2021 classification and reduction techniques of irreducible intertrochanteric fractures / 中华创伤骨科杂志

Objective:To revise the 2017 classification of irreducible intertrochanteric fractures and summarize reduction techniques of 2021 classification.Methods:A retrospective analysis was conducted of the 17 patients with irreducible intertrochanteric fracture who had been treated at Department of Orthopaedic Surgery, The Ninth People's Hospital of Shanghai, Shanghai Jiaotong University School of Medicine from January 2015 to December 2019. They were 7 males and 10 females, with an age of (73.2 ± 16.1) years. On the basis of 2017 classification, the irreducible intertrochanteric fractures were classified into 2 types in the present 2021 classification. Type Ⅰ were interlocking fractures which were further classified into 3 subtypes: type ⅠA were sagittal interlocking ones (7 cases), type ⅠB greater trochanter interlocking ones (one case) and type ⅠC lesser trochanter interlocking ones (one case). Type Ⅱ were separating fractures which were further classified into 4 subtypes: type ⅡA were sagittal separating ones (4 cases), type ⅡB coronal separating ones (one case), type ⅡC rotational separating ones(one case) and type ⅡD complete separating ones (2 cases). All patients were treated by closed reduction and intramedullary nailing with different reduction strategies corresponding to their fracture types (application of ejector rods, clamps or prying techniques, etc.). A total of 132 patients with reducible femoral intertrochanteric fracture who had been admitted during the same period were selected as the control group. The fracture reduction time, intraoperative blood loss and Harris hip score at the last follow-up were compared between the 2 groups.Results:The 2 groups were comparable because there was no significant difference in their preoperative general data ( P>0.05). Type ⅠA accounted for the highest proportion of irreducible intertrochanteric fractures [41.3% (7/17)], followed by type ⅡA [23.6% (4/17)]. The fracture reduction time [(44.6 ± 6.7) min] in the irreducible group was significantly longer than that in the control group [(39.2 ± 9.6) min] ( P<0.05). There was no significant difference in intraoperative blood loss or Harris hip score at the last follow-up between the 2 groups ( P>0.05). Conclusions:Compared with the "2017 classification" , the "2021 classification" is more concise and easy to remember, and can directly prompt the corresponding proper fracture reduction techniques. The patients with irreducible intertrochanteric fracture using proper reduction techniques can obtain functional recovery similar to that in the patients with reducible intertrochanteric fracture after reduction and fixation.

Treatment strategies of complicated extrahepatic bileduct stones / 中华消化外科杂志

Complicated extrahepatic bile duct stone is defined as not easy to achieve the treatment standard of total stone clearance,stricture removal,unobstructed drainage and recurrence preventing in a single operation or combined with other liver diseases,which include hepatic hilar bile duct stones incarceration,distal bile duct stone incarceration,Mirizzi syndrome,residual cystic duct stones,recurrent extrahepatic bile duct stones,and combined with portal hypertension or intrahepatic bile duct stones.Through comprehensive and meticulous preoperative evaluation,we can clarify the cause of extrahepatic bile duct stones,the location of stones and bile duct stenosis,the variability of bile duct,the anatomy of the hepatoduodenal ligament,the condition of liver function and biliary tract infection,and make the proper surgery plan.During the surgery,we apply the perihilar surgical techniques,pancreatic hilar plate reduction techniques,Oddi sphincter incision and shaping,and choledochoscopic lithotripsy and lithotomy comprehensively to achieve the goal of reducing residual stone rate and recurrence rate.It is important that reasonably select endoscopic retrograde cholangiopancreatography indications,correctly hold indications of bilioenteric anastomosis,and prevent iatrogenic injury of extrahepatic bile ducts on the premise of clearing stones.

Predictors and reduction techniques for irreducible reverse intertrochanteric fractures / 中华医学杂志(英文版)

Background@#Reverse intertrochanteric fractures are usually initially treated with closed reduction. However, sometimes these fractures are not amenable to closed reduction and require open reduction. To date, few studies have been conducted on predictors of and reduction techniques for irreducible reverse intertrochanteric fractures. Therefore, this study aimed to summarize the displacement patterns of irreducible reverse intertrochanteric fractures and corresponding reduction techniques, and explore predictors of irreducibility.@*Methods@#We reviewed 1174 cases of trochanteric fractures treated in our hospital from January 2006 to October 2018, 113 of which were reverse intertrochanteric fractures. An irreducible fracture was determined according to intra-operative fluoroscopy imaging after closed manipulation. Fractures were assessed for displacement patterns, radiographic features of irreducibility, and reduction techniques. Logistic regression analysis was performed on potential predictors for irreducibility, including gender, age, body mass index, AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification, and radiographic features.@*Results@#Seventy-six irreducible fractures were identified, accounting for 67% of reverse intertrochanteric fractures. Six patterns of fracture displacement after closed manipulation were identified; the most common pattern was medial displacement and posterior sagging of the femoral shaft relative to the head-neck fragment. Multivariate logistic regression analysis identified three predictors of irreducibility: a medially displaced femoral shaft relative to the head-neck fragment on the anteroposterior (AP) view (odds ratio [OR], 8.00; 95% confidence interval [CI], 3.04-21.04; P < 0.001), a displaced lesser trochanter (OR, 3.61; 95% CI, 1.35-9.61; P = 0.010), and a displaced lateral femoral wall (OR, 2.92; 95% CI, 1.02-8.34; P = 0.046).@*Conclusions@#A high proportion of reverse intertrochanteric fractures are not amenable to closed reduction. Six patterns of fracture displacement after closed manipulation were identified. Different reduction techniques are required for different displacement patterns. Predictors of irreducibility include a medially displaced femoral shaft relative to the head-neck fragment on the AP view, a displaced lesser trochanter, and a displaced lateral femoral wall. These patients warrant special consideration in terms of recognition and management.

Treatment strategies of complicated extrahepatic bileduct stones / 中华消化外科杂志

Complicated extrahepatic bile duct stone is defined as not easy to achieve the treatment standard of total stone clearance, stricture removal, unobstructed drainage and recurrence preventing in a single operation or combined with other liver diseases, which include hepatic hilar bile duct stones incarceration, distal bile duct stone incarceration, Mirizzi syndrome, residual cystic duct stones, recurrent extrahepatic bile duct stones, and combined with portal hypertension or intrahepatic bile duct stones. Through comprehensive and meticulous preoperative evaluation, we can clarify the cause of extrahepatic bile duct stones, the location of stones and bile duct stenosis, the variability of bile duct, the anatomy of the hepatoduodenal ligament, the condition of liver function and biliary tract infection, and make the proper surgery plan. During the surgery, we apply the perihilar surgical techniques, pancreatic hilar plate reduction techniques, Oddi sphincter incision and shaping, and choledochoscopic lithotripsy and lithotomy comprehensively to achieve the goal of reducing residual stone rate and recurrence rate. It is important that reasonably select endoscopic retrograde cholangiopancreatography indications, correctly hold indications of bilioenteric anastomosis, and prevent iatrogenic injury of extrahepatic bile ducts on the premise of clearing stones.

Steinmann Pin Assisted Reduction of Subtrochanteric Femoral Fracture

PURPOSE: Nail insertion is the treatment of choice for subtrochanteric femoral fracture, but displacement of proximal bone fragment makes it difficult to find an ideal entry point. Therefore, in this study we aimed to determine the usefulness of treatment of subtrochanteric femoral fracture using Steinmann pin assisted reduction, internal fixation, and insertion of intramedullary nails. MATERIALS AND METHODS: We evaluated 33 patients who were followed-up more than a year with a displaced subtrochanteric femoral fracture treated with closed reduction and intramedullary nail fixation between January 2008 and March 2013. In addition, we studied postoperative bone union time, postoperative reduction status, change of the femur neck shaft angle, evaluation of hip joint function, return to daily life, and complications. RESULTS: All fractures with Steinmann pin assisted reduction were united but they included three cases of delayed union. In Fogagnolo classification, all cases were up to acceptable states and the varus change of femur neck shaft angle was 0.94degrees+/-3.1degrees; no significant difference in Harris hip score was observed between preoperative and last follow-up (p>0.05). CONCLUSION: There were satisfactory results in bone union and reduction state with Steinmann pin assisted reduction. Therefore, Steinmann pin assisted reduction is a useful surgical technique for subtrochanteric femoral fracture.