Objective To assess the effectiveness of the new anterolateral approach of the distal femur for the treatment of distal femoral fractures. Methods Between July 2007 and December 2009, 58 patients with distal femoral fractures were treated by new anterolateral approach of the distal femur in 28 patients (new approach group) and by conventional approach in 30 patients (conventional approach group). There was no significant difference in gender, age, cause of injury, affected side, type of fracture, disease duration, complication, or preoperative intervention (P gt; 0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, hospitalization days, and Hospital for Special Surgery (HSS) score of knee were recorded. Results Operation was successfully completed in all patients of 2 groups, and healing of incision by first intention was obtained; no vascular and nerves injuries occurred. The operation time and intraoperative fluoroscopy frequency of new approach group were significantly less than those of conventional approach group (P lt; 0.05). But the intraoperative blood loss and the hospitalization days showed no significant difference between 2 groups (P gt; 0.05). All patients were followed up 12-36 months (mean, 19.8 months). Bone union was shown on X-ray films; the fracture healing time was (12.62 ± 2.34) weeks in the new approach group and was (13.78 ± 1.94) weeks in the conventional approach group, showing no significant difference (t=2.78, P=0.10). The knee HSS score at last follow-up was 94.4 ± 4.2 in the new approach group, and was 89.2 ± 6.0 in the conventional approach group, showing significant difference between 2 groups (t=3.85, P=0.00). Conclusion New anterolateral approach of the distal femur for distal femoral fractures has the advantages of exposure plenitude, minimal tissue trauma, and early function rehabilitation training so as to enhance the function recovery of knee joint.
ObjectiveTo evaluate the effectiveness of percutaneous vertebroplasty (PVP) in the treatment of osteoporotic vertebral compression fractures with or without intravertebral clefts by unilateral approach and the impact of intravertebral clefts on the effectiveness. MethodsThe clinical data of 65 patients who met the inclusion criteria of osteoporotic vertebral compression fracture were retrospectively analyzed. According to having intravertebral clefts or not, the patients were divided into 2 groups: cleft group (group A, n=25) and non-cleft group (group B, n=40). There was no significant difference in gender, age, cause of injury, the level of fracture vertebrae, degree of damage, and interval of injury and operation between 2 groups (P gt; 0.05). All patients were given PVP procedure by unilateral approach. The operation time, the injected volume of bone cement, time to ambulate, complications, and adjacent vertebral re-fracture were recorded. The height of anterior and middle column and the posterior convex Cobb angle of injured spine were measured on the lateral X-ray film in standing position at preoperation and 1, 48 weeks after operation. The visual analogue scale (VAS) score and Oswestry disability index (ODI) system were used to evaluate the pain relief and improvement of daily activity function respectively at preoperation and 1, 4, and 48 weeks after operation. ResultsThere was no significant difference in the operation time and time to ambulate between 2 groups (P gt; 0.05). The injected volume of bone cement in group B was significantly less than that in group A (t=1.833, P=0.034). Asymptomatic cement leakage occurred in 6 patients (4 in group A and 2 in group B), in group A including 1 case of venous leakage, 2 cases of paravertebral leakage, and 1 case of intradiscal leakage; in group B including 2 cases of venous leakage. No symptomatic pulmonary embolism was observed. The vital sign was stable during operation and postoperatively. All patients were followed up 12-30 months (mean, 18.5 months). No re-fracture of the vertebrae occurred during the follow-up. The postoperative VAS score, ODI, the height of anterior and middle column, and the posterior convex Cobb angle of injured spine were improved significantly when compared with the preoperative ones in 2 groups (P lt; 0.05), but no significant difference was found between 2 groups at pre- and post-operation (P gt; 0.05). ConclusionPVP by unilateral approach is safty and efficacy in the treatment of osteoporosis vertebral compression fracture combined with intravertebral clefts. Intravertebral clefts have no significant impact on the effectiveness in the pain relief and function improvement.
Objective To compare the effectiveness between improved anterolateral approach and lateral approach in the treatment of senile intertrochanteric fracture. Methods The clinical data were retrospectively analyzed, from 61 patients with senile intertrochanteric fracture treated between February 2008 and February 2010. Of 61 patients, 34 patients underwent improved anterolateral approach combined with fixation of dynamic hip screw (improved group), and 27 patients underwent conventional lateral approach combined with fixation of dynamic hip screw (conventional group). There was no significant difference in gender, age, injury cause, Evans classification, comorbidities, disease duration, or Harris hip scores between 2 groups (P gt; 0.05). Results The operation was successfully completed in all patients. The operation time, blood loss, perspective frequency during operation, drainage volume, hospitalization days, and out-of-bed time in the improved group were significantly less than those in the conventional group (P lt; 0.05). All patients were followed up 12-24 months (mean, 18.7 months). Bone union was achieved in both groups; the fracture healing time was (11.64 ± 1.28) weeks in the improved group and was (12.29 ± 1.12) weeks in the conventional group, showing no significant difference (t=2.15, P=0.15). Harris hip scores at 3, 6, and 12 months were significantly better than preoperative scores in 2 groups (P lt; 0.05), and significant differences were found among different time points after operation in 2 groups (P lt; 0.05), between 2 groups after operation (P lt; 0.05). There was no significant difference in the incidence of incision infection, limb shortening, coax vara, internal fixation loosening, main screw cutting-out from femoral head between 2 groups (P gt; 0.05), but the incidence of total complications in the improved group was significantly lower than that in the conventional group (P lt; 0.05). Conclusion Compared with conventional lateral approach, improved anterolateral approach has the advantages of sufficient exposure, reducing muscle damage and surgical risk in treating intertrochanteric fracture. Operating treatment of improved anterolateral approach combined with early rehabilitation after surgery can recover hip joint function as quickly as possible.
To investigate the effectiveness and safety of microendoscopic decompression via unilateral approach for lumbar spinal stenosis. Methods Between May 2006 and June 2009, 79 patients with lumbar stenosis were treated and divided into 2 groups: posterior lamina fenestration decompression (group A, n=37), endoscopic decompression via unilateral approach (group B, n=42). There was no significant difference in age, sex, segment level, and disease duration between 2 groups (P gt; 0.05). The cl inical outcomes were assessed by using the visual analogue scale (VAS) score and Oswestry Disabil ity Index (ODI). The operation time, blood loss, compl ications were compared between 2 groups. Results Operations were successfully performed in all cases. The operation time, blood loss, and drainage volume were (75.0 ± 25.7) minutes, (140.3 ± 54.8) mL, and (46.5 ± 19.7) mL in group A, were (50.4 ± 18.2) minutes, (80.2 ± 35.7) mL, and (12.7 ± 5.3) mL in group B; there were significant differences between 2 groups (P lt; 0.05). All the wounds healed by first intention. All patients were followed up 12-39 months (mean, 16 months). In group A, 1 patient suffered from intervertebral space infection after operation and recovered after conservative treatment; 4 patients had lumbar instabil ity after operation and recovered after lumbar interbody fusion combined with spine system internal fixation. In group B, 2 patients suffered from spinal dural rupture during operation and recovered after corresponding treatment, and no lumbar instabil ity was found. There was no significant difference in VAS score and ODI between 2 groups at preoperation (P gt; 0.05). Both VAS score and ODI were significantly improved at early stage after operation and last follow-up when compared with preoperation in each group (P lt; 0.05). Comparing with group A, there was significant improvement in VAS score at 24 hours postoperatively and in ODI at 1 month postoperatively in group B (P lt; 0.05), but no significant difference was observed at last follow-up (P gt; 0.05). According to cl inical evaluation of ODI mprovement rate, the excellent and good rate was 89.2% in group A and 92.9% in group B, showing no significant difference (χ2=0.896, P=0.827). Conclusion Comparing with posterior decompression surgery, microendoscopic decompression via unilateral approach is one of effective method to treat lumbar stenosis, with less trauma of fenestration yield and good early outcomes.
Objective To evaluate the effect of anterolateral approach in treating thoracolumbar disc protrusion. Methods From May 2004 to May 2008, 11 patients with thoracolumbar disc protrusion (T10-L3) underwent discectomy, autologous il iac bone graft, and internal fixation via anterolateral approach. There were 9 males and 2 females aged 26-57 years old (average 42.8 years old). The course of disease was 1 week-11 years (average 2.7 years). Nine patients showed the lower l imbs weakness, 8 had sensory disturbance, 6 presented with lumbodorsal pain, 5 had the lower l imb pain, 4 presentedwith sphincter muscle disturbance, 3 suffered from foot drop, and 5 had a history of lower back injury. X-ray, CT, and MRI test showed that 9 cases had the single-segmental protrusion, 2 cases had double-segmental protrusion, 2 cases were accompanied with ossification of the thoracic vertebra yellow l igament, 2 cases were combined with ossification of the vertebra posterior longitudinal l igament, and 1 was compl icated with Scheuermann disease. Preoperatively, the intervertebral height was (7.2 ± 1.3) mm and JOA score was 6.4 ± 2.8. Results The time of operation was 2.5-5.5 hours (average 3.5 hours); the blood loss during operation was 500-1 200 mL (average 750 mL). During operation, intraoperative pleural tear occurred in 1 patient, peritoneal tear in 1 patient, and dural laceration in 1 patient. Repairing was performed intraoperative and preventive suction drainage was used for 3-5 days. No postoperative hydropneumothorax and cerebrospinal fluid leakage occurred. All incisions healed by first intention. No postoperative compl ications of nerve system occurred. All the patients were followed up for 1-4 years (average 2.4 years). X-ray films showed that all the patients achieved bony fusion without the occurrence breakage and loosening of titanium plate and screw 6-9 months after operation. Three cases displayed subtle scol iosis (10-15°) without influence on spinal equil ibration. The intervertebral height increased to (12.3 ± 1.5) mm 2 weeks after operation, indicating there was a significant difference compared with preoperative value (P lt; 0.05). The intervertebral height 1 year after operation when the bony fusion was reached decreased to (7.5 ± 1.2) mm, indicating there was no significant difference compared to the preoperative value (P gt; 0.05). The JOA score increased to 7.6 ± 3.2 at 1 year after operation, indicating there was a significant difference compared with preoperative value (P lt; 0.05). The symptoms and signs of all the patients were improved to various degrees after operation. According to improvement rate evaluation system proposed by Hirabayashi t al., 4 cases were graded as excellent, 6 as good, 1 as fair, and the excellent and good rate was 90.9%. Conclusion Treating thoracolumbar disc protrusion via anterolateral approach is safe and effective.
ObjectiveTo study the effectiveness of a new anterolateral approach of distal femur in the treatment of type C distal femoral fractures by comparing with traditional lateral and anterolateral approaches. MethodsThe clinical data of 51 patients with type C distal femoral fractures treated between January 2008 and August 2011 were retrospectively analyzed. Of 51 patients, 24 patients received the new anterolateral approach of distal femur combined with fixation of condylar buttress plate (modified group), and 27 patients underwent traditional lateral or anterolateral approach combined with fixation of condylar buttress plate (traditional group). There was no significant difference in gender, age, injury cause, American Society of Anesthesiologist (ASA) classification, side, fracture type, complication, and the time from injury to operation between 2 groups (P>0.05). The operation time, intraoperative blood loss, frequency of intraoperative fluoroscopy, hospitalization time, fracture healing time, and Hospital for Special Surgery (HSS) scores of the knee at 3, 6, and 12 months were recorded. ResultsThe operation was successfully completed and the incision healed by first intention in all patients. The operation time and frequency of intraoperative fluoroscopy of modified group were significantly less than those of traditional group (P<0.05). But the intraoperative blood loss and the hospitalization time showed no significant difference between 2 groups (P>0.05). All patients were followed up 12-37 months (mean, 21.3 months). X-ray films showed all fractures were union. The fracture healing time was (12.92±2.24) weeks in the modified group and (13.24±2.52) weeks in the traditional group, showing no significant difference (t=0.476, P=0.637). The knee HSS scores of modified group were significantly higher than those of traditional group at 3, 6, and 12 months after operation (P<0.05). There was no significant difference in the incidence of knee varus or valgus, leg length discrepancy, internal fixator loosening, flexing dysfunction of knee, traumatic arthritis of knee, and total complications between 2 groups (P>0.05). ConclusionComparing with traditional lateral and anterolateral approaches, using the new anterolateral approach to treat type C distal femoral fractures has the advantages of less damage to soft tissue, excellent exposure, less operation time, and frequency of intraoperative fluoroscopy, and better postoperative rehabilitation of knee joint.
ObjectiveTo explore the effectiveness of posteromedial and anterolateral approaches in the treatment of posterolateral tibial plateau collapsed and splited fractures. MethodsNineteen consecutive patients with posterolateral tibial plateau collapsed and splited fractures were treated between August 2010 and August 2013, and the clinical data were retrospectively analyzed. There were 13 males and 6 females, with an average age of 36.9 years (range, 25-75 years). All cases had closed fractures, involving 8 left sides and 11 right sides. Fractures involved posterior column according to the threecolumn classification based on CT scans; according to the Schatzker classification, all fractures were type Ⅱ; according to the AO/Association for the Study of Internal Fixation classification (AO/OTA), all fractures were type 41-B3.1.2. The interval between injury and operation was 7-14 days (mean, 9 days). The reduction of collapsed fractures and implantation of artificial bone allograft were supported by T-shaped distal radius plate via the posteromedial approach. The splited fractures was fixed by less invasive stabilization system (LISS) plate via the anterolateral approach. ResultsThe mean operation time was 69.0 minutes (range, 50-105 minutes). All incisions healed by first intention without neurovascular complications or wound infection. All patients were followed up 14-20 months (mean, 18.2 months). X-ray and CT examinations showed that collapsed tibial plateau and joint surface were completely corrected; bony union was obtained at 12 weeks on average (range, 10-16 weeks). No secondary collapsed fracture and knee varus or valgus occurred. The results were excellent in 12 cases, good in 5 cases, and fair in 2 cases with an excellent and good rate of 89.5% according to the Rasmussen's scoring system for knee function. ConclusionThe posteromedial approach combined with anterolateral approach for posterolateral tibial plateau fractures can fully expose the posterolateral aspects of the tibial plateau, and thus collapsed and splited fractures can be treated at the same time, which will lead to less operative time and good outcomes in the treatment of posterolateral tibial plateau collapsed and splited fractures.
ObjectiveTo evaluate the effectiveness of the modified posterolateral counter-curved incision with double intermuscular approach for the treatment of posterolateral tibial plateau fractures. MethodsA retrospective analysis was made on the clinical data of 32 patients with posterolateral tibial plateau fractures between September 2012 and October 2014. There were 22 males and 10 females, aged 19 to 55 years (mean, 40.5 years). The causes of injury included traffic accident in 17 cases, falling from height in 9 cases, and falling in 6 cases. They had fresh closed fracture; injury to hospitalization time was 3 hours to 5 days (mean, 2 days). According to Schatzker tibial plateau fracture classification criteria, 20 cases were rated as type II, and 12 cases as type III. All patients underwent a modified posterolateral counter-curved incision with double intermuscular approach to expose tibial posterolateral condyle and anterolateral condyle. After a good visual control of fracture reduction, the anterolateral and posterolateral fractures were fixed with two-dimensional buttress plate respectively. ResultsThe incisions healed at stage I, with no major neurovascular injury. According to radiological assessment of the DeCoster score, the results were excellent in 21 cases, and fair in 11 cases. All of the 32 patients were followed up 18 to 30 months (mean, 20.5 months). The X-ray films showed that all patients obtained good fracture union, and the mean time of fracture union was 12.3 weeks (range, 10-16 weeks). No fixation failure or no obvious loss of articular surface reduction was observed during follow-up. The range of motion of the affected knees was 2-135° (mean, 120°). The mean American Hospital for Special Surgery (HSS) score was 90.05 (range, 83-96) at 18 months after operation. ConclusionThe modified posterolateral counter-curved incision with double intermuscular approach could fully expose posterolateral tibia plateau, and good fracture reduction and reliable fixation can be obtained under direct vision.
ObjectiveTo evaluate the advantage of single posterolateral approach for exposing the fragments of lateral malleolus and posterior malleolus in treating bimalleolar and trimalleolar fractures. MethodsBetween January 2013 and June 2015, 47 patients with ankle fractures were treated. Of 47 cases, 16 were male and 31 were female with an average age of 47.7 years (range, 25-65 years); the locations were the left side in 21 cases and the right side in 26 cases. According to types system of Lauge-Hansen, 11 cases were rated as pronation-external rotation and 36 cases as supination-external rotation. There were 9 cases of bimalleolar fractures and 38 cases trimalleolar fractures. CT examination showed that posterior malleolus fracture involved more than 35% of the joint surface in 11 cases, and 9 cases had comminuted posterior malleolus fracture. Of 47 cases, 44 had fresh fractures with a mean disease course of 4 days (range, 8 hours to 7 days), and 3 had old fracture with the disease course of 43, 58, and 62 days respectively. Posterior malleolus fractures were fixed with T-type plates in 12 cases, one-third tubular plates in 10 cases, and cannulated screws in 25 cases. ResultsThe operation time was 60-100 minutes (mean, 80 minutes); the bleeding volume was 50-100 mL (mean, 72 mL). Primary healing of incision was obtained in all patients, and no postoperative complications of infection, cutaneous necrosis, deep venous thrombosis, and sural nerve injury occurred. The CT examinations after operation showed anatomical reduction of fractures. All patients were followed up from 12 to 20 months (mean, 16 months). No fixation failure or reduction loss was found at last follow-up. All patients could walk normally. The active dorsiflexion of the affected ankles was within 5° less than normal side in 43 cases (91.5%) and 5-10° less than normal side in 4 cases (8.5%). The passive dorsiflexion of the affected ankles was within 5° less than normal side in 44 cases (93.6%) and 5-10° less than normal side in 3 cases (6.4%). According to the Olerud-Molander scoring system, the results were excellent in 40 cases, good in 5 cases, and fair in 2 cases; and the excellent and good rate was 95.7% at last follow-up. ConclusionThe single posterolateral approach could simultaneously expose the fragments of lateral malleolus and posterior malleolus, with less complication of the incision, short operation time, and clear exposure of posterior malleolus. The surgery could be performed under direct vision. It especially is suitable for bimalleolar and trimalleolar fractures with lateral malleolus and posterior malleolus.
Objective To investigate the feasibility of anterolateral approach for L5 vertebral resection, bone grafting, and screw rod fixation by imaging and biomechanics researches. Methods Twenty formalized adult cadavers (12 males and 8 females) were randomly divided into 2 groups; L5 vertebral resection, bone graft, and screw rod fixation was performed on 10 specimens by using anterolateral approach (experimental group), and on the other 10 specimens by combined anterior and posterior approach. CT scanning and three-dimensional reconstruction were performed in the experimental group; preoperative maximal safe entry angle and depth of screws and intraoperative actual entry angle and depth of screws were measured; the sacral screw position was observed after operation. The biomechanical test was done in 2 groups. Results Twenty specimens smoothly underwent L5 excision and reconstruction. CT scan showed that there was no significant difference in maximal safe entry angle and depth of screws between males and females in experimental group before operation (P>0.05); the maximal safe entry angle and depth were 51.93° and 47.88 mm for anterior screw, and were 37.04° and 46.28 mm for posterior screw. After operation, depth of the sacral anterior and posterior screws were appropriate, which did not pierce into the spinal canal. The biomechanical test results indicated that the flexion, extension, and lateral flexion displacements, and vertical compression stiffness showed no significant difference between 2 groups (P>0.05). Conclusion For L5 lesions not invading posterior column, to use L5 vertebral resection, bone graft, and screw rod fixation by anterolateral approach is a safe and feasible method to reconstruct lumbosacral stability, with the advantages of no changing posture, less operation time and incision, and prevention of bone graft shift, but effectiveness need further be identified.