Effect of Orthogeriatric Co-Management on Geriatric Hip Fractures in China.

OBJECTIVES: Although geriatric hip fracture is a serious public health problem in China, the result of orthogeriatric co-management (OGC) is rarely reported. This study aimed to evaluate the effect of OGC in Chinese patients aged ≥65 years. METHODS: In this single-centre, pre-post intervention, retrospective study, traditional orthopaedic care (TOC) was used until OGC was implemented in May 2015, a multidisciplinary team was organized, and clinical protocol was designed. Consecutive hip fracture patients who were ≥65 years and injured within 3 weeks were included in this study. Demographic characteristics, comorbidities, fracture patterns, surgical procedure, time to surgery, length of hospital stay, inpatient complications, and in-hospital mortality were extracted and examined. At 1-year after surgery, data on patients' mobility and mortality were collected. The time to surgery, incidence of inpatient complications, mortality and functional outcomes were compared between the groups. RESULTS: There were no significant differences in sex, fracture type, and surgical pattern between OGC (n = 434) and TOC (n = 452) groups. Patients in OGC group were significantly older (P < 0.001) and had a higher age-adjusted Charlson comorbidity index (P < 0.001). However, waiting time between admission and operation was significantly lower in OGC group (P < 0.001). There was no significant difference in the mortality rate at the time of the patient being in-hospital and at 1, 3, and 6 months after surgery. Although 1-year mortality was higher in OGC group (P = 0.036), Cox regression analysis showed no significant correlation of OGC with 1-year mortality. There was no significant difference in pre-injury mobility and 1-year follow-up mobility assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre-injury mobility level. CONCLUSION: OGC significantly shortens time to surgery for geriatric hip fractures compared with TOC. However, there is no significant effect on mortality rate within 1 year and functional status at 1 year of follow-up.

Percutaneous Sacroiliac Screw Placement: A Prospective Randomized Comparison of Robot-assisted Navigation Procedures with a Conventional Technique.

BACKGROUND: Sacroiliac (SI) screw fixation is a demanding technique, with a high rate of screw malposition due to the complex pelvic anatomy. TiRobot™ is an orthopedic surgery robot which can be used for SI screw fixation. This study aimed to evaluate the accuracy of robot-assisted placement of SI screws compared with a freehand technique. METHODS: Thirty patients requiring posterior pelvic ring stabilization were randomized to receive freehand or robot-assisted SI screw fixation, between January 2016 and June 2016 at Beijing Jishuitan Hospital. Forty-five screws were placed at levels S1 and S2. In both methods, the primary end point screw position was assessed and classified using postoperative computed tomography. Fisher's exact probability test was used to analyze the screws' positions. Secondary end points, such as duration of trajectory planning, surgical time after reduction of the pelvis, insertion time for guide wire, number of guide wire attempts, and radiation exposure without pelvic reduction, were also assessed. RESULTS: Twenty-three screws were placed in the robot-assisted group and 22 screws in the freehand group; no postoperative complications or revisions were reported. The excellent and good rate of screw placement was 100% in the robot-assisted group and 95% in the freehand group. The P value (0.009) showed the same superiority in screw distribution. The fluoroscopy time after pelvic reduction in the robot-assisted group was significantly shorter than that in the freehand group (median [Q1, Q3]: 6.0 [6.0, 9.0] s vs. median [Q1, Q3]: 36.0 [21.5, 48.0] s; χ2 = 13.590, respectively, P < 0.001); no difference in operation time after reduction of the pelvis was noted (χ2 = 1.990, P = 0.158). Time for guide wire insertion was significantly shorter for the robot-assisted group than that for the freehand group (median [Q1, Q3]: 2.0 [2.0, 2.7] min vs. median [Q1, Q3]: 19.0 [15.5, 45.0] min; χ2 = 20.952, respectively, P < 0.001). The number of guide wire attempts in the robot-assisted group was significantly less than that in the freehand group (median [Q1, Q3]: 1.0 [1.0,1.0] time vs. median [Q1, Q3]: 7.0 [1.0, 9.0] times; χ2 = 15.771, respectively, P < 0.001). The instrumented SI levels did not differ between both groups (from S1 to S2, χ2 = 4.760, P = 0.093). CONCLUSIONS: Accuracy of the robot-assisted technique was superior to that of the freehand technique. Robot-assisted navigation is safe for unstable posterior pelvic ring stabilization, especially in S1, but also in S2. SI screw insertion with robot-assisted navigation is clinically feasible.

[A comparative research on the treatment of ankle fracture with dislocation between emergency surgery and selective surgery].

OBJECTIVE: To investigate the differences between emergency surgery and selective surgery treatment of ankle fractures with dislocation. METHODS: In the study, 40 patients with ankle fracture and dislocation were treated and followed up from May 2013 to May 2014, and all the data were collected and analyzed. The subjects involved 29 male patients and 11 female patients. The patients were randomly separated into two groups, and the patients in group A were given surgical intervention within 6 hours after injury, while those in group B were initially given close reduction and given selective operation when the soft tissue condition got better. Group A contained 13 male patients and 7 female patients with average age of 37.10; Group B consisted of 15 male and 5 female, with average age of 37.85. RESULTS: The Baird-Jackson score was applied for assessment of the patients' outcomes. According to the score, the outcomes were classified into excellent, good, fair, and poor. In group A (emergency group), the outcomes were 13 (65.0%), 4 (20.0%), 3 (15.0%), and 0, respectively. In group B (selective group), they were 11 (55.0%), 7 (35.0%), 2 (10.0%), and 0, respectively. The numbers of the patients from excellent to poor were 24 (55.0%), 11 (27.5%), 5 (12.5%), and 0, respectively. CONCLUSION: There is no significant difference in postoperative function between the two groups, however, early surgical intervention can benefit in accomplishing anatomical reduction much easier and shortening the time of hospitalization, which is cost-saving for the patients.

Printed three-dimensional anatomic templates for virtual preoperative planning before reconstruction of old pelvic injuries: initial results.

BACKGROUND: Old pelvis fractures are among the most challenging fractures to treat because of their complex anatomy, difficult-to-access surgical sites, and the relatively low incidence of such cases. Proper evaluation and surgical planning are necessary to achieve the pelvic ring symmetry and stable fixation of the fracture. The goal of this study was to assess the use of three-dimensional (3D) printing techniques for surgical management of old pelvic fractures. METHODS: First, 16 dried human cadaveric pelvises were used to confirm the anatomical accuracy of the 3D models printed based on radiographic data. Next, nine clinical cases between January 2009 and April 2013 were used to evaluate the surgical reconstruction based on the 3D printed models. The pelvic injuries were all type C, and the average time from injury to reconstruction was 11 weeks (range: 8-17 weeks). The workflow consisted of: (1) Printing patient-specific bone models based on preoperative computed tomography (CT) scans, (2) virtual fracture reduction using the printed 3D anatomic template, (3) virtual fracture fixation using Kirschner wires, and (4) preoperatively measuring the osteotomy and implant position relative to landmarks using the virtually defined deformation. These models aided communication between surgical team members during the procedure. This technique was validated by comparing the preoperative planning to the intraoperative procedure. RESULTS: The accuracy of the 3D printed models was within specification. Production of a model from standard CT DICOM data took 7 hours (range: 6-9 hours). Preoperative planning using the 3D printed models was feasible in all cases. Good correlation was found between the preoperative planning and postoperative follow-up X-ray in all nine cases. The patients were followed for 3-29 months (median: 5 months). The fracture healing time was 9-17 weeks (mean: 10 weeks). No delayed incision healing, wound infection, or nonunions occurred. The results were excellent in two cases, good in five, and poor in two based on the Majeed score. CONCLUSIONS: The 3D printing planning technique for pelvic surgery was successfully integrated into a clinical workflow to improve patient-specific preoperative planning by providing a visual and haptic model of the injury and allowing patient-specific adaptation of each osteosynthesis implant to the virtually reduced pelvis.

The "lateral gutter drive-through" sign revisited: a cadaveric study exploring its real mechanism based on the individual posterolateral structure of knee joints.

BACKGROUND: Although the validity of the "lateral gutter drive-through" (LGDT) test has been proved to offer high sensitivity and specificity in diagnosing the posterolateral rotational instability of knee joints, the real mechanism on how the injury pattern of individual posterolateral knee structure triggers the positive LGDT sign still remains unknown. HYPOTHESIS: A certain amount of popliteus tendon (POP-T) laxity resulted from specific injury patterns of individual posterolateral knee structure or some degree of medial structural injury will lead to positive LGDT sign. STUDY DESIGN: Controlled laboratory study. METHODS: Seven non-paired intact cadaveric knees were divided into four groups and tested under unique sequential sectioning sequences including: (1) distal POP-T and popliteofibular ligament (PFL) (n = 2); (2) PFL and distal POP-T (n = 3); (3) lateral collateral ligament (LCL), distal POP-T and PFL (n = 1); (4) superficial medial collateral ligament (sMCL), deep MCL, posterior oblique ligament (POL), anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) (n = 1). The LGDT tests and the measurements of external tibial rotational angle (ETRA) were first performed on all the intact knees and then at each time point when an additional structure was sectioned. Results of each LGDT test and the absolute value of increased ETRA compared with the intact knee were recorded. Each knee was tested at 30° of flexion. A navigation system was used to measure motion changes of the tibia with respect to the femur. RESULTS: Initially, the LGDT tests all showed negative on each of the intact knee. Isolated sectioning of the distal POP-T, PFL or the LCL produced increased but insignificant ETRA with the LGDT tests still negative. However, simultaneous sectioning of the distal POP-T and PFL produced significantly increased ETRA with the LGDT tests changed to positive. In addition, for the knee with medial structural injuries, the LGDT test could also be positive only when the posteromedial structures (sMCL, deep MCL, POL) and the cruciate ligaments (ACL and PCL) were all sectioned. CONCLUSION: In this cadaveric sequential sectioning study, the LGDT test showed positive merely at the following two situations: (1) the distal POP-T and PFL were both sectioned; (2) the posteromedial structures (sMCL, deep MCL and POL) and the cruciate ligaments (ACL and PCL) were all sectioned. CLINICAL RELEVANCE: Accuracy of the LGDT test in diagnosing acute or chronic posterolateral corner (PLC) injuries will improve with the information in this study. It was the combined POP-T and PFL injuries that finally led to a positive LGDT sign. However, one should be cautious to use the LGDT test in diagnosing the PLC injuries when posteromedial structures and cruciate ligaments were all involved.

Surgical resection of severe heterotopic ossification after open reduction and internal fixation of acetabular fractures: a case series of 18 patients.

OBJECTIVE: To evaluate the clinical results of surgical resection of severe heterotopic ossification (HO) after the open reduction and internal fixation (ORIF) of acetabular fractures. METHODS: A retrospective chart review was performed between October 2005 and November 2010 on patients undergoing severe HO resection following an acetabular fracture ORIF. Our primary outcome was functional status evaluated by the Harris hip score (HSS). HO resection and hip release was performed using a Kocher-Langenbeck approach in all cases, and a combined radiation and indomethacin regimen was used to prevent HO recurrence. Plain radiographs were also used to evaluate the hip joint for arthritic changes and HO recurrence. RESULTS: A total of 18 patients (17 males and 1 female) were included in our study analysis. The mean patient age was 36.8 (range: 22-54 years old) when HO resection surgery was performed. The mean time interval between acetabular fracture ORIF and HO resection was 9.9 months (range: 3-30 months): it was within 6 months in 7 patients, 6-12 months in 8 patients, and >12 months in 3 patients. The HO was graded as Brooker grade III in 8 patients and grade IV in 10 patients. The mean time interval between HO resection and the latest follow-up was 4.5 years (range: 2.1-7.8 years). The mean Harris hip score (HHS) was 84.5 (range: 38-100), with a clinical outcome rating of excellent in 9 patients, good in 3 patients, fair in 4 patients, and poor in 2 patients (good and excellent rating accounted for 66.7%). The mean hip joint motion arc was 194° (range: 90-260°). Complications included one intraoperative femoral neck fracture, 1 sciatic nerve injury, 2 femoral head avascular necrosis, and 6 mild HO recurrences (33.3%). There was 28.6% recurrence if HO resection was within 6 months and 36.4% if >6 months. There were no cases of severe HO recurrence, wound infections, deep vein thrombosis, or pulmonary embolism. CONCLUSION: The early surgical resection of severe HO after an acetabular fracture ORIF can provide satisfactory results, however the complication rate is relatively high.

Effect of two intensive insulin therapy regimens on perioperative glycemic control in bone fracture patients with type 2 diabetes mellitus.

BACKGROUND: Currently, there are no uniform standards and methods for perioperative glycemic control in bone fracture patients with Type 2 diabetes mellitus (T2DM). We retrospectively analyzed the efficacy and safety of two intensive insulin therapy regimens administered to bone fracture patients with T2DM in the perioperative period, to explore the best method of achieving perioperative glycemic control. METHODS: A number of 159 bone fracture patients with T2DM were divided into two groups. One group (n = 81) received multiple subcutaneous insulin injections (MSII group) and the other (n = 78) received continuous subcutaneous insulin infusion (CSII group). Blood glucose (BG) levels, time to achieve glycemic target, insulin dosage, and the incidence of hypoglycemia and complications were compared between groups. RESULTS: Both regimens reduced BG to desired levels before surgery. The time to reach glycemic target in CSII group (2.5 days) was significantly shorter than that in the MSII group (7.3 days; P < 0.001). Mean insulin dosage in the CSII group (0.66 IU×kg(-1)×d(-1)) was significantly lower than that in the MSII group (0.74 IU×kg(-1)×d(-1); P = 0.005), as were the incidences of hypoglycemia (15.4% vs 32.1%) and infection (6.4% vs. 23.5%). Multiple regression analysis showed that the time to reach glycemia target was associated with the insulin therapy regimen and dosage. The insulin dosage on reaching glycemia target was positively associated with body mass index (BMI), diabetes mellitus course, glycated hemoglobin A1c (HbA1c), and ß-hydroxybutyric acid, and was negatively associated with age. CONCLUSION: The efficacy and safety of CSII was superior to that achieved with MSII, suggesting that CSII should be considered as initial therapy to control perioperative BG in bone fracture patients with T2DM.

[Percutaneous pelvic fracture stabilization using CT-based 3D navigation software combined with targeting mechanical arm: a cadaver model trial].

OBJECTIVES: To investigate a new targeting mechanical arm for CT-based navigated percutaneous fixation of pelvic fractures, and to evaluate the safety and efficiency of the procedures. METHODS: Using CT-based 3D navigation software combined with targeting mechanical arm, percutaneous insertion of pelvic models (3 dry human cadaver pelvic skeletons and 5 plastic Sybone pelvic models) were performed, 8 pelvic models allowed percutaneous cannulated screw insertion of both S-I joint (2 S-I screws placement for each side, total 32 screws in this experiment) and both superior ramus (1 ramus medullary screw placement for each side, total 16 screws in this experiment). Percutaneous insertion of pelvic models (4 dry human cadaver pelvic skeletons and 4 plastic Sybone pelvic models, 1 S-I screws and 1 ramus medullary scre placement for each side, 32 screws in this experiment) were performed using fluoro-navigation system (Stryker, USA). Time necessary for every screw insertion were recorded. Accuracy of screw placement was assessed using C-arm imaging and direct eyes inspecting. The time and accuracy of the two methods were compared. RESULTS: The time required for the CT-based 3D navigation procedure (3.6 ± 1.2) min was significantly less than using the targeting mechanical arm compared to drilling freehand with navigation (9.1 ± 0.8) min (t = 2.50, P < 0.01). There was no significant difference in accuracy between the two methods. CONCLUSION: CT-based 3D navigation software combined with targeting mechanical arm should be potential to apply percutaneous sacroiliac screwing for pelvic fractures with more accurate and more reliable.

[Three nonparallel screws for the treatment of femoral neck fractures].

OBJECTIVE: To explore clinical effects of three nonparallel screws in treating femoral neck fractures. METHODS: From September 2008 and May 2009, 29 patients were treated, including 12 males and 17 females with an average age of 52 years (ranged from 27 to 62 years). Before operation, according to Garden classification system, 2 cases were Garden type II (undisplaced fracture), 18 cases were Garden type III (partial displaced fracture) and 9 cases were Garden type IV (complete displaced fracture). After fracture reduction in operation, Pauwels classification system was used to classify the type, and 12 cases were type II, 17 cases were type III Closed reduction and internal fixation with three non-parallel screws were used to treat. The surgery X-ray and follow-up X-ray were compared to observe whether femoral neck abbreviate and screw exit appeare. Harris scoring was used to evaluate function. RESULTS: All patients were followed-up from 34 to 44 months with an average of 38 months. The mean time of bone union was 7 (ranged, 3 to 12) months. Nonunion occured in 4 cases with Garden IV, and femoral head necrosis occurred in 2 cases. For Harris scoring, two cases with nondisplaced fracture were 100. Among 27 cases with displaced fractures, 23 cases achieved bone union without femoral head necrosis, average Harris scale was 91.35 +/- 8.00, and the average Harris scale of 4 cases with bone nonunion was 61.23 +/- 5.12. For all but one, there was no femoral neck crispation after bone union. CONCLUSION: Nonparallel screws for femoral neck fractures can effectively control abbreviation and screw tail exit after fracture healing.

Computer-assisted navigation systems for insertion of cannulated screws in femoral neck fractures: a comparison of bi-planar robot navigation with optoelectronic navigation in a Synbone hip model trial.

BACKGROUND: Computer-assisted procedures have recently been introduced for navigated femoral neck screw placement. Currently there is little information available regarding accuracy and efficiency of the different navigated procedures. The aim of this study was to compare two fluoroscopic navigation tracking technologies, a novel bi-planar robot navigation and standardized optoelectronic navigation, versus standard freehand fluoroscopic insertion in a Synbone hip model. METHODS: Eighteen fixed Synbone hip models were divided into 3 groups. C-arm navigated cannulated screws (AO-ASIF, diameter 7.3 mm) were inserted using freehand targeting (control group). A novel bi-planar robot system (TINAV, GD2000) and an optoelectronic system (Stryker OTS Navigation System) were used for the navigated procedures (robot group and optoelectronic group). Accuracy was measured using radiographic evaluation including the measurement of screw parallelism and decentralization, and joint penetration. To evaluate the efficiency, the number of guidewire passes, operative time and fluoroscopic images taken were noted. RESULTS: The two computer-assisted systems provided significantly improved accuracy compared to the freehand technique. Each of the parameters, including guidewire passes and number of fluoroscopy images, was significantly lower when using the computer-assisted systems than for freehand-unguided insertion (P <0.05), but operative time was significantly shorter when using freehand-unguided insertion than for the computer-assisted systems (P <0.05). Accuracy, operative time and number of fluoroscopy images taken were similar among the two navigated groups (P >0.05), but guidewire passes in the robot group were significantly less than in the optoelectronic group (P <0.05). CONCLUSIONS: Both bi-planar robot navigation and optoelectronic navigation were similarly accurate and have the potential to improve accuracy and reduce radiation for freehand fluoroscopic targeting for insertion of cannulated screws in femoral neck fractures. Guidewire passes in the robot group were significantly less than in the optoelectronic group. However, both navigated procedures were associated with time-consuming registration and high rates of failed matching procedures.

[Primary clinical application of traction reductor for lower limb fracture].

OBJECTIVE: To develop a traction reductor for the reduction of lower limb fractures during the minimally invasive surgery and explore its safety and efficacy. METHODS: From February 2007 to March 2009, closed or limited open reduction plus percutaneous plate and screw internal-fixation were conducted in 34 patients with fracture of distal femur and tibia metaphysic, among which there were 3 distal femoral fractures (2 33-B, 1 33-C), 14 proximal tibial fractures (9 41-A, 3 41-B, 2 41-C) and 17 distal tibial fractures (9 43-A, 5 43-B, 3 43-C, 2 Gustilo I a), according to the Association for Osteosynthesis-Orthopaedic Trauma Association (AO-OTA) classification. Besides, closed reduction plus interlocking intramedullary nailing on tibial shaft fracture were applied in 36 patients (7 42-A, 21 42-B, 8 42-C, 2 Gustilo I a). All the 70 patients, with an average age of 37.6 years (range: 17 to 63 years) and average time before surgery of 4.7 d (range: 0.7 to 12.0 d), underwent reduction by self-designed traction reductor for lower limb fracture in the surgery. The reduction duration and C-arm fluoroscopy time were recorded. Recovery of the force line of affected limbs after surgery was determined by whether the line from anterior superior iliac spine to the interdigit between the first and second toe-web passed the patella center. And the distance from bilateral anterior superior iliac spine to medial malleolus tip as well as the difference between lower limbs were recorded to determine the recovery of length after surgery. Meanwhile, the varus-valgus and anteroposterior angulations after reduction were measured by AP and lateral X-ray. RESULTS: The reduction duration was 12.7 min (range: 7 to 31 min); X-ray fluoroscopy time, 1.3 min (range: 0.4 to 3.0 min); length difference between both lower limbs (6.5 ± 1.1) mm; and axial alignment difference (7.0 ± 1.8) mm. The X-ray result showed that varus-valgus angle was (2.75 ± 0.16)°; and anteroposterior angulation (5.13 ± 0.51)°. CONCLUSION: The traction reductor for lower limb fracture could achieve satisfying fracture reduction in the minimally invasive surgery of distal femur, tibia metaphysic and tibial shaft fracture.

[Clinical study to the cannulated screws with fluoroscopy in the operation of femoral neck fractures].

OBJECTIVES: To investigate the safe distance from the tip of the cannulated screw to the apex of the femoral head, and to avoid cutting out of the cannulated screws from the femoral head. METHODS: From November 2007 to April 2008, the placement configuration of the cannulated screws in the femoral head on the anteroposterior (AP) and lateral view was investigated. And the relation between the three-dimensional configuration and the two-dimensional perpendicular view of the femoral head to establish a solid geometry formula was analyzed. According to the configuration, the distances from the tips of different cannulated screws to the apex of the femoral head to confirm the screws placement within the femoral head was measured. RESULTS: The actual risk of cutting out of the cannulated screws varied according to the different placement of the cannulated screws in the femoral head, even if the screw tips were within the femoral head on the AP and lateral radiograph. The mean diameter of femoral head was 49.8 mm. If the cannulated screw is in the center of femoral head on the lateral view, the cannulated screw would not cut out as long as it was in the femoral head on the AP view. When the angle was 22.5°on the lateral view, and under 22.5°on the AP view, the distance from the screw tip to the apex of the femoral head would exceeded 2.2 mm. If the angle > 45°on the AP view, the distance would exceed 9.6 mm. When the angle was 45°on the lateral view, and under 22.5°on the AP view, the distance would exceed 8.2 mm. When the angle > 45°on the AP view, the distance would exceed 17.7 mm. When the angle was 67.5°on the lateral view, the distance would exceed 23.1 mm on AP view. CONCLUSIONS: If the cannulated screw is in the center of femoral head on the lateral view, the cannulated screw won't cut out as long as it is in the femoral head on the AP view. The angle is larger on the AP and lateral view (especially on the lateral view), and the distance is longer.

[Treatment of malunited calcaneus fracture with subtalar distraction bone block fusion].

OBJECTIVE: To report and evaluate the results of subtalar distraction bone block fusion in the treatment of malunited calcaneus fracture. METHODS: From September 2004 to January 2008, 32 cases of malunited calcaneus fracture were treated, among which 28 cases were classified type II and 4 cases type III by Stephens-Sander's classification. Preoperative X-ray and CT examination demonstrated a talocalcaneal angle of 18.1 degrees ± 2.3 degrees , and an AOFAS score of 36.3 ± 4.1. Subtalar distraction bone block fusion was performed in all cases in this series. Regular follow-up was done with talocalcaneal angle measurement and AOFAS scoring. RESULTS: All the 32 patients had been followed-up of 34 months, ranging from 24 to 65 months, only to reveal a primary wound healing without infection in all but one, in which superficial skin necrosis occurred postoperatively and healed after dressing-changes. Bone healing at the fusion site was seen 3 months after operation in all cases. At the final follow-up, the talocalcaneal angle was 22.9° ± 1.9° and the AOFAS score 77.5 ± 4.1, both demonstrating a significant difference (P < 0.05), when compared with those before operation. CONCLUSION: Subtalar distraction bone block fusion, together with the lateral wall decompression, can correct the main deformity and reduce major symptoms induced by the malunion of calcaneus fractures, being a convenient and practical option for the treatment of malunited calcaneus fracture.

[New strategy for decision making of Pilon fracture].

OBJECTIVE: To study the guidance of four column theory in decision making of Pilon fractures and its result. METHODS: Ninety-one cases of Pilon fractures classified by four column method and treated by open reduction internal fixation (ORIF) were reviewed from March 2005 to June 2009. Four column classification:lateral column of 67 cases were involved, posterior column of 34 cases were involved, medial column of 34 cases were involved and anterior column of 34 cases were involved. Among all the 94 fractures, single column of 20 fractures were involved, 2 columns of 49 fractures were involved, 3 columns of 15 fractures were involved and all of 4 columns of 10 fractures were involved. RESULTS: Eighty-nine cases had been followed up. The average follow-up time was 16.2 months ranging between 6.0 and 39.0 months. The average healing time was 3.7 months ranging from 3.0 to 5.0 months. Reduction of 91% reviewed Pilon cases were good or acceptable according to Burwell and Charley's radiology evaluation system. Ankle function of 87.6% cases were excellent or good according to AOFAS evaluation system. CONCLUSION: As a simple and comprehensive classification, four column classification can contribute to reasonable operating decision making and good prognosis of Pilon fracture.

[Semi-constrained total elbow arthroplasty for the treatment of the elbow disorders].

OBJECTIVE: To retrospectively review the results of Coonrad-Morrey semi-constrained total elbow arthroplasty (TEA) for the treatment of different elbow disorders. METHODS: Between December 2003 and April 2008, 30 patients with different kinds of elbow disorders including elbow fracture, non-healing elbow fracture, rheumatoid arthritis and osteoarthritis were treated with TEA using the semi-constrained Coonrad-Morrey elbow replacement prostheses. One patient had bilateral total elbow replacements. There were 22 females and 8 males, with a mean age of 66 years (47 to 78). RESULTS: Twenty patients (21 elbows) were available for review. The average length of follow-up was 35 months (from 12 to 52 months). The mean Mayo elbow performance score was 84 points. Excellent results were achieved in 6 elbows (28%), 11 elbows had good outcome (52%), 2 elbows had improvement (10%), while the other 2 elbows had no improvement (10%). The 2 elbows with distal humeral fractures, had no pain after treatment but developed heterotopic ossification, which caused stiffness and lower the Mayo elbow performance score. One delayed healing of the wound, one patient experienced temporary radial nerve hypesthesia and one elbow showed transparent region around the implant without radiological sign of loosening in the implanted prostheses. CONCLUSIONS: This study reveals good to excellent outcome with the use of semi-constrained TEA for the treatment of rheumatoid arthritis, elbow fracture, osteoarthritis and non-healing elbow fractures in elder patients. The non-healing elbow fractures in elder patients would accompany with severe osteoporosis and comminuted fracture, which would affect the result of open reduction internal fixation. So TEA may be one optimal treatment for these patients.

[Posterior monteggia fracture-dislocations of proximal ulna].

OBJECTIVES: To discuss the diagnosis and differential diagnosis, and to establish an effective protocol to treat the posterior Monteggia fracture-dislocations of proximal ulna in adult according to our experience. METHODS: Between April 2004 and December 2007, 16 patients with posterior Monteggia fracture-dislocations were treated surgically, 13 were followed up at a mean of 28 months (range, 12 - 58 months). All the operations were through the posterior midline approach. The fractures of radial head and coronoid process were reduced and fixed, if possible. The proximal ulna fractures were fixed with a single plate in 7 cases, plate combined with K-wires in 2, plate combined with K-wires tension band in 3, and K-wires tension band combined with screws in 1. RESULTS: No elbow was painful or unstable at the last follow up examination. They had an average of 100 degrees (range, 0 degrees to 145 degrees ) of flexion-extension of elbow. The average motion of forearm rotation was 119 degrees (range, 0 degrees to 170 degrees ). The mean Mayo Elbow Performance Score (MEPS) was 93.1 points (67 - 100 points), excellent and good results were achieved in 92.3%. The mean system of Broberg and Morrey score was 88.8 points (53 - 100 points), excellent and good results were achieved in 76.9%. CONCLUSIONS: Attention should be paid to the diagnosis and differential diagnosis of the posterior Monteggia fracture-dislocation of proximal ulna. Anatomically reduction and stable fixation of proximal ulna is the keystone for the surgical treatment.

[Intermittent low-dose administration of recombinant human parathyroid hormone (1-34) promotes the expression of Runx2 during early stage of fracture healing].

OBJECTIVE: To study the correlation of intermittent low-dose administration of recombinant human parathyroid hormone (1-34) [rhPTH (1-34)] and the expression of Runx2 during early stage of fracture healing. METHOD: Sixty 2-month old male Sprague-Dawley rats underwent close unilateral femoral fracture and intramedullary nail fixation, and then were randomly divided into 2 equal groups: treatment group undergoing subcutaneous injection of rhPTH (1-34) 10 microgxkg(-1)xd(-1) immediately after the operation, and control group undergoing subcutaneous injection of normal saline of the same dose. Six rats from each group were killed with their bilateral femurs taken out on days 2, 4, 7, 14, and 21 after the operation to undergo X-ray photography Tissue RNA and protein were extracted from the bone tissues and the levels of Runx2 mRNA and protein expression were evaluated through real time quantitative PCR and Western-blotting. Blood samples were collected from the abdominal aorta before the rats were killed to undergo detection of serum calcium, phosphorus, and alkaline phosphatase (AKP). RESULTS: The Runx2 mRNA levels in the fractured femurs of the rhPTH (1-34) group on days 14 and 21 after the operation were 2.6 and 3.8 times as those of the control group respectively (both P<0.05). The Runx2 protein levels in the fractured femurs of the rhPTH (1-34) group on days 14 and 21 after the operation were significantly higher than those of the control group respectively too. Since day 14 fracture healing was seen, and the status of fracture healing was better in the rhPTH (1-34) group than in the control group on days 14 and 21. The levels of serum calcium ion on days 14 and 21 of the rhPTH (1-34) group were both significantly higher than those of the control group (both P<0.05). There were not significant differences in the serum levels of AKP, osteocalcin and collagen type Iat any time point between the 2 groups. CONCLUSION: Intermittent low-dose administration of rhPTH (1-34) up-regulates the levels of osteogenesis-specific Runx2 mRNA and protein expression to accelerate the early stage fracture healing during the early stage.

[Percutaneous screw fixation in treatment of fractures of acetabular columns using computer-assisted imaging navigation system: experiment with cadaver model].

OBJECTIVE: To establish a new imaging protocol to acquire the most appropriate fluoro-images for fluoro-navigated percutaneous fixation of acetabular fracture and to evaluate the safety and efficiency of the procedures. METHODS: Guide needles were inserted into the bilateral anterior and posterior columns of the acetabula of 4 dry human cadaver pelvic skeletons and 4 plastic pelvic models. Then the pelvis skeletons were fixed to imaging guided surgery mimic operation modules. Dynamic fluoroscopy was conducted with C-arm X-ray machine vertically on the 4 virtual planes of the acetabulum, inner, outer, anterior, and posterior from multiple angles. The fluoroscopic images clearly showing the guide needles, anterior and posterior columns, and acetabulum were selected as registration images, and the relative space positions between the C-arm X-ray fluoroscope and pelvis and operation table. Guided by the navigation system, totally 16 titanium hollow screws were inserted into bilateral anterior and posterior columns of acetabula of the 4 pelvis skeletons. The screw positions were estimated by visual method. The time needed to position the C-arm so as to obtain the standard registration image, time needed for fluoroscopy, and operation time, including establishment of navigation system, software interface operation, and screw insertion, were recorded. RESULTS: All the screws were inserted to the satisfying positions: placed within the desired bony corridor of the column and none of then were inserted into the joint. While inserting the screw into the anterior column fluoroscopy should be conducted with obturated oblique view, obturated inlet view, obturated oblique outlet view, or pelvic AP view. While inserting the screw into the posterior column fluoroscopy should be conducted with iliac-oblique view, obturated oblique view, pelvic inlet view, or obturated oblique outlet view. The total surgical time required for screw insertion was 11.7 min for anterior column, and was 9.2 min for posterior column. 9.5 and 7.3 minutes were needed to position the C-arm X-ray machine so as to obtain the images of the anterior and posterior columns respectively. 2.9 and 1.7 seconds were needed for the actual fluoroscopy during insertion of the screws into the anterior and posterior columns respectively. CONCLUSION: The standard registered fluoro-images are different from the conventional standard Judet-Letournel oblique views. How to get appropriate fluoro-images is the key point for fluoro-navigated percutaneous fixation of acetabular fractures.