[Analysis of risk factors of infection for complex tibial plateau fractures after operation].

OBJECTIVE: To analyze the risk factor of infection for complex tibial plateau fractures after operation. METHODS: Totally clinical data of 293 patients with complex tibial plateau fractures underwent open reduction and internal fixation were retrospectively analyzed from September 2010 to March 2015, including 199 males and 94 females, ranging in age from 17 to 80 years old with an average of 47.3 years old. The possible risk factors such as gender, age, smoking, diabetes, type of fracture(open/closed), classification of open fracture(Gustilo-Anderson classification), classification of soft tissue injury in closed fracture (Tscherne-Gotzen classification), fracture classification(Schatzker V/VI), osteofascial compartment syndrome, ASA score, anesthesia, timing of surgery, operative time(<=150 min/>150 min), surgical approach, combined approach or not, internal fixation site were studied. The multivariate Logistic regression model was used to analyze the risk factors. RESULTS: Twelve patients were infected of all 293 patients after operation, the infection rate was 4.10%. Univariate analysis showed that fracture type(χ ² =14.496, P=0.001), fracture classification(χ²=4.560, P=0.033), osteofascial compartment syndrome(χ²=15.631, P=0.001), operative time(χ²=11.233, P=0.001) were correlated with complex tibial plateau fractures postoperative infection. Multivariate analysis showed that open fractures(χ²=9.696, P=0.002) and osteofascial compartment syndrome(χ²=9.119, P=0.003) were complex tibial plateau fracture risk factors for infection after operation. CONCLUSIONS: Open fractures and osteofascial compartment syndrome are risk factor of complex tibial plateau fracture for infection after operation. While through debridement for open fracture patients, early diagnosis and promt treatment for osteofascial compartment syndrome could reduce incidence of infection.

Learning curves of percutaneous endoscopic lumbar discectomy in transforaminal approach at the L4/5 and L5/S1 levels: a comparative study.

OBJECTIVES: This study aimed to compare the learning curves of percutaneous endoscopic lumbar discectomy (PELD) in a transforaminal approach at the L4/5 and L5/S1 levels. METHODS: We retrospectively reviewed the first 60 cases at the L4/5 level (Group I) and the first 60 cases at the L5/S1 level (Group II) of PELD performed by one spine surgeon. The patients were divided into subgroups A, B, and C (Group I: A cases 1-20, B cases 21-40, C cases 41-60; Group II: A cases 1-20, B cases 21-40, C cases 41-60). Operation time was thoroughly analyzed. RESULTS: Compared with the L4/5 level, the learning curve of transforaminal PELD at the L5/S1 level was flatter. The mean operation times of Groups IA, IB, and IC were (88.75±17.02), (67.75±6.16), and (64.85±7.82) min, respectively. There was a significant difference between Groups A and B (P<0.05), but no significant difference between Groups B and C (P=0.20). The mean operation times of Groups IIA, IIB, and IIC were (117.25±13.62), (109.50±11.20), and (92.15±11.94) min, respectively. There was no significant difference between Groups A and B (P=0.06), but there was a significant difference between Groups B and C (P<0.05). There were 6 cases of postoperative dysesthesia (POD) in Group I and 2 cases in Group IIA (P=0.27). There were 2 cases of residual disc in Group I, and 4 cases in Group II (P=0.67). There were 3 cases of recurrence in Group I, and 2 cases in Group II (P>0.05). CONCLUSIONS: Compared with the L5/S1 level, the learning curve of PELD in a transforaminal approach at the L4/5 level was steeper, suggesting that the L4/5 level might be easier to master after short-term professional training.

Early diagnosis and treatment of trauma in knee joints accompanied with popliteal vascular injury.

OBJECTIVE: The objective of the present study was to investigate the early diagnosis and treatment of trauma in the knee joints accompanied with popliteal vascular injury. METHODS: Fifteen cases of patients with trauma in knee joints accompanied with popliteal vascular injury. These patients included 8 males and 6 females between the ages of 27 and 62, the average age being 39.2. Data of clinical symptoms and signs; blood oxygen saturation, color Doppler examination; vascular intervention by DSA angiography; and surgical operations were analyzed to clearly identify their role in early diagnosis and treatment. RESULTS: In the patient group for this study there were: 1 death case; 4 stage I amputation cases; 4 stage II amputation cases due to failure to salvage limbs; and 6 cases with patients who had successful limb salvage. The six cases of limb survival patients were followed up for 12 to 60 months, with an average follow up time of 28.3 months. The excellent rate of joint function of these patients with successful limb salvage was 83.3%. CONCLUSIONS: For patients with injured limbs, unclear dorsalis pedis artery palpation, decreased skin temperature, and decreased oxygen saturation of the toes, clinical manifestations combined with proper auxiliary inspection (such as color Doppler and blood vessel angiography of interventional DSA) enabled early diagnose of peripheral trauma in the knee joint accompanied with popliteal vascular injury.

[Early diagnosis and treatment for trauma around the knee with popliteal vascular injury].

OBJECTIVE: To investigate the early diagnosis and treatment for trauma around the knee with popliteal vascular injury. METHODS: A retrospective analysis was employed to analyze the clinical data from 15 patients (9 males and 6 females were with a mean age of 39.2 years old,ranging from 26 to 62 years old) with fracture or dislocation around the knee with popliteal vascular injury from January 2007 to January 2013. Combined with clinical symptoms and signs, oxygen saturation monitors, color ultrasound, DSA angiography and interventional surgery were used to determine the vascular injury. The knee fracture and dislocation were fixed with hybrid external fixation and plate-screw fixation, respectively. Then, the blood circulation was reconstructed by thrombectomy, repair and autologous vein graft for individual injured vascular. The average total operation time, average hospitalization days, predictive salvage index (PSI), average blood transfusion amount, average medical expenses and infection cases were recorded to determine the effect of early diagnosis and treatment. RESULTS: There was one patient with death, 8 patients with amputation, and 6 patients with successful repair surgery for popliteal artery, anterior tibial and posterior tibial arteries. These six patients with surviving limbs were followed up for an average of 28.3 months (ranged, 12 to 60 months). Among the 6 successful patients, the joint function of 4 patients was good and excellent. CONCLUSION: The trauma around the knee with popliteal vascular injury is characterized by complex and serious injury, easy misdiagnosis and loss diagnosis, poor prognosis and high risk of amputation. The early diagnosis of trauma around the knee with popliteal vascular injury should depend on the mechanism of trauma, local anatomical characteristics of injury site, clinical presentations and appropriate auxiliary examinations. The appropriate indications for limb salvage and amputation should be used to achieve more effective clinical results.

An efficacy analysis of surgical timing and procedures for high-energy complex tibial plateau fractures.

OBJECTIVE: To identify the most effective treatment for application to high-energy complex plateau fractures. METHODS: 125 patients with closed high-energy complex tibial plateau fractures who had been surgically treated between 2003 and 2010 were reviewed retrospectively. Five procedure methods were studied (e.g. four open reduction and internal fixations, and close reduction via a minimal incision with hybrid external fixation) in five surgical timings, with a control group. The incidence of wound complications after operative treatment in the five surgical timings and the clinical effects of the five surgical procedure options were evaluated statistically. A postoperative follow-up ranging 26-110 months (mean, 36.5 months) was performed. RESULTS: Among the various groups, the respective overall wound complication incidences were 20.0%, 41.6%, 33.3%, 2.5%, and 16.7% within 4 hours, 4 hours to 3 days, 3-5 days, 5-8 days, and more than 8 days after injury. Failed fixation was clearly observed in Group 1 (23.1%, 6/26) and Group 5 (21.7%, 5/23) (P < 0.05). Significant differences were also found among Group 2 (92.6%), Group 3 (93.3%), and Group 5 (69.6%), in terms of the good and excellent rate of joint function according to the Rasmussen score (P < 0.05). CONCLUSION: The optimal surgical timing is within 4 hours after trauma, for which no obvious swelling was observed in the limbs. This is followed by surgical timing within 5-8 days, after which trauma showed only subsided limb swelling. Dual plating provides the best stabilization option, as it allows early joint mobilization, cartilage regeneration, and joint remodeling, thus decreasing the risk of joint stiffness. Hybrid external fixation may provide relative stability to maintain fracture alignment without the need for massive soft tissue dissection, and also minimizes blood loss and potential soft tissue complications.

[Case-control study on operative treatment for complex tibial plateau fracture].

OBJECTIVE: To explore optimal choice of surgical treatment and operative approach for closed complex tibial plateau fractures and its influencing factors. METHODS: From January 2003 to January 2011, 95 patients with closed complex tibial plateau fractures were estimated Schatzker V and Vl, and treated with three different surgical methods. The methods included single plate through anterolateral incision (Group A, 22 cases), double plates through inside and outside incisions (Group B, 36 cases), and double plates through antero-midline incisions (Group C, 37 cases). There were 56 males and 39 females, ranged the age from 19 to 57 years (averaged, 36.3 years), 50 cases in left, 45 cases in right. According to Schatzker classification, 51 cases were type V, 44 cases were VI. The data of operation time, intraoperative blood loss, complications (infectious of wound, necrosis, bad incision, collapse fracture, loosen of internal fixation, fracture failure)and recovery of function of lower limb joint were collected. RESULTS: There were no significant difference among three groups in operation time (P > 0.05); blood loss in group A was obvious better than other groups (P < 0.05); collapse of joint surface and failure rate of internal fixation in group A was higher than other groups (P > 0.05); Merchant score after 1 year were higher in group B, C than group A. For lower limb function, 10 cases got excellent results, 5 good, 4 fair and 3 poor in group A; 21 cases got excellent results, 11 good, 3 fair and 1 poor in group B; 23 cases got excellent results, 11 good,2 fair and 1 poor in group C. CONCLUSION: The blood loss in group A was least, but fracture exposure and joint surface was not satisfactory, and stable fixation could not be achieved, the long-term result was not good. For fractures with double condyles and dislocated involved, double plates through inside and outside incisions or double plates through antero-midline incisions was suggested,which benefit good reduction of joint surface, stable fixation, and erlier exercise.

[Case-control study on MDCT and MRI for the diagnosis of complex fractures of tibial plateau].

OBJECTIVE: To evaluate the clinical value of MDCT and MRI in the diagnosis and treatment of complex fractures of tibial plateau. METHODS: From March 2004 to January 2009,71 patients with complex fractures of tibial plateau estimated Schatzker III, V and VI were included in the study. Their X-ray films, MDCT, MRI were analyzed and compared. Twenty-four patients (14 males and 10 females with a mean age of 33.6 years) were treated with double incision and single plate. Average follow-up period was 31.4 months. Twenty-one patients (12 males and 9 females with a mean age of 33.2 years) were treated with double incision and bilateral plates. Average follow-up period was 28.4 months. Twenty-six patients (17 males and 9 females with a mean age of 35.3 years) were treated with bilateral plates via genicular anterior midline incision. Average follow-up period was 28.4 months. The index such as diagnosis correction for fracture location, fracture comminuted degree,fracture displacement degree,bone defect degree,and positive ration for number of collapsed joint surface,injuries of cruciate ligament, collateral ligament and menisci of knee joint. RESULTS: The satisfaction score of X-ray flims, MDCT and MRI were (1.04 +/- 0.20), (1.82 +/- 0.38) and (1.12 +/- 0.33) separately for fracture positions; (0.81 +/- 0.51), (1.92 +/- 0.26) and (0.83 +/- 0.60) separately for fractures comminuted degree; (1.23 +/- 0.48), (1.92 +/- 0.26) and (0.46 +/- 0.58) separately for fracture displacement degree; (0.36 +/- 0.51), (1.55 +/- 0.79) and (0.26 +/- 0.53) separately for bone defect; the number of patients having collapse of tibial articular surface were 6,61 and 12 separately; the number of patients having cruciate ligaments were 3,10 and 17 separately; the number of patients having menisci injuries were 0,0 and 6 separately;the number of patients having collateral ligament injuries were 1, 1 and 8 separately. MDCT was the most sensitive method in the diagnosis of tibial articular surface collapse,avulsion tibial fracture at the point of cruciate ligament,fracture comminuted degree and fracture displacement degree (P < 0.01). MRI was the most sensitive method in the diagnosis of injuries of cruciate ligament, collateral ligament, menisci, the cartilage peeling of articular surface (P < 0.01). CONCLUSION: MDCT and MRI further detail the Schatzker classification based on X-ray films, which also conduce to make precise diagnosis and reasonable treatments. MDCT and MRI are more sensitive for the diagnosis of insidious damages around knee.

[Experimental study of electrophysiologic effects of regenerative nerve fibres affected by control releasing FK506].

OBJECTIVE: To discuss the electrophysiologic effects of regenerative nerve fibres affected by control releasing of FK506. METHODS: From Mar. to Sep. in 2008, the body weigh of 32 Sprague-Dawley rats which was 200 to 250 g,anesthesia was performed with an intraperitoneal injection of 30 mg/kg 1% continal. The sciatic nerve was transected in each rat by the excision of a 10 mm gap just proximal to the trifurcation of the nerve. The 10 mm gap of sciatic nerve had been bridged with the new double channel nerve conduit of fusiform shape, which were randomly divided into two groups basing on the different drug in the channel, each group contained 16 animals. In group A,100 microl of chitin for medical use was injected into the conduit,in group B the two branches of the conduit respectively contained 100 microl of the chitin and 10 microl FK506 (group B2) or physiologic saline (group B1). At 8 and 12 week after operation, the morphology in regenerative nerve and electrophysiologic effects by detect compound muscle active potential (CMAP) and cortical somatosensory evoked potential (CSEP) were evaluated. RESULTS: There were not significant differences of the regenerative nerve fibres between two channels in group A, but in group B2, the number of the regenerative fibres was much more than that in group B1. The latency of CMAP and CSEP in group B2 was shorter than that in group B1. But its amplitude was higher. There were highly significant difference between the groups (P < 0.01). CONCLUSION: The electrophysiologic effects of regenerative nerve fibres can be significantly promoted by FK506, which provide theory base for immunosuppressive treatment of peripheral nerve.