ObjectiveTo evaluate the effect of using Schwann-like cells derived from human umbilical cord blood mesenchymal stem cells (hUCBMSCs) as the seed cells to repair large sciatic nerve defect in rats so as to provide the experimental evidence for clinical application of hUCBMSCs. MethodsFourty-five male Sprague Dawley (SD) rats in SPF grade, weighing 200-250 g, were selected. The hUCBMSCs were harvested and cultured from umbilical cord blood using lymphocyte separating and high molecular weight hydroxyethyl starch, and then was identified. The hUCBMSCs of 3rd generation were induced to Schwann-like cells, and then was identified by chemical derivatization combined with cytokine. The acellular nerve basal membrane conduit was prepared as scaffold material by the sciatic nerve of SD rats through repeated freezing, thawing, and washing. The tissue engineered nerve was prepared after 7 days of culturing Schwann-like cells (1×107 cells/mL) on the acellular nerve basal membrane conduit using the multi-point injection. The 15 mm sciatic nerve defect model was established in 30 male SD rats, which were randomly divided into 3 groups (10 rats each group). Defect was repaired with tissue engineered nerve in group A, with acellular nerve basal membrane conduit in group B, and with autologous sciatic nerve in group C. The nerve repair was evaluated through general observation, sciatic function index (SFI), nerve electrophysiology, weight of gastrocnemius muscle, and Masson staining after operation. ResultsThe hUCBMSCs showed higher expression of surface markers of mesenchymal stem cells, and Schwann-like cells showed positive expression of glia cell specific markers such as S100b, glial fibrillary acidic protein, and P75. At 8 weeks after operation, the acellular nerve basal membrane conduit had no necrosis and liquefaction, with mild adhesion, soft texture, and good continuity at nerve anastomosis site in group A; group B had similar appearance to group A; adhesion of group C was milder than that of groups A and B, with smooth anastomotic stoma and no enlargement, and the color was similar to that of normal nerve. SFI were gradually decreased, group C was significantly greater than groups A and B, group A was significantly greater than group B (P<0.05). The compound action potential could be detected in anastomotic site of 3 groups, group C was significantly greater than groups A and B, and group A was significantly greater than group B in amplitude and conduction velocity (P<0.05). Atrophy was observed in the gastrocnemius of 3 groups; wet weight's recovery rate of the gastrocnemius of group C was significantly greater than that of groups A and B, and group A was significantly greater than group B (P<0.05). Masson staining showed that large nerve fibers regeneration was found in group A, which had dense and neat arrangement with similar fiber diameter. The density and diameter of medullated fibers, thickness of myelinated axon, and axon diameter of group C were significantly greater than those of groups A and B, and group A was significantly greater than group B (P<0.05). ConclusionTissue engineered nerves from hUCBMSCs-derived Schwann-like cells can effectively repair large defects of the sciatic nerve. hUCBMSCs-derived Schwann-like cells can be used as a source of seed cells in nerve tissue engineering.
ObjectiveTo understand the location characteristics of the lumbosacral autonomic nerve plexus and the morphological changes so as to provide the anatomic theoretical basis for the protection of autonomic nerve during the lower lumbar anterior approach operation. MethodsA random anatomic investigation was carried out on 19 formalin-treated adult cadavers (15 males and 4 females; aged 44-78 years, mean 64 years). The anterior median line (connection of suprasternal fossa point and the midpoint of the symphysis pubis) was determined, and the characteristics of abdominal aortic plexus (AAP), inferior mesenteric plexus (IMP), and superior hypogastric plexus (SHP) were observed. The relationship between the autonomic nerve and the anterior median line was measured and recorded. ResultsAPP and IMP were found to be located chiefly in front of the abdominal aorta in a reticular pattern, and the nerve fibers of the two nerve plexuses were more densely at the left side of abdominal aorta than at the right side. Superior hypogastric plexus showed more distinct main vessel variations, including 4 types. The main vessel length of the SHP was (59.38±12.86) mm, and the width was (11.25±2.92) mm. The main vessels of SHP were mainly located at the left side of the ventral median line (10, 52.6%) and anterior lumbar vertebra (13, 68.4%). The main vessels extended down to form the left and right hypogastric nerves. ConclusionIt is applicable to expose the nerve from the right side of centrum and move the autonomic nerve and blood vessel as a whole during anterior lower lumbar operation. In this way, the dissection to separate nerve plexus is not needed, thus nerve injury can be avoided to the largest extent.
ObjectiveTo assess the long-term effectiveness of the transplantation of iliac bone flap pedicled with deep iliac circumflex vessels for treating avascular necrosis of femoral head (ANFH) at Ficat stage Ⅱ and Ⅲ. MethodsThirty-two cases (43 hips) of ANFH underwent iliac bone flap transplantation pedicled with deep iliac circumflex vessels between October 2000 and February 2006, and the clinical data were retrospectively reviewed. Of 32 cases, 27 were male (38 hips), and 5 were female (5 hips), aged 21-52 years (mean, 36.6 years); there were 8 cases (11 hips) of hormone ANFH, 18 cases (23 hips) of alcoholic ANFH, and 6 cases (9 hips) of idiopathic ANFH. The disease duration ranged from 2-52 months (mean, 8.2 months). According to Ficat staging criteria, 26 hips were classified as stage Ⅱ and 17 hips as stage Ⅲ. The preoperative Harris hip score (HSS) was 68.2±8.4. The HHS scores and X-ray photograph were compared between at pre-and post-operation to assess the outcomes clinically and radiologically. ResultsAll incisions healed by first intention. Two cases had numbness of the lateral femoral skin. Four patients (6 hips) failed to be followed up, and the other 28 cases were followed up 98-187 months (mean, 129.3 months). Five patients (6 hips) showed aggravation or no relief with progression to stage Ⅳ at 8-69 months, who received total hip arthroplasty. The 10-year survival rate was 83.78% (31/37). The HHS score was significantly increased to 86.7±9.0 at last follow-up (t=-48.313, P=0.000). The hip function was excellent in 9 hips, good in 13 hips, and fair in 9 hips, and the success rate was 75.68%. Radiographic examination showed signs of bone remodeling at 6-8 weeks. After bone healing, the femoral head density gradually became uniform. Until last follow-up, ANFH progressed from Ficat stage Ⅱ to Ⅲ in 5 hips, from Ficat stage Ⅱ to Ⅳ in 3 hips, and from Ficat stage Ⅲ to Ⅳ in 3 hips; complete hip shape, continuous Shenton line, and normal joint space were observed in the other 26 hips, and the radiographic success rate was 70.27% (26/37). ConclusionThe pedicled iliac bone flap transplantation for ANFH at Ficat stage Ⅱ and Ⅲ can provide good osteogenesis and vascular reconstruction of the femoral head. The long-term follow-up effectiveness is satisfactory.
ObjectiveTo investigate the effectiveness and technical key points of limb salvage surgery by allotransplantation of cryopreservated vascularized bone in children and adolescents with osteosarcoma. MethodsA retrospective analysis was made on the clinical data of 21 children and adolescents with osteosarcoma receiving limb salvage surgery by allotransplantation of cryopreservated vascularized bone from their relatives between February 2004 and April 2012. There were 13 males and 8 females, aged from 7 to 16 years (mean, 12.6 years). According to Enneking stage system, 15 cases were rated as stage ⅡA and 6 cases as stage ⅡB. The tumors located at the distal femur in 10 cases, at the proximal femur in 1 case, at the proximal tibia in 8 cases, at the proximal humerus in 1 case, and at the distal radius in 1 case. Imaging examination showed that epiphyseal extension of malignant bone tumors in 7 cases. The iliac bone allograft with deep iliac vessels was obtained from their lineal consanguinity. After preservation by a twostep freezing schedule, the iliac bone allograft with deep iliac vessels was implanted into the bone defect area after tumor resection. The size of iliac bone flap was 8.0 cm×3.0 cm×2.0 cm-14.0 cm×5.0 cm×2.5 cm. Reserved joint surgery was performed on 16 cases and joint fusion surgery on 5 cases, and external fixation was used in all cases. The chemotherapy was given according to sequential high-dose methotraxate, adriamycin, and cisplatine before and after operation. ResultsAll 21 cases were followed up from 5 months to 11 years (mean, 6.4 years). At 2 weeks after operation, the erythrocyte rosette forming cells accounted for 56.7%±3.9%, showing no significant difference when compared with that of normal control (58.3%±4.3%) (t=1.56, P=0.13), which suggested no acute rejection. At 4 weeks after operation, single photon emission computerized tomography bone scan indicated that the blood supply of bone graft was rich, and the metabolism was active. At 12 weeks after operation, the digital subtraction angiography showed the artery of iliac bone flap kept patency. X-ray films showed that malunion and non-union occurred at 5 and 6 months after operation in 1 case, respectively. The bone graft healed in the other patients, and the healing time was 3.2-6.0 months (mean, 4.4 months). At last follow-up, American Musculoskeletal Tumor Society (MSTS) score was significantly improved to 26.80±2.14 from preoperative value (17.15±1.86) (t=-4.15, P=0.00). The survival rate was 85.7% (18/21) and the recurrence rate was 9.5% (2/21). ConclusionAllotransplantation of cryopreservated vascularized bone from the relatives provides a new method for the treatment of osteosarcoma in children and adolescents. A combination of allotransplantation and chemotherapy can achieve the ideal treatment effect. The correct cutting, preservation, and transplantation of the donor bone, and indication are the key to improve the effectiveness.
ObjectiveTo assess the effectiveness of pedicled iliac periosteal flap graft for treatment of avascular necrosis of the femoral head (ANFH) after femoral neck fracture in adolescents. MethodsBetween December 2006 and August 2011, 9 patients (9 hips) with ANFH after femoral neck fracture were treated with pedicled iliac periosteal flap graft. There were 6 males and 3 females with an average age of 14.7 years (range, 10-18 years). Fractures were caused by traffic accident injury (5 cases), falling injury from height (3 cases), and fall injury (1 case). The time from injury to internal fixation with Kirschner wires or cannulated screws was 3-16 days, and all fractures healed within 10 months after internal fixation. The interval between fracture fixation and ANFH was 10-42 months (mean, 24.4 months). According to Steinberg staging system, 1 hip was classified as stage Ⅲb, 2 hips as stage Ⅲc, 1 hip as stage IVa, 3 hips as stage IVb, and 2 hips as stage IVc. The Harris scores and Steinberg classification were compared between at pre- and post-operation to assess the outcomes clinically and radiologically. ResultsAll incisions healed by first intention. No complications of infection, deep venous thrombosis of lower limb, and pain and numbness of donor site were observed during or after operation. All patients were followed up 38-76 months (mean, 52 months). Joint pain was relieved; no leg length discrepancy was observed; the walking gait was improved and range of motion of hips was increased. The Harris score was significantly increased from 62.8±3.6 at pre-operation to 92.7±9.9 at last follow-up, showing significant difference (t=-12.244, P=0.000). The hip function was excellent in 5 hips, good in 3 hips, and poor in 1 hip, and the excellent and good rate was 88.89%. Post-operative radiological assessment demonstrated that only 1 hip (stage Ⅲb) had further collapse of the femoral head, the other hips had no incidence of deterioration. The radiological success rate was 88.89% (8/9). ConclusionThe pedicled iliac periosteal flap graft for ANFH after femoral neck fracture in adolescents can provide good osteogenesis and vascular reconstruction of the femoral head.
ObjectiveTo assess the effectiveness of percutaneous Kirschner wire poking reduction and elastic stable intramedullary nailing fixation for treating severe displaced radial neck fractures in children. MethodsBetween November 2010 and August 2014, 17 children with severe displaced radial neck fractures were treated with percutaneous Kirschner wire poking reduction and elastic stable intramedullary nailing fixation. There were 13 boys and 4 girls with an average age of 8.7 years (range, 6-14 years). The right side was involved in 9 cases, and the left side was involved in 8 cases. The causes of injury were falling in all cases. The angular deformity at fracture was 64-102° (mean, 84°). According to the Judet classification, 7 cases were classified as grade ⅠVa and 10 cases as grade ⅠVb. The time from injury to operation was 4.2 days (range, 1-7 days). Metaizeau classification and Tibone-Stoltz elbow performance score were used to access the radiological and clinical results, respectively. ResultsThe operation time was 20-50 minutes (mean, 30 minutes). All incisions healed by first intention. The patients were followed up 12-46 months (mean, 20 months). All fractures healed at 2 months after operation. There was no complication of malunion, early epiphyseal closure, avascular necrosis, enlargement of the radial head epiphysis, cubitus varus and valgus deformities, or proximal radioulnar joint synostosis. One case had elbow extension limitation. At last follow-up, the elbow range of motion in flexion, extension, pronation, and supination showed no significant difference between affected side and normal side (P>0.05). The clinical results were excellent in 16 cases and good in 1 case, with an excellent and good rate of 100%. The angulation was 0-12° (mean, 3.7°) on the X-ray film; anatomic reduction or nearly anatomic reduction was obtained, and the radiological results were excellent in 13 cases and good in 4 cases, with an excellent and good rate of 100%. ConclusionPercutaneous Kirschner wire poking reduction followed by fixation with elastic stable intramedullary nailing is a simple, safe, minimally invasive, and effective method to treat severe displaced radial neck fractures in children.