ObjectiveTo measure the rotation angle of the head-neck fragment of intertrochanteric fracture after cephalomedullary nail fixation by three-dimensional CT imaging, and to explore its clinical significance.MethodsThe clinical data of 68 patients with unstable intertrochanteric fracture of AO/Orthopaedic Trauma Association (AO-OTA) type 31-A2 treated with cephalomedullary nail fixation and with complete intraoperative fluoroscopy and postoperative three-dimensional CT imaging data between July 2016 and October 2018 were retrospectively analyzed. Among them, there were 21 males and 47 females, aged 68-93 years, with an average age of 81.8 years. There were 31 cases of AO/OTA type 31-A2.2 and 37 cases of 31-A2.3. Fracture reduction quality was evaluated according to Baumgaertner et al. and Chang et al. criteria. The anteromedial cortical contact or not of each patient was observed by three-dimensional CT imaging on T3DView software after operation. The rotation of head-neck fragments were divided into three types: non-rotation, flexion rotation, and hyperextension rotation. The rotation angles of each type were measured and the relationship between the rotation type of the head-neck fragments and the contact of the anteromedial cortex was analyzed.ResultsThe reduction and fixation of the small trochanter were not performed in 68 patients. According to Baumgaertner et al. criteria, the quality of fracture reduction was excellent in 15 cases (22.1%), acceptable in 50 cases (73.5%), and poor in 3 cases (4.4%). According to Chang et al. criteria, 31 cases were excellent (45.6%), 33 cases were acceptable (48.5%), and 4 cases were poor (5.9%). Thirty-nine cases (57.4%) received anteromedial cortical support and 29 cases (42.6%) did not receive cortical support. Three-dimensional CT imaging showed non-rotation in 12 cases (17.6%), flexion rotation in 39 cases (57.4%), and hyperextension rotation in 17 cases (25.0%). There were 7 cases (58.3%), 30 cases (76.9%), and 2 cases (11.8%) of cortical support in non-rotation group, flexion rotation group, and hyperextension rotation group, respectively. The rotation angles were (1.05±0.61), (13.96±6.17), (8.21±3.88)°, respectively. There were significant differences between groups (P<0.05).ConclusionIn the unstable intertrochanteric fracture after cephalomedullary nail fixation, the rotation of head-neck fragment exists in most patients, and the types of flexion rotation and non-rotation can easily obtain cortical support reduction.
Objective To introduce a new fluoroscopic method for assessing the quality of medial and lateral joint surface reduction during internal fixation of patellar fractures and to summarize the clinical outcomes of patients treated using this method. Methods A retrospective analysis was conducted on the clinical data of 52 patients with patellar fractures treated between January 2018 and January 2022 who met the inclusion criteria. There were 27 male and 25 female patients, aged 21-75 years, with an average age of 62 years. The types of patellar fractures included 9 transverse fractures, 37 comminuted fractures, and 6 longitudinal fractures. According to the AO/Orthopaedic Trauma Association (AO-OTA)-2018 fracture classification, there were 21 cases of type 34A, 6 cases of type 34B, and 25 cases of type 34C. The time from injury to operation ranged from 1 to 5 days, with an average of 2.3 days. Treatments included internal fixation with hollow screws or hollow screw tension bands, with or without anchor repair. During operation, the medial and lateral joint surfaces of the patella were observed using the tangential fluoroscopic method to assess the smoothness of reduction of the median ridge, lateral joint surface, medial joint surface, and lateral joint edge. Patients were followed up regularly, and X-ray films were taken to observe fracture healing. Knee joint range of motion, Böstman score, and Lysholm score were used to evaluate functional recovery. Results The tangential fluoroscopic method for the medial and lateral joint surfaces of the patella during operation showed satisfactory reduction of the joint surfaces and good positioning of the implants. All patients were followed up 12-16 months, with an average of 13.4 months. During the follow-up, fracture displacement occurred in 1 case and titanium cable breakage in 1 case. All patella fractures healed successfully, with a healing time of 8-16 weeks (mean, 11.4 weeks). At last follow-up, knee joint range of motion ranged from 120° to 140°, with an average of 136°. The Böstman score ranged from 20 to 30, with an average of 28, yielding excellent results in 45 cases and good results in 7 cases. The Lysholm score ranged from 88 to 100, with an average of 93, yielding excellent results in 40 cases and good results in 12 cases. Conclusion The intraoperative application of the tangential fluoroscopic method for the medial and lateral joint surfaces of the patella can quickly determine the fluoroscopic plane of the patella, accurately assess the quality of fracture reduction and the position of internal fixator, thereby improving effectiveness.
Objective To investigate the feasibility and effectiveness of the novel bone hook combined with finger-guided technique in the treatment of irreducible intertrochanteric femoral fractures in elderly. Methods Between January 2021 and August 2023, 23 elderly patients with irreducible intertrochanteric femoral fractures were treated with the novel bone hook combined with finger-guided technique. There were 10 males and 13 females; the age ranged from 68 to 93 years (mean, 76.2 years). The time from injury to operation ranged from 36 to 76 hours (mean, 51.2 hours). According to the classification standard proposed by TONG Dake et al in 2021, there were 10 cases of typeⅠA, 1 case of typeⅠB, 6 cases of type ⅡA, 4 cases of type ⅡB, and 2 cases of type ⅡC. The operation time, intraoperative blood loss, intraoperative fluoroscopy frequences, and quality of fracture reduction were recorded. The fracture healing time and occurrence of postoperative complications were observed during follow-up. At last follow-up, the Harris scoring system was used to evaluate the hip joint function. Results The operation time was 42-95 minutes (mean, 52.1 minutes). The intraoperative blood loss was 40-420 mL (mean, 126.5 mL). Intraoperative fluoroscopy was performed 14-34 times (mean, 20.7 times). According to the criteria proposed by Chang et al, the quality of fracture reduction was rated as good in 20 cases and acceptable in 3 cases. All patients were followed up 6-20 months (mean, 10.2 months). X-ray film showed that all fractures healed with the healing time of 3.0-5.5 months (mean, 4.0 months). At last follow-up, the Harris score of the hip joint ranged from 82 to 97 points (mean, 90.4 points). Among them, 14 cases were rated as excellent and 9 cases as good. No complication such as coxa vara, cutting of the cephalomedullary nail, nail withdrawal, or nail breakage occurred during follow-up. Conclusion The treatment of elderly patients with irreducible intertrochanteric femoral fractures by using the novel bone hook combined with finger-guided technique can achieve high-quality fracture reduction and fixation, and has a good effectiveness.
Objective To investigate the effectiveness of joystick technique assisted closed reduction and cannulated screw fixation in the treatment of femoral neck fracture. Methods Seventy-four patients with fresh femoral neck fractures who met the selection criteria between April 2017 and December 2018 were selected and divided into observation group (36 cases with closed reduction assisted by joystick technique) and control group (38 cases with closed manual reduction). There was no significant difference in gender, age, fracture side, cause of injury, Garden classification, Pauwels classification, time from injury to operation, and complications (except for hypertension) between the two groups (P>0.05). The operation time, intraoperative infusion volume, complications, and femoral neck shortening were recorded and compared between the two groups. Garden reduction index was used to evaluate the effect of fracture reduction, and score of fracture reduction (SFR) was designed and was used to evaluate the subtle reduction effect of joystick technique. ResultsThe operation was successfully completed in both groups. There was no significant difference in operation time and intraoperative infusion volume between the two groups (P>0.05). All patients were followed up 17-38 months, with an average of 27.7 months. Two patients in the observation group received joint replacement due to failure of internal fixation during the follow-up, and the other patients had fracture healing. Within 1 week after operation, the Garden reduxtion index of the observation group was better than the control group; the SFR score of the observation group was also higher than that of the control group; the proportion of femoral neck shortening within 1 week after operation and at 1 year after operation in the observation group were lower than those in the control group. The differences of the above indexes between the two groups were significant (P<0.05). ConclusionThe joystick technique can improve the effectiveness of closed reduction of femoral neck fractures and reduce the incidence of femoral neck shortening. The designed SFR score can directly and objectively evaluate the reduction effect of femoral neck fracture.
Objective To summarize the morphological characteristics of sagittal beak-like deformity of head-neck fragment in femoral intertrochanteric fractures and to investigate the technical skills in fracture reduction. Methods A clinical data of 31 patients with femoral intertrochanteric fractures between May 2021 and April 2023 was retrospectively analyzed. The fractures had sagittal beak-like deformity of head-neck fragment in all patients. There were 13 males and 18 females, with an average age of 76.2 years (range, 68-83 years). The time from injury to operation was 36-76 hours (mean, 51.2 hours). Fractures were classified as type A1.2 in 10 cases, type A1.3 in 11 cases, type A2.2 in 6 cases, and type A2.3 in 4 cases according to the AO/Orthopaedic Trauma Association (AO/OTA)-2018 classification; and as type A1.3 in 10 cases, type A2.1 in 11 cases, type A2.2 in 6 cases, type A2.3 in 2 cases, and type A2.4 in 2 cases according to a novel comprehensive classification for femoral intertrochanteric fractures proposed by the “Elderly Hip Fracture” Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association. Based on preoperative X-ray films, CT scan and three-dimensional reconstruction, the fractures were classified into two types: type 1 (14 cases), with uncomplicated fracture morphology, severe bone interlocking and (or) soft tissue incarceration; type 2 (17 cases), with severe fracture crushing, obvious dissociation between bone blocks, and severe soft tissue hinge destruction. After the failure of the closed reduction, all patients underwent fracture reduction assisted with instrument via anterior minimal incision and proximal femoral nail antirotation nails internal fixation. The operation time, intraoperative fluoroscopy, intraoperative visible blood loss, length of hospital stay, and incidence of complications were recorded. The fracture reduction quality and stability score were assessed at immediate after operation under fluoroscopy. The fracture healing was evaluated and healing time was recorded by X-ray films. The pain visual analogue scale (VAS) score was performed at 48 hours after operation and Parker-Palmer activity score at 3 months after operation for function evaluation. ResultsThe operation time was 39-58 minutes (mean, 46.3 minutes); fluoroscopy was performed 13-38 times (mean, 23.5 times) during operation; the intraoperative visible blood loss was 45-90 mL (mean, 65.3 mL). The fracture reduction quality and stability score were rated as good in 29 cases and acceptable in 2 cases. The pain VAS score was 2-6 (mean, 3.1) at 48 hours after operation. Eleven patients developed deep vein thrombosis of the lower limbs after operation. Patients were hospitalized for 6-10 days (mean, 7.3 days). All patients were followed up 5-8 months (mean, 6.5 months). All fractures healed at 3.5-8.0 months after operation (mean, 4.5 months). Parker-Palmer activity score at 3 months after operation was 9 in 28 cases and 6 in 3 cases. Conclusion The femoral intertrochanteric fracture with sagittal beak-like deformity of head-neck fragment is difficult to manually reduce. The pin combined with cannulated screw insertion to the neck cortex can hold the fragment and assist fracture reduction, which is a simple and effective technique.
Objective To explore the effectiveness of proximal femoral nail antirotation (PFNA) combined with minimally invasive clamp reduction technique by Kocher pincers in the treatment of irreducible intertrochanteric femoral fracture in the elderly. Methods The clinical data of 35 elderly patients with irreducible intertrochanteric femoral fractures who were treated with PFNA combined with minimally invasive clamp reduction technique by Kocher pincers between January 2016 and December 2022 were retrospectively analysed. There were 16 males and 19 females, aged from 63 to 95 years (mean, 75.2 years). The causes of injury included traffic accident in 3 cases and falling in 32 cases. The time from injury to operation was 2-11 days (mean, 3.6 days). According to AO/Orthopaedic Trauma Association (AO/OTA) classification system for intertrochanteric fractures, there were 14 cases of type A1, 18 cases of type A2, and 3 cases of type A3. According to the displacement of fracture by intraoperative fluoroscopy, there were 5 cases with only coronal displacement, 17 cases with only sagittal displacement, and 13 cases with both coronal and sagittal displacement. The operation time, intraoperative blood loss, rate of hemoglobin decline at 1 day after operation, length of hospital stay, and fracture healing time were recorded. The reduction quality of fracture during operation was evaluated according to reduction quality criteria proposed by Chang et al. The Harris scoring system was used to evaluate the hip joint function at last follow-up. Results The operation time was 45-105 minutes (mean, 54.4 minutes); the intraoperative blood loss was 80-300 mL (mean, 116.3 mL). The reduction quality of fracture during operation was good in 22 cases (62.9%) and acceptable in 13 cases (37.1%). The rate of hemoglobin decline at 1 day after operation ranged from 6.2% to 18.6% (mean, 10.2%); the length of hospital stay was 5-18 days (mean, 7.2 days). One case died of respiratory failure due to pulmonary infection, 2 cases were lost to follow-up, and the remaining 32 cases were followed up 6-24 months (mean, 10.6 months). All 32 patients achieved bony union and the healing time was 3-9 months (mean, 3.6 months). There was no complication such as incision infection, internal fixation failure, or coxa varus during follow-up. At last follow-up, the Harris score of hip joint was 67-96 (mean, 88.9); among them, 19 cases were excellent, 10 cases were good, 2 cases were fair, and 1 case was poor, with an excellent and good rate of 90.6%. Conclusion For the elderly patients with irreducible intertrochanteric femoral fracture, the application of PFNA combined with minimally invasive clamp reduction technique by Kocher pincers can achieve high-quality fracture reduction, which has the advantages of simple reduction operation, less trauma, and can avoid the radiation exposure of operators during maintenance reduction.
Objective This review summarized the first 10-year progresses and controversies in the concept of anteromedial cortical support reduction, to provide references for further study and clinical applications.Methods Relevant domestic and foreign literature on cortical support reduction was extensively reviewed to summarize the definition of positive, neutral, and negative support, anteromedial cortices at the inferior corner, intraoperative technical tips for fracture reduction, radiographic assessment at different periods, comparison between positive versus neutral and medial versus anterior support, and the clinical efficacy of Chang reduction quality criteria (CRQC) and postoperative stability score. Results Anteromedial cortical support reduction was only focused on the cortex of anteromedial inferior corner, with no concern the status of lateral wall or lesser trochanter. Anteromedial cortex was seldom involved by fracture comminution, it was thicker, denser, and stronger, and was the key for mechanical buttress of the head-neck fragment to share compression load. Positive, neutral, and negative support were also called “extramedullary, anatomic, and intramedullary reduction”, respectively. There was hardly seen parallel cortical apposition, but characterized by some kinds of head-neck rotation, for example 10°-15° flexed rotation for positive cortical contact and support. Due to intraoperative compression and postoperative impaction, the status of cortical support may be changed at different time of radiographic examination. The positive medial cortex support was more reliable with less reduction loss than its neutral counterpart, and the anterior cortex contact was more predictive than the medial cortex for final results. As incorporation the bearing of cortex apposition and using a 4-point score, CRQC demonstrated more efficacy and was gradually accepted and applied in the evaluation of trochanteric fracture reduction quality. Postoperative stability score (8 points) provided a assessment tool for early weight-bearing in safety to prevent mechanical failure. Conclusion Anteromedial cortical support reduction is a key point for stability reconstruction in the treatment of trochanteric femur fractures. Evidence has definitely shown that non-negative (positive and neutral) is superior to negative (loss of cortical support). There is a tendency that positive cortex support is superior to neutral, but high quality study with large sample size is needed for a clear conclusion.
ObjectiveTo review and evaluate the basic principles and advantages of orthopedic robot-assisted technology, research progress, clinical applications, and limitations in the field of traumatic orthopedics, especially in fracture reduction robots. Methods An extensive review of research literature on the principles of robot-assisted technology and fracture reduction robots was conducted to analyze the technical advantages and clinical efficacy and shortcomings, and to discuss the future development trends in this field. Results Orthopedic surgical robots can assist orthopedists in intuitive preoperative planning, precise intraoperative control, and minimally invasive operations. It greatly expands the ability of doctors to evaluate and treat orthopedic trauma. Trauma orthopedic surgery robot has achieved a breakthrough from basic research to clinical application, and the preliminary results show that the technology can significantly improve surgical precision and reduce surgical trauma. However, there are still problems such as insufficient evaluation of effectiveness, limited means of technology realization, and narrow clinical indications that need to be solved. ConclusionRobot-assisted technology has a broad application prospect in traumatic orthopedics, but the current development is still in the initial stage. It is necessary to strengthen the cooperative medical-industrial research, the construction of doctors’ communication platform, standardized training and data sharing in order to continuously promote the development of robot-assisted technology in traumatic orthopedics and better play its clinical application value.
ObjectiveTo explore effectiveness of intermediate screw assisted reduction and fixation technique in the treatment of Schatzker type Ⅴ and Ⅵ tibial plateau fractures. Methods A clinical data of 22 patients with Schatzker type Ⅴ and Ⅵ tibial plateau fractures, who were admitted between June 2022 and December 2023 and met the selection criteria, was retrospectively analyzed. During operation, the intermediate screw assisted reduction and fixation technique was used. There were 14 males and 8 females with an average age of 46.3 years (range, 17-65 years). The fractures were caused by traffic accident in 13 cases, by falls in 5 cases, and by falling from height in 4 cases. According to Schatzker classification criteria, 9 cases were type Ⅴ and 13 cases were type Ⅵ. The interval between injury and operation was 5-12 days (mean, 7.9 days). The operation time, intraoperative fluoroscopy times, and length of hospital stay were recorded. The range of motion of knee joint and Hospital for Special Surgery (HSS) score were recorded at last follow-up. X-ray films were taken to review the fracture healing. Rasmussen score, tibial plateau varus angle (TPVA), and posterior tibial slope (PTS) were estimated before operation, at immediate after operation, and at last follow-up in order to evaluate the fracture reduction effect and postoperative outcome. Results The operation time was 85-140 minutes (mean, 103.9 minutes). Intraoperative fluoroscopy was performed 7-15 times (mean, 10.1 times). All incisions healed by first intention after operation, and no complication such as nerve or blood vessel injury occurred. The length of hospital stay ranged from 8 to 17 days (mean, 12.4 days). All patients were followed up 10-22 months (mean, 14.8 months). At last follow-up, the range of motion of knee joint was 110°-140° (mean, 125°). HSS score was rated as excellent in 16 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 95.5%. X-ray films reexamination showed that all fractures healed with the healing time of 12-17 weeks (mean, 14.8 weeks). No internal fixation failure occurred. Rasmussen score, TPVA, and PTS at immediate after operation and at last follow-up were significantly superior to those before operation (P<0.05). And there was no significant difference between immediately after operation and last follow-up (P>0.05). Conclusion The treatment of Schatzker type Ⅴ and Ⅵ tibial plateau fractures with intermediate screw assisted reduction and fixation technique is reliable, which can reduce the difficulty of reduction and fixation, improve the efficiency of reduction and fixation, reduce the operation time, achieve satisfactory reduction and fixation effect and postoperative prognosis, and achieve good recovery of knee joint function.
ObjectiveTo summarize the evolving concept and research progress on stability reconstruction in the surgical treatment of intertrochanteric fracture.MethodsRelated literature and author’s own experience concerning the surgical treatment of intertrochanteric fracture were reviewed and analyzed in terms of fracture pathoanatomy, stable and unstable pattern, adequate and in-adequate reduction, primary and secondary stability, postoperative stability evaluation, and early weight-bearing.ResultsIntertrochanteric fracture occur at the translational area of cervico-trochanteric junction, which has a nature tendency to varus instability. Fracture reduction quality is the paramount factor and is evaluated by two views, the anteroposterior and lateral Garden alignment and cortex apposition between the head-neck fragment and the femoral shaft. Rather than the posteromedial lesser trochanteric frag ment, the cortical support concept (positive, neutral, negative) emphasizes the reduction of anteromedial cortex to a nonanatomic positive apposition or an " anatomic” neutral apposition in intraoperative fluoroscopy. Postoperative radiographic stability score provides a quantitative assessment for early weight-bearing standing and walking. However, some fractures may lose cortical contact and buttress (negative) during the process of postoperative telescoping and secondary stability. Further studies are needed to elucidate the risk factors such as tilting, swing or rotation of the head-neck fragment, and propose new preventive methods.ConclusionStability reconstruction of intertrochanteric fracture requires adequate fracture reduction with Garden alignment and anteromedial cortical support apposition, and reliable sustainment by internal fixation implants. Early weight-bearing standing and walking is safe in patients with perfect postoperative stability score.