Isolated limb fractures – the underestimated injury in the Israeli Defence Forces (IDF)

IntroductionMusculoskeletal injuries dominate warfare-related trauma and differ from civilian settings in higher hospitalization costs, morbidity, and mortality. Partly due to introduction of personal protective equipment in the Israel Defence Force (IDF) to minimize head and torso injuries while the extremities remained unprotected. This study describes military extremity injury patterns, prehospital treatment and injury sequela regarding return-to-duty and disability compensation.MethodsThis retrospective study examined cases of battle and non-battle trauma casualties treated by the IDF Medical Corps from 2013 to 2020. Data from the IDF Trauma Registry (IDF-TR) was merged with The Israeli National Trauma Registry (INTR). Cases with high morbidity discharged from military service were compared with lower morbidity patients who returned to active duty service.ResultsOut of 1360 injured soldiers, 280 (20.6%) were found to have isolated limb fractures (ILFs). High morbidity casualties had more open fractures (63% vs. 42%) and higher involvement of lower extremities (79% vs. 58%) (p < 0.001), higher rates of tourniquets use (28% compared to 9%, p < 0.001), external fixation (34% vs. 19%, p < 0.001) and amputations (9% vs. 1%, p = 0.003), required more rehabilitation (34% vs. 7%, p < 0.001), and had 46% medical disabilities compared to 24% with low morbidity (p < 0.001).ConclusionsILFs are associated with significant morbidity and disability. High morbidity is associated with high energy, scar-producing, lower-extremity open fractured limbs treated by tourniquets. Future studies should evaluate whether junctional or extremity protective gear is combat feasible and whether introducing Clinical Practice Guidelines to manage suspected limb fractures can decrease morbidity rates and improve return to duty.     

Surgical strategy for revisional lumbar pedicle subtraction osteotomy to correct fixed sagittal imbalance: The effect of the osteotomy level and iliac screw fixation

BackgroundMore caudal osteotomy is believed to lead to greater sagittal correction; however, the osteotomy level and whether or not to use iliac screw fixation (ISF) are topics of on-going debate. The aim of this study was to compare clinical and radiographic outcomes after revisional lumbar pedicle subtraction osteotomy (PSO) for fixed sagittal imbalance (FSI) according to the osteotomy level and ISF.MethodsAll consecutive patients who underwent revisional PSO (at L3 or L4) for FSI in a single institute from July 2006 to January 2014 were investigated retrospectively. Thirty-eight patients with at least 2-year follow-up were finally included. Clinical outcomes including the visual analogue scale (VAS) and Oswestry Disability Index (ODI) were investigated. Radiographic spinopelvic parameters were analyzed according to the level of PSO, the degree of correction, and the use of ISF.ResultsThe mean number of fused segments after PSO was 6.6 ± 1.8. Sagittal vertical axis (SVA) was restored after the surgery (12, 2.5, and 5.2 cm at preoperative, postoperative, and the last follow-up, respectively). PSO was performed at L3 in 16 patients and at L4 in 22 patients. The osteotomy level was not associated with any changes of spinopelvic parameters (pelvic tilt [PT] or lumbar lordosis) or sagittal alignment (T1-pelvic angle [TPA] or SVA). However, better TPA restoration was achieved with more osteotomy resection angle (P = 0.031). ISF group showed significant improvement in postoperative pelvic orientation (PT and ratio of PT to pelvic incidence) which was maintained until the last follow-up.ConclusionsAlthough postoperative sagittal alignment was different in FSI patients according to the osteotomy level, pelvic orientation improved in ISF group. Also, the degree of correction showed significant associations with sagittal alignment. When performing revisional PSO for FSI, spine surgeon should carefully consider how to correct rather than where to do the osteotomy, and the role of ISF.     

Crossing quartiles: Improving time to theatre for patients with hip fractures in a large UK district general hospital; A quality improvement report

BackgroundNeck of femur fractures are common injuries in the elderly population and carry significant morbidity and mortality. The introduction of a Best Practice Tariff (BPT) in 2010 laid out the criteria for optimising hip fracture care. These outcomes are audited annually by the National Hip Fracture Database. Meeting all six key targets attracts a financial uplift for each patient; one of these criteria is for an operation within 36 hours of admission.Local problemA large district general, seeing on average 551 hip fracture patients a year. In 2017, the trust was ranked 152/160 in England for meeting the 36-hour target to surgery, although theatre capacity was sufficient. The average time to theatre was 43.68 hours, significantly above the national average. BPT was only achieved in 45.7% of cases.MethodIn January 2018 an anaesthetic ‘hot week’ was introduced with the same anaesthetist responsible for the hip fracture lists to allow for continuity of care and timely identification of potential delays to surgery. Further responsibilities include attending trauma meeting, liaising with the orthopaedic and the orthogeriatric teams, and advising on medical optimisation of patients for theatre.ResultsComparing data for 2017 (pre-intervention) with 2018 (post-implementation), the following results in key measures were noted: Surgery within 36 hours increased from 54% to 87.5% of patients. Mean time to surgery fell from 43.68 hours to 25.11 hours. Attainment of BPT targets increased from 45.7% to 84%. Trust ranking went from 152^nd to 20^th for time to surgery and from 131^st to 18^th for meeting BPT. Rescheduled operations went from 126 to 31. As a result, mean length of stay reduced by 5.1 days. Mortality remained unchanged.ConclusionImplementation of an anaesthetic ‘hot week’ may help trusts improve times to theatre where sufficient theatre capacity is already in place.     

筋膜瓣和关节融合在糖尿病足窦道治疗中的应用

目的研究带蒂筋膜瓣转移填充及关节融合术在糖尿病足窦道外科治疗中的作用,探索合理的针对糖尿病足窦道的局部处理方案。方法自2007年2月至2010年8月共纳入糖尿病足伴窦道形成患者6例,其中男性4例,女性2例,年龄47～68岁,平均(58.3±6.7)岁。窦道口位于足跟部1例,基底部深至跟骨;足掌及足底3例,其中足底足掌穿通性窦道1例;足趾2例,均位于趾间关节处。在抗感染、抗凝、控制血糖、血压、血脂的前提下选择不同的手术方法。窦道发生于足跟部、足掌及足底者均采用筋膜瓣填充窦道;生于足趾者采用关节融合方法消除窦道腔。结果 6例患者均接受彻底扩创,其中4例采用筋膜瓣填充窦道,2例采用关节融合方法消除窦道腔。所有患者窦道在术后14～20d获得愈合,其中1例足底足背穿通窦道者,足背切口边缘皮肤部分发黑,经一段时间更换敷料后完全愈合,1例足趾处窦道者创缘红肿、渗液,经调控血糖、更换敷料、抗感染等处理后愈合。结论彻底扩创是糖尿病足窦道愈合的必要前提。用合理设计的邻近带蒂筋膜瓣填充足底、足背部位的糖尿病足窦道可以使其获得良好的愈合。对于足趾部位的窦道,直接行短缩融合较为安全有效。     

浮肩损伤

目的探讨浮肩损伤（floating shoulder injuries,FSI）的临床特征及治疗方法.方法回顾分析1999年6月至2005年6月收治的36例FSI的临床资料,其中肩胛颈骨折合并同侧锁骨骨折31例、肩锁关节脱位5例.患者均有不同程度的合并损伤,其中肋骨骨折、血气胸和（或）肺挫伤占88.9%.伤后至手术时间为3～43 d,平均9.6 d.术中首先复位固定锁骨骨折或肩锁关节脱位,然后采用改良Judet后方入路处理肩胛颈骨折.肩胛颈骨折合并锁骨骨折或肩锁关节脱位行一期内固定33例,术中仅固定锁骨骨折3例.结果术后随访6～69个月,平均19.7个月.肩胛颈骨折在目标区上均获解剖复位.根据Constant和Murley的疗效标准,术后肩关节功能评分为9～100分,平均81.3分,中位数为93%.按照Herscovici的疗效标准,优25例（69.4%）,良6例（16.7%）,可4例（11.1%）,差1例（2.8%）,疗效优良率为86.1%.术后复发血气胸1例,肩关节外展受限、肩峰下间隙疼痛3例,迟发性肩胛上神经损伤1例,肩关节不稳定继发创伤性关节炎1例.结论FSI使肩胛颈的解剖结构及其上方悬吊装置受到双重破坏,非手术治疗难以纠正不稳定型FSI的三维移位,早期切开复位内固定可取得满意疗效.     

多药耐药相关蛋白1在骨肉瘤中的表达

目的　探讨骨肉瘤组织中多药耐药相关蛋白 1(MRP1)的表达及其与临床病理特征的关系。方法　采用免疫组织化学方法检测 6例正常成年骨组织和 4 5例骨肉瘤组织中 MRP1,结合临床病理指标进行分析。结果6例正常骨组织中 MRP1的表达均为阴性。 4 5例骨肉瘤中 MRP1阳性 32例 (71.11% ) ,其中高分化骨肉瘤阳性率2 8.5 7% (2 / 7) ,中、低分化骨肉瘤阳性率 78.95 % (30 / 38) ,两组间差异有显著性 (P<0 .0 5 )。且随着骨肉瘤分化程度的降低 ,MRP1表达率升高 ,MRP1的表达与骨肉瘤的恶性程度呈正相关 (r=0 .84 4 )。根据肿瘤大小、Enneking外科分期、血清碱性磷酸酶 (AL P)含量、患者性别、年龄及就诊前病程长短等分组 ,MRP1表达无统计学意义。结论正常成年骨组织中 MRP1表达阴性。骨肉瘤组织中有 MRP1的表达 ,MRP1的表达与骨肉瘤的恶性程度呈正相关 ,提示 MRP1可能为骨肉瘤原发耐药的重要原因之一。     

Cell immobilization in gelatin–hydroxyphenylpropionic acid hydrogel fibers

Gelatin–hydroxyphenylpropionic acid (Gtn–HPA) hydrogels are highly porous and biodegradable materials. Herein we report a fiber spinning method that can produce cell-seeded solid and hollow hydrogel fibers by enzymatically cross-linking Gtn–HPA in solutions flowing within a capillary tube. The cell-immobilized hydrogel fibers, with feature sizes down to 20 μm, are formed as a result of continuous cross-linking of cell-mixed hydrogel precursors in a multiphase laminar flow. This fiber formation process is mild enough to retain the cell viability. The continuous fiber formation, simultaneous cell encapsulation, as well as versatile combination of fiber structures provided by this approach make it a promising and effective technique for the preparation of cell-seeded hydrogel scaffolds and carriers for tissue engineering.     

全髋关节置换术治疗成人先天性髋关节脱位

目的探讨全髋关节置换术治疗成人先天性髋关节脱位继发假臼骨关节炎的经验。方法1998年4月～2000年4月,对9例14髋成人先天性髋关节脱位继发假臼骨关节炎患者,进行了全髋关节置换术。其中双侧5例,单侧4例。结果术后伤口均一期愈合,经6个月～2年的随访,平均Harris评分由术前的33.93分恢复到术后6个月的89.21分。患者均能自行下地行走,生活自理且恢复日常工作。结论全髋关节置换术是治疗成人先天性髋关节脱位继发假臼骨关节炎的有效方法,但手术难度较大。手术中应充分考虑先天性髋关节脱位的原发及继发性病理改变,以采取相应的措施。     

WO-1生物衍生骨支架与成骨细胞相容性的实验研究

目的 研究WO-1生物衍生骨复合材料与兔成骨细胞的相容性及体外附着规律，为进一步的体内试验提供基础研究。方法 应用同种异体骨、Ⅰ型胶原及WO-1制备WO-1生物衍生骨复合材料；取幼兔的颅顶骨成骨细胞，经培养液体外培养、扩增后，与WO-1生物衍生骨材料联合培养。通过扫描电镜和倒置相差显微镜观察WO-1生物衍生骨复合材料的形貌特征、细胞与材料的粘附和增殖情况。结果 WO-1生物衍生骨复合材料具有天然骨的三维结构；扫描电镜和倒置相差显微镜均显示复合培养的成骨细胞在材料表面和孔隙内生长良好。结论 WO-1生物衍生骨复合材料具有良好的细胞相容性。