Objective To determine the efficacy and safety of external fixation versus intramedulllary nailing in the treatment of adult tibial shaft fracture. Methods We searched the specialized trials register of The Cochrane Collaboration’s Bone, Joint and Muscule Trauma Group, The Cochrane Library (CENTRAL), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006) and PUBMED (1966 to March 2006). We also handsearched some Chinese orthopedic journals. Randomized controlled trials (RCTs) and quasi-randomized trials (quasi-RCTs) comparing external fixation versus intramedullary nailing for tibial shaft fractures in adults were included. The quality of these trials was critically assessed. We used the Cochrane Collaboration’s RevMan 4.2.8 for data analyses. Result Three RCTs and two quasi-RCTs involving a total of 279 patients were included. The results of meta-analyses showed that external fixation for tibial shaft fractures in adults may increase the infection rate [RR 2.45, 95%CI (1.31,4.61), P=0.005], and the malunion rate [RR 2.85, 95%CI (1.20,6.79), P=0.02] but may reduce the duration of hospitalization [RR –5.50, 95%CI (–6.99,–4.01)]. The nonunion rate, delayed healing rate, and healing time, were comparable between external fixation and intramedulllary nailing. Conclusion The trials available for this systematic review are too few and small for reliable estimates of the relative effects of external fixation and intramedulllary nailing. Further studies are needed to determine these effects , especially for patients who have GustiloШ C fractures.
目的 比较股骨近端抗旋髓内钉（PFNA）与动力髋螺钉（DHS）两种方法内固定治疗高龄股骨粗隆间骨折的疗效。 方法 2007年1月－2011年1月分别采用PFNA、DHS治疗高龄股骨间粗隆骨折（EvansⅠ～Ⅳ型）共68例，其中PFNA组36例，平均年龄81.5岁；DHS组32例，平均年龄82.3岁。两组患者在年龄、性别、骨折分型、合并症以及受伤至手术时间方面比较差异均无统计学意义（P＞0.05），有可比性。 结果 术后68例患者均获随访，随访时间6～26个月。与DHS组比较，PFNA组手术时间短、术中出血少，差异有统计学意义（P＜0.05）；PFNA组骨性愈合时间短，但两组差异无统计学意义（P＞0.05）。术后DHS组出现1例髋内翻、1例拉力螺钉切出股骨头颈，PFNA组出现1例主钉退钉，两组术后并发症发生率比较差异有统计学意义（P＜0.01）。术后1年PFNA组髋关节Harris评分显著高于DHS组，差异有统计学意义（P＜0.01）。 结论 PFNA与DHS两种固定方法的骨性愈合时间短、术后并发症少、髋关节功能恢复好，是治疗股骨粗隆间骨折的良好方式，尤其是PFNA能减少手术时间和术中出血量，手术创伤小，对高龄且不能耐受较大手术者可作为一种首选术式。
Objective To compare the effectiveness between locking compression plate (LCP) and locked intramedullary nail (IMN) for humeral shaft fractures of types B and C. Methods Between January 2010 and January 2012, 46 patients with humeral shaft fractures of types B and C were treated, and the clinical data were retrospectively analyzed. LCP was used for internal fixation in 22 cases (LCP group), and IMN in 24 cases (IMN group). There was no significant difference in gender, age, injury causes, the side of fracture, the site of fracture, the type of fracture, associated injury, and time from injury to operation between 2 groups (P gt; 0.05). The regular clinical examination and evaluation of radiography were done. Shoulder function was evaluated by Neer grading system and elbow function was evaluated by Mayo elbow performance score after operation. Results The operation time and intraoperative blood loss in IMN group were significantly lower than those in LCP group (P lt; 0.05). There was no significant difference in hospitalization time between 2 groups (t=0.344, P=0.733). All patients were followed up 16.8 months on average (range, 12-24 months). At 6 months after operation, bone nonunion occurred in 1 patient of LCP group and in 2 patients of IMN group; the bone healing rate was 95.5% (21/22) in LCP group and 91.7% (22/24) in IMN group, showing no significant difference (χ2=0.000, P=1.000). Except for nonunion patients, the bone healing time was (11.77 ± 0.75) weeks in LCP group and (11.38 ± 0.82) weeks in IMN group, showing no significant difference (t=1.705, P=0.095). Between LCP and IMN groups, significant differences were found in radial nerve injury (4 cases vs. 0 case) and impingement of shoulder (0 case vs. 6 cases) (P lt; 0.05), but no significant difference in superficial infection (1 case vs. 0 case) and iatrogenic fracture (1 case vs. 2 cases) (P gt; 0.05). There was no significant difference in shoulder function and elbow function at 1 year after operation between 2 groups (P gt; 0.05). Conclusion LCP fixation and IMN fixation for humeral shaft fractures of types B and C can achieved satisfactory results. More attention should be paid to avoiding radial nerve injury by fixation of LCP; nail tail should be buried deeply into the cortex of the greater tuberosity and rotator cuff should be protected to decrease the rate of impingement of shoulder by fixation of IMN.
Objective To describe a surgical device for closed reduction of tibial fracture and investigate its clinical effectiveness. Methods Between June 2010 and December 2012, 24 cases of tibial fractures were treated with intramedullary nailing using a surgical device for closed reduction. There were 18 males and 6 females with an average age of 40 years (range, 20-64 years). All fractures were closed. There were 3 proximal third fractures, 12 middle third fractures, and 9 distal third fractures. According to AO classification, 12 cases were classified as type A, 8 cases as type B, and 4 cases as type C. The mean time between injury and operation was 3 days (range, 1-12 days). The intraoperative fluoroscopy frequency to confirm closed reduction and guide wire passing the fracture site, and the duration between fracture reduction and nail insertion were recorded. The injured limb alignment and fracture angular deformity were measured as described by Freedman et al. The fuction of affected limb was estimated by Johner-Wruhs criteria. Results Closed reduction was successfully performed in 24 patients. The mean fluoroscopy frequency to confirm closed reduction was 3 (range, 2-5). The fluoroscopy frequency to confirm guide wire passing the fracture site was 2. The mean duration between fracture reduction and nail insertion was 30 minutes (range, 20-42 minutes). No intraoperative or postoperative complication occurred, such as infection, vessel and nerve injuries. All incisions healed by first intention. Seventeen patients were followed up 6-16 months (mean, 10 months). Radiographic evidence showed that bridging callous was observed at 2-4 months (mean, 2.5 months). The injured limb alignment was normal on anteroposterial and lateral radiographs at 5 months postoperatively, no malalignment and obvious angular deformity was observed. The internal fixator had good position. According to Johner-Wruhs criteria for evaluation of the affected limb function, the results were excellent in 12 cases and good in 5 cases with an excellent and good rate of 100%. Conclusion The surgical device for closed reduction of tibial fracture is simple and easy to use, and has good effectiveness combined with intramedullary nailing.
Objective To compare the outcomes between intramedullary nail change and augmentation plating with a retained intramedullary nail for aseptic nonunion of femoral shaft fractures after femoral nailing, and to analyze the cause so as to guide the clinical application. Methods Between June 2001 and June 2011, 28 patients with aseptic nonunion of femoral shaft fractures after femoral nailing were treated with intramedullary nail change (11 patients, group A) and augmentation plating with a retained intramedullary nail (17 patients, group B), and the clinical data were analyzed retrospectively. There was no significant difference in age, gender, smoking, location of fracture, Association for the Study of Internal Fixation (AO/ASIF) classification, type of injury, associated injury, type of nonunion, and time of nonunion between 2 groups (P gt; 0.05). The patients were followed up by imaging and the clinical function at regular intervals to observe the callus growth and the recovery condition of the affected limb function, and clinical curative effectiveness was evaluated by Tohner-Wrnch standard. Results The operation time, intraoperative bleeding volume, and intraoperative erythrocyte-transported volume in group A were significantly higher than those in group B (P lt; 0.05). There was no significant difference in postoperative drainage volume and hospitalization days between 2 groups (P gt; 0.05). All the incisions healed by first intention, and no nerve and blood vessel injury occurred. All patients were followed up 18.6 months on average (range, 12-36 months). All cases obtained bone union, and time of clinical and radiological bone healing in group B was significantly shorter than those in group A (P lt; 0.05). During follow-up, no following complication occurred: deep incision infection, injuries of blood vessels and nerves, loosening and breakage of internal fixation, loss of reduction, angulated and rotational malunion. According to Tohner-Wrnch standard at last follow-up, the results were excellent in 6 cases, good in 3 cases, and poor in 2 cases, with an excellent and good rate of 81.8% in group A; the results were excellent in 12 cases, good in 5 cases, with an excellent and good rate of 100% in group B; and difference was significant between 2 groups (Z= — 2.623, P=0.021). Conclusion Augmentation plating with a retained intramedullary nail is an ideal treatment for aseptic nonunion of femoral shaft fractures after femoral nailing and can achieve satisfactory clinical outcomes because it has simpler operation, shorter operation time, less blood loss, and less trauma than intramedullary nail change.
Objective To exploere the effectiveness and advantages of elastic stable intramedullary nail (ESIN) combined with curettage and graft for the treatment of benign lesions of humerus complicating by pathological fracture in children. Methods ESIN internal fixation combined with curettage and graft was used to treat benign lesions of the humerus complicating by pathological fracture in 11 children patients between January 2007 and January 2011. Of 11 patients, 7 were boy and 4 were girl, aged from 5 to 14 years (mean, 9.4 years). The disease duration ranged from 2 to 14 days (mean, 6 days). All fractures were closed fracture, which locations were the proximal humerus in 6 cases, the humeral shaft in 4 cases, and the distal humerus in 1 case; benign lesions of the humerus included aneurysmal bone cyst in 1 case, simple bone cyst in 7 cases, and fibrous dysplasia in 3 cases. Based on imaging studies, preoperative diagnosis was almost clear. The time from hospitalization to operation was 3-5 days Results Healing of incision by first intention was obtained in all cases, with no infection. The mean follow-up was 25.6 months (range, 12-36 months). All patients achieved pain relief at 6 weeks postoperatively and fractures healed completely at 3 to 4 months after operation (mean, 3.3 months). No recurrence or re-fracture was observed during follow-up. The ESIN was removed at 10-14 months after operation (mean, 12.5 months). The lesion disappeared completely in 8 cases and partially in 3 cases. No pain of affected limb or motion limitation of shoulder and elbows was observed. One patient had limb shortening of 2 cm at last follow-up, but he had no function problem. According to Neer shoulder and Mayo elbow function scores, the results were excellent in 11 cases. Conclusion It is a good method to treat benign lesions of the humerus complicating by pathological fracture in children to use ESIN internal fixation combined with curettage and graft. After only a single operation intervention, it can provide early mechanical stability and rapid fracture healing and allow early rehabilitation exercise.
Objective To compare the effectiveness of the proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS) in the treatment of elderly patients with intertrochanteric fractures. Methods Between May 2007 and May 2010, 63 elderly patients with intertrochanteric fractures were treated, and fractures were fixed with PFNA in 31 patients (PFNA group) and with DHS in 32 patients (DHS group). There was no significant difference in gender, age, injury cause, disease duration, and fracture type between 2 groups (P gt; 0.05). Results All incisions healed by first intention. The incision length, operation time, and blood loss in PFNA group were significantly less than those in DHS group (P lt; 0.05). The averagefollow-up time was 13.6 months in PFNA group and was 13.8 months in DHS group. The fracture heal ing time was (11.80 ± 1.32) weeks in PFNA group and was (12.21 ± 1.26) weeks in DHS group, showing no significant difference (t=1.23, P=0.29). The complication rate was 0 in PFNA group and was 12.5% (4/32) in DHS group, showing no significant difference (P=0.06). After 1 year, Harris hip score of PFNA group (86.55 ± 10.32) was higher than that of DHS group (80.36 ±11.18) (t=2.28, P=0.03). Conclusion There are two surgical methods to treat intertrochanteric fractures in the elderly patient: PFNA and DHS, and each has advantages; for unstable intertrochanteric fractures, PFNA treatment is the first choice.