Autogenous bone grafts have long been considered the "gold standard" and most effective material in bone regeneration procedures.[1] Autogenous bone grafts are used to repair bone defects caused by nonunion, infection, tumor resection, and spinal and joint fusion.[2] It has been reported that more than 200,000 autologous bone grafts are performed in the United States each year.[3] Although there are no specific statistics on the annual number of bone grafts performed in China, autologous bone grafting is the most common surgical technique in orthopedics. The iliac crest remains the most common donor site, along with the fibula, ribs, tibial metaphysis, proximal humerus, distal radius, and greater trochanter.[4,5] Various bone-graft options provide different amounts and qualities of cortical, cancellous, and corticocancellous bone.[6,7] Autogenous bone graft is osteogenic, histocompatible, provides structural support, and has no risk of disease transmission. The disadvantages of autogenous bone grafting are its limited supply and the increase in the magnitude of surgery owing to the need to harvest bone graft material, which increases the operative time, blood loss, and risk of complications. There are no clinical guidelines or consensus report focused on autogenous bone-grafting indications, techniques, and complication.[8] The Trauma Orthopedic Branch of the Chinese Orthopedic Association and National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation developed clinical practice guidelines for indications, techniques, and complications of autogenous bone grafting (detailed information is listed in the Supplementary File, https://links.lww.com/CM9/B551). Definition of autogenous bone grafting Autogenous bone grafting is defined as the transplantation of bone tissue obtained from a donor site into a bone defect, nonunion, or arthrodesis. Cortical bone is osteoconductive, provides functional support, and is suitable for structural defects. Cancellous bone graft has a viable cell and pore structure, which makes it easy to reconstruct blood vessels. Cancellous bone provides an osteoinductive, osteoconductive, and osteogenic substrate, but is not suitable for structural defects that require immediate mechanical stability. The vascularized bone graft (VBG) is categorized into pedicled and free grafts. A pedicled VBG is transferred from the donor site to the recipient site with its native vasculature preserved. A free VBG has its vascular pedicle divided, permitting transfer to virtually any location. Recommended strength The recommendation strength is based on a combination of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and the characteristics of clinical practice in China. Using the weighted value of each characteristic, the experts who wrote the guidelines scored the recommendations individually using a grading system [Supplementary Tables 1–3, https://links.lww.com/CM9/B551]. Types of autogenous bone grafts Autogenous bone is considered the gold standard for most applications in orthopedics because of the physiologic properties of autogenous bone as biocompatible, bioresorbable, osteoconductive, osteoinductive, and structurally supportive. When selecting the graft donor area, clinicians must consider the location of the bone defect, the position of the patient during surgery, and the required amount of graft material. The most common site for bone harvesting is the anterior iliac crest, along with the posterior iliac crest, ribs, fibula, tibial metaphysis, distal radius, and greater trochanter of the femur. Different donor areas have different indications, techniques, and complications. The most common complications are donor site pain, nerve injury, infection, fracture, an extended surgical time, increased blood loss, and limited bone graft material (grade IA). Autologous bone grafts comprise non-vascularized and VBGs. Non-vascularized autogenous bone is divided into cortical, cancellous, and corticocancellous bone. The most common vascularized bone flaps are harvested from the iliac crest with the deep circumflex iliac artery, the fibula with branches of the peroneal artery, the ribs with the posterior intercostal artery, and the distal end of the radius with the supraretinacular artery (grade IIA). Indications, techniques, and complications of non-vascularized bone grafts Anterior iliac crest bone grafting The anterior iliac crest is the most common donor site for autologous bone grafting (grade IA) and is suitable for treating severe open fractures, bone defects, delayed union, nonunion, tumor bone defects, joint fusion, and interbody fusion. The techniques for anterior iliac crest bone grafting include the curettage technique, bicortical or tricortical technique, trapdoor technique, trephine technique, and acetabular reamer technique (grade IIIA). The anterior iliac crest provides a large amount of cancellous, unicortical, bicortical, and tricortical bone. The complications of anterior iliac crest grafting are pain, nerve injury, hematoma formation, infection, incisional hernia, vascular injury, and donor site fracture (grade IA). Posterior iliac crest bone grafting The posterior superior iliac spine is the most common source of autogenous bone graft material during posterior spine fusion or procedures that require a large amount of bone graft material. The trapdoor technique is recommended to protect the integrity of the iliac crest and internal plate, and the depth of resection is limited to 4 to 6 cm to prevent damage to the sacroiliac joint and superior gluteus artery. Complications at the posterior iliac crest donor site are pain, neurovascular injury, avulsion fracture, hematoma, infection, incisional hernia, gait disturbance, sacroiliac joint invasion, and ureteral injury. Injury to the sacroiliac joint and superior gluteal artery can be avoided (grade IA). Autologous rib bone grafting An autologous rib bone graft is suitable for the reconstruction of defects in the spine, maxillofacial region, or limbs. In situ rib split transplantation is recommended, in which the rib is split in the coronal plane, the deep cortex is preserved in situ, and the superficial half of the rib cortex and cancellous bone are removed. This method is technically simple, requires a short operation time, does not damage the pleura, and reduces donor site complications. The complications of autologous rib bone grafting are pneumonia, persistent atelectasis, superficial wound dehiscence, pneumothorax, intercostal neuralgia, and chronic chest wall pain (grade IB). Tibial metaphyseal bone grafting The ipsilateral proximal and distal tibia provide adequate amounts of bone graft material for use in foot and ankle surgery. The tibia is easily accessible and can provide large quantities of cancellous and cortical bone. Tibial bone is commonly harvested using an osteotome, curette, or trephine. The main postoperative complications are pain at the donor site, hematoma, deep infection, and stress fracture (grade IB). Distal radius bone grafting The distal radius is usually used for nonunion or bone defects in the ipsilateral hand and wrist requiring a small amount of bone graft material. The cancellous or corticocancellous bone can be harvested by fenestration through the dorsal first and second compartments or through the palmar approach. The recurrent branch of the radial artery is anatomically constant, and a vascularized free bone flap can be used to repair scaphoid fracture nonunion and lunate osteonecrosis to obtain mechanical support and improve local blood supply. The main complications are donor site pain, tenosynovitis, infection, fracture, and nerve injury (grade IB). Greater trochanter bone grafting The greater trochanter of the femur is mainly composed of cancellous bone, which is suitable for ipsilateral lower limb defects, foot and ankle surgery, femoral neck nonunion, and femoral head necrosis. The greater trochanter free bone graft can be obtained by trephine or fenestration, providing a bone volume of 5–10 cm3. Common complications are donor site pain and stress fracture of the femoral neck due to excessive bone harvesting (grade IB). Reamer irrigator aspirator technique The reamer irrigator aspirator (RIA) is a relatively recent device that is placed in the femoral or tibial medullary canal to harvest a large volume of bone and is supposed to be less invasive than previous methods, allowing the harvest of a greater graft volume. The RIA device allows intramedullary reaming with simultaneous irrigation and aspiration to harvest large amounts of autologous bone from the medullary canal of long bones. The complications of the RIA technique are hemodynamic instability, iatrogenic fracture, pain, hematoma, and deep infection (grade IIIB). Indications, techniques, and complications of vascularized bone grafting Free vascularized fibular grafting Free vascularized fibular grafting (FVFG) is indicated for the reconstruction of upper extremity skeletal defects larger than 6 cm caused by oncologic resection, trauma, osteomyelitis, nonunion, or congenital malformation. Furthermore, FVFG is another important hip-preserving approach for the treatment of osteonecrosis. The most common FVFG technique is Wood's modified method in which the fibula is resected between the peroneus longus and soleus muscles. Complications at the donor site are ipsilateral tibial stress fracture, flexor pollicis longus tendon contracture, peroneal nerve palsy, and compartment syndrome (grade II-B). Vascularized iliac bone grafting The vascularized iliac bone graft based on deep circumflex iliac vessels provides a large concave segment of bone suitable for reconstruction of the extremities and spine. Both pedicled iliac bone flap transfer and FVFG are effective methods for the treatment of femoral head necrosis. Several donor site complications are reported after vascularized iliac bone grafting, namely injury to the lateral cutaneous femoral nerve, gait disturbance, bowel obstruction, and herniation (grade III-B). Vascularized rib bone grafting The vascularized rib graft is suitable for use in adjacent spinal fusion or long bone defects of the extremities that require strong biomechanical support. Vascularized rib grafting can be used in complex cases with a high risk of nonunion, infection, and pseudoarthrosis of the bone defect. There are few donor site complications, namely pneumothorax and hemothorax (grade IIIB). Surgical techniques related to autogenous bone grafting In vitro storage of autogenous bone graft material The common preservation methods after autologous bone harvesting are dry preservation and solvent preservation. Saline or 5% glucose solution is recommended as it better preserves the osteoinduction and osteogenic ability of autologous bone than dry preservation (grade IIIC). Antibiotic-impregnated autogenous bone grafts Antibiotic-impregnated bone grafts have become popular and seem to be effective and safe in the treatment of infected bone and joint defects. Infectious bone defects are common and need to be addressed before a new implant is inserted. A major advantage of antibiotic-impregnated bone grafts is the possibility of impregnating various antibiotics depending on the sensitivity profile of the causative organism (grade IB). Autogenous cancellous bone grafting using the induced membranes treatment technique The induced membranes technique is a common clinical technique that comprises a two-stage procedure. The iliac crest is the most common donor site in clinical practice, and bone can be harvested from the anterior or posterior iliac crest in accordance with the surgical position and the patient's condition. The acquisition of autologous bone by the RIA device obtains relatively more bone mass, reduces the time required for bone harvesting, and reduces donor site complications (grade IIIB). Acknowledgments We thank Kelly Zammit, BVSc, from Liwen Bianji (Edanz) (www.liwenbianji.cn/), for editing the English text of a draft of this manuscript. Funding This work was supported by the grant from the Special Project Program of the National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation (No. 2022-NCRC-000000) and the Beijing Municipal Natural Science Foundation (No. 7232165). Conflicts of interest None.

目的 探讨弹性牵引外架结合部分钩骨腕掌关节面移植在手指指间关节结构性骨缺损功能重建中的价值.方法 回顾性分析2016年11月-2019年1月解放军总医院第七医学中心骨科学部收治陈旧性指间关节部分结构性缺损患者17例(17指),男性15例15指,女性2例2指;年龄20～ 55岁,平均32.2岁.重物挤压伤6例6指,电锯切割伤10例10指,锤击伤1例1指;均采用钩骨部分腕掌关节面移植来进行手指关节缺损修复,术中采用微型螺钉及弹性牵引外架对修复部位进行固定,术后1周开始指导患者进行主动功能锻炼,术后6周拆除外固定架,逐渐加强关节功能锻炼.进行为期10个月以上的随访,观察患者恢复情况.结果 本组随访10～30个月,平均12.0个月.患者手指关节骨性缺损结构性植骨均I期愈合,关节无明显畸形,手指关节总活动度190°～ 260°,平均210°.根据手指关节总活动度(TAM)标准进行评价,优11指,良4指,中2指,优良率88.23％.结论 弹性牵引外架结合部分钩骨关节面移植在治疗陈旧性指间关节损伤中效果确切,利于患者关节活动情况的改善,值得在临床推广应用.

目的:探讨改良双V-Y皮瓣治疗Ⅳ期骶尾部压疮的有效性和安全性.方法:回顾性分析2015年3月-2019年3月中国人民解放军总医院第七医学中心骨科收治骶尾部压疮Ⅳ期患者28例,其中男15例,女13例,年龄49-65岁,创面面积6cm×7cm～8 cm×10cm.彻底清创后设计改良双侧V-Y推移皮瓣覆盖创面并行负压封闭引流,皮瓣供区减张缝合,皮瓣面积6cm×7 cm～8 cm×10cm.术后观察皮瓣整体血运、温度、水肿情况及VSD引流量,定期通过门诊、微信、电话随访.结果:手术后双侧V-Y皮瓣全部成活,1例术后切口周边皮肤表皮坏死,经换药后愈合,28例患者全部获得随访,随访时间12-24个月,平均18.2个月,全部压疮缺损修复成功,无创口裂开、皮瓣淤血、水肿、感染及压疮复发.结论:改良双侧V-Y推移皮瓣是治疗Ⅳ期骶尾部压疮的一种有效治疗方法.

目的 探讨基于电影情景的PBL教学法在培养医学生伤害控制学理念的长期随访效果.方法 回顾性研究2007-2010年在我院实习轮转的原第二军医大学2001-2004级临床医学专业本科生共90名.根据纳入排除标准2001-2002级学生共43名按传统教学方法大班形式教学(SBL组);2003-2004级共44名采用电影情景和经典病例模拟教学(PBL组).教学后即刻进行教研室统一命题考试和结构性问卷调查教学满意度;分别于毕业后1年和10年采用结构性问卷调查教学满意度和伤害控制学的理念与实践使用情况,并统计分析比较.结果 两组教学后即刻伤害控制学考试成绩,PB L组成绩优于SBL组,临床综合思维能力具有显著统计学差异.教学后即刻问卷调查显示,在团结合作和语言表达两组没有统计学差异;PBL组在文献收集、课堂氛围和实践指导优于SBL组,有统计学差异.毕业后1年、10年两组伤害控制学理念和实践应用PBL组虽然高于SBL组,但两组并没有统计学差异;课堂氛围和实践指导的满意度有明显的统计学差异.结论 基于电影情景模拟的PB L教学法指导伤害控制学理念长期满意度高,对活跃课堂气氛、提高医学生临床实践能力有所补益.

Objective:To evaluate the clinical outcome of 3D printing titanium cage combined with Masquelet technology for the treatment of calcaneus infective defect.Methods:Data of 5 cases with chronic calcaneus infectivedefect treated with regional flap, 3D printing titanium cage combined with Masquelet technology with rib autograft from January 2017 to January 2019 were retrospectively analyzed. There were 3 males and 2 females, with an average age of 37 years old (range, 17-52 years). The mechanism of the five patients included two motor vehicle incidents, two high fall injuries and one rolling compaction. All patients were treated by two-stage procedures. First stage included debridement, polymethyl methacrylate (PMMA) filling and regional flap coverage. The soft tissue defect of the 5 cases included 10 cm×8 cm in 2 cases, 8 cm×7 cm, 8 cm×5 cm, and 5 cm×3 cm each in one case. Bone defect included 4 cm×3 cm×2 cm in two cases, 3 cm×3 cm× 2 cm in two cases and 3 cm×1 cm×1 cm in one case. Second stage was 3D printing titanium cage combined with masquelet technology of rib autograft. Time of bone union, morphology of calcaneus, position of implant, Maryland score and AOFAS hind foot score were recorded to evaluate the clinical outcome.Results:All five patients were followed up for an average time of 18.2 months (range, 12-30 months). Infection happened in one patient 2 months after first stage operation and successfully treated by debridement and PMMA replacement. Incision of the rest 4 cases all healed successfully. Germiculture of the five cases included Methicillin-resistant Staphylococcus aureus (MRSA) in three cases, Staphylococcus epidermidis in one case and Bacterium coli in one case. All five patients got calcaneus bone union after second stage operation. The average time for bone union was 4.32 (range, 3-8) month. Bone trabecular were observed in CT scan 13 (range, 10-22) month post-operation. Average Maryland score in 12 months post-operation was 92 (range, 86-98) and average AOFAS ankle hind foot score was 89.8 (range, 83-100).Conclusion:3D printing titanium cage and Masquelet technology maybe an effective treatment for calcaneus infective defect.

目的:探讨不同入路手术对骨盆髋臼骨折患者骨折复位质量、髋关节功能及炎症因子的影响.方法:回顾性分析2016年7月～2018年12月期间我院收治的91例骨盆髋臼骨折患者的临床资料,根据入路方式的不同将其分为A组(n=44,髂腹股沟入路)和B组(n=47,改良Stoppa入路),比较两组患者复位质量、围术期指标、髋关节功能及炎症因子水平,记录两组患者随访期间并发症发生情况.结果:B组术中出血量少于A组,手术切口长度短于A组(P＜0.05);两组手术显露时间比较差异无统计学意义(P＞0.05).B组的骨折复位优良率为85.11％(40/47),高于A组的65.91％(29/44)(P＜0.05).与术前相比,两组患者出院时、术后6个月的改良Postel评分成逐渐升高趋势(P＜0.05);两组患者术前、出院时、术后6个月的改良Postel评分组间比较差异无统计学意义(P＞0.05).两组患者术后7d血清白介素-6(IL-6)、降钙素原(PCT)水平均高于术前,但B组低于A组(P＜0.05).B组随访期间并发症发生率低于A组(P＜0.05).结论:改良Stoppa入路手术与髂腹股沟入路手术均可改善骨盆髋臼骨折患者髋关节功能,但经改良Stoppa入路手术者骨折复位质量更佳,创伤更小,炎症反应更轻,同时还可减少并发症发生率.

目的:探讨限制性液体复苏对多发性骨折合并创伤失血性休克患者凝血功能、心肌损害指标及预后的影响.方法:选取我院收治的多发性骨折合并创伤失血性休克患者77例,分为研究组(n=39)、对照组(n=38),对照组给予常规液体复苏,研究组给予限制性液体复苏,比较两组患者凝血功能、心肌损害指标、输液量、失血量、输血量、并发症发生率及病死率.结果:研究组的输液量、失血量、输血量均少于对照组(P＜0.05).与复苏前相比,两组患者复苏1h后凝血酶原时间(PT)、凝血活酶时间(APTT)、凝血酶时间(TT)均延长,且研究组长于对照组(P＜0.05);两组患者复苏1h后肌酸激酶(CK)、肌酸激酶-同工酶(CK-MB)、肌钙蛋白T(CTnT)水平均下降,且研究组低于对照组(P＜0.05).研究组复苏期间并发症发生率、病死率均低于对照组(P＜0.05).结论:限制性液体复苏治疗多发性骨折合并创伤失血性休克患者,可改善患者凝血功能和预后,降低并发症发生率,同时还可减轻心肌损害.

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