AIM: To analyze the changes of retinal structure and function before and after panretinal photocoagulation(PRP)in patients with proliferative diabetic retinopathy(PDR).METHODS: Prospective study. Totally 98 cases(98 eyes)of PDR patients who underwent PRP in Eye Hospital of Wenzhou Medical University from January 2022 to May 2023 were included. Optical coherence tomography angiography(OCTA)was used to detect central retinal thickness(CRT), central macular thickness(CMT), subfoveal choroidal thickness(SFCT), foveal avascular zone(FAZ), deep vascular complex(DVC)blood flow density, superficial vascular complex(SVC)blood flow density before and at 1 wk, 1 and 3 mo after PRP. During the follow-up, 1 eye underwent vitrectomy, 2 eyes were lost to follow-up, and finally 95 eyes completed 1 a follow-up, with a loss rate of 3%. According to the visual prognosis at 1 a after treatment, the patients were divided into two groups: 73 eyes in good prognosis group and 22 eyes in poor prognosis group(including 9 eyes of visual disability and 13 eyes of visual regression). The changes in retinal structure and function before and after PRP treatment were compared between the two groups of patients, and the receiver operating characteristic(ROC)curve and decision curve were used to analyze the predictive value of retinal structure and function for PDR treatment.RESULTS: There were statistical significant differences in PDR staging, CRT, CMT, SFCT, DVC blood flow density, and SVC blood flow density between the two groups of patients before treatment(all P<0.05). At 1 wk, 1 and 3 mo after treatment, the FAZ area of both groups decreased compared to before treatment, while the blood flow density of DVC and SVC increased compared to before treatment(both P<0.05). However, there was no significant difference in the blood flow density of FAZ, DVC, and SVC between the two groups at 1 wk, 1 and 3 mo after treatment(all P>0.05). The CRT, CMT and SFCT of the two groups at 1 wk after treatment were higher than those before treatment(all P<0.05), but there were no significant differences between the two groups(all P>0.05). The CRT, CMT and SFCT at 1 and 3 mo after treatment were lower than those at 1 wk after treatment and before treatment in both groups. The CRT, CMT and SFCT in the poor prognosis group at 3 mo after treatment were higher than those at 1 mo after treatment, and were higher than those in the good prognosis group(all P<0.05). ROC analysis showed that, at 3 mo after laser treatment in PDR patients, the area under the curve of the CRT, CMT, and SFCT alone or in combination after treatment for 1 a was 0.788, 0.781, 0.783, and 0.902, respectively, and the combined prediction value was better(P<0.05). Decision curve analysis showed that the combined detection of CRT, CMT, and SFCT in PDR patients at 3 mo after treatment can improve the predictive value of visual prognosis.CONCLUSION: The optimal time for retinal structure and function recovery in PDR patients after PRP treatment is between 1 wk and 1 mo. OCTA measurement of CRT, CMT, and SFCT at 3 mo after treatment can predict the visual prognosis during the 1 a treatment period.

Objective:To investigate clinical curative effect of multiple composite tissues replantation with microsurgical technique in single hand.Methods:From May 2008 to December 2021, the clinical data of patients who underwent multiple composite tissue replantation in single hand in Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences and Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, were retrospectively analyzed. According to the severed site, anatomical level, the injury cause, the severity of injury, the size of severed tissue, and replantation conditions (such as blood vessels for anastomosis), the severed tissue was evaluated and carried out modified classification (type Ⅰ-Ⅳ) before the operation, and the surgical plan was designed. The severed composite tissue was debrided in emergency, the severed bone and muscle tissue were fixed, and the arteries, veins and nerves were anastomosed by microsurgical technique under a high-power microscope. The ratio of arteries to veins was 1∶1-1∶2. If enough arteries and veins could not be found, arteriovenous shunt could be used to form arterial venous flap or venous arterialized flap, or form artery flap by just artery anastomosis, or form venous flap by just vein anastomosis. Then skin tissue was sutured after recanalization. After the operation, the patients received specialized treatment and guided rehabilitation exercise. The wound healing of hand, skin color, skin quality, swelling degree, sensation, pain degree of joint, and activity function were followed up after the operation. At the last follow-up, the patient’s self-evaluation of the treatment effect was divided into three levels: satisfactory, average, and unsatisfactory. One chief physician and one doctor-in-charge were responsible for the comprehensive evaluation of curative effect, according to the assessment standard for upper limb function issued by Chinese Medical Association of Hand Surgery. 80-100 points were excellent, 60-79 points were good, 40-59 points were fair, and <40 points were poor.Results:A total of 94 severed composite tissues in 35 patients, including of 20 male patients and 15 female patients were enrolled. The average age was 36.4 years (range, 16-65 years). Fifty severed tissues in 18 cases were classified into type Ⅰ, 40 severed tissues in 15 cases type Ⅱ, 4 severed tissues in 2 cases type Ⅲ. Among the 35 cases, 1 case of thumb pulp severed tissue was necrotic at the edge (0.3 cm×0.5 cm) due to local contusion, 1 case of index finger lateral severed tissue was necrotic at the edge (0.3 cm×0.8 cm) due to local avulsion injury, and healed after dressing change, and the other replanted composite tissue survived. The patients were followed up for 3 to 65 months (average, 18.5 months). The wounds were completely healed, and the color, elasticity, and quality of the replanted tissue was close to the surrounding normal skin. There was no obvious swelling or atrophy deformity of the hands. According to the patients’ self-assessment, 31 cases were satisfied and 4 cases were average. Comprehensive evaluation of hand function and appearance: excellent in 23 cases, good in 9 cases, fair in 3 cases, excellent and good rate was about 91.4% (32/35).Conclusion:Though multiple composite tissues replantation with microsurgical technique in single hand is difficult, and vascular anastomosis technical requirement is high, once surgery succeeds, the function and appearance can get good recovery, and patient satisfaction is also relatively high.

Objective:To investigate clinical curative effect of multiple composite tissues replantation with microsurgical technique in single hand.Methods:From May 2008 to December 2021, the clinical data of patients who underwent multiple composite tissue replantation in single hand in Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences and Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, were retrospectively analyzed. According to the severed site, anatomical level, the injury cause, the severity of injury, the size of severed tissue, and replantation conditions (such as blood vessels for anastomosis), the severed tissue was evaluated and carried out modified classification (type Ⅰ-Ⅳ) before the operation, and the surgical plan was designed. The severed composite tissue was debrided in emergency, the severed bone and muscle tissue were fixed, and the arteries, veins and nerves were anastomosed by microsurgical technique under a high-power microscope. The ratio of arteries to veins was 1∶1-1∶2. If enough arteries and veins could not be found, arteriovenous shunt could be used to form arterial venous flap or venous arterialized flap, or form artery flap by just artery anastomosis, or form venous flap by just vein anastomosis. Then skin tissue was sutured after recanalization. After the operation, the patients received specialized treatment and guided rehabilitation exercise. The wound healing of hand, skin color, skin quality, swelling degree, sensation, pain degree of joint, and activity function were followed up after the operation. At the last follow-up, the patient’s self-evaluation of the treatment effect was divided into three levels: satisfactory, average, and unsatisfactory. One chief physician and one doctor-in-charge were responsible for the comprehensive evaluation of curative effect, according to the assessment standard for upper limb function issued by Chinese Medical Association of Hand Surgery. 80-100 points were excellent, 60-79 points were good, 40-59 points were fair, and <40 points were poor.Results:A total of 94 severed composite tissues in 35 patients, including of 20 male patients and 15 female patients were enrolled. The average age was 36.4 years (range, 16-65 years). Fifty severed tissues in 18 cases were classified into type Ⅰ, 40 severed tissues in 15 cases type Ⅱ, 4 severed tissues in 2 cases type Ⅲ. Among the 35 cases, 1 case of thumb pulp severed tissue was necrotic at the edge (0.3 cm×0.5 cm) due to local contusion, 1 case of index finger lateral severed tissue was necrotic at the edge (0.3 cm×0.8 cm) due to local avulsion injury, and healed after dressing change, and the other replanted composite tissue survived. The patients were followed up for 3 to 65 months (average, 18.5 months). The wounds were completely healed, and the color, elasticity, and quality of the replanted tissue was close to the surrounding normal skin. There was no obvious swelling or atrophy deformity of the hands. According to the patients’ self-assessment, 31 cases were satisfied and 4 cases were average. Comprehensive evaluation of hand function and appearance: excellent in 23 cases, good in 9 cases, fair in 3 cases, excellent and good rate was about 91.4% (32/35).Conclusion:Though multiple composite tissues replantation with microsurgical technique in single hand is difficult, and vascular anastomosis technical requirement is high, once surgery succeeds, the function and appearance can get good recovery, and patient satisfaction is also relatively high.

Objective:To investigate the role and underlying mechanisms of methyltransferase (Mettl) 3 in the process of angiotensin Ⅱ (Ang Ⅱ)-induced pericyte-to-myofibroblast transdifferentiation and renal fibrosis.Methods:C57BL/6J mice were used, in cell experiments, mouse renal pericytes were isolated and cultured using magnetic bead sorting. These pericytes were then induced to transdifferentiate into myofibroblasts with 1×10 6 mmol/L Ang Ⅱ, which was the Ang Ⅱ group, while pericytes cultured in normal conditions served as the control group. Successful transdifferentiation was verified by immunofluorescence staining, Western blotting, and real-time reverse transcription PCR (RT-qPCR) for α-smooth muscle actin (α-SMA). The levels of m6A modifications and related enzymes (Mettl3, Mettl14), Wilms tumor 1-associated protein (WTAP), fat mass and obesity protein (FTO), ALKBH5, YTHDF1, YTHDF2, YTHDC1, YTHDC2, YTHDC3 were assessed by Dot blot, RT-qPCR and Western blot. Mettl3 expression was inhibited in cells using lentivirus-mediated Mettl3-shRNA transfection, creating sh-Mettl3 and Ang Ⅱ+sh-Mettl3 groups, while lentivirus empty vector transfection served as the negative control (Ang Ⅱ+sh-NC group). The impact of Ang Ⅱ on pericyte transdifferentiation was observed, and the expression of downstream phosphatidylinositol 3-kinase (PI3K)/AKT signaling pathway proteins, including PI3K, AKT, phosphorylated AKT at serine 473 (p-AKT (S473)), and phosphorylated AKT at threonine 308 (p-AKT (T308)), were examined. PI3K gene transcription was inhibited by co-culturing cells with actinomycin D, and the half-life of PI3K mRNA was calculated by measuring residual PI3K mRNA expression over different co-culture time. The reversibility of Mettl3 inhibition on Ang Ⅱ-induced pericyte-to-myofibroblast transdifferentiation was assessed by adding the AKT activator SC79 to the Ang Ⅱ+sh-Mettl3 group. In animal experiments, mice were divided into these groups: sham group (administered 0.9% sterile saline), Ang Ⅱ group (infused with Ang Ⅱ solution), sh-Mettl3 group (injected with Mettl3 shRNA lentivirus solution), Ang Ⅱ+sh-Mettl3 group (infused with Ang Ⅱ solution and injected with Mettl3 shRNA lentivirus solution), and Ang Ⅱ+sh-Mettl3+SC79 group (administered Ang Ⅱ solution and Mettl3 shRNA lentivirus, with an additional injection of SC79). Each group consisted of six subject mice. Blood pressure was measured using the tail-cuff method before and after surgery, and serum creatinine, urea, and urinary albumin levels were determined 4 weeks post-surgery. Kidney tissues were collected at 28 days and stained using hematoxylin-eosin (HE) and Masson′s trichrome to assess the extent of renal fibrosis. Results:Primary renal pericytes were successfully obtained by magnetic bead sorting, and intervened with 1×10 6 mmol/L Ang Ⅱ for 48 hours to induce pericyte-to-myofibroblast transdifferentiation. Dot blot results indicated higher m6A modification levels in the Ang Ⅱ group compared to the control group ( P<0.05). RT-qPCR and Western blot results showed upregulation of Mettl3 mRNA and protein levels in the Ang Ⅱ group compared to the control group (both P<0.05). In the Ang Ⅱ+sh-Mettl3 group, Mettl3 protein expression was lower than that in the Ang Ⅱ group, with reduced expression levels of α-SMA, vimentin, desmin, fibroblast agonist protein (FAPa) and type Ⅰ collagen (all P<0.05). Compared to the control group, PI3K mRNA expression level was elevated in the Ang Ⅱ group, along with increased p-AKT (S473) and p-AKT (T308) expressions. In the Ang Ⅱ+sh-Mettl3 group, PI3K mRNA expression and p-AKT (S473) and p-AKT (T308) levels were decreased (all P<0.05). The half-life of PI3K mRNA was shorter in the Ang Ⅱ+sh-Mettl3 group than that in the Ang Ⅱ+sh-NC group (2.34 h vs. 3.42 h). The ameliorative effect of Mettl3 inhibition on Ang Ⅱ-induced pericyte-to-myofibroblast transdifferentiation was reversible by SC79. Animal experiments showed higher blood pressure, serum creatinine, urea, and 24-hour urinary protein levels, and a larger fibrosis area in the Ang Ⅱ group compared to the sham group (all P<0.05). The fibrosis area was smaller in the Ang Ⅱ+sh-Mettl3 group than that in the Ang Ⅱ group ( P<0.05), but increased again upon addition of SC79. Conclusion:Mettl3-mediated RNA m6A epigenetic regulation is involved in Ang Ⅱ-induced pericyte-to-myofibroblast transdifferentiation and renal fibrosis, potentially by affecting PI3K stability and regulating the PI3K/AKT signaling pathway.

Objective:To investigate the clinical effect and indications of the three kinds of pedicled perforator flaps in repairing soft tissue defects around the elbow joint.Methods:The clinical data of patients with soft tissue defects around the elbow joint, admitted to the Department of Center for Orthopaedic Repair and Reconstruction of Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences (Xinhua Hospital Chongming Branch) from December 2013 to November 2022 were retrospectively analyzed. The distal based medial antebrachial neurocutaneous flap in the middle and distal part of the upper arm, the perforator pedicled propeller flap of inferior cubital artery or the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery in the proximal forearm were respectively designed according to the location, appearance, size of the recipient site and the perforating point of the perforating vessel in the donor site to repair soft tissue defects around the elbow joint. The donor site was directly closed or covered by free skin grafting cut from the hidden area of the affected limb. The donor and recipient sites were followed up and observed to evaluate the curative effect from the following three aspects. (1) The self-evaluation of the curative effect was divided into three grades: satisfactory, general and unsatisfactory. (2) Elbow joint function evaluation: according to Mayo’s elbow joint function scoring standard which was divided into four grades: excellent, good, general and poor. (3) Comprehensive evaluation: the evaluation criteria for wound repair around the ankle joint of the lower extremity were used for scoring: 16 to 21 points as excellent, 11 to 15 points as good, 6 to 10 points as general, 0 to 5 points as poor, and the excellent and good ratio was calculated at the same time, that is, the sum of the number of excellent and good cases/the total number of cases×100%.Results:A total of 51 patients were enrolled, including 31 males and 20 females. The age ranged from 16 to 87 years old, with a mean of 56.1 years old. About the defect location, there were 20 cases in the anterior side of the elbow joint, 18 cases in the posterior side of the elbow joint, 8 cases in the medial side of the elbow joint, and 5 cases in the lateral side of the elbow joint. The defect sizes after debridement were from 3.5 cm×2.5 cm to 16.0 cm× 6.0 cm. Among the 51 patients, 21 cases were repaired by the distal based medial antebrachial neurocutaneous flap, 19 cases were repaired by the perforator pedicled propeller flap of inferior cubital artery, and the other 11 cases were repaired by the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery. The sizes of the flaps were from 4.5 cm × 3.5 cm to 18.0 cm × 8.0 cm. Forty-six of the 51 patients got primary healing, and the other five had necrosis of different degrees at the distal edge of the flap (≤1.5 cm×1.0 cm), including 2 cases of the distal based medial antebrachial neurocutaneous flap, 2 cases of the perforator pedicled propeller flap of inferior cubital artery and 1 case of the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery who were healed after dressing change. The patients were followed up for 3 to 60 months after the operation, with a mean of 12 months, the flaps in the recipient sites survived well, at the same time, the color and elasticity of the flaps were close to normal, and the two-point discrimination was 4-9 mm without bloated appearance. The elbow joint of the affected limb was stable and with good movement. No obvious deformity was observed, and the functional recovery was excellent. The incision of the donor site healed well and the scar was easily accepted. Self-evaluation: 39 patients were satisfied and 12 were general. Elbow joint function evaluation: excellent in 15 cases and good in 36 cases. Comprehensive evaluation: excellent in 17 cases, good in 30 cases, general in 4 cases, that meant the excellent and good ratio reached to 92%(47/51).Conclusion:The three kinds of pedicled perforator flaps have constant perforating vessels, abundant blood supply and simple operation. They can be used to repair soft tissue defects around the elbow joint while good clinical result can be obtained. The distal based medial antebrachial neurocutaneous flap is focused on the anterior and ulnar sides of the elbow joint, the perforator pedicled propeller flap of inferior cubital artery is focused on the elbow fossa, and the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery is focused on the posterior and radial sides of the elbow joint.

Objective:To explore the treatment method and clinical effect of chronic diabetic wounds of lower limbs in elderly patients with comorbidities.Methods:The clinical data of elderly comorbid patients with chronic diabetic wounds of lower limbs admitted to Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences from December 2019 to November 2022 were retrospectively analyzed. Multidisciplinary consultation and comprehensive evaluation were conducted for the patient before surgery and the indicators related to the underlying disease were also adjusted to the safe range for surgery. The wound secretions were taken in time for bacterial culture and drug sensitivity test, and the wound was treated with dressing change and other standardized treatments. According to the location, shape, size and depth of the lower limb wound defect, as well as the infection degree, duration of infection, and extent of surrounding skin damage, debridement, vacuum sealing drainage, tension-reduced suture, skin or flap transplantation, limb (toe) amputation and other method were selected for treatment. After surgery, the prevention and control of the comorbidities of the elderly and nursing management were continued, and the wound healing was observed. According to the evaluation criteria of flap swelling at grade 4 (increased from grade Ⅰ to grade Ⅳ), the swelling degree of the lower leg and dorsum of the foot was evaluated in the early stage (3 to 12 weeks) and the later stage (13 to 52 weeks). At the last follow-up, according to the evaluation criteria of the ankle joint wound repair, the curative effect was comprehensively evaluated (excellent, good, general, poor), and the satisfaction evaluation (satisfied, general, unsatisfied) was also conducted.Results:A total of 85 patients were included, of which 41 were males and 44 were females; the age ranged from 65 to 93 years, with a mean of 71.4 years. Comorbidities of the elderly include hypertension, coronary heart disease, cerebrovascular accident, renal insufficiency, diabetes, tumor, gout, senile dementia, senile neurasthenia, sleep disorders, malnutrition, epilepsy, urinary incontinence, delirium, depression, etc. The wound duration ranged from 6 months to 15 years. The depth of the wound reached muscle or bone, and the defect area ranged form 3.5 cm×2.5 cm to 22.0 cm×10.5 cm. All 85 patients had positive bacterial cultures of wound secretions. Drug sensitivity test results: 72 cases were sensitive, 10 cases were intermediate, and 3 cases were completely resistant. Clinical medication was based on the drug sensitivity test result and the principles of antibiotic use. For the 3 resistant cases, nutrition, support and other treatments to enhance immunity were given, and the local wound was dressed with 0.45%-0.55% iodophor. Among the 85 cases, 65 were treated with vacuum sealing drainage, 10 patients were treated with tension-reduced suture, 19 were treated with full-thickness skin graft, and 21 were treated with local flap transfer, 20 were repaired by perforator pedicle flap, and 15 underwent amputation (toe). The follow-up period was 6 to 36 months, with an average of 12.5 months. Wound healed by primary intention in 57 cases; delayed healing in 21 cases, wound healed after dressing change or surgical repair; wound not healed in 7 cases, wound completely healed after amputation (toe) or other surgical treatment. Evaluation of the degree of swelling in the lower leg and dorsum of the foot: 18 cases of grade Ⅰ, 47 cases of grade Ⅱ, 15 cases of grade Ⅲ, and 5 cases of grade Ⅳ in the early stage; 62 cases of grade Ⅰ, 18 cases of grade Ⅱ, and 5 cases of grade Ⅲ in the later stage. Comprehensive evaluation of the therapeutic effect: 23 cases were excellent, 45 cases were good, 16 cases were general, and 1 case was poor, with an excellent-good rate of 80%. Satisfaction evaluation: 78 cases were satisfied, 7 cases were general, and the satisfaction rate was 91.8%.Conclusion:Generalist clinical thinking and multidisciplinary collaborative model are important strategies for treating chronic diabetic wounds of lower limbs in elderly patients with comorbidities. By controlling infection with antibiotics and dressing changes, and using reconstructive surgery techniques to repair the wound, the wound healing rate can be improved and satisfactory treatment outcomes can be achieved.

Objective:To investigate the clinical effect and indications of the three kinds of pedicled perforator flaps in repairing soft tissue defects around the elbow joint.Methods:The clinical data of patients with soft tissue defects around the elbow joint, admitted to the Department of Center for Orthopaedic Repair and Reconstruction of Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences (Xinhua Hospital Chongming Branch) from December 2013 to November 2022 were retrospectively analyzed. The distal based medial antebrachial neurocutaneous flap in the middle and distal part of the upper arm, the perforator pedicled propeller flap of inferior cubital artery or the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery in the proximal forearm were respectively designed according to the location, appearance, size of the recipient site and the perforating point of the perforating vessel in the donor site to repair soft tissue defects around the elbow joint. The donor site was directly closed or covered by free skin grafting cut from the hidden area of the affected limb. The donor and recipient sites were followed up and observed to evaluate the curative effect from the following three aspects. (1) The self-evaluation of the curative effect was divided into three grades: satisfactory, general and unsatisfactory. (2) Elbow joint function evaluation: according to Mayo’s elbow joint function scoring standard which was divided into four grades: excellent, good, general and poor. (3) Comprehensive evaluation: the evaluation criteria for wound repair around the ankle joint of the lower extremity were used for scoring: 16 to 21 points as excellent, 11 to 15 points as good, 6 to 10 points as general, 0 to 5 points as poor, and the excellent and good ratio was calculated at the same time, that is, the sum of the number of excellent and good cases/the total number of cases×100%.Results:A total of 51 patients were enrolled, including 31 males and 20 females. The age ranged from 16 to 87 years old, with a mean of 56.1 years old. About the defect location, there were 20 cases in the anterior side of the elbow joint, 18 cases in the posterior side of the elbow joint, 8 cases in the medial side of the elbow joint, and 5 cases in the lateral side of the elbow joint. The defect sizes after debridement were from 3.5 cm×2.5 cm to 16.0 cm× 6.0 cm. Among the 51 patients, 21 cases were repaired by the distal based medial antebrachial neurocutaneous flap, 19 cases were repaired by the perforator pedicled propeller flap of inferior cubital artery, and the other 11 cases were repaired by the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery. The sizes of the flaps were from 4.5 cm × 3.5 cm to 18.0 cm × 8.0 cm. Forty-six of the 51 patients got primary healing, and the other five had necrosis of different degrees at the distal edge of the flap (≤1.5 cm×1.0 cm), including 2 cases of the distal based medial antebrachial neurocutaneous flap, 2 cases of the perforator pedicled propeller flap of inferior cubital artery and 1 case of the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery who were healed after dressing change. The patients were followed up for 3 to 60 months after the operation, with a mean of 12 months, the flaps in the recipient sites survived well, at the same time, the color and elasticity of the flaps were close to normal, and the two-point discrimination was 4-9 mm without bloated appearance. The elbow joint of the affected limb was stable and with good movement. No obvious deformity was observed, and the functional recovery was excellent. The incision of the donor site healed well and the scar was easily accepted. Self-evaluation: 39 patients were satisfied and 12 were general. Elbow joint function evaluation: excellent in 15 cases and good in 36 cases. Comprehensive evaluation: excellent in 17 cases, good in 30 cases, general in 4 cases, that meant the excellent and good ratio reached to 92%(47/51).Conclusion:The three kinds of pedicled perforator flaps have constant perforating vessels, abundant blood supply and simple operation. They can be used to repair soft tissue defects around the elbow joint while good clinical result can be obtained. The distal based medial antebrachial neurocutaneous flap is focused on the anterior and ulnar sides of the elbow joint, the perforator pedicled propeller flap of inferior cubital artery is focused on the elbow fossa, and the V-Y advancement flap based on the perforator of proximal forearm posterior interosseous artery is focused on the posterior and radial sides of the elbow joint.

Objective:To explore the treatment method and clinical effect of chronic diabetic wounds of lower limbs in elderly patients with comorbidities.Methods:The clinical data of elderly comorbid patients with chronic diabetic wounds of lower limbs admitted to Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences from December 2019 to November 2022 were retrospectively analyzed. Multidisciplinary consultation and comprehensive evaluation were conducted for the patient before surgery and the indicators related to the underlying disease were also adjusted to the safe range for surgery. The wound secretions were taken in time for bacterial culture and drug sensitivity test, and the wound was treated with dressing change and other standardized treatments. According to the location, shape, size and depth of the lower limb wound defect, as well as the infection degree, duration of infection, and extent of surrounding skin damage, debridement, vacuum sealing drainage, tension-reduced suture, skin or flap transplantation, limb (toe) amputation and other method were selected for treatment. After surgery, the prevention and control of the comorbidities of the elderly and nursing management were continued, and the wound healing was observed. According to the evaluation criteria of flap swelling at grade 4 (increased from grade Ⅰ to grade Ⅳ), the swelling degree of the lower leg and dorsum of the foot was evaluated in the early stage (3 to 12 weeks) and the later stage (13 to 52 weeks). At the last follow-up, according to the evaluation criteria of the ankle joint wound repair, the curative effect was comprehensively evaluated (excellent, good, general, poor), and the satisfaction evaluation (satisfied, general, unsatisfied) was also conducted.Results:A total of 85 patients were included, of which 41 were males and 44 were females; the age ranged from 65 to 93 years, with a mean of 71.4 years. Comorbidities of the elderly include hypertension, coronary heart disease, cerebrovascular accident, renal insufficiency, diabetes, tumor, gout, senile dementia, senile neurasthenia, sleep disorders, malnutrition, epilepsy, urinary incontinence, delirium, depression, etc. The wound duration ranged from 6 months to 15 years. The depth of the wound reached muscle or bone, and the defect area ranged form 3.5 cm×2.5 cm to 22.0 cm×10.5 cm. All 85 patients had positive bacterial cultures of wound secretions. Drug sensitivity test results: 72 cases were sensitive, 10 cases were intermediate, and 3 cases were completely resistant. Clinical medication was based on the drug sensitivity test result and the principles of antibiotic use. For the 3 resistant cases, nutrition, support and other treatments to enhance immunity were given, and the local wound was dressed with 0.45%-0.55% iodophor. Among the 85 cases, 65 were treated with vacuum sealing drainage, 10 patients were treated with tension-reduced suture, 19 were treated with full-thickness skin graft, and 21 were treated with local flap transfer, 20 were repaired by perforator pedicle flap, and 15 underwent amputation (toe). The follow-up period was 6 to 36 months, with an average of 12.5 months. Wound healed by primary intention in 57 cases; delayed healing in 21 cases, wound healed after dressing change or surgical repair; wound not healed in 7 cases, wound completely healed after amputation (toe) or other surgical treatment. Evaluation of the degree of swelling in the lower leg and dorsum of the foot: 18 cases of grade Ⅰ, 47 cases of grade Ⅱ, 15 cases of grade Ⅲ, and 5 cases of grade Ⅳ in the early stage; 62 cases of grade Ⅰ, 18 cases of grade Ⅱ, and 5 cases of grade Ⅲ in the later stage. Comprehensive evaluation of the therapeutic effect: 23 cases were excellent, 45 cases were good, 16 cases were general, and 1 case was poor, with an excellent-good rate of 80%. Satisfaction evaluation: 78 cases were satisfied, 7 cases were general, and the satisfaction rate was 91.8%.Conclusion:Generalist clinical thinking and multidisciplinary collaborative model are important strategies for treating chronic diabetic wounds of lower limbs in elderly patients with comorbidities. By controlling infection with antibiotics and dressing changes, and using reconstructive surgery techniques to repair the wound, the wound healing rate can be improved and satisfactory treatment outcomes can be achieved.

Objective:To investigate the clinical effect of the repair and reconstruction of severe foot trauma by microsurgical methods.Methods:Patients with severe foot trauma were admitted to Xinhua Hospital (Chongming), Affiliated with Shanghai Jiao Tong University School of Medicine, and Taizhou Hospital, Affiliated with Wenzhou Medical University in Zhejiang Province from November 2008 to October 2019. All patients were treated with orthotopic replantation using microsurgical anastomosis in emergency and precise microsurgical reconstruction in the second stage. A retrospective analysis of the clinical effect of the reconstructed appearance and function was performed. The evaluation and surgical design were carried out according to the characteristics of the injury site, range, plane, degree, etc., and adequate debridement and orthotopic replantation of residual tissue was performed under the microscope in emergency. Then regular follow-up was conducted to evaluate the postoperative efficacy, the degree of foot swelling, and the observation of foot activity and function.Results:A total of 23 patients with severe foot trauma were enrolled, including 15 males and 8 females, aged from 17 to 69 years old, with an average of 38.5 years old. Among them were the left foot in 10 cases and the right foot in 13 cases. 15 of the 23 patients survived orthotopic replantation. 2 cases of medial plantar skin necrosis were treated by skin graft in the second stage, 1 case of heel skin necrosis and 2 cases of anterior plantar skin necrosis with infection were repaired by flaps, and 3 cases of dorsal skin necrosis with infection combined with bone defect were repaired by flaps or osteocutaneous flap. After the operation, 23 patients were followed up for 6 to 48 months, with an average of 18.5 months. The wounds were completely healed, the color and elasticity were close to the surrounding normal skin, and there was no apparent swelling deformity on foot. The sensory function of the foot was all restored to grades S3-S4, with a small scar, and they walked freely without noticeable limping. The efficacy was evaluated according to a survival situation, color elasticity, appearance and morphology, donor scar, skin sensation, infection control, and patient recognition. 16 cases were satisfied with the outcomes, and 7 reported moderate. Skin swelling rating in the early stage was 1st degree in 3 cases, 2nd degree in 10 cases, 3rd degree in 8 cases, 4th degree in 2 cases; in the later stage was 1st degree in 15 cases, 2nd degree in 6 cases, 3rd degree in 2 cases. Foot function is assessed by the degree of postoperative pain, function of flexion and extension, degree of deformity, and walking ability, which is excellent in 3 cases, good in 13 cases, general in 7 cases, with a reasonable rate of about 69.6%(16/23).Conclusions:The microsurgical technique is one of the most effective methods to repair and reconstruct the function and appearance of the foot with severe trauma for now.

Objective:To investigate the clinical effect of the repair and reconstruction of severe foot trauma by microsurgical methods.Methods:Patients with severe foot trauma were admitted to Xinhua Hospital (Chongming), Affiliated with Shanghai Jiao Tong University School of Medicine, and Taizhou Hospital, Affiliated with Wenzhou Medical University in Zhejiang Province from November 2008 to October 2019. All patients were treated with orthotopic replantation using microsurgical anastomosis in emergency and precise microsurgical reconstruction in the second stage. A retrospective analysis of the clinical effect of the reconstructed appearance and function was performed. The evaluation and surgical design were carried out according to the characteristics of the injury site, range, plane, degree, etc., and adequate debridement and orthotopic replantation of residual tissue was performed under the microscope in emergency. Then regular follow-up was conducted to evaluate the postoperative efficacy, the degree of foot swelling, and the observation of foot activity and function.Results:A total of 23 patients with severe foot trauma were enrolled, including 15 males and 8 females, aged from 17 to 69 years old, with an average of 38.5 years old. Among them were the left foot in 10 cases and the right foot in 13 cases. 15 of the 23 patients survived orthotopic replantation. 2 cases of medial plantar skin necrosis were treated by skin graft in the second stage, 1 case of heel skin necrosis and 2 cases of anterior plantar skin necrosis with infection were repaired by flaps, and 3 cases of dorsal skin necrosis with infection combined with bone defect were repaired by flaps or osteocutaneous flap. After the operation, 23 patients were followed up for 6 to 48 months, with an average of 18.5 months. The wounds were completely healed, the color and elasticity were close to the surrounding normal skin, and there was no apparent swelling deformity on foot. The sensory function of the foot was all restored to grades S3-S4, with a small scar, and they walked freely without noticeable limping. The efficacy was evaluated according to a survival situation, color elasticity, appearance and morphology, donor scar, skin sensation, infection control, and patient recognition. 16 cases were satisfied with the outcomes, and 7 reported moderate. Skin swelling rating in the early stage was 1st degree in 3 cases, 2nd degree in 10 cases, 3rd degree in 8 cases, 4th degree in 2 cases; in the later stage was 1st degree in 15 cases, 2nd degree in 6 cases, 3rd degree in 2 cases. Foot function is assessed by the degree of postoperative pain, function of flexion and extension, degree of deformity, and walking ability, which is excellent in 3 cases, good in 13 cases, general in 7 cases, with a reasonable rate of about 69.6%(16/23).Conclusions:The microsurgical technique is one of the most effective methods to repair and reconstruct the function and appearance of the foot with severe trauma for now.