Severe open tibiofibular fractures account for approximately 28.1% of all open fractures. Among them, Gustilo-Anderson type IIIB/C fractures present significant clinical challenges due to associated bone and soft tissue defects, high infection rates, and risk of amputation. Inadequate preoperative assessment may lead to suboptimal emergency surgical planning or intraoperative complications. Historically, external fixation was often preferred, but this approach has been associated with limitations such as restricted joint mobility, delayed bone union, joint stiffness, and disuse osteoporosis, resulting in poor functional recovery. With advancements of debridement techniques, standardization of antibiotic use, and popularization of early soft tissue coverage, early internal fixation has gained broader acceptance. Nevertheless, controversies persist regarding the choice of fixation method, timing of definitive fixation, use of reamed versus unreamed intramedullary nailing, and necessity of fibular fixation. To standardize the diagnosis and early management of severe open tibiofibular fractures, reduce complication rates, and improve functional recovery, the Society of Microsurgery of the Chinese Medical Association organized a panel of domestic experts to develop the Evidence-based guideline for the diagnosis and early fixation of severe open tibiofibular fractures ( version 2025), using evidence-based methodology. The guidelines provided 12 recommendations covering diagnostic and early fixation strategies of severe open tibiofibular fractures, aiming to provide clinicians with scientifically grounded and standardized guidance.

BACKGROUND:Epidemiologic investigations and some experiments have shown that there is a close relationship between peripheral blood cells and osteoporosis,but the causal relationship between the two at the genetic level is still unclear. OBJECTIVE:To explore the causal relationship between peripheral blood cells and osteoporosis using Mendelian randomization methods. METHODS:Genome-wide association study data sets on peripheral blood cells,overall bone density at different ages,and calcaneal bone density were obtained from databases such as Blood Cell Consortium and MRC Integrative Epidemiology Unit. Blood cells were used as exposure data,with bone density at different ages and calcaneal bone density serving as outcome data. Mendelian randomization analyses were performed using methods such as inverse variance weighting,MR-Egger,weighted median method,and simple median. The results were assessed for heterogeneity,pleiotropy,and sensitivity using Cochran's Q,MR-Egger regression,and Leave-one-out method. The causal relationship between exposure and outcomes was evaluated using β values. RESULTS AND CONCLUSION:Due to the heterogeneity revealed by Cochran's Q test in the Mendelian randomization results,the results of the study were based on the inverse variance weighting method. The inverse variance weighting results showed that when age-specific bone density was used as an outcome,there was a negative causal relationship between white blood cell count and whole-body bone mineral density at the age of 45-60 years[β=-0.07,95％ confidence interval (CI):-0.13,-0.01,P=0.02],a positive causal relationship between monocyte count and whole-body bone mineral density at the age of 45-60 years (β=0.05,95％ CI:0.00,0.10,P=0.037),a negative causal relationship between white blood cell and basophil counts and whole-body bone mineral density over 60 years old (β=-0.04,95％ CI:-0.07,-0.01,P=0.005;β=-0.04,95％ CI:-0.07,-0.00,P=0.038),a positive causal relationship between hemoglobin concentration and hematocrit and whole-body bone mineral density over 60 years old (β=0.04,95％ CI:0.01,0.08,P=0.012;β=0.04,95％ CI:0.00,0.07,P=0.039),and a negative causal relationship between white cell count and whole-body bone mineral density at an undistinguished age (β=-0.10,95％ CI:-0.16,-0.03,P=0.002). When heel bone mineral density was used as an outcome,there was a negative causal relationship between white cell count and heel bone mineral density (β=-0.04,95％ CI:-0.07,-0.01,P=0.016),and a positive causal relationship between hemoglobin concentration and hematocrit and heel bone mineral density (β=0.05,95％ CI:0.01,0.08,P=0.007;β=0.05,95％ CI:0.01,0.08,P=0.004). To ensure the robustness of the results,meta-analyses of Mendelian randomization results of peripheral blood cells and whole-body bone mineral density as well as heel bone mineral density in different age groups were conducted. The results suggested that for every standard deviation decrease in log-transformed white blood cell count,there was a 5％ reduction in the risk of decreased bone mineral density (OR=0.95,95％ CI:0.94,0.97,P<0.001);whereas for every standard deviation increase in hemoglobin concentration and hematocrit,there was a 4％ reduction in the risk of decreased bone density (OR=1.04,95％ CI:1.03,1.06,P<0.001). In conclusion,increased white blood cell count in peripheral blood is a risk factor for bone mineral density;whereas increased hematocrit and hemoglobin concentration are protective factors for bone mineral density.

BACKGROUND:Epidemiologic investigations and some experiments have shown that there is a close relationship between peripheral blood cells and osteoporosis,but the causal relationship between the two at the genetic level is still unclear. OBJECTIVE:To explore the causal relationship between peripheral blood cells and osteoporosis using Mendelian randomization methods. METHODS:Genome-wide association study data sets on peripheral blood cells,overall bone density at different ages,and calcaneal bone density were obtained from databases such as Blood Cell Consortium and MRC Integrative Epidemiology Unit. Blood cells were used as exposure data,with bone density at different ages and calcaneal bone density serving as outcome data. Mendelian randomization analyses were performed using methods such as inverse variance weighting,MR-Egger,weighted median method,and simple median. The results were assessed for heterogeneity,pleiotropy,and sensitivity using Cochran's Q,MR-Egger regression,and Leave-one-out method. The causal relationship between exposure and outcomes was evaluated using β values. RESULTS AND CONCLUSION:Due to the heterogeneity revealed by Cochran's Q test in the Mendelian randomization results,the results of the study were based on the inverse variance weighting method. The inverse variance weighting results showed that when age-specific bone density was used as an outcome,there was a negative causal relationship between white blood cell count and whole-body bone mineral density at the age of 45-60 years[β=-0.07,95％ confidence interval (CI):-0.13,-0.01,P=0.02],a positive causal relationship between monocyte count and whole-body bone mineral density at the age of 45-60 years (β=0.05,95％ CI:0.00,0.10,P=0.037),a negative causal relationship between white blood cell and basophil counts and whole-body bone mineral density over 60 years old (β=-0.04,95％ CI:-0.07,-0.01,P=0.005;β=-0.04,95％ CI:-0.07,-0.00,P=0.038),a positive causal relationship between hemoglobin concentration and hematocrit and whole-body bone mineral density over 60 years old (β=0.04,95％ CI:0.01,0.08,P=0.012;β=0.04,95％ CI:0.00,0.07,P=0.039),and a negative causal relationship between white cell count and whole-body bone mineral density at an undistinguished age (β=-0.10,95％ CI:-0.16,-0.03,P=0.002). When heel bone mineral density was used as an outcome,there was a negative causal relationship between white cell count and heel bone mineral density (β=-0.04,95％ CI:-0.07,-0.01,P=0.016),and a positive causal relationship between hemoglobin concentration and hematocrit and heel bone mineral density (β=0.05,95％ CI:0.01,0.08,P=0.007;β=0.05,95％ CI:0.01,0.08,P=0.004). To ensure the robustness of the results,meta-analyses of Mendelian randomization results of peripheral blood cells and whole-body bone mineral density as well as heel bone mineral density in different age groups were conducted. The results suggested that for every standard deviation decrease in log-transformed white blood cell count,there was a 5％ reduction in the risk of decreased bone mineral density (OR=0.95,95％ CI:0.94,0.97,P<0.001);whereas for every standard deviation increase in hemoglobin concentration and hematocrit,there was a 4％ reduction in the risk of decreased bone density (OR=1.04,95％ CI:1.03,1.06,P<0.001). In conclusion,increased white blood cell count in peripheral blood is a risk factor for bone mineral density;whereas increased hematocrit and hemoglobin concentration are protective factors for bone mineral density.

Severe open tibiofibular fractures account for approximately 28.1% of all open fractures. Among them, Gustilo-Anderson type IIIB/C fractures present significant clinical challenges due to associated bone and soft tissue defects, high infection rates, and risk of amputation. Inadequate preoperative assessment may lead to suboptimal emergency surgical planning or intraoperative complications. Historically, external fixation was often preferred, but this approach has been associated with limitations such as restricted joint mobility, delayed bone union, joint stiffness, and disuse osteoporosis, resulting in poor functional recovery. With advancements of debridement techniques, standardization of antibiotic use, and popularization of early soft tissue coverage, early internal fixation has gained broader acceptance. Nevertheless, controversies persist regarding the choice of fixation method, timing of definitive fixation, use of reamed versus unreamed intramedullary nailing, and necessity of fibular fixation. To standardize the diagnosis and early management of severe open tibiofibular fractures, reduce complication rates, and improve functional recovery, the Society of Microsurgery of the Chinese Medical Association organized a panel of domestic experts to develop the Evidence-based guideline for the diagnosis and early fixation of severe open tibiofibular fractures ( version 2025), using evidence-based methodology. The guidelines provided 12 recommendations covering diagnostic and early fixation strategies of severe open tibiofibular fractures, aiming to provide clinicians with scientifically grounded and standardized guidance.

The polyfoliate perforator flap is a new type of flap that was developed on the basis of the traditional polyfoliate myocutaneous flap, polyfoliate fascial flap and perforator flap. It overturns the traditional idea that the deep fascial vascular network is the fundamental for a survival of the flap, and enables the flaps to achieve the best profile and function of the recipient areas with minimal damage to the donor area. In order to improve the understanding of the polyfoliate perforator flap and further standardise its clinical application, this paper forms a consensus on the definition, classification, indications, operative points and precautions of the polyfoliate perforator flap, so as to provide references in diagnosis and treatment process and practical application for the surgeons.

The polyfoliate perforator flap is a new type of flap that was developed on the basis of the traditional polyfoliate myocutaneous flap, polyfoliate fascial flap and perforator flap. It overturns the traditional idea that the deep fascial vascular network is the fundamental for a survival of the flap, and enables the flaps to achieve the best profile and function of the recipient areas with minimal damage to the donor area. In order to improve the understanding of the polyfoliate perforator flap and further standardise its clinical application, this paper forms a consensus on the definition, classification, indications, operative points and precautions of the polyfoliate perforator flap, so as to provide references in diagnosis and treatment process and practical application for the surgeons.