Caracterización de las fracturas supracondíleas del húmero en niños que requirieron manejo quirúrgico en un hospital de Santander, Colombia / Characterization of Supracondylar Fractures of the Humerus in Children who Required Surgical Management at a Hospital in Santander, Colombia / Caracterização das fraturas supracondilianas do úmero em crianças que precisaram de tratamento cirúrgico em um hospital de Santander, Colômbia

Introducción. El objetivo del estudio fue describir las características sociodemográficas, tratamiento y complicaciones pre y posquirúrgicas de las fracturas supracondíleas del húmero distal en niños que requirieron manejo quirúrgico en un hospital de Santander, Colombia. Metodología. Se trata de un estudio observacional, descriptivo, de corte transversal con 58 pacientes que cumplieron los siguientes criterios de inclusión: edad entre 3 a 14 años, fracturas supracondíleas de manejo quirúrgico; como criterios de exclusión se tomó: antecedente de enfermedad ósea o neurológica previa y fracturas de más de 7 días de evolución. Para las variables continuas se usó medidas de tendencia central y dispersión, las categóricas en porcentajes y frecuencias absolutas. Resultados. La edad media de presentación fue de 6.2 años, el principal mecanismo de trauma fue caídas de altura con un 96.5%. El 65.5% provenía de zonas urbanas. El 13.8% se asoció con fracturas de antebrazo, y el 3.4% de epitróclea. La fijación se realizó en un 75% con técnica cruzada y un 17.2% se asoció con lesión iatrogénica del nervio ulnar. Discusión. En el estudio no se informaron lesiones vasculares; sin embargo, se documentó una alta prevalencia de lesión neurológica con la fijación medial, similar a lo descrito en la literatura (1.4%-17.7%); algunos autores describen técnicas que disminuyen estas lesiones hasta en un 0%. Conclusión. Las características sociodemográficas de nuestra población coinciden con la estadística publicada mundialmente; la principal complicación fue la lesión iatrogénica nervio ulnar, que se puede disminuir con un uso racional del pin medial y con el empleo de técnicas que busquen rechazar directamente el nervio. Palabras clave: Fracturas del Húmero; Fijación Interna de Fracturas; Clavos Ortopédicos; Codo; Niño; Nervio Cubital.

Introduction. The objective of this study was to describe sociodemographic characteristic, treatment, and pre- and post-surgical complications of supracondylar fractures of the distal humerus in children who required surgical management at a hospital in Santander, Colombia. Methodology. This was an observational, descriptive, and cross-sectional study involving 58 patients who met inclusion criteria: age between 3 and 14 years old, supracondylar fractures with surgical management; exclusion criteria include previous bone or neurological illness and fractures with more than 7 days of evolution. Central tendency and dispersion measures were used for continuous variables, and categorical variables in percentages and absolute frequencies. Results. The average age at presentation was 6.2 years old, the main mechanism of trauma was fall from height (96.5%). 65.5% came from urban zones. The 13.8% were associated with forearm fractures, and 3.4% with epitrochlear fractures. Pinning was performed at 75% with crossed technique and 17.2% were associated with iatrogenic ulnar nerve injury. Discussion. Study didn't inform vascular injuries. However, a high prevalence of neurological injury with medial pinning was documented, similar to that describe in the literature (1.4%-17.7%); some author described techniques that reduce these lesions by 0%. Conclusion. The sociodemographic characteristics of our population match with worldwide published statistics; the main complication was iatrogenic ulnar nerve injury, which can be reduced with the rational use of medial pin and with the application of techniques that seek to directly spare the nerve. Keywords: Humeral Fractures; Fracture Fixation, Internal; Bone Nails; Elbow; Child; Ulnar Nerve.

Introdução. O objetivo do estudo foi descrever as características sociodemográficas, o tratamento e as complicações pré e pós-cirúrgicas das fraturas supracondilianas do úmero distal em crianças que precisaram de tratamento cirúrgico em um hospital de Santander, Colômbia. Metodologia. Trata-se de um estudo observacional, descritivo e transversal com 58 pacientes que atenderam aos seguintes critérios de inclusão: idade entre 3 e 14 anos, fraturas supracondilianas tratadas cirurgicamente. Os critérios de exclusão foram: histórico de doença óssea ou neurológica prévia e fraturas com duração superior a 7 dias de evolução. Para variáveis contínuas foram utilizadas medidas de tendência central e dispersão, as categóricas em percentuais e frequências absolutas. Resultados. A média de idade de apresentação foi de 6.2 anos, o principal mecanismo de trauma foi a queda de altura com 96.5%. 65.5% vieram de áreas urbanas. 13.8% estavam associados a fraturas de antebraço e 3.4% a epitróclea. A fixação foi realizada em 75% com técnica cruzada e 17.2% esteve associada à lesão iatrogênica do nervo ulnar. Discussão. Nenhuma lesão vascular foi relatada no estudo. No entanto, foi documentada alta prevalência de lesão neurológica com fixação medial, semelhante à descrita na literatura (1.4%-17.7%). Alguns autores descrevem técnicas que reduzem essas lesões em até 0%. Conclusão. As características sociodemográficas da nossa população coincidem com as estatísticas publicadas mundialmente. A principal complicação foi a lesão iatrogênica do nervo ulnar, que pode ser reduzida com o uso racional do pino medial e com o uso de técnicas que buscam rejeitar diretamente o nervo. Palavras-chave: Fraturas do Úmero; Fixação Interna de Fraturas; Pinos Ortopédicos; Cotovelo; Criança; Nervo Ulnar

Child Fractures: Are We Getting More Surgical? / Fraturas na criança: Estamos ficando mais cirúrgicos?

Abstract Historically, surgeries on the immature skeleton were reserved for open or articular fractures. In recent years, the improvement in the quality and safety of anesthesia, new imaging equipment, implants designed especially for pediatric fractures, associated with the possibility of shorter hospitalization time and rapid return to social life has demonstrated a new tendency to evaluate and treat fractures in children. The purpose of this update article is to answer the following questions: (1) Are we really turning more surgical in addressing fractures in children? (2) If this is true, is this surgical conduct based on scientific evidence? In fact, in recent decades, the medical literature demonstrates articles that support better evolution of fractures in children with surgical treatment. In the upper limbs, this is very evident in the systematization of the reduction and percutaneous fixation of supracondylar fractures of the humerus and fractures of the forearm bones. In the lower limbs, the same occurs with diaphyseal fractures of the femur and tibia. However, there are gaps in the literature. The available published studies show low scientific evidence. Thus, it can be inferred that, even though the surgical approach is more present, the treatment of pediatric fractures should always be individualized and conducted according to the knowledge and experience of the professional physician, taking into account the presence of technological resources available for the care of the small patient. All possibilities, non-surgical and/or surgical, should be included, always instituting actions based on science and in agreement with the family's wishes.

Resumo Historicamente, as cirurgias no esqueleto imaturo eram reservadas às fraturas expostas ou articulares. Nos últimos anos, a melhora na qualidade e segurança das anestesias, novos equipamentos de imagem, implantes desenhados especialmente para fraturas pediátricas, associados à possibilidade de menor tempo de hospitalização e rápido retorno ao convívio social vêm demonstrando uma nova tendência de avaliar e tratar fraturas na criança. O objetivo deste artigo de atualização é responder às seguintes questões: (1) estamos realmente ficando mais cirúrgicos na abordagem das fraturas em crianças? (2) Caso isto seja verdadeiro, esta conduta cirúrgica está baseada em evidências científicas? De fato, nas últimas décadas, a literatura médica demonstra artigos que suportam melhor evolução das fraturas na criança com o tratamento cirúrgico. Nos membros superiores, isto fica muito evidente na sistematização da redução e fixação percutânea das fraturas supracondilianas do úmero e das fraturas de ossos do antebraço. Nos membros inferiores, o mesmo ocorre com fraturas diafisárias do fêmur e tíbia. No entanto, há lacunas na literatura. Os estudos publicados são geralmente com baixa evidência científica. Assim, pode-se deduzir que, mesmo sendo a abordagem cirúrgica mais presente, o tratamento de fraturas pediátricas deve ser sempre individualizado e conduzido de acordo com o conhecimento e experiência do médico profissional, levando em conta a presença de recursos tecnológicos disponíveis para o atendimento do pequeno paciente. Deve-se incluir todas as possibilidades, não cirúrgicas e/ou cirúrgicas, sempre instituindo ações baseadas na ciência e em concordância com os anseios da família.

Retrospective study on the treatment of phalanx fractures with absorbable materials / 中国医师进修杂志

Objective:To investigate the effect of absorbable material internal fixation in the treatment of phalanx fracture and its effect on the complications related to hypersensitive C-reactive protein (hs-CRP), interleukin-10 (IL-10), adrenocorticotropic hormone (ACTH) and foreign body reaction.Methods:The clinical data of 98 patients with phalangeal fracture in Huishan District People′s Hospital of Wuxi City from January 2018 to January 2020 were divided into absorbable group (49 cases, treated with absorbable material internal fixation) and microplate group (49 cases, treated with minimally invasive plate internal fixation). The rates of excellent and good treatment, operation conditions, serum inflammatory stress response indexes levels before and 1 d and 1 week after surgery were compared, and recovery at 3 and 6 months after surgery, the incidence of complications and the degree of treatment satisfaction were counted.Results:The rates of excellent and good treatmentin the absorbable group were higher than that in the micro plate group: 95.92%(47/49) vs. 81.63%(40/49), χ2 = 5.02, P<0.05. The duration of operation in the absorbable group was longer than that in the microplate group: (43.28 ± 12.18) min vs. (31.29 ± 11.69) min; and the duration of hospital stay, fracture healing time and recovery time were shorter than those in the microplate group: (4.09 ± 1.18) d vs. (6.89 ± 2.12) d, (4.35 ± 1.05) weeks vs. (5.69 ± 1.38) weeks, (4.89 ± 1.10) d vs. (6.20 ± 2.01) d; the differences were statistically significant ( P<0.05). The levels of serum hs-CRP, IL-10 and ACTH in absorbable group were lower than those in microplate group at 1 d and 1 week after surgery ( P<0.05). At 3 and 6 months after surgery, the range of motion of metacarpophalangeal joint in the absorbable group was greater than that in the microplate group, and the loss of grip strength of the healthy side was less than that in the microplate group ( P<0.05). The incidence of complications in absorbable group was lower than that in microplate group: 6.12%(3/49) vs. 20.41%(10/49), χ2 = 4.35, P<0.05. Conclusions:The absorbable material internal fixation can achieve good results in the treatment of phalanx fracture, the postoperative recovery is fast, the incidence of complications is lower.

Effects of metacarpal inclination angle and ulnar deviation angle on radius length shortening after distal radius fracture combined with internal fixation of ulnar styloid fracture / 国际外科学杂志

Objective:To investigate the effects of metacarpal inclination angle and ulnar deviation angle on radius length shortening after internal fixation of distal radius fracture combined with ulnar styloid fracture.Methods:A retrospective case-control study was conducted to analyze the clinical data of 84 patients with distal radius fracture complicated with ulnar styloid fracture treated by Beijing Daxing District People′s Hospital from February 2018 to January 2022. According to whether the ulnar styloid fracture was fixed or not, the patients were divided into two groups: 18 patients with ulnar styloid fractures who were surgically fixed were in the fixation group, and 66 patients with ulnar styloid fractures who were not surgically fixed were in the non-fixation group. The perioperative indexes (operation time, intraoperative blood loss, surgical incision length), wrist joint function indexes [Gartland-Werley score, disability of the arm, shoulder, and hand (DASH) score, forearm rotation, ulnar deviation, metacarpal flexion, radial deviation, dorsal extension, grip strength] and complications (bone nonunion, osteolysis, ulnar pain, internal fixation failure, lower ulnar and radial instability, postoperative infection) were compared between the two groups. The changes of metacarpal inclination angle, ulnar deviation angle and distal radius distance of the two groups were analyzed by generalized estimation equation (GEE). The patients were followed up for 12 months, they were divided into two groups: non-shortening group (radius shortening distance < 4 mm, n=61) and radius shortening group (radius shortening distance ≥ 4 mm, n=23) according to whether the radius shortening distance was ≥ 4 mm at the last follow-up. The influencing factors of postoperative radius shortening were evaluated by Logistic regression analysis. Results:Compared with the non-fixation group, the Gartland-Werley score(1.79±0.62 vs 4.65±0.97), DASH score (16.43±4.71 vs 28.72±6.06) and the incidence of complications (11.11% vs 39.40%) in the fixation group were significantly lower, and the forearm rotation angle [(81.29±6.60)° vs (70.79+ 5.15)°], ulnar deviation angle [(21.36±2.35)° vs (16.77±2.11)°], metacarpal flexion angle [(45.84±2.80)° vs (37.55±2.45)°] and dorsal extension angle [(50.23±5.16)° vs (40.65±3.580°] were significantly larger in the fixation group, all the differences were statistically significant ( P<0.05). GEE analysis and evaluation showed that treatment time, treatment plan and their interaction had significant effects on metacarpal inclination, ulnar deviation and distal radius ( P<0.05). The change of metacarpal inclination angle and ulnar deviation angle were independent influencing factors of radius shortening after internal fixation ( P<0.05). Conclusions:In the treatment of distal radius fracture combined with ulnar styloid fracture, internal fixation of distal radius combined with ulnar styloid process can improve wrist joint function, reduce the incidence of complications, and improve metacarpal inclination angle and ulnar deviation angle. A certain degree of radius shortening will occur after internal fixation. The changes of metacarpal inclination angle and ulnar deviation angle are the independent influencing factors of radius shortening after internal fixation.

Volumetric measurement to diagnose syndesmotic injury in Danis-Weber B type ankle fractures / 国际外科学杂志

Objective:To investigate the change of syndesmotic volume via CT scan in Danis-Weber B type ankle fracture, aiming to provide a non-invasive diagnostic method for Danis-Weber B type ankle fracture combined with syndesmotic injury.Methods:Retrospective analysis was performed on 48 patients with Danis-Weber B type ankle fractures in Shanghai Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2018 to March 2022, including 30 males and 18 females, aging (43.71±19.41) years. Ankle CT scans and three-dimensional reconstructions were performed before surgery and at the last follow-up, measuring the syndesmotic volume between the tibiotalar joint and 1, 3 and 5 cm above the ankle and compared with each other. Intraoperative exploration was used as the gold standard for the syndesmotic injury. Based on the results of exploration of the syndesmotic injury, patients were divided into simple ankle fracture group (fracture group, 25 cases) and ankle fracture combined with syndesmotic injury group (fracture + ligament group, 23 cases). The sensitivity and specificity of this diagnostic method were statistically evaluated. The assessments at the last follow-up were performed to value the clinical effect of surgery. The metric data conforming to the normal distribution were expressed as mean ± standard deviation ( ± s), and the t-tests were used for comparison between groups. The measurement data of skewed distribution were expressed as quartile M( Q1, Q3), and nonparametric tests were used for intergroup comparison. Counting data were expressed as number of cases and percentage (%), and Chi-square test were used for intergroup comparison. Results:In the fracture group, there were no statistically significant differences of the syndesmotic volume at 1, 3, and 5 cm above the ankle joint before surgery and at the last follow-up ( P=0.219, 0.269, 0.103). On the contrary, the volume above were statistically significant in the fracture + ligament group ( P<0.001). There were statistically significant differences in syndesmotic volume between the two groups at 1, 3, and 5 cm above the ankle joint preoperatively ( P=0.005, 0.004, 0.038). By contrast, there were no statistical differences between the two groups postoperatively ( P=0.082, 0.155, 0.249). For the sensitivity and specificity of Danis-Weber B type ankle fractures combined with syndesmotic injury, they were 92% and 67% at 1 cm above the ankle joint, 69% and 87% at 3 cm above the ankle joint, and 62% and 87% at 5 cm above the ankle joint, respectively. The last follow-up clinical function score indicated a good surgical outcome. Conclusions:Volumetric measurement via CT scan is one of the diagnostic methods for evaluating Danis-Weber B type ankle fracture combined with syndesmotic injurys. Open resection internal fixation combined with elastic fixation of the ankle fracture combined with syndesmotic injurys can significantly reduce the lower tibiofibular volume, and the efficacy is definite.

Meta-analysis of the effect of hollow nail and bone plate on Lisfranc injury / 中国骨伤

OBJECTIVE@#To compare the clinical efficacy of screw and bone plate internal fixation in the treatment of Lisfranc injury.@*METHODS@#The databases of Wanfang, CNKI, Pubmed, EMBASE, VIP, BIOSIS and other databases were retrieved by computer, and the clinical trial literature from January 1, 2000 to August 1, 2021 was retrieved, the methodological quality of the included studies was strictly evaluated and the data were extracted, and the obtained data were meta-analyzed by Revman 5.4 software.@*RESULTS@#Nine randomized controlled trial literature and 10 retrospective cohort studies were included, of which 416 patients in the experimental group were treated with screw internal fixation, and 435 patients in the control group were treated with bone plate internal fixation. Meta-analysis showed that the surgical time of the bone plate internal fixation group was longer than that of the screw internal fixation group [MD=-14.40, 95%CI(-17.21, -11.60), P<0.000 01], the postoperative X-ray anatomical reduction of the bone plate internal fixation group [MD=0.47, 95%CI(0.25, 0.86), P=0.01], the excellent and good rate of postoperative American orthopedic foot and ankle society(AOFAS) foot function score[MD=0.25, 95%CI(0.15, 0.42), P<0.000 01], postoperative AOFAS foot function score [MD=-5.51, 95%CI(-10.10, -0.92), P=0.02] of the bone plate fixation group was better than those of the screw internal fixation group. Two kinds of operation method had no statistical different for postoperative fracture healing time[MD=1.91, 95%CI(-1.36, 5.18), P=0.25], postoperative visual analgue scale(VAS)[MD=0.38, 95%CI(0.09, 0.86), P=0.11], postoperative complications [MD=1.32, 95%CI(0.73, 2.40), P=0.36], the postoperative infection [MD=0.84, 95%CI(0.48, 1.46), P=0.53], the postoperative fracture internal fixation loosening [MD=1.25, 95% CI(0.61, 2.53), P=0.54], the postoperative incidence of traumatic arthritis [MD=1.80, 95%CI(0.83, 3.91), P=0.14].@*CONCLUSION@#Bone plate fixation has better short-term and medium-term results and lower reoperation rate in the treatment of Lisfranc injury, so it is recommended to use bone plate fixation in the treatment of Lisfranc injury.

Analysis of three minimally invasive methods in the treatment of the fifth metacarpal neck fracture / 中国骨伤

OBJECTIVE@#To explore the effective method of applying Chinese medicine manipulative repositioning Kirschner wire fixation for minimally invasive treatment of fractures of the neck of the fifth metacarpal.@*METHODS@#From January 2018 to November 2021, 90 patients with closed fractures of the neck of the fifth metacarpal bone were treated minimally invasively with closed repositioning Kirschner wires, all fractures AO type was type A. All patients were divided into three groups according to the mode of internal fixation involving 30 cases in the crossed Kirschner's wire group, 30 cases in the transverse Kirschner's wire group, 30 patients in the intramedullary Kirschner's wire group. By comparison, gender, age, disease duration, and preoperative neck-stem angle were not significant. The postoperative fifth metacarpal neck-stem angles, postoperative fifth metacarpophalangeal joint flexion mobility and fifth metacarpophalangeal joint extension hyperextension angles were compared among three groups. The overall clinical efficacy was evaluated according to the patient outcomes of surgery-hand/arm(POS-Hand/Arm) scoring system.@*RESULTS@#All patients had 12-month follow-up and achieved bony union without malunion. There was no significant difference in the 5th metacarpal neck-stem angle, the fifth metacarpophalangeal joint flexion angle and the fifth metacarpophalangeal joint extension hyperextension angles among three groups at 12 months after surgery(P>0.05). There was no significant difference in physical activity and symptom scores in POS-Hand/Arm scores at 12 months after surgery(P>0.05), psychological status and aesthetic score among three groups(P<0.05) and between cross and transverse Kirschner wire groups(P>0.05). The three POS-Hand/Arm total scores were statistically different(P<0.05), between the crossed and transverse(P>0.05), and the intramedullary group had the highest POS-Hand/Arm scores.@*CONCLUSION@#All three techniques of Kristener's wire fixation could achieve minimally invasive treatment, and patients have need for cosmetic and early activity, and the author recommend minimally invasive intramedullary fixation with manipulative repositioned Kristen wires as the preferred procedure.

Posterior cervical pedicle screw rod short-segment internal fixation for the treatment of atlantoaxial fracture and dislocation / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of posterior cervical pedicle screw short-segment internal fixation for the treatment of atlantoaxial fracture and dislocation.@*METHODS@#The clinical data of 60 patients with atlantoaxial vertebral fracture and dislocation underwent surgery between January 2015 and January 2018 were retrospectively analyzed. The patients were divided into study group and control group according to different surgical methods. There were 30 patients in study group, including 13 males and 17 females, with an average age of (39.32±2.85) years old, were underwent short-segment internal fixation with posterior cervical pedicle screws. There were 30 patients in control group, including 12 males and 18 females, with an average age of (39.57±2.90) years old, were underwent posterior lamina clip internal fixation of the atlas. The operation time, intraoperative blood loss, postoperative ambulation time, hospitalization time and complications between two groups were recorded and compared. The pain visual analogue scale(VAS), Japanese Orthopedic Association(JOA) score of neurological function, and fusion status were evaluated between two groups.@*RESULTS@#All patients were followed up for at least 12 months. The study group was better than control group in operation time, intraoperative blood loss, postoperative off-bed activity time, and hospital stay (P=0.000). One case of respiratory tract injury occurred in study group. In control group, 2 cases occurred incision infection, 3 cases occurred respiratory tract injury, and 3 cases occurred adjacent segmental joint degeneration. The incidence of complications in study group was lower than that in control group (χ2=4.705, P=0.030). At 1, 3, 7 days after operation, VAS of study group was lower than that of control group(P=0.000). At 1, 3 months after operation, JOA score of study group was higher than that of control group(P=0.000). At 12 months after operation, all the patients in the study group achieved bony fusion. In control group, there were 3 cases of poor bony fusion and 3 cases of internal fixation fracture, the incidence rate was 20.00%(6/30). The difference between two groups was statistically significant (χ2=4.629, P=0.031).@*CONCLUSION@#Posterior cervical short-segment pedicle screw fixation for atlantoaxial fracture and dislocation has the advantages of less trauma, shorter operation time, fewer complications, and less pain, and can promote the recovery of nerve function as soon as possible.

Treatment of acute non-displaced scaphoid fracture of wrist with syringe needle-guided percutaneous cannulated headless hollow compression screw internal fixation / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of needle-guided percutaneous cannulated compression screw fixation in the treatment of acute non-displaced scaphoid fracture of wrist.@*METHODS@#The clinic data of twenty-eight patients with acute non-displaced scaphoid fracture from January 2014 to January 2019 were analyzed retrospectively. According to the intraoperative method of placement of cannulated screw, they were divided into Guide group(16 patients)and Conventional group(12 patients). There were 13 males and 3 females in Guide group, aged from 20 to 60 years old with an average of(31.42±9.71)years old;5 patients were classified as type A2, 3 patients were classified as type B1 and 8 patients were classified as type B2 according to Herbert classification;they were treated with percutaneous cannulated compression screw fixation under the guidance of needle. There were 11 males and 1 female in Conventional group, aged from 23 to 61 years old with an average of(30.51±7.52)years old;5 patients were classified as type A2, 2 patients were classified as type B1 and 5 patients were classified as type B2 according to Herbert classification;they were treated with conventional percutaneous cannulated compression screw fixation. The operation time, screw angle relative to the longitudinal axis of the scaphoid and wrist function score were assessed and compared between the two groups.@*RESULTS@#A total of 28 patients were followed up from 20 to 45 months with an average of (33.00±8.72) months. None of patients had intraoperative complication and incision infection. These patients returned to work gradually 2 weeks after operation, and all fractures healed within 12 weeks. The operation time in the Guide group was significantly less than that in the Conventinal group(P<0.05). Screw angle relative to the longitudinal axis of the scaphoid in the Guide group was significantly smaller than that in the Conventional group(P<0.05). There was no significant difference in Mayo wrist function scores at the last follow-up between the two groups(P>0.05). During the follow-up period, none of the 28 patients showed internal fixation displacement, arthritis, scaphoid necrosis and other complications.@*CONCLUSION@#In the treatment of acute non-displaced scaphoid fractures, the operation time of needle-guided percutaneous cannulated headless compression screw fixation is significantly shorter than that of conventional percutaneous screw fixation, and the screw axis is easier to be parallel to the longitudinal axis of the scaphoid.

Risk of Neurovascular Injury during Screw Fixation of Tibial Tubercle Fractures in Pediatric and Adolescent Patients / Risco de lesão neurovascular durante a fixação com parafuso de fraturas da tuberosidade da tíbia em pacientes pediátricos e adolescentes

Abstract Objective To review knee magnetic resonance imaging (MRI) scans for the analysis of the location of neurovascular structures (NVSs), and to define the risk of bicortical fixation. Methods Distances between the posterior cortex and the popliteal NVSs were measured on the MRI scans of 45 adolescents (50 knees) at 3 levels (C1: center of the proximal tibial epiphysis; C2: 10 mm distal to the physis; and C3: 20 mm distal to the physis). The NVSs located between 5 mm and 10 mm from the incision were considered in a zone of moderate risk for damage, while those less than 5 mm from the incision were considered in a zone of high risk for damage, and those more than 10 mm from the incision were considered to be in a zone of low risk for damage. The independent Student t-test was used for the comparison of the NVS distance 0with gender, skeletal maturity, and the tibial tubercle-trochlear groove (TT-TG) distance. Values of p < 0.05 were regarded as statistically significant. Results The path of the C1 screw posed an increased risk of damage to the popliteal artery and vein compared with other screw paths (p < 0.001). The popliteal artery has a high risk of damage at the level of C1 (4.2 ± 2.2mm), and a moderate risk at C2 (9.6 ± 2.4mm), and the popliteal vein has a moderate risk at C1 (6.0 ± 2.7 mm), and a low risk at C2 and C3 (10.8 ± 3.1mm, and 12.05 ± 3.1mm respectively). The C3 position presented the lowest risk of damage to these structures (p < 0.001). The distance between the posterior tibial cortex and the posterior tibial nerve was < 15 mm at the 3 levels analyzed (C1: 11.0 ± 3.7 mm; C2:13.1 ± 3.8 mm; and C3:13 ± 3.9 mm). Conclusions The present study clarifies that the popliteal vessels are at risk of injury during tibial tubercle screw fixation, particularly when drilling the proximal tibial epiphysis. Monocortical drilling and screw fixation are recommended for the surgical treatment of tibial tubercle fractures. Level of Evidence III Diagnostic study.

Resumo Objetivo Revisar estudos de ressonância magnética (RM) do joelho para análise da localização das estruturas neurovasculares (ENVs) e definição do risco de fixação bicortical. Métodos As distâncias entre o córtex posterior e as ENVs poplíteas foram medidas nas RMs de 45 adolescentes (50 joelhos) em 3 níveis (C1: centro da epífise proximal da tíbia; C2:10 mm distalmente à fise e C3: 20 mm distalmente à fise). Considerou-se que as ENVs entre 5mme10mmda incisão estavam na zona de risco moderado de lesão, as ENVs a menos de 5 mm da incisão, na zona de alto risco de lesão, e as ENVs a mais de 10 mm da incisão, na zona de baixo risco de lesão. O teste t de Student independente foi usado para comparar a distância até as ENVs com o gênero, a maturidade esquelética e a distância entre a tuberosidade tibial e a garganta (fundo) da tróclea (TT-GT). Valores de p < 0,05 foram considerados estatisticamente significativos. Resultados A trajetória do parafuso em C1 apresentou maior risco de lesão à artéria e à veia poplítea em comparação com outras trajetórias (p < 0,001). A artéria poplítea apresenta risco de lesão alto em C1 (4,2 ± 2,2 mm) e moderado em C2 (9,6 ± 2,4 mm), e a veia poplítea tem risco moderado em C1 (6,0±2,7 mm) e baixo em C2 e C3 (10,8±3,1 mm e 12,05±3,1mm, respectivamente). A posição C3 apresentou o menor risco de lesão dessas estruturas (p < 0,001). A distância entre o córtex tibial posterior e o nervo tibial posterior foi inferior a 15 mm nos 3 níveis analisados (C1: 11,0±3,7mm; C2: 13,1±3,8 mm; e C3: 13±3,9mm). Conclusões Este estudo esclarece que os vasos poplíteos correm risco de lesão durante a fixação do parafuso na tuberosidade tibial, principalmente durante a perfuração da epífise proximal da tíbia. A perfuração monocortical e a fixação com parafusos são recomendadas para o tratamento cirúrgico das fraturas da tuberosidade tibial. Nível de Evidência III Estudo diagnóstico.

Fixation of Mallet Fractures Using a Modified Hook Plate Technique: A Prospective Case Series of 17 Patients / Fixação de fraturas em martelo com técnica de placa de gancho modificada: Uma série de casos prospectivos de 17 pacientes

Abstract Objective Various modalities have been suggested to manage mallet fractures; however, inappropriate treatment can lead to extension lag, a swan neck deformity, or arthritis of the distal interphalangeal joint (DIPJ). The current study aimed to evaluate the results (functional, radiological, and complications) of open reduction and internal fixation (ORIF) of mallet fractures using low-cost hook plates fabricated from low-profile titanium mini plates. Methods A prospective case series of 17 consecutive patients (average age of 32.3 years) with mallet fractures (six were Wehbe Type IB and 11 were Wehbe Type MB). Eleven (64.7%) were males. The affected hand was dominant in all patients, and the affected digit was the index in 6 (35.3%), the ring in 5 (29.4%), the small in 3 (17.65%), and the middle in 3 (17.65%) patients. The same fellowship-trained hand surgeon performed all surgeries. Results The average operative time was 37.65 minutes. After an average follow-up of 10.94 months (range 6-27), the average DIPJ motion was 50º º (range 20º-70º), the extensor lag was noted in 4 (23.5%) patients, and complications were reported in 6 (35.29%) patients. According to Crawford criteria, 6 (35.3%) patients achieved excellent results, 7 (41.2%) achieved good results, and 4 (23.5%) achieved fair results. Conclusion The modified hook plate technique for fixation of mallet fractures is a beneficiai, economical, yet demanding technique that adequately provides stable fixation to allow early DIPJ motion with acceptable functional outcomes.

Resumo Objetivo Diversas modalidades têm sido sugeridas para o tratamento de fraturas em martelo; no entanto, o tratamento inadequado pode causar retardo de extensão, deformidade em pescoço de cisne ou artrite da articulação interfalangiana distal (AIFD). Este estudo teve como objetivo avaliar os desfechos (funcionais, radiológicos e complicações) da redução aberta e fixação interna (RAFI) das fraturas em martelo com placas de gancho de baixo custo fabricadas com mini placas de titânio de baixo perfil. Métodos Série de casos prospectivos de 17 pacientes consecutivos (idade média de 32,3 anos) com fraturas em martelo (seis do tipo IB e 11 do tipo IIB de Wehbe). Onze (64,7%) pacientes eram do sexo masculino. A mão acometida era a dominante em todos os pacientes, com acometimento do dedo indicador em seis (35,3%), anelar em cinco (29,4%), mínimo em três (17,65%) e médio em três (17,65%) pacientes. O mesmo cirurgião de mão experiente realizou todas as cirurgias. Resultados O tempo operatório médio foi de 37,65 minutos. Após um acompanhamento médio de 10,94 meses (intervalo de 6 a 27), observou-se movimento médio da AIFD de 50º (intervalo de 20º a 70º), retardo de extensão em quatro (23,5%) pacientes e complicações em seis (35,29%) pacientes. De acordo com os critérios de Crawford, os desfechos foram excelentes em seis (35,3%), bons em sete (41,2%) e regulares em quatro (23,5%) pacientes. Conclusão A técnica da placa de gancho modificada para fixação de fraturas em martelo é benéfica e econômica, mas exigente; permite fixação estável e adequada para permitir a movimentação precoce da AIFD com desfechos funcionais aceitáveis.

Biomechanical comparison of spatial weaving and conventional calcaneal plate fixation for calcaneal fracture / 中华骨科杂志

Objective:To compare the biomechanical characteristics of screw only spatial weaving fixation and calcaneal plate fixation in calcaneal fractures.Methods:Sanders type III calcaneus fracture model was established by using calcaneus model specimens: the physiological model group were the normal calcaneal models; the steel plate group were conventional steel plate fixation fracture models; the metal screw group were fracture models with only metal screw weaving fixation; seven and nine absorbable screw spatial weaving groups (seven absorbable screw group, nine absorbable screw group) were used to weave and fix fracture models with seven and nine absorbable screws. Cyclic test and mechanical compression test were carried out, and load-displacement curves were recorded. The material properties of metal screw spatial weaving and calcaneal anatomical plate system were replicated, finite element fracture models were established, and the calcaneal internal fixation models of plate screw group and spatial weaving screw group were completed by reverse processing. The changes of biomechanical characteristics of calcaneal bone in human (70 kg) standing on one foot were simulated, and the distribution of structural strength was analyzed by Von Mises equivalent stress cloud diagram and displacement cloud diagram.Results:In the cyclic test of 20-200 N load, the physiological model group, the plate group, the metal screw group, the absorbable 7 screw group, the absorbable 9 screw group were 0.87±0.22, 0.82±0.08, 0.70±0.12, 1.04±0.13 and 0.83±1.76 mm, the difference in model gap was statistically significant ( F=3.16, P=0.037). Among them, the absorbable 7 screws group was larger than the metal screws group ( t=4.28, P=0.003), and the other pin-two comparisons were not statistically significant ( P>0.05). The deformation of the five groups was 0.37±0.06, 0.38±0.07, 0.38±0.06, 0.52±0.07 and 0.42±0.07 mm, and the difference was statistically significant ( F=4.39, P=0.010). The deformation of absorbable 7 screws group was greater than that of physiological model group, the plate group and metal screw group ( t=3.69, P=0.006; t=3.25, P=0.012; t=3.51, P=0.008). In static test, compression displacement was 7.14±0.79, 7.30±0.66, 6.95±0.28, 8.19±0.61 and 7.16±0.55 mm, the difference was statistically significant ( F=3.28, P=0.032). The displacement of the absorbable 7 screws group was greater than that of the metal screws group ( t=4.13, P=0.003). The stiffness changes were 570.60±122.62, 512.86±80.77, 497.40±66.50, 456.21±58.19 and 560.39±94.40 N/mm, respectively, with no statistical significance ( F=1.44, P=0.258). The results of finite element analysis showed that under 3 500 N axial pressure load, the maximum compression displacement and stiffness of the plate and screw set were 6.47 mm, 540.96 N/mm, and the Von Mises equivalent stress peaks were 450.31 and 353.15 MPa, respectively. The maximum compression displacement and stiffness of the braided screw group were 5.25 mm, 666.67 N/mm, and the peak Von Mises equivalent stress of the screw was 396.20 MPa. Conclusion:Compared with lateral plate fixation, spatial weaving fixation can provide sufficient biomechanical stability for calcaneal healing and is superior to plate fixation in terms of structural stability, which may help to improve the effectiveness of calcaneal fracture fixation.

Reduction of valgus-impacted femoral neck fractures by Schanz screw combined with rod stick technique / 中华骨科杂志

Objective:To investigate the clinical efficacy of the femoral neck system (FNS) after the reduction of the Schanz screw combined with the rod stick technique in the treatment of valgus-impacted femoral neck fracture.Methods:A retrospective analysis of clinical data from 66 patients with valgus-impacted femoral neck fractures from December 2019 to November 2021 has been performed. All patients were treated with the Femoral Neck System. Auxiliary reduction group (using the Schanz screw and rod stick technique), including 32 cases, 9 males and 23 females with an average age of 52.7±12.0 years (range, 28-77 years); 14 patients on the left side and 18 patients on the right side; body mass index 23.1±2.6 kg/m 2. Manual reduction group (using the traditional Flynn closed reduction technique), including 34 cases, 18 males and 16 females with an average age of 52.1±12.7 years (range, 26-75 years); 18 patients on the left side and 16 patients on the right side; body mass index 23.4±2.3 kg/m 2. The surgery time, intraoperative blood loss, complications, and Harris hip score at the last follow-up were collected and compared between the two groups. Preoperative and postoperative abduction angle and posterior tilt angle were measured in the anterior-posterior and lateral positions of the hip, as well as the length of the femoral neck shortening at the last follow-up. Pearson analysis was used to evaluate the correlation between preoperative and postoperative abduction angle and posterior tilt angle, the length of femoral neck shortening, and Harris hip score. Results:There were no significant differences in baseline data such as gender, age, side of injury, height, weight, and body mass index, and the surgery time and intraoperative blood loss between auxiliary reduction group and manual reduction group ( P>0.05). All 66 cases with a mean follow-up of 20.4 months (ranges 12-29 mouths). The fracture healing time was 5.0±0.9 weeks in the auxiliary reduction group and 4.9±0.8 weeks in the manual reduction group ( t=-0.41, P>0.05). There were no significant statistical difference in the preoperative abduction angle and preoperative posterior tilt angle between the auxiliary reduction group and the manual reduction group ( P>0.05). The postoperative abduction angle and posterior tilt angle of the auxiliary reduction group (1.8°±3.1°, 1.2°±3.0°) were significantly lower than those of the manual reduction group (13.7°±6.5°, 6.8°±4.1°, t=-9.55, P<0.001; t=-7.42, P<0.001). Preoperatively, 61 cases (92%) were associated with a posterior tilt of the femoral head, and 30 (46%) of them had a posterior tilt angle of more than 10°. The length of femoral neck shortening at the last follow-up and the moderate and severe femoral neck shortening rate postoperatively in the auxiliary reduction group (1.4±2.1 mm, 0, and 3%) were significantly lower than those in the manual reduction group (8.1±4.8 mm, 38%, and 32%, P<0.05). Harris hip score at the last follow-up in the auxiliary reduction group 91.1±4.5 was significantly higher than those in the manual reduction group 85.5±5.4 ( t=4.54, P<0.001). The postoperative abduction angle and length of femoral neck shortening showed correlations with the Harris hip score respectively ( r=-0.551, -0.743; P<0.001). In the auxiliary reduction group, 1 case of broken temporary fixed Kirschner wire was removed by nucleus pulposus forceps, and the fracture site healed after surgery. In 2 cases, the Schanz screw loosened and pulled out during the reduction process, and the successful reduction was achieved after increasing the depth of the Schanz screw insertion, and no peri-Schanz screw fracture occurred. After surgery, 3 cases (1 case in the auxiliary reduction group and 2 cases in the manual reduction group) developed avascular necrosis of the femoral head (18 months, 18 months, and 2 years after surgery, respectively), femoral head collapse and severe shortening of the femoral neck, all of which underwent total hip arthroplasty. Conclusion:FNS after the reduction of the Schanz screw combined with the rod stick technique in the treatment of valgus-impacted femoral neck fracture has the advantages of effectively correcting preoperative abduction angle and posterior tilt angle and reducing the length of femoral neck shortening, and it can obtain satisfactory short and medium-term clinical efficacy.

"Frame and buttress" fixation for the treatment of acetabular quadrilateral fractures / 中华骨科杂志

Objective:To investigate the efficacy and safety of the "frame and buttress" fixation in the treatment of acetabular quadrilateral fractures.Methods:A total of 26 patients with acetabular quadrilateral fractures treated with the "Frame and buttress" fixation strategy (reconstructing frame and providing buttress for quadrilateral surface) from January 2017 to January 2021 were retrospectively analyzed in the Department of Orthopaedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, including 17 males and 9 females, aged 47.7±16.5 years, (range, 25-71 years). There were 13 cases from car accidents, 8 cases from falls, and 5 cases from heavy objects. Quadrilateral fractures were classified according to whether the anterior column (A) and posterior column (P) of the acetabulum were fractured and whether the quadrilateral plate (Q) was partially (1) or completely (2) separated from the two columns. Among these cases, there were 5 cases of type AQ1, 1 case of type AQ2, 1 case of type PQ2, 14 cases of type APQ1 and 5 cases of type APQ2. The "frame and buttress" fixation strategy was used to perform open reduction and internal fixation. The Matta scale was used to assess the quality of resurfacing based on pelvic radiographs, and the Matta modified Merle d'Aubigne and Postel scores were referenced to evaluate hip function.Results:All the 26 patients successfully completed the operation, the operation time was 88.1±57.8 min (range, 90-320 min), the intraoperative bleeding was 753.8±309.5 ml (range, 400-1 400 ml). There were 14 cases of anatomical reduction, 8 cases of satisfactory reduction and 4 cases of unsatisfactory reduction with an excellent rate of 85% (22/26), the excellence rate was 85% (22/26). All patients were followed up for 16.3±4.3 months (range, 12-24 months). The hip function score after operation was higher than that before operation, and the difference was statistically significant ( F=19.80, P<0.001). The hip function score was 13.1±2.2 at 3 months postoperatively, increased to 15.9±2.3 at 6 months postoperatively, and increased to 16.6±1.9 at the last follow-up, with a statistically significant difference ( P<0.001). After operation, 5 patients showed symptoms of lateral femoral cutaneous nerve injury such as hypoesthesia and numbness in the anterolateral thigh. During the follow-up, there was no ectopic ossification, traumatic arthritis, necrosis of the femoral head and central dislocation of the femoral head. Conclusion:The "frame and buttress" fixation strategy based on quadrilateral fracture typing for acetabular quadrilateral fracture open reduction internal fixation provides strong fixation, satisfactory reduction quality, and facilitates joint function recovery after operation.

Robot-assisted screws fixation for the treatment of fragility fractures of the pelvis / 中华骨科杂志

Objective:To investigate the clinical outcomes of fragility fractures of the pelvis (FFP) treated with robot-assisted screws, minimally reduction according to the pelvic osseous pathways.Methods:A retrospective analysis was performed on the data of 50 elderly patients with FFP treated by the Department of Trauma and Pelvic Trauma of Tianjin Hospital from March 2016 to October 2021, and the 50 patients with FFP were divided into robotic-assisted screw fixation group (robot group) and open reduction steel plate fixation group (open group) according to the fixation method. There were 30 patients in the Robot group, 6 males and 24 females, average age 75.03±7.32 years (range, 60-90 years). According to Rommens and Hofmann FFP classification, there were 4 cases of IIc type, 8 cases of IIIa type, 1 case of IIIb type, 12 cases of IIIc type, 3 cases of IVa type, 2 cases of IVb type. There were 20 patients in the open group, 5 males and 15 females, average age 71.90±5.51 years (range, 62-85 years). According to Rommens and Hofmann FFP classification, there were 2 cases of IIc type, 6 cases of IIIa type, 9 cases of IIIc type, 3 cases of IVa type. The two groups were compared with age, pelvic fracture classification, operation time, intraoperative blood loss, fracture reduction quality, visual analogue scale (VAS), Majeed score, and wound healing or not.Results:All patients were followed up for 12.72 months (range, 6-24 months). In the robot group, the operation time was 50.17±19.32 min (range, 30-120 min), and intraoperative blood loss was 55.50±28.60 ml (range, 10-150 ml); in the open group, the operation time was 92.25±27.55 min (range, 60-180 min), and intraoperative blood loss was 217.50±67.20 ml (range, 150-400 ml), there were statistical differences ( t=6.36, P<0.001; t=11.72, P<0.001). According to Mears and Velyvis imaging evaluation criteria, in the robot group, anatomical reduction were achieved in 10 cases, satifactory reduction were achieved in 20 cases; in the open group, anatomical reduction were achieved in 14 cases, satifactory reduction were achieved in 6 cases, there were statistical differences (χ 2=6.46, P=0.011). In the robot group, VAS for pelvic pain was 7.33±1.32 points (range, 4-9 points) before operation, 4.13±1.07 points (range, 3-8 points) one week after surgery, and 2.30±0.84 points (range, 1-5 points) at the last follow-up; in the open group, VAS for pelvic pain was 7.45±1.23 points (range, 5-9 points) before operation, 5.25±1.25 points (range, 3-8 points) one week after surgery, and 2.80±1.24 points (range, 1-6 points) at the last follow-up, the difference between the two groups was statistically significant ( F=162.18, P<0.001; F=70.18, P<0.001), the difference between the two groups was statistically significant 1 week after surgery ( t=3.37, P=0.001), and there was no statistically significant difference between the two groups before surgery and the last follow-up ( P>0.05). The Majeed score was 82.10±4.80 (range, 65-95) in the robot group, 77.60±5.40 (range, 70-93) in the open group at the last follow-up, there were statistical differences ( t=3.09, P=0.003). There was no wound complication in the robot group, there were 4 cases with wound infection or rupture in the open group. One LC-II screw loosen in the robot group, which needed reoperation with cement, there was also 1 screw of plate loosening in the open group with no reoperation. Conclusion:Robot-assisted screws fixation with minimally reduction based pelvic osseous pathways shows satisfactory clinical outcomes, satisfactory reduction, effective pain relief, and fewer postoperative complications in treatment of elderly FFP.

Surgical method and clinical effect of modified LC-II screws for fragility fractures of the pelvis in the elderly / 中华骨科杂志

Objective:To investigate the surgical method of LC-II screws for fragility fractures of the pelvis (FFP) in the elderly and evaluate its clinical efficacy.Methods:A retrospective analysis was performed on 45 patients with FFPs operated in our department from January 2011 to January 2022. The clinical information was as follows. The FFP classification of pelvic fracture was IIIA in 26 cases and IIIB in 19 cases. Among them, 22 cases were fixed with closed reduction and modified LC-II screws (experimental group), and 23 cases were fixed with open reduction and reconstruction plates (control group). In the experimental group, there were 6 males and 16 females. The age range was 62-90 years, with an average of 73.2±9.2 years. The FFP classification of pelvic fracture was IIIA in 12 cases and IIIB in 10 cases. In the control group, there were 8 males and 15 females. The age range was 60-87 years, with an average of 72.8±6.6 years. FFP classification of pelvic fracture was IIIA in 14 cases and IIIB in 9 cases. After admission, pelvic X-ray and CT scan were performed, and the surgery was prepared. In the experimental group, after closed reduction of the posterior ring, the modified LC-II screw was inserted below the anterior inferior iliac spine (AIIS) toward the sacroiliac joint and penetrated the sacroiliac joint. For combined anterior ring fractures, the INFIX was used for anterior ring fixation. In the control group, the posterior ring was fixed with a reconstruction plate and/or sacroiliac screw after open reduction through the lateral rectus approach (LRA). The clinical efficacy was evaluated between the experimental group and the control group.Results:All 45 patients were successfully operated and followed up for 6 months to 3 years. All the pelvic fractures healed. In the experimental group of 22 cases, the time from injury to operation was 3-9 days, with an average of 5.8±1.9 days; the operation time was 25-70 min, with an average of 42.0±12.9 min. The intraoperative bleeding was 20-40 ml, with an average of 29.1±6.7 ml. According to the X-ray reduction evaluation criteria of Matta, 7 cases were excellent, 11 cases were good and 4 cases were medium, with an excellent and good rate of 81.8%. According to rehabilitation criteria of Majeed, 10 cases were excellent, 6 cases were good and 6 cases were fair, with a total excellent and good rate of 72.7%. At the last follow-up, sacroiliac joint pain was evaluated by VAS score: 0 in 10 cases, <3 in 7 cases, and 4-6 in 5 cases. No internal fixation loosening occurred. In the control group, the time from injury to operation was 5-20 days, with an average of 9.9±3.8 days; the operation time was 50-150 min, with an average of 89.1±29.5 min; the intraoperative bleeding was 220-1 000 ml, with an average of 509.2±214.3 ml. According to the X-ray reduction evaluation criteria of Matta, 16 cases were excellent, 4 cases were good and 3 cases was medium, with an excellent and good rate of 87.0%. According to rehabilitation criteria of Majeed, 12 cases were excellent, 6 cases were good and 7 cases were fair, with a total excellent and good rate of 78.3%. At the last follow-up, sacroiliac joint pain was evaluated by VAS score: 0 in 14 cases, <3 in 6 cases, and 4-6 in 3 cases. In the control group, posterior ring plate loosening was found in 2 cases and anterior ring pubic ramus plate and screw loosening was found in 4 cases, but there was no reduction loss.Conclusion:The modified LC-II screw is theoretically feasible in the treatment of FFP. Preliminary clinical results show good safety and efficacy, providing a new idea for minimally invasive treatment of FFP.

Imaging and clinical study on the relationship between abnormal development of the proximal sacrum and precise insertion of sacroiliac screws / 中华骨科杂志

Objective:To investigate the clinical efficacy of robot-assisted sacroiliac screw implantation in the treatment of proximal dysplasia sacral fractures.Methods:A retrospective analysis was conducted on 191 patients admitted to the Pelvic Department of Tianjin Hospital from May 2016 to January 2021 who underwent robot assisted sacroiliac screw implantation with sacral fractures, including 105 males and 86 females, aged 38.5±6.5 years (ranging from 19 to 69 years old). Among them, there were 85 patients with dysplasia of proximal sacrum. According to the classification of proximal sacral dysplasia, the patients were divided into five groups: the steep sacral alar slope group ( n=60), the mastoid protrusion group ( n=30), the lumbar sacralization group ( n=25), the sacral foramen oval degeneration group ( n=23) and the S 1 anterior cortical depression group ( n=10). The remaining 106 patients were normal group. Iliac cortical density (ICD) line typing was recorded in the 85 patients. The the completion of sacroiliac screw implantation, the Gras score of screw position after operation, the postoperative complications, the minimum diameter of S 1 screw channel (R1), the angle ∠A between the S 1 sacroiliac screw in the coronal plane and the cephalic side, and the angle ∠B between the S 1 sacroiliac screw in the water plane and the ventral side were recorded and compared with those of normal development patients. Results:The incidence of steep sacral alar slope was the highest (31.4%, 60/191). There were 2 or more developmental abnormalities in 24 cases. In 85 cases with dysplasia of proximal sacrum, ICD line type I was found in 8 cases, type II in 12 cases and type III in 65 cases. 49 patients (58.8%, 49/85) were able to complete the implantation of S 1 sacroiliac screw, while 36 patients (35.3%, 36/85) were only able to complete the implantation of S 2 sacroiliac screw. The Gras score of postoperative screw position was 90.05% for grade I, 9.94% for grade II, and 0 for grade III. In 1 case the sacroiliac screw pierced through the anterior cortex of the sacrum, and in 1 case the screw partially threaded into the sacral foramen, and there were no symptoms of iatrogenic nerve injury. The R1 values of the preoperative steep sacral alar slope group, the mastoid protrusion group, the sacral foramen oval degeneration group, the lumbar sacralization group, the sacral foramen oval degeneration group and normal development patient group were 11.4±3.0, 11.6±3.2, 9.8±3.0, 8.8±4.2, 6.5±4.4, and 11.4±3.4 mm, respectively. The differences between the lumbar sacralization group, the sacral foramen oval degeneration group, and the S1 anterior cortical depression group with the normal development patients were statistically significant, respectively ( t=-3.05, P=0.005; t=-2.32, P=0.022; t=-3.45, P=0.006). The postoperative angle ∠A of the above six groups were 33.8°±4.2°, 20.8°±3.5°, 25.8°±2.5°, 35.5°±4.5, 27.8°±3.5° and 26.8°±5.0°, respectively. The postoperative angle ∠B of the above six groups were 27.8°±3.5°, 36.2°±3°, 26.3°±1.8°, 29.8°±2.7°, 14.8°±1.5° and 37.2±4.2°, respectively. The differences between the ∠A of the steep sacral alar slope group, the mastoid protrusion group, and tthe lumbar sacralization group with that of the normal development patients were statistically significant, respectively ( t=9.17, -7.48, 7.97, P<0.001). The differences between the ∠B of the steep sacral alar slope group, the lumbar sacralization group, the sacral foramen oval degeneration group, and the S 1 anterior cortical depression group with that of the normal development patients were statistically significant, respectively ( t=-14.68, -10.93, -19.79, -35.8, P<0.001). Conclusion:This study proposes the "absolute stenosis" of the S 1 screw channel; In the treatment of patients with abnormal proximal sacral fracture, attention should be paid to S 1 anterior cortical depression and lumbar sacralization, and robot-assisted sacroiliac screw implantation can further improve the safety and accuracy of sacroiliac screw implantation.

Robot-assisted sacroiliac screw fixation to treat fragility fractures of the sacrum in the elderly / 中华骨科杂志

Objective:To evaluate the clinical outcome of Robot-assisted sacroiliac screw fixation in the treatment of fragility fracture of the sacrum in the elderly.Methods:From March 2016 to June 2022, a retrospective analysis was performed on 30 patients with fragility fractures of the sacrum in the elderly who accepted robot-assisted sacroiliac screw to treat fragility fractures of the sacrum in our hospital. There were 12 males and 18 females with average age 71.03±8.25 years (range, 60-89 years). According to the classification of fragility fractures of the pelvis (FFP) in the elderly, there were 22 patients with FFP II, 2 patients with FFP III, and 6 patients with FFP IV. Surgical planning was based on the average CT value of S 1 channel and whether there is a transsacral screw channel. Robot-assisted sacroiliac screw fixation was performed during surgery. The pain of pre-operation and post-operation was evaluated using the visual analogue scale (VAS), the position of sacroiliac screws was evaluated by Gras grading, and the degree of functional recovery after surgery was evaluated using the Majeed function score. Results:All 30 patients successfully completed the operation. The mean operation time was 27.00±6.68 min (range, 18-35 min), the mean fluoroscopy times were 27.13±5.16 (range, 18-34), and the mean blood loss was 30.53±6.61 ml (range, 23-38 ml). All patients were followed up, and the mean follow-up time was 19.03±7.8 months (range, 8-25 months). The VAS was 5(5, 6), 4(3, 4), 3(2, 3), 0(0, 1) points before surgery, 1 week, 2 months and 6 months after surgery, respectively, and the difference was statistically significant ( H=103.26, P<0.001). After the surgery of 2 months, 6 months and the last follow-up time, the Majeed function scores were 88(83, 90), 91(87, 92), 92(90, 93) points, respectively, and the difference was statistically significant ( H=19.59, P<0.001). Screw position was evaluated according to Gras grading at 3 days after surgery, including 28 cases of level I, 2 cases of level II, and no screw penetrated the cortical bone or entered the sacral canal or sacral foramen. No vascular or nerve injury occured during the operation. 28 patients with FFS met the fracture healing criteria, and the healing time was 4.54±1.57 months (range, 3-7 months). Two patients had bone nonunion, one of whom underwent anterior ring plate removal due to infection of the pelvic anterior wound, and one month later, pelvic CT scan revealed loosening of the sacroiliac screw; the other one is considered to be related to too early weight bearing. Conclusion:For fragility fractures of the sacrum in elderly, Robot-assisted sacroiliac screw is an effective minimally invasive treatment, with high accuracy of screw placement, effective pain reduction, improved fracture healing rate, and achieve the satisfactory clinical efficacy.

Treatment of transverse with posterior wall fractures of acetabulum using robot-aided percutaneous anterior column screw combined with posterior plate / 中华骨科杂志

Objective:To explore the effectiveness and safety of robot-aided percutaneous anterior column screw combined with posterior plate fixtation treatment for transverse acetabular fractures with posterior wall.Methods:A retrospective analysis was conducted on the data of 13 patients with transverse acetabular fractures and posterior wall fractures treated by robot-aided percutaneous anterior column screws combined with posterior plate in Tianjin Hospital from May 2016 to May 2021. There were 9 males and 4 females, aged 49.1±8.5 years (range, 25-65 years), 9 cases of vehicle accidents, 2 cases of falling injuries, 2 cases of impact injuries, 7 cases of combined posterior hip dislocations, and 1 case of sciatic nerve injury. Apply Kocher-Langenbeck approach for reduction and fixation of the posterior wall and the posterior column and indirect reduction of the anterior column. Use robot navigation for percutaneous anterior column screw fixation, and record the time of inserting anterior column screws, incision length, and complications. The quality of fracture reduction was evaluated using Matta imaging, and the degree of ectopic ossification was evaluated using Brooker classification. The Matta modified Postel Merle D'Aobigne score was used to evaluate the function at 3, 6 months after surgery and at the last follow-up.Results:All 13 patients successfully completed the surgery. The insertion time of the anterior column screw was 19.4±4.0 min (range, 17-23 min), and the incision length was 8.0±1.4 mm (range, 6-10 mm). Postoperative imaging examination showed that all anterior column screws were located within the bone canal, with a screw length of 108.3±11.2 mm (range, 90-130 mm), and no complications such as nerve or vascular injury or incision infection occurred. All 13 patients were followed up for a period of 12-36 months, with an average of 18.6 months; All fractures healed, with a healing time of 2-6 months, average 3.4 months. According to the Matta imaging evaluation method, 11 of 13 patients had anatomical reduction of fractures, and 2 were evaluated as incomplete reduction due to a 1-2 mm gap in the anterior column. The anatomical reduction rate was 84%. At postoperative 3, 6 months and the last follow-up, the modified Postel Merle D'Aobigne scores were 13.4±1.1, 15.8±1.5, and 17.0±1.7, respectively, with statistically significant differences ( F=7.78, P=0.007). The difference between the last follow-up and postoperative 3 months was statistically significant ( P=0.002), and there was no statistically significant difference compared to postoperative 6 months ( P=0.222). At the last follow-up, 8 cases were excellent, 4 cases were good, and 1 case was fair, with an excellent and good rate of 92%. There was no occurrence of ectopic ossification, traumatic arthritis, or necrosis of the femoral head. Conclusion:Robot-aided percutaneous anterior column screw combined with posterior plate treatment for transverse acetabular fractures with posterior wall is safe and effective, and is worthy of clinical promotion.

Combination pattern of internal fixation for periprosthesis fractures of the proximal femur after hip replacement / 中华骨科杂志

Objective:To investigate the combination of internal fixation for periprosthetic fractures of the proximal femur (PFFF) after hip arthroplasty.Methods:The data of 58 patients with periprosthetic fractures after hip arthroplasty from May 2008 to March 2022 were retrospectively analyzed, including 31 males and 27 females. The average age was 75.5±18.2 years (range, 35-95 years). There were 39 total hip arthroplasty and 19 hemiarthroplasty; 37 biological prosthesis and 21 cemented prosthesis. Intraoperative periprosthetic fractures occurred in 6 cases and 52 cases postoperatively. Unified classification system (UCS): UCS IV.3A1 type 2 cases, 3A2 type 1 case, 3B1.1 type 19 cases, 3B2.1 type 25 cases, 3B3 type 2 cases, 3C type 9 cases. Fracture site: 3 cases in zone A (greater trochanter), 46 cases in zone B (around the femoral stem), and 9 cases in zone C (distal to the tip of the femoral stem. Internal fixation is composed of primary and secondary fixation, the main fixation method was the cerclage of steel wire or titanium cable, locking compression plate, and locking attachment plate fixation. The secondary fixation method was the cerclage of titanium cable, which was required to cover three zones A, B and C to form an overall balanced fixation. The modified Harris hip scores (mHHS), plate length, working length and screw number of different internal fixation combinations were compared.Results:The follow-up time was 54.2±21.6 months (range, 11-86 months). All patients showed signs of fracture healing at 10.2±1.5 weeks (range, 7-13 weeks) after operation, and bony union was observed at 19.6±1.3 weeks (range, 17-22 weeks) after operation. No delayed union or nonunion was observed. After operation, one case had a stress fracture and was revised with double-plate internal fixation; one case had a failed internal fixation and was revised with double-plate internal fixation and a large allograft bone graft. The mHHS score of UCSIV.3B2.1 group (80.3±4.6) was the lowest at 6 months after operation, and the difference between the groups of different types was statistically significant ( F=256.72, P<0.001). The score of simple internal fixation group (91.6±4.2) was higher than that of revision combined with internal fixation group (81.9±4.1), and the difference was statistically significant ( t=8.32, P<0.001). The plate length and working length were 24.9±2.5 cm and 12.6±1.7 cm for UCS IV.3B1.1, 25.4±2.6 cm and 13.6±1.8 cm for 3B2.1 and 28.1±2.5 cm and 4.9±1.9 cm for 3C, respectively ( F=5.33, P=0.005; F=6.78, P<0.001). The number of screws in zone A was significant difference among different UCS types ( F=52.67, P<0.001); UCS IV.3B1.1 (6.5±2.3) and 3B2.1 (6.7±2.2) were more than 3B3 (3.5±1.5) and 3C (3.7±1.6). The number of screws in zone B was significant difference among different UCS types ( F=42.15, P<0.001); The number of UCS IV.3B1.1 (2.3±1.6) and 3B2.1 (2.8±1.9) were significantly more than that of 3B3 (1.0±0.5) and 3C (1.2±0.6). The number of screws in zone C was significant differences among different UCS types ( F=39.62, P<0.001); The number of UCS IV.3B1.1 (3.8±1.9) and 3B2.1 (3.9±1.7) were more than that of 3B3 (2.0±0.5), the difference was statistically significant ( P<0.05). Conclusion:The function of hip after simple internal fixation of proximal femoral periprosthetic fractures was better than that of those who underwent revision at the same time; the number of screws of UCSIV.B1 and B2 is more than that of B3.