Objective To explore the reduction and support effect of the subchondral screw compression technique for residual or secondary collapse of the lateral tibial plateau during operation. Methods Between January 2020 and June 2021, 11 patients with residual or secondary collapse of the lateral tibial plateau during operation were treated with the subchondral screw compression technique. There were 6 males and 5 females, aged 52.3 years old (range, 27-64 years). The fractures were caused by traffic accident in 10 cases and falling from height in 1 case and located at the left knee in 6 cases and the right knee in 5 cases. According to Schatzker classification, there were 5 cases of type Ⅱ fractures, 4 cases of type Ⅲ fractures, and 2 cases of type Ⅴfractures. According to the three columns classification, there were 5 cases of lateral column, 4 cases of lateral column and posterior column, and 2 cases of three columns. The time from injury to operation was 4.5 days (range, 3-7 days). During the follow-up, X-ray films were obtained and the Rasmussen standard was used to evaluate the quality of fracture reduction, meanwhile fracture healing was observed. The medial proximal tibial angle (mPTA), posterior tibial slope angle (pTSA), and articular surface collapse were measured at immediate and 12 months after operation. The knee joint range of motion was evaluated at last follow-up, and the knee joint function was evaluated using the Hospital for Special Surgery (HSS) score. Results All operations were successfully completed, with a mean operation time of 71.4 minutes (range, 55-120 minutes), and a mean hospital stay of 8.0 days (range, 5-13 days). The incisions all healed by first intention, without complications such as infection, flap necrosis, or vascular and nerve injury. All patients were followed up 16.5 months on average (range, 12-24 months). X-ray films showed that the fracture reduction score was 14-18 (mean, 16.7) according to Rasmussen score criteria; and 5 cases were rated as excellent and 6 as good. All fractures healed clinically with a mean clinical healing time of 14.9 weeks (range, 12-16 weeks), and there was no complications such as plate or screw loosening. At 12 months after operation, the mPTA and pTSA were (87.5±1.7)° and (6.2±3.1)°, respectively; there was no significant difference when compared to the values at immediate after operation [(87.6±1.8)° and (6.5±3.1)°] (P>0.05). The articular surface of the tibial plateaus was effectively supported, and it collapsed again by 0-1.0 mm at 12 months, with an average of 0.4 mm. At last follow-up, the knee joint range of motion was 115°-135° (mean, 126.8°) and the HSS score for knee joint function was 87-98 (mean, 93.9). Five patients underwent secondary operation to remove the internal fixator at 12-18 months after operation.ConclusionThe subchondral screw compression technique is helpful for the reduction of residual or secondary collapse of the lateral tibial plateau during operation, and can provide good support for osteochondral blocks.
Objective To evaluate the effectiveness of Confidence high viscosity bone cement system and postural reduction in treating acute severe osteoporotic vertebral compression fracture (OVCF). Methods Between June 2004 and June2009, 34 patients with acute severe OVCF were treated with Confidence high viscosity bone cement system and postural reduction. There were 14 males and 20 females with an average age of 72.6 years (range, 62-88 years). All patients had single thoracolumbar fracture, including 4 cases of T11, 10 of T12, 15 of L1, 4 of L2, and 1 of L3. The bone density measurement showed that T value was less than —2.5. The time from injury to admission was 2-72 hours. All cases were treated with postural reduction preoperatively. The time of reduction in over-extending position was 7-14 days. All patients were injected unilaterally. The injected volume of high viscosity bone cement was 2-6 mL (mean, 3.2 mL). Results Cement leakage was found in 3 cases (8.8%) during operation, including leakage into intervertebral space in 2 cases and into adjacent paravertebral soft tissue in 1 case. No cl inical symptom was observed and no treatment was pearformed. No pulmonary embolism, infection, nerve injury, or other complications occurred in all patients. All patients were followed up 12-38 months (mean, 18.5 months). Postoperatively, complete pain rel ief was achievedin 31 cases and partial pain refief in 3 cases; no re-fracture or loosening at the interface occurred. At 3 days after operation and last follow-up, the anterior and middle vertebral column height, Cobb angle, and visual analogue scale (VAS) score were improved significantly when compared with those before operation (P lt; 0.05)；and there was no significant difference between 3 days and last follow-up (P gt; 0.05). Conclusion Confidence high viscosity bone cement system and postural reduction can be employed safely in treating acute severe OVCF, which has many merits of high viscosity, long time for injection, and easy-to-control directionally.
Objective To investigate the application of the fibrous envelope of tissue expanders for the tension reduction. Methods Between June 2005 and May 2011, 21 patients with facial scar were treated with skin soft tissue expansion. There were 6 males and 15 females, aged 19-33 years (mean, 24.5 years), including 19 cases of hypertrophic scar and 2 cases of atrophic scar with disease duration of 1-31 years. The scars ranged from 4 cm × 2 cm to 25 cm × 10 cm. The tissue expander was implanted under normal skin adjacent to lesions in the first stage. And the post-expanded skin flap was designed as advance flap or transpositional flap as supplement in the second stage. Fibrous envelope at the base was fixed to the periosteum or fascia nearby first, and then sutures were used between envelopes at the base and on the skin flap or to the dermis of the skin flap to keep the mouth and lower eyelid in proper position. It reduced the tension of incision and maintained the contour of the face and neck. Results After the first stage operation, 2 cases had replaced expanders because of infection and leakage. No complication of infection or hematoma occurred after the second stage operation. The patients were followed up 1-18 months (mean, 10.2 months); of them,12 were followed up more than 1 year. No secondary deformity (deviation of mouth angle, eyebrows pulling, or eyelid ectropion) occurred. The flaps had good appearance and color. The satisfactory results were achieved. Conclusion In skin soft tissue expansion of the face, the fibrous envelopes at the base could reduce the tension of the incision and prevent the deformity of the mouth and lower eyelids.
ObjectiveTo compare the early effectiveness of minimally invasive open reduction and internal fixation via posterior median approach versus arthroscopic double-tunnel suture fixation in treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL).MethodsA clinical data of 31 patients with the tibial avulsion fracture of the PCL and met the criteria between January 2015 and January 2019 was retrospectively analyzed. Nineteen patients (group A) were treated with open reduction and internal fixation with cannulated screw via posterior median approach. The other 12 patients (group B) were treated with arthroscopic double-tunnel suture fixation technique. There was no significant difference between the two groups (P>0.05) in the gender, age, side of effected limb, the injury cause, the time from injury to operation, the combined meniscus injury, Meyers & McKeever classification and preoperative Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and the difference of tibial posterior displacement between bilateral knees. The operation time, postoperative complications, fracture healing, and the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score were recorded.ResultsGroup B spent significantly longer operation time than group A (t=7.347, P=0.000). No postoperative complication occurred in group B, and 1 patient in group A had a screw breakage. All patients were followed up 6-36 months (mean, 22 months). X-ray films showed that all fractures healed at 3 months after operation. At last follow-up, there was no significant difference in the patients with normal knee range of motion between the two groups (P=0.510). At last follow-up, the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score in the two groups were superior to those before operation (P<0.05); while there was no significant difference between the two groups (P>0.05).ConclusionFor the tibial avulsion fracture of PCL, the minimally invasive open reduction and internal fixation and arthroscopic double-tunnel suture fixation can obtain similar early effectiveness. However, arthroscopic surgery has the advantages of being able to simultaneously deal with intra-articular combined injuries, avoiding internal fixator complications, and eliminating the need for secondary operation.
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.
ObjectiveTo investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation.MethodsThe clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients’ preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation.ResultsX-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference (χ2=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences (χ2=3.143, P=0.000; χ2=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation.ConclusionCT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.
【Abstract】 Objective Through a retrospective study, to observe the cl inical therapeutic effect for closed reductiontreatment of developmental dislocation of the hip (DDH), and to dynamically analyze characteristics of acetabular development after closed reduction in DDH. Methods A total of 100 single side DDH children who were treated by “the treatment mode of closed reduction” from January 2002 to December 2005 were followed up, including 18 males and 82 females, with the average age of 19.4 months (ranging from 7 months to 36 months). Sixty-eight patients had left side dislocation, while 32 had right side dislocation. According to Zionts dislocation grades, 15 cases were degree I, 50 degree II, 26 degree III and 9 degree IV. Adductor tenotomies and skeletal traction were carried out in 74 cases, while direct closed reduction was performed in 26 cases. The four-level functional evaluation criterion was used to assess the cl inical therapeutic effect. Lesional and homeochronous normal hips were paired, and acetabular index (AI) and AI (D/W) of lesional and normal hips, before the reduction and in the 3rd, 6th, 9th and 12th month, respectively, after the reduction, were dynamically measured. Results The total choiceness rate of 100 children was 88.00%. Twelve months after the reduction, lesional AI decreased from (37.17 ± 2.17) º to (27.02 ± 3.54) º, while lesional AI(D/W) increased from 22.06% ± 1.65% to 29.80% ± 3.56%, and the differences among each time-point had statistical significance (P lt; 0.01). Both rates of lesional AI decrease and AI(D/W) increase were obviously faster than those of normal side physiological development (P lt; 0.01). In all durations after 12 months reduction, the rates of lesional AI were (3.22 ± 1.42) º and (3.41 ± 2.03) º in 1 - 3 months and 10 - 12 months , respectively, and the rates of AI(D/W) were 2.69% ± 1.83%and 2.33% ± 1.13%, respectively, and they were obviously faster than the other durations (P lt; 0.01). Both rates of lesional AI decrease and AI(D/W) increase were obviously faster than the homeochronous rate of normal side physiological development in each duration (P lt; 0.01). The rates of lesional AI were (13.71 ± 3.96) º and (11.48 ± 4.15) º in 7 - 12 age group and 13 - 18 age group, respectively, and the rates of AI(D/W) were 9.95% ± 3.81% and 8.28% ± 3.58%, respectively, and they wereobviously faster than the other age groups (P lt; 0.05). Both changes of lesional AI and AI(D/W) were obviously faster than the homeochronous changes of normal side in each age group(P lt; 0.01). Conclusion There are simple operating requirements and fine therapeutic effect of “the treatment mode of closed reduction” . Within 12-month after the closed reduction treatment, the rate of lesional acetabular development is obviously faster than that of normal side physiological development. The cresttime of lesional acetabular development is during 1 - 3 months and 10 - 12 months, and the best treatment time of closed reduction is the age before 18 months.
Objective To summarize the characteristics and clinical significance of irreducible Pipkin type Ⅰ and Ⅱ femoral head fracture-dislocations. Methods The clinical data of 4 patients with irreducible Pipkin type Ⅰ and Ⅱ femoral head fracture-dislocations between January 2010 and December 2019 were collected. There were 2 males and 2 females and the age ranged from 24 to 41 years, with an average age of 33.5 years. The cause of injury included traffic accident in 3 cases and falling in 1 case. Pipkin classification was 2 cases of type Ⅰ and 2 cases of type Ⅱ. The time from injury to operation was 1-2 days. The clinical features were that the hip joint of the affected limb was in a locked position, and the passive range of motion was poor. The affected limb was slightly flexed at the hip joint and shortened, in a state of neutral position or slight adduction and internal rotation. The imaging data suggested that the femoral head dislocated backward and upward, and the hard cortex of the posterior edge of the acetabulum was embedded in the cancellous bone of the femoral head, and the two were compressed and incarcerated. Patients of cases 1-3 underwent closed reduction of hip dislocation 1-2 times at 3, 1, and 3 hours after injury respectively, and femoral neck fracture occurred. The injury types changed to Pipkin type Ⅲ, and open reduction and internal fixation were performed. Patient of case 4 did not undergo closed reduction, but underwent open reduction and internal fixation directly. Results Patients of cases 1-3 were followed up 14, 17, and 12 months, respectively. They developed osteonecrosis of the femoral head at 9, 5, and 10 months after operation respectively, and all underwent total hip arthroplasty. Patient of case 4 was followed up 24 months and had no hip pain and limited mobility; the imaging data indicated that the internal fixator position was good and the fracture healed; no collapse or deformation of the femoral head was seen, and no osteonecrosis of the femoral head occurred. Conclusion Clinicians need to improve their understanding of the unique clinical features and imaging findings of irreducible Pipkin type Ⅰ and Ⅱ femoral head fracture-dislocations. It is suggested that open reduction and simultaneous fixation of femoral head fracture should be directly used to reduce the incidence of osteonecrosis of the femoral head.
Objective To investigate the effectiveness of the acetabular reconstruction surgery in children pathological dislocation of the hip joint. Methods Between January 2006 and January 2011, 59 patients (59 hips) with pathological dislocation were treated by open reduction combined with acetabular reconstruction surgery. There were 22 boys and 37 girls, aged from 1 to 15 years (mean, 4.9 years). There were 9 cases of hip subluxation and 50 cases of hip joint dislocation, which were caused by suppurative arthritis of the hip (33 cases) and tuberculosis of the hip (26 cases). The diseases duration ranged from 1 month to 10 years. At preoperation Harris hip score was 43-78 (mean, 61); 14 cases had normal acetabular index (AI), 32 cases had slightly increased AI, and 13 cases had significantly increased AI. The concomitant diseases included acetabular destruction in 28 cases; avascular necrosis of the femoral head in 25 cases, femoral head partial defect in 12 cases, femoral head complete defect in 6 cases, and femoral head and neck defects in 3 cases; 25 cases had increased anteversion angle; and 9 cases had varus deformity. Results Immediately postoperative X-ray films showed center reduction in all the hips. Healing of incision by first intention was achieved in 55 cases, and delayed healing in 4 cases. Fifty-three children were followed up 2 to 5 years (mean, 3 years). No re-dislocation of the hip occurred during follow-up. Thirty-eight cases had normal AI, 15 cases had slightly increased AI. The anteversion angle was 15-25 ° (mean, 20 ° ); the neck shaft angle was 110-140 ° (mean, 125 ° ); and the anatomical relation between the head and neck returned to normal. After 2 years, 18 cases had normal function of the hip joint; 30 cases had mild limitation of flexion and rotation; and 5 cases had fibrous ankylosis. The Harris hip score was 62-95 (mean, 87). Conclusion Pathological dislocation caused by neonatal acute suppurative arthritis of the hip and the hip joint tuberculosis is often associated with severe bone destruction and deformity of the acetabular and femoral head and neck. Treatment should strictly follow the principle of individual. Proper acetabular reconstruction should be selected according to pathological changes of the hip; if combined with the femoral head and neck reconstruction processing, the satisfactory results can be obtained.
Objective To evaluate the effectiveness and safety of external fixation (EF) and open reduction and internal fixation (ORIF) for unstable distal radius fractures in adults. Methods We searched MEDLINE (1966 to September 2008), Cochrane Central register of controlled Trials (The Cochrane Library, Issue 3, 2008), EMbase (1974 to September 2008), CBM, CNKI, and collected randomized controlled trials (RCTs) of EF and ORIF for unstable distal radius fractures in adults. The quality of the included studies was critically assessed and data analyses were performed with the Cochrane Collaboration’s RevMan 5.0 software. Results Seven RCTs involving 634 patients were included, of which 269 were in EF group, and 293 were in ORIF group. Only 1 study had relative high quality, all the others had some limitation in randomization, blinding, and allocation concealment. The results of meta-analyses showed that, 1) about the effectiveness: according to the Gartland and Werley grade standard, the ORIF group was better than the EF group with statistic difference (RR=1.50, 95%CI 1.11 to 2.03, P=0.008); because of the original studies did not offer the detailed data including pad strength, grip strength, flexion-extension, radial deviation, and ulnar deviation, we only processed a descriptive analysis; and 2) about complications: the infection rate of the pin track was higher in the EF group than that in the ORIF group with statistic difference (RR=0.24, 95%CI 0.08 to 0.76, P=0.02); but there were no differences between the two groups in reflex sympathetic dystrophy (RSD) (RR=0.88, 95%CI 0.30 to 2.56, P=0.82), extensor tendon rupture (RR=3.93, 95%CI 0.45 to 34.62, P=0.22), and compartment syndrome (RR=3.13, 95%CI 0.51 to 19.09, P=0.22). Conclusions Compared with EF, ORIF is much better based on Gartland and Werley grade standard, and causes much less infection. Because of the limited quality and quantity of the included studies, more proofs are required from more RCTs with large sample.