The association between intracompartmental pressure and skeletal muscle recovery after tibial diaphyseal fractures: an ambispective cohort study.

BACKGROUND: Due to the special anatomy of the lower leg, tibial diaphyseal fracture causes increased intracompartmental pressure (ICP). Not only is this increased ICP the manifestation of skeletal muscle injury, but it induces further deterioration of the injury. The aim of this study was to assess the association between short-term ICP elevation and long-term skeletal muscle recovery after severe limb trauma. METHODS: In this single-center ambispective cohort study, we retrospectively screened and recruited a cohort of tibial diaphyseal fracture patients with integrated ICP data during the early post-traumatic period, and performed a prospective observational study to evaluate their skeletal muscle recovery through long-term follow-up and MR imaging after the removal of the implants. We analyzed the association between ICP elevation and skeletal muscle recovery using statistical methods. RESULTS: A total of 46 patients with healed fractures underwent intramedullary nail removal and MR imaging. The absolute values of the Pearson product-moment correlation coefficients between various ICP parameters and the cross-sectional area ratio (CSAR) ranged from 0.588 to 0.793, and the correlation coefficients between the ICP parameters and the average T2-weighted signal intensity ratio (T2SIR) varied from 0.566 to 0.775. Statistically significant associations were observed between the ICP parameters and the MR imaging parameters when simple linear regression analysis was performed. Among the ICP parameters, the accumulated ΔP (ΔP = diastolic blood pressure minus ICP) had the highest determination coefficient and explained 62.1% and 59.1% of the variance in CSAR and T2SIR, respectively. CONCLUSIONS: Short-term ICP elevation was associated with long-term skeletal muscle recovery following tibial diaphyseal fracture, especially for ICP data that integrated time factors. LEVEL OF EVIDENCE: Level 3.

Difficult diagnosis and genetic analysis of fibrodysplasia ossificans progressiva: a case report.

BACKGROUND: Fibrodysplasia ossificans progressiva (FOP), an ultra-rare and disabling genetic disorder of skeletal malformations and progressive heterotopic ossification, is caused by heterozygous activating mutations in activin A receptor, type I/activin-like kinase 2 (ACVR1/ALK2). The rarity of the disease makes it common to make a misdiagnosis and cause mismanagement. CASE PRESENTATION: We reported a case of a sixteen-year-old male patient who had suffered from pain and swelling in the biopsy site for two months. His physical examination presented serious stiffness and multiple bony masses in the body, with his bilateral halluces characterized by hallux valgus deformity and macrodactyly. Imaging examinations showed widespread heterotopic ossification. All laboratory blood tests were normal except for the one on alkaline phosphatase. A de novo heterozygous mutation (c.617G > A; p.R206H) were found in the ACVR1/ALK2 using gene sequencing. CONCLUSION: Even though FOP is a rare disorder of genetic origin, which is generally misdiagnosed, the genetic analysis could provide definitive confirmation of the disease. Awareness of such an important approach can help clinicians to avoid the commonly practiced misdiagnosis and mismanagement of the rare disease.

Comparison of 2 available methods with Bland-Altman analysis for measuring intracompartmental pressure.

BACKGROUND: Acute compartment syndrome (ACS) is the result of increased intracompartmental pressure (ICP), and to avoid a delay in diagnosis requires ICP measurement. This study was designed to compare 2 available methods with Bland-Altman analysis for measuring ICP in experimental animal models, healthy volunteers, and patients with suspected ACS to evaluate their agreement and interchangeability. METHODS: In 20 New Zealand White rabbits, we inflated a tourniquet to stop arterial blood flow to establish ACS rabbit models, of which ICP was measured and recorded by the Whitesides apparatus and the invasive arterial blood pressure monitor system (IABPMS) before and after modeling. The same 2 measurements were applied to the tibialis anterior compartment's ICP of 30 healthy volunteers. The experimental data were analyzed using the Bland-Altman method. Once it was considered to be a substitute for the Whitesides apparatus based on statistical analysis, we used IABPMS to measure the ICP of the patients suspected of having ACS to estimate its clinical prospect. RESULTS: The rabbit models' ICP estimated by the Whitesides apparatus and IABPMS were 9.60±2.74 and 9.55±2.33 mm Hg, with an increase to 30.20±4.44 and 30.05±4.58 mm Hg after modeling, respectively. The limits of agreement for the ICP were -2.01/2.11 and -2.41/2.71 mm Hg before and after model establishment. The healthy volunteers' ICP were 10.92±6.06 and 10.85±5.87 mm Hg; the limits of agreement for the ICP were -2.53/2.66 mm Hg. With IABPMS to continuously monitor the ICP increasing (40.45±10.42 vs 13.82±4.94 mm Hg) and ΔP (34.54±11.77 mm Hg) to guide the diagnosis of ACS, 5 of 11 patients underwent the emergency fasciotomy for decompression. CONCLUSION: The invasive pressure monitoring via IABPMS can be used as an alternative to the Whitesides method, thanks to the sufficient agreement between the 2 methods in ICP measurement, and also for its advantages recommended as a novel diagnostic approach to ACS in experimental and clinical applications.

[APPLICATION OF COMPUTER-ASSISTED SURGICAL PLANNING IN SURGICAL TREATMENT OF ANKLE FRACTURES].

OBJECTIVE: To explore the clinical value of computer-assisted surgical planning in the treatment of ankle fractures. METHODS: Between January 2012 and January 2014, open reduction and internal fixation were performed on 42 patients with ankle fractures. There were 22 males and 20 females with an average age of 52 years (range, 19-72 years). The causes were spraining injury (20 cases), traffic accident injury (14 cases), and falling from height injury (8 cases). The time from injury to operation was 5 hours to 12 days (mean, 2.5 days). All fractures were closed trimalleolar fractures. According to Lauge-Hansen classification, 25 cases were rated as supination extorsion type IV, 13 as pronation extorsion type IV, and 4 as pronation abduction type III. The preoperative planning was made by virtual reduction and internal fixation using Superimage software. RESULTS: The mean operation time was 93.7 minutes (range, 76-120 minutes). Delayed wound healing occurred in 1 case, and secondary healing was obtained after treatment; primary healing of incision was achieved in the other patients. Postoperative X-ray films and CT images showed anatomic reduction of fracture and good position of internal fixation. All patients were followed up 14.6 months on average (range, 9-27 months). The range of motion of the affected ankle was close to the normal side at 6-8 weeks. The mean fracture healing time was 13.1 weeks (range, 11-17 weeks). Degenerative change of the ankle joint was observed in 3 cases (7.1%) with manifestation of mild narrowing of joint space on the X-ray films at last follow-up. According to Baird-Jackson score system, the results were excellent in 24 cases, good in 13 cases, and fair in 5 cases, with an excellent and good rate of 88%. CONCLUSION: Computer-assisted surgical planning for ankle fractures can help surgeons identify type of ankle fractures and improve surgical scheme for guiding fracture reduction and selecting and placing implants, so good effectiveness can be obtained.

Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures - a randomized controlled trial.

OBJECTIVE: We aimed to compare the clinical outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation with conventional plate via L-shaped lateral approach (routine treatment) versus those with percutaneous plate via a sinus tarsi approach (minimally invasive treatment). METHODS: One hundred and seventeen displaced intra-articular calcaneal fractures in 108 patients from January 2007 and September 2010 were randomly allocated to receive routine treatment (49 patients) or minimally invasive treatment (59 patients). Operative time, preoperative and postoperative calcaneal height, width, length, Böhlers angle, Gissanes angle, and incision healing were recorded. Maryland foot score system was used to evaluate clinical functional outcomes. RESULTS: The operative time of minimally invasive group was significantly shorter than that of the routine group [46-80 min (mean, 62 min) vs 65-110 min (mean, 93 min), p < 0.01]. Postoperative X-ray showed the calcaneal height, width, length, Böhlers angle and Gissanes angle were significantly improved in both two groups, and no significant difference was observed between two groups postoperatively. No feet developed wound complications in minimally invasive group, but incision complications occurred in 8 feet in routine group. The excellent and good rate according to the Maryland foot score was significantly higher in minimally invasive group than that in the routine group (93.8% vs 86.8%). CONCLUSION: Compared with L-shaped lateral approach treatment of displaced intra-articular calcaneal fractures, sinus tarsi approach for the reduction and internal fixation with percutaneous plate seems to be more safe and effective, with satisfactory clinical therapeutic effects and without postoperative complications.

A minimally invasive sinus tarsi approach with percutaneous plate and screw fixation for intra-articular calcaneal fractures.

According to characteristic of anatomical structure of calcaneus and sinus tarsi approach, the minimally invasive plate for treatment of displaced intra-articular calcaneal fractures had been designed. Here we aimed to review the effect of this treatment. Forty intra-articular calcaneal fractures in 38 patients from September 2006 to September 2008 were treated with percutaneous plate via sinus tarsi approach under the monitoring of C-shaped arms. All calcaneal anatomical parameters, including height, width, length, Böhlers angle and Gissane angle were measured by X-ray before and after surgery. Postoperative lateral wound healing was also evaluated and clinical functional outcomes were graded using the Maryland foot score. All patients had been followed up for an average of 12 months ranged from 3 months to 24 months. X-ray indicated satisfactory restoration of the calcaneal height, width, length, Böhlers angle and Gissanes angle. Maryland foot score demonstrated that excellent result was achieved in 32 cases, good in 6 cases, fair in 2 cases, and the excellent and good rate was 95%. Postoperative complications were not found in all fractured feet. Our results suggest that this minimally invasive sinus tarsi approach with new designed plate and screw fixation technique for the treatment of intra-articular calcaneal fractures can not only obtain the satisfactory outcomes, but also can effectively prevent surgical complications.

Analysis of trabecular distribution of the proximal femur in patients with fragility fractures.

BACKGROUND: Multi-detector computed tomography (MDCT) was used in order to assess the trabecular distribution of proximal femur and its relationship with hip fragility fractures. METHODS: A total of 99 elderly women were scanned by MDCT including: 27 trochanteric hip fractures (group A), 40 femoral neck fractures (group B), and 32 non-fractures (group C). A mid-coronal MPR image of the proximal femur was reconstructed for every patient by e-Film95 software. Four regions of interest (ROI) were chosen in the images including compressive trabecula (ComT), tensile trabecula (TenT), trochanteric trabecula (TroT) and Ward's triangle (WT) region. The mean CT values were measured by the software. RESULTS: The mean age was 81.44, 74.10 and 69.25 years for groups A, B and C, respectively. There was significant inter-group differences based on one-way ANOVA (P<0.05). The CT values in the four ROIs had significant differences in the groups except for TenT between group A and B (P>0.05). After the age adjustment with ANCOVA, the mean CT values of TroT and WT were significantly lower in group A as compared to that of the group B (P<0.05). However, there were no significant differences for ComT and TenT between groups A and B (P>0.05). CONCLUSIONS: The occurrence of femoral neck fracture was closely related to the degeneration of ComT and TenT. Trochanteric hip fractures were associated with a more severe degeneration in TroT as well as an enlargement of WT region besides the ComT and TenT degeneration. We concluded that the hip fragility fractures might be predicted by the measurement of the mean CT values in ComT, TenT, TroT and WT region.

[Application of minimally invasive locking compression plate in treatment of proximal humeral fractures].

OBJECTIVE: To evaluate the clinical and radiological outcomes of minimally invasive plate osteosynthesis (MIPO) with locking compression plate (LCP) in the treatment of proximal humeral shaft fracture. METHODS: From July 2004 to April 2008, 26 patients with displaced fractures of the proximal humeral shaft were recruited, including 8 males and 18 females. Age of patients averaged 66 years old (range, 34-82 years old). According to AO classification, there were 4 cases of type A1, 2 cases of type A2, 8 cases of type B1, 4 cases of type B2, 2 cases of type B3, 4 cases of type C1 and 2 cases of type C2. The time from injury to surgery averaged 2 days (range, 1-5 days). There were 8 osteoporotic fractures. RESULTS: All surgical wound healed primarily, and there was no wound infection. Three patients had postoperative radial nerve neurapraxia, which recovered at 4, 6, 8 months respectively. All patients were followed up for 6-24 months with an average of 14.1 months. Radiological examination revealed bony union within 6 months in 25 cases. There was 1 delayed union which remained asymptomatic and eventually healed at 8 months with acceptable Constant-Murley score. There were 3 cases of shoulder impingement syndrome diagnosed at 3 months post-operatively. After implant removal, they all achieved an acceptable Constant-Murley score. According to Constant-Murley scoring system, there were 11 excellent, 10 good and 5 acceptable results. The excellent or good rate was 80.8%. CONCLUSION: MIPO technique using LCP is an effective method to treat proximal humeral shaft fractures, which facilitates functional recovery of the shoulder joint. During the surgery, it is important to achieve a good fracture reduction and to avoid complications.