Operative Treatment of Terrible Triad of the Elbow via Posterolateral and Anteromedial Approaches.

The aim of the study was to explore the clinical outcome of posterolateral and anteromedial approaches in treatment of terrible triad of the elbow. The study involved 12 patients with closed terrible triad of the elbow treated by posterolateral and anteromedial approaches between January 2010 and June 2012. The mechanism of injury included fall from height in 9 patients and traffic accident in 3. According to O'Driscoll classification for fractures of the ulnar coronoid, there were 11 patients with type Ⅰ and 1 with type Ⅱ fractures. According to Mason classification for fractures of the radial head, there were 3 patients with type Ⅰ, 7 with type Ⅱ and 2 with type Ⅲ fractures. All patients were followed up for 12-27 months (average 15.5 months), which showed no pain or severe pain in all patients except for 2 patients with mild pain. At the last follow-up, the mean flexion was for 125°(range, 90°-140°), the mean extension loss for 20°(range, 0°-70°), the mean pronation for 66°(range, 20°-85°) and the mean supination for 60°(range, 30°-85°). The bony union time was 8-14 weeks (average 11 weeks) and the elbows were stable in flexion-extension and varus-valgus in all patients. The elbows maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation. Mild heterotopic ossification of the elbow occurred in 3 patients at 6 months after operation and mild degenerative change in 1 patient at 18 months after operation. The Broberg and Morrey elbow performance score was 82 points (range, 58-98 points). The results were excellent in 6 patients, good in 4, fair in 1 and poor in 1, with excellence rate of 83.3%. The results showed that the combined posterolateral and anteromedial approaches can facilitate the reduction and fixation of terrible triad of the elbow. Repair of radial head, coronoid, medial and lateral collateral ligaments can sufficiently restore the elbow stability, allow early postoperative motion and enhance the functional recovery.

Clinical efficacy of simple decompression versus anterior transposition of the ulnar nerve for the treatment of cubital tunnel syndrome: A meta-analysis.

OBJECTIVES: The aim of this study was to evaluate the clinical efficacy of simple decompression (SD) versus anterior transposition (AT) of the ulnar nerve for the treatment of cubital tunnel syndrome. METHODS: Seven public databases (PubMed, MEDLINE and EMBASE, Springer, Elsevier Science Direct, Cochrane Library and Google scholar) were searched from 1971 to December 2013. The overall odds ratios (OR) and their 95% confidence intervals (CI) were pooled to compare the clinical outcomes. Subgroup analysis was performed based on the region, study type, Jadad score, type of AT, and follow-up duration. Meta-analysis was conducted by using Rev. Man 5.1 and Stata 11.0 software. RESULTS: Finally, we included 13 studies involved 1009 (500 patients receiving SD and 509 patients receiving AT) patients with cubital tunnel syndrome. The overall estimate (OR=0.91, 95% CI=0.67-1.23, P=0.536) indicated that there was no significantly statistical difference between the clinical outcomes of patients treated with SD and AT. Meanwhile, subgroup analyses by region, study type, Jadad score, type of AT and follow-up duration showed the consistent results with the overall estimate. In addition, we found that the incidence of complications in patients treated by SD was significantly lower than that in patients treated by AT (OR=0.32, 95% CI=0.17-0.60, P=0.05). CONCLUSIONS: In conclusion, although SD had equivalent clinical outcomes with AT for the treatment of cubital tunnel syndrome, SD should be preferred due to having lower incidence of complications.

Open reduction and internal fixation of posterolateral tibial plateau fractures through fibula osteotomy-free posterolateral approach.

OBJECTIVE: To evaluate the outcome of patients with posterolateral tibial plateau fractures after open reduction and internal fixation with a fibula osteotomy-free posterolateral approach. DESIGN: Retrospective chart and operation note review. SETTING: A medical college-affiliated tertiary hospital. MATERIALS AND METHODS: A retrospective chart and radiographic review of posterolateral tibial plateau fractures treated with a posterolateral approach between January 2006 and July 2010 was performed. The primary (ie, the total Rasmussen function score) and secondary (ie, the postoperative infection, knee deformity, and complications) outcomes were analyzed. RESULTS: A total of 32 patients were identified for this study. Patients were followed for an average of 18.2 months (range, 12-36 months); the total Rasmussen function score was 24.8 ± 2.9 points. The results were rated as excellent (≥27 points) in 19 patients, good (20-26 points) in 11, and fair (10-19 points) in 2 patients. No wound infections, screw loosening or implant fracture, and nonunion, deformity, or fracture redisplacement were seen. Stretch injury of the common peroneal nerve was found in 1 patient, who obtained recovery 2 months after additional conservative management. CONCLUSIONS: Adequate open reduction and internal fixation with a fibula osteotomy-free posterolateral approach can attain a satisfactory clinical outcome for patients with posterolateral tibial plateau fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ten versus five polymorphonuclear leukocytes as threshold in frozen section tests for periprosthetic infection: a meta-analysis.

We objectively appraised available evidence regarding the threshold for the number of polymorphonuclear leukocytes required in frozen section tests used to diagnose periprosthetic infection. Pooled summary estimates for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio (OR) were compared for ten and five polymorphonuclear leukocytes per high power field as the threshold. The total cohort included 1011 patients and the rate of infection was 19.2%. Although there was no difference in sensitivity or diagnostic OR, specificity was significantly higher for ten than for five polymorphonuclear leukocytes per high power field (p=0.007) In sum, a threshold of 10 polymorphonuclear leukocytes is better for diagnosing periprosthetic infections.

[Recent progress in the treatment of posterior tibial plateau fractures].

There is a lack of ideal clinical classification systems for posterior tibial plateau fractures, and they need to be perfected in clinical practices. There are controversies over surgical approaches due to special characters of posterior tibial plateau fractures. It is difficult for the conventional techniques and approaches to achieve satisfactory reduction and fixation. A modified posterior approach is an ideal approach for the treatment of posterior tibial plateau fractures. This paper summarizes the classification, approach and internal fixation of posterior tibial plateau fractures.

[Operative treatment for posteromedial condylar split fracture of tibial plateau].

OBJECTIVE: To investigate the clinical effects of surgery reduction and internal fixation through posteromedial knee approaches in the treatment of posteromedial condylar split fracture of tibial plateau. METHODS: From January 2006 to July 2009,21 patients with posteromedial condylar split fracture of tibial plateau were treated by posteromedial knee approaches. Among the patients, 14 cases were males and 7 cases were females,ranging from 28 to 68 years old with an average of 36.9 years old. For traumatic causes, 14 cases were injured by traffic accident and 7 cases by fall. Compound injury, 15 cases combined with anterior cruciate ligament injury and tibia insertion avulsion fracture; 14 cases combined with posterolateral de-pressed tibial plateau fracture. Rasmussen assessment criteria was used to evaluate the therapeutic effects. RESULTS: All patients were followed up,from 12 to 30 months with an average of 17.3 months. All patients didn't undergo infection,looseness and rupture of fixation,nonunion of fracture,inversion and eversion of the knee or displacement of fracture. All cases attained anatomical reduction after operation,only 1 patient felt numbness of posterior lower part of the calf. According to Rasmussen assessment criteria, 12 cases got an excellent result, 7 good and 2 fair. CONCLUSION: It is beneficial for the postermedial knee approaches to be used in the reduction and fixation of posteromedial condylar split fracture of tibial plateau. It has advantages of clearly exposure, convenient placement of the internal fixation, less trauma and good therapeutic effects.

Treatment of unstable sacral fractures with percutaneous reconstruction plate internal fixation.

PURPOSE: To study the effects of percutaneous reconstruction plate internal fixation in the treatment of unstable sacral fractures. METHODS: Percutaneous reconstruction plate internal fixation was applied on 21 cases of unstable sacral fracture (15 males and six females, at age range of 16-65 years, mean 38.3 years) including four cases of Denis Zone I, 14 cases of Zone II and three cases of Zone III. In operation, an arc incision (about 3-5 cm long) was made along the iliac crest on the outside border of posterior superior iliac spine (PSIS) on both sides, and then the plate was transported from the wounded side to the opposite one through the subcutaneous tunnel. RESULTS: The mean incision length, operation time, intraoperative blood loss was 4.3 cm, 45.2 min, and 160.8 ml respectively. All these patients were followed up for 12-33 months (average 16.3 months), which showed no incision infection, intraoperative neurovascular injury, internal fixation loose or breakage, disunion, or obvious lower limb length inequality. The function result was rated as excellent in six cases, good in 12 and fair in 3, with excellence rate of 85.7%, according to the Majeed scoring system. CONCLUSION: Percutaneous reconstruction plate internal fixation is an ideal surgical approach to unstable sacral fractures, as it is easy, safe, causing less trauma and fewer complications, and conducive to quicker recovery.

Treatment of unstable sacral fractures with percutaneous reconstruction plate internal fixation / Tratamento de fraturas sacrais instáveis com reconstrução percutânea com fixação de placa interna

PURPOSE: To study the effects of percutaneous reconstruction plate internal fixation in the treatment of unstable sacral fractures. METHODS: Percutaneous reconstruction plate internal fixation was applied on 21 cases of unstable sacral fracture (15 males and six females, at age range of 16-65 years, mean 38.3 years) including four cases of Denis Zone I, 14 cases of Zone II and three cases of Zone III. In operation, an arc incision (about 3-5 cm long) was made along the iliac crest on the outside border of posterior superior iliac spine (PSIS) on both sides, and then the plate was transported from the wounded side to the opposite one through the subcutaneous tunnel. RESULTS: The mean incision length, operation time, intraoperative blood loss was 4.3cm, 45.2min, and 160.8ml respectively. All these patients were followed up for 12-33 months (average 16.3 months), which showed no incision infection, intraoperative neurovascular injury, internal fixation loose or breakage, disunion, or obvious lower limb length inequality. The function result was rated as excellent in six cases, good in 12 and fair in 3, with excellence rate of 85.7%, according to the Majeed scoring system. CONCLUSION: Percutaneous reconstruction plate internal fixation is an ideal surgical approach to unstable sacral fractures, as it is easy, safe, causing less trauma and fewer complications, and conducive to quicker recovery.

OBJETIVO: Estudar os efeitos da reconstrução percutânea com fixação de placa interna no tratamento de fraturas sacrais instáveis. MÉTODOS: A reconstrução percutânea com fixação de placa interna foi aplicada em 21 casos de fratura sacral instável (15 homens e seis mulheres, com idade variando entre 16 e 65 anos, média de 38,3 anos) incluindo quatro casos de Zona I de Denis, 14 casos de Zona II e três casos de Zona III. No ato operatório, uma incisão arqueada (cerca de 3 a 5cm de comprimento) foi feita ao longo da crista ilíaca na borda externa da espinha ilíaca supero-posterior (PSIS) em ambos os lados, e então a placa foi transportada do lado da ferida para o lado oposto através do túnel subcutâneo. RESULTADOS: O comprimento médio da incisão, tempo operatório e perda sanguínea intra-operatória foram, respectivamente, 4,3cm, 45,2min e 160,8ml. Todos estes pacientes foram acompanhados por 12 a 33 meses (média 16,3 meses), o que mostrou nenhuma infecção de ferida operatória, lesão neurovascular intraoperatória, perda da fixação interna ou quebra, desunião ou desigualdade nos comprimentos dos membros inferiores. O resultado funcional foi excelente em seis casos, bom em doze e falho em três, com taxa excelente de 85,7%, de acordo com o sistema de escore de Majeed. CONCLUSÃO: Reconstrução percutânea com fixação de placa interna é uma abordagem cirúrgica ideal para fraturas sacrais instáveis, sendo fácil e segura, causando menos trauma e poucas complicações, conduzindo a uma recuperação mais rápida.

Low-intensity pulsed ultrasound (LIPUS) may prevent polyethylene induced periprosthetic osteolysis in vivo.

We investigated the effect of local low-intensity pulsed ultrasound (LIPUS) on polyethylene debris induced periprosthetic osteolysis. The periprosthetic osteolysis model was made by injecting endotoxin-free pure polyethylene particles into the distal part of the femur canal and inserting a stainless steel plug into this femur. The effects of polyethylene and LIPUS were assessed histologically and by the shear strength test and periprosthetic bone mineral density (BMD) test. Sixteen rabbits received a stainless steel plug on one side and both polyethylene and a stainless steel plug on the other side. Three months later, the side that received polyethylene showed periprosthetic osteolysis. Subsequently, another 16 rabbits received polyethylene plus local LIPUS (200 mW/cm(2) for 20 min daily) on one side and polyethylene alone on the other side. Three months later, LIPUS effectively prevented the periprosthetic osteolysis caused by polyethylene in this rabbit model.

Isolated u-shaped sacral fracture with cauda equina injury.

A highly unstable and neurological injury, the isolated U-shaped sacral fracture without pre-pelvic ring fracture but combined with cauda equina injury is rare in clinics, and the treatment method remains unclear. It can occur when patients fall from a height, the lower extremities hit the ground in extreme flexion, and the sacrum is the direct touchdown point. The direct impact on the sacrum and the vertical extrusion energy through the spinal column may be the main mechanism of injury. The U-shaped sacral fracture is easily missed, and diagnosis is often delayed as it is difficult to detect on anteroposterior view pelvic radiograph due to angulation of the fracture and bowel shadow. When clinical signs suggested a possible U-shaped sacral fracture, a 2- to 3-mm cut computed tomography scan with coronal and sagittal reconstruction can provide optimal imaging to identify and evaluate the sacral fracture.This article describes 2 patients, a 16-year-old girl and a 40-year-old man, with U-shaped sacral fractures. The patients were treated with posterior sacral laminectomy within 1 week after injury and achieved satisfactory postoperative recovery. Follow-up showed bony union with no further displacement or internal fixation failure, wound infection, delayed healing, or compression of the skin by the plate and screws. The results show that posterior vertebral plate decompression and reconstructive plate internal fixation can obtain a satisfactory outcome with minor operation trauma and few complications.

[Computed tomographic classification of posterior condylar tibial plateau fractures].

OBJECTIVE: To study the new computed tomographic (CT) classification, surgical approaches and clinical efficacy of posterior condylar tibial plateau fractures. METHODS: From January 2006 to July 2009, a total of 39 patients of posterior condylar tibial plateau fractures were treated by posteromedial and posterolateral knee approaches. There were 23 males and 16 females. The mean age was 41.6 years old (range: 28 - 68). Among all patients, the causes were traffic accidents (n = 26), falls (n = 9) and other injuries (n = 4). By CT classification, there were type I with posteromedial condylar tibial plateau split fracture (n = 7), type II with posterolateral condylar tibial plateau split fracture (n = 5), type III with posterolateral condylar tibial plateau depression fracture (n = 11), type IV with posterolateral condylar tibial plateau split depression fracture (n = 2) and type V with posteromedial split and posterolateral condylar tibial plateau depression fracture (n = 14). RESULTS: The mean follow-up period was 18.1 months (range: 12 - 30). The radiographic bony union time was 11 - 16 weeks (mean: 15.2) and the full weight-bearing time 12 - 20 weeks (mean: 15.6). No infection, knee varus/valgus, nerve injury or screw loosening/breakage was found. Bony union was achieved in all cases. According to the Rasmussen functional scoring, the results were excellent in 20, good in 14 and fair in 5. And the excellent and good rate was 87.2%. The radiological results were graded with the Rasmussen score to evaluate the reduction of fracture. The outcome was excellent in 28, good in 8 and fair in 3. And the excellent and good rate was 92.3%. CONCLUSION: This new CT classification scheme of posterior condylar tibial plateau fractures can significantly improve the reliability, guide the clinicians to select appropriate treatment plans and design an ideal regimen of operative approach and internal fixation.

[Treatment of unstable pelvic posterior ring fractures with percutaneous reconstruction plate internal fixation].

OBJECTIVE: To analyze the method and clinical effect of percutaneous reconstruction plate internal fixation for the treatment of unstable pelvic posterior ring fractures. METHODS: From March 2004 to October 2008, 36 patients with unstable pelvic posterior ring fractures were treated with percutaneous reconstruction plate internal fixation. Heavy traction was used to correct vertical displacement of sacrum, then arc incisions (3-5 cm) were made from both sides of posterior superior iliac spine to ipsilateral inferior iliac spine along iliac crest. The reconstruction plate was pushed through the cutaneously tunnel to the other incision. There were 26 males and 10 females, the age ranged from 10 to 65 years, with an average of 37.3 years old. RESULTS: All the patients were followed up, the duration ranged from 12 to 36 months (means 17.8 months). There were no infection, no vascular nerve injuries and loosening or breakage of the external fixation. All cases attained bone union and lower limbs were equal. The average length of incisions, operative time and intraoperative blood loss were (4.36 +/- 0.99) cm, (42.61 +/- 7.97) min, (168.61 +/- 40.44) ml, respectively. According to the Majeed standards, the functional recovery was excellent in 12, good in 18 and fair in 6. CONCLUSION: Percutaneous reconstruction plate internal fixation is an ideally safe and effective way to treat unstable pelvic posterior ring fractures, it has many advantages such as minimal invasion, less complications and quicker recovery.

[Treatment of unstable pelvic fractures with minimally invasive internal fixation].

OBJECTIVE: To explore the clinical effects of minimally invasive internal fixation in the treatment of unstable pelvic fractures. METHODS: From January 2005 to January 2009, the data of 48 patients with unstable pelvic fractures were retrospectively analyzed. There were 31 males and 17 females. The age ranged from 12 to 66 years with an average of 37.8 years. Among them, 29 cases were caused by traffic accident, 14 by fall from height and 5 by crush injury. According to Tile's classification, type B1 was in 4 cases, B2 in 3, C1 in 25, C2 in 14 and C3 in 2. All patients were treated with minimally invasive internal fixation of percutaneous reconstruction plate (including 20 cases with percutaneous pubic ramus screws fixation and 8 cases with pubic tubercle screws fixation) and percutaneous sacroiliac screws (including 16 cases with percutaneous pubic ramus screws fixation and 4 cases with pubic tubercle screws fixation). With X-ray films to observe the reduction of fractures and according to Majeed standard to evaluate the clinical effects. RESULTS: All patients were followed up for 12-39 months with an average of 17 months. No infection of incision,nerve injuries, loosening or breakage of the screw was found. All cases attained bone union. Anatomical reduction achieved in 29 cases,satisfactory reduction 18 cases, and unsatisfactory reduction 1 case. According to the Majeed standards, 29 cases obtained excellent results, 15 good and 4 fair, the rate of excellent and good was 91.7%. CONCLUSION: Treatment of unstable pelvic fractures with minimally invasive internal fixation had advantages of minimal trauma, less bleeding, less postoperative complications, high bone union rate, reliable fixation and satisfactorily functional recovery after operation, but the method demanded skillful surgical techniques.

[Treatment of proximal tibial multi-segment comminuted fractures with closed reduction and less invasive stabilization systems].

OBJECTIVE: To explore the clinical effects of closed reduction and less invasive stablization system for the treatment of proximal tibial multi-segment comminuted fractures, and to discuss the influence of LISS on reduction and bone union. METHODS: From 2003.7 to 2007.12, 19 patients with proximal tibial multi-segment comminuted fractures were treated with closed reduction and LISS fixation. Fourteen patients were male, 5 patients were female, ranging in age from 21 to 49 years, with an average of 39.2 years. Fifteen patients were injured with direct violence, 4 indirect violence. The reasons of the injuries were vehicle crashes for 14 cases and falling from high places for 3 cases and falling to the ground for 2 cases. All the patients were followed up postoperatively. Callus formation and bony union were recorded by X-ray. RESULTS: All the patients were followed up for a period averaged 12.2 months (ranged 8 to 21 months). No failure of fixation and nonunion. No deformation of plates and screws occurred in patients,no superficial wound infection. According to the criteria of Merchan, 14 patients got an excellent result, 3 good, and 2 poor. CONCLUSION: Closed reduction and less invasive stabilization systems can provide rigid internal fixation for proximal tibial multi-segment comminuted fractures. The LISS provides stable fixation, a high rate of union, and a low rate of infection for proximal tibial multi-segment comminuted fractures.

[Surgical treatment of acetabular posterior wall fractures].

OBJECTIVE: To analyze the clinical effect of acetabular posterior wall fractures with reconstruction plate internal fixation. METHODS: From January 2001 to January 2006, 45 cases were studied retrospectively including, 31 males and 14 females. The age ranged from 19 to 68 years, mean 37.6 years. All patients of acetabular posterior wall fractures were treated by open reduction and internal fixation with reconstruction plate. All patients were reviewed retrospectively. All patients were treated with the Kocher-Langenbeck approach. RESULTS: Forty-five patients were followed up for 12 to 48 months, averaged 26 months. By Matta's X-ray reduction criteria, there were 38 cases of anatomical reduction, 7 cases of satisfactory. By modified d'Aubigne clinical evaluation criteria, the clinical results were excellent in 30 cases, good in 10 cases and fair in 5 cases, excellent and good rate of clinical results was 88.9%. There were no infection and non-union. The complications included traumatic osteoarthritis in 4, aseptic necrosis of the femoral head in 2, heterotopic osteogenesis in 2 and deep venous thromboembolism in 1. CONCLUSION: Fractures of acetabular posterior wall with reconstruction plate internal fixation can gain good clinical results. The quality of fracture reduction, the time to surgery after injury, experience of surgical operation and the degree of fracture comminution are the factors influencing the operative results of posterior wall fractures of the acetabulum.

[Surgical treatment of talar neck fractures].

OBJECTIVE: To explore the clinical effect of talar neck fractures treated by open reduction and internal fixation with screws. METHODS: Among 28 cases in the study, 20 cases were males and 8 cases were female. The age ranged from 22 to 72 years with an average of 38 years. Based on the Hawkins classification,there were 6 cases of type I,18 of type I and 4 of type II. They were treated by open reduction and internal fixation with screws. RESULTS: Twenty-eight cases were followed up for 1 to 7 years(mean 2.8 years). The evaluation of the results by Hawkins functional rating scale revealed excellent in 14 cases,good in 9 cases, fair in 3 cases and poor in 2 cases. The excellent and good rate were 83.2%. Osteonecrosis occurred in 5 cases with 3 of type II and 2 of type III fractures. Two of 3 cases with talar displacement were found with osteonecrosis or painful arthritis. The subtalar arthritis occurred in 6 cases, 3 of which were associated with ankle arthritis. Two cases underwent arthrodesis because of painful arthritis of the subtalar joint or osteonecrosis of the talar body. Wound infection and anteromedial skin necrosis of the ankle were not found. CONCLUSION: Treatment of talar neck fractures could obtain satisfactory clinical results through open reduction and internal fixation with screws. Protection of the residual blood supply, anatomically reduction and stable fixation are essential for successful treatment of talar neck fractures.

[Treatment of chronic osteomyelitis with antibiotic-loaded calcium phosphate cement].

The antibiotic delayed release system which has the characteristics of high local antibiotic concentration,few adverse effects, slow release and long duration, has became one of important methods of treating chronic osteomyelitis. Because of its double action as drug carrier and bone repair material which can induce bone growth and degrade synchronously, drug impregnated calcium phosphate cement (diCPC) is an ideal and safe antibiotic slow release carrier. After clearing focus thoroughly, defect implant with diCPC is an effective method, which has the virtues of convenient operation, good effects and short staying time etc. This paper aims to summarize the biological properties, experimental study and clinical application of diCPC.