Anterior expansion of sacral foramen and decompression of sacral plexus via lateral-rectus approach for sacral fractures complicated with sacral plexus injury / 中华创伤骨科杂志

Objective:To evaluate the anterior expansion of sacral foramen and decompression of sacral plexus via the lateral-rectus approach (LRA) in the surgical treatment of sacral fractures complicated with sacral plexus injury.Methods:From January 2013 to June 2018, 11 patients were treated at Department of Orthopaedics, The Third Hospital Affiliated to Southern Medical University for obsolete sacral fractures complicated with sacral plexus injury. They were 8 males and 3 females, aged from 17 to 54 years (average, 38 years). According to the Denis classification, all the sacral fractures belonged to Denis Zone Ⅱ. According to British Medical Research Council (BMRC) grading system, the nerve injury was complete damage in 2 cases and partial damage in 9. The mean time from injury to surgery was 6 months (range, from 0.7 to 12.0 months). After the sacroiliac joint was exposed via the LRA, the lumbosacral trunk was exposed and released between iliac vessels and the iliopsoas. Next, the S1 foramen was expanded and the S1 nerve root was released after separation of the median sacral artery and the internal iliac artery. Reduction and fixation of the sacroiliac joint was carried out for patients with unstable sacral fracture. X-ray and CT examinations of the pelvis were performed to evaluate fracture healing and neurological function recovery postoperatively.Results:Of this cohort of 11 cases, operation succeeded in 10 but failed in one whose sacral fracture was found to have completely healed with the S1 foramina totally occluded. The surgical time averaged 110 min (range, from 70 to 220 min) and the blood loss 1, 100 mL (range, from 450 to 2, 800 mL). Postoperative X-ray and CT examinations showed that the sacral foramens were expanded significantly without any complications. The follow-up time averaged 18 months (range, from 12 months to 4 years). By the BMRC grading system at the last follow-up, the neural function was completely recovered in 5 cases, partially recovered in 4 cases and not recovered in one.Conclusion:Significant anterior expansion of sacral foramen and decompression of sacral plexus via the LRA is a viable and effective alternative for treatment of sacral fractures complicated with sacral plexus injury.

The W-shaped acetabular angular plate for the treatment of acetabular posterior wall fractures through the direct posterior approach / 中华骨科杂志

Objective:To evaluate the follow-up clinical results of W-shaped acetabular angular plate for the treatment of acetabular posterior wall fractures through a direct posterior approach (DPA).Methods:Fifteen cases (10 males and 5 females, average aged 42.1±10.0 years) were involved in this study, with acetabular posterior wall fractures treated by using the W-shaped acetabular angular plate through a DPA between March 2017 and June 2019. Nine patients with fractures were injured by traffic accidents and the other 6 cases by falling. Based on the three-column classification for acetabular fractures, all of the cases belonged to posterior wall fractures (A2.1), which included 6 cases of simple fractures and 9 cases of comminuted fractures. The mean time interval between injury and surgery was 5.6±1.1 (range, 4-8) days. The DPA was adopted in all cases. The posterior wall fractures of the acetabulum were reduced and fixed with W-shaped acetabular angular plates. The reduction quality of the acetabulum was evaluated by X-ray and CT scan during follow-up visits according to the criteria proposed by Matta. The function of the hip joint was assessed by the Merle d'Aubigné-Posteal score modified by Matta.Results:The length of the surgical incision was 9.5±1.1 (range, 8-12) cm. The operation time was 45.3±10.1 (range, 35-75) mins. The amount of intraoperative blood loss was 248.0±94.7 (range, 100-380) ml. All the patients who were followed up for 20.5±6.3 (range, 16-38) months. All cases were evaluated according to Matta's reduction quality criteria, the satisfactory ratio of reduction was 100%. Among cases, 10 cases were matched the anatomic reduction, and the other 5 cases have belonged to satisfy. All cases of fractures had healed (the mean of healing time was 9.4±1.3 (range, 8-12 weeks). At the final follow-up visit, the mean of modified Merle d'Aubigne-Postel score was 16.9±1.6 (range, 13-18). Excellent clinical outcomes were obtained in 10 cases, good in 3 cases, and fair in 2 cases. One case had deep venous thrombosis of the lower extremities. The clots disappeared after anticoagulation treatment. One case had the heterotopic ossification, Brooker grade I, without any special treatment due to not affecting the hip joint activity in the follow-up visits. One patient had incision fat liquefaction and the wound healed after intensive dressing change. No internal fixation loosening or losing of fracture reduction was found at the follow-up visits.Conclusion:This study shows that using W-shaped acetabular angular plate for the treatment of acetabular posterior wall fractures through the DPA could obtain early satisfactory clinical outcomes.

Clinical effects of direct posterior approach with the fixation of percutaneous tunnel screw and plate for acetabular posterior comminuted fractures / 中华骨科杂志

Objective:To investigate the surgical technique and the clinical effects of direct posterior approach (DPA) with the fixation of percutaneous tunnel screw and plate for acetabular posterior comminuted fractures.Methods:Thirty-six cases with acetabular posterior comminuted fractures treated by this technique from January 2016 to July 2020 were retrospectively analyzed in this study. There were 28 males and 8 female, aged 42.0±12.1 (range 19-64) years. According to Letournel-Judet classification, there were 28 cases of transverse associated with posterior wall fractures, 6 cases of posterior column with posterior wall fractures and 2 cases of T shape with posterior wall fractures. DPA was adopted in prone position. The anterior and posterior column fractures of the acetabulum were reduced under direct vision and then fixed with percutaneous tunnel screw. Further, the posterior wall fractures of the acetabulum were reduced and fixed with plate and screws. The operation duration, intraoperative blood loss, incision length, fracture union time, fracture reduction quality, postoperative complications and hip function were recorded.Results:The incision was 9.8±1.2 (range 8-12) cm. The operation duration was 102.9±21.4 (range 65-145) min. Intraoperative bleeding was 214.0±116.9 (range 100-640) ml. Postoperative X-ray and CT examinations showed perfect reduction. All the patients were followed up for 20.9±9.2 (range 10-38) months. The fracture healing time was 4.6±1.0 (range 3-6) months. There was no patient with damaged superior gluteal nerve and blood vessel. There were 2 cases of femoral head cystic changes without pain in walking, 1 case of postoperative infection and bacteremia who was cured at 1 month after debridement and anti-infection treatment, 1 case of sciatic nerve injury but recovered at 3 months after operation, and 1 case of heterotopic ossification at 3 months after surgery without affecting hip motion. According to the Matta's criteria, the reduction quality of the acetabular fracture was rated as excellent in 28 cases, good in 6 cases, fair in 2 cases. According to the modified Merle D'Aubigné and Postel scoring system, hip joint function was excellent in 24 cases, good in 10 cases and fair in 2 cases.Conclusion:DPA approach can directly reduce acetabular posterior comminuted fractures through a minimal incision. Combined with the technique of percutaneous tunnel screw, it displays great advantages of less trauma and with good clinical effects.

Treatment of pelvic fragility factures in the elderly patients via lateral-rectus approach / 中华骨科杂志

Objective:To explore the surgical method and clinical efficacy of lateral-rectus approach (LRA) in the treatment of fragility fractures of the pelvis (FFP) in the elderly.Methods:A retrospective study was conducted for elderly FFP patients from January 2011 to December 2019. All the pelvic fractures should be exposed and reduced through LRA and fixed with pelvic reconstruction plates and channel screws. Then, a total of 30 elderly patients were included in the study, including 9 males and 21 females, with an average age of 72.5 years (range, 60-87 years). Fractures were caused by car accident in 5 cases, by falling from high places in 8 cases and by tumbling in 17 cases. According to the FFP classification, there were 6 cases of type IIc (6/30, 20%), 22 cases of type III (22/30, 73.33%, of which 13 cases were type IIIa, 7 cases were type IIIb, and 2 cases were type IIIc), 2 cases of type IVa (2/30, 6.67%). Among that, 2 cases suffered ipsilateral acetabular fractures, 17 suffered medical diseases such as hypertension, coronary heart disease, diabetes, etc., and none suffered extremities fractures or other types of injuries. Surgical field was exposed retroperitoneally through LRA, combined with lower limb traction to reduce the anterior and posterior pelvis ring fractures. Then, the reductions were done in direct visions and verified through X-ray fluoroscopy. After that, the posterior ring was fixed with reconstruction plate and/or sacroiliac screws, and the anterior ring was fixed with reconstruction plate or INFIX. The quality of fracture reduction was evaluated by Matta score and the postoperative function was evaluated by Majeed score.Results:All the 30 patients were surgical treated through LRA. The time from injury to operation was 5 to 20 days, with an average of 9.9 days. The operating time ranged from 35 to 150 min (mean, 73.5 min) and the intraoperative bleeding ranged from 220 to 2 400 ml (mean, 586.7 ml). Fractures were successfully reduced under direct vision and the positions of the plates and screws were monitored through X-ray fluoroscopy during the operation. Postoperative X-rays and CT scans showed satisfactory reduction of the pelvic ring. According to Matta criteria, the quality of fracture reduction was evaluated as excellent in 18 cases, good in 6 cases, fair in 4 cases and poor in 2 cases. The overall excellent and good rate was 80% (24/30). All patients were followed up for 6-24 months, the fractures were all healed, and all fractures healed for 2-5 months, with an average of 3.5 months. At the last follow-up, Majeed scores were 86.1±6.11 (range, 66-92), including 21 excellent cases, 7 good cases and 2 fair cases, with an excellent and good rate of 93.3% (28/30). As for complications, 1 patient developed deep venous thrombosis of the affected lower limb, and the thrombosis disappeared after thrombolytic therapy. One patient had fat liquefaction in the incision, and the wound healed after intensive dressing change. After INFIX fixation, 2 patients showed numbness on the lateral thigh of the affected side, and the symptoms were relieved after symptomatic treatment. Four patients were found to have internal fixation screws loosening during follow-up, but still achieved good fracture healing.Conclusion:The entire hemipelvic ring could be exposed through LRA without cutting the peritoneum, so that the sacroiliac joint, ilium wing and anterior ring fractures could be reduced under direct version. In the treatment of pelvis fragility fractures of the elderly, effective reduction and fixation could be achieved using reconstruction plates or channel screws through LRA.

The therapeutic strategies for pelvic fractures complicated with nerve injuries / 中华骨科杂志

Pelvic fractures usually are high-energy injuries, which often involve high incidence of nerve injury, including lumbosacral plexus injuries and cauda equina injuries. Duo to 50% of neurological improvement has been reported regardless of the type of operative or nonoperative management after pelvic fractures complicated with nerve injuries, it still remains controversial whether surgical exploration is effective in such cases at an early stage and there is also some disagreement between anterior exploration or posterior exploration. We should find out the mechanism of pelvic fractures and the nature of nerve injuries. What's more, we must have a clear understanding of the location and qualitative diagnosis of the nerve injuries. After admission of patients, a detailed physical examination, combined with pelvic X-ray, CT, magnetic resonance neurography (MRN) and other imaging findings, which are conducive to make accurate diagnosis of the nature of nerve injuries, are carried out to make a targeted treatment plan. Generally speaking, cauda equina injuries are more common injuries in U-shaped sacral fractures, which cause the compression and space-occupying lesions of the sacral canal, so the posterior approach is a major approach to achieve the reduction and fixation of the sacral fractures and the decompression of sacral canal. While the lumbosacral plexus injuries are caused by the anterior compression, it is better to perform anterior approach to achieve the desired effect.

Periacetabular osteotomy through the lateral-rectus approach for obsolete acetabular fractures / 中华创伤骨科杂志

Objective:To investigate the surgical techniques and clinical efficacy of periacetabular osteotomy through the lateral-rectus approach (LRA) for obsolete acetabular fractures.Methods:The 22 patients with old acetabular fracture were retrospectively analyzed who had been admitted to Department of Traumatic Surgery, The Third Affiliated Hospital to Southern Medical University from June 2012 to June 2019. They were 16 males and 6 females, aged from 22 to 61 years (average, 45.0 years). By the Judet-letournel classification, there were 4 anterior + posterior hemitransverse fractures, 2 T-shaped fractures and 16 both column fractures. The time from injury to surgery was 3 to 12 weeks in 15 cases, 3 to 6 months in 5 cases, 9 months in one case, and 3 years in one case. After the whole acetabulum was exposed outside the peritoneum through LRA in all patients, periacetabular osteotomy was conducted under direct vision, followed by fixation with multiple reconstruction plates or integrated acetabular airfoil anatomical plates after reduction. Recorded were the operation time, intraoperative blood loss, fracture reduction quality, affected hip function and complications in the patients.Results:In this cohort the operation time ranged from 110 to 205 min, averaging 140.5 min; intraoperative blood loss ranged from 500 to 2,100 mL, averaging 1,250.4 mL. According to the Matta X-ray criteria, the postoperative reduction was assessed as excellent in 7 cases, as good in 11 and as poor in 4, yielding an excellent and good rate of 81.8% (18/22). All the 22 patients were followed up for 12 to 36 months (mean, 22.1 months) and achieved fracture union. The one-year follow-up showed that their modified Merle d'Aubigné & Postel scores ranged from 6 to 18 points, averaging 14.6 points and giving 6 excellent, 10 good, 3 fair and 2 poor cases [an excellent and good rate of 72.7% (16/22)]. Osteonecrosis of the femoral head developed in 2 patients one of whom underwent total hip replacement.Conclusions:As LRA can expose the entire hemipelic ring from the medial side of the pelvis, the periacetabular osteotomy can be performed and the fractures of anterior or posterior column and the quadrilateral area can be reduced under direct vision through the medial side of the acetabulum. Moreover, ideal results can be achieved with the use of multiple reconstruction plates or integrated acetabular airfoil anatomical plates.

Treatment of vertical shear pelvic fracture combined with lumbosacral plexus injury through the lateral-rectus approach / 中华创伤骨科杂志

Objective:To investigate the clinical efficacy of lateral-rectus approach(LRA) for vertical shear fracture of pelvis combined with lumbosacral plexus nerve injury.Methods:A retrospective study was conducted of the 37 patients who had been treated at Department of Orthopaedics, The Third Affiliated Hospital to Southern Medical University for vertical shear pelvic fracture combined with lumbosacral plexus nerve injury from August 2010 to August 2018. They were 25 males and 12 females, aged from 18 to 61 years (mean, 36.2 years). By the Tile classification, there were 31 cases of type C1.3, 5 cases of type C2 and one of type C3. LRA was used in all the patients to explore and release the lumbosacral plexus nerve and to reduce the sacral fracture. The posterior ring was fixated with an anterior iliac plate or sacral screws before fixation of the anterior ring and treatment of the acetabular fracture. The operation time, intraoperative bleeding volume, quality of fracture reduction, fracture union time and recovery of nerve and muscle strength were recorded.Results:For this cohort, the operation time ranged from 105 to 228 minutes (mean, 155.0 minutes) and the intraoperative bleeding volume from 680 to 2, 440 mL (mean, 1, 070 mL). Thefollow-up time ranged from 1 to 8 years (average, 2 years). According to the Matta criteria, the quality of fracture reduction was evaluated as excellent in 21 cases, as good in 12 cases and as fair in 4 cases, giving an excellent and good rate of 89.2%. Follow-ups revealed reduction loss in 4 patients, nonunion and reduction loss in one patient and bony union in the other 32 patients after 8 to 12 weeks (mean, 10.1 weeks). According to the criteria by the Nerve Injuries Committee of the British Medical Research Council (BMRC), the recovery of nerve and muscle strength achieved M5 (full recovery of neurological symptoms) in 22 cases, M4 (fine recovery of neurological symptoms) in 7 cases, M1, M2 and M3 (partial recovery of neurological symptoms) in 5 cases, and M0 (no recovery of neurological symptoms) in 3 cases.Conclusion:LRA is an ideal surgical approach for treatment of pelvic vertical shear fractures complicated with lumbosacral plexus nerve injury, because it can well expose the medial pelvic joint from the sacroiliac joint to the symphysis pubis, allow direct release of the lumbosacral plexus nerve compressed and stretched, and, together with traction of the lower limbs, lead to satisfactory fracture reduction.