Purpose: To describe and evaluate the anatomical skin shape of the first web space in cadavers and to guide flap design for this area. Methods: Twelve cadavers (24 hands on both sides) were selected. Marker points were chosen based on the characteristics of the first web for morphological measurement and observation. The morphological characteristics of the first web under the radial or palmar abduction position of the thumb were measured and compared. The best morphologic features and parameters of the first web repairing flap were obtained. Results: When the thumb was in the palmar abduction position, the maximum distance a(p) was 6.78 +/- 0.72 cm and the skin area s(p) was 20.09 +/- 2.63 cm(2), both of which were significantly greater than the distance a(r) of 5.86 +/- 0.74 cm and the skin area s(r) of 17.39 +/- 2.15 cm(2) when the thumb was in the radial abduction position (P < 0.05). There was no significant difference in the length b(r) and b(p) of the long axis of the flap between two different abduction positions (P > 0.05). It is found that the shape of the first web area was not a symmetrical spindle but an irregular quadrilateral inclined to the index finger side. Conclusion: The flap design and measurement for the first web space covering should take the maximum palmar abduction position of the thumb as a reference. The asymmetric quadrilateral flap design is more in line with the anatomical and morphological characteristics of the region. (c) 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

目的:介绍应用彩色多普勒在术前对股前外侧皮瓣穿支血管进行精准定位后，切取不携带主干血管的短蒂单穿支股前外侧皮瓣游离移植修复四肢中小面积皮肤缺损的手术方法和临床效果。方法:自2017年12月至2019年9月，我科对15例四肢中小面积皮肤缺损患者应用短蒂股前外侧单穿支皮瓣游离移植修复，皮瓣供养动脉与受区动脉端侧吻合，皮瓣静脉与受区静脉端端吻合。皮瓣切取面积6 cm×5 cm~11 cm×7 cm，所有皮肤缺损创面均伴有肌腱或骨外露，皮瓣均为单穿支皮瓣，皮瓣的游离时间为30~40 min，平均切取时间为35 min。皮瓣供区一期缝合。结果:术后15例皮瓣全部存活，随访时间3~12个月，平均7.2个月，皮瓣外形满意，供区创面Ⅰ期愈合。结论:利用彩色多普勒在股前外侧的近中段对皮瓣穿支入皮点及穿支血管在皮下和肌肉内的行径进行精确定位，选择合适的穿支作为皮瓣的供养血管，应用"Free-style"理念切取短蒂股前外侧皮瓣，对供区损伤小，切取较传统方式简便，手术时间短，供区能直接缝合，是一种理想的应对血管变异的手术方法。对显微外科技术和彩色多普勒操作技术和要求较高。

Background: The application of random pattern skin flaps is limited in plastic surgery reconstruction due to necrosis. Fibroblast growth factor 9 (FGF9) was reported to exert a protective effect against myocardial damage and cerebral ischemia injury, but the impact of FGF9 in random flap survival is still unclear. In this study, we used a mouse model of random flaps to verify that FGF9 can directly increase flap survival area and blood flow intensity by promoting angiogenesis. Materials and Methods: In total, 84 male C57BL/6 mice weighing between 22 and 25 g were randomly divided into three groups (n = 28 each group). After skin flap operation, one group served as a control, a treatment group received FGF9, and a treatment group received FGF9+U0126. All flap samples were incised on postoperative day 7. Results: Our results showed that flap survival was significantly increased in the FGF9 group compared with that in the control group. This protective function was restrained by U0126. The results of histopathology, laser Doppler, and fluorescent staining all showed significant increases in capillary count, collagen deposition, and angiogenesis. FGF9 also significantly increased the expression of antioxidant stress proteins SOD1, eNOS, HO-1, vascular marker proteins CD31, VE cadherin, and pericyte marker protein PDGFRβ. Western blot showed that the phosphorylation degree of ERK1/2 increased after FGF9 treatment, and the expression of Nrf2, a downstream factor, was u-regulated. Western blot and immunofluorescence results of apoptosis-related proteins cleaved caspase-3, BAX, and Bcl2 showed that FGF9 inhibited apoptosis. ERK inhibitor U01926 reduced the beneficial effects of FGF9 on skin flap survival, including promoting angiogenesis, and showing antiapoptosis and antioxidative stress activities. Conclusions: Exogenous FGF9 stimulates angiogenesis of random flap and survival of tissue. the impact of FGF9 is closely linked to the prevention of oxidative stress mediated by ERK1/2-Nrf2. In the function of FGF9 in promoting effective angiogenesis, there may be a close interaction in the FGF9–FGFR–PDGFR–ERK–VE cadherin pathway. In particular, PDGFR and VE cadherin may interact.

Although hydrogels have been widely studied because of their satisfactory biocompatibility and plasticity, their application is limited in bone tissue engineering (BTE) owing to their inadequate mechanical properties and absence of osteogenic activity. To address this issue, we developed an updated alendronate (ALN)-Ca2+/Mg2+-doped supramolecular (CMS) hydrogel based on our previously developed mechanically resilient “host-guest macromer” (HGM) hydrogel to improve the hydrogel's mechanical properties and osteogenic activity. The CMS hydrogel was prepared by introducing a new physical crosslinking comprising the strong chelation of the comonomer acrylate alendronate (Ac-ALN) and Ca2+/Mg2+ in the HGM hydrogel. Compared with the previously developed HGM hydrogel, the upgraded CMS hydrogel presented better mechanical properties because of the additional physical crosslinking, while possessing injectable and self-healing properties like the HGM hydrogel. Moreover, the addition of Ac-ALN and Ca2+/Mg2+ also effectively promoted the in vitro proliferation, migration, and osteogenic differentiation of bone marrow-derived stem cells. The healing effect of a rat cranial defect further proved that the in vivo bone regeneration ability of CMS hydrogel was better than that of HGM hydrogel. The updated CMS hydrogel shows significant potential for BTE application.

The serious clinical challenge of peripheral nerve injury (PNI) is nerve regeneration. Nerve conduit represents a promising strategy to contribute to nerve regeneration by bridging injured nerve gaps. However, due to a unique microenvironment of nerve tissue, autologous nerves have not been substituted by nerve conduit. Nerve regeneration after nerve conduit implantation depends on many factors, such as conductivity and biocompatibility. Therefore, Gelatin (Gel) with biocompatibility and polypyrrole (Ppy) with conductivity is highly concerned. In this paper, Gel-Ppy modified nerve conduit was fabricated with great biocompatibility and conductivity to evaluate its properties of enhancing nerve regeneration in vivo and in vitro. The proliferation of Schwann cells on Gel-Ppy modified nerve conduit was remarkably increased. Consistent with in vitro results, the Gel-Ppy nerve conduit could contribute to the regeneration of Schwann cell in vivo. The axon diameters and myelin sheath thickness were also enhanced, resulting in the amelioration of muscle atrophy, nerve conduction, and motor function recovery. To explain this interesting phenomenon, western blot results indicated that the Gel-Ppy conduit facilitated nerve regeneration via upregulating the Rap1 pathway to induce neurite outgrowth. Therefore, the above results demonstrated that Gel-Ppy modified nerve conduit could provide an acceptable microenvironment for nerve regeneration and be popularized as a novel therapeutic strategy of PNI.

A diabetic wound is a refractory disease that afflicts patients globally. MicroRNA-146a-5p (miR-146a-5p) is reported to represent a potential therapeutic target for diabetic wounds. However, microRNA easily degrades in the wound microenvironment. This study extracted bone marrow mesenchymal stem cell (BMSC)-derived exosomes (EXO). Electroporation technology was used to load miR-146a-5p into EXO (labeled as EXO-miR-146a). The endothelial cells (human umbilical vein endothelial cells [HUVECs]) and macrophages were cocultured in transwell chambers in the presence of high glucose. Cell proliferation, migration, and angiogenesis were measured with cell counting kit 8, scratch, and tube forming assays, respectively. Flow cytometry was introduced to validate the biomarker of macrophages and BMSCs. The expression level of macrophage polarization-related proteins and tumor necrosis factor receptor-associated factor 6 (TRAF6) was assessed with western blotting analysis. The full-thickness skin wound model was developed to verify the in vitro results. EXO-miR-146a promoted the proliferation, migration, and angiogenesis of HUVECs in the hyperglycemic state by suppressing the TRAF6 expression in vitro. Additionally, EXO-miR-146a treatment facilitated M2 but inhibited M1 macrophage polarization. Furthermore, EXO-miR-146a enhances reepithelialization, angiogenesis, and M2 macrophage polarization, thereby accelerating diabetic wound healing in vivo. The EXO-miR-146a facilitated M2 macrophage polarization, proliferation, migration, and angiogenesis of HUVECs through TRAF6, thereby ameliorating intractable diabetic wound healing. These results established the basis for using EXO to deliver drugs and revealed mediators for diabetic wound treatment.

Objective Intractable pain after peripheral nerve injury has become a major concern in the field of pain. Current evidence shows that routine medications or surgical treatment is associated with inconsistent results and different curative effects. Stable and effective treatment methods in clinical practice are also lacking. To date, there is no consensus on the pathophysiological mechanisms of pain. The present study investigates the potential regulatory role of regulatory T cells in the differentiation of macrophages on dorsal root ganglion (DRG) and explores the mechanism of nociceptive signals in the signal transfer station. The findings are expected to guide the prevention of various types of peripheral neuropathic pain. Methods Thirty-six male Sprague Dawley (SD) rats and 18 male Nude rats, of equal weight (250–300g), were used in this study. The rats were divided into 3 groups: SD rat sciatic nerve transection group (SNT group, n = 18), SD rat nerve transection experimental group (SNT/RAPA group, n = 18) and Nude rat nerve transection experimental group (SNT/NUDE group, n = 18). The behavior related to neuropathic pain of animals were comprehensively evaluated in all groups. Furthermore, we analyzed the degree of neuroma development, histology, gene, and protein expression, and compared their correlation with the ultrastructural changes of M1/M2 type differentiation of macrophages in DRG. Results Sciatic nerve transection (SNT), induced the aggregation of several types of macrophages in lumbar DRG of SD rats leading to a higher ratio of M1/M2. Following the inhibition of the M1 type polarization of macrophages, axon outgrowth increased significantly. A significantly lower average autotomy score was reported in the SNT/NUDE group (* p < 0.05) and the SNT/RAPA group ( @ p < 0.05) as compared to that of the SNT group. The SNT/NUDE group showed no noticeable neuroma formation 30 days after the nerve transection. However, bulbous neuromas were observed in the nerve stumps of both the SNT control and SNT/RAPA groups. Immunofluorescence staining revealed a significant decrease in the proportion of M1/M2 macrophages in lumbar DRG of the SNT/NUDE group ( ** p < 0.001) and the SNT/RAPA group ( @ p < 0.05) compared to the SNT group. The expression of pain-related proteins was also decreased ( @ p < 0.05, * p < 0.05, ** p < 0.001). Also, the expression of alpha-smooth muscle actin (α-SMA), neurofilament 200 (NF-200), and nerve growth factor low-affinity receptor p75 were significantly down-regulated in the nerve tissue ( @ p < 0.05, @@ p < 0.001, ** p < 0.001). Conclusion M1/M2 type differentiation of macrophages on DRG plays a significant role in the formation of traumatic painful neuroma after neurotomy. In combination with our previous study, the results of this study suggest that regulatory T cells reduce the ratio of M1/M2 macrophages and alleviate the pain of neuroma by regulating the polarization direction of macrophages on neuroma. These findings provide key insights into developing new strategies to manage painful neuroma.

Peripheral nerve injuries (PNIs) are common and debilitating, cause significant health care costs for society, and rely predominately on autografts, which necessitate grafting a nerve section non-locally to repair the nerve injury. One possible approach to improving treatment is bolstering endogenous regenerative mechanisms or bioengineering new nervous tissue in the peripheral nervous system. In this review, we discuss critical-sized nerve gaps and nerve regeneration in rats, and summarize the roles of adipose-derived stem cells (ADSCs) in the treatment of PNIs. Several regenerative treatment modalities for PNI are described: ADSCs differentiating into Schwann cells (SCs), ADSCs secreting growth factors to promote peripheral nerve growth, ADSCs promoting myelination growth, and ADSCs treatments with scaffolds. ADSCs’ roles in regenerative treatment and features are compared to mesenchymal stem cells, and the administration routes, cell dosages, and cell fates are discussed. ADSCs secrete neurotrophic factors and exosomes and can differentiate into Schwann cell-like cells (SCLCs) that share features with naturally occurring SCs, including the ability to promote nerve regeneration in the PNS. Future clinical applications are also discussed.

Random-pattern skin flap is widely used in tissue reconstruction. However, necrosis occurring in the distal part of the flap limits its clinical application to some extent. Activation of autophagy has been considered as an effective approach to enhance the survival of skin flaps. Pseudoginsenoside F11 (PF11), an ocotillol-type saponin, is an important component of Panax quinquefolium which has been shown to confer protection against cerebral ischemia and alleviate oxidative stress. However, it is currently unknown whether PF11 induces autophagy to improve the survival of skin flaps. In this study, we investigated the effects of PF11 on blood flow and tissue edema. The results of histological examination and western blotting showed that PF11 enhanced angiogenesis, alleviated apoptosis and oxidative stress, thereby improving the survival of the flap. Further experiments showed that PF11 promoted nuclear translocation of TFEB and by regulating the phosphorylation of AMPK. In summary, this study demonstrates that PF11 activates autophagy through the AMPK-TFEB signal pathway in skin flaps and it could be a promising strategy for enhancing flap viability.

目的 评价背侧入路复位固定结合韧带修复治疗月骨周围脱位的临床疗效.方法 2013年9月至2018年7月,我院收治21例月骨周围脱位患者.其中1例开放性病例合并严重前臂损伤,1例因急性腕管综合征掌侧切开减压予剔除.其余19例(19侧)行背侧入路复位克氏针固定腕骨结合韧带修复,15例获(32.6±9.1)个月的随访.男14例,女1例.左侧10例,右侧5例.年龄19～65岁,平均(40.7±12.5)岁.术前正中神经支配区域麻木4例,受伤至手术时间1～52天.结果 4例术前正中神经支配区域麻木病例均恢复,末次随访疼痛采用视觉模拟评分(visual analogue scale,VAS),仅3例遗留活动时疼痛VAS 2～3分,其余12例无明显疼痛.腕关节活动范围(117.6±20.1)°,平均握力相当于健侧的(83±17)％.Cooney腕关节功能评分结果75～100分,平均(80±10)分,其中优5例,良6例,可3例,差1例.Herzberg分类:A型7例;A1型2例.B型2例,B1型4例.结论 单纯背侧入路复位固定结合韧带修复治疗月骨周围脱位可取得满意效果.

Total scalp avulsion is a rare but devastating injury currently without proven reconstructive techniques. While microsurgical anastomosis procedures have advanced and allowed for the replantation of digits and limbs, special anatomical considerations and risk of fatal blood loss add to the difficulty of replanting totally avulsed scalps. The authors present their replantation experience of 4 totally avulsed scalps between 2008 and 2017. Despite meticulous reconstructive techniques with proven success in limb and digit replantation, the first 3 cases failed due to various factors (i.e., thrombosis, venous congestion, reavulsion), and with experience, the fourth case was successful. Since total scalp avulsions are rare injuries, case reports are scarce, with only few publications commenting on failures which hold crucial information for surgeons to avoid pitfalls and optimize techniques. In this article, we highlight our experience with both successful and failed replantation of totally avulsed scalps, and offer recommendations and insight for optimization of this rare procedure.

目的 探讨显微外科修复手术治疗手足皮肤撕脱伤的疗效,分析影响疗效的相关因素.方法 选取2015年3月至2020年3月本院收治的手足皮肤撕脱伤患者96例.均采用显微外科修复治疗,术后进行疗效评价.记录患者相关临床资料分析影响患者术后疗效的相关因素.结果 96例患者中有效率为91.67％.单因素分析显示,年龄、受伤原因、撕脱面积、术后开始功能锻炼时间与其术后疗效有关(P<0.05).多因素Logistic分析表明,年龄、撕脱面积、负压调节适当、术后开始功能锻炼时间是其术后疗效的独立影响因素(P<0.05).结论 显微外科修复手术治疗手足皮肤撕脱伤有效率较高,值得推广.年龄、撕脱面积、负压调节适当、术后开始功能锻炼时间与其术后疗效有关.

Objective To introduce the design of modified Reading man flap, and observe the clinical effect of modified flap for repairing digit and toe wounds. Methods From July 2014 to September 2017,dorsal skin defects on 37 digits and 18 toes were repaired with our modified Reading man flaps. The revised design was characterized with enlargement the major flap and extending the minor flap proximally, and all donor site defect were sutured primarily through the major flap recover the defect and the minor flap repair the subsequent donor defect. Results All the detects in 55 patients were repaired by the modified Reading man flaps with direct donor sites closure. With average of 11. 5 months ( 9. 5-25. 7 months ) follow-up, all flaps survived with satisfactory texture and appearance, the bulky deformity and scar contracture did not occur. Partial necrosis of tip in the minor flaps occurred in 2 toes and healed by wound dressing. The function of the toe joints was good and the walking gait was normal. Partially impaired PIP joint function with limited flexion occurred in 2 cases. Based on the TAM evaluation criteria, the results were excellent in 28 digits, good in 7 digits, and the overall satisfactory rate was 94. 6％. Conclusions The modified Reading man flap can get good clinical effects for treatment of the digit and toe dorsal skin defect with the advantages of simple procedure, easy transfer and direct closure of donor sites. Flaps appearance and joints function can get good result postoperatively.

Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou 325027, People’s Republic of China; Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou 325027, People’s Republic of China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou 325027, People’s Republic of China; Pediatric Research Institute, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou 325027, People’s Republic of China; Department of Orthopaedics, Huzhou Central Hospital, Huzhou 313300, People’s Republic of China; School of Pharmaceutical Science, Wenzhou Medical University, Wenzhou, 325027, People’s Republic of China; Department of Obstetrics and Gynecology, The Second Affliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou 325027, People’s Republic of China

目的:探讨苏拉明对增生性瘢痕(HPS)的治疗作用及其机制.方法:使用机械牵拉的方法制造小鼠HPS模型后,分别在瘢痕部位涂抹低剂量(5 mg/kg)和高剂量(10 mg/kg)苏拉明溶液,每天1次,持续10 d.宏观观察瘢痕增生的程度;苏木精-伊红(HE)染色评价HPS组织中瘢痕横截面积与瘢痕抬高指数;然后通过免疫组化法检测HPS组织中转化生长因子β1(TGF-β1)和白细胞介素6(IL-6)的表达水平;免疫荧光、RT-qPCR和Wes-tern blot法分别检测HPS组织中α-平滑肌肌动蛋白(α-SMA)的表达水平;ELISA检测HPS组织中肿瘤坏死因子α(TNF-α)、IL-6、IL-10和TGF-β1的含量.结果:大体观察可见,低、高剂量苏拉明治疗后HPS小鼠瘢痕表面积均显著减少(P<0.01);HE染色下可见低、高剂量苏拉明治疗后HPS小鼠瘢痕横截面积和瘢痕抬高指数均显著减少(P<0.05或P<0.01);免疫荧光染色、RT-qPCR和Western blot结果显示,低、高剂量苏拉明治疗后HPS小鼠瘢痕组织中α-SMA阳性细胞数及α-SMA mRNA表达和蛋白表达均显著降低(P<0.05或P<0.01);免疫组化结果显示,低、高剂量苏拉明治疗后HPS小鼠瘢痕组织中TGF-β1和IL-6表达均显著降低(P<0.01);ELISA结果显示,低、高剂量苏拉明治疗后HPS小鼠瘢痕组织中TNF-α、IL-6、IL-10和TGF-β1水平均显著降低(P<0.01).结论:苏拉明具有抑制HPS形成的作用,这一作用可能与其抑制纤维增生和减轻局部炎症反应有关.

Objective To compare the clinical efficacy of supercutaneous locking plate,Kirschner wire and external fixator in the treatment of open metacarpal fractures,and to analyze the advantages and disadvantages of the three different fixation methods.Methods From March 2015 to February 2017,62cases of open metacarpal fractures with poor soft tissue conditions were treated with cross Kirschner wire (group A with 23 cases),external fixator (group B with 20 cases) and supercutaneous locking plate (group C with 19 cases).The clinical effects of the three methods were analyzed from the operation time,plaster extemal fixation time,fracture healing time,finger joint range of motion and postoperative complications.Results All the three groups were follow-up for 8 to 26 months with an average of 10.6 months.The mean operation time was (25.6±2.6) minutes in group A,(42.3±3.4) minutes in group B and (43.1±4.3) minutes in group C.The mean plaster external fixation time was (5.1±l.0) weeks in group A,(3.6±0.6) weeks in group B and (1.8±0.4) weeks in group C.The mean fracture healing time was (8.5±1.0) weeks in group A,(8.2±0.9) weeks in group B and (6.1±0.7) weeks in group C.The excellent and good rates of finger joint range of motion at 4 and 24 weeks after the operation were 34.8％ and 73.9％ in group A,40.0％ and 80.0％ in group B and 89.5％ and 94.7％ in group C respectively.The incidence of postoperative complications was 34.8％ in group A,25.0％ in group B and 5.3％ in group C,respectively.Except the operation time of group C was longer than that of group A and group B,the other indexes were better.Except for the excellent and good rate of finger joint range of motion at 24 weeks after the operation,the other differences had statistical significance (P＜0.05).Conclusion For the open metacarpal fractures with severe contamination or soft tissue injuries,the supercutaneous locking plate fixation can achieve better clinical results than cross Kirschner wire and external fixator.

Background: Random skin flap is frequently used in plastic and reconstructive surgery, but its distal part often occurs ischemia and necrosis. Pravastatin (Prava) with bioactivities of pro-angiogenesis, anti-apoptosis and anti-oxidative stress, may be beneficial for flap survival. Materials and methods: A modified McFarlane flap model was performed in Sprague-Dawley rats. The animals were divided into the Control and Prava groups and treated as follows: the Prava group was injected intraperitoneally with 2 mg/kg Prava for consecutive 7 days, and the Control group received an equal volume of vehicle daily. On day 7, the necrosis skin flaps were observed, while visualization of blood flow below the tissue surface was performed by Laser Doppler blood flow imaging (LDBFI). Then animals were euthanized, and levels of angiogenesis, apoptosis and oxidative stress were analyzed. Results: Prava decreased necrosis and edema of skin flaps compared with the Control group, with more blood flow in the flap under LDBFI. Prava treatment increased the mean vessels density, elevated the expression levels of angiogenic proteins (matrix metallopeptidase 9, vascular endothelial growth factor, Cadherin5) and antioxidant proteins (superoxide dismutase 1 (SOD1), endothelial nitric oxide synthase, heme oxygenase), and decreased the expression of apoptotic factors (BAX, CYC, Caspase3). In addition, malondialdehyde content was reduced, and glutathione level and SOD activity were increased in the skin flaps after treatment with Prava. Conclusion: Prava promotes survival of random skin flap through induction of angiogenesis, and inhibition of apoptosis and oxidative stress.

To introduce the repairation procedure of composite distal soft tissue defect of thumb and finger with mini toenail flap. Methods From June, 2015 to June, 2018, 7 cases with composite tissue defect at 7 distal fingers, including 5 thumbs, 1 index finger and 1 middle finger, were reconstructed with mini toenail flap transfer.The flap sizes which were raised during the operation ranged from 4.5 cm×3.0 cm-3.0 cm×1.5 cm.The donor sites were covered by toe phalanx shortening, V-Y advancement flap and local pedicle flap. Microsurgical routine treatment was made after the operation, and followed-up regularly. Results Seven flaps of 7 cases completely sur-vived without any necrosis. All the wounds at the donor sites healed well. All patients were followed-up for 6-36 months. The motive, sensor and cosmetic result were satisfied. In sensory function, the two-point discrimination dis-tance could restore to be 4-6 mm. Conclusion The mini toenail flap transfer is a reliable and suggested method.It can anatomically restored the distal digit sensor function with cosmetic contour, and regain the motive, sensory func-tion and satisfied cosmetic appearance.

Objective To explore the clinical effect of fracture reduction,autologous cancellous bone graft and palmar double-tiered subchondral locking support plate fixation through the extended flexor carpi radialis approach for treatment of comminuted distal radius fractures.Methods From October 2015 to August 2016,a total of 18 cases of comminuted distal radius fractures (AO type C3) were treated.The extended flexor carpi radialis approach were applied by transection of radialis septum and brachioradialis tendon insertion.Proximal end of radius fractures were dissected subperiosteally and pronated to expand the exposure range.Proper reduction and autogenous cancellous bone graft harvested from the proximal radius were achieved by using the intrafocal technique.The fractures were fixed by a volar double-tiered subchondral support locking plate.The clinical effect was analyzed according to the amount of autologous cancellous bone,postoperative wrist activity,postoperative radiographic parameters and Gartland-Werley wrist score.Results The amount of autologous cancellous bone was 1.2 to 3.1 cm3,with an average of 2.3 cm3.All the patients were follow-up for 9 to 19 months,with an average of 12.4 months.All the fractures were healed.No extensor tendon and median nerve injury symptoms occurred.At 9 months after the operation,the activity of affected wrist was (51.24 + 4.72) ° on flexion,(48.86±6.32)° on extension,(15.58±3.72)°on radial deviation,(24.67±5.82)° on ulnar deviation,(76.34±11.54)° on pronation and (74.58±10.56)° on supination.According to the Gartland-Werley wrist score,the results were excellent in 7 cases,good in 8 cases,fair in 2 cases and poor in 1 case.The results of imaging examination showed that the ulnar deviation angle was 13.1 ° to 24.6° with an average of 23.8°,the volar tilt angle was 10.3° to 14.3° with an average of 13.2°,the radial height was 9.3 to 14.8 mm with an average of 13.1 mm.Conclusion The sufficient volar exposure by the extended flexor carpi radialis approach can facilitate the fracture reduction under direct vision and subchondral support with autogenous cancellous bone graft harvested from the proximal fragment using the intrafocal technique.And stable fixation of the dorsal,volar and central fragments with double-tiered subchondral support plate can also facilitate the functional restoration in the treatment of comminuted distal radius fractures.

Background Random skin flaps are commonly applied during plastic surgery, but distal flap necrosis limits their clinical applications. Valproic acid (VPA), a histone deacetylase inhibitor and a traditional antiepileptic agent, may promote flap survival. Materials and methods Sprague–Dawley rats were randomly divided into VPA-treated and control groups. All rats received VPA or saline by intraperitoneal injections once daily for 7 days after the modified McFarlane flap model was established. On postoperative day 7, flap survival, laser Doppler blood flow, and water content were examined for flap viability, hematoxylin and eosin staining (H&E), immunohistochemistry (IHC), and Western blot analysis, and the status of angiogenesis, apoptosis, and oxidative stress were detected in the ischemic flaps. Results VPA increased the survival area, blood flow, and number of microvessels in skin flaps on postoperative day 7 and reduced edema. VPA promoted angiogenesis by enhancing vascular endothelial growth factor (VEGF) mRNA transcription and upregulating VEGF and cadherin 5 expression, inhibited apoptosis via reduction of caspase 3 cleavage, and relieved oxidative stress by increasing superoxide dismutase (SOD) and glutathione (GSH) levels and reducing the malondialdehyde (MDA) level. Conclusion VPA promoted random skin flap survival by enhancing angiogenesis and inhibiting oxidative stress and apoptosis.