Semi-constrained total elbow arthroplasty for the treatment of the elbow disorders / 中华外科杂志

<p><b>OBJECTIVE</b>To retrospectively review the results of Coonrad-Morrey semi-constrained total elbow arthroplasty (TEA) for the treatment of different elbow disorders.</p><p><b>METHODS</b>Between December 2003 and April 2008, 30 patients with different kinds of elbow disorders including elbow fracture, non-healing elbow fracture, rheumatoid arthritis and osteoarthritis were treated with TEA using the semi-constrained Coonrad-Morrey elbow replacement prostheses. One patient had bilateral total elbow replacements. There were 22 females and 8 males, with a mean age of 66 years (47 to 78).</p><p><b>RESULTS</b>Twenty patients (21 elbows) were available for review. The average length of follow-up was 35 months (from 12 to 52 months). The mean Mayo elbow performance score was 84 points. Excellent results were achieved in 6 elbows (28%), 11 elbows had good outcome (52%), 2 elbows had improvement (10%), while the other 2 elbows had no improvement (10%). The 2 elbows with distal humeral fractures, had no pain after treatment but developed heterotopic ossification, which caused stiffness and lower the Mayo elbow performance score. One delayed healing of the wound, one patient experienced temporary radial nerve hypesthesia and one elbow showed transparent region around the implant without radiological sign of loosening in the implanted prostheses.</p><p><b>CONCLUSIONS</b>This study reveals good to excellent outcome with the use of semi-constrained TEA for the treatment of rheumatoid arthritis, elbow fracture, osteoarthritis and non-healing elbow fractures in elder patients. The non-healing elbow fractures in elder patients would accompany with severe osteoporosis and comminuted fracture, which would affect the result of open reduction internal fixation. So TEA may be one optimal treatment for these patients.</p>

Arthroscopic rotator cuff repair for the treatment of rotator cuff tear / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss and evaluate the surgical techniques of arthroscopic rotator cuff repair and its clinical results.</p><p><b>METHODS</b>From March 2002 to May 2005, 44 out of 68 patients treated by arthroscopic rotator cuff repair had been reviewed with a mean post-operation time of 12 months. Of the 44 patients, 40 were available for follow-up, with a mean period of 20.6 (12 - 40) months. The mean age was 56 (30 - 81) years. According to Gerber classification, there were 8 partial tears, 27 small tears and 5 massive tears. No irreparable tear was included in this series. All tears were repaired under the scope, and metal suture anchor (Super-Revo, Linvatec) had been used in all patients. ASES score (American shoulder & elbow surgeons' score), Constant-Murley score and SST (simple shoulder test) questionnaire were adopted before operation and at the latest follow-up.</p><p><b>RESULTS</b>The pre-operation and post-operation mean ASES score was 72.6 vs. 92.3 (P < 0.001), with the mean VAS score for pain 6.2 vs. 1.8 (P < 0.001), the mean forward flexion 74.5 degrees vs. 146.0 degrees (P < 0.001), and the mean external rotation 27.8 degrees vs. 38.3 degrees (P < 0.01). The excellent and good rate for post-operation ASES was 92.5%. The pre-operation and post-operation mean Constant-Murley score was 69.6 vs. 90.4 (P < 0.001), with an excellent and good rate of 90.0%.</p><p><b>CONCLUSIONS</b>Arthroscopic rotator cuff repair is a successful treatment for rotator cuff tear. By the use of suture anchors, scope surgery shares the advantages of minimal morbidity, quick functional recovery and protection of deltoid muscle. With appropriate indication control, descent surgical skill and intense postoperative rehab, gratifying outcome can usually be anticipated.</p>

The role of CT in the diagnosis and treatment of distal radius fracture / 中华外科杂志

<p><b>OBJECTIVES</b>To investigate and discuss the role of CT in the diagnosis and treatment of comminutive distal radius fractures.</p><p><b>METHODS</b>One hundred and eleven consecutive patients (118 cases of fractures) who were admitted to Jishuitan hospital from January 2003 to January 2005 were included in this study. These patients all need operative treatment and accepted CT scans for better understandings of these injuries and helping to make operation plans.</p><p><b>RESULTS</b>after comparing the results of X planes and CT scans, considerable differences existing between the two examinations were found in the measurements of articular compression and step-off, gapping, comminution degree and subdislocation. This difference was manifested not only in the alteration of quantity but also in the change of quality.</p><p><b>CONCLUSIONS</b>Computed tomography can provide more vivid and detailed information of fractures for practitioners. Undoubtedly, CT is especially valuable in the evaluation of severity degree and stability of comminutive distal radius fractures, thus it helps us to determine whether operation is obligatory and choose the best method and approach of operation. Moreover, CT can also clearly show the important parts of fractures which need special attention in the process of operation. At the same time, practitioners are required to understand the indications of CT examination completely and know how to choose scan planes properly.</p>

Percutaneous pinning for the treatment of proximal humerus fractures / 中华外科杂志

<p><b>OBJECTIVE</b>The indication, surgical techniques and results had been discussed through clinical analysis of percutaneous pinning for the treatment of proximal humerus fractures.</p><p><b>METHODS</b>Forty-nine patients with 49 shoulders treated with percutaneous pinning had been reviewed with a mean follow-up period of 16.9 months. All were acute fractures, with a mean age of 40.4 years. There were 39 2-part surgical neck fractures, 6 impacted 2-part greater tuberosity fractures and 4 valgus-impaction 4-part fractures. SST (Simple Shoulder Test) questionnaire, ASES (American Shoulder & Elbow Surgeon) score, Constant-Murley score and UCLA score had been adopted for final evaluation at the latest follow-up.</p><p><b>RESULTS</b>The mean ASES score was 91.4, the mean VAS score was 1.7, the mean forward flexion was 146.7 degrees, external rotation 39.6 degrees, internal rotation at T(8)-T(9) level; the mean Constant-Murley score was 88.2; the mean UCLA score was 31.2; the mean number of questions for "yes" in SST questionnaire was 10.1. All fractures healed with a mean period of 8.8 weeks. No patient had been found for any evidence of humeral head necrosis at the latest follow-up The total satisfaction rate for pain relieve was 95.9% (47/49), and for functional recovery was 91.8% (45/49).</p><p><b>CONCLUSIONS</b>Most 2-part surgical neck fractures, impacted 2-part greater tuberosity fractures and 4-part valgus-impaction fractures are good indications for percutaneous pinning. With appropriate and intense rehabilitation, satisfactory results can be expected in percutaneous pinning for the treatment of certain types of proximal humerus fractures.</p>

Hinged external fixator in elbow trauma management / 中华外科杂志

<p><b>OBJECTIVE</b>To introduce a new way of treatment for elbow stiffness and instability.</p><p><b>METHODS</b>30 cases of elbow trauma were treated with mobile hinged Orthofix elbow fixator, 26 of them were followed up. There are 15 male patients and 11 female patients. The average age is 32.6 years old. The 26 injured elbows involved 12 cases on left side and 14 cases on right side; Sixteen cases on the dominant side and 10 cases on the non-dominant side. Sixteen cases had elbow stiffness, 5 cases had acute radial head fracture and posterior dislocation of the elbow, 3 of cases had Monteggia's fracture dislocation, and 2 cases had neglected posterior dislocation of the elbow.</p><p><b>RESULTS</b>The average follow up time was 6 months (3 - 12 month). The mean time of fixation with fixator was 8.5 weeks (6 - 11 weeks). The mean ROM of the 16 cases of elbow stiffness was (37.5 +/- 0.8) degrees before operation, and (96.5 +/- 0.6) degrees operation, with a significant difference (P < 0.05). The mean Mayo elbow score was (69.5 +/- 1.7) before operation, compared with (82.8 +/- 1.6) after operation, with a significant difference (< 0.05). For the other 10 cases (5 cases with acute radial head fracture and posterior dislocation of the elbow, 3 cases with Monteggia's fracture dislocation, 2 cases with neglected posterior dislocation of the elbow), the average ROM of the elbow flexion-extension was 95 degrees (65 degrees - 150 degrees ); The average range of flexion was 117 degrees; the average loss of extension was 22 degrees; the average pronation was 76 degrees (20 degrees - 90 degrees ), the average supination was 75 degrees (15 degrees - 90 degrees ). Nine of the cases achieved anatomic reduction and proved by X-ray. The mean Mayo elbow score was 84 (49 - 96). Three cases were rated excellent, 4 good, 2 fair and 1 poor. The rate of excellent and good was 70% (7/10). Nine cases had no pain or mild pain, and did not need analgesic. Eight cases returned to their former work, 5 of the cases had complications.</p><p><b>CONCLUSIONS</b>The mobile hinged elbow external fixator have following advantages: (1) distraction of the articular space and enhance fracture healing; (2) allow early movement of the elbow during healing; (3) provide stable environment for the healing after arthrolysis and reconstruction. Mobile hinged elbow external fixator can achieve successful result in the treatment of elbow stiffness or unstable fracture dislocation of elbow.</p>

Biomechanical study of percutaneous pinning as the treatment of proximal humerus fractures / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the influence on fracture stability by different pin construct during percutaneous pinning for the treatment of proximal humerus fractures.</p><p><b>METHODS</b>Eighteen pairs (36) adult fresh-frozen humeri were match-paired and divided into 4 groups. Dual-energy bone density scan had been used in order to rule out the influence by different degrees of osteoporosis of the cadaver. Two-part surgical neck fracture model was carried out unanimously in all 36 humeri. Four terminal threaded pins (2.5 mm in diameter) were used in fixation for all specimen. Parallel type pinning (box type) were carried out in 2 groups and convergent type pinning (fan shape) in the other 2 groups. Instron5566 biomechanical tester was applied in determining both anti-shear and anti-torsion ultimate load of each specimen.</p><p><b>RESULTS</b>There was no statistical difference between parallel pin construct and convergent construct in regard of anti-shear resistance (P = 0.73). But by mean of anti-torsion resistance, the parallel construct had significant advantage over the convergent construct (P = 0.04).</p><p><b>CONCLUSION</b>According to our biomechanical data, parallel pin construct seems to have better torsional stability. We suggest that parallel pin fixation should be applied whenever possible. Convergent pin construct should be considered when parallel construct is not possible or the distance between pins are too small (< 1 cm).</p>

The experimental study of histomorphology and biomechanical of cortical strut allograft in proximal femoral / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the deep-frozen allograft strut in the rabbits for the sake of finding some evidence to support the clinical practice of cortical strut allograft.</p><p><b>METHODS</b>Fifty deep-frozen allograft struts were implanted on the lateral side of the femur in 50 male New Zealand white rabbits. These rabbits were randomly divided into 5 groups. The specimen were retrieved at 2, 4, 8, 16, 24 weeks after surgeries. In each group histomorphology and biomechanic properties were studied.</p><p><b>RESULTS</b>From the X ray photography the edge of the strut would turn blunt at the 4th week, union could be found at the 8th week, the inner side of the strut could be absorbed at the 24th week. In the early stage when the strut was implanted in the rabbit, the capillary would be found to grow into the cortical strut from the interior side of it. Then the capillaries were found to converge at the 16th week. This phenomenon is correspondent with the resorption of the dead bone and formation of the new bone. There are few neoformated capillaries on the lateral side of the strut. From the decalcificied section, allograft struts were found to unit to the host at 4 to 8th week. Osteoclast and the new bone formation could be seen at the 8th week, and 3% of the total area of what had been the allograft was replaced by the new bone at that time, 12% was replaced at the 16th week, 21% at the 24th week. There are few resorption or neoformated bone at the lateral side of the strut. The biomechanical property indicated that the strength of the strut decreased at the early time, and only 38% of its original strength remained at 16 weeks.</p><p><b>CONCLUSIONS</b>The cortical allograft strut can unit to the host by the callus. The capillaries invading into the allograft from the interior side, new bone is formed from the interior side. The biomechanical strength of the strut decreased at early stage.</p>

Clinical research of Schatzker type IV tibial plateau fracture / 中华外科杂志

<p><b>OBJECTIVE</b>To study the characteristic, treatment and prognosis of tibial plateau fracture Schatzker type IV.</p><p><b>METHODS</b>According to the roentgenogram and CT scan in 51 patients, Schatzker type IV injury is divided into 3 types: split, total condylar, depression. In the treatment of split and total condylar injury, if there was no articular depression on CT scan, reduction is done through medial approach; if CT scan demonstrated articular depression, middle approach was used to reduce the depression and bone graft. In split injury, buttress plate was fix on posterior-medial side. In total condylar injury, buttress plate is fix on medial side. In depression injury, fracture was reduced through medial approach, bone graft and buttress plate was fix on medial side. Thirty-three patients were followed up in 41 months averagely. And the statistical analysis was done.</p><p><b>RESULTS</b>The average Lysholm score of 33 patients was 83.2. Eight patients were excellent, 9 were good, 14 were fair, 2 were poor. The range of motion from 30 degrees to 147 degrees (average 110 degrees ). The factors that caused bad results were: the fracture was not anatomical reduced; tibial plateau is more than 4 mm wider than femoral condylar or lateral subluxation exceed 8 mm; varus deformity of knee. They also caused the increase of osteoarthritis.</p><p><b>CONCLUSIONS</b>In order to get anatomical reduction and stable fixation, the approach and fix pattern should be chosen on the bases of classification and CT scan of Schatzker IV injury. The factors which influence the prognosis are: (1) tibial plateau is more than 4mm wider than femur condylar, or lateral subluxation more than 8 mm; (2) Varus deformity. Attention should be paid to avoid these during operation.</p>

Arthroscopic double-bundle posterior cruciate ligament reconstruction using quadriceps tendon-patellar bone autograft / 中华外科杂志

<p><b>OBJECTIVE</b>To describe an alternative procedure of arthroscopic posterior cruciate ligament reconstruction using quadriceps tendon-patellar bone autograft and evaluate the early stage follow-up results.</p><p><b>METHODS</b>Twenty consecutive cases of isolated and combined posterior cruciate ligament deficiency were studied. Quadriceps tendon with patellar bone block was used for preparation of Y-shaped autograft. Double femoral tunnels and single tibial tunnel were precisely drilled respectively at their anatomical footprint. By using this technique, the anterolateral bundle was fixed and tensioned in 90 degrees flexion, whereas the postero-medial bundle was fixed in full extension. In cases of combined injury, reconstruction or primary repair was conducted in one-stage or two-stage procedure.</p><p><b>RESULTS</b>All cases were followed up for 6 months to 12 months, averaging 7.5 months. Lysholm rating scales and IKDC evaluation were used to make clinical subjective evaluations. Anteroposterior translation was measured with KT-1000 arthrometer and stress view radiography. Final Lysholm evaluation showed 5 patients (25%) were excellent, 14 (70%) good, and 1 (5%) poor. IKDC evaluation showed that 1 patient (5%) was graded as A, 16 (80%) as B, 2 (10%) as C and 1 (5%) as D. Stress view examination and KT-1000 arthrometer measurement showed that the average posterior translation improved from 11.5 mm and 11.0 mm preoperatively to 5.2 mm and 5.5 mm postoperatively. One patient was graded as failure.</p><p><b>CONCLUSIONS</b>Arthrosopy assisted procedure of double-bundle posterior cruciate ligament reconstruction is effective and reproducible. The short follow-up clinical results are encouraging. Quadriceps tendon is an ideal autograft alternative for posterior cruciate ligament reconstruction.Combined posterior cruciate ligament injury, especially posterolateral complex insufficiency, should be early recognized and treated properly.</p>

Complications of operative treatment of acetabular fractures / 中华外科杂志

<p><b>OBJECTIVE</b>To improve the effect of operative management of acetabular fractures.</p><p><b>METHODS</b>One hundred and seventy eight acetabular fractures were treated operatively from August 1993 to December 2000. Their functional results and complications were analyzed.</p><p><b>RESULTS</b>One hundred and twelve hips were followed up for an average of 45.7 months. Heterotopic ossification was noted in 26 hips, post-operative osteoarthritis in 22 hips, avascular necrosis of the femoral head in 8 hips, and sciatic nerve injury in 7 hips after operations. No death and infection were found in this series.</p><p><b>CONCLUSIONS</b>Ectopic bone formation develops at extended ilio-femoral and Kocher-Langeneck approaches. Cartilaginous injury of the femoral head is contributable to post-operative osteoarthritis, and imperfect reduction is an important factor in the genesis of osteoarthritis.</p>

Close needling for the treatment of calcifying tendinitis / 中华外科杂志

<p><b>OBJECTIVE</b>To study the effect of close needling in the treatment of calcifying tendonitis.</p><p><b>METHODS</b>Seventeen patients with calcifying tendonitis who had received close needling treatment were followed-up for 9.3 months on average. An 18-gauge or 16-gauge needle was used during needling. X-ray examination was given 4, 6, 8 and every 4 weeks after needling. SST (simple shoulder test) questionnaire, ASES (American Shoulder & Elbow Surgeon) score, constant-Murley score and UCLA score were adopted for evaluation before and after treatment.</p><p><b>RESULTS</b>Calcium deposition disappeared within 4 - 20 weeks mean 9.4 weeks in 15 of the 17 patients after needling for 1 - 3 times. Average ASES score before treatment was 47.7 (34 - 59), forward elevation was 90 degrees (70 degrees - 100 degrees ), external rotation was 15 degrees (0 degrees - 30 degrees ), and internal rotation was L3-4 (L1-buttock). Average constant-Murley score before treatment was 44.6 (34 - 54), UCLA score was 11.6 (8 - 15), and numbers of questions for "yes" in SST questionnaire was 3.4 (2 - 5). After needling the average ASES score was 87.1 (72 - 91), forward elevation was 143.5 degrees (120 degrees - 160 degrees ), external rotation was 40 degrees (30 degrees - 50 degrees ), internal rotation was T(8)-T(9), constant-Murley score was 87.8 (64 - 94), UCLA score was 29.5 (19 - 33), and numbers of questions for "yes" in SST questionnaire was 9.1 (6 - 12). Significant difference was found between before and after needling (ASES: P < 0.01, forward elevation, external rotation and internal rotation: P < 0.01, constant-Murley: P < 0.01, UCLA: P < 0.01, SST: P < 0.01).</p><p><b>CONCLUSIONS</b>Close needling is an effective method for the treatment of calcifying tendonitis. Symptoms and disability are greatly relieved non-surgically in most of patients. Care should be taken in differential diagnosis of degenerative calcification in chronic rotator cuff disease.</p>

Selection of dorsal or volar internal fixation for unstable distal radius fractures / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the results of T-plate in the treatment of unstable distal radius fractures.</p><p><b>METHODS</b>Dorsal or volar T-plate fixation was used for unstable distal radius fractures according to different types of fracture. For comminuted fractures with severe cortex destruction and insufficient buttress, artificial bone graft or autograft was adopted to restore local stability.</p><p><b>RESULTS</b>Satisfactory reduction was achieved after surgery. Functional rehabilitation under surveillance began from the 2nd or 3rd post-operative day. The overall excellent or good recovery rate was 90.77% after a mean follow-up of 29.63 months. For the 55 sides of volar fixation (30 sides with a dorsal displacement fragment), excellent or good recovery rate was 92.72%. Dorsal fixation was used in delayed cases (> 6 weeks) or certain fracture patterns unsuitable for volar approach. The excellent on good recovery rate was 77.77%.</p><p><b>CONCLUSIONS</b>Volar approach is an ideal option not only for distal radius fracture with a volar displaced fragment but also for dorsal displaced fractures (Colles' fracture). The advantages of this approach include flat cortex for easy plate fixation, better tension band effect, less soft tissue destruction, leaving dorsal soft tissue hinge intact, and avoiding bone graft leakage. Satisfactory results can be obtained in those patients with unstable distal radius fracture through volar approach plate fixation, especially in those with fresh fractures. If possible, volar approach can also be used in delayed fractures within 6 weeks. The results of dorsal fixation is a little bit inferior.</p>

Comparison of evaluating system for patients with spinal metastases / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the differences in selecting patients who will undergo operation by comparing the evaluating systems and to discuss the indication of surgery performed on patients with spinal metastases.</p><p><b>METHODS</b>Of the 113 patients presented at Jishuitan Hospital, Beijing, PRC. from February 1994 to February 2002, who were diagnosed as spinal metastases, the clinical, pathological and imaging records of 82 patients were reviewed. Harrington's classification system, Tokuhashi's scoring system, Tomita's scoring system, and Grubb's scoring system were used to evaluate each of these patients at the same time. The classification or score concerning each patient was recorded and compared. SPSS software was used for statistical analysis. McNemar Test was used to compare the proportion of surgery indicated by different evaluating systems.</p><p><b>RESULTS</b>(1) Surgical treatment was indicated for 92.7% of patients by Tomita's scoring system and 69.5% by Harrington's classification system respectively. The difference was statistically significant at the level of P < 0.001. (2) Seventy-five cases with spinal cord palsy and progressive pain could be assessed by Tokuhashi's system. These patients were evaluated by Tomita's system at the same time. The type of surgery determined by Tokuhashi's score was excisional operation for 20% of the patients, palliative operation for 20%. As for the remaining 60%, either excisional or palliative operation might be chosen. The type of surgery determined by Tomita's score was excisional operation for 49.3% of the patients, palliative for 42.7%, and nonsurgical modality for the remaining 8.0%. (3) Twenty-five patients were classified as I, II or III, by Harrington's classification system. These patients were evaluated by the Grubb scoring system to predict the possibility of pathologic fracture and by Tomita's system at the same time to determine if an operation was necessary. By Grubb's system, prophylactic stabilization was necessary for twenty-two patients. By Tomita's system, surgery was chosen for 23 patients. But the treatment options were different in 5 patients assessed by the two systems.</p><p><b>CONCLUSIONS</b>There was a great difference in the selection of treatment modality for patients with spinal metastases by different evaluating systems. That no systems have incorporated the evaluation of life expectancy and the local lesion causes differences. The patients should be evaluated individually by more factors than those proposed by the established systems.</p>

Humeral head replacement for the complex treatment of proximal humerus fractures / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate indication, technical key during surgery and early results of humeral head replacement for the treatment of complicated proximal humerus fractures.</p><p><b>METHODS</b>Sixteen patients who received humeral head replacement were reviewed with a mean follow-up period of 6.8 months. Of the 16 patients, 15 suffered acute fractures with the mean interval between injury and surgery being 8 days. 1 case was a malunion after ORIF 1 year ago. The mean age for these patients were 58.9 years. Trauma series X-rays were taken at post-operation 2-week, 6-week, 10-week, 16-week 6-month and the latest follow-up. SST (Simple Shoulder Test) questionnaire, ASES (American Shoulder & Elbow Surgeon) score, Constant-Murley score and UCLA score had been adopted for evaluation at the latest follow-up.</p><p><b>RESULTS</b>The mean ASES score was 89.1 (64 - 94); the mean VAS score was 2.7 (0 - 5); the mean forward flexion was 128.1 degrees (90 degrees - 150 degrees ), external rotation 35 degrees (30 degrees - 40 degrees ), internal rotation at T8-T9 level (L1-T6); the mean Constant-Murley score was 85.7 (53 - 95); the mean UCLA score was 30.4 (21 - 33); the mean number of questions for "yes" in SST questionnaire was 9.3 (7 - 11). The total satisfaction rate for pain relief was 93.8% (15/16), and functional recovery was 87.5% (14/16).</p><p><b>CONCLUSIONS</b>Through strict indication control, appropriate timing, meticulous surgical techniques and long intense rehabilitation, satisfactory results can be obtained in humeral head replacement for the treatment of complicated proximal humerus fractures. Our report is only a preliminary one on early results, and a long-term follow-up data is needed for further evaluation.</p>

Operative treatment of delayed acetabular fractures / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the operative methods of delayed acetabular fractures and the operative results.</p><p><b>METHODS</b>The operative approaches, procedures, results and complications of the delayed acetabular fractures between August 1993 and August 2001 in Jishuitan Hospital were evaluated retrospectively.</p><p><b>RESULTS</b>Thirty-two patients were followed up 49.6 months on average. Sciatic nerve palsy was found in 1 patient. Excellent functional results of hip joints were found in 3 patients, good in 16, fair in 10, and poor in 3. Ectopic bone formation was observed in 6 patients and necrosis of the femoral head in 3.</p><p><b>CONCLUSION</b>Careful selection of operative indications of delayed acetabular fractures in combination with proper operative approach and appropriate reduction and fixation, good results can be obtained.</p>