Delay between admission and surgery as a potential risk factor for postoperative morbidity and mortality in elderly patients with hip fractures: A retrospective study.

BACKGROUND: This study aimed to assess the impact of delay between admission and surgery on the postoperative outcomes such as mortality and related complications in elderly patients with acute hip fractures. METHODS: 840 patients aged ≥65 years from January 2009 to September 2015 were included in this retrospective study. According to the interval from admission to surgery, the patients were divided into four groups: group A (surgery within 24 h), group B (surgery within 24 h-48 h), group C (surgery within 48 h-72 h), and group D (surgery later than 72 h). Postoperative complications during hospitalization and mortality at different follow-up time points were compared. RESULTS: A total of 763 cases were successfully followed up, with an average follow-up time of 30.4 ± 13.1 months. The mean age of the patients was 79.4 ± 6.8 years. The difference in gross postoperative complications among groups was statistically significant in terms of pressure sore (P = 0.02), respiratory complications (P = 0.001), and urological complications (P < 0.001). The multivariate logistic regression analysis identified 3 factors independently associated with the postoperative morbidity, including age (odds ratio [OR] = 1.040), postoperative drainage volume (OR = 1.002) and time from admission to surgery (OR = 1.108). The difference in postoperative mortality among groups was statistically significant at 1 year (P = 0.046) after operation. The multivariate logistic regression analysis identified that age, postoperative drainage volume and time from admission to surgery were independently associated with mortality at 1 year postsurgery. CONCLUSION: The incidence of postoperative morbidity and mortality in elderly patients with hip fracture is usually the result of multiple factors, surgeons should pay attention to the patient's age, postoperative wound status and surgical delay time, which may significantly affect the outcome of the treatment.

Outcomes of posterior malleolar fractures with intra-articular impacted fragment.

INTRODUCTION: An intra-articular impacted fragment (IAIF) could lead to articular incongruity and malreduction in ankle fractures with posterior malleolar fractures (PMFs). No studies have been conducted to determine whether the presence of IAIF affects the outcome of ankle fractures with PMF. The aim of our retrospective study was to evaluate the effect of IAIF on postoperative outcomes in PMF and analyze the relationship between area of IAIF and outcomes. MATERIALS AND METHODS: We conducted a retrospective study of patients with a posterior malleolar fractures between June 2012 and January 2019 with a minimum follow-up of 2 years. Results of the Olerud-Molander ankle score (OMAS), EuroQol-5D (EQ-5D) index, EQ-5D visual analog scale (VAS), AOFAS (American orthopedic foot and ankle society ankle-hindfoot scale), visual analog scale (VAS) pain score and overall patient satisfaction scale were recorded. Outcomes of the PMF with IAIF group and PMF without IAIF group were compared. Sub-group analysis was given emphasis on the AIAIF > 40 mm2 group and AIAIF < 40 mm2 group in PMF with IAIF. RESULTS: A total of 128 patients were included in the study, consisting of 86 patients with IAIF and 42 patients without IAIF. Regarding the osteoarthritis grade (> 1, ≤ 1), the differences werestatistically significant between the two groups (P = 0.044). The risk of articular malreduction was higher in the PMF with IAIF group than in the PMF without IAIF group (P = 0.035). Osteoarthritis grade (> 1, ≤ 1) was closely related to articular malreduction (P < 0.001). There were 51 patients in the AIAIF > 40 mm2 group and 35 patients in the AIAIF < 40 mm2 group of 86 patients in PMF with IAIF. There were statistically significant differences in trimalleolar fracture (P = 0.004), malreduction (P = 0.022), osteoarthritis grade (> 1, ≤ 1; P = 0.027), EQ-5D VAS score (P = 0.031), and AOFAS score (P = 0.047) between the subgroups. CONCLUSION: The incidence of IAIF is associated with the area of the posterior malleolar fragment. Articular malreduction can lead to post-traumatic osteoarthritis, while IAIF is an important element for the quality of reduction, which is more likely to lead to articular malreduction. IAIF should be reduced if AIAIF is over 40 mm2. Otherwise, the patient will suffer a poor prognosis and post-traumatic osteoarthritis. Therefore, ankle fractures with PMF should undergo a CT scan preoperatively in order for providers to optimal treatment protocols. LEVEL OF EVIDENCE: Level III.

Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans.

BACKGROUND: Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. MATERIALS AND METHODS: Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge-Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann-Whitney U test, Fisher's test) and Spearman's correlation test. RESULTS: Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18-89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6-64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8-39.7%) and 52.6% (1.2-235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. CONCLUSION: Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. LEVEL OF EVIDENCE: Level III, retrospective case analysis.

Heparin-induced thrombocytopenia and acute colonic pseudo-obstruction after therapeutic anticoagulation in a very elderly patient with hip fracture: a case report.

BACKGROUND: Hip fractures have become a severe public health problem, especially in very elderly patients. Most of them are treated with low molecular weight heparin as prophylaxis or treatment of venous thromboembolism. Heparin-induced thrombocytopenia is one of the complications induced by low molecular weight heparin, which may cause poor prognosis. However, there is not enough awareness for heparin-induced thrombocytopenia in very elderly trauma patients. CASE PRESENTATION: We report a case of hip fracture with heparin-induced thrombocytopenia in a very elderly patient. The patient developed heparin-induced thrombocytopenia, digestive hemorrhage and acute colonic pseudo-obstruction after the use of low molecular weight heparin, which eventually led to death. CONCLUSIONS: This is the first case report of digestive hemorrhage and acute colonic pseudo-obstruction in heparin-induced thrombocytopenia patients with major trauma. This case highlights the severity of HIT in very elderly patients with hip fractures using low molecular weight heparin, and the need for platelet monitoring in these patients. We indicate that there may be a correlation of pathogenesis between digestive hemorrhage and acute colonic pseudo-obstruction in heparin-induced thrombocytopenia patients.

Incidence of venous thromboembolism and hemorrhage related safety studies of preoperative anticoagulation therapy in hip fracture patients undergoing surgical treatment: a case-control study.

BACKGROUND: Venous thromboembolism is a common postoperative complication following orthopedic surgeries, with morbid and potentially fatal consequences. Perioperative low-molecular-weight heparin (LMWH) therapy can reduce the incidence of venous thromboembolism, but may also increase the risk of bleeding complications. Current literature reflects the need to balance the improved efficacy of early initiating prophylaxis with increased risk of perioperative bleeding. The purpose of this study was to compare the effectiveness and hemorrhage related safety of preoperative versus postoperative LMWH therapy for prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) in hip fracture patients. METHODS: We retrospectively evaluated 222 patients who underwent surgical treatment at Peking University People's Hospital between January 2009 and December 2010. Patients were allocated to two groups, receiving either preoperative or postoperative initiation of LMWH therapy for venous thromboembolism prophylaxis. Preoperative anticoagulation therapy was initiated 1-12 days prior to surgery (133 patients), and postoperative anticoagulation therapy was initiated 12 h after completion of surgery (89 patients). The preoperative group was further subdivided into four subgroups according to the time of initiation of therapy: 1-3 days before surgery (group A, 54 patients), 4-6 days before surgery (group B, 57 patients), 7-9 days before surgery (group C, 15 patients), and 10-12 days before surgery (group D, 7 patients). Occurrences of DVT, PE, adverse drug effects, intraoperative and postoperative bleeding were recorded, along with concentrations of preoperative and postoperative hemoglobin and length of hospital stay. The above parameters were compared between groups. RESULTS: Among recipients of preoperative anticoagulation therapy, two patients developed postoperative PE (1.5 %), one patient developed DVT (0.75 %). In the group receiving postoperative initiation of anticoagulation therapy, one patient each developed PE and DVT (1.1 %, 1.1 %). There was no difference in the occurrence of PE and DVT between the two groups (P>0.05, Chi-square tests). We identified the incidences of major bleeding, minor bleeding, and intraspinal hematoma after spinal anesthesia, which were 0 %/0 %, 3.76 %/3.37 %, and 0 %/0 %, respectively in preoperative and postoperative anticoagulation groups. There was no significant difference in the incidence of bleeding complications between patients receiving preoperatively initiated LMWH with patients receiving postoperatively initiated LMWH. Spinal anesthesia was administered to 168 patients, with no cases of postoperative intraspinal hematoma. CONCLUSIONS: Preoperative anticoagulation therapy with LMWH may not increase intraoperative or postoperative blood loss, or the rate of intraspinal hematoma after spinal anesthesia, but also does not significantly reduce the risk of postoperative DVT or PE, compared to postoperative initiation.

Different interaction profiles of direct-acting anti-hepatitis C virus agents with human organic anion transporting polypeptides.

Simeprevir (SMV), asunaprevir (ASV), daclatasvir (DCV), and sofosbuvir (SFV), which are newly developed direct-acting antiviral agents (DAAs) against hepatitis C virus (HCV) infection, are among the key components of anti-HCV regimens. Preclinical studies have identified inhibitory properties for some of these DAAs against organic anion transporting polypeptide 1B (OATP1B) functions. However, their details remain mostly uncharacterized. Because OATP1B1 and OATP1B3 play determinant roles in the pharmacokinetics of various drugs via their uptake into human hepatocytes, it is plausible that the inhibition of these OATP1Bs by a DAA would create a potential risk of drug-drug interaction, which has been an emerging concern in anti-HCV therapy. Accordingly, in the present study, we intended to clarify the inhibitory characteristics of newly developed DAAs toward OATP1B1 and -1B3 functions. The results of our coincubation inhibition assays have shown that all tested DAAs could inhibit OATP1B1 functions and that SMV, ASV, and DCV (to a lesser extent), but not SFV, exhibited long-lasting preincubation inhibitory effects on OATP1B1 functions. It was also found that the preincubation inhibitory effects of SMV and ASV could augment their coincubation inhibition potency. Furthermore, significant, but differential, inhibitory effects of the DAAs on the OATP1B3 function were identified. To summarize, our results clearly show that the newly developed DAAs are newly identified OATP1B1 and OATP1B3 inhibitors with distinctive interaction properties. It is believed that these inhibition profiles will provide essential information to all concerned parties with respect to the clinical significance of DAA-mediated inhibition of OATP1Bs in anti-HCV therapy.

[Surgical treatment of internal fixation failure after clavicular fracture operation].

OBJECTIVE: To investigate the surgical treatment results of implant failure after clavicular fracture open reduction and internal fixation (ORIF). METHODS: Fifteen cases from Jan. 2005 to Jan. 2013 were treated surgically according to fracture classification, time of implant failure and implant type. The fracture union, shoulder function and pain were evaluated postoperatively. RESULTS: All the patients had full follow-up for 5 to 101 months (mean: 43.8 months). All the fractures were united well. The constant scores to assess the shoulder function were 82 to 100 (mean: 93.3 in the fracture side) and were 85 to 100 (mean: 96.7 in the uninjured side); statistically significant difference of the constant scores between the two sides was found (P=0.02). Eight cases did not have shoulder pain in the fracture side, while the other 7 cases had mild pain, The visual analogue scale (VAS) scores to evaluate shoulder pain were 1 to 3 in the fracture side, which were statistically different from those in the uninjured side (P=0.03). CONCLUSION: Implant instability causes early implant failure after clavicular fracture ORIF and re-fixation with stable implant is effective. Fracture nonunion leads to late implant failure, and bridging fixation using locking plate associated with bony autograft with iliac crest is a successful method to treat atrophy clavicular nonunion. Surgical treatment can bring good results.

Machine learning-based models for prediction of the risk of stroke in coronary artery disease patients receiving coronary revascularization.

BACKGROUND: To construct several prediction models for the risk of stroke in coronary artery disease (CAD) patients receiving coronary revascularization based on machine learning methods. METHODS: In total, 5757 CAD patients receiving coronary revascularization admitted to ICU in Medical Information Mart for Intensive Care IV (MIMIC-IV) were included in this cohort study. All the data were randomly split into the training set (n = 4029) and testing set (n = 1728) at 7:3. Pearson correlation analysis and least absolute shrinkage and selection operator (LASSO) regression model were applied for feature screening. Variables with Pearson correlation coefficient<9 were included, and the regression coefficients were set to 0. Features more closely related to the outcome were selected from the 10-fold cross-validation, and features with non-0 Coefficent were retained and included in the final model. The predictive values of the models were evaluated by sensitivity, specificity, area under the curve (AUC), accuracy, and 95% confidence interval (CI). RESULTS: The Catboost model presented the best predictive performance with the AUC of 0.831 (95%CI: 0.811-0.851) in the training set, and 0.760 (95%CI: 0.722-0.798) in the testing set. The AUC of the logistic regression model was 0.789 (95%CI: 0.764-0.814) in the training set and 0.731 (95%CI: 0.686-0.776) in the testing set. The results of Delong test revealed that the predictive value of the Catboost model was significantly higher than the logistic regression model (P<0.05). Charlson Comorbidity Index (CCI) was the most important variable associated with the risk of stroke in CAD patients receiving coronary revascularization. CONCLUSION: The Catboost model was the optimal model for predicting the risk of stroke in CAD patients receiving coronary revascularization, which might provide a tool to quickly identify CAD patients who were at high risk of postoperative stroke.

[Effect of cement implantation and pressor agents in hip replacement on blood pressure].

OBJECTIVE: To discuss the change of blood pressure involved by pressor agents after the implantation of cement in hip replacement. METHODS: A total of 172 cases of femoral neck fracture underwent hip replacement in Department of Orthopedics and Trauma, Peking University People's Hospital between July 2008 and July 2013 were involved in this retrospective study. The blood pressure and usage of pressor agents were recorded before and after bone cement implantation. The data of blood pressure and usage of agents were collected according to anesthesia records. All the cases were divided into four groups by the application of pressor agents: Free of using agent group (Free-agent group), agents used before implantation of cement group (Pre-agent group), agents used after implantation of cement group (Post-agent group) and agent used before & after implantation of cement group (Pre and Post-agent group). Further statistic analysis was then performed. RESULTS: Free-agent group's mean systolic blood pressure decreased for (4.0 ± 10.3) mmHg. The decreasing was significant (t=3.660, P=0.000). Free-agent group's mean diastolic blood pressure decreased (1.3 ± 7.5) mmHg. The decreasing was not significant (t=2.286, P=0.149). Pre-agent group's mean systolic blood pressure decreased for (0.5 ± 20.2) mmHg. The decreasing was not significant (t=0.114, P=0.911). Pre-agent group's mean diastolic blood pressure increased (0.7 ± 10.2) mmHg. The increasing was not significant (t=-0.316, P=0.756). Post-agent group's mean systolic blood pressure decreased for (6.9 ± 15.0) mmHg. The decreasing was significant (t=3.195, P=0.002). Post-agent group's mean diastolic blood pressure decreased (3.6 ± 7.4) mmHg. The decreasing was significant (t=3.407,P=0.001). Pre & Post-agent group's mean systolic blood pressure decreased for (5.0 ± 12.2) mmHg. The decreasing was not significant (t=1.667, P=0.115). Pre & Post-agent group's mean diastolic blood pressure increased (1.3 ± 8.5) mmHg. The increasing was not significant (t=-0.656, P=0.521). CONCLUSION: Implantation of cement in hip replacement surgery causes blood pressure decreasing. The application of pressor agents before cement implantation can stabilize blood presure and shorten the period of hypotension.

[Minimal invasive internal fixation with U-shaped break-off pedicle screws for treatent of thoracolumbar fractures].

OBJECTIVE: To investigate the clinical outcome of minimal invasive internal fixation with U-shaped break-off pedicle screws through paraspinal muscle sparing approach to treat thoracolumbar fractures, and to discuss its advantages. METHODS: From August 2010 to June 2012, we had 40 thoracolumber fractures patients (27 males and 13 females). Their ages ranged from 22 to 60 years. Of the 40 cases, 4 were T11 fractures, 13 T12 fractures ,17 L1 fractures,6 L2 fractures. According to Denis classification,all of them were burst fractures, with vertebral canal compromise less than 1/3. According to AO classification they were type A or type B1 injuries. All the cases had no nerve injury. The patients were randomly divided into two groups. With Group A (20 cases) we took the method of minimal invasive internal fixation with U-shaped break-off pedicle screws to fix one level above and below the injured vertebra through the parespinal muscle sparing approach. With Group B (20 cases), we took the traditional posterior midline approach and open procedure. Then we compared the two groups by operation time, blood loss, drainage, Visual Analogue Scales and X-ray exposure. RESULTS: Minimal invasive group had obvious advatages in operation time, bleeding control and early pain relief of post-operation. The X-ray exposure and long-term follow-up outcome were almost the same. CONCLUSION: Through paraspinal muscle sparing approach minimal invasive internal fixtation with U-shaped break-off pedicle screws to treat thoracolumber has more advantages than traditional procedure in blood control and quick recovery. The method needs no special instruments and don't increase X-ray exposure.

[Surgical treatment of deltoid ligament injury associated with ankle fractures].

OBJECTIVE: To observe the clinical outcome after the surgical treatment of the deltoid ligament injury associated with ankle fractures. METHODS: From January 2005 to December 2009, 16 deltoid ligament ruptures associated with ankle fractures were repaired. According to the AO/OTA system, 2 cases belonged to fracture A, 8 to B, and 6 to C. Radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and visual analogue scale (VAS) were used for the outcome measurements. RESULTS: The 16 patients were followed up for 30 to 84 months,with the mean follow-up of 47 months. All wounds healed at the first stage. The mean time of bone union was 12.8 weeks (range: 10-14 weeks). The mean AOFAS ankle-hindfoot score in the last follow-up was 93 points (range: 85-100 points). The mean score of VAS was 0.94 points (range: 0-2 points). CONCLUSION: Surgical treatment of ankle fractures associated with deltoid ligament rupture can achieve satisfactory outcomes, but it is important to decide the operation indication.

[Treatment of comminuted clavicle shaft fractures with provisional intra-medullary K-wire fixation and bridging plate internal fixation].

OBJECTIVE: To discuss the operation effect of comminuted clavicle shaft fractures with provisional intramedullary K-wire fixation and bridging plate internal fixation. METHODS: From Mar. 2008 to Jul. 2012, 22 cases of comminuted clavicle shaft fractures was treated with open reduction, and provisional intramedullary K-wire fixation and bridging plate internal fixation. The fracture healing was investigated through X-rays. The 22 cases were followed up to evaluate the function of the affected shoulder with Constant score. RESULTS: Through the follow-up for average 15 months, all the fractures healed and the average healed time was 14.6 weeks. The average Constant score of the affected shoulder was 95.3. There were 13 excellent cases, 7 good cases, and 2 fair cases. The fineness rate was 90.9% (20/22). Soft tissue problem resulting from plate tilting occurred in 2 cases. At last, they accepted second operation to remove the implant. CONCLUSION: Applying provisional intramedullary K-wire fixation and bridging plate internal fixation in comminuted clavicle shaft fractures, makes procedure simple, improves healing rate and decreases the complications.

[Radix hedysari extract promotes peripheral nerve regeneration].

Treatment of peripheral nerve injury is a major challenge in clinical practice. With advances in molecular biology and development of microsurgical techniques and tissue engineering, peripheral nerve repair procedures have been greatly improved. In the last 10 decades, most treatments for peripheral nerve injury in animal models have achieved histological and functional recovery, the treatments in humans, however, produce insufficient recovery, especially for proximal nerve injury. Increasing attention has been paid to the Traditional Chinese Medicine (TCM) for promoting peripheral nerve regeneration, since these remedies often display effective clinical outcome, minor side effects and effectiveness for multiple targets. Although TCM has complex ingredients and the specific pharmacological mechanisms for their effectiveness are still unclear, an effective clinical outcome is welcomed by many clinicians. In the past 20 years, we have made a series of detailed studies including the toxicity tests, pharmacodynamic tests, pharmacological experiments etc, about a new traditional formula which mainly contains the Radix hedysari, Epimedium etc. RESULTS have shown that this formula is safe to be used in both animals and humans with no toxicity and adverse effect, and systemic administration of this formula could enhance the peripheral nerve regeneration.

A Transosseous Suture as an Alternative to Suture Anchor on Anterior-Avulsion Greater Tuberosity Fragment Fixation in Neer Three-Part Proximal Humeral Fracture: A Biomechanical Study.

OBJECTIVE: Greater tuberosity (GT) fragments were communicated, and additional techniques to increase the GT fragment stability after the locking plate fixation was necessary. This study aimed to analyze the reinforcement effects on the anterior-avulsion GT fragment in Neer three-part proximal humeral fractures (PHFs) using transosseous suture and suture anchor techniques. METHODS: Eighteen fresh-frozen human cadaveric shoulder specimens were used in the study. Standardized fracture of the GT and surgical neck was created in 18 human cadaveric proximal humerus. The GT fragments were reinforced with transosseous suture (TS), suture anchor (SA), and suture in addition to the PHILOS plate fixation. The fixed humerus was tested by applying static loading to the supraspinatus tendon. Load forces and fragment displacement were evaluated by a biomechanical testing machine, and the load to 3- and 5-mm displacements, load to failure, and mode of failure were recorded for all specimens. Nonparametric variables were examined by the Kruskal-Wallis test, and the Bonferroni post hoc test was used to analyze the mean loads to create 3- and 5-mm displacements as well as the failure load. RESULTS: The age, female proportion, and bone mineral density showed no statistically significant differences between the three groups. The mean loading force to create 3-mm and 5-mm displacement in the TS group (254.9 ± 77.4, 309.6 ± 152.7) were significantly higher than those in the suture group (136.1 ± 16.7, 193.4 ± 14.5) (P = 0.024, P = 0.005). For the SA group, the force to create 3- and 5-mm displacement (204.3 ± 60.9, 307.8 ± 73.5) were comparable to those in the TS group (P = 0.236, P = 0.983). Moreover, the loading force to failure in the TS group (508.6 ± 217.7) and SA group (406.6 ± 114.9) was significantly higher than that in the suture group (265.9 ± 52.1) (P = 0.021, P = 0.024). In the TS group, three failed due to tendon-bone junction rupture; bone tunnel broken occurred in two specimens; suture rupture could also be seen in one specimen. All specimens in the suture group failed because of suture rupture. In the SA group, three specimens failed due to suture rupture; two failed secondary to tendon-bone junction rupture; and one failed because of shaft fracture. CONCLUSIONS: Transosseous suture is a new type of reinforcement for GT fragment in Neer-three part PHFs. The transosseous suture was superior to the suture only in the reinforcement of the anterior-avulsion GT fragment of Neer three-part PHFs, and it had comparable biomechanical strength to the suture anchor.

Fracture Line Morphology of Greater Tuberosity Fragments of Neer Three- and Four-Part Proximal Humerus Fractures.

OBJECTIVE: In complicated Neer three- and four-part proximal humerus fracture (PHF), greater tuberosity (GT) fragments are often comminuted, and the currently widely used locking plate may not fix GT fragments effectively. A further understanding of morphological characteristics of the GT fragments may help explore new fixation devices. This study aimed to determine the fracture line morphology of the GT fragment of Neer three- or four-part PHF and analyze the location relationship between the locking plate and the GT fragment. METHODS: Seventy-one three-dimensional computed tomography scans of Neer three- and four-part PHF were retrospectively reviewed between January 2014 and June 2019. Fracture fragments were reconstructed and virtually reduced in the Mimics software, and fracture lines of GT fragments were depicted on a humerus template in the 3-matic software and then were superimposed altogether. The common sites of the GT fracture were identified, and the location relationship between the locking plate and GT fragments was analyzed in a computer-simulated scenario. RESULTS: The fracture line morphology of GT fragments was similar between Neer three- and four-part PHF. The overall morphology of GT fragments was in a fan shape, which could be summarized as anterior, superior, posterior, and middle lines. Of these, we identified 51 split and 29 avulsion type GT fragments based on the Mutch classification, and they could occur simultaneously in a PHF. The overall morphology of split type fragments was in a fan shape, and avulsion type fragments showed a quite distinguishable distribution pattern. A GT fragment could be classified as anterior-split, posterior-split, complete-split, anterior -avulsion, and posterior-avulsion type based on its morphology and location. The median percentage of fragment area covered by the plate was 32.3% in all of the fragments, and it was 69.4%, 23.0%, 37.2%, 21.8%, 0.0% in anterior-split, posterior-split, complete-split, anterior-avulsion, and posterior-avulsion type GT fragments. We defined the posterior-split, anterior-avulsion, and posterior-avulsion type GT fragments as the risky GT fragments, and they occurred in 43 (60.6%) Neer three- and four-part PHFs. CONCLUSION: The fracture line morphology of GT fragments of Neer three- and four-part PHF was in a fan shape. GT fragments could be classified based on their location and morphology. The extent of GT fragment coverage provided by the locking plate differed in various fragment types, and we identified the anterior-avulsion, posterior-avulsion, and posterior-split type fragments as the risky GT fragments with a high incidence rate in Neer three- and four-part PHFs.

Mid-term follow-up evaluation of a new arthroscopic Broström procedure for chronic lateral ankle instability.

BACKGROUND: Chronic lateral ankle instability (CLAI) usually progresses from a previous lateral ankle sprain that was not treated properly. Several procedures have been introduced to address these patients, including open or arthroscopic techniques, the most common of which is the Broström procedure. Here, we describe a new outside-in arthroscopic Broström procedure and its results for treating patients with CLAI. METHODS: Thirty-nine patients (16 male and 23 female; mean age, 35 years [range, 16-60 years]) with CLAI were treated arthroscopically after failing non-operative management. All patients were symptomatic with a combination of recurrent ankle sprains, "giving way," and avoidance of sports and presented with a positive anterior drawer test upon the physical examination. All patients underwent arthroscopic lateral ligament reconstruction using the new technique. Patient characteristics and pre- and postoperative visual analog scale (VAS), American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale system (AOFAS), and Karlsson scores were recorded. RESULTS: The mean AOFAS score increased from 48 (mean 48, range 33-72) preoperatively to 91 (mean 91, range 75-98) at the final follow-up, Karlsson-Peterson and FAAM scores were also significantly improved. Two patients (5.13%) reported superficial peroneal nerve irritation symptoms postoperatively. Three patients (7.69%) complained of mild pain anteroinferior to the lateral ankle. CONCLUSIONS: The arthroscopic outside-in Broström procedure with a single suture anchor was a safe, effective, and reproducible technique for CLAI. Ankle stability resumed with a high clinical success rate. The main complication was injury to the superficial peroneal nerve, which crossed the area of repair.

Morphological analysis and classification of posterior malleolar fractures based on CT scans.

OBJECTIVES: The aim of the study was to propose a classification system of posterior malleolar fractures by fracture lines with the use of CT scans, including 3D CT reconstruction, which can better understand morphological characteristics, analyze the mechanism and guide the surgeon to choose the optimal approach and fixation. METHODS: Patients with OTA/AO type 44 fractures involving the posterior malleolus and preoperative CT scans were included. We retrospectively analyzed 128 consecutive patients with posterior malleolar fractures from January 2013 to December 2019 at our institution. CT data were loaded into Mimics software (V20.0, Materialize), in which 3D CT reconstruction, morphological analysis and data measurements were made. RESULTS: Based on the number of fracture lines in 128 consecutive patients, posterior malleolar fractures were classified into three types: type 1 with a single fracture line, type 2 with double fracture lines and type 3 with multiple fracture lines. According to the distribution of the fracture line, type 1 was divided into types 1A, 1B and 1C, and type 2 was divided into types 2A, 2B and 2C. The fracture line from the fibular notch to the posterior rim of the distal tibia was defined as type 1A, and the fracture line to the medial malleolus was defined as type 1B. Type 1C was a small fragment in the posterior rim of the distal tibia. Type 2A was regarded as type 1A with type 1C. It was considered type 2B because another fracture line started from the fracture line of type 1A and extended to the medial malleolus. In type 2C, we could see that the double fracture lines were all from the fibular notch to the posterior rim of the distal tibia and did not cross. Type 3 fractures were comminuted fractures with multiple fracture lines. CONCLUSION: The morphology of posterior malleolar fractures, involvement of the fibular notch, or the medial malleolus can be obviously assessed by our classification system. We found the relation of the injury mechanism between type 1 and type 2 by comparing the area of the fragment. We have indicated that each type of fracture corresponds to its associated injury mechanism and which surgical approach and fixation can be chosen.

A retrospective study of posterior malleolus fractures.

PURPOSE: In this retrospective study, we evaluated the treatment effect of ankle joint fracture surgery involving the posterior malleolus, and discuss relevant factors influencing the occurrence of traumatic arthritis of the ankle joint. METHODS: A total of 102 cases of ankle joint fractures involving the posterior malleolus in five large-scale skeletal trauma centres in China, from January 2000 to July 2009, were retrospectively analysed in terms of surgical treatment and complete follow-up. Ankle joint mobility, posterior malleolus fragment size, articular surface evenness, Ankle-Hindfoot Scale of the American Orthopedic Foot and Ankle Society (AOFAS) score, and imaging scale score for arthritis were recorded. The degree of fracture pain during rest, active movement, and weight-bearing walking, and satisfaction with treatment were evaluated using a visual analogue scale (VAS). RESULTS: The average AOFAS score was 95.9, excellence rate was 92.2 %, and average VAS scores for degree of fracture pain during rest, active movement, and weight-bearing walking were 0.15, 0.31, and 0.68, respectively. Thirty-six cases showed arthritic manifestations. Ankle joint mobility along all directions on the injured side was lower than that on the unaffected side. There was no obvious difference in treatment effect between the fixed and unfixed posterior malleolus fragment groups for all and for fragment size of < 25 %; between fixing the posterior malleolus fragment from front to back or from back to front; or between elderly patients (≥ 60 years old) and young patients (< 60 years old). There was a distinct difference in the treatment effect between articular surface evenness and unevenness for all and for fragment size of ≥ 25 %. CONCLUSIONS: For all 102 cases of ankle joint fracture involving the posterior malleolus, the treatment effect was satisfactory. Restoration of an even articular surface, especially when fragment size ≥ 25 %, should be attempted during treatment.

[Surgical treatment of proximal humeral fracture involving metaphysis and humeral shaft].

OBJECTIVE: To surgically treat proximal humeral fracture involving metaphysis and humeral shaft with long locking plate osteosynthesis. METHODS: In the study, 9 proximal humeral fracture cases [6 male patients and 3 female, with an average age of (48.9±11.5) years and the average postoperation follow-up duration of 21.3 months from 12-46 months] treated with locking plate and with complete follow-up observation from May 2008 to April 2011 were recruited. Visual Analogue Score (VAS), Constant-Murley Score and shoulder range of motion (forward elvation, abduction, internal rotation) were used to evaluate postoperation shoulder joint function. RESULTS: All the cases got union of their fractures, without nonunion or delayed union. The complications were 2 cases with humeral head varus deformity, 1 with wound superficial infection and 1 with postoperation radius nerve paralysis. The last follow-up functions were that the average VAS was 0.22 (0-1), Constant-Murley score 79.7±6.5 (71-91), the average range of shoulder joint anteflexion 118°±20° (90°-160°), abduction 95°±14° (75°-120°) and internal rotation L1. CONCLUSION: Treatment of proximal humeral fracture with the fracture line implicating upper humerus metaphysis and humeral shaft is difficult because the medial cortex is injured and the longitudinal fracture line involves bone shaft. A good selection of operative approach and careful operation guarantee postoperative function restoration.

[Open arthrolysis for elbow stiffness: a report of 17 cases].

OBJECTIVE: To investigate the treatment effect of open arthrolysis for elbow stiffness. METHODS: From Aug. 2007 to Apr. 2012, 17 cases of elbow stiffness were treated with open arthrolysis,in which, 11 were post-traumatic stiffness and 6 elbow stiffness resulted from rheumatoid arthritis and osteoarthritis. The preoperative Mayo elbow score was 65.1±16.4. Posterior middle approach was applied for 15 cases, and primary lateral approach for 2 cases. The ulnar nerve release and antedisplacement were performed for 12 cases with series limited flexion. The mobile hinged fixator were applied for 2 cases of unstable elbow after debridement of series hero ossification. RESULTS: With follow-up time for 6 to 41 months (average 13.1 months), all the patients acquired the follow-up and evaluation. According to Mayo elbow score of the last follow-up, the score was 87.5±16.7, and compared with the preoperation, the difference was significant: 9 cases were excellent, 6 good, 1 fair, and 1 poor, and the total excellent and good rate was 88.23%. The active range of motion (ROM) of flexion-extension was 110.6°±27.5°. However, 1 case developed chronic infection, and 1 ulnar nerve symptom. CONCLUSION: In applying open arthrolysis to treat elbow stiffness, as long as we release completely and assure stable elbow and early postoperative motion, we can get satisfying results.