Early posterior spinal canal decompression and circumferential reconstruction of rotationally unstable thoracolumbar burst fractures with neurological deficit.

BACKGROUND: Among the various treatments of neurologically involved unstable thoracolumbar burst fractures, the combination of anterior and posterior instrumentation provides the most stable reconstruction. However, the use of both approaches on a trauma patient may increase the morbidity. This study is a retrospective matched cohort study to evaluate the advantages of a single stage posterior approach for spinal canal decompression in combination with circumferential reconstruction by comparing the clinical and radiographic results. METHODS: From March 2005 to September 2009, patients with matched type spinal fracture, ages at surgery, and involved levels in our institute underwent either a single stage posterior approach (group one, n = 12) or traditional combined approach (group two, n = 14) for spinal canal decompression and circumferential reconstruction were reviewed. Pre- and post-operative X-ray flms were reviewed and changes in Cobb angle of thoracolumbar spine were documented. Intra-operative, post-operative, and general complications were registered. RESULTS: The mean follow-up was (27.7 ± 9.6) months (range, 14 to 56 months) in group one and (29.2 ± 7.4) months (range, 20 to 60 months) in group two (P > 0.05). The mean operation time was 214 minutes (range, 186 ± 327 minutes) in group one and 284 minutes (range, 219 ± 423 minutes) in group two (P < 0.05). The average volume of intraoperative blood loss was 1856 ml (range, 1250 ± 3480 ml) in group one and 2453 ml (range, 1600 ± 3680 ml) in group two (P < 0.05). There was no statistical difference between the groups one and two in average vertebral body height loss at the injured level and the average Cobb angle in sagittal plane before and immediately after surgery. Postoperatively, there was an epidural hematoma in one patient in group one and two patients in group two. Bony union after stabilization was obtained in all patients, without loosening or breakage of screws. Loss of correction (5°) was seen in 1 patient in group one at the 6th month owing to the subsidence of the Titanium mesh cages into the vertebra. In group two, totally four patients suffered respiratory-related complication, including pneumonia in two, severe atelectasis in one and pleural effusions in one. Importantly, there were no intraoperative or postoperative deaths in any group. All patients with incomplete neurologic deficits improved at least 1 Frankel grade. CONCLUSION: Single-stage posterior vertebra resection in combination with circumferential reconstruction is a new option to manage severe thoracolumbar burst fractures.

[Surgical treatment of compound fracture of the ankle].

OBJECTIVE: To report the clinical outcome of the treatment of compound ankle fractures by vacuum sealing drainage and spanning external fixator. METHODS: From April 2005 to April 2009, 19 cases of Gustilo type III compound ankle fractures were treated, with type IIIA in 10 cases, Type IIIB in 7 and Type IIIC in 2. All cases underwent emergency debridement, and had the fractures fixed with spanning external fixator following indirect reduction, the wound closed with vacuum sealing drainage and repaired through direct suture, split-thickness skin graft or flap transposition. RESULTS: In this series, following VSD of 5.0 to 18.0 d (mean 10.3 d), 2 cases had their wounds closed by direct suture, 12 by skin graft and 3 by flap transposition. The other 2 cases had repeated wound debridement and multiple use of VSD, and had their wounds repaired by flap transposition. All the 19 cases were followed up for 8 to 36 months with an average of 26 months. All the fractures united 3.0 to 10.0 (mean 3.8) months. At the final follow-up functional evaluation of the affected ankle joints was performed only to find excellent in 9 cases, good in 5, fair in 4 and poor in 1. CONCLUSION: Gustilo type III compound ankle fracture can effectively be treated with VSD and spanning external fixator.

[A comparisive study between intramedullary interlocking nail and plate-screw fixation in the treatment of tibial shaft fractures].

OBJECTIVE: To evaluate the effects of tibial shaft fractures treatment with plate-screw or intramedullary interlocking nail. METHODS: Thirty-five fractures were treated with intramedullary interlocking nail. Tape A, B and C were 11, 18 and 6 cases respectively according to AO classification. Forty-five fractures were treated with plate-screw system. Type A,B and C were 10,22 and 13 cases respectively. The mean time between injury and operation was 3 days and 3.5 days respectively. The patients were evaluated with operation time,range of motion,time of bone union,and complications after a mean followup of 13 months(range 8 to 26 months). RESULTS: The mean operation time and the mean range of motion of the ankle and knee were found similar in both groups. The average dorsiflexion angle of ankle was 13 Degrees (0 degrees to 20 degrees) in locked intramedullary nailing group and 11 degrees (0 degree to 20 degrees) in plate group. The average plantar flextion angle of ankle was 41 degrees (30 degrees to 50 degrees) in locked intramedullary nailing group and 47 degrees (30 degrees to 50 degrees) in plate-screw group. The mean time of bone union was 3.3 months with intramedullary nailing and 3.5 months with plate-screw fixation. Length discrepancy occurred in only two patients (2 and 2.5 cm) with intramedullary interlocking nail. One patient treated by intramedullary interlocking nail for a type III open fracture occured osteomyelitis. Plain radiographs showed rotation in two patients with intramedullary interlocking nail and angulation in 3 patients with plate-screw fixation, which were distal-third tibial fractures. CONCLUSION: Plate-screw osteosynthesis could attain satisfactory results in uncomminuted tibia shaft fractures, and locked intramedullary nailing is more appropriate in comminuted fractures.

[Clinical research of hemiprosthesis arthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients].

OBJECTIVE: To report the clinical results of hemiprosthesis for unstable intertrochanteric fractures in elderly patients. METHODS: 86 cases (male 35 and females 51) of unstable intertrochanteric fractures in elderly patients were treated with hemiprosthesis arthroplasty in our hospital. The average age was 87 years old (range from 80 to 98 years old). According to the Evans classification of intertrochanteric fractures, there were 31 cases in type IIIA, 35 cases in IIIB and 20 cases in type IV. Most of the patients fell in the room and fractured, with concomitant diseases. After admitted to the hospital, the patients were consulted and treated for the concomitant diseases, and after the general conditions got stable and no absolute contraindications were found, the hemiprosthesis arthroplasty was performed. Almost all of the patients were operated on within 3 days with general anesthesia under the multi-function monitoring. The greater trochanter was reconstructed with figure of 8 wire fixation, the lesser trochanter with figure of 8 wire fixation, the lesser trochanter was fixed with circular wire around proximal femur. The defect within the femoral calcar was filled with bone cement and in a part of the patients, the intertrochanteric fracture was transformed into femoral neck fracture and the femoral calcar was fixed with femoral prosthesis stem. RESULTS: All operations were successful and the duration of the operation was 45 to 70 minutes with an average of 55 minutes. Blood was transfused in 73 patients during the operation between 400-800 ml with an average 450 ml. The patients got out of the bed within 3 days in 33 cases, 4-7 days in 43 cases, more than 8 days in 8 cases, and 2 patients couldn't get out of the bed. The period of hospitalization was between 13 to 27 days with an average of 16.8 days. COMPLICATIONS: 2 patients got slight deep phlebitis, 5 patients showed psychological disorders, and disorders in bacterial spectrum appeared in 3 patients, and after appropriate treatments, the complications gradually recovered and had no effect on the function of the affected extremity. 2 cases died of multiple organ failure during the hospitalization. 59 patients were followed up for 6 to 48 months with an average 16 months. The result was excellent in 17 cases who resumed their activities as before they got fractured, good in 35 cases who could walk with walking aid, fair in 5 cases who could walk with others help, and poor in 2 cases who could not walk. 1 patient died of other diseases 5 months after discharged. No dislocation, loosening or late infections occurred. 88.1% showed excellent or good result. CONCLUSION: It's an effective method to treat the unstable intertrochanteric fractures in elderly patients with hemiprosthesis arthroplasty. The result was satisfactory. It can decrease the complications, reduce the mortality, improve the patient's the living quality, and reduce the burden of the patient's family.