AIM:To explore the effect of Toll-like receptor ( TLR) 2 and TLR4 in Mycobacterium bovis Bacil-lus Calmette-Guérin (BCG)-induced human proximal renal tubule epithelial cell (HK-2) injury.METHODS:HK-2 cells were stimulated by BCG, and the expression of TLR2, TLR4, chemokine (C-X3-C motif) ligand 1 (CX3CL1) and trans-forming growth factor beta 1 ( TGF-β1 ) was detected by quantitative real-time PCR and Western blotting .TLR2 monoclonal antibody and TLR4 inhibitor were used to treat the HK-2 cells 1 h before BCG stimulation.The expression of CX3CL1 and TGF-β1 was evaluated by quantitative real-time PCR and Western blotting .RESULTS: BCG increased the expression of TLR2, TLR4, CX3CL1 and TGF-β1 in the HK-2 cells.Additionally, the expression of CX3CL1 and TGF-β1 was inhibited partly by TLR2 monoclonal antibody or TLR4 inhibitor.CONCLUSION:BCG is able to increase the production of TLR 2, TLR4, CX3CL1 and TGF-β1 in the HK-2 cells.TLR2 and TLR4 signaling pathways play important roles in tubule epitheli-al cell injury induced by BCG .

Objective:To observe influence of simvastatin on differentiation ,proliferation ,migration and adhesion of marrow-derived smooth muscle progenitor cells (SPCs) and screen coated eluting stent drugs of new generation . Methods :The mononuclear cells (MNCs) were isolated from rat marrow by density gradient centrifugation method , and then plated on fibronectin-coated culture dishes ,after culture 8d ,marrow-derived SPCs were identified by α-smooth muscle actin (α-SMA) immunofluorescent staining and counted under inverted fluorescence microscope .The MNCs and adhesion cells were treated with simvastatin (0.01~10 μmol/L) respectively for 8 d and 24h .SPCs pro-liferation ,migration and adhesion were observed by Tritium thymidine (3 H-TdR) intake method ,modified Boyden chamber assay and adhesion assay .Results:Compared with control group (no simvastatin intervention ) ,0.01μmol/L simvastatin significantly inhibited the MNCs differentiation towards SPCs [ (85 ± 4) vs .(79 ± 5)] ,proliferation [ (4070 ± 184) vs .(3833 ± 126)] ,migration [ (44 ± 3) vs .(39 ± 3)] and adhesion of SPCs [ (59 ± 5) vs .(52 ± 4)] , P<0.05 all ,and number of SPCs significantly reduced along with simvastatin concentration increased (P<0.01) . Conclusion:Simvastatin could inhibit the differentiation ,proliferation ,migration and adhesion of marrow-derived smooth muscle progenitor cells .

Objective:To explore the efficacyof direct anterior approach (DAA) combined with direct posterior approach (DPA) for the treatment of Pipkin IV fracture.Methods:Data of 18 patients with Pipkin IV fracture treated through DAA combined with DPA from January 2016 to April 2019 was retrospectively analyzed. There were 13 males and 5 females, with an average age of 43.2 years (range,19-56 years). Fractures were caused by traffic accident in 15 and by falling in 3. The fracture lines of 13 cases were located below the fovea of the femoral head and 5 cases were located above the fovea. According to Letournel-Judet classification for acetabular fractures, there were 14 cases of posterior acetabular wall fractures, 2 cases of posterior wall fractures involving posterior column, and 2 transverse plus posterior wall fractures. The operation was performed through DAA approach to treat the femoral head fractures, and DPA approach was used to treat acetabular fractures. Radiographs and CT scans of the pelvis were reexamined after surgery, and fracture reduction, healing, and complications such as femoral head necrosis, sciatic nerve injury, superior gluteal neurovascular injury and heterotopic ossification were evaluated. Quality of acetabular reduction was evaluated according to the criteria proposed by Matta. Thompson-Epstein scoring system was used to evaluate hip function.Results:The average operation time was 133 min (range, 75-205 min). And the average blood loss was 371 ml (range, 240-600 ml). All 18 patients were followed up for 6 to 36 months, with an average period of 15.7 months. All fractures healed 10 to14 weeks after surgery. Three patients had symptoms of sciatic nerve injury after the injury, who recovered 6 to 12 weeks after the operation. All femoral head fractures were reduced. According to Matta criteria of reduction quality, anatomic reduction was gained in 13 cases, and satisfactory reduction was obtained in 3 cases, while unsatisfactory reduction was found in 2 cases, and the overall satisfactory rate was 88.9%(16/18). Two patients had Brooker I level heterotopic ossification. There was no iatrogenic vascular injury, avascular necrosis of femoral head, infection, internal fixation failure or other complications. According to the Thompson-Epstein scoring system at the latest follow-up, the functional results of the affected hip were excellent in 7 cases, good in 8, fair in 2 and poor in 1.Conclusion:Treatment of Pipkin IV fractures through DAA combined with DPA approach reduces surgical invasion. And it can directly reduce and fix the femoral head and posterior acetabular fracture, and protect the important structures such as the arteriae circumflexa femoris medialis, sciatic nerve and lateral femoral cutaneous nerve, and reduce the occurrence of complications such as femoral head necrosis and heterotopic ossification. Therefore, DAA combined with DPA is aneffective method for the treatment of Pipkin IV fractures.

Objective To investigate the effects of mefformin on the differentiation of osteoclastas well as relative mechanism.Methods Raw264.7 cells from the murine macrophage cell line was used.Receptor activator of NF-κB ligand (RANKL) was used to stimulate osteoclast differentiation from Raw264.7 cells.Osteoclast differentiation was assessed by tartrate-resistant acid phosphatase (TRAP) and actin fluorescence staining and counting the TRAP-positive cells after exposure to different concentrations of mefformin (0 μmol/L,400 μmol/L,800 μmol/L and 1000 μmol/L) or rapamicin (100 nmol/L) in the presence of 50 ng/ml RANKL for 5 days.Bone-resorbing activity was evaluated by BD BioCoatTM OsteologicTM Bone Cell Culture System.The expression of osteoclast-specific genes like TRAP,capthesin K,calcitonin receptor (CTR) and matrix metalloproteinase (MMP-9) was evaluated by RT-PCR.The expression of tumor necrosis factor-α(TNF-ct) S6K1Thr389,S6 Ser235/236,4E-BP1Thr37/46 and c-Fos protein was evaluated by ELISA kit and Western blot analysis,respectively.Results Mefformin dose-dependently inhibited RANKL-stimulated osteoclasts differentiation in Raw264.7 cell culture,as manifested by decrease of TRAP-positive multinucleated cells and pit erosion area,down-regulation of TRAP,cathepsin K,CTR and MMP-9 mRNA and reduction of TNF-α and c-Fos protein expression.Further study revealed that RANKL activated mTOR complex 1(mTORC1) signaling,while mefformin impaired RANKL-stimulated mTORC1 signaling.Rapamycin,an mTORCl-specific inhibitor and immunosuppressive macrolides could also prevent RANKL-induced osteoclast differentiation and bone resorption in vitro.Conclusion Mefformin inhibits osteoclastogenesis in vitro,which may due to reduction of TNF-α and c-Fos protein expression,and mTORC1 signaling is involved in this process.

Objective:To evaluate the anterior expansion of sacral foramen and decompression of sacral plexus via the lateral-rectus approach (LRA) in the surgical treatment of sacral fractures complicated with sacral plexus injury.Methods:From January 2013 to June 2018, 11 patients were treated at Department of Orthopaedics, The Third Hospital Affiliated to Southern Medical University for obsolete sacral fractures complicated with sacral plexus injury. They were 8 males and 3 females, aged from 17 to 54 years (average, 38 years). According to the Denis classification, all the sacral fractures belonged to Denis Zone Ⅱ. According to British Medical Research Council (BMRC) grading system, the nerve injury was complete damage in 2 cases and partial damage in 9. The mean time from injury to surgery was 6 months (range, from 0.7 to 12.0 months). After the sacroiliac joint was exposed via the LRA, the lumbosacral trunk was exposed and released between iliac vessels and the iliopsoas. Next, the S1 foramen was expanded and the S1 nerve root was released after separation of the median sacral artery and the internal iliac artery. Reduction and fixation of the sacroiliac joint was carried out for patients with unstable sacral fracture. X-ray and CT examinations of the pelvis were performed to evaluate fracture healing and neurological function recovery postoperatively.Results:Of this cohort of 11 cases, operation succeeded in 10 but failed in one whose sacral fracture was found to have completely healed with the S1 foramina totally occluded. The surgical time averaged 110 min (range, from 70 to 220 min) and the blood loss 1, 100 mL (range, from 450 to 2, 800 mL). Postoperative X-ray and CT examinations showed that the sacral foramens were expanded significantly without any complications. The follow-up time averaged 18 months (range, from 12 months to 4 years). By the BMRC grading system at the last follow-up, the neural function was completely recovered in 5 cases, partially recovered in 4 cases and not recovered in one.Conclusion:Significant anterior expansion of sacral foramen and decompression of sacral plexus via the LRA is a viable and effective alternative for treatment of sacral fractures complicated with sacral plexus injury.

Objective To evaluate the clinical outcome of bleeding control by preoperative embolization of internal iliac artery with DSA and intra?operative presetting abdominal aorta balloon, combine with the operation techniques of exposure, reduc?tion and internal fixation of pelvic fracture through lateral?rectus approach. Methods From March 2012 to May 2015, 7 patients with type C3 pelvic fractures admitted to our department from March 2012 to May 2015, treated with preoperative embolization of internal iliac artery under digital subtraction angiography 2 h before surgery and presetting abdominal aorta balloon were retrospec?tively reviewed. There were 3 males and 4 females, with an average age of 34 years (range, 16 to 61 years). According to AO classi?fication, all 7 cases belonged to type C3 (3.2:5 cases;C3.3:2 cases), including 5 cases with limb fracture, 2 cases with craniocere?bral trauma, 4 cases with pulmonary contusion, 2 cases with injury of abdominsal organs. Time from injury to operation was 19 days on average (10 to 33 days). Patients received damage control surgery treatment including bleeding control and temporary ex?ternal fixation, and ipsilateral tractions with heavy weight, intensive care and corrections of general situation before operation. The fracture model was manufactured by 3D printing and fracture reduction was simulated on computer preoperatively. Embolization of internal iliac artery was performed in the side of severe displaced sacroiliac joint with DSA 2 hours preoperatively. Reduction was performed to stabilize anterior-posterior pelvic ring and acetabular fractures via the intraoperative lateral?rectus approach. And 2 cases were performed by temporary balloon occlusion of abdominal aorta (≤60 min) for bleeding control in reduction of in the side of sacroiliac joint fractures. Results All the 7 cases had undergone the operations successfully, and the operating time was from 135-320 min with blood loss from 440-3 350 ml. According to Matta radiological evaluation postoperatively, reduction of pelvic fracture was rated as anatomic in 5 cases, satisfactory in 2, without complications. All 7 cases were complicated with lumbosacral plexus injury or lumbosacral trunk injury at different degrees (M0 2 cases, M1 2 cases, M2 2 cases, M3 1 case). According to the BMRC scoring system, 5 cases had well recovered and the other 2 cases had no improvement after three months (M4 2 cases, M5 3 cases). Conclusion Surgical management of pelvic fracture through preoperative internal iliac artery embolization and intra?oper?ative occlusion of abdominal aorta could effective control bleeding and achieve favorable conditions for reduction. Lateral?rectus approach can provide adequate exposure of the anterior and posterior ring, and this approach could also provide excellent visual control of reduction and fixation.

Objective:To investigate the clinical efficacy of lateral-rectus approach(LRA) for vertical shear fracture of pelvis combined with lumbosacral plexus nerve injury.Methods:A retrospective study was conducted of the 37 patients who had been treated at Department of Orthopaedics, The Third Affiliated Hospital to Southern Medical University for vertical shear pelvic fracture combined with lumbosacral plexus nerve injury from August 2010 to August 2018. They were 25 males and 12 females, aged from 18 to 61 years (mean, 36.2 years). By the Tile classification, there were 31 cases of type C1.3, 5 cases of type C2 and one of type C3. LRA was used in all the patients to explore and release the lumbosacral plexus nerve and to reduce the sacral fracture. The posterior ring was fixated with an anterior iliac plate or sacral screws before fixation of the anterior ring and treatment of the acetabular fracture. The operation time, intraoperative bleeding volume, quality of fracture reduction, fracture union time and recovery of nerve and muscle strength were recorded.Results:For this cohort, the operation time ranged from 105 to 228 minutes (mean, 155.0 minutes) and the intraoperative bleeding volume from 680 to 2, 440 mL (mean, 1, 070 mL). Thefollow-up time ranged from 1 to 8 years (average, 2 years). According to the Matta criteria, the quality of fracture reduction was evaluated as excellent in 21 cases, as good in 12 cases and as fair in 4 cases, giving an excellent and good rate of 89.2%. Follow-ups revealed reduction loss in 4 patients, nonunion and reduction loss in one patient and bony union in the other 32 patients after 8 to 12 weeks (mean, 10.1 weeks). According to the criteria by the Nerve Injuries Committee of the British Medical Research Council (BMRC), the recovery of nerve and muscle strength achieved M5 (full recovery of neurological symptoms) in 22 cases, M4 (fine recovery of neurological symptoms) in 7 cases, M1, M2 and M3 (partial recovery of neurological symptoms) in 5 cases, and M0 (no recovery of neurological symptoms) in 3 cases.Conclusion:LRA is an ideal surgical approach for treatment of pelvic vertical shear fractures complicated with lumbosacral plexus nerve injury, because it can well expose the medial pelvic joint from the sacroiliac joint to the symphysis pubis, allow direct release of the lumbosacral plexus nerve compressed and stretched, and, together with traction of the lower limbs, lead to satisfactory fracture reduction.

Objective: To explore surgical technique and clinical results of the direct posterior approach (DPA) for acetabular fractures involving posterior column, posterior wall, or posterior column and wall. Methods: From January 2016 to June 2017, data of 10 cases (7 males, 3 females, an average age of 37 years, ranging from 17 to 54 years) with posterior acetabular fractures treated by the DPA were retrospectively analyzed. Fractures were caused by traffic accident in 6 cases and by falling in 4 cases. According to Letournel-Judet classification of acetabular fractures, there were 6 cases of posterior acetabular wall fractures, 4 cases of posterior wall fractures involving posterior column. A straight skin incision was made from the middle of the line between the posterior margin of the tip of the femoral greater trochanter and the posterior superior iliac spine, to the posterior margin of the femoral greater trochanter. The gluteus maximus muscle was cleaved longitudinally. A view of the area from hip capsule to the superior margin of the greater sciatic foramen was obtained by entering along the interspace of the gluteus medius and pyriformis muscle, and the superior gluteal neurovascular bundle was protected. Acetabular posterior column and posterior wall fractures were reduced and fixed under direct vision. The fracture reduction, fracture healing, femoral head necrosis, sciatic nerve injury, superior gluteal neurovascular injury and heterotopic ossification were evaluated by the postoperative X-ray and CT examination. The function of hip joint was assessed by the Merle d’Aubigné-Posteal score modified by Matta. Results: The average operative incision length was 9.6 cm (range, 8-11 cm). The average operation time was 50 min (range, 35-80 min). The average blood loss was 310 ml (range, 200-440 ml). The time of follow-up was 12-30 months. All the patients were healed within 8-12 weeks without any complications such as superior gluteal nerve injury, superior gluteal vessel injury, or sciatic nerve injury. One case of acetabular posterior wall and posterior column fracture with posterior dislocation of hip joint, suffered from femoral head necrosis at the 9th months after surgery, which was treated by total hip arthroplasty and was recovered one year after surgery. In one case of actebular posterior wall and posterior column fracture, heterotopic ossification occurred 3 month after operation, without any special treatment and the hip joint activity was not affected at the follow-up of 15 months after surgery. During the 12-month follow-up after surgery, the Merle d’Aubigné-Postel score modified by Matta was 13-18, among which there were excellent in 6 cases, good in 2, acceptable in 2, with an overall excellent and good rate of 80% (8/10). Conclusion The direct posterior approach for posterior acetabular fractures can obtain satisfactory clinical results. The advantages of the DPA include decreasing trauma, shortening operation time, reduing blood loss and decreasing risks of iatrogenic injury to the gluteus medius muscle, the external rotators, the arteriae circumflexa femoris medialis and sciatic nerves as well as reducing and fixing the fractures under direct vision. Thus, the DPA is a relatively safe surgical approach for acetabular posterior wall/column fracture.

Objective To explore the efficacy of the anterior lateral-rectus approach combined with preoperative simulation assisted by 3D printing for treatment of acetabular fractures in the elderly.Methods A total of 52 elderly patients with acetabular fracture were admitted to Department of Orthopaedics and Trauma,The Third Affiliated Hospital to Southern Medical University from January 2014 to December 2017.They were 36 males and 16 females,with an average age of 71.6 years (from 65 to 88 years).According to the Judet-Letournel classification,there were 5 anterior column fractures,6 transverse fractures,18 anterior and posterior hemi-transverse fractures,and 23 both-column fractures.For all cases a preoperative surgical simulation was implemented based on their 3D-printed acetabular models.A pre-bent reconstruction plate or a custom acetabular aliform plate was placed to fixate the fracture after reduction via the anterior lateral-rectus approach.The reduction quality,healing time,function of affected hip and complications were recorded.Results The operation time for this cohort ranged from 85 to 138 min (average,102 min);the intraoperative bleeding ranged from 280 to 750 mL(average,520 mL).Perioperatively,implant failure,wound infection or symptomatic lower extremity phlebothrombosis was observed in none of the patients.According to the Matta radiological evaluation,the postoperative reduction was rated as excellent in 40 cases,as good in 7 and as poor in 5 (an excellent and good rate of 90.4％).All cases were followed up for 6 to 18 (mean,10.6 months).All the acetabular fractures united after 8 to 20 weeks (average,12 weeks).According to the modified Merle d'Aubigne-Postal scoring at the final follow-up,the function of affected hip was categorized as excellent in 29 cases,as good in 12 and as fair in 11 (an excellent and good rate of 78.8％).Walking pain was experienced by 5 patients 6 months after operation,diagnosed by imaging examination as traumatic arthritis of the hip joint.Follow-ups observed no such complications as screw loosening or heterotopic ossification.Conclusion In the treatment of acetabular fractures in the elderly,the anterior lateral-rectus approach combined with preoperative simulation assisted by 3D printing can achieve effective reduction and fixation,decrease intraoperative hemorrhage,shorten operation time and reduce such complications as screw loosening caused by osteoporosis.

Objective:To explore the surgical technique and the clinical efficacy of the lateral-rectus approach with traction reduction by the modified Starr pelvic reduction frame for Tile C pelvic nonunions and malunions.Methods:Data of 7 patients with Tile C pelvic nonunions and malunions from June 2017 to June 2018 who were treated via the lateral-rectus approach combined with traction reduction by the modified Starr pelvic reduction frame were retrospectively analyzed. There were 5 males and 2 females, aged from 22 to 53 (mean, 40 years). The injury mechanism included 3 cases of car accident injury, 3 of falling injury and 1 of crushing injury. The reasons for retreatment were pain in 7 cases, inability to walk and sit in 3, unequal length of lower limbs and lameness in 3. According to Tile classification, there were 4 cases of C1 type, 2 of C2 type and 1 of C3 type. A complete pelvic model with equal size as the patient’s pelvis was 3D-printed out according to three-dimensional reconstruction CT. The osteotomy or release site was designed, and the preoperative plan was detailed. Expose and release via the lateral rectus approach combined with traction reduction was conducted using the modified Starr pelvic reduction frame. Operative time, intraoperative blood loss and postoperative complications were collected. Visual analogue scale (VAS) at 6 months after surgery were recorded. Majeed score was used to evaluate the clinical efficacy. The quality of fracture reduction was evaluated by the Mears-Velyvis radiological evaluation criterion at the latest follow-up.Results:The operation time was 140-280 min, with an average of 190 min. The intraoperative blood loss was 700-2,800 ml, with an average of 1,250 ml. In 6 cases, the final fixation was performed at one time, while 1 case of Tile C3 type was performed in two stages. All patients were followed up for 10-22 months, and all the fractures healed. The mean time of bony union was 8 weeks (range, 6-12 weeks). The VAS of the 7 patients was improved from an average of 6.4 points to an average of 0.7 points during 6 months postoperative follow-up. The Majeed clinical efficacy score of the latest follow-up was improved from the average 60 points preoperative to 85 points postoperative. According to the Mears-Velyvis radiological evaluation criterion, the satisfaction rate reached 85.7%(6/7). After operation, 1 case occurred obturator nerve injury who recovered within 3 months, and 1 case remained limb shortening deformity of 1 cm. There was no fixation failure.Conclusion:The anterior osteotomy via the lateral-rectus approach can fully cut off nonunions and malunions of the pelvis, effectively release the soft tissues around the osteotomy site, with minimal surgical trauma and low risks of neurovascular injuries. Combined the modified Starr pelvic reduction frame, it can effectively correct pelvic deformities, lower limb rotation and unequal length deformities to achieve the expected effect of surgery.