Comparison of the Effect of Rhombic and Inverted Triangle Configurations of Cannulated Screws on Internal Fixation of Nondisplaced Femoral Neck Fractures in Elderly Patients.

OBJECTIVE: To investigate whether four-screw fixation in rhombic configuration could improve the clinical outcomes and decrease the complication rate compared with three-screw fixation in inverted triangle configuration in elderly patients with nondisplaced femoral neck fractures. METHOD: From January 2018 to January 2019, 91 elderly patients with nondisplaced femoral neck fractures who were treated with a cannulated screw system were reviewed retrospectively. The inverted triangle configuration was applied in 51 patients and rhombic configuration in 40 patients. The demographic and perioperative information of the patients were extracted from medical records and surgical records. Variables including incision size, surgical blood loss, surgical time, fluoroscopy time, hospital stays, fracture union time, postoperative visual analogue scale (VAS) scores, and complications were compared between the two groups. Also, Harris hip score at the final follow-up was used to evaluate the functional outcomes. RESULTS: All patients were followed up from 24 to 36 months, with an average of 29.75 months. The average age of patients was 72.37 ± 7.16 years. No significant differences were found between the two groups with regard to patients' age, gender, affected side, Garden classification, Pauwels classification and comminution of posterior wall (P > 0.05). We found shorter incision size (P < 0.001), less blood loss (P = 0.020), less surgical time (P = 0.026), and shorter fluoroscopy time (P < 0.001) in inverted triangle configuration group. However, shorter hospital stays (P = 0.001) and fracture union time (P = 0.002) were found in the rhombic configuration group. The VAS scores were lower in the rhombic configuration group at the first (P < 0.001) and third months (P = 0.010), but no significant difference was found at the sixth month (P = 0.075). Meanwhile, the total complication rate was relatively lower in the rhombic configuration group compared to the inverted triangle configuration group (P = 0.041). Harris hip score presented no significant difference between the two groups at final follow-up (P = 0.078). No wound infection or cortical perforation occurred in either group. CONCLUSION: Four-screw fixation in rhombic configuration was superior to three-screw fixation in inverted triangle configuration in the treatment of nondisplaced femoral neck fractures in elderly patients in terms of less early postsurgical pain, shorter fracture union time, and lower complication rate.

Unilateral locking plate versus unilateral locking plate combined with compression bolt for Schatzker I-IV tibial plateau fractures: a comparative study.

BACKGROUND: The quality and durability of fracture reduction play an important role in the functional prognosis of articulation. The purpose of this study was to investigate the radiological and clinical effects of compression bolts in the treatment of Schatzker I-IV tibial plateau fractures (TPFs). METHODS: Between May 2015 and April 2018, a total of 96 consecutive adult patients with operatively treated Schatzker I-IV TPFs were included and divided into two groups according to the internal fixations: Group 1 (unilateral locking plate) and Group 2 (unilateral locking plate combined with compression bolt). Data on demographic and fracture characteristics, postoperative follow-up imaging, intraoperative indicators, postoperative reduction quality and durability, clinical outcomes, and complications were retrospectively collected and compared between the two groups. RESULTS: There were no significant intergroup differences in preoperative baseline data, duration of operation, intra-operative blood loss, days in hospital, rate of immediate post-operative reduction loss, or complications. The time of fracture healing, the rate of secondary reduction loss, and the mean WOMAC score were significantly reduced compared with those in Group 1 (P = 0.024, 0.015, and 0.024, respectively). There were significant intergroup differences in the mean HSS score (89.0 ± 11.4 vs. 94.4 ± 6.7, P = 0.042), the mean Lysholm score (83.8 ± 9.6 vs. 88.4 ± 5.2, P = 0.027), and the mean SF-36 score (82.8 ± 12.5 vs. 90.5 ± 7.6, P = 0.001). Additionally, there were similar significant differences in subgroup analysis (only included patients with Schatzker II-III), except for WOMAC score. CONCLUSION: Compared with unilateral locking plate fixation, unilateral locking plate combined with compressing bolt fixation can reduce the rate of secondary reduction loss, accelerate fracture healing, and show better clinical outcomes for patients with Schatzker I-IV TPFs.

Incidence and risk factors of occult posterior malleolar fracture in patients with spiral distal tibial fracture: Reexamination and analysis.

OBJECTIVE: To evaluate the incidence and risk factors for posterior malleolar fractures (PMFs) in patients with spiral distal tibial fractures (SDTFs). METHODS: In a retrospective study, 248 adults with SDTFs who underwent treatment were enrolled between November 2017 and May 2020. In a prospective study, we recruited 113 consecutive, skeletally mature patients with SDTFs who were identified from the trauma clinic of our hospital between June 2020 and May 2021. Radiographs and CT scans of the ankle region on the affected side were obtained to determine the presence of PMFs. If the CT scan was negative, additional MRI examination of the ankle was performed as a supplementary protocol in the prospective study. Univariate analysis and multivariate analysis were conducted to analyze the risk factors. RESULTS: In the retrospective study, the incidence of PMFs associated with simple SDTFs was 74.0% (105/142), which was significantly lower than 90.8% (69/76) in the prospective study. Independent predictors of PMFs in patients with simple SDTFs identified by multivariate analysis in the retrospective study were age (OR = 1.07; P = 0.001) and external rotation of the proximal tibia (OR = 3.36; P = 0.027) and those in the prospective study were osteoporosis (OR = 0.04; P = 0.007) and spiral fibula fractures (OR = 16.05; P = 0.046). CONCLUSION: This study reexamined the high incidence of concurrent PMFs. Additionally, ankle radiographs and CT scans were recommended for all simple SDTF patients. For simple SDTF patients with negative CT scans, especially those caused by external rotation of the proximal tibia, combined with nonosteoporotic or spiral fibula fractures, additional MRI examinations are recommended.

Nomogram for predicting reoperation following internal fixation of nondisplaced femoral neck fractures in elderly patients.

OBJECTIVE: We aimed to evaluate risk factors and develop a nomogram for reoperation after internal fixation of nondisplaced femoral neck fractures (FNFs) in elderly patients. METHODS: We conducted a retrospective study involving a total of 255 elderly patients who underwent closed reduction and internal fixation with cannulated screw system for nondisplaced FNFs between January 2016 and January 2019. We collected data on demographics, preoperative radiological parameters, surgery, serum biochemical markers, and postoperative rehabilitation. In addition, we performed univariate and multivariate logistic regression analyses to determine independent risk factors for reoperation, and then developed a nomogram to assess the risks of reoperation. Besides, discriminative ability, calibration, and clinical usefulness of the nomogram were evaluated using the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA), respectively. We employed bootstrap method to validate the performance of the developed nomogram. RESULTS: Our analysis showed that among the 255 patients, 28 (11.0%) underwent reoperation due to osteonecrosis of the femoral head (14 cases), mechanical failure (8 cases) or nonunion (6 cases). All of the 28 patients underwent conversion surgery to arthroplasty. The multivariate logistic regression analysis demonstrated that preoperative posterior tilt angle ≥ 20°, Pauwel's III type, younger patients, preoperative elevated levels of alkaline phosphatase (ALP), preoperative hypoalbuminemia, and early postoperative weight-bearing were independent risk factors for reoperation. In addition, the C-index and the bootstrap value of the developed nomogram was 0.850 (95% CI = 0.803-0.913) and 0.811, respectively. Besides, the calibration curve showed good consistency between the actual diagnosed reoperation and the predicted probability, while the DCA indicated that the nomogram was clinically valuable. CONCLUSIONS: Our analysis showed we successfully developed and validated a nomogram for personalized prediction of reoperation after internal fixation of nondisplaced FNFs in elderly patients. This model would help in individualized evaluation of the need for reoperation and inform strategies aimed at eliminating the need for the reoperation.

Cemented versus uncemented hemiarthroplasty for femoral neck fractures in patients with neuromuscular diseases: a minimum of 2 years' follow-up study.

BACKGROUND: The aim of this study was to compare the outcomes of cemented and uncemented hemiarthroplasty for femoral neck fractures in patients with neuromuscular disease. METHODS: We reviewed 156 patients with neuromuscular disease who underwent hemiarthroplasty between June 2015 and December 2019. Patients were divided into cemented group (n = 105) and uncemented group (n = 51), with a minimum follow-up of 2 years. Factors including preoperative features, duration of surgery, intraoperative blood loss, complications, pain, Harris hip scores (HHS), and quality of life were compared across groups, and Kaplan-Meier curves were used to estimate survival. RESULTS: In the uncemented group, the mean duration of surgery was 16.0 min. shorter (p = 0.001) and the mean intraoperative blood loss was 71.1 mL less (p = 0.01). Visual analog scales (VAS), HHS, and European Quality of Life-5 Dimensions (EQ-5D) scores were not different between the groups. Despite a few potential trends, we did not observe a difference in complications such as periprosthetic fractures and dislocations. The rates of mortality were similar between groups (p=0.821). CONCLUSIONS: Both arthroplasties may be used with good medium-term results in the treatment of femoral neck fractures in patients with neuromuscular diseases.

Prevalence and risk factors of preoperative deep venous thrombosis in closed patella fracture: a prospective cohort study.

BACKGROUND: The preoperative prevalence of deep venous thromboembolism (DVT) of patella fracture is not well established. The study aimed to investigate the preoperative prevalence, the associated risk factors, and the locations of deep venous thrombosis (DVT) in patients with closed patella fracture. METHODS: Patients who sustained closed patella fracture between January 1, 2016, and April 1, 2019, were included. Blood analyses and ultrasonography of bilateral lower extremities were routinely performed. Data of demographics, comorbidities, mechanism of injury, fracture type, total hospital stay, time from injury to DVT, and laboratory indexes were prospectively collected and compared between groups with and with non-DVT. Multivariate logistic regression analyses were performed to determine the independent risk factors of DVT. RESULTS: Among the study cohort of 790 patients, 35 cases occurred in preoperative DVTs, indicating a prevalence of 4.4%, with 3.2% distal and 1.2% proximal DVT. Age ≥ 65 years old (OR, 3.0, 95% CI, 1.1-8.1), D-dimer > 0.5 mg/L (OR, 2.3, 95% CI, 1.1-4.8), and albumin < 35 g/L (OR, 2.5, 95% CI, 1.2-5.3) were identified to be risk factors of DVT in closed patella fracture. Among the DVTs, 30 cases (85.7%) occurred in the injured extremity, 3 cases (8.6%) in bilateral extremities, and 2 cases (5.7%) solely in the uninjured extremity. CONCLUSION: The prevalence of preoperative DVT in closed patella fracture was 4.4%, with 3.2% for distal and 1.2% for proximal DVT. We recommend individualized risk stratification and early anticoagulation for patients with risk factors (age ≥ 65 years, D-dimer > 0.5 mg/L and albumin < 35g/L).

Prevalence and risk factors of surgical site infection after closed isolated patella fracture surgery: A prospective cohort study.

PURPOSE: Surgical site infection (SSI) after patella fracture surgery could be devastating and challenging. There is no large sample size study to investigate the prevalence and risk factors of it. The purpose of this study was to address this clinical issue. METHODS: A total of 820 patients who underwent patella fracture surgery between October 2014 and December 2018, were included. Demographic data, fracture type, injury mechanism, pre-operative stay, surgery-related variables, and pre-operative laboratory indexes were obtained from a prospective database. The optimum cutoff value of surgery duration was detected by receiver operating characteristic analysis. Univariate analysis and multivariate analysis were performed to determine the risk factors. RESULTS: A total of 17 patients developed SSI after patella fracture surgery, indicating a prevalence of 2.1%, with 11 cases (1.3%) for superficial infection and six cases (0.8%) for deep infection. After adjustment of multiple variables, current smoking, (OR, 18.6, CI, 3.5-99.0); albumin < 35 g/L, (OR, 7.4, CI, 1.1-52.3); diabetes mellitus, (OR, 8.8, CI, 1.3-59.4) and surgery duration > 79.5 minutes, (OR, 13.2, CI, 1.5-117.3) were identified to be independent risk factors of SSI after patella fracture surgery (p < 0.05). CONCLUSION: The prevalence of SSI in patients with closed isolated patella fracture was 2.1%, with 1.3% for superficial and 0.8% for deep infection. We recommend individualized risk stratification and targeted interventions for patients with risk factors (current smoking, albumin < 35 g/L, diabetes mellitus, and surgery duration > 79.5 minutes).

Dual plating or dual plating combined with compression bolts for bicondylar tibial plateau fractures: a retrospective comparative study.

The aim of this study was to compare secondary loss of reduction outcomes in dual plating fixation and dual plating combined with compression bolt fixation for bicondylar tibial plateau fractures (TPFs). We performed a retrospective study from January 2015 to April 2019. A consecutive series of 72 bicondylar TPFs underwent surgical treatment and was divided into two groups: group 1 (dual plating, n = 46) and group 2 (dual plating combined with compression bolts, n = 26). The outcomes collected included demographic characteristics, imaging characteristics, intraoperative indicators, clinical outcomes and reduction quality after surgery. Functional outcome was rated according to the Hospital for Special Surgery (HSS) score and Lysholm score. The secondary loss of reduction rate in group 2 was reduced compared with that in group 1 (P = 0.025), and the mean HSS score of group 2 was higher than that of group 1 (P = 0.013). The rate of complications was 30.4% (14/46) in group 1 and 30.8% (8/26) in group 2 (P = 0.976). Compared with single dual plating fixation, dual plating combined with compressing bolt fixation reduced the secondary loss of reduction rate for patients with bicondylar TPFs and showed better functional outcomes.

Incidence and risk factors for deep venous thrombosis of lower extremity after surgical treatment of isolated patella fractures.

BACKGROUND: Limited information exists on the incidence of postoperative deep venous thromboembolism (DVT) in patients with isolated patella fractures. The objective of this study was to investigate the postoperative incidence and locations of deep venous thrombosis (DVT) of the lower extremity in patients who underwent isolated patella fractures and identify the associated risk factors. METHODS: Medical data of 716 hospitalized patients was collected. The patients had acute isolated patella fractures and were admitted at the 3rd Hospital of Hebei Medical University between January 1, 2016, and February 31, 2019. All patients met the inclusion criteria. Medical data was collected using the inpatient record system, which included the patient demographics, patient's bad hobbies, comorbidities, past medical history, fracture and surgery-related factors, hematological biomarkers, total hospital stay, and preoperative stay. Doppler examination was conducted for the diagnosis of DVT. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. RESULTS: Among the 716 patients, DVT was confirmed in 29 cases, indicating an incidence of 4.1%. DVT involved bilateral limbs (injured and uninjured) in one patient (3.4%). DVT involved superficial femoral common vein in 1 case (3.4%), popliteal vein in 6 cases (20.7%), posterior tibial vein in 11 cases (37.9%), and peroneal vein in 11 cases (37.9%). The median of the interval between surgery and diagnosis of DVT was 4.0 days (range, 1.0-8.0 days). Six variables were identified to be independent risk factors for DVT which included age category (> 65 years old), OR, 4.44 (1.34-14.71); arrhythmia, OR, 4.41 (1.20-16.15); intra-operative blood loss, OR, 1.01 (1.00-1.02); preoperative stay (delay of each day), OR, 1.43 (1.15-1.78); surgical duration, OR, 1.04 (1.03-1.06); LDL-C (> 3.37 mmol/L), OR, 2.98 (1.14-7.76). CONCLUSION: Incidence of postoperative DVT in patients with isolated patella fractures is substantial. More attentions should be paid on postoperative DVT prophylaxis in patients with isolated patella fractures. Identification of associated risk factors can help clinicians recognize the risk population, assess the risk of DVT, and develop personalized prophylaxis strategies.

Changes in patellar height and posterior tibial slope angle following uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy.

PURPOSE: The purpose of this study was to evaluate changes of patellar height and posterior tibial slope angle following uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy. METHODS: All patients who underwent uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy between January 2017 and February 2019 were included and assessed retrospectively. Radiological assessment was made in terms of the changes in patellar height and posterior tibial slope angle between pre-operative and post-operative radiographs. RESULTS: Thirty-five patients (9 males and 26 females) with a mean age of 57.3 years (range 50.8-64.2 years) were enrolled in this study protocol and demonstrated decreased posterior tibial slope angle post-operatively (9.7° ± 2.5° pre-operatively and 7.3° ± 1.8° post-operatively, P < 0.001). Patellar height was unchanged significantly post-operatively (Caton-Deschamps: 0.83 ± 0.12 pre-operatively and 0.82 ± 0.09 post-operatively, P > 0.05). CONCLUSIONS: Uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy can decrease posterior tibial slope and maintain the patellar height.

Prognostic Value of the Preoperative Lymphocyte-to-C-Reactive Protein Ratio and Albumin-to-Globulin Ratio in Patients with Osteosarcoma.

PURPOSE: Growing evidence indicates that preoperative biomarkers could be identified as independent prognostic factors in various cancers. The purpose of this study was to assess prognostic value of the preoperative lymphocyte-to-C-reactive protein ratio (LCR), albumin-to-globulin ratio (AGR), lymphocyte-monocyte ratio (LMR), and C-reactive protein to albumin ratio (CAR) in patients with osteosarcoma. METHODS: A total of 137 osteosarcoma patients treated at our hospital between 2011 and 2019 were enrolled in the study. Patient demographics, clinical characteristics, and laboratory data were collected and analyzed. The optimal cutoff values of LCR, AGR, LMR, and CAR were assessed with receiver operating characteristic (ROC) analysis. Kaplan-Meier analysis was performed to estimate overall survival (OS). Univariate and multivariate Cox regression models were employed to determine the independent prognostic factors. The hazard ratios (HR) and 95% confidence intervals (95% CI) were calculated to evaluate relative risk. RESULTS: The optimal cutoff values of LCR, AGR, LMR, and CAR were 0.14, 1.79, 3.05 and 0.24, respectively. According to the univariate analysis, OS was remarkably associated with neoadjuvant chemotherapy (P < 0.001), pathological fracture (P < 0.001), local recurrence (P = 0.020), metastasis (P < 0.001), LCR (P = 0.035), AGR (P = 0.028), LMR (P = 0.010), and CAR (P = 0.004). In multivariate analyses, pathological fracture (P = 0.025), metastasis (P < 0.001), LCR (P = 0.012), and AGR (P = 0.001) were identified as independent risk predictors for OS. CONCLUSION: The present study provides new evidence that the preoperative LCR and AGR could serve as independent prognostic factors for patients with osteosarcoma. These findings will help physicians to stratify patients for appropriate treatment protocols and facilitate decision-making so as to improve the patients' survival condition.

An Often Easily Missed Injury in the Presence of Orthopaedic Trauma: A Case Series of Derived Injury.

Derived disaster is a common concept in emergencies such as earthquakes. With the progress of society, the incidence of fractures caused by high-energy trauma has increased year by year. After the first injury, the possibility of derived injury caused by the original injury also increases rapidly. Orthopaedic surgeons, especially trauma orthopaedic surgeons, lack sufficient understanding and recognition of this kind of injury. The purpose of this article is to present a case series of an often missed injury pattern that is associated with an original injury. The diagnosis of derived injury may go unrecognized in a considerable number of cases and delayed treatment decreases the success rate of soft tissue repairing; therefore, a high index of suspicion and a proper early diagnosis is of paramount importance. We also describe the current surgical management used by the authors, and propose the concept of "derived injury", studying its clinical significance in traumatic orthopaedics.