Hidden blood loss and the influential factors after minimally invasive treatment of posterior pelvic ring injury with sacroiliac screw.

BACKGROUND: To analyze the perioperative bleeding and hidden blood loss (HBL) of sacroiliac screw minimally invasive treatment of pelvic posterior ring injury and explore the influential factors of HBL after operation for providing reference for clinical treatment. METHOD: A retrospective analysis was conducted on data from 369 patients with posterior pelvic ring injuries treated with sacroiliac screws internal fixation at our hospital from January 2015 to January 2022. The research was registered in the Chinese Clinical Trial Registry in July 2022 (ChiCTR2200061866). The total blood loss (TBL) and HBL of patients were counted, and the factors such as gender, age, and surgical duration were statistically analyzed. The influential factors of HBL were analyzed by multiple linear regression. RESULTS: The TBL was 417.96 ± 98.05 ml, of which the visible blood loss (VBL) was 37.00 ± 9.0 ml and the HBL was 380.96 ± 68.8 ml. The HBL accounted for 91.14 ± 7.36% of the TBL. Gender, surgical duration, fixed position, and fixed depth had significant effects on the HBL (P < 0.05). CONCLUSIONS: The HBL was the main cause of anemia after minimally invasive treatment of posterior pelvic ring injury with a sacroiliac screw. Gender, surgical duration, fixed position, and fixed depth were closely related to the occurrence of HBL. In clinical treatment, we should consider these influential factors and take effective measures to reduce the impact of HBL on patients.

[Treatment of Tile type C pelvic ring fracture using orthopedic robot combined with Starr pelvis reduction frame].

OBJECTIVE: To investigate the clinical effect of orthopedic robot combined with Starr pelvic reduction frame in the treatment of Tile type C pelvic ring fracture. METHODS: From October 2019 to May 2021, 14 patients with type C pelvic ring fracture were treated with robotic combined with Starr pelvic reduction frame, including 9 males and 5 females. The age ranged from 33 to 69 years. All the 14 patients had fresh closed fractures without femur, tibia and fibula fracture. Surgery was completed from 4 to 7 d after hospital admission. During the operation, the X-ray carbon bed was used, the pelvic ring was reduced by Starr pelvis reduction frame, and pelvic ring fracture was treated by orthopedic robot. Operation time, bleeding volume, fluoroscopy times of single screw placement, fracture reduction quality, affected limb function and complications were observed. Radiological reduction was evaluated using Matta scoring standard, and clinical efficacy was evaluated by Majeed pelvic function scoring system at the final follow-up. RESULTS: All of 14 patients successfully completed the operation, the operation time was 84 to 141 min, the bleeding volume was 20 to 50 ml, and the fluoroscopy times of single screw insertion was 4 to 9 times. All of 14 patients were followed up for 12 to 24 months. The healing time was 3 to 7 months. No complications such as fracture of internal fixation, screw loosening, infection and nerve injury were found. According to the evaluation criteria of Matta imaging reduction, 9 cases were excellent, 4 cases were good, and 1 case was fair. At the final follow-up, Majeed pelvic function scoring system was used:10 cases were excellent, 4 cases were good. CONCLUSION: The treatment of type C pelvic ring fracture with robotic combined Starr pelvis reduction frame is simple, time-saving, less trauma, less complications and effective.

Biomechanical insights into ankle instability: a finite element analysis of posterior malleolus fractures.

BACKGROUND: Posterior malleolus fractures are known to be associated with ankle instability. The complexities involved in obtaining precise laboratory-based spatial pressure measurements of the ankle highlight the significance of exploring the biomechanical implications of these fractures. METHODS: Finite element analysis was utilized to examine the stress distribution across the contact surface of the ankle joint, both in its natural state and under varied sagittal fracture line angles. The study aimed to identify stress concentration zones and understand the influence of sagittal angles on stress distribution. RESULTS: Three distinct stress concentration zones were identified on the ankle's contact surface: the anterolateral tibia, the anteromedial tibia, and the fracture line. The most significant stress was observed at the fracture line when a fracture occurs. Stress at the fracture line notably spikes as the sagittal angle decreases, which can potentially compromise ankle stability. Larger sagittal angles exhibited only minor stress variations at the contact surface's three vertices. It was inferred that sagittal angles below 60° might pose risks to ankle stability. CONCLUSIONS: The research underscores the potential implications of fractures on the stress profile of the ankle joint, emphasizing the role of the contact surface in ensuring stability. The identification of three zones of stress concentration and the influence of sagittal angles on stress distribution offers a valuable reference for therapeutic decision-making. Further, the study reinforces the importance of evaluating sagittal fracture angles, suggesting that angles below 60° may compromise ankle stability.

"In-Out-In" Percutaneous Reduction Technique for Treatment of Valgus-Impacted Femoral Neck Fractures: A Technical Trick and Case Series.

OBJECTIVE: Valgus-impacted femoral neck fractures with or without posterior tilt of the femoral head are very common and full of pitfalls in clinical practice, which may lead to femoral neck shortening (FNS) and avascular necrosis (AVN). The study tries to introduce a novel technical trick aiming at anatomical reduction of valgus-impacted femoral neck fracture with minimally invasive procedure, and summarize the clinical prognosis in case series. METHODS: In this retrospective study, 24 patients (seven men and 17 women) with valgus-impacted femoral neck fractures between May 2017 and July 2020 were managed by "in-out-in" percutaneous reduction technique (percutaneous reduction group). Another 24 cases (10 men and 14 women) suffering the fractures underwent in situ fixation were enrolled as control group for function comparison (in situ fixation group). All patients were followed up for 24-42 months. The clinical outcomes included complications after operations (χ2 test) and Harris Hip Score (HHS) for hip function (unpaired t test) in the two groups. The radiographic outcomes were evaluated by collodiaphyseal angle, posterior tilt angle, and FNS before the operation and during the follow-up in the percutaneous reduction group (unpaired t test). RESULTS: Patients' preoperative data, including age, sex, affected side, fracture types, and medical history, were similar between the two groups, respectively (p > 0.05). After surgery, the mean HHS at 6, 12, and 24 months were all better in the percutaneous reduction group (76 ± 6.72, 85.34 ± 6.33 and 90.54 ± 5.81) than that in the in situ fixation group (70.86 ± 6.91, 80 ± 6.11 and 84.1 ± 7.82), respectively (p < 0.05). One patient suffered fixation failure with screws retreat and one patient suffered AVN in the percutaneous reduction group. In the in situ fixation group, AVN occurred in two patients at last follow-up. There was no significant difference in complication amounts between the two groups (p > 0.05). In the percutaneous reduction group, collodiaphyseal angle, posterior tilt angle, and amount of FNS were significantly different between preoperative cases and immediately postoperative cases (p < 0.05). However, there was no statistical difference of the measurements among postoperative cases at different time points (within 24 h, 6 months, and 2 years postoperatively) (p > 0.05). CONCLUSIONS: Our experience of the technique and the case series show that "in-out-in" percutaneous reduction technique for treatment of valgus-impacted femoral neck fracture with or without posterior tilt of the femoral head is safe and effective for achieving successful bone union and satisfactory function.

Clinical Comparison of the "Windowing" Technique and the "Open Book" Technique in Schatzker Type II Tibial Plateau Fracture.

OBJECTIVE: Surgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high-quality research. The aim of the study is to compare the "windowing" and "open book" techniques for the treatment of Schatzker type II tibial plateau fractures. METHODS: In this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. "Windowing" group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the "windowing" technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The "open book" group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post-traumatic arthritis. The radiographic outcome (x-ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient-reported outcome was visual analogue scale (VAS) scores. RESULTS: The mean follow-up time for the158 patients was 32 months (range, 24-42 months). The time elapsed from injury to surgery in "windowing" group and "open book" group were 3.7 ± 1.2 (range, 1-10 days) and 3.5 ± 1.4 days (range, 1-11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the "windowing" group (61.0 ± 8.3 min, range, 45-120 min) and the "open book" group (61.2 ± 10.4 min, range, 40-123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the "windowing" and "open book" groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow-up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post-traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05). CONCLUSIONS: The "windowing" and "open book" techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the "windowing" technique provides better reduction quality, leading to a satisfactory prognosis.

[Staged operation for complex closed Pilon fracture].

OBJECTIVE: To explore clinical efficacy of staged surgery in treating complex closed Pilon fracture. METHODS: From June 2019 to January 2021, 29 patients with complex closed Pilon fracture were treated by staging surgery, including 18 males and 11 females, aged ranged from 31 to 68 years old with an average of (43.50±6.62) years old;7 cases were typeⅡand 22 cases were type Ⅲ according to Ruedi-Allgower classification. All patients had fresh closed fractures without talus and calcaneal fractures. The time from injury to closed reduction and external fixation, the interval between two stages of surgery, fracture healing time and complications were recorded. American Orthopedic Foot and Ankle Society(AOFAS) was used to assess clinical effects. Burwell-Charnley system was used to evaluate radiological reduction. RESULTS: All 29 patients were followed up from 13 to 30 months with an aver age of (15.43±5.31) months. All fractures healed well from 2 to 6 months with an average of (3.77±1.22) months. No internal fixation fracture, screw loosening, infection, internal fixation irritation, ankle stiffness occurred. The time from injury to closed reduction and cross-ankle fixation ranged from 1.22 to 7.34 h with an average of(2.31±3.52) h, the interval between two stages ranged from 5 to 9 days with an average of (5.98±2.11) days. AOFAS score was improved from 34.11±6.89 before operation to 90.10±10.11 after oepration at 12 months(P<0.05). According to AOFAS grading, 16 patients got excellent result, 9 good and 4 moderate. Fifteen patients got anatomic reduction, 12 patients were good reduction, and 2 cases were poor reduction according to Burwell-Charnley system. CONCLUSION: Staged surgery for complex closed Pilon fracture has advantages of less complications, statisfied reduction, stable fixation, which could obtain good recovery of ankle joint.

A Comparative Study between Proximal Femoral Locking Plate and Multiple Cannulated Screws for Fixation of Femoral Neck Fractures in Young Adults.

OBJECTIVE: To compare the clinical effect of proximal femoral locking plate (PFLP) versus multiple cancellous screw (MCS) for FNF. METHODS: FNF patients were treated with the PFLP implant or multiple cancellous screws (MCSs). Patient has been followed up for at least 12 months after surgery nonunion, and the occurrence of complications, femoral neck shortening, fracture healing time, and Harris hip score were recorded and compared. RESULTS: 77 FNF patients were treated with the PFLP (36 patients) or MCS (41 patients). The sex, age, side of the injured limb, type of Garden fracture, time from injury to surgery, and fracture healing time of two groups patients were comparable. The operation time and intraoperative blood loss in the PFLP group were worse than those in the MCS group. Two patients with the PFLP (5%) and nine patients (21%) with the MCS experienced cut out of the lag screw or avascular necrosis of the femoral head or nonunion and received hip replacement. However, the number of fluoroscopies in the PFLP group was significantly lower than that in the MCS group. Additionally, the femoral neck shortening and Harris hip score were all strongly better in the PFLP group than in the MCS group. CONCLUSIONS: Compared with the MCS, PFLP treatment for FNF in young adults can decrease the fluoroscopy times, improve hip functional recovery, and reduce the complications rate and femoral neck shortening.

Percutaneous posteroanterior screw fixation for Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture: Operative technique and randomized clinical results.

PURPOSE: The study described a novel surgical treatment of Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture and patient outcomes at intermediate period follow-up. METHODS: All patients from January 2015 to December 2017 with tri-malleolar fracture of which posterior malleolar fractures were Haraguchi type 1, were surgically treated in this prospective study. Lateral and medial malleolar fractures were managed by open reduction and internal fixation through dual incision approaches. 36 cases of Haraguchi type 1 posterior malleolar fractures were randomly performed by percutaneous posteroanterior screw fixation with the aid of medial exposure (group 1). And 40 cases were performed by percutaneous anteroposterior screw fixation (group 2). Clinical outcomes, radiographic outcomes and patient-reported outcomes were recorded. RESULTS: Seventy-six patients with mean follow-up of 30 months were included. There were no significant differences in the mean operation time (81.0 ± 11.3 vs. 77.2 ± 12.4), ankle function at different periods of follow-up, range of motions and visual analog scale (VAS) at 24 months between the two groups (p > 0.05). However, the rate of severe post-traumatic arthritis (Grade 2 and 3) and the rate of step-off rather than gap in radiological evaluation were lower in group 1 than that in group 2 (p < 0.05). CONCLUSION: Using our surgical technique, more patients had good outcome with a lower rate of severe post-traumatic arthritis, compared with the group of percutaneous anteroposterior screw fixation. Percutaneous posteroanterior screw fixation can be a convenient and reliable alternative in treating Haraguchi type 1 posterior malleolar fracture.

Clinical comparison of single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures: A randomized controlled trial.

PURPOSE: The purpose of this study was to clinically compare the single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures. METHODS: In total, 93 patients were enrolled, and the mean follow-up was 15 months (range 12-19 months). The patients treated for open reduction and internal fixation were randomly classified into two groups based on the approach used: 45 patients were treated using the single-incision approach (group 1) and 48 patients were treated using the dual-incision approach (group 2). In these two groups, operation time, discharge time, postoperative complications, and ankle function evaluations (Olerud-Molander Ankle Score) were compared between the two groups. RESULTS: There were no significant differences in the mean operation time (98.2 ± 18.5 vs. 103.6 ± 19.3), discharge time (11.1 ± 3.9 vs. 12.5 ± 5.7), overall surgical complication rates (9/45 vs. 15/48), or ankle function between the two groups (p > 0.05). However, the rate of soft tissue-related complications, such as skin slough, infection, nonunion, and delayed union, was significantly lower in group 1 (5/45) than in group 2 (14/48) (p < 0.05). CONCLUSION: The two incision approaches were found to have similar clinical outcomes. However, with regard to soft tissue conservation, the single-incision approach was superior to the dual-incision and maybe a reliable alternative.

Management of comminuted mid-shaft clavicular fractures: Comparison between dual-plate fixation treatment and single-plate fixation.

BACKGROUND: We consider dual-plate fixation to improve construct rigidity in cases with fracture complexity. The purpose of this study is to compare the rate of nonunion, prognosis, and complications at 6-12 months for surgically treated acute mid-shaft clavicle fractures when extra-periosteal dual-plate fixation is used in place of the conventional single-plate fixation. MATERIALS AND METHODS: The comparative study was conducted on 47 patients who received acute mid-shaft clavicular fracture treatment in our hospital from March 2015 to July 2018. All patients were divided into dual-plate fixation treatment (group A) and single-plate fixation (group B). Patients undergoing single-plate fixation were compared to dual-plate fixation. Patients were followed up for 6-12 months. Charts were reviewed to assess union rates, prognosis, and complications. RESULTS: Forty-seven clavicles (30 single plates and 17 dual plates) were evaluated. All patients (100%) in dual plating group and 128 (93.3%) in single plating group obtained bony union by 1 year. When comparing groups at 3 months, radiographic union was present in 50.0% of single plates and 64.7% in the dual plating group (p = 0.032). However, at 6 months, no significant difference existed (90.0% vs. 94.1%, p = 0.297). Comparing groups at 1.5 and 6 months, Constant-Murley outcome scores were present with no significant difference (p = 0.129, p = 0.054) between single plates and dual plating group. However, at 3 months, significance difference existed. DISCUSSION: Three months after the operation, patients with dual-plate fixation showed good functional recovery. Extra-periosteal dual plating for acute mid-shaft clavicle fractures can be safely considered for the treatment of complex acute mid-shaft clavicle fractures without increasing the risk of nonunion or revision. CONCLUSIONS: Open reduction and internal fixation with an extra-periosteal dual plating technique is a reliable option for treatment of acute mid-shaft clavicle fractures, especially in the setting of severely comminuted fractures and in situations where bone quality is questionable and additional fixation is desired.

Detection of dorsal screw penetration during volar plating of the distal radius fractures: A comparison of different fluoroscopic views and screw sizes.

OBJECTIVE: The objective of this study was to compare different screw lengths combined with different fluoroscopic views to detect intraoperative dorsal screw penetration in distal radius fractures treated with volar locked plating. MATERIAL AND METHODS: From April 2014 to October 2018, one hundred and eighty patients were included. We divided the patients into four groups. Intraoperative AP and lateral views were taken and sizes of the screws were chosen based on actual measurement (Group A, 45 patients). AP, lateral and tangential views were taken and sizes of the screws were also chosen based on actual measurement (Group B, 45 patients). Intraoperative AP and lateral views were taken and the selected screws were 2mm shorter than actual measurement (Group C, 45 patients). AP, lateral and tangential views were taken and the selected screws were 2mm shorter than actual measurement (Group D, 45 patients). Prominent screws were changed intraoperatively according to each view. A computed tomography (CT) was taken postoperatively to identify residual prominent screws. RESULTS: The number of dorsally prominent screws exceeding 1mm was 6 of 301 in Group A (2.0%), 15 of 290 (5.2%) in Group B, 2 of 289 in Group C (0.7%), and 2 of 282 (0.7%) in Group D. All these prominent screws (25 screws) were exchanged for shorter screws during surgery. Group A and Group B had significant difference in detecting intraoperative dorsal screw penetration (p<0.05). Group C and Group D had no significant difference in detecting intraoperative dorsal screw penetration (p>0.05). Postoperative CT identified 12 additional prominent screws with≥1mm dorsal penetration in Group A, 2 screws in Group B, 1 screw in Group C and 0 screw in Group B respectively. Significant difference was found between Group A and Group B of CT results (p<0.05) while no statistical difference was found between Group C and Group D of CT results (p>0.05). DISCUSSIONS: Tangential view helped identify screw penetration. If tangential view was not available intraoperatively, screw penetration could also be avoided by downsizing the distal locking screw by 2mm shorter than actual measurement.

Sparing the pronator quadratus for volar plating of distal radius fractures: a comparative study of two methods.

OBJECTIVES: The objective of this study was to compare the results of two methods for sparing the pronator quadratus in volar plating of distal radius fractures. METHODS: A total of 110 patients were randomized to volar plating with sparing of the pronator quadratus either by a transverse incision along the distal border of the pronator quadratus (Group A, 55 people) or by the brachioradialis splitting method (Group B, 55 people). The operative and radiation time, range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Visual Analog Scale (VAS) scores, and complications were recorded. RESULTS: There were no significant differences in the mean operative time, radiation time, mean bone union time, or total complication rate between the groups. We found no significant differences in range of motion, grip strength, VAS scores, and DASH scores at any of the study intervals between the groups. Although neurapraxia of the superficial branch of the radial nerve was more common in Group B than in Group A (6.7% vs. 0%), the difference was not significant. CONCLUSIONS: Both methods were efficient approaches for sparing the pronator quadratus and had similar clinical outcomes, but they had different indications.

[Surgical methods and curative effect of tibial plateau fracture with medial large block split].

OBJECTIVE: To explore the clinical effects of protecting the internal structure of the knee and internal fixation through two different directions for the treatment of tibial plateau fractures with medial large block split. METHODS: From January 2010 to January 2016, data of 21 patients of tibial plateau with medial large block split fractures who were treated with protecting the internal structure of the knee and internal fixation through two different directions were retrospectively analyzed, including 17 males and 4 females, with an average age of (39.2±3.2) years old ranging from 27 to 63 years. Anteroposterior and lateral radiographs as well as computed tomography(CT) images were obtained in the course of preoperative. It was made in the operation to protect medial knee structure, combining with internal fixation via two different directions plates(medial and posteromedial). If the posterolateral condyle fracture was involved, a plate was applied through posterolateral approach. Rasmussen score was used for radiological assessment, and HSS knee score was used for efficacy assessment at 1 year after operation. The fracture healing time was judged by X-ray and clinical examinations, additionally, the complications and corresponding outcomes were also recorded. RESULTS: All patients were followed up for 10 to 24 months with an average of(17.2±1.7) months. All fractures were healed, the healing time was 9 to 16 weeks with an average of(11.1±3.2) weeks. The Rasmussen score after surgery was 1 to 18 points with an average of(16.7±1.5) points. Sixteen cases got excellent, 3 good and 2 fair. At the final follow-up, HSS functional scores ranged from 60 to 100 points with an average of (87.3±6.7) points, the result was excellent in 18 cases, good in 2 cases and fair in 1 case. CONCLUSIONS: For a split fracture of the medial tibial plateau, the medial incision, full protection of the medial knee structure, and two different directions of supporting plate fixation are feasible, and the short-term effect is satisfactory.

Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture.

BACKGROUND: There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN). MATERIALS AND METHODS: 9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale. RESULTS: All patients were followedup, with a mean period of 29 months (range 25-40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°-134°) and the mean postoperative HSS was 93 (range 85-97) at 24 months followup. None of the patients sustained neurovascular complication. CONCLUSIONS: The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region.