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The aim of this meta-analysis was to compare the efficacy and safety between the microfracture (MFx) and augmented microfracture (MFx+) techniques for articular cartilage defects of the talus (OLTs). PubMed and EMBASE were searched from January 1950 to October 2020. Only randomized controlled trials, quasi-randomized controlled trials, and observational studies (retrospective and prospective) applying MFx and MFx+ techniques to treat talar cartilage defects were selected. Ten trials with 492 patients were included. There was significant difference in final American Orthopaedic Foot & Ankle Society score (AOFAS) (mean difference [MD] = 7.07; 95% confidence interval [CI], 3.70-10.44; p < .01), AOFAS change (MD = 7.97; 95% CI, 4.27-11.66; p < .01), visual analog scale (VAS) change score (MD = 0.44; 95% CI, 0.29-0.59; p < .01), Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score (MD = 12.51; 95% CI, 7.16-17.86; p < .01), complication (RR = 0.33; 95% CI, 0.16-0.69; p < .01), and revision (Relative risk = 0.34; 95% CI, 0.15-0.77; p < .05), between the MFx and MFx+ groups. No significant difference was observed for final VAS pain score (MD = -0.53; 95% CI, -1.2 to 1.05; p = .13) and Tegner scale (MD = 0.31; 95% CI, -1.05 to 1.66; p = .66) in either group. Our results suggest that augmented microfracture is superior to microfracture alone in the treatment of talar OLTs based on the AOFAS, MOCART, VAS score, complication rate, and revision ratio. Therefore, microfracture with augmentation should be considered as a treatment for OLTs of talus. However, more randomized trials are still required to determine the long-term superiority of MFx+.

This study aimed to compare the efficacy and safety of the microfracture (MFx) and microfracture augmented (MFx + ) techniques for the treatment of cartilage defects of the knee. The PubMed and EMBASE databases were searched from 1 January, 1950 to 1 May, 2019. RevMan5.3 was used to perform statistical analysis. Relative risk was calculated for binary variables, and weighted mean difference and standardized mean difference (SMD) were measured for continuous variables. The 95% confidence interval (CI) of each variable was assessed. Thirteen trials with 635 patients were included. There was a significant difference in the Lysholm's score (SMD = 0.26, 95% CI: 0.01–0.50, p = 0.04) and magnetic resonance observation of cartilage repair tissue score (SMD = 14.01, 95% CI: 8.01–20.02, p

Background miRNAs play an important role in the pathogenesis of intervertebral disc degeneration (IDD). The role and the underlying mechanism of miR-424-5p in human nucleus pulposus (NP) are still unknown. We aimed to explore the role of miR-424-5p in IDD. Methods Real-time PCR was used to detect the expression of miR-424-5p and Bcl2 in IDD tissues and idiopathic scoliosis tissues. Human NP cells were used in our study. MTT and Hoechst apoptosis assays were used to detect the proliferation and apoptosis of NP cells, respectively. Western blotting assays were used to detect the expression levels of Bcl-2, cleaved caspase-3, cleaved caspase-9, caspase-3 and caspase-9 in degenerative NP cells. A luciferase reporter assay was applied to confirm the relationship between miR-424-5p and Bcl2. Results Our results showed that the expression of miR-424-5p was increased and Bcl2 was decreased in degenerative NP cells. miR-425-5p expression was negatively correlated with Bcl2 expression in IDD tissues. Suppression of miR-424-5p using an inhibitor increased Bcl2 expression at both the mRNA and protein levels, and it promoted cell viability and inhibited apoptosis. Furthermore, the levels of cleaved caspase-3 and cleaved caspase-9 were downregulated in miR-424-5p-silenced NP cells. Interestingly, we found that silencing miR-424-5p increased p62 expression at both the mRNA and protein levels. Finally, a luciferase reporter assay verified the binding of the miR-424-5p and the 3’UTR of Bcl2. Conclusion These results suggested that silencing miR-424-5p suppressed NP cell apoptosis by upregulating Bcl2. Therefore, miR-424-5p might be a novel target for IDD therapies.

Objective The aim of the study was to explore the feasibility and early effect of digital design combined with 3-dimensional (3D) printing technique in the transplantation of vascular pedicled iliac bone flap in the treatment of avascular necrosis of the femoral head. Methods The navigation template was designed according to computed tomography scan and printed in 3D printing technique before operation, which was used to guide the localization and clearance of osteonecrosis of the femoral head in vascular pedicled iliac bone flap transplantation. In blank control group, 28 cases (32 hips) of osteonecrosis of the femoral head were treated with vascular pedicled iliac bone flap without the assistance of 3D navigation template from February 2002 to February 2009, including 19 males (21 hips) and 9 females (11 hips), with an average age of 37 years (range, 20–61 years). There were 12 cases of left hip, 16 cases of right hip, and 4 cases of double hip. According to the International Association of Bone Circulation staging, there were 8 hips in stage II B, 9 hips in stage II C, 8 hips in stage III B, and 7 hips in stage III C. In the experimental group, from February 2014 to June 2014, 15 patients (24 hips) with avascular necrosis of the femoral head were treated with vascular pedicled iliac bone flap with the aid of 3D navigation template. There were 11 males (17 hips) and 4 females (7 hips) with an average age of 38 years (range, 18–56 years). There were 2 cases of left hip, 4 cases of right hip, and 9 cases of double hip. According to the International Association of Bone Circulation staging, there were 5 hips in stage II B, 8 hips in stage II C, 6 hips in stage III B, and 5 hips in stage III C. The operation time, bleeding volume, and postoperative Harris score of the experimental group and the control group were statistically analyzed. Results The incisions in both groups healed in the first stage, and there were no operation-related complications such as deep venous thrombosis and infection of lower extremities. All patients were followed up for 12 to 16 months (with an average of 14 months). On the second day after operation, X-ray and computed tomography showed that the necrotic focus of the femoral head and the surrounding sclerotic bone was completely removed, and the position of the vascular pedicled iliac bone flap was satisfactory and did not penetrate the articular surface. The iliac bone flap and bone graft achieved bony fusion. In the navigation template group, the mean ± SD operation time was 135.38 ± 9.49 minutes, the mean ± SD blood loss was 225.13 ± 13.41 mL, the mean ± SD postoperative Harris score was 89.53 ± 5.83, 12 hips were excellent, 10 hips were good, and 2 hips were moderate, whereas in the group without navigation template, the mean ± SD operation time was 151.00 ± 15.28 minutes, the mean ± SD blood loss was 283.56 ± 30.60 mL, the mean ± SD postoperative Harris score was 83.32 ± 3.75, 15 hips were excellent, 14 hips were good, and 3 hips were fair. By independent sample t test, there were significant differences in average operation time, average blood loss, and postoperative Harris score between the 2 groups (P < 0.05). Conclusions Compared with not using navigation template, vascular pedicled iliac bone flap combined with navigation template in the treatment of osteonecrosis of femoral head could locate the area of osteonecrosis of femoral head more accurately, shorten the time of operation, and reduce the amount of bleeding during operation. Postoperative hip joint function recovery was better, and the early effect was satisfactory.

Background: With the development of transportation in modern China, the incidence of traumatic fracture and the global degree of fracture complexity are increasing. This study explored the use and curative effect of a novel custom-manufactured bridge combined fixation system for traumatic fractures of the femur. The bridge combined fixation system can be tailored to the specific patient's requirements by bending the rods and sliding the attachment modules. Methods: From May 2013 to August 2017, 14 patients with traumatic femur fractures were managed with the bridge combined fixation system. The operation was conducted according to the routine incision approach of femur fracture. The patients were given early postoperative functional rehabilitation exercise. The curative effect was evaluated according to clinical manifestations, postoperative imaging, and a self-developed standard for bone healing. Results: All patients were followed for 12–24 (median: 12.5) months. Fracture healing was assessed based on clinical symptoms and postoperative X-ray. After 3 months, complete weight-bearing on the affected leg was painless. X-ray showed that the fracture line had disappeared by 6–9 months postoperatively and showed bone healing. According to the self-developed standard for bone healing, 13/14 (92.8%) patients achieved excellent/good clinical outcomes. Bone union was achieved in all patients within 2 years. Conclusion: The custommanufactured bridge combined fixation system is simple and can effectively achieve tailored reduction of the fracture. The fixation was stable, with few complications after surgery and with good treatment effect for traumatic fractures.

Background The study was designed to investigate the safety and efficacy of trifocal bone transport (TFT) and soft-tissue transport with the Ilizarov technique for large posttraumatic tibial bone and soft tissue defects. Methods We retrospectively reviewed 31 patients with massive posttraumatic tibial bone and soft tissue defects from May 2009 to May 2016. All of the eligible patients were managed by TFT and soft-tissue transport. The median age was 33.4 years (range, 2-58 years). The mean defect of bone was 11.87cm ± 2.78cm (range, 8.2-18.2cm) after radical resection performed by TFT. The soft tissue defects ranged from 7cm x 8cm to 24cm x 12cm. The observed results included bone union time, wound close time and true complications. The Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system was used to assess bone and functional results and postoperative complications were evaluated by Paley classification. Results The mean duration of follow-up after frame removal was 32 months (range, 12-96 months). All cases achieved complete union in both the elongation sites and the docking sites, and eradication of infection. The mean bone transport time was 94.04 ± 23.33 days (range, 63.7-147 days). The mean external fixation time was 22.74 ± 6.82 months (range, 14-37 months), and the mean external fixation index (EFI) was 1.91 ± 0.3 months/cm (range, 1.2–2.5 months/cm). The bone results were excellent in 6 patients, good in 14 patients, fair in 8 patients and poor in 3 patients. The functional results were excellent in 8 patients, good in 15 patients, fair in 5 patients and poor in 3 patients. Conclusion The TFT in concert with soft-tissue transport technique can be used successfully to manage large tibial bone and soft-tissue defects. Soft-tissue transport can offer a feasible method for the defects with good soft tissue coverage on the bone ends. However, imprecision in the series results precludes a definitive conclusion, and comparative study is needed to assess whether soft-tissue transport is more effective than flap transfer for such soft-tissue defect.

Scaphoid fracture is the most common carpal fracture, accounting for 50%-80% of all carpal fractures in the Youngers and manual workers. The nonunion rate of scaphoid fractures was approximately 10-15%. Scaphoid nonunion can lead to wrist deformity, wrist collapse, ischemic necrosis, and traumatic osteoarthritis resulting in the loss of wrist function and seriously influence the patients' lives. Achieving bony union is essential for the treatment of scaphoid nonunion. Although many surgical procedures including various forms of bone grafting have been developed to improve bony union, there is no conclusion about which method is the most effective and optimal. In this review, we provide an overview of the diagnostic, classification and progress in the treatments of scaphoid nonunion fractures.

Objective Osteoarthritis (OA) is a chronic joint disease characterized by degeneration of articular cartilage and secondary osteogenesis. Cell-based agents, such as mesenchymal stem cells, have turned into the most extensively explored new therapeutic agents for OA. However, evidence-based research is still lacking. Methods We searched public databases up to February 2020 and only included randomized controlled trials. The outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Knee Injury and Osteoarthritis Outcome Score (KOOS), the visual analogue scale (VAS) score, and serious adverse events (SAEs). A network meta-analysis was also performed in this work. Results We included 13 studies in the meta-analysis. The effect size showed that cell-based therapy did not significantly reduce the WOMAC score at the 6-month follow-up (standard mean difference [SMD] −3.6; 95% confidence interval [CI] −0.90 to 0.18; P = 0.1928). However, cell-based therapy significantly improved the KOOS at the 12-month follow-up (SMD 0.68; 95% CI 0.07-1.30; P = 0.0288) and relieved pain (SMD −1.05; 95% CI −1.46 to −0.64; P < 0.0001). The findings also indicated that high-dosage adipose-derived mesenchymal stem cells (ADMSCs) may be more advantageous in terms of long-term effects. Conclusions Cell-based therapy had a better effect on KOOS improvement and pain relief without safety concerns. However, cell-based therapy did not show a benefit in terms of the WOMAC. Allogeneic cells might have advantages compared to controls in the WOMAC and KOOS scores. The long-term effect of high-dose ADMSC treatment for OA is worthy of further study.

Severe motorcycle spoke injuries of the heel lead to Achilles tendon defects, calcaneal tubercle exposure or loss, and overlying soft tissue defects, which are challenging to treat. Given the special physiological and developmental characteristics of children, severe spoke injuries of the heel in children are especially troublesome.We report details of 31 cases of severe motorcycle spoke injuries of the heel in children. The reconstruction timing depended on the time since injury, systematic conditions, and concurrent injuries. Eighteen cases were reconstructed at the time of emergency surgery, and 13 cases underwent delayed reconstruction. Appropriate flap transfer and Achilles tendon repair were conducted based on the defect size of the Achilles tendon, the main location of the soft tissue defect, and the distal residues of the Achilles tendon.Of the 31 cases, 16 cases were reconstructed with sliding gastrocnemius musculocutaneous flaps, 7 cases had saphenous neurocutaneous flaps, 4 cases had posterior tibial perforator flaps, 3 cases had sural neurocutaneous flaps, and 1 case was repaired with a peroneal artery perforator flap. All flaps healed uneventfully except for 3 cases of flap partial necrosis and 1 case of local infection of the Achilles tendon. During 6 months to 4 years of follow-up, dorsiflexion of the ankle was obviously limited at first but gradually recovered and enabled normal walking. However, due to the possibilities of calcaneal defects, epiphyseal injuries, and Achilles tendon problems, long-term follow-up is indicated.

Microsurgery techniques are being applied to an expanding range of orthopaedic problems. The success of microsurgical surgery depends not only on the operation, but also on the proper management of the perioperative period. If we only pay attention to intra-operative operation and neglect the preparation of perioperative period, these practices may cause surgical failures. Such lessons are common occurrences in the operating room. Therefore, as a microsurgeon, you must correctly grasp the surgical indications as well as the skillful surgical ability. More importantly, you should deal with the related issues during the perioperative period. This chapter deals with perioperative management in microsurgery for replantation, repair of vessels and nerves, and flap transfer.

The radial forearm flap which is known as the Chinese flap abroad was first reported by Guofan Yang in 1981 and applied widely in clinic in the early period since its advent. However, its indication becomes increasingly narrow because of the need to sacrifice one of the main arteries in the forearm and the ugly appearance of skin graft in the donor site. Both Chinese and international scholars have carried out a series of researches on the anatomy of the perforators on the radial aspect of the forearm, on the basis of which several surgical approaches have been put forward, such as the proximal radial artery perforator flap, the posterolateral mid-forearm perforator flap, the distal radial artery perforator flap and the snuff-box radial perforator flap.

Toe skin perforator flap refers to the mini island flap with blood supply provided by proper plantar digital artery and dorsal digital artery. Theoretically speaking, the first to fifth toes can all be used as the donor site of the flap, but the great toe is most frequently used one in clinical practice as the donor site for the flap, followed by the second. The other three toes are seldom used in clinical application.

The blood supply of the dorsal forearm has multiple sources, mainly deriving from the perforators arising from the posterior interosseous artery and the dorsal carpal branches of anterior interosseous artery. Most area of the dorsal forearm is supplied by the posterior interosseous perforators, while the distal area of the dorsal forearm is supplied by the dorsal carpal branch of anterior interosseous artery. A posterior interosseous perforator flap or an anterior interosseous dorsal perforator flap could be designed based on the dorsal antebrachial perforators.

The anterolateral crus flap obtained its blood supply from the septocutaneous perforator, the musculocutaneous perforator and the periosteal cutaneous perforator which emerged from the anterior tibial artery. This flap could be designed as a flap based on the proximal-middle segments of the anterior tibial artery perforator or a flap based on the distal segment of the anterior tibial artery perforator (the anterosuperior malleolar perforator flap).

Before the 1950s, due to the lack of in-depth studies carried on the cutaneous vasculature, the pedicled random pattern flap was the mainstream in flap surgery; during 1950s–1960s, studies on flap vessels resulted in the advent of muscle flap and axial pattern flap; in 1970s, along with the development of the organ transplants using the microsugical technique, the free flap, musculocutaneous flap and musculoskeletal flap involving with vascular anastomosis were applied in clinical practice; since 1980s, the flourishing and development of microdissection greatly promoted the development of flap surgery, and many achievements were gained in flap surgery, not only in theoretical field, but in the clinical application of relevant technologies. A variety of new types of flaps were developed and employed in surgeries, such as flap with main artery, reverse-flow island flap, fasciocutaneous flap, flap with intermuscular septal vascules, distally pedicled flap, venous flap, subcutaneous vascular plexus flap, veno-neurocutaneous vascular flap and perforator flap. With continuous increase of flap donor sites, the transposition of flap with a vascular pedicle was widely applied in clinical practice.

Medial pedis perforator flap is located in a hidden site of the non-weight-bearing area between the medial planta and medial dorsal foot, with a good skin texture and multi-sources for blood supply. It can be used to repair skin and soft tissue defect in the medial malleolus and the Achilles tendon by proximal transfer, and to repair the forefoot wounds by distal transfer. Free transplantation can be used to repair soft tissue defects in hands or wrists.

The lateral arm flap was first reported by Ruyao Song in 1982, and its anatomy and clinical application were investigated for repair of soft-tissue defects at the limbs by Katsaros in 1984. Mingjiang Liu designed a lateral arm perforator flap modified from the lateral arm flap in 2011. Transposition or advance of the lateral arm perforator flap is suitable for repairing the lack of elbow parenchyma, and free form of the flap could be used for repair of defect at hand, foot, and the cephalofacial area.

The circumflex scapular artery perforator flap is an axial flap with the trilateral space perforator of circumflex scapular vessel as its vascular pedicle. This flap was first reported by Gilbert in 1979. Nassife introduced the applied anatomy of combined scapular/parascapular bilobar flap in 1982, which was used to repair huge leg defect by Koshima and Soeda in 1985, and also to repair the high-voltage electric burn of upper limb by Cerkes. Angriginant used expanded scapular flap to repair cervical contracture in 1994.

Digital dorsal perforator flap is a minimal island flap of finger dorsal area that relies on the blood supply from dorsal branch of proper palmar digital artery and digital dorsal artery. It is mainly used for repairing the skin defects at middle and distal segments of the same finger. It can be designed as thumb radial/ulnar palmar artery perforator flap, thumb dorsal artery perforator flap and other digital dorsal perforator flap.

The medial crus flap obtained its nutrition from the spatium intermusculare perforator, myocutaneous perforator and periosteum cutaneous perforator of the posterior tibial artery. This flap had the advantage of not sacrificing the major blood vessels of the cruris. It could be designed as: (1) The flap based on the middle segment of the posterior tibial artery perforator which was suitable for repair of the wound on the knee and upper cruris by transposition or the wound on hand and foot by free transplantation; (2) The flap based on the distal segment of the posterior tibial artery perforator (superior medial malleolus perforator flap) was suitable for repair of the wound on the middle-lower segment of the cruris and on the achilles tendon region.

The antebrachial ulnar flap first reported by Lovie in 1984 is one of the most widely used antebrachial flaps in clinic following the antebrachial radial flap. However, it has its own disadvantages such as injury to the main antebrachial artery and ugly appearance of skin graft in the donor site which limits its clinical application. The proximal and middle ulnar perforator flaps and the distal ulnar perforator flap could be designed with its blood supply deriving from the proximal and middle perforators and the distal perforator arising from ulnar artery.

Dorsal pedis perforator flap is a flap with blood supply from dorsal pedal artery or dorsal metatarsal artery, and can be designed as the perforator flap pedicled with dorsal pedal artery or with dorsal metatarsal artery. The flap has sensory nerves and is characterized by small thickness, long vascular pedicle, and a wide diameter of the blood vessel which is convenient for anastomosis. As one of the commonly used flaps in clinical practice, it is a great convenience to use dorsal pedis perforator flap for pedicled flap transplantation or free flap transplantation. However, a poor coverage on the donor site may compromise the functions of the foot and shoes wearing, so it should be cautiously selected.

The superior and inferior gluteal artery perforator flap was developed from gluteus maximus myocutaneous flap. The superior gluteal artery perforator flap supplied by superior gluteal artery was first reported to repair sacral bedsore by Koshima in 1993. It was then applied in reconstruction of breast by Allen, and also used for repair of spinal meningocele and bedsore wound in pedicled form. The inferior gluteal artery perforator flap supplied by inferior gluteal artery was first reported to repair sciatic wound by Xiancheng Wang.

The blood supply of the medial thigh was characterized as multi-sources. The medial thigh perforator flap was nourished by the medial thigh perforating artery with a constant origin and course and a long vessel pedicle. It could be designed as a flap supplied by different blood supplies, such as vastus medial perforator flap, descending genicular artery perforator flap and saphenous artery perforator flap.

The nutritious vessel of perforator flap is tinier than that of axial pattern flap, so during the procedure of flap design, dissection, vascular pedicle dissociation and flap transplantation, slight carelessness will result in complications, including major ones and minor ones.

The deep inferior epigastric perforator flap (DIEP) was first reported by Koshima in 1988. Ever since it was first used for breast reconstruction by Allen in 1994, this flap could also be applied to total tongue reconstruction, repair of defects post midfacial tumor operations and coverage of huge limb soft-tissue defects with bone exposure. As a modified flap based on traditional transverse rectus abdominis musculocutaneous flap (TRAM), DIEP isolated the inferior epigastric vessel and its perforator from rectus abdominis to avoid muscular injury and decrease postoperative complications such as abdominal heria, bulge and weakness in donor sites.

The internal mammary artery perforator flap was first reported by Yu in 2006 for coverage of defects left by tracheostomy or defects by other causes in the anterior aspect of the neck. This perforator flap, an islanded one supplied by a single perforator given off from the internal thoracic artery, enjoys a greater arc of rotation. As a modification of the thoracic triangular flap, this perforator flap has overcome such drawbacks of the thoracic triangular flap as having a broad base, and limited rotational radium.

The dorsal hand is considered as a perfect tissue donor site, as it is distributed with multiple vessels can covered with smooth skin with moderate thickness and elasticity, and also has rich resources for tissue transplantation, such as metacarpal dorsal nerve, extensor tendon and metacarpus. Multiple types of flaps can be designed with dorsal hand, such as dorsal metacarpal artery perforator flap, ulnar palmar digitus minimus artery perforator flap, hand dorsum perforator flap from dorsal carpal branch of ulnar artery.

As the color, thickness and texture of skin at the pectoral region are all extremely similar to those of the cephalofacial skin, the pectoralis major myocutaneous flap (by Ariyan 1979) and thoracic triangle skin flap (by Bakamjian 1968) used to repair the cephalofacial soft tissue defects are both based on this region. However, the pectoralis major myocutaneous flap is bulky and impair the function of the donor site, and the thoracic triangle skin flap is inconvenient to use in flap transposition because of position and length of the vascular pedicle. Prof. Yixin Zhang reported the successful application thoracoacromial artery perforator flap (TAAP) in clinic practice. This flap could be used in coverage of soft tissue defects at the cephalofacial area, the shoulder joint and the superior area of the arm.

The thoracodorsal artery perforator flap first reported by Angrigiani was based on the latissimus dorsi myocutaneous flap. This flap which was supplied by thoracodorsal artery retained latissimus dorsi muscle and thoracodorsal nerve, so it was suitable for repair of trunk and limb defects in pedicled or free form, and also for repair of maxillary defect with scapula.

The lateral thorax perforator flap was located at lateral thoracic part of axillary fossa with the lateral thorax perforator as its axial artery. It was first reported by Boeckx in 1976. This flap could be applied to free grafting, and transposition of the flap could be used for soft-tissue defects of anterior part of homolateral shoulder, upper thoracic part, and also the thoracic and dorsalis part on sides of the flap.