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Objective:To investigate the clinical significance of excessive inlet view in fluoroscopy-assisted placement of sacroiliac screws.Methods:Included for this prospective study were 47 patients with unstable pelvic fracture who had been admitted to Department of Orthopaedic Trauma, Xi'an Honghui Hospital between January 2020 and January 2021. There were 30 males and 17 females, with a mean age of 39.4 years (from 25 to 66 years). By the Tile classification, 21 fractures were type B and 26 ones type C. The inlet view and the angle of excessive inlet view were measured before operation. The intraoperative placement of sacroiliac screws was assisted by C-arm fluoroscopy navigation in the excessive inlet view. The positions of sacroiliac screws were verified by CT or O-arm fluoroscopy after operation. The screw placement time, fracture reduction quality, fracture healing time, and pelvic function at the last follow-up were recorded.Results:A total of 67 screws were implanted in the 47 patients, including 56 sacroiliac screws. The insertion time for each screw averaged 19.9 min (from 9 to 31 min); the angle of excessive inlet view averaged 17.38° (from 12.1° to 24.8°). Verification by O-arm fluoroscopy or CT revealed that all sacroiliac screws were located in the sacral canal without dislocation or breaking through the cortical bone. By the postoperative Matta scoring, the reduction was excellent in 22 cases, good in 17, acceptable in 6, and poor in 2, giving an excellent to good rate of 83.0%(39/47). The average follow-up time for the 47 patients was 9.5 months (from 5 to 15 months); fracture healing time averaged 10.5 weeks (from 7 to 16 weeks). By the Mejeed scoring at the last follow-up, the pelvic function was excellent in 26 cases, good in 15 and acceptable in 6, giving an excellent to good rate of 87.2% (41/47).Conclusions:Fluoroscopy in the excessive inlet view is a simple and easy intraoperative technique. It can improve accuracy and safety of sacroiliac screw placement because it allows clear identification of the posterior border of the sacrum and effectively avoids iatrogenic injury to the sacral nerve caused by screws breaking through the bone cortex.
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Objective:To evaluate the effects of weight-bearing area compression injury of the femoral head on the prognosis of elderly acetabular fractures after open reduction and internal fixation.Methods:A retrospective analysis of 36 elderly patients with acetabular fractures treated with open reduction and internal fixation during January 2014 to January 2018 were conducted. All patients with compression injury of the weight-bearing area of the femoral head, including 22 males and 14 females with 73.2±6.5 years old (range 60-87 years old), were included. The compression injury of weight-bearing area of the femoral head was not treated. According to the Letournel-Judet classification of acetabular fractures, there were 14 cases with both-column, 12 cases with anterior column and posterior hemitransverse, 4 cases with T type, 4 cases with transverse, and 2 cases with posterior column+ posterior wall. A total of 14 cases were accompanied by acetabular joint surface compression, while 29 cases were accompanied by joint dislocation. The Merle d'Aubigné score was used to evaluate the hip function during follow-up. The Matta classification method was used to evaluate the results of acetabular fracture reduction. The Kellgren-Lawrence classification standard and Ficat-Alert staging method were used to evaluate the traumatic arthritis of the hip and femoral head necrosis, respectively. During the follow-up, the femoral head necrosis with stage III, IV, or traumatic arthritis III, IV, or with indications for joint replacement was defined as surgery failure. CT scans of the pelvis were performed before and at 2-5 days after operation. The compression size of the femoral head on the coronal and axial planes of the CT scan was calculated for the compression volume. The compression severity was divided into small (<1 cm 3), medium (1-2 cm 3) and large (>2 cm 3) according to the volume. Binary Logistic regression analysis was used to analyze whether the postoperative measurement of the femoral head compression volume was associated with the risk of surgical failure. Results:All patients were followed up for 34.7±8.9 months (range 25-54 months). There were 7 cases with large compression of femoral head, 14 cases with medium, and 15 cases with small pre-operatively. However, there were 12 cases, 10 cases and 14 cases with large, medium and small at 2-5 days after operation, respectively. Six cases were excellent reduction, 22 cases were good, and 8 cases were poor. Thus, the excellent and good rate was 78% (28/36). At the last follow-up, Merle d'Aubigné score was excellent in 2 cases, good in 8 cases, fair in 5 cases, and poor in 21 cases. The excellent and good rate was 28% (10/36). There were 20 cases with surgery failure with 56% (20/36) failure rate. There were no statistically significant differences in the patient's age, body mass index, operation duration, blood volume, fracture type, fracture reduction, combined acetabular joint surface compression, and combined joint dislocation between the two groups. However, there was a statistically significant difference in the frequency distribution of compression volume in the weight-bearing area of the femoral head after surgery (χ 2=22.047, P<0.001). In patients with large, medium, and small-volume compression of the femoral head weight-bearing area, the surgery failure rates were 92%, 80%, and 7%, respectively. The large and medium-volume compression of the femoral head weight-bearing area were independent risk factors for surgical failure. Conclusion:Open reduction and internal fixation can be used to treat elderly patients with acetabular fractures combined with femoral head compression injury. Despite satisfactory reduction for acetabular fractures, the larger volume of femoral head compression affects the clinical outcomes with extremely high rate of surgical failure within 2 years.
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Objective:To compare the predictive values between 4 risk assessment scales for deep venous thrombosis (DVT) in patients with pelvic or acetabular fracture.Methods:The clinical data of 235 patients with pelvic or acetabular fracture were retrospectively analyzed who had been admitted to Xi'an Honghui Hospital from July 2014 to July 2018. They were 168 males and 67 females, aged from 18 to 90 years (average, 43.5 years). They were divided into a DVT group and a DVT-free group according to the results of vein ultrasongraphy. The RAPT, Caprini, Wells, and Autar scales were used respectively to assess the risk of DVT in the patients. The 2 groups were compared in terms of the scores of the 4 scales. After the receiver operating characteristic curve (ROC) was drawn and the area under the ROC curve (AUC) was calculated, the predictive values of the 4 scales were evaluated for lower limb DVT in the patients with pelvic or acetabular fracture.Results:Of the 235 patients, 104 (44.3%) had DVT. There was no statistically significant difference in the preoperative general data between the 2 groups, showing comparability ( P>0.05). The DVT group scored significantly higher in RAPT, Wells and Autar scales than the DVT-free group( P<0.05). The AUCs for the RAPT, Caprini, Wells, and Autar scales were respectively 0.84±0.02, 0.65±0.05, 0.81±0.02 and 0.72±0.03, showing significant differences ( F=1.254, P=0.031). The AUCs for RAPT and Wells scales were significantly higher than those for Caprini and Autar scales, and the AUS for Autar scale was significant higher than that for Caprini ( P<0.05). The sensibilities for RAPT, Caprini, Wells and Autar scales were respectively 94.0%, 65.0%, 90.6% and 84.0% while the specificities for them 62.1%, 51.8%, 67.2% and 32.5%. Conclusion:Although all the 4 scales have a certain predictive value for the DVT risk in patients with pelvic or acetabular fracture, RAPT and Wells scales are more valuable.
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Objective To compare the perioperative incidence of deep venous thrombosis (DVT) and level of plasma D-dimer between different ages in patients with lower limb fracture in Northwest China.Methods The data were retrospectively analyzed of the 1,185 patients with lower limb fracture in 5 provinces in Northwest China from July 2014 to March 2017.They were 583 males and 602 femals,with an average of 60.3 years(from 18 to 102 years).Of them,723 were from Shaanxi Province,148 from Gansu Province,137 from Qinghai Province,128 from Ningxia Hui Nationality Autonomous Regions and 49 from Xinjiang Uygur Autonomous Region.They were divided into a young group (≤44 years old) (n =288),a middle-aged group (from 45 to 59 years old) (n =256),a junior elderly group (from 60 to 74 years old) (n =263),and a senior elderly group (≥75 years old) (n =378).The incidences of perioperative deep venous thrombosis (DVT) and levels of plasma D-dimer were compared between the 4 age groups.Results The DVT incidences before and after operation in the young group were significantly lower than in the other 3 groups (P ＜ 0.05);the DVT incidence after operation in the middle-aged group was significantly lower than that in the junior elderly group (P ＜ 0.05).The pre-and post-operative levels of plasma D-dimer increased with the age of the patients;the pre-and post-operative levels of plasma D-dimer in the senior elderly group were significantly higher than in the other 3 groups (P ＜ 0.05).Conclusions The perioperative incidence of DVT was high in the elderly patients with lower limb fracture in Northwest China,peaking in the age range from 60 to 74 years old.The pre-and post-operative levels of plasma D-dimer increased with the age of the patients.
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Objective To investigate the therapeutic efficacy of contralateral less invasive stabilization system (LISS) through a medial-posterior approach for fractures of femoral medial condyle.Methods From December 2010 to December 2014,14 patients with fracture of femoral medial condyle were treated surgically at our department.They were 10 males and 4 females,aged from 33 to 64 years (average,44.6 years).By AO classification,10 cases were type 33-B2 and 4 cases type 33-B3.Causes of injury included traffic accident in 7 cases,falling in 6 and heavy object crush in one.Internals from injury to operation ranged from 3 to 10 days (average,5.4 days).All the patients were treated by open reduction and internal fixation with contralateral LISS plate or T plate through a knee medial posterior approach.Results The 14 patients were followed up for 12 to 24 months (average,18 months).All fractures got bony healing after 3 to 5 months (average,3.5 months).No collapse of joint surface,joint stiffness,joint infection,malunion or nonunion occurred.According to the Schatzker-Lambert criteria for functional recovery of the distal femoral fractures,the function of the affected knee was assessed at the last follow-up as excellent in 9 cases,good in 3,fair in one and poor in one.Conclusion Open reduction and internal fixation with contralateral LISS plate through a medial-posterior approach is effective for fractures of femoral medial condyle due to its strong buttress,rigid fixation,advantage for early functional exercise,and satisfactory therapeutic outcome.
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Objective To evaluate the clinical treatment of unstable pelvic fractures by posterior ring fixation using percutaneous minimally invasive pedicle screws following anterior ring fixation.Methods From January 2010 to January 2016,31 patients with unstable pelvic fracture were treated at our department.They were 20 males and 11 females,with an average age of 44.4 years (range,from 18 to 65 years).According to the Tile classification,6 cases were type B2,8 cases type B3,12 cases type C1,and 5 cases type C2.The anterior pelvic ring was fixated in supine position first,and the posterior pelvic ring was fixated next using percutaneous minimally invasive pedicle screws.The operation time,intraoperative bleeding,and frequency of fluoroscopy needed for the posterior ring fixation were recorded.Reduction quality,complications like loss of reduction and pelvic function at the final follow-up were also assessed.Results For the posterior ring fixation in the 31 patients,the operation time ranged from 40 to 60 minutes (average,50.7 minutes),blood loss from 30 to 80 mL (average,42.9 mL),and fluoroscopic frequency from 7 to 12 times (average,9.7 times).By the Tornetta evaluation,the reduction was rated postoperatively as excellent in 15 cases and as good in 16 ones,yielding an excellent and good rate of 100％.Twenty-nine patients obtained complete follow-up for 12 to 83 months (average,34.7 months),and they achieved bone union after an average of 14.5 weeks (range,from 12 to 16 weeks).According to the Majeed criteria for pelvic function at the final follow-up,10 cases were rated as excellent,16 cases as good,and 3 cases as fair,giving an excellent and good rate of 89.7％.No reduction loss,incision infection,vascular or nerve injury,screw loosening or breakage,or fracture displacement was observed during follow-up.Conclusion In the treatment of unstable pelvic fractures,posterior ring fixation using percutaneous minimally invasive pedicle screws following anterior ring fixation can lead to less operation time,intraoperative bleeding and fluoroscopic radiation,and satisfactory fracture reduction and functional recovery of the pelvis as well.
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Objective To evaluate the clinical outcomes in patients with both column acetabular fractures involvement posterior wall using lag screw through single ilioinguinal approach.Methods Between August 2008 to August 2014,35 consecutive patients with both columns acetabular fractures and fracture also involved posterior wall and fixed by lag screws were retrospectively analyzed.There were 25 males and 10 females.The average age was 44.4+ 12.5 years (range,18-72 years).According to Letournel classifications,the acetabular fracture involved both columns and posterior wall in all cases,and 2 cases with additional seagull sign.The surgeon reduced posterior wall by pressing the fragment through a small tunnel in the soft tissue leaning against the external cortex of iliac bone and fixed the fragment using lag screws from the anterior side.Clinical and functional outcomes were assessed using the modified Merle d'Aubigné scoring system.Radiographic results were evaluated based on Matta scoring system.Results The patients were follow for an average of 44.7+ 18.9 months (range,24-96 months).The average operative time was 257.7±60.4 min (range,160-490 min).The average blood loss during the operating was 742.9±+614.5 ml (range,300-4 000 ml).Loss of reduction of the posterior wall was not found in any case.At the latest follow-up,radiographic results were excellent in 11,good in 19,and poor in 5.The average modified Merle d'Aubigné score was 16.4 (range,13-18).There were 8 cases of excellent,23 cases of good,and 4 cases of fair.Four patients developed deep venous thrombosis of the lower extremities after 3-4 days of operation.Warfarin was used for anticoagulation therapy and thrombi disappeared 6 months postoperatively.One case had superficial wound infection and was treat with vacuum sealed drainage (VSD) and anti-infection therapy.The incision healed without infection after one month.One case with poor quality of reduction and remaining seagull sign was treated with total hip arthroplasty after 35 months because of severe traumatic arthritis.The total reoperation rate was 5.7％ (2/35).latrogenic sciatic nerve injury as well as heterotopic ossification was not found in any case.Conclusion Satisfactory quality of reduction and good clinical outcomes can be achieved in patients with acetabular fractures involved both columns and posterior wall by single ilioinguinal approach and lag screw fixation for posterior wall.Iatrogenic sciatic nerve injury as well as heterotopic ossification was not found in any case.
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Objective To assess the effect of preoperative administration of tranexamic acid (TXA) on the hidden blood loss in the surgery of intertrochanteric fractures with proximal femoral nail anti-rotation (PFNA).Methods Eighty patients with intertrochanteric fracture were treated with PFNA in our hospital from November 2015 to July 2016.They were 15 men and 65 women,with a mean age of 72.6 years.Of them,39 were included into TXA group where TXA was administered preoperatively and 41 were assigned into the control group where no TXA was used preoperatively.Blood routine examinations were carried out on one day before operation,the first and third days after operation.The surgical blood loss,operative blood transfusion,24-hour drainage after operation,and postoperative 3-day blood transfusion were recorded.The total and hidden blood losses were calculated according to the formula.The 2 groups were compared in terms of blood loss and complications.Results In TXA group,the total blood loss (1,632.3 ± 849.2 mL),the hidden blood loss (1,270.9 ± 623.3 mL) and the transfusion rate (28.2％) were significantly lower than those in the control group (2,014.8 ± 924.7 mL,1,549.1 ± 624.9 mL and 56.1％) (P ＜ 0.05).There was no significant difference between the 2 groups in visible blood loss (361.4 ± 154.3 mL for TXA group versus 465.7 ± 191.3 mL for the control group) (P ＞ 0.05).Deep venous thrombosis occurred in 2 patients,limb swelling in one patient and wound dehiscence in one patient in TXA group while deep venous thrombosis occurred in one patient,limb swelling in 3 patients and wound dehiscence in none in the control group,showing no significant differences between the 2 groups (P ＞ 0.05).No infection was observed in either group.Conclusion Preoperative administration of TXA can reduce surgical hidden blood loss and transfusion rate as well but will not increase the risk of deep vein thrombosis in the surgery of intertrochanteric fractures with PFNA.
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Objective To evaluate the clinical outcomes of ilioinguinal approach with short infrapectineal buttress plate fixing posterior column for patients with complex acetabular fractures. Methods Data of 29 consecutive patients (male 22, fe?male 7, age range 25-72 years, average age 53 ± 6.3 years) with complex acetabular who had operated by single ilioinguinal ap?proach with infrapectineal buttress plate from September 2008 to August 2012 were retrospectively analyzed. According to Letour?nel?Judet classifications, there were 4 cases of anterior column and posterior hemi?transverse, 11 cases of associated both?column, 4 of T?shaped and 6 with seagull sign. The acetabular fractures model was printed preoperatively by 3D printing technique for sur?gical simulation, open reduction and internal fixation through single ilioinguinal approach with a short infrapectineal plate fixing posterior column, particularly an ox horn shape K?wire sleeve was developed for drilling and screw insertion using flexible screw?driver. Clinical, radiographic, and functional outcomes assessed by the modified Merle d’Aubigné score were collected. Results Two patients were lost to follow?up, including one patient who died at 15 days postoperative because of pulmonary embolism, and the other one who had moved abroad at 12 months postoperative. The remaining 27 (93%) had a mean follow?up of 40 months (range, 24-75 months). The operating time was 180±35.5 min;the time for the fracture union was 3.5±0.9 month;blood loss during the operating was 500±43.9 ml;no case had fracture re?displacement. At the latest follow?up, radiographic grades were excellent in 17, good in 8, poor in 4, including one poor patient who had a total hip arthroplasty (3%) at 35 months after the internal fixation. The average modified Merle d’Aubigné score was 16 (range, 10-18), and categorized as excellent in 12, good in 8, fair in 5, and poor in 2. Three patients had developed deep venous thrombosis of the lower extremities, and one of them died of pulmonary embo?lism 15 days after operation; two cases of deep venous thrombosis of the lower extremity were found 3-4 days after operation. Thrombosis disappeared 6 months after anticoagulant therapy by warfarin. One case who had superficial wound infection after oper?ation was treated by anti?infection and VSD negative pressure, and incision was healed after one month. One case with poor quality of fracture reduction and seagull sign was treated with total hip arthroplasty after 35 months because of traumatic arthritis. The to?tal complication rate was 24%(7/29). Conclusion In the patient with complex acetabular fractures combining posterior column medial displacement, single Ilioinguinal approach with infrapectineal buttress plates could achieve a stable concentric hip joint, and immediate postoperative ambulation can result in reasonable clinical, radiographic, and functional outcomes.
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Objective To investigate the incidence and risk factors of deep venous thrombosis (DVT) of lower extremity in patients with pelvic or acetabular fracture.Methods From August 2015 to December 2016,110 patients with pelvic or acetabular fracture were treated in our hospital.They were 76 males and 34 females with a mean age of 44.2 years (range,from 16 to 76 years).There were 48 pelvic fractures,including 12 anterior and posterior compression,16 lateral compression and 20 vertical shear ones by the Young-Burgess classification;there were 62 acetabular fractures,including 26 simple and 36 complex ones by the Letournel-Judet classification.The incidence of lower extremity DVT was detected preoperatively and postoperatively using ultrasound detection.The factors associated with the incidence of DVT were analyzed statistically.The risk factors were screened by single factor logistic regression analysis;the major independe risk factors were determined by multi-factor logistic regression analysis.P ＜ 0.05 was considered as statistically significant.Results DVT occurred in 32 patients (29.09％),including 21 cases (19.09％) of proximal thrombosis and 3 cases of combined pulmonary embolism.The incidence of DVT in patients with acetabular fracture was significantly higher than in those with pelvic fracture (P ＜ 0.05);the incidence of proximal DVT in patients with complex acetabular fracture was significantly higher than in those with simple acetabular fracture (P ＜ 0.05).Multivariate analysis showed that age of ＞ 60 years,combined injuries and interval of ＞ 2 weeks from injury to surgery were independent risk factors for incidence of DVT (P ＜ 0.05).Conclusions The risk of lower extremity DVT is high in patients with pelvic or acetabular fracture in spite of active prophylaxis,especially the risk of proximal thrombosis.Age of ＞ 60 years,combined injuries and interval of ＞ 2 weeks from injury to surgery may be the independent risk factors for incidence of DVT.
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Objective To explore the effect of treating posterolateral tibial plateau fractures via the fibular osteotomy approach.Methods From August 2009 to August 2011,17 patients with posterolateral tibial plateau fractures,including 12 males and 5 females,aged from 24 to 76 years (average,37.8 years),were treated via the fibular osteotomy approach in our hospital.According to the Schatzker classification,8 cases were type Ⅱ,3 cases were type Ⅲ,6 cases were type V.After operation,X-rays were taken in all patients,and Rasmussen's radiological and functional gradings were used to evaluate radiological and functional outcomes of knees.Results All patients obtained follow-up,ranged from 9 to 35 months (average,18months).The healing time of the fracture ranged from 10.0 to 18.0 weeks (average,13.5 weeks).During the period of followed-up,there was no loss of reduction; one case presented with symptoms of common peroneal nerve injury,such as local hypesthesia in distal lateral lower leg and dorsi pedis,which recovered two weeks postoperatively.According to Rasmussen's radiological grading,the mean score of the knee joint was 17.5(range,14.0 to 18.0).The range of motion of the knee joint ranged from -5°to 135°(average,123.5o).According to Rasmussen's functional grading,the mean score of the knee joint was 26.9 (range,22 to 30).Conclusion Treating posterolateral tibial plateau fractures via the fibular osteotomy approach can obtain sufficient exposure,good reduction and fixation,and avoid flexion contracture of the knee and peripheral vascular nerve injury.Moreover,postoperative function and stability of the knee joint recover well.
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AIM AND METHODS: To explore the effects calcitonin gene-related peptide (CGRP) and endothelin-1(ET-1) on the mechanisms of hypoxic pulmonary hypertension (HPH),the contents of CGRP and ET-1 in plasma of pulmonary artery and thoracic aorta and in extractives of lung and ventricular tissues of the chronic hypoxic rats were determined by radioimmunoassay. The changes of their hemodynamic indices and right heart hypertrophy index were monitored simultaneously. RESULTS: The level of pulmonary artery plasma CGRP was significantly higher than that of thoracic aorta plasma,but just the reverse was ET-1 or the ratio of ET-1 and CGRP in control rats( P