Osteoarthritis （OA） is characterized by articular cartilage degeneration， synovial hyperplasia， hyperosteogeny， and narrowing of joint space， which can be caused by trauma， inflammation， and other factors. With the increasing global population aging， the incidence of OA is rising year by year， making it a major public health problem that urgently needs to be addressed. Exploring effective treatment schemes is particularly important. The pathogenesis of OA is complex， including oxidative stress， autophagy， and apoptosis. Recent studies have found that ferroptosis， a new type of cell death， is also an important pathogenic factor in OA， characterized by a series of complex changes such as iron ion accumulation， glutathione （GSH） depletion， and mitochondrial dysfunction. Research shows that inhibiting ferroptosis in chondrocytes can promote chondrocyte proliferation， delay extracellular matrix （ECM） degradation， and reduce synovial hyperplasia and inflammation. Targeting ferroptosis is a new direction in the treatment of OA. OA treatment includes intra-articular injections of steroids or hyaluronic acid and artificial joint replacement， but there are limitations. Traditional Chinese medicine （TCM） has been widely used in the treatment of various diseases because of its low cost， low drug resistance， and few side effects. Cell and animal experiments have further confirmed that TCM can intervene in the treatment of OA with ferroptosis from multiple targets， multiple levels， and aspects， but the mechanism of its treatment of OA based on ferroptosis has not been clarified. This paper discussed iron metabolism， lipid peroxidation， cysteine/glutamate transporter system Xc^- （system Xc^-）/GSH/glutathione peroxidase 4 （GPX4） pathway， nicotinamide adenine dinucleotide phosphate（NADPH）/ferroptosis suppressor protein 1 （FSP1）/coenzyme Q₁₀ （CoQ₁₀） pathway， tumor protein p53 in OA， and related molecular targets of Chinese medicine monomers and compounds on ferroptosis inhibition. Their potential therapeutic mechanisms were further analyzed to provide theoretical guidance for the treatment of OA by TCM and useful reference for the research and development of related drugs.

Objective To discuss the perioperative care and wound protection of xenotransplantation from genetically edited pigs to monkeys, with the goal of improving the success rate of such experimental procedures. Methods From October 2022 to October 2023, perioperative care and wound protection were performed on 7 recipient rhesus monkeys undergoing xenotransplantation of genetically edited pig tissues and organs. Customized wound protective garments were designed based on monkeys' size and surgical area to protect the wounds, alongside meticulous perioperative care. This included preoperative preparation and medication, intraoperative monitoring of physiological indicators and anesthesia management, and postoperative care comprising wound protection, observation and monitoring, and nutritional support. Results All seven monkeys successfully underwent xenotransplantation. With the aid of protective garments and detailed care, all surgical wounds healed by first intention, and postoperative recovery was satisfactory. Conclusion Proper care and wound protection during xenotransplantation from genetically edited pigs to monkeys not only promote wound healing, but also alleviate pain and harm to animals. This has significant implications for advancing experimental research in pig-monkey xenotransplantation and enhancing animal welfare.

Objective:To explore the factors affecting the prognosis of severe pediatric acute respiratory distress syndrome (ARDS) after receiving extracorporeal membrane oxygenation (ECMO) support.Methods:It was a multicenter prospective observational study. A total of 95 children with severe ARDS who were treated with ECMO salvage therapy from January 2018 to December 2022 in 9 pediatric ECMO centers in China were enrolled in the study. The general data, disease severity, organ function, comprehensive treatment and prognosis were recorded, and they were divided into survival group and death group according to the outcome at discharge. T test, chi-square test, multivariate Logistic regression and mixed linear model were used to analyze the relationship among baseline before ECMO treatment, some important indicators (pediatric critical scores, platelet count, albumin, fibrinogen, etc) during ECMO treatment and prognosis. Results:Among the 95 children with severe ARDS who received ECMO, 55 (58%) were males and 40 (42%) were females, aged 36.9 (0.5, 72.0) months. Twelve children (13%) were immunodeficient. Sixty-eight (72%) children were treated with venous artery (VA) mode and 27 (28%) with venous vein (VV) mode. The discharge survival rates of overall, VA, and VV mode children were 51% (48/95), 47% (32/68), and 59% (16/27), respectively. The number of immunodeficient children in the death group was higher, and there were lower pediatric critical scores, platelet count, albumin, fibrinogen and arterial oxygen partial pressure/fraction of inspired oxygen (PaO 2/FiO 2), higher ventilator driving pressure (ΔP), oxygenaion index (OI), and longer ARDS duration before ECMO (all P<0.05). There were no statistically significant differences in other indicators, including age, gender, weight, and ECMO mode among different prognostic groups (all P>0.05). High ΔP, high OI, low P/F, and low albumin were high-risk factors affecting prognosis(all P<0.05). After further grouping, it was found that ΔP≥25 cmH 2O (1 cmH 2O=0.098 kPa), P/F≤67 mmHg (1 mmHg=0.133 kPa) and OI≥35 were the thresholds for predicting poor prognosis ( P<0.05). From 24 h after ECMO, there were significant differences in ΔP, P/F and OI between the dead group and the survival group (all P<0.05), and the differences gradually increased with the ECMO process. The platelet level was significant from 7 days after ECMO ( P<0.05) and gradually expanded. Blood lactate levels showed a significant difference between the 2 groups on before and after ECMO ( P<0.05) and gradually increased from 24 h after ECMO. Conclusions:The risk factors affecting the prognosis of severe ARDS in ECMO include high ΔP, high OI, low P/F and low albumin purification therapy before ECMO. The gradual decrease of ΔP, OI and increase of P/F from 24 h of ECMO predicted a good prognosis, while the gradual increase of lactate after ECMO application showed a poor prognosis.

Objective:To explore the clinical value of a trinity strategy for the treatment of multiple orthopedic trauma.Methods:A retrospective case series study was conducted to analyze the clinical data of 1 267 patients with multiple orthopedic trauma admitted to Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the First Affiliated Hospital of Navy Medical University from June 2013 to May 2023, including 862 males and 405 females, aged 18-93 years [(55.2±19.8)years]. Associated injuries included hemorrhagic shock in 632 patients, traumatic wet lung in 274, cranial injuries in 135, abdominal and pelvic bleeding in 116, pneumothorax in 89, urinary injury in 13, and vesical rupture in 8. All the patients were treated with the trinity strategy and the treatment process was divided into the phases of first aid, remodeling, and rehabilitation. The first aid phase focused on stabilizing symptoms and saving lives; the remodeling phase centered on restoring the anatomical structure and alignment; the rehabilitation phase aimed for functional recovery through the integration of both Western and traditional Chinese medicine. The all-cause mortality within 30 days after surgery and fracture healing time were calculated; the excellent and good rates of Constant-Murley shoulder score, Mayo elbow score, Gartland-Werley wrist score, Harris hip score, Hospital for Special Surgery (HSS) knee score and the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at the last follow-up and the overall excellent and good rate of all joint function scores were measured. The short form health survey (SF-36) scores were collected preoperatively and at 6 months postoperatively, including 8 aspects such as physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The incidence of postoperative complications was recorded.Results:All the patients were followed up for 6-18 months [(10.2±4.2)months]. The mortality rate during the acute phase (within 30 days after surgery) was 2.37% with 12 deaths due to hemorrhagic shock, 10 due to traumatic brain injury, 6 due to multiple organ dysfunction syndrome (MODS), and 2 due to pulmonary infection. The average fracture healing time averaged 3.8-18 months [(11.5±4.2)months], with 89.49% of the patients having bone union within 12 months after surgery, 8.93% having bone union within 18 months after surgery, and 1.58% undergoing reoperation. For the patients with internal fixation failure and nonunion, the average healing time was extended to (10.2±2.2)months and (13.7±3.3)months respectively. At the last follow-up, the excellent and good rates of Constant-Murley shoulder score, Mayo elbow score, Gartland-Werley wrist score, Harris hip score, HSS knee score, and AOFAS ankle-hindfoot score were 83.93%, 90.24%, 94.12%, 85.57%, 88.46%, and 92.31% respectively, with an overall excellent and good rate of 89.11%. At 6 months after surgery, the SF-36 scores of all the patients in the eight dimensions,including the physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health were (74.4±8.6)points, (44.7±14.4)points, (77.4±10.9)points, (68.4±18.2)points, (72.5±16.0)points, (76.8±8.7)points, (49.9±17.6)points, and (72.8±17.9)points, significantly improved compared with those before operation [(63.4±12.7)points, (30.9±17.4)points, (56.4±18.0)points, (55.4±24.7)points, (53.5±21.0)points, (55.8±24.3)points, (36.9±24.0)points, (58.8±21.6)points] ( P<0.01). Complications of different degrees occurred in 214 patients (16.89%), including lung infections in 118 patients (9.31%), lower extremity deep vein thrombosis in 50(3.95%), pressure injuries in 26(2.05%), internal fixation failure in 12(0.95%), and nonunion in 8(0.63%). Conclusions:The trinity strategy provides whole-process management, personalized treatment, and overall rehabilitation for multiple orthopedic trauma. It can decrease mortality, shorten fracture healing time, improve joint function and quality of life, and reduce the incidence of complications.

Objective:To compare the application effect of remote intelligent rehabilitation system and conventional rehabilitation in rehabilitation of patients with rotator cuff injury following minimally invasive arthroscopic surgery.Methods:A retrospective cohort study was used to analyze the clinical data of 47 patients with rotator cuff injury admitted to Xinhua Hospital, Shanghai Jiao Tong University School of Medicine from January to July 2022, including 18 males and 29 females; aged 45-65 years [(56.7±6.3)years]. All patients underwent minimally invasive arthroscopic surgical repair of rotator cuff rupture. After surgery, 25 patients underwent self-rehabilitation with conventional education (conventional rehabilitation group), and 22 patients underwent systematic rehabilitation with remote intelligent rehabilitation system (remote rehabilitation group). Constant shoulder score, University of California at Los Angeles (UCLA) shoulder score, self-rating anxiety scale (SAS) score, self-rating depression scale (SDS) score and visual analog score (VAS) were compared between the two groups on the day of admission, 4, 8, 12 weeks after surgery and at the last follow-up. Shoulder MRI was applied at 6 weeks after surgery to compare the degree of intra-articular effusion and bone marrow edema between the two groups. The shoulder range of motion of the two groups was compared at 12 weeks after operation. The satisfaction with the rehabilitation of the two groups was compared at the last follow-up.Results:All the patients were followed up for 6-10 months [(8.5±2.2)months]. There was no significant difference in Constant shoulder score, UCLA shoulder score, SAS score, SDS score and VAS between the two groups on the day of admission (all P>0.05). There was no significant difference in Constant score, UCLA score and SAS score between the two groups at 4 weeks after surgery (all P>0.05). The values of SDS score and VAS at 4 weeks after surgery were (31.8±6.6)points and (3.6±1.1)points in the remote rehabilitation group, which were better than those in the conventional rehabilitation group [(40.5±5.6)points and (4.7±1.3)points] (all P<0.05). The values of Constant score, UCLA score, SAS score, SDS score and VAS at 8 weeks after surgery were (62.5±5.5)points, (18.5±3.3)points, (20.5±4.7)points, (22.5±4.6)points and (2.5±0.6)points in the remote rehabilitation group, which were better than those in the conventional rehabilitation group [(41.3±4.7)points, (15.3±3.1)points, (28.5±4.8)points, (38.5±3.7)points and (3.3±1.3)points] ( P<0.05 or 0.01). The values of Constant score, UCLA score, SAS score and SDS score at 12 weeks after surgery were (85.4±6.4)points, (32.2±3.8)points, (13.6±2.8)points and (18.4±3.9)points in the remote rehabilitation group, which were better than those in the conventional rehabilitation group [(60.3±6.7)points, (25.2±4.1)points, (21.5±4.9)points and (26.7±6.6)points] (all P<0.05), while there was no significant difference in VAS between the two groups ( P>0.05). At the last follow-up, there were no significant differences in Constant score, UCLA score, SAS score, SDS score and VAS between the two groups (all P>0.05). MRI of the shoulder joint at 6 weeks after surgery indicated that the degree of intra-articular effusion in the shoulder joint and bone marrow edema of the proximal humerus in the remote rehabilitation group was significantly reduced than that in the conventional rehabilitation group. At 12 weeks after surgery, the remote rehabilitation group had better shoulder range of motion than the conventional rehabilitation group ( P<0.05 or 0.01). At the last follow-up, the satisfaction with the rehabilitation of the remote rehabilitation group was better than that of the conventional rehabilitation group ( P<0.01). Conclusion:For patients with rotator cuff injury who undergo minimally invasive arthroscopic surgery, postoperative application of remote intelligent rehabilitation system, in comparison with the conventional rehabilitation system, can help to facilitate shoulder function recovery, anxiety and depression improvement and pain relief in the early stage, reduce shoulder soft tissue and bone marrow edema of the shoulder, and increase shoulder range of motion and patients′ satisfaction with the rehabilitation.

Objective:To design and construct a bone nonunion organoid on chip and explore the mechanism of aseptic bone nonunion.Methods:First a semi-open microfluidic chip was designed, on which human bone marrow mesenchymal stromal cells (BMSC), human fetal lung fibroblast 1, (HFL1) and human umbilical vein endothelial cells (HUVEC) were co-cultured, and a three-dimensional organ on chip system was established. Different proportions of HFL1 and HUVEC were co-cultured with BMSC, which were divided into the control group (HFL1∶HUVEC=1∶1), the fibrosis group (HFL1∶HUVEC=3∶1) and the vascularization group (HFL1∶HUVEC=1∶3). The osteogenic differentiation of BMSC was observed by alkaline phosphatase (ALP) and Alizarin red staining. The transcription level of osteogenic marker genes SP7, RUNX2, ALPL, and BGLAP, and vascularization related genes KDR and VWF were analyzed by qPCR. The expression levels of RUNX2 and ALP were determined by Western Blot. Results:In the co-culture system of BMSCs, HFL1, and HUVECs, BMSCs exhibited normal growth and apparent biomineralization behavior. Endothelial cells were capable of forming structured vascular networks, confirming the successful establishment of the system. Compared to the baseline group, the fibrotic group showed no significant decrease in BMSC osteogenic differentiation. The relative expression levels of the mineralization marker genes ALPL and BGLAP were 0.55±0.19 ( P<0.001) and 0.42±0.27 ( P<0.001), respectively. Vascularization genes KDR and VWF were downregulated, with relative expression levels of 0.49±0.17 ( P<0.001) and 0.49±0.21 ( P<0.001). In contrast, in the vascularized group, BMSC osteogenic differentiation genes SP7, RUNX2, ALPL, and BGLAP were upregulated, with relative expression levels of 2.91±0.52 ( P<0.001), 3.83±1.87 ( P<0.001), 3.22±1.29 ( P<0.001), and 5.21±1.46 ( P<0.001), respectively. Vascularization genes KDR and VWF were also upregulated, with relative expressions of 8.24±2.84 ( P<0.001) and 5.32±1.67 ( P<0.001). Western blot results indicated increased expression of RUNX2 and ALP in the vascularized group and decreased expression in the fibrotic group. Conclusion:The bone nonunion organoid on chip could partially simulate the local microenvironment of bone nonunion. Fibrosis may lead to a significant decrease in bone formation ability and vascularization level, which might be an important reason for the occurrence of aseptic bone nonunion.

Periarticular fracture of the shoulder is a common type of fractures in the elderly. Postoperative adverse events such as internal fixation failure, humeral head ischemic necrosis and upper limb dysfunction occur frequently, which seriously endangers the exercise and health of the elderly. Compared with the fracture with normal bone mass, the osteoporotic periarticular fracture of the shoulder is complicated with slow healing and poor rehabilitation, so the clinical management becomes more difficult. At present, there is no targeted guideline or consensus for this type of fracture in China. In such context, experts from Youth Osteoporosis Group of Chinese Orthopedic Association, Orthopedic Expert Committee of Geriatrics Branch of Chinese Association of Gerontology and Geriatrics, Osteoporosis Group of Youth Committee of Chinese Association of Orthopedic Surgeons and Osteoporosis Committee of Shanghai Association of Chinese Integrative Medicine developed the Chinese expert consensus on the diagnosis and treatment of osteoporotic periarticular fracture of the shoulder in the elderly ( version 2023). Nine recommendations were put forward from the aspects of diagnosis, treatment strategies and rehabilitation of osteoporotic periarticular fracture of the shoulder, hoping to promote the standardized, systematic and personalized diagnosis and treatment concept and improve functional outcomes and quality of life in elderly patients with osteoporotic periarticular fracture of the shoulder.

Chronic refractory wound (CRW) is one of the most challengeable issues in clinic due to complex pathogenesis, long course of disease and poor prognosis. Experts need to conduct systematic summary for the diagnosis and treatment of CRW due to complex pathogenesis and poor prognosis, and standard guidelines for the diagnosis and treatment of CRW should be created. The Guideline forthe diagnosis and treatment of chronic refractory wounds in orthopedic trauma patients ( version 2023) was created by the expert group organized by the Chinese Association of Orthopedic Surgeons, Chinese Orthopedic Association, Chinese Society of Traumatology, and Trauma Orthopedics and Multiple Traumatology Group of Emergency Resuscitation Committee of Chinese Medical Doctor Association after the clinical problems were chosen based on demand-driven principles and principles of evidence-based medicine. The guideline systematically elaborated CRW from aspects of the epidemiology, diagnosis, treatment, postoperative management, complication prevention and comorbidity management, and rehabilitation and health education, and 9 recommendations were finally proposed to provide a reliable clinical reference for the diagnosis and treatment of CRW.

BACKGROUND: Emergence delirium (ED) is a kind of delirium that occured in the immediate post-anesthesia period. Lower body temperature on post-anesthesia care unit (PACU) admission was an independent risk factor of ED. The present study was designed to investigate the association between intraoperative body temperature and ED in elderly patients undergoing non-cardiac surgery. METHODS: This study was a secondary analysis of a prospective observational study. Taking baseline body temperature as a reference, intraoperative absolute and relative temperature changes were calculated. The relative change was defined as the amplitude between intraoperative lowest/highest temperature and baseline reference. ED was assessed with the confusion assessment method for intensive care unit at 10 and 30 min after PACU admission and before PACU discharge. RESULTS: A total of 874 patients were analyzed with a mean age of 71.8 ± 5.3 years. The incidence of ED was 38.4% (336/874). When taking 36.0°C, 35.5°C, and 35.0°C as thresholds, the incidences of absolute hypothermia were 76.7% (670/874), 38.4% (336/874), and 17.5% (153/874), respectively. In multivariable logistic regression analysis, absolute hypothermia (lowest value <35.5°C) and its cumulative duration were respectively associated with an increased risk of ED after adjusting for confounders including age, education, preoperative mild cognitive impairment, American Society of Anesthesiologists grade, duration of surgery, site of surgery, and pain intensity. Relative hypothermia (decrement >1.0°C from baseline) and its cumulative duration were also associated with an increased risk of ED, respectively. When taking the relative increment >0.5°C as a threshold, the incidence of relative hyperthermia was 21.7% (190/874) and it was associated with a decreased risk of ED after adjusting above confounders. CONCLUSIONS: In the present study, we found that intraoperative hypothermia, defined as either absolute or relative hypothermia, was associated with an increased risk of ED in elderly patients after non-cardiac surgery. Relative hyperthermia, but not absolute hyperthermia, was associated with a decreased risk of ED. REGISTRATION Chinese Clinical Trial Registry (No. ChiCTR-OOC-17012734).
Humans ; Aged ; Body Temperature ; Emergence Delirium ; Hypothermia ; Postoperative Complications/epidemiology* ; Prospective Studies

Objective:To explore the efficacy of pedicled bladder muscle flap in the repair of urinary tract obstruction.Methods:The data of 26 patients with urinary tract obstruction admitted to Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2016 to June 2021 were retrospectively reviewed. There were 14 males and 12 females, with the age ranged from 2 to 75 years old. Refractory bladder neck obstruction after prostatic hyperplasia surgery in 12 cases, with the age of (70.0±3.5) years old.They all experienced at least 2 times of transurethral stenosis incisionor resection. Transpubic cystostomy tube was placed in 9 patients. Posttraumatic pelvic fractures lead to bladder neck atresia and urethral injury in 6 girls, with the age of (10.5±2.1) years old. The bladder neck atresia and urethral obliteration length was 1-2 cm determined by urethrography. Eight cases suffered ureteral strictures after gynecological myomectomy or ureteroscopy holmium laser lithotripsy(4 cases of each type), including two males and six females, with the age of (55.0±3.2) years old. The length of ureteral stricture or defect was 5-6 cm determined by intravenous urography(IVU) or CT urography(CTU). The patients with bladder neck obstruction underwent the following surgery: The "Y" incision of the bladder and stenosis of the prostate urethra was performed and the pedicled bladder muscle flap was inserted into the normal urethral mucosa to complete the Y-V plasty. In the 6 girl patients, pedicled bladder muscle flap(2-4 cm) augmented reconstruction were performed. All above 18 patients, whose urethral catheter was indwelled for 3-4 weeks, urinary flow rate and urethroscopy examination were performed to evaluate the effect of surgery 4 weeks and 3 months after the operation. As the 8 cases with ureteral strictures, the pedicled bladder muscle flap (7-8 cm) ureteroplasty was performed and the ureteral stent was retained for 4 weeks. Ultrasonography and IVU/CTU were performed 4 weeks and 3 months postoperatively. The patency of the ureteral lumen and whether it is accompanied by hydronephrosis, lower back pain, and urinary tract infection were assessed.Results:All patients underwent pedicled bladder muscle flap reconstructive surgery successfully and no serious complications occurred postoperatively. The patients were followed up for (8.2± 2.2) months. As urethral catheters were removed, 10 patients with refractory neck obstruction could return to normal urination with the urinary flow Q max (17.2±2.8)ml/s, while 2 patient had dysuria and were treated with regular urethral dilatation. The catheter was removed 4 weeks after the reconstructive surgery in 6 girls with bladder neck atresia and urethral injury after posttraumatic pelvic fracture. Five could successfully urinate with the urinary flow Q max of (16.7±1.1)ml/s, and one girl had urinary incontinence, waiting for further operation.The ureteral stent was removed after ureteroplasty in 8 patients. CTU and IVU examination showed no ureters with obstruction.No one had low back pain, discomfort, or urinary tract infection. Conclusions:The reconstruction using the pedicled bladder muscle flap was a convenient, minimally invasive and effective technique for the management of adjacent lower ureters, bladder neck, and proximal urethra.