[Clinical characteristics and cost-effectiveness of intramedullary nail and plate for the treatment of open tibial fractures]

OBJECTIVE

To analyze clinical characteristics and cost-effectiveness of different final surgical options for treating patients with open tibial fractures.

METHODS

A retrospective analysis was conducted by enrolling 55 surgically treated patients with open tibial fractures from January 2018 to June 2019. All the patients were categorized in intramedullary nailing (IMN) group and locking compression plate(LCP) group according to the final fixation option. There were 35 cases in group IMN including 27 males and 8 females, aged from 25 to 69 years old with an average of (49.0±10.6) years old. Based on Gustilo-Anderson classification, there were 1 case of typeⅠ, 19 cases of typeⅡand 15 cases of type Ⅲ. There were 20 cases in group LCP including 15 males and 5 females, aged from 46 to 72 years old with an average age of (53.4±14.7) years old. Based on Gustilo-Anderson classification, there were 2 cases of typeⅠ, 11 cases of typeⅡand 7 cases of type Ⅲ. Preoperative waiting time, surgical debridement times, intraoperative bleeding loss, blood and albumin transfusion, operation time, bacterial cultures and complications, bone union time, Johner-Wruhs criteria at 1 year after operation and total cost within 1 year after surgery between two groups were compared. The variables recorded between two groups were statistically analyzed and compared respectively, then the factors affecting hospital costs were evaluated by univariate and multiple linear regression analysis respectively, finally the cost-effectiveness analysis was performed.

RESULTS

Total 55 patients were enrolled with an average follow-up time of(16.4±7.1) months ranged from 14 to 27 months postoperatively. There were no significantly statistical differences of the demographic materials between the two groups. The intraoperative bleeding loss were(243.18±118.82) ml and (467.86±490.53) ml respectively in group IMN and LCP, the significantly statistical difference was discovered(P<0.05). The surgical duration were(247.50±57.94) min and(350.00±178.77) min respectively in group IMN and LCP, the significantly statistical difference was discovered(P<0.05). There were no significantly statistical differences of the average days before operation, surgical debridement times, received blood and albumin transfusion, wound cultures, complications and bone union time between the two groups(P>0.05). The univariate analysis of the factors affecting the hospital costs indicated that patients with smoke or alcohol (P=0.042), high energy damage (P=0.012), patients with comorbidity diseases(P=0.045), surgical debridement over 2 times (P=0.001), intraoperative bleeding loss over 400 ml (P<0.001), blood and albumin transfusion (P=0.027), wound cultures (P=0.000) and complications (P=0.035) were the factors. The multiple linear regression analysis demonstrated the smoke or alcohol using[β=-0.256, t=-2.628, 95%CI(-29 667.09, -4 997.47), P=0.014] was the only factor affecting the total cost. The excellent and good rate were 80% and 85% respectively based on the Johner-Wruhs criteria. The average total cost within 1 year after surgery was (136 435.90±39 093.98) CNY in group IMN and (140 034.62±56 821.12) CNY in group LCP. The total surgical duration and total intraoperative bleeding loss were significant lower in group IMN than in group LCP. The average total costs of was significantly higher. The average cost for every 1% of excellent and good rate was 1 705.45 CNY in group IMN and 1 647.46 CNY in group LCP. Each 1% increasing of excellent and good rate cost 719.74 CNY more in group LCP compared with group IMN.

CONCLUSION

Both IMN and LCP could provide a satisfactory outcome for open tibial fractures. Meanwhile considering the total cost, patients with smoke or alcohol history, traffic accident, comorbidity diseases, surgical debridement over 2 times, intraoperative bleeding loss over 400 ml, and complications should not be ignored.

[Efficacy of percutaneous short segment fixation in the treatment of Magerl A3 thoracolumbar fractures with low bone mineral density:a retrospective study]

OBJECTIVE

To explore the clinical efficacy of percutaneous pedicle screw short segment internal fixation with or without the intermediate screw in the treatment of Magerl A3 thoracolumbar fractures with low bone mineral density.

METHODS

Patients with Magerl A3 thoracolumbar fracture underwent percutaneous pedicle screw short segment internal fixation from January 2017 to July 2020 were retrospectively analyzed, 93 cases met the diagnosis and inclusion criteria, 9 cases were excluded according to the exclusion criteria, and the remaining 84 cases obtained complete imaging follow-up data. There were 38 males and 46 females, the age ranged from 56 to 73 years old with an average of (64.78±7.12) years old, bone mineral density (BMD) ranged from 0.61 to 0.89 g/cm³ with an average of (0.73±0.14) g/cm³, the follow-up time was 11 to 25 months with an average of (17.58±6.12) months. There were 45 cases in group A with intermediate screw and 39 cases in group B without intermediate screw. The operation time and intraoperative blood loss were recorded, Oswestry Disability Index (ODI) and visual analogue scale (VAS) were used for clinical evaluation. The Cobb angle, vertebral wedge angle (VWA) and anterior vertebral body height (AVBH) were measured by X-ray after the operation. The corrected loss of the above parameters was calculated.

RESULTS

There were 5 cases of screw loosening in 84 patients (2 cases in group A and 3 cases in group B, P>0.05). There were significant differences in operation time and intraoperative blood loss between two groups(P<0.01). Clinical effects of two groups were good, postoperative VAS and ODI after operation obviously improved, there was no significant difference between two groups during all follow-up periods (3 days, 1 month after operation and the final follow-up) (P>0.05). Three days after the operation, the image evaluations (Cobb angle, VWA and AVBH) were significantly improved (P<0.05), but significant reduction loss was observed in both groups at 1 month after the operation and at the final follow-up (P<0.05). At the final follow-up, the loss of Cobb angle, VWA and AVBH in group A were (5.26±4.18) °, (4.63±3.80) ° and (9.54±8.71)%, respectively;group B was (6.01±4.34) °, (6.55±6.21) ° and (11.67± 9.95)%, respectively;however, there was no significant difference in reduction loss between the two groups(P>0.05).

CONCLUSION

Although the curative effect of the patients is satisfactory, the stability of the patients can not be improved by increasing the middle injured vertebra screw placement, the two groups of percutaneous short segment internal fixation can not resist the reduction loss of Magerl-A3 thoracolumbar fracture with low bone mineral density. Because the injured vertebra screw increases the operation time and intraoperative blood loss, it is not significant to use the intermediate screw for the elderly Magerl A3 thoracolumbar fractures with low bone mineral density.

[Effect analysis of trajectory screw technique in fragility fracture of pelvic ring]

OBJECTIVE

To assess the clinical efficacy of minimally invasive technology with trajectory screw fixation for fragility fractures of pelvic(FFP).

METHODS

A retrospective case control study was performed to analyze the clinical data of 35 patients with FFP who were treated and followed up between January 2016 and December 2019. There were 12 males and 23 females, aged from 65 to 99 years with an average of(75.4±7.8) years old. There were 13 cases of type Ⅱb, 7 cases of type Ⅱc, 8 cases of type Ⅲa, 2 cases of type Ⅲb, 2 cases of type Ⅲc, 1 case of type Ⅳb, and 2 cases of type Ⅳc according to Rommens FFP comprehensive classification. All patients received the treatment of minimally invasive technology with trajectory screws fixation. According to the different methods of anterior pelvic ring fixation, FFP patients were divided into two groups:12 cases were fixed with the pedicle screw rod system in the anterior pelvic subcutaneous internal fixator (INFIX) group;23 cases were fixed with hollow screws of the pubic symphysis, superior ramus of pubis or acetabular anterior column in the screw group. The operation time, intraoperative blood loss, intraoperative fluoroscopy times, length of hospital stay, cost of internal fixation, pre- and post-operative visual analogue scale(VAS) were compared between the two groups. The fracture reduction quality was evaluated according to the Matta criteria, and the clinical function was evaluated by the Majeed functional scoring system respectively.

RESULTS

All patients were followed up for 12 to 39(16.5±5.4) months after surgery. There was no statistically significant difference in the operation time, intraoperative blood loss, intraoperative fluoroscopy time, and length of hospital stay between the two groups(P>0.05). As for the cost of internal fixation, the cost of internal fixation in the screw group [2 914 (2 914, 4 371) yuan] was significantly lower than that of the INFIX group [6 205 (6 205, 6 205) yuan] (P<0.05). No significant difference was observed in the incidence of postoperative complications between the two groups (P>0.05). There was no significant difference in VAS assessment at admission, 1 week, and 3 months after surgery between the two groups(P>0.05). However, the VAS assessment at 1 week and 3 months after surgery of the two groups were significantly better than those at admission(P<0.05). There was no significant difference in the quality of fracture reduction after the operation and the efficacy evaluation at the last follow-up between the two groups(P>0.05).

CONCLUSION

For the treatment of fragility fractures, minimally invasive technology with trajectory screw fixation can achieve good clinical efficacy. It has the advantages of being relatively minimally invasive, less bleeding, relieving the pain. It deserves clinical application.

[Femoral head necrosis rate and risk factors after internal fixation of femoral neck fracture:a Meta-analysis]

OBJECTIVE

To study the incidence and risk factors of osteonecrosis of the femoral head (ONFH) after internal fixation in adult patients with femoral neck fracture (FNF) after 2000, and identify high-risk population of ONFH.

METHODS

PubMed, Medline, The Cochrane Library, CNKI, Wanfang and VIP Database were searched to collect all the literatures on ONFH and related risk factors after internal fixation of FNF from January 1th 2000 to July 1th 2020. Study extraction was performed according to inclusion and exclusion criteria. Endnote X9 and Excel 2019 were used for literatures extraction, management and data entry, and R Studio 3.6.5 software was used for Meta-analysis. Subgroup analysis, sensitivity analysis and publication bias detection were used to explore the sources of heterogeneity and the reliability of the evaluation results.

RESULTS

A total of 16 studies with 5521 patients were included. Meta-analysis showed that the incidence of ONFH after internal fixation for adult FNF was 14.5% [95% CI(0.126-0.165)]. Fracture displacement[OR=0.27, 95%CI(0.21-0.35)] and reduction quality [OR=0.15, 95%CI(0.09-0.27)] were related risk factors for ONFH. The results of subgroup rate analysis showed that the non-displaced fracture necrosis rate was 6.2%[95%CI(0.051-0.077)] and the displaced fracture necrosis rate was 20.4% [95%CI(0.166-0.249)];the good reduction fracture necrosis rate was 8.3%[95%CI(0.072-0.095)] and the poor reduction fracture necrosis rate was 35.5%[95%CI(0.233-0.500)]. The included literatures have good consistency and no publication bias.

CONCLUSION

After 2000, the total incidence of ONFH after internal fixation of adult FNF has decreased, while the necrosis rates of patients with displaced fracture and poor reduction are still at a high level. The interval between injury and surgery was not analyzed in this study because of the inconstant division in the original literature.

[Fixation of anterior pelvic ring fracture with long reconstruction plate combined with MIPPO technique]

OBJECTIVE

To evaluate the efficacy of long reconstruction plate combined with minimally invasive percutaneous plate osteosynthesis(MIPPO) technique in the treatment of unstable pelvic anterior ring fractures.

METHODS

From January 2013 to February 2019, 16 patients with unstable pelvic fracture were treated, including 12 males and 4 females, aged from 20 to 60 years(mean 46.5 years). According to Tile classification, there were 4 cases of type B1, 6 cases of type B2, 4 cases of type C1 and 2 cases of type C2. The fracture of all patients was closed, and the time from injury to operation was 7 to 10 days with an average of 6.2 days. The operation time, intraoperative blood loss, fracture reduction quality, fracture healing time, complications and limb function during the final follow-up were evaluated in 16 patients.

RESULTS

All 16 patients were followed up for 12 to 23 months (mean 19.1 months). The operation time was 60 to 180 min (mean 107.8 min). The intraoperative blood loss was 120 to 600 ml (mean 368.1 ml). The fracture healing time was 12 to 20 weeks (mean 16.3 weeks). According to Matta criteria, the fracture reduction was excellent in 6 cases, good in 8 cases and fair in 2 cases. One patient suffered from lateral femoral cutaneous nerve injury during the operation, and the lateral thigh sensation decreased after operation, which recovered after 6 months. One patient had pain stimulated by internal fixation at the iliac fossa. The symptoms were improved after the internal fixation was removed. The fractures of 16 patients were healed satisfactorily and there was no internal fixation loosening. Majeed score at the final follow-up was 67 to 95, excellent in 10 cases, good in 4 cases and fair in 2 cases.

CONCLUSION

Closed reduction and fixation of pelvic anterior ring fracture with long reconstruction plate combined with MIPPO technique through anterior approach has the advantages of less injury, less bleeding time during operation, saving operation time, high intraoperative safety, high fracture healing rate, early functional exercise after operation, and effective treatment of pelvic anterior ring fracture.

[Treatment of abduction and insertion femoral neck fracture with closed reduction technique]

OBJECTIVE

To explore feasibility of closed reduction technique under monitoring of C-arm and three screws in the fixation of abduction and insertion femoral neck fracture.

METHODS

Seventeen patients with abduction and insertion femoral neck fracture operated from January 2014 to December 2019 were analyzed retrospectively, including 10 males and 7 females, aged from 21 to 59(42.09±7.30) years old. According to preoperative X-ray and CT data, angle of retroversion and abduction displacement of femoral head were determined. Two 2 mm diameter Kirschner wires crossed and gently knocked into the bone of the acetabular roof from outside and front of femoral head. The proximal fracture segment was fixed on the acetabulum. Under the monitoring of C-arm, lower limb (distal fracture segment) was gradually rotated inward and retracted against direction of fracture displacement, three cannulated screws were used for internal fixation after anatomical reduction of the distal fracture end and the proximal fracture end. Garden index was evaluated, postoperative complications were observed, and Harris functional score was performed.

RESULTS

All 17 cases of femoral neck fracture with abduction and insertion were successfully completed closed reduction and internal fixation. The operation time was 36 to 68(43.87±7.63) min and intraoperative bleeding was 15 to 50(28.36±5.93) ml. The quality of fracture reduction was evaluated by garden index during operation. There were 12 cases of anatomical reduction, 5 cases of acceptable reduction, and no cases of unsuccessful reduction were changed to open reduction. 17 cases were followed up for 3 to 41(27.5±8.4) months. There were no complications such as femoral head necrosis, fracture nonunion, hip impingement and femoral neck shortening. MR examination showed no femoral head necrosis and articular cartilage injury. Two years after operation, Harris score of hip joint was excellent in 13 cases and good in 4 cases.

CONCLUSION

Closed reduction and three screws internal fixation can obtain good anatomical reduction rate and therapeutic effect in the treatment of abduction and insertion femoral neck fracture.

[Treatment of comminuted fracture of inferior pole of patella with locking suspension and vertical fixation with three steel wires]

OBJECTIVE

To explore the clinical application of lockedge suspension combined with three steel wires vertical fixation in comminuted fracture of inferior pole of patella.

METHODS

From August 2016 to May 2019, 23 patients with comminuted fracture of the lower pole of the patella, including 14 males and 9 females, were treated with lockedge suspension combined with three steel wires vertical fixation. The age ranged from 34 to 68 (55.0±1.2) years. One year after operation, the pain and function were evaluated by pain visual analogue scale(VAS) and knee flexion and extension range of motion, and the clinical efficacy was evaluated by Lysholm knee score standard.

RESULTS

All 23 patients were followed up for 12 to 14, with a mean of(13.0±0.5) months. One patient had skin irritation by the tail of the steel wire, and the rest had no postoperative complications such as incision infection, internal fixation loosening and fracture displacement. The fractures of 23 patients were healed, and the healing time was 10 to 14 weeks with a mean of(12.0±1.1) weeks. The VAS score decreased from 7.96±0.93 before operation to 0.83±0.65 one year after operation. The range of knee flexion and extension activities increased from(20.30±8.69) ° before operation to 1 year after operation(127.39±6.55) °. Lysholm knee score increased from 18.48±4.00 before operation to 96.09±4.91 one year after operation(P<0.05).

CONCLUSION

The treatment of comminuted fracture of the lower pole of patella by lockedge suspension combined with three steel wires vertical fixation has reliable fixation and high fracture healing rate. It can meet the requirements of rapid rehabilitation and functional exercise, and the early clinical effect is satisfactory.

[Comparison of functional recovery of distal radius fracture by suture of pronator muscle through modified Henry approach]

OBJECTIVE

To investigate the effect of suture of pronator muscle on forearm function after modified Henry approach for distal radius fractures.

METHODS

from January 2018 to December 2020, 220 patients with distal radius fractures were treated with open reduction and locking plate internal fixation through the modified Henry approach. They were divided into two groups according to different suture methods. There were 112 cases in the intraoperative suture group, including 35 males and 77 females;The age ranged from 37 to 65(48.5±7.4) years;AO classification of fracture, 46 cases of type B and 66 cases of type C;After fracture reduction and locking plate fixation, the pronator muscle was opened and sutured. There were 108 cases in the non suture group, 32 males and 76 females;The age ranged from 34 to 67(47.6±7.8) years;There were 41 cases of fracture type B and 67 cases of fracture type C;After fracture reduction and locking plate fixation, the open pronator muscle was not sutured, and it was laid on the surface of the plate in situ. The range of wrist motion (pronation, supination, palmar inclination and dorsiflexion), the score of disability of arm shoulder and hand dash and visual analog scale(VAS) were compared between the two groups at 6 weeks and 6 months after operation.

RESULTS

All 220 patients were followed up for 6 to 18 (8.5±1.3) months. There was no significant difference in the range of motion and DASH score of forearm and wrist between the two groups 6 weeks after operation (P>0.05);There was significant difference in VAS score between suture group (2.6±1.2) and non suture group (5.8±2.3)(P<0.05). Six months after operation, there was no significant difference in the range of motion, DASH score and VAS score of forearm and wrist between the two groups(P>0.05).

CONCLUSION

The modified Henry approach has no obvious advantages in the range of wrist movement and upper limb function, but the intraoperative suture of pronator can reduce the early postoperative pain. It is suggested that the pronator should be sutured during the operation.

Primary stability of cement augmentation in locking plate fixation for proximal humeral fractures: A comparison of absorbable versus non-absorbable cement

BACKGROUND

Cement augmentation has been suggested to increase the stability of screw anchoring in osteoporotic humeral fractures. Initial results are promising but may be jeopardized by cement leakage into the joint and difficult implant removal. Absorbable cement might have advantages in this regard, but it is unclear if the primary stability of both techniques is equivalent to each other. Therefore, this study aimed to compare its primary stability with that of non-absorbable cement augmentation.

METHODS

Nineteen cadaveric humeri with two-part fracture models were treated with locking plate osteosynthesis and cement augmentation using either absorbable calcium phosphate cement (group 1) or polymethylmethacrylate (group 2). Fracture movement, stiffness, failure mode, and ultimate load under cyclic compressive loading were examined and compared between the groups.

FINDINGS

The absolute and relative stiffness values in group 1 were significantly smaller than those in group 2 after 50 cycles (group 1: 114 ± 38 N/mm and 94 ± 8% vs. group 2: 188 ± 71 N/mm and 106 ± 9%; p₅₀ = 0.022), 2000 cycles (group 1: 97 ± 34 N/mm and 81 ± 15% vs. group 2: 153 ± 47 N/mm and 88 ± 15%; p₂₀₀₀ = 0.028), and 5000 cycles (group 1: 98 ± 40 N/mm and 81 ± 22% vs. group 2: 158 ± 40 N/mm and 92 ± 16%; p₅₀₀₀ = 0.028). The failure load was not statistically significantly different between the groups.

INTERPRETATION

Although the PMAA group showed higher values for absolute and relative stiffness, no statistically significant difference was found in the primary stability between absorbable and non-absorbable cement augmentation supporting plate osteosynthesis in proximal humeral fractures. In view of the potential advantages of bio-absorbable cement during the healing process, its use should be considered for the augmentation and stabilization of osteoporotic fractures.

ISOLATED CAPITELLAR FRACTURE FIXATION WITH HEADLESS SCREWS IN DIFFERENT CONFIGURATIONS

Introduction

We evaluated the clinical and radiological outcomes of capitellar fractures treated with modified screw insertion (inserting the first fixation screw anteroposteriorly and the second screw posteroanteriorly), a technique that can be applied with a minimally invasive lateral elbow approach.

Materials and Methods

Twenty-one isolated capitellum fractures that were surgically treated were included in the study. Fixation was achieved with two headless cannulated compression screws placed in anteroposterior and posteroanterior order using the modified lateral elbow approach. The Broberg-Morrey rating system was used to assess the post-operative functional status of the patients.

Results

According to the Broberg-Morrey criteria, the mean score was 92.7 (77-100) and 13 cases had excellent, 7 had good, and 1 had fair results. None of the patients developed avascular necrosis or heterotopic ossification. According to the Broberg-Morrey arthrosis score, two cases had Grade 1 and one had Grade 2 arthrosis. One patient had a superficial wound site infection that was treated with antibiotics, and in one case a 60° extension loss was observed in the elbow.

Conclusion

Treatment of isolated capitellar fractures with 2 headless screws placed anteroposteriorly and posteroanteriorly can provide stable fixation and is less traumatic for the elbow joint. Level of Evidence IV; Therapeutic Studies - Investigating the results of treatment.

[A case-control study of two internal fixation methods in the treatment of comminuted fracture of inferior pole of patella]

OBJECTIVE

To compare the effects of tension band combined with patellar cerclage and memory alloy patellar concentrator fixation in the treatment of comminuted fracture of the lower pole of patella.

METHODS

From July 2015 to July 2019, 60 patients with distal patellar fracture were treated and were divided into two groups according to different operation methods. In group A, 30 patients were fixed with memory alloy patellar concentrator (NiTi PC), 17 males and 13 females, aged 20 to 71 (39.4±9.9) years, including 19 cases of falling injury, 9 cases of traffic injury and 2 cases of sports injury. The time from injury to operation was 10 to 75 (33.1±7.8) hours; 30 cases in group B were fixed with tension band andcerclage, 15 males and 15 females, aged 21 to 76 (38.6±10.2) years, including 17 cases of falling injury, 12 cases of traffic injury and 1 case of smashing injury. The time from injury to operation was 10 to 91 (34.5±9.1) hours. The curative effects of two groups were observed and compared.

RESULTS

All 60 patients were followed up for 9 to 30 months. There was no significant difference in intraoperative bleeding, operation time, follow-up time and fracture healing time between the two groups. Six months after operation, according to the Bostman function score of knee joint:30 cases in group A, the total score was 28.6±4.7, of which 26 cases were excellent and 4 cases were good. The total score of 30 cases in group B was 25.5±4.4, of which 20 cases were excellent, 8 cases were good and 2 cases were poor. There were significant differences in Bostman total score and curative effect evaluation between two groups (P<0.05). The score of group A was significantly better than that of group B. In group B, 1 case had Kirschner wire withdrawal, 2 cases had joint stiffness and 3 cases had internal fixation irritation.

CONCLUSION

Memory alloy patellar concentrator is strong and reliable in the treatment of inferior patellar fracture. It can take early rehabilitation exercise after operation, with good recovery of joint function and range of motion and less complications.

[Comparative study of femoral head replacement and internal fixation in the treatment of unstable intertrochanteric fractures in the elderly]

OBJECTIVE

To compare the clinical efficacy of femoral head replacement and internal fixation in the treatment of unstable intertrochanteric fractures in the elderly.

METHODS

Retrospective analysis of 70 cases of unstable intertrochanteric fractures treated from January 2016 to January 2019 and meeting the inclusion and exclusion criteria, 39 cases were fixed with closed reduction and new proximal femoral intramedullary nail(InterTAN), and 31 cases were treated with open trochanter reconstruction and artificial femoral head replacement. The operation time, intraoperative bleeding, hospital stay, weight bearing time, postoperative complication rate and hip function recovery (Harris score) were compared between two groups.

RESULTS

All cases were followed up for 12 to 24 months. There were no significant differences in intraoperative bleeding and hospital stay between the two groups (P>0.05). The operation time in replacement group was longer than that in internal fixation group (P< 0.05). The postoperative weight-bearing time in replacement group was significantly earlier than that in internal fixation group (P<0.05). In the replacement group, there were 1 case of pulmonary infection, 1 case of deep venous thrombosis and 1 case of periprosthetic fracture;in the internal fixation group, there were 4 cases of pulmonary infection, 3 cases of internal fixation failure, 3 cases of cerebral infarction and 2 cases of urinary infection;there was significant difference between two groups (P< 0.05). The Harris score in replacement group was higher than that in internal fixation group one month after operation (P< 0.05), but there was no significant difference between two groups at 12 months after operation(P>0.05).

CONCLUSION

InterTAN and femoral head replacement can treat unstable intertrochanteric fractures in the elderly, but femoral head replacement can move down early, improve the quality of life at the end of life, reduce postoperative complications and facilitate the treatment of coexisting diseases in internal medicine.

[Correlation between metabolic syndrome and adverse events after internal fixation of femoral intertrochanteric fracture in the elderly]

OBJECTIVE

To explore the effect of metabolic syndrome on 15 days postoperative adverse events of femoral intertrochanteric fractures with internal fixation.

METHODS

From January 2011 to June 2019, 986 elderly patients with intertrochanteric fracture were treated with internal fixation, including 312 males and 674 females, with an average age of(77.71± 7.58) years old. And there were 97 patients with metabolic syndrome and 889 patients without metabolic syndrome. Through the electronic medical record system, the patient's age, gender, fracture type, cause of trauma, body mass index, smoking history, preoperative comorbidities, preoperative bloodtransfusion, operation timing, ASA classification, anesthesia method, internal fixation type, operation duration, and 15 days postoperative adverse events, which include surgical site infection, acute heart failure, acute respiratory failure, pulmonary infection, acute renal failure, DVT, embolism in important organs, urinary tract infection, death, and blood transfusion after surgery were collected. The differences of preoperative and intraoperative baseline datas and 15 days postoperative adverse events between the two groups were compared and analyzed by t text or univariate χ² test. Adjusted for the preoperative and intraoperative mixed factors with P<0.05, and 15 days postoperative adverse events with P<0.05 were then analyzed by multivariate unconditional Logistic regression analysis to further study the independent effects of metabolic syndrome on 15 days postoperative adverse events.

RESULTS

There were statistical differences in age, body mass index, history of cardiac insufficiency, history of COPD, history of renal insufficiency, operation timing, ASA classification, operation duration, surgical site infection, acute heart failure, DVT, urinary tract infection and blood transfusion between two groups (P<0.05). Adjusted for the preoperative and intraoperative mixed factors, multivariate unconditional logistic regression analysis showed that metabolic syndrome could increase the infection rate of the surgical site [OR=3.785, 95%CI (1.086-13.188), P= 0.037], DVT incidence rate[OR=2.265, 95%CI(1.096-4.682), P=0.027], urinary tract infection rate[OR=2.703, 95%CI (1.049-6.963), P=0.0390], and blood transfusion rate [OR=1.811, 95%CI (1.142-2.870), P=0.012].

CONCLUSION

Elderly patients with intertrochanteric fracture with metabolic syndrome had higher postoperative surgical site infection rate, DVT incidence rate, urinary tract infection rate, and postoperative blood transfusion rate. Therefore, the orthopedic treatment team should give more attentionand optimize the treatment plan during the perioperative period with the cooperation of internal physician and anesthesiologist.

[Influence of degenerative scoliosis on the treatment of lumbar spinal stenosis by MIS-TLIF]

OBJECTIVE

To evaluate the effect of degenerative scoliosis on the difficulty and efficacy of minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF) in the treatment of lumbar spinal stenosis.

METHODS

From September 2016 to September 2019, 52 patients with lumbar spinal stenosis treated by MIS-TLIF were retrospectively analyzed, including 16 males and 36 females, aged from 42 to 71(63.44±5.96) years old, the course of disease from 1.5 to 6.5 years, with an average of (3.69±1.10) years. All patients had lower extremity root pain or numbness, 41 patients had intermittent claudication. There were 31 cases of L_{4, 5} and 21 cases of L₅S₁. There were 18 cases in scoliosis group, lumbar spinal stenosis combined withdegenerative scoliosis, and 34 cases in stenosis group, lumbar spinal stenosis alone. The perioperative data and postoperative complications were recorded, the postoperative interbody fusion was evaluated by CT, and the clinical outcomes were evaluated by VAS score, Oswestry Disability Index (ODI).

RESULTS

All patients were followed up for 12 to 36 months, with an average of (19.58±5.33) months. The operation time and intraoperative bleeding in stenosis group were better than those in scoliosis group (P<0.05). There were no significant differences in postoperative drainage volume, postoperative Hb, CRP, postoperative landing time, discharge time, VAS score at discharge and follow-up, ODI score at 3 months and follow up, postoperative complications and interbody fusion rate between two groups (P>0.05).

CONCLUSION

For patients with lumbar spinal stenosis undergoing MIS-TLIF, degenerative scoliosis can lead to prolonged operation time and increased bleeding. However, it has no significant effect on therelief of postoperative symptoms, postoperative complications and the recovery of lumbar function.

Accurate Placement of Cannulated Screws in Femoral Neck Fractures: Screw and Guide Wire Combined Technique

Cannulated screw fixation is widely used in the treatment of femoral neck fractures. During surgery, we often face the situation that a guide wire needs to be adjusted because of poor positioning in the femoral neck. It is difficult to adjust the direction of the guide wire in the neck of the femur due to its elasticity. This study developed a practical technique to adjust the guide wire to the correct position. When the direction of insertion of the guide wire has deviated, first, measure the length of the guide wire. Second, select the appropriate cannulated screw based on the measurement, and screw the cannulated screw in along the direction of the guide wire to Ward's triangle. Then return the guide wire to the front of the cannulated screw. At this time, the cannulated screw can be used as a built‐in guide, and a screwdriver can be used to fine‐tune the position of the screw to the optimal direction under the X‐ray guidance. Finally, the cannulated screw is screwed in in this direction until it passes through the Ward triangle area, and the guide wire is inserted. This technique can help doctors insert a guide wire more quickly and accurately, reducing intraoperative injury and the operation time.

[Comparative study on curative effect of minimally invasive locking plate for the treatment of intra-articular calcaneal fractures via sinus tarsi approach]

OBJECTIVE

To compare clinical efficacy of minimally invasive locking plate and anatomic locking plate in treating intra-articular calcaneal fractures via sinus tarsi approach.

METHODS

A retrospective analysis was conducted of 48 patients with intra-articular calcaneal fractures treated with surgery via sinus tarsi approach from July 2016 to June 2017. According to differernt methods of internal fixation, the patients were divided into minimally invasive locking plate group and anatomic locking plate group. In minimally invasive locking plate group, there were 14 males and 10 females, aged from 27 to 46 years old with an average age of (38.70±5.58) years old, 18 patients were typeⅡand 6 patients were type Ⅲ according to Sanders classification. In anatomic locking plate group, there were 17 males and 7 females, aged from 26 to 46 years old with an average age of (37.10±6.44) years old, 16 patients were typeⅡ and 8 patients were type Ⅲ according to Sanders classification. Operative time, visual analogue scale (VAS), postoperative complications between two groups were compared, and Böhler angle, Gissane angal, calcaneal width and height were recorded and compared between two groups at 1 week after operation and final follow up. The functional effect was assessed according to Maryland foot function score at final follow up.

RESULTS

All patients were followed up for (14.10±1.94) months (ranged 12 to 18 months). All patients were obtained bone union from 8 to 16 weeks with an average of (10.60±2.25) weeks. Operation time, VAS score and complication rate in minimally invasive locking plate group were (69.50±7.51) min, (2.80±1.07) and 2 cases respectively, and (77.50±7.15) min, (3.80±1.09) and 8 cases in anatomic locking plate group respectively, there were statistical difference between two groups (P<0.05). However, there were no statistically differences in Maryland foot function score, Böhler angle, Gissane angle, calcaneal width and height at 1 week after opertaion and final follow-up between two groups (P>0.05).

CONCLUSION

Compare with anatomic locking plate, minimally invasive locking plate via sinus tarsi approach for Sanders typeⅡ and Ⅲ intra-articular calcaneal fractures could obtain similar reliable fixation and functional recovery with more simple operation, shorter operative time, lighter postoperative pain and less complications.

[Case control study on the application of artificial bone and autogenous bone in internal fixation of complex calcaneal fracture with special-shaped plate]

OBJECTIVE

To compare clinical effects of artificial bone and autogenous bone in internal fixation of complex calcaneal fracture with profitated plate.

METHODS

From April 2015 to April 2019, 60 patients with complex calcaneal fractures were treated with open reduction and heteromorphic plate internal fixation, and were divided into experiment group and control group by implant bone substitutes, and 30 patients in each group. In experiment group, there were 21 males and 9 females aged from 18 to 71 years old with an average of (36.85±7.42) years old;19 patients were classified to type Ⅲ and 11 patients were type Ⅳ according to Sanders classification;implanted with artificial bone. While in control group, there were 23 males and 7 females aged from 20 to69 years old with an average of (37.26±7.38) years old;18 patients were classified to type Ⅲ and 12 patients were type Ⅳ according to Sanders classification; implanted with autogenous bone. Operation time, intraoperative blood loss, drying time of incision, fracture healing time and complications were compared between two groups, changes of preoperative and postoperative Böhler angle and Gissane angle were also compared, and Maryland scoring was applied to evaluate recovery of affected foot.

RESULTS

Both of two groups were followed up from 3 to 15 months with an average of (10.15±2.67) months. Operation time and intraoperative blood loss in experiment group were (89.32±12.43) min, (101.64±5.13) ml, respectively;while in control group were (112.45±13.82) min, (119.01±5.26) ml, respectively;and there were statistical difference between two groups (P<0.05). There were no differences in drying time of incision, fracture healing time and complications between two groups(P>0.05). Preoperative and postoperative Böhler angle at 3 months in experiment group were (14.19± 2.47)°, (34.52±4.41)°;while in control group were (14.08±2.35)°, (33.67±4.36)°;preoperative and postoperative Gissane angel at 3 months in experiment group were (90.16±6.43)°, (131.45±9.83)°;while in control group were (90.11±6.37)°, (130.87±9.24)°;there were statistical significance in Böhler angle and Gissane angel compared with 3 months after operation and before operation between two groups (P<0.05);while no difference at 3 months after operation between two groups (P> 0.05). There were no statistical meaning in Maryland items, total score and good rate between two groups at the final following up (P>0.05).

CONCLUSION

Artificial bone and autogenous bone in internal fixation of complex calcaneal fracture with irregular plate have similar function in promoting fracture healing, drying time of incision, fracture healing time and complications, while artificial bone has better effects in reducing intraoperative blood loss, shorten operation time.

[Intraoperative arthrography monitoring assisted closed reduction and internal fixation for intercondylar fracture of humerus in children]

OBJECTIVE

To investigate clinical effects of intraoperative arthrography monitoring assisted closed reduction and internal fixation for intercondylar fracture of humerus in children.

METHODS

From January 2013 to July 2018, 18 children with intercondylar fracture of humerus were treated by operation, including 13 males and 5 females aged from 3 to 12 years old with an average age of (8.50±2.57) years old. According to Toniolo & Wilkinson classification, 8 children were typeⅠand 10 children were typeⅡ. During the operation, closed reduction and internal fixation were performed under the monitoring of intraoperative radiography, open reduction and internal fixation were performed in necessity. Mayo score of elbow joint was used to evaluate clinical effect at 6 months after operation.

RESULTS

All children were underwent arthrography monitoring during operation, 5 children were treated with closed reduction and internal fixation for intraoperative arthrography found no fracture of articular cartilage, 11 children by closed reduction and internal fixation because of fracture of articular cartilage involving the joint space with displacement less than 2 mm, and 2 children by closed or open reduction and internal fixation for fracture of articular cartilage surface with displacement above 2 mm, which 1 child with smooth of joint surface was performed closed reduction and internal fixation, 1 child without smooth of joint surface and displacement above 2 mm was performed open reduction and internal fixation. All children were followed up from 8 to 26 months with an average of (20.28±4.40) months. All factures were healed from 6 to 9 weeks with an average of (7.33±0.77) weeks. Postoperative Mayo score of elbowjoint at 6 months was (89.44±11.36), and 12 patients got excellent results, 5 good and 1 poor. One patient occurred partial limitation of flexion or extension of elbow joint. No elbow deformity and other complications occurred.

CONCLUSION

The treatment of intercondylar fracture of humerus in children under monitoring of intraoperative radiography could reduce opertaion injuries and complications, confirm the reduction effect of articular surface of cartilage in time and clearly, and promote recovery of elbow joint function.

[Short-segment pedicle screw fixation combined with vertebroplasty for the treatment of Kümmell disease with kyphosis]

OBJECTIVE

To explore the clinical effects of posterior short-segment pedicle screw internal fixation combined with vertebroplasty for the treatment of Kümmell disease with kyphosis.

METHODS

Twenty-four patients with Kümmell disease complicated with kyphosis treated by posterior short-segment pedicle screw internal fixation combined with vertebroplasty from January 2016 to December 2018 were retrospectively analyzed, including 6 males and 18 females, aged 63 to 85 (73.1±6.5) years old. The clinical effect was evaluate by visual analogue scale (VAS), Oswestry Disability Index (ODI), the anterior height of injured vertebral body, and the sagittal Cobb angle of the affected segment beforeoperation, at 3 days and final follow up after operation. And the surgical complications were observed.

RESULTS

All 24 patients were followed up from 12 to 24 months with an average of (15.5±3.2) months. The VAS score was decreased from 5.21±1.06 preoperatively to 2.38±0.58 at 3 days postoperatively and 1.71±0.75 at final follow-up;ODI was decreased from (50.4±13.5)% preoperatively to (20.9±8.0)% at 3 days postoperatively and (16.7±9.6)% at final follow-up;the anterior height of injured vertebral body was restored from (8.0±4.2) mm before surgery to (18.1±5.0) mm at 3 days after surgery and (16.8±5.1) mm at final follow up;the sagittal Cobb angle of affected segment was decreased from (19.5±6.3)° preoperatively to (7.6±2.1)° at 3 days after surgery and(8.4±1.7)° at final follow-up. VAS, ODI, anterior height of injured vertebral body, and sagittal Cobb angle of affected segment were significantly improved at 3 days after operation and at final follow-up (P<0.05). Two patients had complications, including asymptomaticcement leakage in 1 patient and superficial wound infection in 1 patient.

CONCLUSION

Posterior short-segment pedicle screw internal fixation combined with vertebroplasty for the treatment of Kümmell disease with kyphosis has relatively small surgical trauma, excellent clinical results, good vertebral height recovery, satisfactory correction of kyphotic angle, and fewer complications, etc. It is a safe and effective surgical method to treat Kümmell disease with kyphosis.

[Case control study on T-plate combined with suture anchors for the treatment of Neer Ⅱb clavicle fractures]

OBJECTIVE

To compare the clinical efficacy of distal radius T-plate combined with suture anchor and distal clavicle anatomical locking plate combined with suture anchor in the treatment of Neer Ⅱb distal clavicle fracture.

METHODS

From June 2014 to June 2018, 42 patients with Neer Ⅱb distal clavicle fractures were retrospectively analyzed. According to different surgical methods, they were divided into the observation group (T-shaped plate combined with suture anchor) and the control group (anatomical locking plate combined with suture anchor). There were 22 patients in the observation group and 20 patients in the control group. In the observation group, there were 13 males and 9 females, aged from 22 to 70 (45.78± 14.44) years old, 12 cases on the left side and 10 cases on the right side, 8 cases of traffic accident injury and 14 cases of fall. In the control group, there were 12 males and 8 females, aged from 24 to 66 (44.17±15.58) years, 13 cases on the left side and 7 cases on the right side, 6 cases of traffic accident injuryand 14 cases of fall. The operation time, intraoperative blood loss and fracture healing time were compared between the two groups, and Constant Murley score was used to evaluate shoulder joint function.

RESULTS

The patients in both groups were followed up for 18 to 24 (20.96±2.02) months. The incisions of both groups were healed at stageⅠ. The fracture ends of both groups were bony healed at the last follow up. There was no significant difference in operation time, intraoperative blood loss and fracture healing time between two groups (P>0.05);there was no significant difference in shoulder joint function between two groups at 3 months after operation (P>0.05).

CONCLUSION

The two methods can obtain satisfactory results in the treatment of Neer Ⅱb distal clavicle fractures, especially suitable for patients with comminuted distal clavicle fractures or osteoporosis; the clinical effect of the treatment of NeerⅡb distal clavicle fractures with T type distal radius plate combined with suture anchor is satisfactory, which provides another feasible treatment scheme for clinic.

[Novel sternoclavicular hook-plate for treatment of proximal clavicle fracture with dislocation of sternoclavicular joint]

OBJECTIVE

To explore the efficacy of a novel sternoclavicular hook-plate for treatment of proximal clavicle fracture with dislocation of sternoclavicular joint.

METHODS

Retrospective analysis of 13 cases of proximal clavicle fracture with dislocation of sternoclavicular joint treated with sternoclavicular hook-plate from June 2011 to January 2019 in our department. There were 9 males and 4 females, aged 26 to 78 years old, with an average age of (54.08±13.91) years old. All the patients had closed injuries without damage of blood vessels and nerves. The patient's operation time, intraoperative blood loss, hospital stay time, and postoperative complications were recorded. Fracture healing and reduction were evaluated according to X-ray and CT after operation. Constant-Murley score and Rockwood sternoclavicular joint score were used to evaluate limb function at 12 months after operation.

RESULTS

All the patients were treated with sternoclavicular hook-plate. The operation time ranged from 50 to 76 min, with a mean of (54.08±13.91) min. The intraoperative blood loss ranged from 20 to 56 ml, with a mean of (46.08±11.15) ml. The hospital stay time ranged from 6 to 14 d, with a mean of (8.31±2.32) d. X-ray and CT examination on the second day after operation showed that all fractures and dislocations were anatomically reduced, and shoulder joint function exercise was performed early. All patients were followed up, and the duration ranged from 12 to 24 months, with a mean of (16.77±4.63) months. The healing time ranged from 9 to 13 d, with a mean of (11.00±1.75) d;and the bone healing time ranged from 3 to 4 months, with a mean of (3.65±0.46) months. There were no complications such as infection, internal fixation failure and nerve injury. At 12 months follow-up, the constant Murley score ranged from 78 to 100, with a mean of 87.83± 11.26; and Rockwood score ranged from 9 to 15, with a mean of 13.70±1.85. Among them, 11 cases were excellent, 1 case was good, and 1 case was general.

CONCLUSION

The use of the novel sternoclavicular hook-plate for treatment of proximal clavicle fracture with dislocation of sternoclavicular joint is an effectively internal fixation with high safety, allowing early functional exercise for patients.