Biomechanical study of a new rim plate fixation strategy for two kinds of posterolateral depression patterns of tibial plateau fractures: a finite element analysis

PURPOSE

The biomechanical capacity of "Barrel Hoop Plate (BHP)" in the treatment of the posterolateral tibial plateau (PL) depression fractures remains unknown. In this study, two kinds of posterolateral tibial plateau depression models involving mild slope-type depression fracture (MSDF) and local sink hole-type depression fracture (LSDF) were created to test and compare the biomechanical capacities of BHP with the other two conventional fixations (Anterolateral Plate and Posterolateral Plate, ALP and PLP) by finite element analysis.

METHODS

The 3D models of three kinds of plate-screw systems and the two kinds of PL-depression models (MSDF and LSDF) were created. An axial force of 400N was applied from the distal femur to the tibial plateau. The maximal displacements of the posterolateral fractures (PLFs), the distribution on the PLFs articular surface and key points displacements were measured. Stresses in the fixation complex including the maximal Equivalent (von-Mises) Stress of implants, the max shear stress of PLFs and stiffness of the fixation were calculated.

RESULTS

The maximal displacement of MSDF was least in Group BHP. The maximal displacement of LSDF was least in Group ALP. In MSDF, BHP showed the best rim fix effect in MSDF, but unsatisfactory results in LSDF. In both MSDF and LSDF, the greatest max Equivalent Stress of the plate and the screw occurred in the PLP system. ALP and BHP showed a comparable stiffness in MSDF and ALP had the strongest stiffness in the fixation of LSDF.

CONCLUSIONS

In MSDF, the BHP has the best biomechanical capacity, especially in displacements of key points such as the PL rim, fracture line, and depression center. In LSDF, the ALP system shows the best biomechanical effect. Although the PLP has the best fixation effect on the posterior wall, it is not suitable for PL-depression fracture fixation.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire

INTRODUCTION

The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture.

METHODS

This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes.

RESULTS

Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores.

CONCLUSION

Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Novel Rim Plating Technique for Treatment of the Inferior Pole Fracture of the Patella

To aim of the present paper was to introduce a novel fixation technique for the treatment of inferior pole fracture of the patella. We performed a prospective observational study of consecutive cases of inferior pole fracture of the patella that were treated at our institution between January 2018 and June 2019. The patients include three men and one woman, with an average age of 47 years (range: 42–59 years). All patients were treated with the novel rim plating fixation technique for preserving the inferior pole of the patella. During the surgery, a 2.4 mm straight locking compression plate was contoured to adapt to the arc of the lower half of the patella as the rim plate. After reduction of the fracture, the rim plate was fixed to the proximal fragment of the patella through multiple locking screws, against the continuous pull of the patellar tendon. The rim plate encircles and constricts the inferior pole fragments, functioning as a compression and blocking construct. If necessary, an additional anterior tension band or mini locking plate can be used to further prevent anterior displacement of the inferior pole fragments. Under this rigid fixation, motion of the knee and full weight‐bearing were encouraged postoperatively. The patients were followed up monthly until 12 months after surgery. The time to achieve 90°pain‐free, full range of motion of the knee, and fracture healing, were recorded. Related complications were monitored, including infection, loss of reduction, fixation failure, anterior knee pain, and soft‐tissue irritation. The modified Cincinnati knee rating system was used for knee function assessment. The average operative time was 58.8 min (range: 52–63 min). The average blood loss was 59.8 mL (range: 45–71 mL). For all patients, pain‐free 90° range of motion was restored in 2–4 weeks, and the full range of motion was restored in 8–11 weeks. All patients achieved bone union in 6–9 weeks with no displacement of the fragments or breakage of the implant. No patient complained of anterior knee pain or soft‐tissue irritation. The modified Cincinnati score at 12‐month follow up demonstrated excellent outcomes in all four patients. The rim plating technique may be a feasible option for the treatment of the inferior pole fracture of the patella.

Evaluation of an expectation and outcome measurement questionnaire in ankle fracture patients: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) Eurasia study

BACKGROUND

The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) questionnaire is a self-administered, patient-rated outcome measurement questionnaire designed to measure both 'expectation' and 'outcome' in orthopaedic trauma patients using two subsets of 10 items. We aimed to validate this instrument in a culturally diverse cohort of patients recruited from Asian and European regions.

METHODS

A total of 193 adult patients with surgically treated AO Foundation/Orthopaedic Trauma Association types 43 and 44 ankle malleolar and distal tibia fractures were recruited with 158 followed up till 1 year. Expectations were assessed prior to surgery, at 2 weeks and after 6 months using the trauma expectation factor (TEF) score. Outcomes were evaluated at 2 weeks, 6 and 12 months using the trauma outcome measure (TOM), American Academy of Orthopaedic Surgeons (AAOS), foot and ankle outcome score (FAOS) and short form-36 (SF-36) questionnaires. Psychometric properties of TEFTOM were assessed.

RESULTS

TEF and TOM demonstrated good internal consistency (Cronbach's α > 0.87) and reliability at all time points (intra-class correlation coefficients > 0.90). TOM showed strong correlations (R² ≥ 0.60) with the AAOS foot and ankle score, all FAOS subscales, except 'symptoms' and SF-36 physical functioning, role physical, bodily pain, social functioning and the physical component summary at 6 and 12 months. Effect sizes for TOM were 2.30 and 0.74 from 2 weeks to 6 months and from 6 months to 12 months, respectively. The baseline patient TEF was predictive for the 1-year TOM score.

CONCLUSIONS

TEFTOM demonstrated good psychometric properties in this cohort of patients with ankle fractures. The TEF 'expectation' score was predictive of the TOM 'outcome' score. We recommend researchers and clinicians to utilize TEFTOM when patient expectation measurement is concerned for orthopaedic trauma patients.

Biomechanical analysis of "Barrel hoop plate" technique for the posterolateral fragments of tibial plateau fractures with different displacement tendency

OBJECTIVES

The purpose of our study is to evaluate the three-dimensional biomechanical properties of "Barrel Hoop plate" in two kinds of artificial posterolateral tibial plateau fracture fragment (PLF) by using of synthetic models, each of which has an initial amplifying displacement tendency.

MATERIAL AND METHODS

Thirty-six tibiae models were randomly assigned into two groups with different displacement tendencies: posterior displacement (PD) and lateral displacement (LD). Each model was then fixed with three patterns: Anterolateral plate (AP), Posterolateral plate (PP), and "Barrel Hoop plate" (BHP). Displacement in three axes of vertical, sagittal and horizontal axis was captured by Optotrak Certus motion analysis system. Bluehill 2 software was used for load control and data collection.

RESULTS

In Model-PD, when the load was over 1000 N, the posterior displacement of Group-PP and Group-BHP were less than Group-AP (P<0.01). The inferior displacement in the vertical axis of Group-PP was larger than both Group-AP and Group-BHP in all the loading set (P<0.01). In Model-LD, both of the lateral displacement in Group-AP and Group-BHP was less than that of Group-PP when the load was over 1000 N (P<0.01). The inferior displacement of Group-AP was less than that of Group-PP in the load of 1500 N (P<0.01). Both of the posterior displacement of Group-AP and Group-BHP was less than that of Group-PP when the loading was 1500 N (P<0.01). The stiffness of Group PP was less than that of Group AP (P<0.01).

CONCLUSIONS

The results demonstrated that the 2.7 mm "Barrel Hoop plate" had a greater capacity of anti-three-dimension axes displacement of PLF. The 3.5 mm Anterolateral plate had the advantage in anti-lateral displacement and anti-inferior displacement but was weak at anti-posterior displacement of PLF. The 2.7 mm Posterolateral plate was stronger in anti-posterior, however, weak in anti-inferior displacement capacity.

Medial Open-wedge Osteotomy with Double-plate Fixation for Varus Malunion of the Distal Femur

Objective

To present our clinical experience of treating varus malunion of the distal femur through a medial open‐wedge osteotomy with double‐plate fixation.

Methods

A prospective cohort study was performed. From January 2005 to February 2015, 15 consecutive patients with varus malunion following distal femur fractures were surgically treated at a single level I trauma center. The coronal and sagittal deformity were corrected by a medial open‐wedge osteotomy of the distal femur. A medial buttress plate was used to maintain the realignment. A lateral locking plate was additionally used as a protection plate. The mean age of patients at the time of the surgery was 35.5 years (range, 22–58 years). The radiographical evaluation included the mechanical femorotibial angle, the mechanical lateral distal femoral angle, the anatomic posterior distal femoral angle, and the leg length discrepancy. Clinical outcome evaluation consisted of the range of motion (ROM) and Hospital for Special Surgery (HSS) score.

Results

Mean follow‐up was 7.4 years (range, 4–11.5 years). Varus and flexion malalignment and limb discrepancy were adequately corrected in all patients. The mechanical femorotibial angle, the mechanical lateral distal femoral angle, and the anatomic posterior distal femoral angle were restored from 17.5° (range, 13°–25°) to 2.3° (range, − 2°–7°), 102.3° (range, 95°–112°) to 85.2° (range, 81°–92°), and 77.1° (range, 65°–87°) to 82.7° (range, 76°–88°), respectively. The leg length discrepancy was diminished from 3.4 cm (range, 2.4–4.5 cm) to 0.8 cm (range, 0–1.7 cm). The average bone healing time was 4.1 months (range, 2.5–6 months). The average ROM of the affected knees at 24‐month follow‐up was 3.4°–112.55°. The score of HSS at 4‐years follow‐up was 76.1 (range, 64–88). No internal fixation failure or secondary operation was noted until the last follow‐up.

Conclusion

Medial open‐wedge osteotomy can adequately correct the posttraumatic varus malunion of the distal femur. With fixation of the double plate, non‐displaced bone healing and good functional outcome are expected.

Tibial plateau fractures in elderly people: an institutional retrospective study

BACKGROUND

Tibial plateau fractures are the most common intra-articular fractures, which require careful evaluation and preoperative planning. The treatment of tibial plateau fractures in elderly patients is challenging, and the comprehension of epidemiology and morphology can be helpful. This study described the characteristics of geriatric tibial plateau fractures.

METHODS

A total of 327 (23.24%) patients aged ≥60 years were reviewed in our level one trauma center over a 4-year period (from January 2013 to November 2016). The following parameters were collected and evaluated: (1) demographic data, (2) injury mechanisms and (3) fracture classifications.

RESULTS

Females accounted for 60.86% in all included elderly patients. Electric-bike accidents were the cause of 32.42% of all these injuries, and 39.62% of these led to high-energy injuries. The most common type of fracture was Schatzker II (54.74%). According to the three-column classification, single lateral column fracture (28.75%) and four-quadrant fracture (involving lateral, medial, posterolateral and posteromedial fractures) (23.24%) were the two most frequent patterns. In all cases, 67.58% involved the posterior column, and the prevalence of posterolateral and posteromedial fractures were 62.69% and 37.92% respectively. Isolated posterior column fractures accounted for 12.54% of patients in total, which mostly consisted of posterolateral fracture in older females (85.37%).

CONCLUSIONS

The majority of elderly patients with tibial plateau fractures are females, and Electric-bike accidents are an important cause of injury. Geriatric tibial plateau fractures have unique distribution in classification.

A new method to locate the radial head "safe zone" on computed tomography axial views

PURPOSE

Direct location of the "safe zone" on a CT axial view is impossible because the radial head is circular in shape. Previous "safe zone" location methods are not appropriate if the physician is unable to visualize the actual radial head. This study aims to introduce a new method to locate the "safe zone" on CT.

METHODS

CT scans were performed on 20 intact cadaveric upper limbs from 20 different corpses in full pronation and supination. The DICOM-format raw data were then re-sliced and analyzed in Mimics 17.0 (Materialise, Belgium). The radial interosseous border (IB) is shaped like a droplet on the axial view; its axis was selected as our reference line (RL). A parallel line in the radial head axial slice was created, and its position relative to the "safe zone" was studied. Deviation in RL direction was evaluated.

RESULTS

Safe-zone scope was 114.41°±11.99. The rotation angle from the RL to the safe-zone's anterior and posterior border was 215.03°±5.99 and 100.62°±8.12, respectively. Rotation direction (clockwise or anti-clockwise) depended on relative radius-ulna position. The safe zone was located by determining these two borders. The reference line's direction was stable in the upper half of the IB; its distance to the radial head fovea was 77.33° mm±6.24.

CONCLUSIONS

The radial head "safe zone" can be located on CT axial view based on the upper half of the IB using this new method. The method is clinically applicable to determine whether postoperative elbow malrotation results from plate impingement.

Interlocking Intramedullary Nailing Versus Locked Dual-Plating Fixation for Femoral Shaft Fractures in Patients with Multiple Injuries: A Retrospective Comparative Study

PURPOSE

Intramedullary nailing (IMN) is a popular method in the management of femoral shaft fractures (FSFs). However, whether the association of IMN with pulmonary fat emboli can compromise the pulmonary and nervous systems is debatable. The purpose of this study is to compare IMN with the locked dual plating (LDP) method by assessing the clinical outcomes of FSF patients with head or chest injury.

METHOD

A total of 126 FSF patients were included in this study between January 2010 and July 2016 and divided into LDP and IMN groups. Patient demographic characteristics, operative time, blood loss, Harris Hip Score, Lysholm Knee Score, radiological outcomes, and systemic complications were collected and compared between the two treatment groups. Patients were followed up for at least 12 months.

RESULTS

The LDP group performed better than IMN in terms of operative time, estimated blood loss amount, and malunion rate. Differences in function scores, fracture union rate, overall pulmonary complication rate, and in-hospital mortality between the two groups were not significant. Average radiographic union time was significantly longer in the LDP group (36.3 weeks) than in the IMN group (32.5 weeks). One case of fixation failure occurred postoperatively in the LDP group, whereas one case of fracture nonunion took place in the IMN group.

CONCLUSION

Our findings suggest that dual-plating fixation is a promising method for FSFs with multiple injuries. However, the retrospective nature of this study necessitates high-quality trials to be performed to assess the clinical efficiency of dual plating.

Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture

BACKGROUND

There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN).

MATERIALS AND METHODS

9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale.

RESULTS

All patients were followedup, with a mean period of 29 months (range 25-40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°-134°) and the mean postoperative HSS was 93 (range 85-97) at 24 months followup. None of the patients sustained neurovascular complication.

CONCLUSIONS

The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region.

Minimally invasive surgery under fluoro-navigation for anterior pelvic ring fractures

BACKGROUND

The incidence of pelvic fractures in trauma patients is reported to be 3-8.2%, with roughly half of these fractures being caused by high energy injuries with a potential for catastrophic hemorrhage and death. Indications for internal fixation of anterior pelvic ring are controversial. Because of fears of disturbing the pelvic hematoma and causing additional hemorrhage, open reduction and internal fixation of pelvic ring disruption is routinely delayed. In contrast to conventional surgery, percutaneous screw fixation is gaining popularity in the treatment of pelvic and acetabular fractures mainly because of minimal soft tissue damage, less operative blood loss, early surgical intervention and comfortable mobilization of the patient. Fluoro-navigation is a new surgical technique in orthopedic trauma surgery. This study is to investigate clinical results of fluoro-navigation surgery in anterior pelvic ring fractures.

MATERIALS AND METHODS

From January 2006 to October 2011, 23 patients with anterior pelvic ring fractures were treated with percutaneous cannulated screw under fluoro-navigation. There were 14 men and 9 women, with a mean age of 40.1 years (range 25-55). According to the AO and Orthopedic Trauma Association classification, there were seven A 2.1, two A 2.2, one A 2.3, six B 1.2, one B 2.1: 1, one B 2.2, one C 1.2, two C 1.3 and two C 2.3 types of fractures. Amongst these patients, 13 had posterior pelvic ring injuries, 8 had other injuries including urethral, lumbar vertebrae fractures and femoral fractures. All patients were operated when their general condition stabilized after emergency management. The mean time from injury to percutaneous screw fixation of the anterior pelvic ring fracture was 12 days (3-15 days). All the anterior ring fractures were fixed with cannulated screws by two senior surgeons. They were familiar with the navigation system and had gained much experience in the computer-assisted percutaneous placement of screws.

RESULTS

A total of 32 screws were inserted, including 19 in the pubic ramis and 13 in the anterior acetabular columns. The average surgical time was 23.3 min/screw. The average time of X-ray exposure was 19.1 ± 2.5 s/screw. The virtual images of fluoro-navigation were compared with real-time X-rays during and after the surgery. Compared to the final position of the screw, the average deviated distance was 3.11 mm and the average trajectory difference was 2.81°. Blood loss during the operation was minimal (22.3 ml/screw). One screw (3.1%) deviated out of the fracture site during the operation. No superficial or deep infection occurred. No patient sustained recognized neurologic, vascular, or urologic injury as a result of the percutaneous screw fixation. All fractures united at the last followup.

CONCLUSIONS

Fluoro-navigation technique could become a safe, accurate, and fairly quick method for the treatment of anterior pelvic ring fractures. Standardization of the operative procedure and training are mandatory for the success of this procedure.

Extended anterolateral approach for treatment of posterolateral tibial plateau fractures improves operative procedure and patient prognosis

PURPOSE

The treatment of posterolateral tibial plateau fracture remains controversial and challenging. Several approaches for this fracture have been applied for direct exposure and support plate fixation. However, several structures are to be at risk via posterior approach, which may affect exposure and plate application. To solve this problem, an extended anterolateral approach was developed and reported.

METHODS

15 patients with posterolateral tibial plateau fractures treated with this approach were reviewed. The primary outcomes, such as Rasmussen functional score, and the secondary outcomes, such as knee deformity, postoperative infection, as well as complications were evaluated.

RESULTS

All 15 cases have been followed up for 12 to 30 months (19.7 months at average). Rasmussen functional score after surgeries was 25.0 ± 2.8 points. A score ≥ 27 points was considered as excellent (ten patients), a score of 20-26 points (four patients) was considered as good; and a score of 10-19 points (one patient) was considered as fair. Anatomic reductions were obtained in 14 patients, but a 3 mm gap was found in one patient. For all patients, there were no wound complications, nonunion, valgus knee deformities, plate loosening or breakages, or fracture re-displacements. No vascular or neural injuries occurred in any patient.

CONCLUSION

The extended anterolateral approach provides excellent visualization, which can facilitate the internal fixation and reduction of posterolateral tibial plateau fractures, and shows encouraging results.

A posterior reversed L-shaped approach for the tibial plateau fractures-A prospective study of complications (95 cases)

PURPOSE

This study was aiming to investigate intraoperative and postoperative complications and outcomes of a posterior reversed L-shaped approach (PRLA) in the treatment of the tibial plateau fractures.

METHODS

Inclusion criterion was tibial plateau fractures treated through the PRLA either separated or combined with other approaches. Main exclusion criterion was poly-trauma patients. Ninety-five patients with tibial plateau fractures from a prospectively collected database were included and followed in this study. The intraoperative and postoperative complications consisted of vascular and nerve injury, wound infection, dehiscence, haematoma, nonunion, skin necrosis and skin paresthesia. Hospital for Special Surgery Knee Score (HSS) was adopted to evaluate patients' knee function while Short Form 36 Health Survey (SF-36) was used to investigate the patients' general health status.

RESULTS

Patients' average age was 46.2 years old (range, 22.0-89.0). The fractures were mainly from high energy injuries involving posterior (and medial) column. 78 of 95 cases were combined with an additional anterolateral approach due to the lateral column involvement. The average follow-up was 52.0 months (range, 12.4-102.6). The total complications rate was 4.2% (4/95). Intraoperative complications occurred in two patients (2.1%). One suffered a popliteal artery injury resulted from an antero-posteriorly drilled K-wire. The patient had a loss of 7° knee extension at one year's follow-up. The other endured an injury of nutrient vessel within the medial head of gastrocnemius. Postoperative skin paresthesia occurred in two patients (2.1%). The other complications associated with the PRLA were not observed. The mean HSS score was 96.1 (range, 80-100). The mean SF-36 score was 94.2 (range, 80-100).

CONCLUSIONS

The posterior reversed L-shaped approach allows satisfied visualization of the medial and posterior tibial plateau and has promising clinical results with low complication occurrence. It can be recommended as a routine approach for the treatment of the tibial plateau fractures involving the posterior column.

Combined approaches for fixation of Schatzker type II tibial plateau fractures involving the posterolateral column: a prospective observational cohort study

INTRODUCTION

This study aimed to investigate the surgical techniques and the clinical efficacy of combined approaches for the treatment of Schatzker type II tibial plateau fractures involving the posterolateral column [lateral and posterolateral columns (LPCs) fractures] in a prospective cohort.

MATERIALS AND METHODS

From January 2007 through December 2010, a total of 65 patients with LPCs underwent dual-plate fixation via a combined anterior and posterior approach. The anterior and posterior approaches were the conventional anterolateral approach and a posteromedial inverted L-shaped approach, respectively, with the patients in a floating position.

RESULTS

Ultimately, 41 patients were followed up for a mean period of 52.5 months. All fractures healed. The mean time to radiographic bony union was 15.2 weeks and the mean time to full weight-bearing was 18.7 weeks. No parameter associated with knee alignment changed significantly between immediately postoperation and 2 years postoperation. No collapse of the reduced articular surface was detected. Two years postoperation, the mean Hospital for Special Surgery score was 92.3; the mean Short Form-36 score was 90.1, and the mean range of knee motion was 1.7°-123.6° (extension-flexion). Two patients suffered dehiscence of the anterolateral incision and another suffered partial necrosis at the margin of the posteromedial incision postoperatively. All healed in response conservative treatment. Another two patients experienced numbness in the posteromedial inferior region of the calf. No implant loosening, breakage, fixation failure, or other complication was observed during follow-up.

CONCLUSIONS

LPCs are not uncommon. Careful preoperative analysis of computed tomography images and impeccable preparation are necessary to avoid neglecting a posterolateral column fracture. It is inappropriate to generalize one scenario for all Schatzker type II fractures: a single approach cannot address all subtypes of these fractures. Dual-plate fixation via a combined approach is an effective treatment for LPCs.

Pathoanatomy and incidence of the posterolateral fractures in bicondylar tibial plateau fractures: a clinical computed tomography-based measurement and the associated biomechanical model simulation

OBJECTIVES

The aim of our study is to evaluate the incidence and pathoanatomy of posterolateral fragments and analyze the associated fracture mechanism in bicondylar tibial plateau fractures.

METHODS

From 1.1.2008 to 3.15.2012, all patients suffering bicondylar tibial plateau fractures were identified, scanned and analyzed at the Shanghai Clinical Trauma Center. Furthermore cadaver knees were selected into three groups of 30/60/90 knee flexion to simulate the posterolateral tibial plateau fracture by an impact device.

RESULTS

One hundred and sixty-four (44.32 %) bicondylar tibial plateau fractures finally satisfied our requirements. Fifty-three and ninety-four cases were measured eventually in the groups of posterolateral split and depression. The posterolateral articular fragment proportion was 15.43 %. The posterolateral articular fragment angle showed an average of 12.94°. The posterolateral fragment cortical height was on average 2.96 cm. The posterolateral sagittal fragment angle averaged at 72.06°. Ninety-four cases were measured in the posterolateral depression group. The average posterolateral articular depression proportion was 16.74 %. The average posterolateral articular depression height was 2.47 cm. In the biomechanical modeling of such kinds of fracture patterns, posterolateral split fractures in 30° and 60° flexion are significantly more than those in 90° flexion. Posterolateral splits combined with anterolateral depression fractures in 30° flexion are significantly more than those in 90° flexion.

CONCLUSION

The incidence of posterolateral fractures is 44.32 % in bicondylar tibial plateau fractures. The morphology of posterolateral area can be referenced for the surgeon in the future clinical work. The information is also helpful for the design of locking plate and fracture modeling in biomechanical test. In addition, that posterolateral split and posterolateral depression might be caused by different injury mechanisms. Different angles of knee flexion under the axial impact loading are possibly the interpretations for these two fracture patterns.

A prospective, randomised trial comparing the use of absorbable and metallic screws in the fixation of distal tibiofibular syndesmosis injuries: mid-term follow-up

Our aim was to compare polylevolactic acid screws with titanium screws when used for fixation of the distal tibiofibular syndesmosis at mid-term follow-up. A total of 168 patients, with a mean age of 38.5 years (18 to 72) who were randomly allocated to receive either polylevolactic acid (n = 86) or metallic (n = 82) screws were included. The Baird scoring system was used to assess the overall satisfaction and functional recovery post-operatively. The demographic details and characteristics of the injury were similar in the two groups. The mean follow-up was 55.8 months (48 to 66). The Baird scores were similar in the two groups at the final follow-up. Patients in the polylevolactic acid group had a greater mean dorsiflexion (p = 0.011) and plantar-flexion of the injured ankles (p < 0.001). In the same group, 18 patients had a mild and eight patients had a moderate foreign body reaction. In the metallic groups eight had mild and none had a moderate foreign body reaction (p < 0.001). In total, three patients in the polylevolactic acid group and none in the metallic group had heterotopic ossification (p = 0.246). We conclude that both screws provide adequate fixation and functional recovery, but polylevolactic acid screws are associated with a higher incidence of foreign body reactions.

Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People's Hospital

BACKGROUND

Terrible triad of the elbow can be a challenging injury to treat, with a history of well-known complications. The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries.

METHODS

We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. Our surgical procedure includes fixation or replacement of the radial head and repair of the ruptured lateral collateral ligament (LCL) through a lateral approach. Simultaneous fixation of the coronoid process and repair of the common flexor muscle and medial collateral ligament (MCL) injury were performed through an anteromedial incision. Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. The Broberg and Morrey classification was used for evaluating traumatic arthritis.

RESULTS

There were 21 patients (21 elbows) included in the analysis, and the mean follow-up period was 32 months (range, 24-48 months). At the last follow-up the mean flexion-extension arc of the elbow was 126° and the mean forearm rotation was 139°. The mean MEPS was 95 points (range, 85-100 points), with 19 excellent results and two good results. Concentric stability was restored in all cases. Two patients had heterotopic ossification, one patient had radial head nonunion, one patient had a superficial infection, and one patient had ulnar nerve neuropathy.

CONCLUSION

Our surgical strategy for terrible triad of the elbow has the advantage of providing both bony and soft-tissue stability simultaneously, thereby allowing active early motion as well as functional recovery of the elbow.

[Unilateral external fixation assisted with closed reduction and interlocking intramedullary nail fixation for the treatment of comminuted fracture of femoral shaft]

OBJECTIVE

To introduce the use of single arm external fixation assisted reduction and closed complex intramedullary nail fixation for the treatment of femoral shaft fracture operation method and to study its effects.

METHODS

From June 2008 to October 2012, 24 patients with femoral shaft fractures were treated with unilateral external fixation assisted by closed reduction, interlocking intramedullary nail fixation. Among the patients, 19 patients were male and 5 patients were female, ranging in aged from 20 to 68 years,with an average of 45.6 years old. The fracture was caused by traffic accidents in 14 cases, by falling in 6 cases, by heavy bruising in 4 cases. Admission diagnosis was femoral shaft fracture. Operation was performed after traction from tibial tubercle for about 1 week.

RESULTS

All the patients were followed up, and the duration ranged from 6 to 24 months, with a mean of 16.2 months. The X-ray showed fracture healing time ranging from 11 to 17 weeks, with an average of 13.8 weeks. All fractures healed without nails broken or close joint dysfunction. According to femoral shaft efficacy evaluation standards, 23 patients got an excellent result, 1 good.

CONCLUSION

Unilateral fixator assisted closed reduction and interlocking intramedullary nail fixation for the treatment of femoral shaft fracture has following advantages: less trauma, simple operation, effective reduction, high rate of fracture healing, and low complication rate.

Anatomical evaluation of the modified posterolateral approach for posterolateral tibial plateau fracture

OBJECTIVE

The study was undertaken to evaluate the efficacy and safety of a posterolateral reversed L-shaped knee joint incision for treating the posterolateral tibial plateau fracture.

METHODS

Knee specimens from eight fresh, frozen adult corpses were dissected bilaterally using a posterolateral reversed L-shaped approach. During the dissection, the exposure range was observed, and important parameters of anatomical structure were measured, including the parameters of common peroneal nerve (CPN) to ameliorate the incision and the distances between bifurcation of main vessels and the tibial articular surface to clear risk awareness.

RESULTS

The posterolateral aspect of the tibial plateau from the proximal tibiofibular joint to the tibial insertion of the posterior cruciate ligament was exposed completely. There was no additional damage to other vital structures and no evidence of fibular osteotomy or posterolateral corner complex injury. The mean length of the exposed CPN was 56.48 mm. The CPN sloped at a mean angle of 14.7° toward the axis of the fibula. It surrounded the neck of the fibula an average of 42.18 mm from the joint line. The mean distance between the opening of the interosseous membrane and the joint line was 48.78 mm. The divergence of the fibular artery from the posterior tibial artery was on average 76.46 mm from articular surface.

CONCLUSIONS

This study confirmed that posterolateral reversed L-shaped approach could meet the requirements of anatomical reduction and buttress fixation for posterolateral tibial plateau fracture. Exposure of the CPN can be minimized or even avoided by modifying the skin incision. Care is needed to dissect distally and deep through the approach as vital vascular bifurcations are concentrated in this region. Placement of a posterior buttressing plate carries a high vascular risk when the plate is implanted beneath these vessels.

[Clinical application of blocking screws and rooting technique in the treatment of distal tibial fracture with interlocking intramedullary nail]

OBJECTIVE

To introduce the clinical method of blocking screws and rooting technique in the treatment of distal tibial fracture with interlocking intramedullary nails.

METHODS

From June 2006 to March 2011, 26 patients with distal tibial fracture were treated with interlocking intramedullary nails using blocking screws and rooting technique, included 18 males and 8 females with an average age of 46.2 years old ranging from 24 to 64 years. According to AO classification: 10 cases of type A1, 4 cases of type A2, 8 cases of type B1, 4 cases of type B2. The average distance of the fractures end to the ankle joint was 85 mm ranging from 55 to 125 mm, the mean time between injured and operation was 4.5 days. The patients were evaluated with pain, range of motion, walking.

RESULTS

All cases were followed-up for 6 to 22 months (averaged 15 months). According to Iowa ankle joint grading system,the score was improved from preoperative (66.8 +/- 8.2) to postoperative (94.6 +/- 4.8). All fractures had united, and got satisfactory reduction and stable fixation with no complications had happen such as breakage of screw.

CONCLUSION

Fixation with interlocking intramedullary nail using blocking screws and rooting technique in treating distal tibial fracture, is a safe and effective technique for the improvement of stability.

Percutaneous screw fixation for the acetabular fracture with quadrilateral plate involved by three-dimensional fluoroscopy navigation: surgical technique

BACKGROUND

The percutaneous three-dimensional (3D)-fluoroscopic-navigated screw directing to the quadrilateral plate was attempted.

MATERIALS AND METHODS

Five patients with acetabular fractures were treated by 3D navigated percutaneous screw. The quadrilateral plate was involved in all the patients. The Arcadis 3D (ARCADIS Orbic 3D(®); Siemens AG Healthcare Sector, Erlangen, Germany) and computer navigation system (stryker navigation system) were employed, screwing trajectory was attempted to anchor the quadrilateral plate perpendicularly to the fracture line and close to the joint cartilage as much as possible. Parameters including fracture gap closure (P1), distance to the joint cartilage (P2), angulations between the screw and the fracture line (P3), were measured with the software installed on the machine of Arcadis 3D.

RESULT

Seven screws were inserted with the use of 3D fluoroscopic navigation. The quadrilateral plate was hold by percutaneous screws. The closure of fracture gap was achieved in 3 patients by 2-3mm. The nearest distance from the screw to the joint cartilage was ranged from <1mm to 6mm. The angulations between the screw and the fracture line was 80-90° in three patients, it was 60° and 65° respectively on the rest two patients. All patients felt pain free 1week after the operation. No complication was noted postoperatively.

CONCLUSION

The surgical technique of percutaneous screwing for the acetabular fracture with three-dimensional fluoroscopy-based navigation was demonstrated.

Biomechanical analysis of four different fixations for the posterolateral shearing tibial plateau fracture

The posterolateral shearing tibial plateau fracture is uncommon in the literature, however with the increased usage of computer tomography (CT), the incidence of these fractures is no longer as low as previously thought. Few studies have concentrated on this fracture, least of all using a biomechanical model. The purpose of this study was to compare and analyse the biomechanical characteristics of four different types of internal fixation to stabilise the posterolateral shearing tibial plateau fracture. Forty synthetic tibiae (Synbone, right) simulated the posterolateral shearing fracture models and these were randomly assigned into four groups; Group A was fixed with two anterolateral lag screws, Group B with an anteromedial Limited Contact Dynamic Compression Plate (LC-DCP), Group C with a lateral locking plate, and Group D with a posterolateral buttress plate. Vertical displacement of the posterolateral fragment was measured using three different strengths of axial loading force, and finally loaded until fixation failure. It was concluded that the posterolateral buttress plate is biomechanically the strongest fixation method for the posterolateral shearing tibial plateau fracture.

Minimally invasive fluoro-navigation screw fixation for the treatment of pelvic ring injuries

Intensive use of intraoperative fluoroscopy is mandatory to achieve good accuracy and avoid neural or vascular injury and may prolong surgical time and increase exposure-related hazards. New methods of percutaneous treatment in conjunction with innovative fluoroscopy-based computerized navigation have evolved in an attempt to overcome the existing difficulties. This report described our experience in applying fluoroscopic surgical navigation technique and evaluated its clinical application to pelvic ring injuries, including its feasibility, merits and limitations. Twenty-two patients with pelvic ring injuries were treated with percutaneous pubic ramus screw and sacroiliac screw techniques under the guidance of a fluoroscopy-based navigation system. A total of forty-four screws were inserted, including twenty-seven pubic ramus screws and seventeen sacroiliac screws. The average operation time and the average fluoroscopy time per screw were 23.6 minutes and 22.2 seconds respectively. Compared to the final position of the screw, the average deviated distance of wire tip was 2.8 mm and the average trajectory difference was 2.6°. A ventral cortex perforation of the sacrum was found in one sacroiliac screw without any clinical symptoms. No superficial or deep infection occurred. No patient sustained recognized neurologic, vascular, or urologic injury as a result of percutaneous screw fixation of pubic ramus fractures, sacroiliac disruptions, or sacral fractures. Our results showed that fluoroscopy-based navigation technique for the pelvic ring injuries could become a safe and effective alterative method for the treatment of pelvic ring injuries in some selected patients.

Biomechanical analysis of posteromedial tibial plateau split fracture fixation

The purpose of this study was to compare the biomechanical strength of four different fixation methods for a posteromedial tibial plateau split fracture. Twenty-eight tibial plateau fractures were simulated using right-sided synthetic tibiae models. Each fracture model was randomly instrumented with one of the four following constructs, anteroposterior lag-screws, an anteromedial limited contact dynamic compression plate (LC-DCP), a lateral locking plate, or a posterior T-shaped buttress plate. Vertical subsidence of the posteromedial fragment was measured from 500 N to 1500 N during biomechanical testing, the maximum load to failure was also determined. It was found that the posterior T-shaped buttress plate allowed the least subsidence of the posteromedial fragment and produced the highest mean failure load than each of the other three constructs (P=0.00). There was no statistical significant difference between using lag screws or an anteromedial LC-DCP construct for the vertical subsidence at a 1500 N load and the load to failure (P>0.05). This study showed that a posterior-based buttress technique is biomechanically the most stable in-vitro fixation method for posteromedial split tibial plateau fractures, with AP screws and anteromedial-based LC-DCP are not as stable for this type of fracture.

Fractures of the distal tibia treated with polyaxial locking plating

We evaluated the healing rate, complications, and functional outcomes in 32 adult patients with very short metaphyseal fragments in fractures of the distal tibia treated with a polyaxial locking system. The average distance from the distal extent of the fracture to the tibial plafond was 11 mm. All fractures healed and the average time to union was 14 weeks. Six patients (19%) reported occasional local disturbance over the medial malleolus. There were two cases of postoperative superficial infections and evidence of delayed wound healing. Using the American Orthopaedic Foot and Ankle Society ankle score, the average functional score was 87.3 points (of 100 total possible points). Our results show the polyaxial locking plates, which offer more fixation versatility, may be a reasonable treatment option for distal tibia fractures with very short metaphyseal segments.

Initiatory biomechanical study on humeral head migration after coracoacromial ligament cut

OBJECT

To design and evaluate the strength of muscles in preventing humeral head migration after acromioplasty by biomechanical research on cadaver models.

METHODS

Six fresh shoulder cadavers were studied. The coracoacromial ligament cut model was prepared in five shoulders for the study. Different forces were applied to the head of humerus with designed strengthened force on rotator cuff muscles. The results were calculated with SPSS software.

RESULTS

The anterior and superior pulling force caused obvious migration of humeral head in coracoacromial ligament cut model; after strengthening the rotator cuff muscles, especially the supraspinatus and subscapular muscle, the humeral head migration was reduced.

CONCLUSION

Modified acromioplasty with supraspinatus and subscapular muscle, strengthened in our experiment, helped to control the migration of humeral head.

Biomechanical evaluation of different fixation methods for fracture dislocation involving the proximal tibia

BACKGROUND

Fracture dislocations of the knee involving the proximal tibia are difficult to treat because of the operative approach that maybe required and the instability of the construct. The optimal fixation method of these fractures remains controversial, improper fixations usually lead to an unsatisfactory prognosis. The purpose of this study was to compare the mechanical strength of four different fixation constructs for this kind of fracture.

METHODS

Twenty-eight Synbone simulated fracture models were created, reduced, and instrumented with one of four constructs: medial single plate, medial double plates, bilateral double plates, or lateral locked plate. Biomechanical testing was done to determine the postfixation construct stiffness, the maximum load to failure, and the medial condylar displacement for each of the four constructs.

FINDINGS

The medial double plates construct was shown to provide the highest overall construct stiffness and the least medial condylar displacement than each of the other three constructs (both P=0.000); The lateral locked plate construct was shown to provide the lowest overall construct stiffness and the largest medial condylar displacement than each of the other three constructs (both P=0.000); There was no significant difference measured between the medial single plate construct and the bilateral double plates construct for overall construct stiffness and medial condylar displacement.

INTERPRETATION

This study suggests that the medial double plates technique is biomechanically the best fixation method for fracture dislocations involving the proximal tibia, while lateral locked plate technique is not indicated to this kind of fracture due to its insufficient stability.

[Minimally invasive surgery of pelvic-acetabular fractures with fluoro-navigation]

OBJECTIVE

To investigate the clinical application of fluoro-navigation in the surgery for pelvic fractures.

METHODS

A fluoro-navigation system was used to guide the placement of screws for the fixation of pelvic and acetabular fractures in 22 patients, 14 males and 8 females, aged 39.4. Totally 41 screws were inserted, 15 in pubic ramus, 13 in acetabulums, and 13 in sacroiliac joints. The images of fluoro-navigation were compared with those of the real X rays during and after surgery.

RESULTS

The average time for operation was 22.7 minutes/screw, and the average time of X rays exposure was 20.2 seconds/screw. The mean deviated distance was 2.9 +/- 1.2 mm and the mean deviated angle was (2.2 +/- 0.3) degrees in the post operational verification. The blood loss during the operation was minimal (< 21.7 ml/screw). One screw (2.4%) was deviated out of the fracture during the operation. No complication was recorded after surgery.

CONCLUSION

Fluoro-navigation-assisted operation for the pelvic and acetabular fracture makes the surgery more precise, safer, and time-saving with less X-ray exposure.

A comparative study of Less Invasive Stabilization System (LISS) fixation and two-incision double plating for the treatment of bicondylar tibial plateau fractures

The present investigation is a prospective study comparing the use of locked plates and classic double plates for the repair of bicondylar tibial plateau fractures. Eighty-four patients with bicondylar tibial plateau fractures were treated with plate fixation by either a locked plate (Less Invasive Stabilization System, LISS) or classic double plates (DP). All patients were followed for a minimum of 24 months. Outcomes were assessed by recording the surgical experience with each approach, post-operative complications and improvements in knee function as measured by the Hospital for Special Surgery (HSS) score. For all patients, no differences in the mechanisms of injury, fracture type, open fracture grade, mean age, gender distribution, associated medical conditions, pre-surgical stay, surgical time, bony union rate or radiographic healing times were observed between the two groups. Also, the HSS score and incidences of infection, seroma, hematoma, deep venous thrombosis, loss of reduction, loss of alignment, hardware failure and overall post-operative complications were all similar in both groups (P>0.05). Wound size and blood loss were significantly less in the LISS group than in the DP group (both P<0.05). A significantly higher incidence of post-operative malalignment of the proximal tibia (P=0.041) and a trend toward significance of a higher incidence of symptomatic hardware irritation (P=0.057) were observed in the LISS group compared to the DP group. In conclusion, LISS provides an alternative treatment for bicondylar tibial plateau fractures, but it may not replace the conventional two-incision double plating technique as the standard of care.

Minimally invasive plating for complex humeral shaft fractures

INTRODUCTION

The treatment for humeral shaft fracture is still controversial, especially for complex fractures. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating complex humeral shaft fractures by using locking compression plate with minimally invasive technique.

MATERIALS AND METHODS

A total of 21 patients with 21 acute complex humeral shaft fractures (AO type C) were included in this study. All were treated with locking compression plate in a minimally invasive way. The average age of the patients was 42.9 years and there were 14 males and 7 females. Plain radiographs of humerus were used to assess bony union. Functional recovery of the shoulder joint was assessed using the Constant and HSS scoring systems.

RESULTS

The patients were followed for a mean of 28.7 months (range 19-37). With one operation, nineteen fractures (90.4%) achieved a solid union in an average of 14.3 weeks. At final follow-up, 20 patients (95.2%) had satisfactory alignment, except for one associated with olecranon fracture, all patients had a good to excellent elbow function with a mean HSS score of 91.7 points. Eighteen patients (85.7%) achieved satisfactory shoulder function with a mean Constant score of 83.1 points. One superficial infection (4.8%) and two non-unions (9.6%) were found postoperatively.

CONCLUSIONS

It was concluded that use of a minimally invasive plate osteosynthesis with locking compression plate is a safe alternative way to classic surgical methods in the treatment of complex humeral shaft fractures, which had a high union rate with less risk of complications.

Locking compression plating: a new solution for fractures in rheumatoid patients

Osteoporosis is a well-known phenomenon in rheumatoid arthritis (RA) that is characterized by marked loss of peripheral bone. It was found that the frequency of osteoporosis in RA can be increased significantly compared with the reference population, which implies a higher risk of fracture in this group of patients. Osteoporosis makes the treatment of fracture in RA patients more challenging, including the difficulty of fracture fixation, delayed union, secondary loss of reduction, and fixation failure. The locking compression plate was designed using the concept of "internal fixator," which provides a new solution for the fixation of osteoporotic fractures. The fixed angle between the screw and the plate increases the pull-out strength of the system, so the stability of the fixation no longer depends totally on the quality of the bone. The other benefits of this system include the fact that no accurate contouring is required, it protects the local blood supply, and it supports minimally invasive plate osteosynthesis.

Medial double-plating for fracture dislocations involving the proximal tibia

Fracture dislocations of the knee involving the proximal tibia are difficult to treat because of the operative approach that maybe required and the instability of the construct. This paper evaluates the use of a two-incision approach with a medial double-plating technique. The clinical results of a case series of 42 patients collected prospectively are presented. At final follow-up 37 out of 42 (88%) had satisfactory reduction of the articular surface and 41 (98%) had satisfactory alignment. At one year postoperation there was no loss in reduction or alignment. The mean HSS score was 90.9 (s.d. 3.35, range 83 to 97). There were no superficial or deep infections, however four cases (10%) had a sanguinous effusion for more than one week postoperatively. It was concluded that the medial double-plating operation is an effective way of managing fracture dislocations involving the proximal tibia.

Backstroke technique: an effective way to improve the healing of tibia fracture

To assess the method and results of applying a backstroke technique, we treated 43 patients with tibial shaft fracture using unreamed tibial nails (UTN). Of these patients, 27 suffered a closed fracture and 16 an open fracture. After the operation, the effect of treatment was evaluated: 42 of 43 cases were followed up from four to 18 months, averaging 13.6 months. The four-month and 12-month healing rates of open fracture were 54.6 and 80.9%, respectively, the former of which is significantly higher than the average rate of the AO/ASIF multicentre study. Our results indicate that applying a backstroke technique in treating tibial shaft fracture with UTN can improve the healing rate and reduce complications.

Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: short-term results in eighteen patients

OBJECTIVE

This study was designed to evaluate the efficacy of the treatment of diaphyseal fractures of the forearm using the ForeSight forearm interlocking intramedullary nail.

DESIGN

Retrospective study.

SETTING

University-affiliated teaching hospital.

PATIENTS

Eighteen patients with 32 displaced diaphyseal forearm fractures were identified.

INTERVENTION

All fractures were treated with the ForeSight forearm interlocking intramedullary nail. Eighteen fractures were stabilized with static interlocking technique.

MAIN OUTCOME MEASURES

The assessment of patients was based on the time to union, the functional recovery, and the incidence of complications. Physical capability was evaluated by using the rating system of Grace and Eversmann. Patient-rated outcome was assessed by completion of the Disability of Arm Shoulder Hand questionnaire (DASH).

RESULTS

All fractures healed with the index procedure. The average time to union for fractures utilizing a closed technique was 10 weeks; for fractures using an open reduction technique, 15 weeks. The mean pronation was 62 (range, 0-96) degrees, and the mean supination was 80 (range, 0-105) degrees. Compared with the normal arm, the mean loss of rotation of the forearm was 32 (range, 5-162) degrees. Using the rating system of Grace and Eversmann, 13 patients had an excellent or good result, 3 had an acceptable result, and 2 had an unacceptable result. Using the patient-rated functional questionnaire, the mean DASH of 19 (range, 4-72) points at the time of the most recent follow-up indicated a mild-to-moderate impairment. There were 7 postoperative complications. The incidence of complications was 22% (7/32). One cross-union between forearm bones occurred in a patient with a closed head injury and high-energy trauma. Two nondriving end screws of the ulna nail backed out causing wrist pain and had to be removed. There were 4 superficial infections occurring all in the fractures that necessitated an open reduction technique. The overall rate of infection was 12.5% (4/32). Three patients who presented with an open fracture needed a skin graft to cover the open wound.

CONCLUSIONS

Forearm interlocking intramedullary nailing is an acceptable method to stabilize displaced diaphyseal forearm fractures in adult.

Reference axes for reconstruction of the knee

Knee alignment is an essential problem in reconstructive surgeries of the knee. Quite a number of reference parameters have been suggested to help the surgeons to get proper alignment during operations. In this article, most commonly used reference axes, both for the axial and the rotational, are reviewed, in an attempt to highlight their reliabilities and clinical relevance.

Transepicondylar line and condylar line as parameters for axial alignment in knee arthroplasty

In order to investigate the reliability of the transepicondylar line and the condylar line as indicators for lower limb alignment in knee arthroplasty, the femorotibial angle (FTA), and the angle between the transepicondylar line and the tangential line of tibial plateau (angle epsilon) and condylar-plateau angle (CPA) were measured in 107 (78 patients) full-length standing X-ray films of lower limbs. The mean FTA was measured to be 178.0+/-9.3 degrees, the CPA 1.5+/-8.5 degrees and angle epsilon -0.8+/-8.5 degrees. The correlation between FTA and the CPA was analyzed to be significant with a correlation coefficient of 0.63, while another correlation between FTA and angle epsilon was calculated to be significant with a correlation coefficient of 0.81 at the same time. As a result, the correlation of the latter one was highly significant, having a R2 value of 0.648 (P<0.001), while the R2 of the former was only 0.397 (P<0.001). In conclusion, the transepicondylar line could be considered as a more reliable indicator for lower limb alignment, which may play an important role in ligament balancing and improvement of the guiding system in knee arthroplasty.

Reliability of the transepicondylar line as a parameter of femoral axial alignment

The purpose of this research was to determine the significance of the transepicondylar line as a parameter of femoral axial alignment. Standing full-length X-ray films of 124 knees of 91 patients (63 women, 28 men) with osteoarthritis, rheumatoid arthritis, or osteonecrosis were used in this study, in which the lateral angles formed by the femoral anatomical axis intersecting with the transepicondylar line (angle a'), horizontal line (angle b'), and femoral condylar line (angle r') were measured. The mean value of angle b' in knees with neutral alignment was significantly smaller than that in knees with varus alignment, and significantly larger than that in knees with valgus alignment; no significant difference was found in angle a'. Also, there was no significant difference in angle a' among the patients with osteoarthritis, rheumatoid arthritis, and osteonecrosis. These findings suggest that the transepicondylar line, which is a stable reference of femoral rotation, is also a very reliable parameter of axial alignment of the femur. In the future design of extramedullary guiding for total knee arthroplasty, the transepicondylar line may play an important role as a parameter for proper and accurate implant setting.

[Study of self-threading pins in the preservative restoration of teeth with large area defects]

OBJECTIVE

To investigate the application of self-threading pins in the preservative of teeth with large area defects.

METHODS

A follow-up study of 42 out of 50 patients with large area defects in vital teeth were restored by self-threading pins.

RESULTS

Among the cases that had been followed up for 5 years, except 2 upper molars which were extracted because of fraction, other cases achieved good effects.

CONCLUSION

Self-threading pins are very suitable to restore large area defects of teeth with healthy pulp, and can be widely used because of significant clinical effects.