm×50 cm. The recipient and donor sites were assessed based on CTA guided precision flap surgery, then choose the optimal flap to repair the defect. The flap types, outcomes and complications were recorded. The visual analogue scale (VAS), British Medical Research Council sensory rating scale, and revascularization assessments of digital replantation standard by Hand Surgery Branch of Chinese Medical Association was used to assess clinical results.Results:All flaps were uneventfully harvested as planned according to the CTA guided precision flap surgery concept.A total number of 181 flaps were harvested, including 125 free flaps and 56 pedicled flaps. The flap area rangedfrom 4 cm×3 cm to 40 cm×8 cm. After surgery, 165 cases were survival completely, 7 cases were total necrosis, 9 cases were partial necrosis. A total of 174 cases of flaps survived. The mean follow-up was 9.2 months (range, 6-60 months). After surgery 53 flaps were bulky, and 7 cases with other complications.At the last follow-up, only 6 patients had mild pain, the VAS score was 1-3. The sensation of the flaps recovered partially. According to the British Medical Research Council sensory rating scale: 68 cases were grade S2 and 106 cases were grade S3. According to the revascularization assessments of digital replantation standard by Hand Surgery Branch of Chinese Medical Association, 171 cases were excellent and 3 cases were good.Conclusion:The concept of precision flap surgery based on CTA can effectively guide flap surgery and achieve precise wound repair.
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Objective:To investigate the clinical efficacy of induced membrane technique in the staged treatment of adult chronic hematogenous osteomyelitis (CHOM) of long bone.Methods:The clinical data were retrospectively analyzed of the 22 adult patients with CHOM of long bone who had been admitted to the 920th Hospital, Joint Logistics Support Force of PLA from January 2016 to December 2019. There were 18 males and 4 females, aged from 16 to 56 years (average, 31.81 years). Their disease duration ranged from 0.6 to 42.0 years, averaging 18.4 years. By the Cierny-Mader anatomical classification, 4 cases were type Ⅰ, 6 cases Type Ⅲ, and 12 cases type Ⅳ. In the first stage, the bone defects were filled with antibiotic bone cement after thorough debridement. In the second stage when the infection had been controlled, the bone defects were repaired with bone grafts after removal of the bone cement. Bone healing time and complications were followed up. The treatment effects were evaluated by comparisons of the infection control indexes [including clinical manifestations like local redness, swelling, pus, and pain, and blood white blood cell count, C-Reactive protein (CRP), and erythrocyte sedimentation rate (ESR) as well] before the primary surgery, before the secondary surgery and at the last follow-up.Results:The volumes of the bone defects after stage-one debridement ranged from 54 cm 3 to 176 cm 3 (mean, 90.9 cm 3). All patients were followed up for 20 to 51 months (mean, 30.1 months) after surgery. All bone defects healed after 4 to 11 months (mean, 6.6 months). Postoperatively, infection developed at the bone extraction site of the posterior superior iliac spine in 3 cases and pain was observed at the donor site in one case, but the conditions were relieved after symptomatic treatment. Fracture and plate breakage occurred at the bone defect site in one case who had fallen down 7 months after operation, but responded to reoperation. The last follow-up revealed such symptoms as redness, swelling and pus discharge in none of the patients. The white blood cell count [(5.70 ± 1.57) × 10 9/L and (5.65 ± 1.58) × 10 9/L], CRP [(7.56 ± 2.57) mg/L and (7.25 ± 3.83) mg/L] and ESR [(9.64 ± 2.90) mm/h and (10.55 ± 5.23) mm/h] before the secondary surgery and at the last follow-up were significantly lower than those before the primary surgery [(8.24 ± 2.18) × 10 9/L, (49.54 ± 19.56) mg/L, and (42.68 ± 13.77) mm/h] (all P < 0.05). However, there were no significant differences between the indexes before the secondary surgery and at the last follow-up ( P > 0.05). Conclusion:In the staged treatment of adult CHOM of long bone, the induced membrane technique can effectively control infection, achieve repair of bone defects, and reduce complications.
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Objective:To investigate the effect of flap combined with 3D printed microporous titanium(tantalum)prosthesis in the treatment of lower extremity soft tissue defect with large bone defect.Methods:From January 2019 to December 2020, 2 patients with large soft tissue defects on dorsal foot together with large metatarsal bone defect and 4 patients with soft tissue defects of calf with large tibial bone defect were treated. The areas of soft tissue defect were 5.0 cm×8.0 cm-15.0 cm×10.0 cm. The length of the bone defect were 3.8 cm to 7.0 cm, 5.75 cm in average. In the first stage, metatarsal bone defect or tibial bone defect was filled with vancomycin blended bone cement, meanwhile, soft tissue defect was repaired with anterolateral femoral flap(ALTF) with vascular anastomosis in 2 cases of feet, and local fascia flap was trans-positioned in 4 cases of lower extremity defects. The sizes of repairing flap were 6.0 cm×8.5 cm-16.0 cm×11.0 cm. Two to 7 months after the initial surgery, the customer designed microporous titanium prostheses were used(5 cases with microporous titanium and 1 with microporous tantalum) to repair the bone defects. The wound healing, the integration of metatarsal and tibial fractures with 3D printed microporous titanium(tantalum) prostheses, and the walking condition were observed after surgery. The follow-up lasted from 6 to 25 months, with an average of 12.7 months.Results:The wound healing in 5 patients was good. The patients stood on the foot in 2 months after surgery, started to walk with the assistance of crutch in 3 months after surgery, and took walk without assistance in 5-6 months after surgery. Good osseous integration were achieved. One diabetic patient had infection of foot wound 3 months after surgery. After removal of microporous titanium prosthesis and replacement of vancomycin blended interstitial substance of bone cement, the wound healed and the patient resumed walking.Conclusion:It is an effective method to encourage the patients to take early ambulation after the surgery for lower extremity soft tissue defect with large bone defect that was repaired by a flap and 3D printed microporous titanium(tantalum)prosthesis. Further observations are required to investigate the long-term efficacy, and the reduction of prosthesis infection rate requires further exploration.
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Objective:To investigate the clinical value of digital technology in repair of soft tissue defect in hand by anterior tibial artery perforator flap.Methods:From January 2015 to February 2021, 9 patients with soft tissue defects in hand were repaired with anterior tibial artery perforator flap assisted by digital technology in flap design, including 6 males and 3 females aged from 19 to 63 years with a mean age of 33 years. The size of defects varied from 2.0 cm×1.5 cm to 4.0 cm×3.0 cm, with exposed bones or tendons. Preoperative CTA scan of lower limb was performed and three-dimensional image was reconstructed with Mimics 20.0. The anterior tibial artery perforator flap was designed according to the shape and size of the defect, then the resection of flap was digitally simulated. The flap based on the digital design was harvested and the defect was repaired in the operation. The size of flap was 2.5 cm×2.0 cm~4.5 cm×3.5 cm. Outpatient clinic follow-up was performed to evaluate the survival of flaps. Disability of Arm, Shoulder and Hand(DASH) was used for function evaluation.Results:All flaps were harvested successfully and all donor sites were closed directly. After surgery, 8 flaps survived completely. One flap developed venous occlusion that showed partial necrosis of the flap, and it was rescued after exploration and re-anastomosis. The follow-up period ranged from 6 to 21 months, with an average of 13 months. The DASH scores of the affected limb were 2 to 15 points at the last follow-up, with an average of 6.4 points. Mild scar hyperplasia occurred at donor site in 1 case without sensory abnormality.Conclusion:The digital technology is able to accurately locate the perforators by allowing an individualised design of the anterior tibial artery perforator flap. The flap is suitable for repair of small and medium-sized soft tissue defect in hand, and the digital technology has certain value in clinical application.
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Objective:To estimate the preliminary result of circumflex scapular perforator propeller flap in reconstruction of axillary scar contractures.Methods:From January 2016 to June 2021, circumflex scapular perforator propeller flaps were used in 7 cases for reconstruction of soft tissue defect after axillary scar contractures. Patients were 5 males and 2 females. Age ranged from 23 to 38 years old, mean age of 27.7 years old. According to Kurtzman and Stern classification of axillary scar contractures, there were 1 case with type 1a, 1 with type 1b, 2 with type 2, and 3 with type 3. The preoperative range of motion of the shoulder joint were 40°-85°, with an average of 63.7°. All the patients were underwent scar release and circumflex scapular perforator propeller flap transfer. All flaps were transferred as the manner of perforator propeller flap. All the donor sites were closed directly. The defects after releasing ranged from 5.0 cm×7.0 cm to 11.0 cm×9.0 cm, and the flaps ranged from 16.0 cm×7.0 cm to 24.0 cm×9.0 cm. Flap survival, complications of donor site and recipient site were recorded after surgery. The range of motion of the shoulder joint, donor and recipient sites were reviewed in outpatient clinic.Results:All flaps survived uneventfully after surgery, besides 1 case complicated with distal venous congestion. The follow-up time ranged from 6 to 23 months, with an average of 12 months. The texture and contour of the flaps were good in all. At last follow-up, the range of motion of the shoulder joints were 90°-120°, with an average of 107°. Mild scar hyperplasia occurred in 2 cases.Conclusion:The circumflex scapular perforator propeller flap is an effective protocol in reconstruction of axillary scar contractures.
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A patient suffered a sustained soft tissue necrosis and infection at the radial interphalangeal joint of left thumb after laser nevus removal. He was treated in the Department of Orthopaedics, No. 920 Hospital of Joint Logistic Support Force of Chinese People's Liberation Army in February 2020. CTA combined with digital technology of Mimics software was used to accurately locate the perforator of posterior tibial artery septal perforator flap at the appropriate part of the calf and the super flap (1.20 cm×0.80 cm×0.46 cm) for the repair was designed. After 1 year of follow-up, the left thumb flap had no swelling with a satisfactory texture and appearance. The sensory recovered to S 3, and the left thumb movement was completely normal. Only a linear scar remained at the donor site of the calf.
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Objective:To explore the treatment of pressure sores in different parts of the buttocks.Methods:From May, 2005 to March, 2020, 170 (157 patients) pressure sores in different parts of buttocks were treated. Eighty-two pressure sores located at sacrococcyx, 52 at ischial tuberosity, 24 at greater trochanter (without hip joint exposure) and 12 at femoral greater trochanter with exposure of the hip joint. Flaps were used to repair the pressure sores. ①Seventy-one sacrococcygeal pressure sores were repaired by the gluteal epithelial neurovascular flap; ②10 (10 patients) sacrococcygeal and 42 (36 patients) sciatic tubercle pressure sores were repaired by the posterior femoral neurovascular flap; ③24(24 patients) femoral trochanter pressure sores and 1(1 patient) sacrococcygeal pressure sore were repaired by the tensor fascia lata myocutaneous flap; ④2 (2 patients) sciatic tubercle pressure sores were repaired by the gracilis myocutaneous flap; ⑤12 (10 patients) femoral trochanter pressure sores were with hip joint exposure treated with hip joint amputation; ⑥8 (8 patients) pressure sores at ischial tuberosity were treated with VSD. The pressure sores were measured at 5.0 cm×8.0 cm-15.0 cm×30.0 cm, and the flaps were sized 10.0 cm×12.0 cm-17.0 cm×32.0 cm. The follow-up was conducted in 2 methods: visit of outpatient clinic by patients and WeChat distanced interview by medical staff.Results:The gluteal epithelial neurovascular flaps, tensor fasciae lata flaps, gracilis myocutaneous flaps and posterior femoral neurovascular flaps all survived; 4 of 10 posterior femoral neurovascular flaps had partial necrosis and healed after dressing change. A total of 139 patients were treated by flap repair, of which 136 pressure sores healed, except 1 sacrococcygeal pressure sore and 1 femoral greater trochanter pressure sore did not heal because the patient was in old age, long-term hypoproteinaemia and anaemia, and 1 ischial tubercle pressure sore failed to heal due to osteomyelitis osteomyelitis. Ten pressure sores at femoral greater trochanter decubitus with hip joint exposure treated by hip joint amputation and 8 pressure sores at ischial tubercle decubitus treated by simple insertion of VSD were all healed. The follow-up period was 0.5-15.0 years, 7.5 years in average. The results of follow-up showed that pressure sores healed without recurrence in 154 patients, but failed to heal in 3 patients.Conclusion:The gluteal epithelial neurotrophic vascular flap has reliable blood supply and is simple to harvest, and it is a good flap to repair sacrococcygeal pressure sores. The tensor fascia lata myocutaneous flap has reliable blood supply and is simple to harvest, hence it is a good flap to repair greater trochanteric pressure sores. Transposition of the posterior femoral cutaneous nerve nutrient vessel flap or the V-Y advancement flap is simple and effective in repair of the sciatic tuberosity pressure sores. However, it is not recommended to apply the transposition of posterior femoral cutaneous nerve nutrient vessel flap in repair of the sacrococcygobtaineal pressure sore, because it would cause a necrosis at the distal part of the flap. When a greater trochanteric pressure sore coexists with an expose of hip joint, the hip joint can be dissected. For the pressure sore at ischial tuberosity, and if there is a small wound with a large internal cavity, it can be treated with simple insertion of VSD.
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Objective:To investigate the preliminary clinical effect of posterior interosseous artery propeller flap in the repair of dorsal of wrist and hand wounds.Methods:From March, 2015 to December, 2019, 9 cases of dorsal of wrist and hand wounds were repaired with posterior interosseous artery propeller flap, including 6 cases of dorsal hand defect and 3 cases of dorsal wrist defect. Defect area: 6 cm × 4 cm-3 cm × 3 cm; There were 3 cases of metacarpal fracture, 1 case of phalangeal fracture and 1 case of tendon rupture. According to the size and shape of the wound, the posterior interosseous artery propeller flap was designed to transfer and repair the soft tissue defect wound. The size of the flap: 20 cm × 5 cm-12 cm × 3 cm, the size of posterior interosseous artery propeller flap was recorded and the surgical characteristics were summarized; The survival of the flap, donor and recipient complications were observed and followed-up.Results:All flaps were cut smoothly and the donor areas were sutured directly. The flap survived completely in 8 cases and partial necrosis in 1 case; One case complicated with wound infection. The follow-up ranged from 6 to 31 months, with an average of 14 months. The texture and shape of the flap were good; The last DASH score was 3-18, with an average of 9.3; There were 2 cases of mild scar hyperplasia in the donor area and 1 case of mild scar hyperplasia at the edge of the flap.Conclusion:Posterior interosseous artery propeller flap may be an effective method to repair small and medium-sized wounds of dorsal of wrist and hand.
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Objective:To investigate the diagnostic performance of Xpert Mycobacterium tuberculosis/rifampin (Xpert MTB/RIF) assay for pulmonary tuberculosis (TB) in patients with acquired immunodeficiency syndrome (AIDS). Methods:Clinical data of 226 patients with AIDS and suspected pulmonary TB in Shanghai Public Health Clinical Center, Fudan University from July 2017 to November 2019 were retrospectively analyzed. Fluorescence staining microscopy of sputum smear, BACTEC MGIT 960 liquid culture (or Roche solid culture) and Xpert MTB/RIF assay were implemented respectively. The sensitivity and specificity of Xpert MTB/RIF in the diagnosis of Mycobacterium tuberculosis (MTB) infection and rifampin resistance were analyzed. Results:Totally 226 patients of suspected pulmonary TB were enrolled. There were 94(41.6%) patients had positive mycobacterium culture, in which 51 (54.3%) were MTB and 43 (45.7%) were nontuberculous mycobacteria (NTM). Using the positive MTB culture of sputum and mycobacterial protein from BCG of Rm 0.64 in electrophoresis (MPB64) as reference standard, the sensitivity and specificity of Xpert MTB/RIF assay for MTB diagnosis were 72.6%(95% confidence interval ( CI) 66.7%-78.4%) and 97.1% (95% CI 95.0%-99.3%), respectively. The sensitivity and specificity of Xpert MTB/RIF assay for MTB diagnosis in patients with positive sputum smear were 76.7%(95% CI 67.7%-85.8%) and 90.0(95% CI 83.6%-96.5%), respectively. The sensitivity and specificity of Xpert MTB/RIF assay for MTB diagnosis in patients with negative sputum smear were 50.0%(95% CI 41.8%-58.2%)and 99.3%(95% CI 97.9%-100.0%), respectively. With phenotypic resistance as reference standard, the sensitivity and specificity of Xpert MTB/RIF assay for rifampicin resistance were 75.0% and 100.0%, respectively. Conclusion:Among AIDS patients, the performance of Xpert MTB/RIF assay for pulmonary TB diagnosis is pretty good and could differentiate MTB from NTM rapidly, which has good application value.
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Objective:To investigate the effectiveness of CT angiography (CTA) combined with three-dimensional modeling-assisted design of superficial peroneal artery perforator flap for reconstruction of traumatic hand wound.Methods:A retrospective case series study was conducted to analyze the clinical data of 15 patients with hand injury admitted to 920th Hospital of Joint Logistic Support Force of PLA from January 2016 to December 2019. There were 11 males and 4 females, aged 19-51 years [(27.8±8.1)years]. All patients had soft tissue defect of the hand with exposed bone or tendon, and the defect area ranged from 2.0 cm×1.0 cm to 6.0 cm×4.0 cm. All patients underwent CTA of the abdominal aorta to dorsalis pedis artery before surgery. The three-dimensional models of bones, blood vessels, skin and other tissues were reconstructed by Mimics 20.0 software. The location, diameter and length of the superficial peroneal artery perforator vessels were accurately measured, and the perforator flap was designed according to the shape and size of the defect, then the resection of flap was simulated. During the operation, the superficial peroneal artery perforator flap was removed and transplanted to repair the defect according to the design. The location, diameter and length of perforator vessels were measured intraoperatively and compared with the preoperative modeling measurement. The operation time and intraoperative blood loss were recorded. The survival of the flap and healing of the donor site were observed after operation. The function of the affected limb was evaluated according to the upper limb function evaluation standard of Chinese Medical Association before and 3 months after surgery. The appearance, sensation and motion of the donor site were observed 3 months after surgery.Results:The origin and course of superficial peroneal artery perforator vessels could be clarified preoperatively based on the three-dimensional model. There was no significant difference in the location, diameter and length of perforator vessels between the pre- and intra-operative measurements ( P>0.05). All patients were followed up for 6-20 months [(12.2±3.8)months]. The operation duration was 50-125 minutes [(91.2±10.4)minutes], with blood loss of 150-450 ml [(364.1±44.7)ml]. The partial epidermal necrosis occurred in 2 patients after surgery, which gradually healed after dressing change, and other flaps survived smoothly. All donor sites could be sutured directly, and all incisions healed by first intention. According to the upper limb function evaluation standard of the Chinese Medical Association, the affected limb scored (76.4±9.7)points 3 months after surgery, higher than the preoperative score of (48.2±10.1)points ( P<0.05). The results were excellent in 8 patients, good in 6 and fair in 1, with the excellent and good rate of 93%. All patients had slight scar growth in donor sites and showed no obvious abnormalities in the sensation of foot dorsum and donor sites, with normal walking gait. Conclusion:CT angiography combined with three-dimensional modeling can accurately locate the perforating vessels, realize the individualized and precise design of the superficial peroneal artery perforator flap, and assist in the rapid and accurate flap resection, and hence promote wound healing and functional recovery of the hand.
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Objective:To investigate the efficacy of induced membrane technique combined with anterolateral thigh flap transfer in treating composite foot defect.Methods:A retrospective case series study was performed for 7 patients with composite foot defect treated at 920th Hospital of Joint Logistic Support Force of PLA from February 2014 to December 2018. There were 5 males and 2 females, with the age of 20-73 years [(38.9±16.3)years]. The composite defect located at the forefoot in 5 patients, midfoot in 1, and hindfoot in 1. There were 9 metatarsal bone defects, 1 medial cuneiform bone defect, and 1 calcaneus bone defect. The size of soft tissue defect varied from 6 cm×5 cm to 70 cm×35 cm. At stage I, the anterolateral thigh flap transfer and vancomycin loaded cement implantation were performed. The flap survival and complications were recorded. At stage II, the cement was removed and autogenous bone was grafted into the induced membrane. The duration of two-stage operation, bone union time, and complications were recorded. The postoperative function was assessed using Maryland foot score system before operation and at the last follow-up and postoperative compications were documented.Results:All patients were followed up for 22-54 months [(33.8±9.7)months]. At stage I, flaps survived in all patients, and bulking of the flap was seen in 3 patients. One patient with calcaneus bone defect had repeated infection after operation, and received debridement. At stage II, 6 patients received bone grafting surgery. The duration of two-stage operation was 2-4 months [(2.8±0.9)months]. The bone union time was 3 and 7 months [(4.7±1.2)months]. At the last follow-up, the Maryland foot function score was 63-92 points [(82.1±8.7)points], significantly different from 0 point before operation ( P<0.01). The results were excellent in 1 patient, good in 5, and fair in 1. Except for one nonunion of metatarsal bone, all the other 8 sites were with bone union uneventfully. Conclusion:The induced membrane technique combined with anterolateral thigh flap transfer is an effective protocol for composite foot defect, which can well repair soft tissue and bone defect, and restore walking.