Effects of topical tranexamic acid during open reduction and internal fixation of acetabular fractures: A retrospective study

ObjectiveThe aim of this study was to assess the effect of topical tranexamic acid on blood loss and transfusion rates in acetabular fracture surgery.MethodsThe medical records of 61 patients who underwent open reduction and internal fixation for acetabular fracture between 2012 and 2015 were retrospectively reviewed. The patients were divided into two groups: Group I consisted of 31 patients (19 men and 12 women, mean age: 52 ± 19 years) who received intraoperatively a topical tranexamic acid solution of 3 g and Group 2 consisted of 30 control patients (17 men and 13 women, mean age: 48 ± 24 years) who received only 0.9% saline solution. The groups were compared based on their intraoperative blood loss, Postoperative drain output at 24 and 48 h, and postoperative hemoglobin levels, and transfusion rates.ResultsThe mean intraoperative blood loss was 410 ± 100 ml in Group 1, compared to 570 ml ± 160 ml of the control group (p < 0.05). The postoperative drain output after 24 h was 210 ± 70 ml in Group 1 compared to 330 ± 90 ml of the control group (p < 0.05). The drain output at 48 h was (50 ± 20 ml) in group 1 compared to 90 ± 40 ml of the control group (p < 0.05). The transfusion rate was significantly low group 1 (42%) than the control group (97%). Hemoglobin drop was again significantly less in tranexamic acid group (2.1 ± 1.1) than the control group (3.2 ± 1.3). The nadir postoperative hemoglobin was higher in the Group 1 (10.4 ± 1.5) than the control group (9.2 ± 1.3).ConclusionTopical administration of tranexamic acid reduces intraoperative and postoperative blood loss in acetabular fracture surgery, decreasing transfusion rates.Level of EvidenceLevel III, Therapeutic Study.     

Does use of a quadrilateral surface plate improve outcome in elderly acetabular fractures?

BackgroundAcetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome.MethodsThis was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study’s cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips).ResultsTen patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3).ConclusionElderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.     

髋臼螺钉对非骨水泥全髋置换术中假体稳定性的影响

目的探讨髋臼螺钉在非骨水泥全髋置换术中对髋臼假体稳定性的影响。 方法回顾性分析2009年8月至2015年8月在深圳市龙岗区人民医院骨科行非骨水泥全髋置换术114例(117髋)病例资料，患者根据术中是否植入髋臼螺钉分成两组，其中A组无螺钉组59髋，B组螺钉固定组58髋。分别在术后3个月、12个月、24个月和末次随访时对病人进行随访，评估并比较影像学的改变及Harris评分。A组57髋B组56髋获得完整随访资料，平均随访(5.7±1.6)年。以Kaplan-Meier法分析两组假体生存率。 结果A组平均手术时间(t＝2.213, P<0.05)、术中出血量均小于B组(t＝2.342, P<0.05)；随访末期，A、B组术后平均Harris评分为(95.0±2.1)分及(93.0±5.5)分(P>0.05)；A、B组术后3个月、12个月、24个月分别有4髋(7.0%)、3髋(5.3%)、1髋(1.8%)和1髋(1.8%)、2髋(3.6%)及2髋(3.6%)出现髋臼周围透亮线；A组1髋术后4年出现骨溶解，B组2髋出现骨溶解。以影像学证明假体松动作为失败标准，计算两组假体平均随访(5.7±1.6)年生存率分别为97%和95%，两者差异无统计学意义(P >0.05)。 结论髋臼骨质条件良好时是否使用髋臼螺钉固定对臼杯的稳定性无明显影响，全髋关节置换术中植入髋臼螺钉不是必需的。     

髋臼横韧带定位髋臼假体前倾校正骨盆旋转

目的通过观察后外侧入路全髋关节置换术中骨盆的旋转变化，探讨术中骨盆旋转对髋臼假体前倾角植入的影响，评估使用髋臼横韧带作髋臼假体前倾定位的准确性以及对骨盆旋转角度变化的校正作用。 方法2015年1月至2016年1月河池市第三人民医院关节外科收治的行初次THA的40例44髋的髋关节疾病患者纳入本研究。纳入标准为：初次THA术的患者，术前、术后CT扫描质量符合标准、能确定髋臼解剖前倾角、髋臼假体前倾角的患者。排除标准：髋臼发育不良、强直性脊柱炎、既往有髋关节严重创伤手术史以及翻修术等，术前、术后双髋关节CT扫描，CT横断面上骨盆明显倾斜、两侧髋关节的中心显示明显不在同一层面、难以确定水平线测量前倾角的患者，予以排除。手术均采用侧卧位后外侧入路，切皮前将1枚施氏针以垂直于地面方向打入髂骨嵴，术中髋臼假体的前倾角，以髋臼横韧带为参照标志，通过直接参照或间接参照髋臼横韧带进行髋臼挫磨及安装臼杯，使髋臼假体开口平行韧带进行安放，在此过程中用摄像机记录施氏针相对于地面的角度变化，确定手术过程中骨盆旋转度数，同时测量并记录挫磨髋臼及安放假体时，相对于身体长轴髋臼手术前倾角的数值。术后通过CT测量髋臼假体前倾角，对术中手术前倾角和术后髋臼假体的前倾角、术前髋臼解剖前倾角数据进行t检验分析。 结果术中骨盆旋转发生在本研究中的平均度数为(18±4)°。44个髋关节中，所有的病例都能对髋臼横韧带进行辨认，术中手术前倾角平均为(33±5)°，有93%(41髋)的病例大于Lewinnek提出的"安全区"的前倾角上限25°，余下的7%(3个髋)也全部大于24°。术后CT测量髋臼假体的解剖前倾角为(21±10)°，与术前髋臼解剖前倾角度(19±7)°比较，差异无统计学意义(t＝1.264，P >0.05)。 结论在后外侧入路THA术中，体位改变骨盆前旋转会影响髋臼假体植入的准确性，使用髋臼横韧带作为解剖标志指导髋臼假体前倾角度的植入，可以排除患者体位改变骨盆旋转对前倾角的影响，提高髋臼假体放置的准确性。     

Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

IntroductionPatients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures.MethodsAdults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality.ResultsAfter propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality.ConclusionCirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture.Level of EvidencePrognostic Level III.     

髂腹股沟下和髂腹股沟入路的解剖比较研究及在髋臼骨折中的应用

目的：比较治疗髋臼骨折的髂腹股沟下入路和髂腹股沟入路的解剖学差别,并探讨髂腹股沟下入路的临床疗效.方法：选取男女新鲜尸体标本7具,同一标本做左右两侧对比研究,左侧采用髂腹股沟入路,右侧采用髂腹股沟下入路,切口内侧均自耻骨联合上方2 cm开始横行,切口外侧沿髂骨嵴至髂前上棘后外5 cm处,对比测量切口第1窗暴露的长径、横径和髂腰肌游离度.并随访观察2010年5月至2012年8月采用单一髂腹股沟下入路治疗的15例髋臼骨折患者的手术疗效,其中男12例,女3例;年龄20～65岁,平均40.6岁,采用Matta标准进行疗效评价.结果：髂腹股沟下入路在切口第1窗暴露长径、横径和髂腰肌游离度均优于髂腹股沟入路（P＜0.01）.临床观察15例髋臼骨折患者,根据Mata复位标准,10例获得解剖复位,5例复位满意;所有患者X线片结果为优.结论：相比经典的髂腹股沟入路,髂腹股沟下入路可显著扩大第1窗口的暴露范围,同时手术步骤简单.此入路是暴露髋臼前柱、前内侧壁和髋关节前方的理想手术入路.     

双尖钢板技术治疗髋臼后壁骨折

目的 探讨双尖钢板在治疗髋臼后壁骨折中的应用价值.方法 回顾性分析2008年7月-2012年7月应用双尖钢板技术治疗的11例髋臼后壁骨折,其中男8例,女3例,年龄22 ～ 53岁,平均35.3岁,受伤至手术时间为1～19d,平均7.8d.所有患者均采取Kocher-langenbeck入路,取AO1/3管型钢板制成双尖钢板,结合重建钢板固定后壁骨折块.术后采用Matta复位标准评价骨折复位情况,采用改良Merled'Aubigne和Postel标准评定髋关节功能.结果 本组11例患者获得平均25个月(12 ～33个月)门诊或电话随访.末次随访时骨折复位质量:优7例,良3例,可1例,差0例,优良率90.9％;根据Merled'Aubigne和Postel评分标准评定患者疗效:优6例,良3例,可2例,差0例,优良率81.8％.其中术后1例患者发生异位骨化;无感染、无股骨头缺血性坏死、无创伤性关节炎等并发症的发生.结论 对于髋臼后壁存在无法用螺钉固定的骨折块或存在臼缘小型骨折块时,双尖钢板结合重建钢板可以提供坚强、牢靠的固定,术后患者功能恢复好,是一项有效的固定方式.     

成人髋关节发育不良不同Crowe分型的三维CT影像学特征

 目的 通过三维CT重建分析成人髋关节发育不良不同Crowe分型之间髋臼形态的演变规律。方法 2010年6月至2013年1月收治成人髋关节发育不良患者62例68髋,男6例8髋,女56例60髋;年龄47~59岁,平均（53.7±5.8）岁。CroweⅠ型14例17髋,Ⅱ型17例17髋,Ⅲ型15例17髋,Ⅳ型16例17髋。行标准髋关节CT扫描及三维重建。在侧位三维图像上标记Harris窝,确定髋臼旋转中心,利用十字坐标轴确定髋臼旋转中心的冠状面和横断面位置;在正位三维图像上利用Ranwant三角确定髋臼旋转中心的矢状面位置;在髋臼水平重建图像上确定髋臼旋转中心。观察髋臼前后缘增生及髋臼前后柱发育不良程度,测量并比较不同Crowe分型患者的髋臼前倾角、前覆盖角、后覆盖角和内壁宽度。结果 随Crowe分型增加,髋臼前倾角逐渐加大,两者呈正相关,除CroweⅠ型和Ⅱ型组间外,其余组间差异有统计学意义;髋臼前覆盖角逐渐减小,两者呈负相关,各组间差异均有统计学意义,CroweⅢ、Ⅳ型组平均值小于50°;髋臼后覆盖角逐渐减小,两者呈负相关,各组间差异均有统计学意义, CroweⅢ、Ⅳ型组平均值小于90° ;髋臼内壁宽度逐渐增加,两者呈正相关,各组间差异均有统计学意义。结论 不同Crowe分型成人髋关节发育不良的髋臼形态变化存在一定的演变规律。对CroweⅠ型和Ⅱ型髋臼的重建可充分利用髋臼前后柱骨量,对CroweⅢ、Ⅳ型髋臼的重建可适度上移和（或）内移髋臼中心。     

髋臼发育不良全髋关节置换术髋臼旋转中心原位固定与上移的比较研究

目的 比较分析全髋关节置换术（THA）治疗成人髋臼发育髋臼旋转中心原位固定与上移的临床疗效.方法 回顾分析24例髋臼发育不良（DDH）全髋置换术病例中期疗效,其中髋臼旋转中心上移及原位固定各12例,平均随访4.3年,比较分析手术时间、出血量、术后康复时间及髋关节Harris评分.结果 两组病例随访期内无假体脱位、松动、髋关节感染等发生,二者在手术时间、出血量、Harris评分无明显差异性.结论 髋臼旋转中心的选择以软组织平衡为原则,二者术后中期髋关节功能无显著差异.     

偏心髋臼旋转截骨术的生物力学机制及初步临床疗效

 目的 探讨偏心髋臼旋转截骨术治疗髋关节发育不良的生物力学机制及其初步临床疗效。方法 取6具经福尔马林防腐处理的女性尸体骨盆标本,建立髋关节生物力学模型,在模型上模拟偏心髋臼旋转截骨术。对骨盆缓慢施加连续纵向压力0~500 N,测量术前和术后载荷100、200、300、400、500 N时的股骨头承重区应变值,计算应力值。2007年7月至2014年10月应用偏心髋臼旋转截骨术治疗髋关节发育不良25例（26髋）,男6例,女19例;年龄11~57岁,平均31岁。术后以Harris髋关节评分评价髋关节功能,摄骨盆正位X线片测量头臼指数、中心边缘角（center-edge-angle,CE角）及Sharp角。结果-随着脊柱纵向压力加大,股骨头上的应力值随之增加。偏心髋臼旋转截骨术后应力值在载荷超过300 N后由上升趋势转变为下降趋势,总体呈抛物线状。100~500 N载荷下偏心髋臼旋转截骨术后的应力值与术前差异均无统计学意义。临床随访18例（19髋）,随访率72%。随访时间7~85个月,平均40个月。Harris髋关节评分由术前（64.3±7.2）分提高至末次随访时（85.6±5.3）分;头臼指数平均增加36.5%、CE角平均增加33.1°、Sharp角平均减少12.3°,与术前比较差异均有统计学意义。结论-偏心髋臼旋转截骨术具有较好的矫正髋臼畸形的能力,可增大股骨头的髋臼覆盖面和降低承重区压力。