Analysis of Factors Affecting Postoperative Loss of Reduction in Unstable Thoracolumbar Fractures

STUDY DESIGN: Retrospective analysis OBJECTIVES: Loss of fracture reduction after posterior surgery to treat unstable thoracolumbar fractures can cause several complications. We analyzed the factors influencing postoperative loss of reduction. SUMMARY OF LITERATURE REVIEW: Controversy exists about the factors causing postoperative loss of reduction in thoracolumbar fractures during the follow-up period. MATERIALS AND METHODS: We analyzed the records of 59 patients who underwent posterior surgery for thoracolumbar unstable fractures and had completed a minimum follow-up of 1 year. Postoperative loss of reduction was defined as 30% or more loss of vertebral body height or 15° or more progression of the kyphotic angle at the 1-year follow-up compared to immediately after surgery. The associations between the patients??gender, age, level of fracture, injury of the posterior column, initial loss of fractured vertebral body height, load-sharing score, Thoraco-Lumbar Injury Classification and Severity score, number of fixed segments, type of pedicle screws, degree of postoperative reduction, degree of postoperative corrected kyphotic angle, changes in the insertion angle of the most proximal and the most distal pedicle screws, decreases in the upper and lower disc height of the fractured vertebral body, and postoperative loss of reduction were analyzed. RESULTS: Thirteen patients (22.0%) had postoperative loss of reduction. Age at the time of the operation (p=0.034), initial loss of fractured vertebral body height (p=0.042), and changes in the insertion angles of the most distal pedicle screws (p=0.021) were significantly associated with postoperative loss of reduction. However, the other factors did not show a significant relationship. CONCLUSIONS: In patients who underwent posterior surgery for unstable thoracolumbar fractures, the frequency of loss of reduction was high in patients more than 45 years old at the time of the operation, with a 50% or more loss of the initial fractured vertebral body height, and with changes of 5° or more in the insertion angles of the most distal pedicle screws.

Fracturas intertrocantéricas inestables tratadas con clavos endomedulares cortos intertrocantéricos/subtrocantéricos. Valoración de la calidad de vida y de la recuperación funcional / Unstable intertrochanteric fractures treated with ITST short intramedullary nails. Quality of life and functional recovery assessment

Introducción: El objetivo de este estudio fue evaluar una serie de pacientes con fracturas intertrocantericas inestables tratados con clavos cortos intertrocantericos/subtrocantericos (ITSTR), con especial atencion en la calidad de vida y la recuperacion funcional. Materiales y Métodos: Se incluyeron 171 pacientes con fracturas AO 3.1 A2 y A3, un seguimiento minimo de 14 meses y una edad promedio de 79 anos. Se evaluaron la calidad de vida mediante la escala WOMAC reducida convertida a una escala del 1 al 100, la recuperacion funcional en funcion del tiempo en que se logro la bipedestacion, la necesidad de ortesis al final del seguimiento y el regreso a las actividades diarias utilizando la subescala de funcion de la Musculoskeletal Tumor Society. Resultados: A los 14 meses, el promedio de la escala WOMAC total fue 77. El 73% de la poblacion camino dentro de las 36 h de la cirugia. El 48% retorno a las actividades diarias con una restriccion minima, el resto tuvo restricciones recreativas y parciales. El 71% del grupo que no utilizaba ortesis conservo tal condicion al finalizar el seguimiento. La incidencia de complicaciones intraoperatorias y posoperatoria fue del 6,5% y 23%, respectivamente. La fractura distal al clavo y el cut-out se produjeron solo en el 1%. Conclusiones: La baja incidencia de cut-out y de fractura distal al clavo con la posibilidad de retorno temprano a las actividades, con una calidad de vida y funcion buenas, convierten al ITSTR en una alternativa de eleccion para tratar las fracturas intertrocantericas inestables de cadera. Nivel de evidencia: IV.

Introduction: The aim of this study was to evaluate a consecutive series of patients with unstable inter- or subtrochanteric fractures (AO 3.1 A2 and A3) treated with short nail fixation (ITSTR), focusing mainly on quality of life and functional recovery. Methods: We included 171 patients with intertrochanteric hip fractures (AO 3.1 A2 and A3), with a minimum follow-up of 14 months. The average age was 79 years. The following parameters were evaluated: quality of life using the WOMAC reduced scale converted to a 1 to 100 scale; functional recovery based on the time needed to achieve standing position, need for orthesis at the end of the follow-up, and return to daily activities using the American Musculoskeletal Tumor Society functional scale. Results: After 14 months the average WOMAC score was 77. The 73% of the group was walking within 36 hours after surgery, 48% of the patients were able to return to their daily activities with minimal restriction, and the rest only presented partial or recreational restrictions. Considering the group without orthesis before surgery, 71% were able to maintain this condition at the end of the follow-up. The incidence of complications was 6.5% during the procedure and 23% after it. The nail distal fracture and the "cut-out" were observed in only 1% of the cases. Conclusions: The low incidence of nail distal fracture and the "cut-out", together with the early return to the daily activities and the good quality of life and function make the short ITSTR nail fixation the treatment of choice for unstable intertrochanteric hip fractures. Level of evidence: IV.

Comprehensive evaluation of intramedullary fixation and extramedullary fixation in the treatment of unstable femoral intertrochanteric fractures / 中国组织工程研究

BACKGROUND:Nowadays, the internal fixation materials for the clinical treatment of unstable femoral intertrochanteric fractures are broadly divided into two categories:intramedul ary fixation system and extramedul ary fixation system. However, the effects of the treatments usual y lack of macro evaluation. OBJECTIVE:To compare the effect of intramedul ary fixation system and extramedul ary internal fixation system in the treatment of unstable femoral intertrochanteric fractures. METHODS:217 patients with unstable femoral intertrochanteric fracture (Evans typing: Ⅲ type to Ⅴ type and R type) were treated by using intramedul ary fixation system and extramedul ary internal fixation system:18 cases were treated with dynamic condylar screw, 67 cases were treated with dynamic hip screw, 43 cases were treated with reconstruction nail, 72 cases were treated with proximal femoral anti-rotation blade nail, and 17 cases were treated with new generation of antegrade interlocking intramedul ary nail. The operative time, length of incision, blood loss, time in bed, fracture healing time, complications and Harris hip score were analyzed and compared. RESULTS AND CONCLUSION:In the aspects of operative time, blood loss, time in bed, complications and Harris hip score, the intramedul ary fixation system was superior to extramedul ary internal fixation system. But there were significant differences in the aspects of length of incision and fracture healing time between two methods. The results showed that the treatment of unstable femoral intertrochanteric fractures by using intramedul ary fixation system was better than the extramedul ary internal fixation system, as the intramedul ary fixation system could effectively shorten the operative time and reduce blood loss. This stable and reliable fixation enables patients to take early postoperative functional exercise, and could significantly shorten the time in bed and reduce the incidence of complications and it is conducive to postoperative hip function recovery. Therefore, intramedul ary fixation system is an ideal method for the treatment of unstable femoral intertrochanteric fractures.

Operative Management of Metacarpal and Phalangeal Fractures.

Fractures of metacarpals and phalanges are probably the most common fractures in the skeletal system and are often neglected as minor injuries. Most of the fractures are treated conservatively but some form of fixation is often indicated in unstable fractures, intra-articular fractures, open fractures and multiple fractures. Various implants ranging from K-wires to mini-plates are used. A retrospective analysis of 50 cases of metacarpal and phalangeal fractures treated by different methods over a period of one year was undertaken. The study showed that right hand was more commonly involved. Most common mechanism of injury was fall and second ray was most commonly involved. Most common fracture pattern was transverse and K-wires were frequently used as mode of fixation followed by mini-plates. The patients were followed up at regular intervals and union was achieved in 98% of fractures. From our study we would emphasize that operative management of metacarpal and phalangeal fractures has definitely an advantage over the closed methods of treatment especially in displaced, unstable, comminuted, intraarticular, open and multiple fractures. Operative management of hand fractures should be undertaken only if a definite indication exists. Indiscriminate use of it should be avoided. The operative management of metacarpal and phalangeal fractures results in accurate reduction of the fracture and joints should be mobilised early following fixation to prevent stiffness of the fingers and regain the desired range of motion at the joint.

Comparison of anatomical dynamic hip lock plate and Gamma nail for the treatment of unstable intertrochanteric femoral fractures / 中国矫形外科杂志

[Objective] To compare anatomical dynamic hip lock plate with Gamma nail internal fixation in terms of the early intermediate clinical effect of the unstable intertrochanteric femoral fractures. [Methods]From January 2003 to August 2008, 69 patients with unstable intertrochanteric femoral fractures were fixed with plate (n=34)and Gamma nail(n=35).They were randomized into two treatment groups.A retrospective comparison was made between the two differet fixation devices in terms of operation time,blood loss,intraoperative and postoperative complications,frequency of exposure to X-ray,healing time of fracture and functional recovery of hip-joint.[Results]Comparing with Gamma nail,cases with anatomical dynamic hip lock plate experienced fewer X-ray during operation and had fewer postoperative complications,and the differences had statistical significance(P

External Fixation with Five Pins for Unstable Fractures of the Distal Radius

PURPOSE: To evaluate the results of five-pin external fixation, with the fifth pin stabilizing the distal radius articular fragment, for unstable distal radial fractures. MATERIALS AND METHODS: Twenty cases of unstable distal radial fractures were treated with five-pin external fixation (5-pin group). The fifth pin was inserted into the distal articular fragment and attached to the external fixation frame. Metacarpal pins were removed at sixth week in 12 cases and at third in 8 cases, and radial pins were removed at eighth or ninth week. The radiographic results of 5-pin group were compared with those of 20 cases of traditional four-pin external fixation (4-pin group). RESULTS: The postoperative radial inclination was 23.1 degrees in 5-pin group and 22.2 degrees in 4-pin group; while at last follow-up 21.8o and 15.1 degrees respectively. Postoperative volar tilt was 8.5 degrees and 7.3o; while at last follow-up 6.3 degrees and 0.1 degrees respectively. Postoperative radial shortening was 0.3 mm, 0.4 mm; while at last follow-up 1.1 mm and 2.1 mm respectively. In 5-pin group, there were no significant differences in results whether the metacarpal pins were removed at sixth or third week. CONCLUSION: Five-pin external fixation, with the fifth pin stabilizing the distal articular fragment, enhanced early motion of the wrist maintaining fracture stability in unstable fractures of the distal radius.

A Clinical Study of the Surgical Treatment of the Thoraco-Lumbar Spinal Injuries / 대한정형외과학회잡지

Among 334 thoracolumbar spinal injury patients who were admitted to this hospital from June 1972 to June, 1982, 66 patients with fracture and fracture dislocation of thoraco-lumbar spine which were defined as unstable clinically and radiologically were treated with surgical measures. The ratio between male and female was 7.3:1, the majority was found in third and fourth decade (46 cases, 69%), and the most common cause of injury was falling from a height (38 cases, 58%). The most common site of the injury was lumbar spine (29 cases, 44%) and the most common mechanism of injury was flexion-rotation (29 cases, 44%). Our surgical measures were Harrington rod instrumentation with either anterior or posterior fusion (25 cases, 38%), posterior wiring and fusion (14 cases, 21%), anterior decompression and anterior fusion (14 cases, 21%), posterior fusion (4 cases, 6%), anterior fusion and posterior fusion (3 cases, 5%) and etc. The average correction of displacement was 65% and the average correction of kyphotic deformity was 50%. The most remarkable correction was found at the cases of Harrington rod instrumentation (71%, 74%). Neurological deficit had already developed in 43 cases(65%) prior to operation, and the recovery was observed in 18 cases(42%). Most excellent recovery of neural deficit was found also at the cases of Harrington rod instrumentation (11 cases, 52%). We have analysed the results of these treatment and obtained following conclusions. 1. For the unstable fracture and fracture-dislocation of thoraco-lumbar spine with or without neural involvement, immediate surgical treatments were valuable to expect restoration of anatomical reduction and promotion of every possible recovery of neural function with spinal stability and fewest complication. 2. Fixation with Harrington rod instrumentation appears to provide better reduction and stability with neural improvement than other methods, and therefore early undertaking of rehabilitation activities is possible. 3. For the patients who are seriously compromised or require anterior decompression, immediate posterior reduction and fixation with Harrington rod instrumentation followed anterior decompression and anterior fusion of the involved segments at the eariest feasible time, we feel, is the treatment of choice.