[Bridging system for severe comminuted femoral fracture]

OBJECTIVE

To explore the clinical effect of bridging system in the treatment of severe comminuted femoral fracture.

METHODS

From March 2016 to October 2018, 50 patients with severe comminuted femoral fracture including 35 males and 15 females, aged 48 to 72(54.6±8.7) years, were admitted. All cases were comminuted fractures of the femoral shaft, 16 with proximal femur fractures and 7 with distal femur fractures. All cases were all unilateral fractures, 23 on the left and 27 on the right. The time from injury to operation was 5 to 60 (26.7±13.3) hours. The cause of injury was traffic accident, 12 cases with high fall, 35 cases fell and 3 cases fell accidentally. The patients were treated with bridge combined internal fixation system, and the operative effect and fracture healing were analyzed.

RESULTS

The operation was successful in all patients. There was no change to other fixed operation. The operation time was (75.8±12.3) min, the amount of bleeding was(356.4±64.8) ml, and there was no serious postoperative complications such as infection, internal fixation displacement, re fracture and nonunion. After 6 to 36 months follow-up, the fracture healing was evaluated by Warden's score. With the extension of observation time, Warden's score gradually increased, and the time of bone healing was(5.5±0.9) months. Harris score and HSS score were used to evaluate the function of hip and knee joint respectively. With the extension of time, Harris score and HSS score increased gradually. Six months after operation, Harris score was 83.5±11.2, HSS score was 79.7±10.5. During the follow-up period, there were no serious complications such as internal fixation displacement, re-fracture, nonunion of fracture and deep vein thrombosis of lower extremity.

CONCLUSION

The bridge combined internalfixation system has better safety and effectiveness in the treatment of severe comminuted femoral fracture. As long as the requirements of local anatomy and biomechanics are strictly mastered and the operation risks are fully evaluated in combination with imaging, the better fixation effect can be achieved. The operation has less trauma, fewer complications and simple operation, which is believed to have a wider application potential. Due to the limited sample size and follow-up time, no clinical control was set up, the results of the study still need to be further verified by prospective trials.

[Treatment of femoral periprosthetic fracture of Vancouver type B1 and C with bridge combined internal fixation system]

OBJECTIVE

To evaluate the clinical effect of bridge combined internal fixation system in the treatment of periprosthesis fracture of femur after hip replacement.

METHODS

From October 2016 to June 2018, 5 patients of periprosthesis fractures of femur classified type B1 and type C in Vancouver were treated by open reduction and bridging combined with internal fixation, including 2 males and 3 females, with ages of 68, 70, 74, 75, 79 years;type B1 fractures in 4 and type C fractures in 1. Causes of injury:1 case of traffic injury, 4 cases of fall. After the operation, the patients were followed up for complications and fracture healing time by clinical and imaging examination, and Parker activity score was performed.

RESULTS

The wounds of 5 patients healed without infection. One case of DVT was confirmed by venography. Five patients were followed up, and the durations were 2, 8, 9, 10, 15 months. One patient died of myocardial infarction 2 months after operation. The average healing time was 12.5 weeks. No loss of reduction or failure of internal fixation was found. Two patients could walk without protection and 1 patient needed to rely on single crutch. One case of periprosthetic fracture had to walk with a single crutch before operation and move indoors with two crutches after operation. The average Parker activity score was 51.8% before operation.

CONCLUSION

The bridge combined internal fixation system can be used to fix the fracture after hip replacement with stable femoral prosthesis.

[Open pulling reduction and bone graft by overstretched wrist traction and internal fixation for the treatment of distal radius type Fernandez Ⅲ fractures]

OBJECTIVE

To explore the clinical effect of the treatment of Fernandez type Ⅲ fracture of the distal radius with hyperextension traction prying, volar reduction, bone grafting and internal fixation.

METHODS

From February 2017 to March 2018, 11 cases of Fernandez type Ⅲ fracture of the distal radius were treated with intraoperative hyperextension traction and volar prying reduction and bone grafting and internal fixation, including 6 males and 5 females, aged 55 to 67 years. Preoperative X-ray and CT evaluated the distal radius fracture dorsal angulation with articular surface compression, collapse. According to Fernandez, all of them were type Ⅲ. After operation, the reduction of articular surface and fracture healing were evaluated. VAS score and Cooney wrist score were used to evaluate the curative effect.

RESULTS

All the patients were followed up for 12 to 14 months. All the fractures healed. Cooney wrist score scale was used to evaluate the curative effect, 9 cases were excellent, 1 case was good and 1 case was fair.

CONCLUSION

In the operation of Fernandez type Ⅲ fracture of the distal radius, hyperextension traction was used to enlarge the angle, and through the volar fracture end prying reduction and internal fixation with bone graft, the collapsed articular surface could be effectively reduced and fixed. The early functional exercise after the operation had satisfactory clinical effect.

[Lateral mini plate and Kirschner wire assisted fixation for the treatment of distal humeral metaphyseal junction fracture in children]

OBJECTIVE

To explore the operative method and clinical effect of lateral mini plate and Kirschner wire in the treatment of distal humeral metaphysis junction fracture in children.

METHODS

From January 2015 to December 2018, 21 cases of distal humeral diaphyseal metaphyseal junction fracture were analyzed retrospectively, including 12 males and 9 females, aged 2 to 10 years with an average age of 4.5 years, and the time from injury to operation was 6 hours to 7 days. The imaging data showed that the fracture line was located at the junction of the distal humerus and metaphysis. There were 10 oblique fractures, 8 transverse fractures and 3 comminuted fractures. The operation methods were open reduction, lateral mini plate and Kirschner wire assisted internal fixation, and the improved Flynn elbow joint scoring standard was used to evaluate the clinical effect.

RESULTS

All the 21 children were followed up for 8 to 24 months, with an average of 13 months. The healing time was 6 to 8 weeks, with an average of 7.2 weeks. There were no complications such as fracture displacement, cubitus varus and ulnar nerve injury. According to the improved Flynn elbow joint scoring standard, 19 cases were excellent and 2 cases were good.

CONCLUSION

The treatment of distal humeral metaphyseal junction fracture in children is different from that of supracondylar fracture of humerus.

[Delayed combined approach with three plates internal fixation for Pilon fracture with fibula fracture]

OBJECTIVE

To explore clinical effect of delayed internal fixation through anteromedial and posterolateral approach of ankle joint in treating Pilon fracture combined with fibula fracture.

METHODS

From December 2016 to December 2018, 18 patients with Pilon and fibula fracture treated by internal fixation through anteromedial and posterolateral approach of ankle joint with three plates, including 12 males and 6 females, aged from 38 to 51 years old with an average of (44.00±3.45) years old. According to classification of Rüedi and Allgöwer, 9 patients were typeⅡand 9 patients were type Ⅲ. All patients were closed fractures. Burnell Charnley standard was used to evaluate reduction of articular surface fracture at 7 days after operation, and Mazur ankle evaluation grading system was used to compare the improvement of ankle function between 9 and 12 months after operation.

RESULTS

All patients were followed up for 12 to 18 months with an average of (14.00± 1.57) months. According to standard of Burwell Charnley at 7 days after operation, 13 patients got excellent results and 5 patients good. All fracture healed well from 9.5 to 15 months with an average of (12.00±1.43) months. No infection, skin necrosis, loosen and broken of internal fixation, loosing of fracture reduction occurred. Mazur ankle joint score at 12 months (92.11± 5.28) scores was higher than 9 months (89.33±5.20) scores (t=7.976, P<0.001) .

CONCLUSION

Delayed internal fixation through anteromedial and posterolateral approach of ankle joint for Pilon fracture combined with fibula fracture has advantages of simple operation, satisfied reduction, stable fixation, less postoperative complications and satisfied ankle joint function.

[Clinical analysis of Pilon fractures treated through a single lateral approach for 28 patients]

OBJECTIVE

To explore clinical effect of open reduction and internal fixation through a single lateral approach for Pilon fractures.

METHODS

From January 2016 to May 2017, 28 patients with Pilon fractures were treated with open reduction and internal fixation through a single lateral approach. Among them, including 17 males and 11 females, aged from 25 to 59 years old with an average of (39.2±12.2) years old; 13 patients on the left side and 15 patients on the right side; according to Rüedi-Allgöwer classificaton, 7 patients were typeⅠ, 11 patients were typeⅡ, 10 patients were type Ⅲ. All patients were performed external fixation or calcaneal traction within 24 h of emergency, and open reduction and internal fixation was performed after swelling of soft tissue. Healing of incision and fracture, postoperative complications were observed, and AOFAS score at 1 year after operation was used to evaluate ankle joint function.

RESULTS

Twenty-eight patients were followed up from 12 to 25 months with an average of (16.4±7.2) months. Two patients occurred superficial wound infection caused delayed wound healing, 1 patient occurred partial skin necrosis and healed after wound dressing change. The healing time of incision ranged from 11 to 25 days with an average of (15.2±8.4) days. All patients got bone union and the time ranged from 12 to 18 weeks with an average of (15.2±3.4) weeks. Two patients suffered from ankle pain after walking postoperatively and X-ray showed traumatic arthritis, the pain got better with the treatment of non steroidal anti inflammatory drugs. No cases of deep infection, nonunion, delayed union, malunion, loosening of internal fixation occurred after operation. AOFAS score at 1 year after operation was 89.6±5.7, 14 patients got excellent results, 12 good, and 2 fair.

CONCLUSION

The single lateral approach for surgical treatment of Pilon fractures could provide sufficient exposure, reduction and fixation with less soft tissue application and the clinical curative effect is satisfied. However, for Pilon fracture with varus deformity or comminuted fracture on the medial side of tibial, it is difficult to place the main plate on the medial side of tibial. Instead, anteromedial incision or extensive anterior incision is more suitable.

[Comparative study of percutaneous bridging plate and retrograde suprapubic intramedullary screw fixation for anterior pelvic ring fracture]

OBJECTIVE

To compare the effect of percutaneous bridging plate and retrograde suprapubic intramedullary screw in the treatment of anterior ring fracture of pelvis.

METHODS

From January 2013 to June 2017, 40 patients with unstable pelvic fractures involving anterior ring were analyzed retrospectively. According to the fixation method, they were divided into two groups, there were 20 patients in percutaneous bridging plate group (plate group) including 9 males and 11 females; according to tile classification, fractures were classified as type B1 in 1 case, type B2 in 14, type B3 in 2, type C1 in 2 and type C2 in 1. There were 20 cases in retrograde suprapubic intramedullary screw group (screw group) including 10 males and 10 females; according to tile classification, there were 1 case of type B1, 12 cases of type B2, 3 cases of type B3, 3 cases of type C1 and 1 case of type C2. The incision length, operation time, times of fluoroscopy, intraoperative bleeding volume, postoperative Matta score, postoperative complications and the last follow-up Majeed function score of the two groups were compared and analyzed.

RESULTS

Both groups were followed up for 8 to 15 (12.25±2.24) months in the plate group and 6 to 18 (12.4±2.6) months in the screw group, there was no significant difference between the two groups. The incision length of screw group was (3.85±0.75) cm shorter than that of steel plate group (7.05±1.39) cm; the operation time of screw group was (27.70±5.36) min longer than that of steel plate group (15.10±2.07) min; the fluoroscopy times of screw group was (6.00±1.83) more than that of steel plate group (3.75±1.33) . The bleeding volume was (22.50±10.82) ml in of screw group, (25.00±9.93) ml in steel plate group, there was no significant difference between the two groups (P>0.05) . There was no significant difference in Matta evaluation and Majeed functional score in the last follow-up. One case of superficial skin infection occurred in screw group, one case of superficial skin infection and one case of transient paralysis of lateral femoral cutaneous nerve occurred in steel plate group.

CONCLUSION

Percutaneous bridging plate and retrograde suprapubic intramedullary screw fixation of pelvic anterior ring fracture have the same effect. The operation time of the percutaneous plate group was shorter, the times of intraoperative fluoroscopy was less, and the learning curve was shorter, but the variation of the lateral femoral cutaneous nerve should be noted during the operation.

[Curative effect comparison for fixation of fibula or not for the treatment of middle and lower 1/3 fractures of tibia and fibula with intramedullary nail]

OBJECTIVE

To analyze and compare the effect of fibular plate fixation on the treatment of tibial and fibular fractures.

METHODS

From July 2016 to September 2018, 65 cases of middle and lower 1/3 fractures of tibia and fibula were retrospectively analyzed, including 46 males and 19 females, aged 22 to 61 years old. There were 37 cases in fibular fixation group (27 males and 10 females) , 28 cases in fibular non fixation group (19 males and 9 females) . By comparing the operation time, intraoperative bleeding, fracture healing time, ankle rotation and valgus angle, postoperative complications, last follow-up ankle mobility and Baird Jackson score, the operation effect was evaluated.

RESULTS

All patients were followed up for 12 to 16 months with an average of (13.67±1.23) months. There were 3 cases of infection of the fibular incision, all of which healed in the first stage without incision dehiscence, and 4 cases of delayed union without nonunion. In the fibula fixation group, the external rotation of ankle joint increased (7.16±1.36) ° and the valgus angle increased (3.35±1.16) °; while in the non fixation group, the external rotation increased (10.25±1.58) ° and the valgus angle increased (6.46±1.23) ° with statistical significance (P<0.05) . There was no significant difference in ankle joint activity, fracture healing time and complication rate between two groups (P>0.05) ; there was significant difference in operation time, intraoperative hemorrhage and Baird Jackson score at the latest follow-up (P<0.05) .

CONCLUSION

The fibular plate fixation can prevent the ankle joint from malrotation and valgus deformity, and can obtain better surgical effect and functional prognosis.

[3D image enhancer-adjusted percutaneous triangular stabilization of geriatric pelvic ring fractures : Operation technique and indications]

The 3D image enhancer-adjusted percutaneous triangular stabilization of geriatric pelvic ring fractures avoids implant-associated perioperative complications. Displaced fractures of the posterior pelvic ring require stable instrumentation to enable solid bony fusion in a balanced alignment and to control the risk of neurological and vascular damage. This is mandatory in high-energy injuries in young patients and especially in low-energy injuries of geriatric patients. Various surgical techniques have been established. The triangular stabilization technique shows the best biomechanical results. The percutaneous instrumentation reduces access-related morbidity and provides all the benefits of minimally invasive surgery. In order to avoid implant-associated complications, such as vascular and nerve injuries, anatomical and radiological principles are indispensable. The use of 3D image enhancement ensures a safe instrumentation. Nevertheless, pitfalls have to be considered. This article presents the technique of percutaneous triangular stabilization using the 3D scan. After percutaneous insertion of the guide wires into the L4 vertebral body, the iliac bone and transiliosacrally under 2D X‑ray control, the correct wire position is verified by the 3D scan. Then, screws are inserted and the instrumentation is completed in a standard fashion. Using this technique implant-associated perioperative complications, such as nerve and vascular damage due to screw misplacement can be reduced.

[Clinical research of arthroscopy with minimally invasive percutaneous plate osteossynesis for low energy tibial plateau fracture with ligament injury]

OBJECTIVE

To compare clinical effects of minimally invasive percutaneous plate osteosynthesis(MIPPO) and open reduction and internal fixation under arthroscopy for the treatment of low energy tibial plateau fracture with ligament injury.

METHODS

From March 2016 to March 2017, 60 tibial plateau fracture patients with ligament injury were divided into A and B groups according to random number table. In group A, there were 30 patients including 14 males and 16 females aged from 30 to 63 years old with an average of (47.25±5.36) years old; 8 patients were classified type I, 12 patients were typeII and 10 patients type III; treated by MIPPO under arthroscopy. In group B, there were 30 patients including 16 males and 14 females aged from 32 to 60 years old with an average of (43.39±4.62) years old; 10 patients were classified to type I, 11 patients were type I and 9 patients type III; treated by open reduction and internal fixation. Imaging data, length of incision, postoperative volume of drainage, intraoperative blood loss, complications, postoperative activity time and hospital stays were observed and compared. Postoperative HSS score at 18 months was used to compare recovery of knee joint function.

RESULTS

Sixty patients were followed up for 12 to 24 months with average of 18 months. There were no statistical differences in tilt angle of the tibial plateau (TPA), posterior angle of tibial plateau (PA) and femoro tibial angle (FTA) between two groups at 3 days and 12 months after operation. There was no significance in width of internal joint apace before operation, while group B(6.59±0.71) mm was bigger than group A (4.25±0.65) mm after operation at 12 months. Two patients in group A occurred complications and 6 patients in group B occurred complications, and had differences between two groups(P<0.05). Length of incision, hospital stays, postoperative volume of drainage, intraoperative blood loss and postoperative activity time in group A were(5.17±1.89) cm, (2.14±0.65) weeks, (30.02±3.15) ml, (62.63±9.58) ml, (3.16±1.87)d, respectively; while in group B were(16.25±3.47) cm, (4.57±1.09) weeks, (63.75±9.84) ml, (145.89±12.61) ml, (7.86±2.14) d, respectively; and had statistical differences between two groups(P<0.05). HSS score in group A (87.68±7.39) was higher than that of in group B(69.42±5.13) at 18 months after operation (P<0.05).

CONCLUSIONS

Both of MIPPO and open reduction and internal fixation under arthroscopy for low energy tibial plateau fracture with ligament injury could provide stable fixation. Open reduction and internal fixation has advantages of simple operation, but had seriously-injured, MIPPO has advantages of less trauma, good recovery of joint function, less complications and could deal with ligament and meniscus injury.

[Treatment of comminuted Neer IV fracture of proximal humerus with lower shoulder replacement assisted by 3D technique]

OBJECTIVE

To observe and compare the shoulder joint function, complications and clinical effects of hemiarthroplasty and open reduction and locking plate in the treatment of comminuted proximal humeral fracture (Neer IV) with 3D printing technique.

METHODS

From March 2012 to April 2018, 31 middle age and elderly patients with comminuted proximal humeral fractures (Neer IV) were treated, including 4 males and 27 females, aged from 55 to 94 years old with an average age of 71 years, with a course of 1 to 3 years. Among them, 20 cases were treated with open reduction and locking plate internal fixation (ORIF group) and 11 cases were treated with lower half shoulder replacement (HA group) assisted by 3D printing technology. Using CT data and Mimics software of Materialise Company in Belgium, the reconstruction of fracture was simulated on computer. The height of fracture end to humeral head, the height of tubercle to humeral head, the angle of humeral head backward obliquity were measured to assist the hemiarthroplasty. Follow-up and X-ray examination were performed, the incidence of complications were observed, and Neer score was used for the shoulder joint function.

RESULTS

Thirty-one patients were followed up for 1 to 3 years with an average of 2 years. In HA group, there was no prosthesis loosening, fracture and subsidence, the head of artificial humerus was intact, the fracture of nodules and nodules did not heal in 1 case, Neer score was 84.18±3.55; in ORIF group, there were 8 cases of proximal humerus bone resorption, 1 case of fracture nonunion, 1 case of internal fixation loosening, Neer score was 55.91±10.78; there was significant difference in Neer score of shoulder joint function between the two groups(P<0.05).

CONCLUSIONS

Ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures, which promise minimal incision, protect sural nerve, ensure quality of tendon anastomosis and fixation, and is a ideal method for repairing acute closed Achilles tendon ruptures.

Fluoroscopically guided acetabular posterior column screw fixation via an anterior approach

Objective

Safe posterior column screw fixation via an anterior approach under two-dimensional fluoroscopic control.

Indications

Anterior column with posterior hemitransverse fractures (ACPHF); transverse fractures; two-column fractures and T‑type fractures without relevant residual displacement of the posterior column after reduction of the anterior column and the quadrilateral plate.

Contraindication

Acetabular fractures requiring direct open reduction via a posterior approach; very narrow osseous corridor in preoperative planning; insufficient intraoperative fluoroscopic visualization of the anatomical landmarks.

Surgical technique

Preoperative planning of the starting point and screw trajectory using a standard pelvic CT scan and a multiplanar reconstruction tool. Intraoperative fluoroscopically controlled identification of the starting point using the anterior–posterior (ap) view. Advancing the guidewire under fluoroscopic control using the lateral–oblique view. Lag screw fixation of the posterior column with cannulated screws.

Postoperative management

Partial weight bearing as advised by the surgeon. Postoperative CT scan for the assessment of screw position and quality of reduction of the posterior column. Generally no implant removal.

Results

In a series of 100 pelvic CT scans, the mean posterior angle of the ideal posterior column screw trajectory was 28.0° (range 11.1–46.2°) to the coronal plane and the mean medial angle was 21.6° (range 8.0–35.0°) to the sagittal plane. The maximum screw length was 106.3 mm (range 82.1–135.0 mm). Twelve patients were included in this study: 10 ACPHF and 2 transverse fractures. The residual maximum displacement of the posterior column fracture component in the postoperative CT scan was 1.4 mm (0–4 mm). There was one intraarticular screw penetration and one perforation of the cortical bone in the transition zone between the posterior column and the sciatic tuber without neurological impairment.

[Fragility fractures of the pelvis]

Fragility fractures of the pelvis are increasing in frequency. In most cases patients suffer a minor injury, have intense pain in the pelvic region and impaired mobility. The new fragility fractures of the pelvis (FFP) classification distinguishes between four types with increasing instability. The FFP types I and II are treated conservatively. For FFP types III and IV and type II with unsuccessful conservative treatment, minimally invasive stabilizing techniques are recommended. Both the posterior and anterior pelvic ring must be stabilized. Alternative techniques for dorsal stabilization are iliosacral screw and transsacral bar osteosynthesis, transiliac internal fixator and lumbopelvic fixation. External fixation, retrograde transpubic screw fixation, anterior internal fixation and plate and screw osteosynthesis are alternatives for the anterior pelvic ring. Treatment of fragility fractures of the pelvis should be carried out as part of an orthogeriatric co-management.

[Primary fracture protheses and reverse shoulder arthroplasty in complex humeral head fractures : An alternative to joint-preserving osteosynthesis?]

BACKGROUND

The surgical management of complex humeral head fractures has adapted dynamically over the course of the last decade. The primary use of reverse shoulder arthroplasty in elderly patients has gained in relevance due to promising short and middle-term results. Long-term results, however, are still pending. The appliance of anatomical hemiarthroplasty, on the other hand, has lost in significance in favour of osteosynthesis and reverse shoulder arthroplasty.

INDICATIONS

This review article follows the question as to under which circumstances primary fracture arthroplasty reflects an alternative or even a preference to joint-preserving osteosynthesis in the treatment of complex proximal humeral fractures. It also specifies spectrums of indications for anatomical hemiarthroplasty and reverse shoulder arthroplasty.

Lessons Learned from Long-Term Management of Hip Fracture in Patients with Osteopetrosis: A Report of Nine Hips in Five Patients

Background

Treating patients with osteopetrosis is very challenging even in very skilled surgeons with many experiences. We present an account of 5 patients treated for hip fracture related problems occurring throughout their life due to this disease. Difficulties encountered during their treatment prompted us to present some general management principles.

Methods

From January 2003 to December 2016, 5 patients with osteopetrosis (9 hips; 3 men, 2 women), who underwent operative or conservative treatment were retrospectively reviewed. We evaluated their clinical features and rate of union, malunion and post-operative infection.

Results

Four of 5 patients (80%) suffered bilateral fracture, and 8 of 9 fractures (89%) are transverse and occurred at subtrochanteric area resulted from minor trauma. Among 9 hips, surgery was performed in seven hips. Nonunion were found in 3 hips (33%), malunion in 1 hip (11%) and oteomyelitis was developed in 2 hips (22%) at a median of 8.1 years.

Conclusions

Clinical features of hip fracture in osteopetrosis are very similar to atypical subtrochanteric femoral fractures. Patients should be informed of the possibilities of several anticipated complications including the risk of nonunion and infection after surgery.

Robot-assisted Percutaneous Cannulated Screw Fixation of Femoral Neck Fractures: Preliminary Clinical Results

OBJECTIVE

To assess the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of femoral neck fractures.

METHODS

From September 2015 to July 2017, 26 patients with unilateral femoral neck fractures were treated with TiRobot-assisted percutaneous cannulated screw fixation. The femoral necks were fixed using three cannulated screws with robot assistance applying the following procedure: image acquisition, path planning, and needle and screw placement. The results of the treatment, including operation duration, frequency of fluoroscopy use, implant placement accuracy, intraoperative bleeding, total drilling, surgical complications, fracture healing time, fracture healing rate, and Harris scores at the last follow-up, were recorded and compared with 23 similar patients who underwent conventional manual positioning surgery.

RESULTS

A total of 147 cannulated screws were placed in all patients. The TiRobot group had shorter operation duration (62.6 ± 8.7 min vs 72.4 ± 10.3 min) and fracture healing time (5.1 ± 2.4 months vs 5.9 ± 2.8 months) than the conventional group (P > 0.05). The robot group had significantly less use of fluoroscopy (26.5 ± 7.4 times vs 51.3 ± 9.4 times), intraoperative bleeding (8.2 ± 5.3 mL vs 36.4 ± 12.5 mL), and total drilling (9.4 ± 4.2 times vs 18.3 ± 9.1 times) than the conventional group (all P < 0.05). The screw parallelism was significantly improved (24.0 ± 0.6 points vs 21.5 ± 1.2 points) and the neck-width coverage (72.0 ± 6.7 mm² vs 53.8 ± 10.4 mm² ) was significantly enlarged compared to the conventional group (P < 0.05). Only three guiding needles were used to penetrate the femoral head during manual insertion in the TiRobot group, which was significantly lower than that in the conventional group (3/78, 3.8% vs 9/69, 13.0%; P < 0.05). Other complications such as wound infection, vascular or nerve injury, screw loosening, and secondary screw displacement, did not occur in the two groups. There was no significant difference between the two groups in fracture healing rate (88.4% vs 82.6%) and Harris scores at the last follow up (88.2 ± 3.6 points vs 87.3 ± 4.7 points; P > 0.05).

CONCLUSION

TiRobot-assisted percutaneous cannulated screw fixation of femoral neck fractures is advantageous over conventional surgery with manual positioning due to easier manipulation, more accurate screw insertion, less invasion, and less radiation exposure, suggesting that it is a better method to stabilize femoral neck fractures.

[Expanded curettage and bone cement filling combined with internal fixation for the treatment of Campanacci III giant cell tumour of knee joint]

OBJECTIVE

To evaluate clinical effects of expanded curettage and bone cement filling combined with internal fixation in treating Campanacci III giant cell tumor of knee joint.

METHODS

From January 2006 to December 2016, 21 patients with Campanacci III giant cell tumor of knee joint were treated by expanded curettage and bone cement filling combined with internal fixation, including 11 males and 10 females with an average age of(35.24±10.56) years old (ranged from 21 to 61 years old). The courses of disease ranged from 1.5 to 24.0 months with an average of(8.1±4.4) months. Among them, 8 patients were distal femur and 13 patients were proximal tibia. All patients were primary tumors. Musculoskeletal Tumor Society(MSTS) scores were used to evaluate lower limb function before and after operation. X-ray was used to observe healing of lesions and the occurrence of adverse reactions.

RESULTS

All incisions were healed at grade A without complications such as infection and internal fixation failure. All patients were followed up from 8 to 56 months with an average of (29.62±9.48) months. MSTS score at the latest follow-up 26.71±2.35 was higher than that of before operation 15.24±1.14, and had statistical significance(t=20.160, P=0.000). The results of X-ray at final following-up showed internal fixation was well, and no loosening and fracture of subchondral bone. Three patients recurred giant cell tumor and replaced with tumor prosthesis.

CONCLUSIONS

Expanded curettage and bone cement filling with internal fixation for the treatment of Campanacci III giant cell tumor of knee joint could effectively retain limb function and reduce tumor recurrence rate.

Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients

Background

Femoral neck fractures in patients ≤ 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial.

Methods

We will conduct a multicenter, concealed randomized controlled pilot study, using a 2 × 2 factorial design in 60 patients aged 18–60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed.

Discussion

Results of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations.

Trial registration

The FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0458-x) contains supplementary material, which is available to authorized users.

[Meta-analysis of clinical effects between non-metallic materials and metallic materials by internal fixation for patellar fracture]

OBJECTIVE

To systematically evaluate clinical effects of metal and non-metallic materials in internal fixation for patellar fracture.

METHODS

The reports concerning about controlled trial of metallic and non-metallic materials for patellar fracture from create database to June 2018 were searched from PubMed, EMBASE, Web of science, CNKI and Wanfang data. Information was screened and taken out according to inclusion and exclusion criteria by 2 researchers, and risk of bias in non-andomised studies of interventions (ROBINS-I) was used to evaluate literature quality. Rate of reoperation, excellent and good rate of clinical rehabilitation, incidence of postoperative complications were compared with Revman 5.3 software for Meta-analysis.

RESULTS

Totally 9 retrospective cohort studies including 493 patients were selected. There was no significant difference in reoperation rate of internal fixation failure between metallic implants and non-metallic implants[OR=0.52, 95% CI (0.25, 1.08) P=0.08]. The excellent and good rate of postoperative clinical rehabilitation in patients receiving non-metallic implants were higher than those in receiving metallic implants[OR=3.34, 95% CI (1.67, 6.71), P=0.000 7]; incidence of total complications was also lower than that of metallic implants[OR=0.21, 95% CI (0.07, 0.60), P=0.003]. There was no significant difference in the incidence of non-metallic related complications after removing Kirschner wire needle and complications of skin irritation [OR=1.08, 95% CI(0.45, 2.56), P=0.86].

CONCLUSIONS

Non-metallic plants could provide the same success rate of internal fixation as metal plants, could improve the excellent and good rate of postoperative rehabilitation by reducing incidence of complications associated with metallic plants. In further, more evidence-level research is needed to confirm in the future.

[Transfer of gastrocnemius muscle flap for postoperative infection with patellar internal fixation]

OBJECTIVE

To investigate clinical effect of gastrocnemius muscle flap for repairing postoperative infection of patellar internal fixation.

METHODS

From January 2011 to January 2017, 15 patients with postoperative infection of patellar internal fixation were treated, including 9 males and 6 females ranged from 31 to 66 years old with an average age of (42.5±11.2) years old. The courses of disease ranged from 2 to 8 months with an average of (4.3±1.5) months. All wounds were repaired by gastrocnemius muscle flap after debridement. The coverage of muscle flap was performed by free skin graft and donor site was closed directly. Survival of muscle flap, healing of incision were observed. HUANG Yong-xin clinical criteria and KSS score criteria were used to evaluate knee joint function 9 after operation.

RESULTS

All muscle flaps were survived without necrosis. Incision of 13 patients were healed at stageI, and 2 patients had wound dehiscence after operation and healed after symptomatic treatment. All patients were followed up from 9 months to 30 months with an average of(20.6±8.3) months. No recurrence of infection was observed, and texture of muscle flap, skin color, appearance were good. According to HUANG Yong-xin clinical criteria, 13 excellent and 2 moderate. The clinical score of KSS score was 83.3±7.8, and functional score of KSS score was 86.3±10.4.

CONCLUSIONS

Gastrocnemius muscle flap is an effective method in repairing postoperative infection of patellar internal fixation with stable curative effect and low recurrence rate, which is worthy popularizing.

[Clinical effects of Kirschner wire with hole transverse fixation combined with titanium cable purse string suture for the treatment of refractory fracture of patellar comminuted fracture]

OBJECTIVE

To explore clinical effects of Kirschner wire with hole transverse fixation combined with titanium cable purse string suture in treating refractory fracture of patellar comminuted fracture.

METHODS

From January 2014 to January 2016, 17 comminuted fracture treated by Kirschner wire with hole transverse fixation combined with titanium cable purse string suture were retrospectively analyzed, including 10 males and 7 females aged from 28 to 67 years old with an average of (48.7±3.2) years old. According to AO/OTA fracture classification, all fractures were type 34-C3.2. Operative time, blood loss, intervals of the first functional exercise postoperatively and complications were observed. Meanwhile, function recovery was evaluated by Böstman scoring at 10 months after operation.

RESULTS

All patients were followed up with an average of(14.6±2.1) months ranged from 10 to 24 months. All incisions healed at stage I. Clinical fracture healing time ranged from 11.7 to 16.5 weeks with an average of (12.7±1.7) weeks; operative time ranged from 67 to 95 min with an average of (71.4±11.5) min; blood loss ranged from 41 to 72 ml with an average of (57.0±7.5) ml; the first time of functional exercise ranged from 2 to 5 d with an average of (2.2±1.7) d. No complications including Kirschner pin stabbing the skin, loose or slippery of Kirschner pin, bursitis with pain brought by tip of Kirschner pin, wire escaped and broken occurred. Postoperative Böstman score at 10 months were 28.15±1.74, 12 patients got excellent results, 4 well and 1 lose.

CONCLUSIONS

Kirschner wire with hole transverse fixation combined with titanium cable purse string suture in treating refractory fracture of patellar comminuted fracture has advantages of simple operation, good anatomical reduction, stable fixation and less complications, which is worth popularizing.

[Comparison of long Gamma 3 nail and proximal femur locking plate for the treatment of femoral subtrochanteric fractures]

OBJECTIVE

To compare clinical efficacy of long Gamma 3 nail and proximal femur locking plate (PFLP) in treating femoral subtrochanteric fractures.

METHODS

From January 2010 to January 2017, clinical data of 58 patients with subtrochanteric fractures followed more than 12 months were retrospective analyzed. Among them, 35 patients were treated with long Gamma 3 nail including 18 males and 17 females aged from 25 to 78 years old with an average of(66.5±23.5) years old;Causes of injury included fall on the ground in 18 cases, traffic accidents in 7 cases, and fall from height in 10 cases. The other 23 patients were treated with PFLP fixation including 8 males and 15 females aged from 31 to 81 years old with an average of (63.4±22.4) years old;Causes of injury included fall on the ground in 12 cases, traffic accidents in 6 cases, and fall from height in 5 cases. Operative time, blood loss (intraoperative and hidden blood loss), hospital stays, bone healing and complications were observed and compared. Harris hip score after 1-year following-up was used to evaluate postoperative clinical effect.

RESULTS

Fifty-one patients were followed up from 14 to 36 months with an average of 24.8 months, including 31 patients were treated with long Gamma 3 and 20 patients were treated with PFLP. Blood loss(intraoperative and hidden blood loss) in PFLP group was less than that of long Gamma 3 nail group(P<0.05). There was no significant in operative time, hospital stays and complications between two groups(P>0.05). There was no significant differences in healing time of fractures between long Gamma 3 nail group (17.2±2.4) weeks and PFLP group (18.1±2.6) weeks(P<0.05). At 1-year following-up, there was no significant differences in Harris hip score between long Gamma 3 nail group(80.29±10.28) and PFLP group (76.49±12.28)(P<0.05). No complications such as pulmonary embolism and nonunion occurred. Two patients were treated with fitler whose occurred deep vein thrombosis. Postoperative pulmonary infection curred in 4 cases and was cured by anti-infection therapy.

CONCLUSIONS

Both of long Gamma 3 nail and PFLP in treating patients with femoral subtrochanteric fractures can receive good clinical effects, long Gamma 3 nail is not suitable for the patients of the narrow medullary cavity and prominent anterior arch. PFLP is eccentric fixation, so early weight-bearing was not stress.

[Photodynamic intramedullary bone stabilization of pathological fractures]

Pathological fractures of long tubular bones are stabilized with conventional implants. Essentially, plates and intramedullary nails are used for stabilization and are two different techniques, which compete with each other with respect to the surgical treatment. A large number of such means of osteosynthesis are commercially available but are primarily focused on acute fractures in otherwise biologically healthy bones. The pathological fracture or the treatment of impending pathological fractures due to metastatic osteolysis differs from the treatment of healthy bones in some fundamental aspects. The characteristics of pathological fractures make the development of new technologies that meet the specific needs of both the patient and the surgeon desirable. A new approach in treatment is stabilization of internal long bone fractures by the use of a cylindrical balloon implant, which is introduced into the bone via a small proximal or distal hole and then filled and expanded to a much larger diameter with a liquid monomer. The curing process is initiated with the application of blue light forming a rigid implant by polymerization (IlluminOss™). Many of the well-known disadvantages of conventional implants can be eliminated with this technology. Specifically, with respect to the irregular shape of the natural medullary canal it is possible to completely fill the medullary canal of the tubular bone. The filling of the canal provides torsional stability without the use of interlocking screws. Similarly, the use of the balloon technique enables minimally invasive surgery and furthermore permits the additive use of conventional metallic plates whenever necessary. The new balloon techniques show high primary stability in the treatment of pathological shaft fractures. In particular cases, the addition of a supplemental plate osteosynthesis is recommended.

TREATMENT OF SCHAPHOID NONUNION WITH VOLAR LOCKED PLATE

Objective:

To assess and compare radiographic, tomographic and functional pre and postoperative parameters of patients submitted to treatment of nonunion of the scaphoid waist with locked plate for scaphoid.

Methods:

This is a case series of scaphoid waist nonunion, operated from March 2017 to March 2018 at the Institute of Orthopedics and Traumatology of HCFMUSP, using the technique of Fisk-Fernandez and osteosynthesis with locked plate for scaphoid APTUS®Hand from Medartis. The patients were submitted to radiographs, computed tomography and functional evaluation by the occupational therapy team in the pre and postoperative periods.

Results:

There was consolidation of the scaphoid waist nonunion in all cases, improvement in the parameters of carpal alignment in the imaging examinations, but functionally we observed reduction of the range of motion and grip strength in relation to the contralateral limb.

Conclusions:

The treatment of the scaphoid waist nonunion with locked plate was effective, with a high index of consolidation and improvement of the carpal alignment in the imaging tests, although with a reduction in the range of motion and grip strength in relation to the contralateral limb when evaluated with 12 weeks postoperatively. Level of Evidence IV, Case series.