ObjectiveTo explore the effectiveness and operative methods to treat first metatarsal diaphysis comminuted fractures with mini-plate via medial approach. MethodsBetween January 2012 and January 2013, 15 patients with first metatarsal shaft comminuted fractures were treated. There were 11 males and 4 females (6 left feet and 9 right feet) with an average age of 38.6 years (range, 27-56 years). The injury causes included falling injury in 6 cases, crash injury of heavy object in 7 cases, and sprain in 2 cases. The left side was involved in 6 cases and the right side in 9 cases. The time from injury to operation was 8.5 days on average (range, 7-10 days). According to AO classification, all cases were rated as 81(T)-C2 type. The surgical treatments included open reduction and internal fixation with mini-plate by medial approach. ResultsPrimary healing of incision was obtained in all cases, and no infection occurred. Twelve patients were followed up 18 months on average (range, 12-24 months). All fractures healed well, and the mean time of bone union was 11.5 weeks (range, 10-14 weeks). No loosening or breakage of internal fixation was observed. At last follow-up, the patients could walk with full weight-bearing, and had no pain. According to American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, the mean score was 85.2 (range, 76-96). ConclusionAnatomic reduction and stable internal fixation are important for first metatarsal comminuted fracture, which is the key point for recovery of foot form and foot arch function. And the medial approach could achieve full exposure and improve the cosmetic results.
ObjectiveTo investigate the countermeasures for difficult removal of screws in the plate. MethodsThe clinical data were retrospectively analyzed from 47 patients having difficult removal of screws in the plate between January 2004 and May 2014. There were 30 males and 17 females, aged 16-58 years (mean, 34 years). The time from internal fixation to removal of internal fixation was 10 months to 20 years (mean, 22 months). The locations of internal fixation were upper extremity in 25 cases and lower extremity in 22 cases. The number of difficult removal screws in the plate was 1 in 18 cases, 2 in 15 cases, 3 in 9 cases, and 4 in 5 cases. The plate types included general plate in 15 cases and locking plate in 32 cases; stainless steel plate in 10 cases and titanium plate in 37 cases. The reason for difficult removal, plate, screw, incision, and bone quality of patient were comprehensively analyzed, and different methods for difficult removal were chosen according to the principle that first simply then complicated. ResultsAll plates and screws were removed, and no iatrogenic fracture or nerve and vascular injuries occurred. The operation time was 65-270 minutes (mean, 125 minutes). The blood loss was 80-775 mL (mean, 157 mL). The postoperative drainage was 20-250 mL (mean, 92 mL). The incision healing by first intention was obtained in 39 cases, and delayed healing in 8 cases. The patients were followed up 3-24 months (mean, 10 months). No infection or re-fracture was observed. ConclusionThere are many countermeasures for difficult removal of screws in the plate, but each has indication. As long as a well arranged preoperative condition, mastering a variety of methods, and being familiar with its indication, as well as reasonably choosing method based on the specific situations, the plate and screw maybe smoothly removed.
ObjectiveTo design and produce a lesser trochanteric reduction fixation system and verify its value and effectiveness. MethodsA lesser trochanteric reduction fixation system was designed and produced according to the anatomical features of the lesser trochanteric fractures. Sixty-six patients with intertrochanteric fractures of Evans type Ⅲ were included between January 2010 and July 2012. Of 66 patients, 32 were treated with dynamic hip screw (DHS) assisted with the lesser trochanteric reduction fixation system (study group), and 34 cases were treated with DHS only (control group). The 2 groups were comparable with no significant difference in gender, age, the reasons, and the types of the fractures (P>0.05). The operation time, intraoperative blood loss, neck-shaft angle, bone healing time, ratio of successful fixations, and the functional evaluation of the hip joint after operation were compared between 2 groups. ResultsThe study group had shorter operation time [(58.4±5.3) minutes] and less intraoperative blood loss [(186.3±6.6) mL] than the control group[(78.5±6.2)minutes and (246.2±8.7) mL], showing significant differences (t=-14.040, P=0.000; t=-31.145, P=0.000). There was no significant difference in neck-shaft angle between study group [(138.6±3.0)°] and control group [(139.4±2.9)°] (t=-1.044, P=0.301). The wounds healed by first intention in both groups. The 30 and 31 patients were followed up 12 to 24 months (mean, 15 months) in the study group, and 13 to 25 months (mean, 16 months) in the control group, respectively. All fractures healed well in 2 groups. The study group had significantly shorter healing time [(8.8±2.0) weeks] than the control group [(10.7±3.4) weeks] (t=-2.871, P=0.006). At 12 months after operation, coxa vara happened in 2 cases of the study group with a successful fixation ratio of 93.3% and in 10 cases of the control group with a successful fixation ratio of 67.7%, showing significant difference (χ2=6.319, P=0.022). According to Harris hip score, the excellent and good rate was 83.3% in the study group (25/30) and was 58.1% in the control group (18/31), showing significant difference (χ2=4.680, P=0.049). ConclusionThe application of the lesser trochanteric reduction fixation system can reduce stripping of the soft tissue around the fracture fragments, shorten the operation time and the healing time, and preserve the function of the hip joint maximumly.
ObjectiveTo compare the effectiveness of treatment of isthmic spondylolisthesis between two different fusion surgeries combined with pedicle screw fixation system. MethodsA retrospectively analysis was made on the clinical data of 98 patients with lumbar isthmic spondylolisthesis treated between February 2009 and May 2012. Of 98 cases, 53 underwent posterior lumbar interbody fusion (PLIF) combined with internal fixation (group A), and 45 underwent posterolateral fusion (PLF) with internal fixation (group B). There was no significant difference in gender, age, disease duration, segmental lesions, and degree of spondylolisthesis between 2 groups (P>0.05). The operation time, intraoperative blood loss, reduction rate of spondylolisthesis, reduction loss rate, fusion rate, intervertebral space height, Japanese Orthopedic Association (JOA) score, and the recovery rate of JOA score were compared between 2 groups. ResultsThe operation time and intraoperative blood loss of group A were significantly higher than those of group B (P<0.05). Dural tear occured in 4 cases of group A and 1 case of group B during operation; 6 cases had radicular symptoms after operation in group A; incision infection was found in 1 case of 2 groups respectively. The follow-up time was 24-36 months in group A and was 26-40 months in group B. No significant difference was found in the JOA score at preoperation and 2 weeks after operation between 2 groups (P>0.05). The JOA score and the recovery rate of JOA score of group A were significantly better than those of group B at 2 years after operation (P<0.05). X-ray film showed that the reduction rate of group A was significantly higher than that of group B after 2 weeks of operation (P<0.05); the reduction loss rate of group A was significantly lower than that of group B after 2 years after operation (P<0.05). The intervertebral space height of group A was significantly higher than that of group B at 2 weeks and 2 years after operation (P<0.05). The fusion rate of group A was significantly better than that of group B at 2 years after operation (P<0.05). ConclusionPLIF can achieve a greater degree of reduction, better restore disc height, and lumbar curvature than PLF. PLIF is superior to PLF in maintaining intervertebral height after operation. And PLIF has higher fusion rate, restores the stability of the spine in a greater extent, and it also can achieve a better long-term outcome.
ObjectiveTo compare the fixation strength of optimum placed pedicle screw (OS) with re-directionally correctly placed pedicle screw (RS) following a violation of lateral pedicle. MethodsThirty fresh lumbar vertebrae (L1-5) were obtained from 6 pigs weighing 95-105 kg, male or female. Each vertebra was instrumented with a monoaxial pedicle screw into each pedicle using two different techniques. On one side, a perfect screw path was created using direct visualization and fluoroscopy. A pedicle screw of 5 mm in diameter and 35 mm in length was placed with a digital torque driver (OS). On the other side, a lateral pedicle wall violation was created at the pedicle-vertebral body junction with a guide wire, a cannulated tap, and a pedicle probe. This path was then redirected into a correct position, developed, and instrumented with a 5-mm-diameter by 35-mm-long pedicle screw (RS). For each pedicle screw, the maximal torque, seating torque, screw loosening force, and post-loosening axial pullout were measured. Screw loosening and axial pullout were assessed using an MTS machine. ResultsMaximal insertion torque was (111.4±8.2) N·cm and (78.9±6.4) N·cm for OS and RS respectively, showing significant difference (Z=3.038, P=0.002). The seating torque was (86.3±7.7) N·cm and (59.7±5.3) N·cm for OS and RS respectively, showing significant difference (Z=2.802, P=0.005). The screw loosening force was (76.3±6.2) N and (53.0±5.8) N for OS and RS respectively, showing significant difference (Z=2.861, P=0.004). The post-loosening axial pullout force was (343.0±12.6) N and (287.0±10.5) N for OS and RS respectively, showing significant difference (Z=2.964, P=0.003). ConclusionCompared with OS, RS placement after a lateral wall violation shows significantly decreased maximal insertion torque, seating torque, screw loosening force, and post-loosening axial pullout. On this occasion, RS augmentation is a probable option for remediation.
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.
Objective To compare the effects of arthroplasty with that of intenal fixation for displaced femoral neck fractures in the elderly. Methods We searched for all randomized controlled trials and quasi-randomized controlled trials of hip arthroplasty versus internal fixation for displaced femoral neck fractures in the elderly by electronically searching MEDLINE( 1966 to September, 2006),EMbase(1966 to September, 2006), Cochrane Library( Issue 4 2006), CBM( up to September, 2006) and CNKI (September, 2006) and handsearching grey literatures. The quality of the trials was assessed and meta-analyses were conducted using The Cochrane Collaboration’s RevMan 4.2.8 software. The quality of the trials was assessed. And meta-analysis was conducted by using RevMan4.2.8 software. Results A total of 228 papers were retrieved, but only 15 published randomized controlled trials involving a total of 2 254 patients were suitable for inclusion in the review. Based on the meta-analyses, hip arthroplasty showed obvious advantages over internal fixation in terms of the incidences of major complications after 2 years (RR 0.15 ; 95%CI 0.09 to 0.23) and after 5 years (RR 0.18 ; 95%CI 0.11 to 0.30) as well as re-operation rate (RR0.12 ; 95%CI 0.08 to 0.18) after 2 years, and after 5 years (RR0.11 ; 95%CI 0.06 to 0.22), there was an advantage to performing hip asthroplasty. After one year, the mortality was the same in both groups with RR 1.05 and 95%CI 0.89 to 1.23. Conclusion There is an evidence base to support arthroplasty as a treatment for displaced femoral neck fractures in the elderly. Arthroplasty can not only decrease the rate of re-operation, but can also reduce the incidence of complications, with similar one-year mortality when compared to internal fixation.
Objective To study the role of ultracision harmonic scalpel and skin flap in axillary fossa external fixation in operation of breast cancer. Methods One hundred and sixty-six patients with breast cancer were included in this study between May 2009 and November 2009. Combined group (n=51) applied ultracision harmonic scalpel combined with skin flap external fixation. External fixation group （n=52） used the skill of skin flap external fixation. Routine group included 63 patients. Operative time, accidental injury during operation， volume of bleed and drainage, time of drainage, detection amount of lymph node, and complications such like subcutaneous fluidity were observed and recorded. Results The operative time and detection amount of lymph node were not different among three groups （Pgt;0.05）. The volume of bleed in combined group was less than that in other groups （Plt;0.05）. The volume of drainage and the time of drainage were decreased or shorten by turns from routine group, external fixation group to combined group （Plt;0.05）. The incidence rate of subcutaneous fluidity in combined group was lower than that in routine group （Plt;0.05）. Conclusions Using ultracision harmonic scalpel in operation of breast cancer can remarkably reduce the volume of bleed and drain postoperatively. Ultracision harmonic scalpel combined with skin flap external fixation is safety and can reduce the incidence rate of subcutaneous fluidity, thus can be applied widely in breast cancer operation.
Objective To evaluate clinical efficacy of four-claw Ti-planes for internal fixation of multiple rib fractures and flail chest. Methods Clinical data of 93 patients with multiple rib fractures and flail chest who were admittedto Shanghai Pudong Hospital from December 2011 to November 2012 were retrospectively analyzed. There were 78 male and 15 female patients with their age of 20-80 years. All the patients received internal fixation of rib fractures using four-clawTi-planes. Finite element modeling and analysis were performed to investigate biomechanical behaviors of rib fractures after internal fixation with four-claw Ti-planes. Results The average number of rib fractures of the 93 patients was 5.9±2.1，and each patient received 3.8±1.3 four-claw Ti-planes for internal fixation. The operations were performed 6.3±3.2 days after admission. After the rib fractures were fixed with four-claw Ti-planes，rib dislocations and chest-wall collapse of flail chest were restored，and patients’ pain was relieved. Postoperative CT image reconstruction of the chest showed no dislocationor displacement at the fixation areas of the four-claw Ti-planes. Rib fractures were stabilized well，and normal contours of the chest were restored. Finite element analysis showed that the maximum bearable stress of the rib fractures after internal fixation with four-claw Ti-planes was twice as large as normal ribs. Conclusion Clinical outcomes of four-claw Ti-planesfor internal fixation of rib fractures are satisfactory with small incisions and less muscle injury of the chest wall，so this technique deserves wide clinical use.
Objective To investigate the short-term effectiveness of reconstructive locked plate for treating sternoclavicular joint dislocation. Methods Between February 2008 and February 2012, 11 patients with sternoclavicular joint dislocation were treated with reconstructive locked plate, and the clinical data were retrospectively analyzed. There were 7 males and 4 females, aged 30-55 years (mean, 44 years). The causes of injury included traffic accident in 8 cases and crashing in 3 cases. The disease duration ranged from 2 hours to 11 days (median, 6 days). All patients had anterior dislocation of sternoclavicular joint. According to the Grade system, there were 2 cases of type II and 9 cases of type III. Results All patients obtained healing of incisions by first intention after operation. There was no neurovascular injury. The X-ray films showed that satisfactory reduction of joint dislocation and stable internal fixation were obtained at 2 days after operation. All patients were followed up 9-24 months (mean, 16 months). According to the Rockwood criteria, the score was 10-15 (mean, 13.2); the results were excellent in 9 cases and good in 2 cases, with an excellent and good rate of 100% at 9 months after operation. No internal fixation failure or re-dislocation occurred. All internal fixators were removed at 9-15 months after operation. Both the stability and the functions of the shoulder joint were good. Conclusion The reconstructive locked plate in treating sternoclavicular joint dislocation has the advantages of good stability and satisfactory reduction, and the patients can do functional exercises early and obtain good recovery of the shoulder joint function. The short-term effectiveness is satisfactory.