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1.
Purpose
To explore the hidden blood loss (HBL) in treatment of extra-articular tibial fractures with plate and intramedullary nail fixation.Methods
We conducted a retrospective study including 209 consecutive patients treated by plate (Group LCP) or intramedullary nail fixation (Group IMN) for extra-articular tibial fractures between January 2015 to December 2017. Demographics, intraoperative data, perioperative laboratory values, transfusion rate, and early complications were collected and analyzed.Results
Of 209 patients, 96 patients fixed with IMN and 113 fixed with LCP. The average HBL was 272.71?±?57.88?ml in Group LCP and 507.66?±?109.81?ml in Group IMN, and there was statistical difference in the HBL between two groups (p?<?0.001). The Hb and Hct loss, surgical duration, and postoperative number of anemic patients in Group IMN were significantly higher than in Group LCP (p?<?0.001), and IMN fixation has a significantly higher rate of transfusion (p?=?0.027), whereas patients in group IMN has significantly less VBL (p?<?0.001), shorter postoperative hospital stay (p?<?0.001), and less superficial infection (p?=?0.014).Conclusions
There was a significant amount of hidden blood loss after reamed intramedullary nail fixation for extra-articular tibial fractures, which was much higher than expected. In view of the morbidity of acute anaemia and transfusion, we suggest that for patients who suffer from extra-articular tibial fractures with multiple injuries, or those with low haemoglobin preoperatively, plates might be more suitable than nail fixation. 相似文献2.
Objectives
The purpose of this study is to analyze posteromedial fragment morphology using two-dimensional computed tomography fracture mapping and to compare posteromedial fragment morphology in various Schatzker type tibial plateau fractures.Materials & methods
One hundred twenty-seven consecutive AO/OTA B- and C-type tibial plateau fractures were retrospectively analyzed using 2DCT fracture mapping. The posteromedial articular fracture angle and articular surface areas of all fractures with posteromedial fragments were calculated. Based on biomechanical studies, posteromedial fragments with coronal fracture angles >68° were considered amenable for anterolateral stabilization with standardized plating. Kruskall-Wallis non-parametric test was used for statistical comparison of morphological features of posteromedial fragments between the various Schatzker types.Results
Forty-seven out of 127 tibial plateau fractures included a posteromedial fragment. The mean posteromedial articular fracture angle was 44° (range: 2°-90o, standard deviation: 23°). Forty fragments (85%) had a fracture angle of <68°, increasing the risk for insufficient stabilization with standardized anterolateral plating. The mean articular surface area was 34% of the entire tibial plateau (range: 7%–53%, SD: 12%). There were no significant differences in posteromedial fragment morphology between Schatzker type IV, V, and VI fractures.Discussion and conclusion
Posteromedial fragments commonly occur not only in Schatzker type V and VI, but also in Schatzker type IV tibial plateau fractures. Eighty-five percent of tibial plateau fractures with a posteromedial fragment may benefit from non-standard customized lateral plating, or may require an additional medial or posterior surgical approach for fracture-specific fixation to optimize screw purchase and biomechanical stability. 相似文献3.
Matthew R. Walker Ashraf N. El Naga Omar H. Atassi Christopher H. Perkins Scott A. Mitchell 《Injury》2019,50(3):686-689
Objectives
Hip dislocations are highly morbid injuries necessitating prompt reduction and post-reduction assessment for fracture and incarcerated fragments. Recent literature has questioned the need for initial pelvic radiographs for acute trauma patients, resulting in computed tomography (CT) scans as the initial evaluation. This study investigates the relationship between choice of pre-reduction imaging and treatment of acute hip dislocations.Design
Retrospective Case-Control.Setting
Single Academic Level I Trauma Center.Methods
All acute hip dislocations from 2011 to 2016 were reviewed. Exclusion criteria were diagnosis of dislocation at another facility, death prior to reduction, emergent surgical or ICU intervention, and periprosthetic dislocation. Patients were grouped by those with only a radiograph prior to reduction, Group I, versus those with a pre-reduction CT scan, Group II. The primary outcomes were time to reduction and the acquisition of a second CT scan.Results
Of the 123 hip dislocations identified, 35 patients were excluded, mostly for transfer with a known dislocation. Group I included 29 patients and Group II included 59 patients. The mean time to reduction was 74?min in Group I and 129?min in Group II for a difference of 55?min (p?<?0.001). The rate of repeat CT scan was 0 in Group I versus 48 (81%) in Group II (p?<?0.001).Conclusion
Initial trauma pelvic radiography prior to CT is still important in the setting of suspected hip pathology to decrease time to hip reduction and unnecessary radiation exposure.Level of evidence
Prognostic Level III. 相似文献4.
Aims
The anatomical safe zone for intra-medullary nail insertion through the tibial plateau is small, insertion outside of this area risks damage to intra-articular structures and poor fracture reduction. The purpose of this retrospective study was to determine if the new supra-patella (SP) approach confers improved nail insertion accuracy, when compared with the standard infra-patella (IP) technique.Patients and Methods
Two hundred cases were included in the study (SP 95, IP 105). Insertion accuracy was assessed on AP and lateral radiographic imaging, and measured as the distances between the central axis of the proximal nail and the ideal entry point.Results
The median distance from the ideal entry point was 4.4?mm (SP) and 5.1?mm (IP) (p?=?0.046) in the coronal plane, and 4.0?mm (SP) and 3.7?mm (IP) (p?=?0.527) in the sagittal plane. A narrower range in measurements was observed in the SP technique in both sagittal and coronal planes, 17.8?mm vs 28.6?mm, and 19.7?mm vs 30.3?mm respectively.Conclusion
We found that the SP technique achieved significantly improved nail insertion accuracy in the coronal plane. Insertion accuracy was equivocal between the two techniques in the sagittal plane. A narrower range in entry points was observed in the SP cohort in both planes suggesting improved control in nail insertion using this technique. 相似文献5.
Anton A. Semenistyy Elena A. Litvina EA Anna G. Fedotova Chukwuweike Gwam Andrey N. Mironov 《Injury》2019,50(2):515-520
Background
Intramedullary nailing is considered a “gold standard” for treatment of tibial shaft fractures. However, some types of fractures are typically considered as “difficult for nailing”. This group includes the periarticular fractures, fractures of both bones at the same level, comminuted and segmental fractures of the tibia. Fixator-assisted nailing (FAN) is an effective method treatment of these types of fractures. The main requirements for the ideal reduction device are an ease of its installation and an ability of multiplanar fracture reduction. Fixator-assisted nailing (FAN) with the use of two perpendicular to each other monolateral tubular frames perfectly meets these requirements. In this study we present this new surgical technique and the analysis of first 30 cases.Methods
A prospective analysis was conducted for 30 patients with “difficult for nailing” tibial fractures treated with fixator-assisted nailing in our institution between September 1st, 2017, and March 1st, 2018. The duration of surgery and its different stages, the time of fluoroscopy, difficulties encountered during surgery, were analyzed. Clinical and radiological methods were used to evaluated reduction quality.Results
In all 30 cases the acceptable reduction was achieved. The mean duration of the surgical procedure was 73.7?±?3?min. The mean duration of fluoroscopy 85.9?±?4.8?s. In 7 cases we faced with technical difficulties, which were successfully addressed.Conclusion
The described technique of FAN is an effective method for the treatment of “difficult for nailing” tibial fractures. Future multi-centered studies with a larger number of patients are needed to validate our results. 相似文献6.
Objective
Symptomatic distal interlocking screws in retrograde femoral nailing are common due the difficulties of imaging the trapezoidal femur. Screws appearing to have appropriate length on imaging may possibly be prominent, creating symptoms. Screw trajectory may influence the degree of this radiographic error. We hypothesize that external rotation of screw trajectory will increase measurement error of screw length.Design
Retrospective.Setting
Urban Level I Tertiary Trauma Center.Participants
283 patients with Computer Tomography (CT) scans of the native knee were retrospectively identified. Simulation was done of the trajectory of an interlock at 20?mm and 40?mm proximal to the nail entry point, which represent common screw positions associated/not associated respectively, with removal. The distance between the radiographic medial cortex and the tip of the transverse screw was calculated (D). The angle (Ψ) between the transverse trajectory and a modified trajectory aimed at the most medial cortex to avoid radiographic measurement error was calculated. Geometric modeling was utilized to calculate the measurement error (D) in the event of accidental external rotation. The angle of the medial slope was also measured (Θ).Intervention
Review of CT imaging of normal distal femora.Main Outcome Measurements
CT measurements of distal femora.Results
The mean distance (D) at 20/40?mm was 4.21 [95%CI 4.02–4.402] and 2.03?mm [95%CI 1.78–2.83], respectively (p?<?0.0001). The mean angle (Ψ) between the transverse and modified trajectory at 20/40?mm was 12° [95%CI 11.5–12.5] and 9.60° [95%CI 9–10.2], respectively (p?<?0.0001). External rotation by a similar amount nearly triples the measured difference (D). The measured medial slope was significantly increased as screws were placed more proximal (Θ20 mm 46.5 vs Θ40 mm: 48.7?°, p?<?0.00001).Conclusion
The distance between the perceived medial cortex and the tip of the most transverse screw is 4.21?mm and could account for painfully prominent screws. In more proximal screws this distance is decreased. Internal rotation of the screw trajectory 12° can reduce this distance (D), which has implications in nail design. External rotation, amplifies this difference nearly three-fold. Surgeons should avoid external rotation of the aiming arm to prevent prominent screws. 相似文献7.
Christina Marie Joseph Chandrasekaran Gunasekaran Abel Livingston Hepsy Chelliah Thilak Samuel Jepegnanam P.R.J.V.C. Boopalan 《Injury》2019,50(3):784-789
Background
Contrary to acute posterior cruciate ligament (PCL) bony tibial avulsions, surgical management of chronic injuries is technically challenging and appears to be controversial. We sought to assess the outcome of a novel screw post augmentation technique in neglected cases.Methods
16 patients were followed up in a tertiary single-center retrospective study. The bony fragment was fixed using a lag screw with a spiked washer and an additional screw post through an open posterior approach. The pre- and postoperative knee range of movement (ROM), laxity, and modified Tegner–Lysholm (TL) scores were compared.Results
The median time from injury to surgery was 10 weeks (range, 3–260). The mean clinical follow-up time was 24.25?±?9.21 months. At the final follow-up, the mean knee ROM flexion was 130°?±?11.55° with no extension lag. 3 patients had grade 1 laxity. The TL grade was predominantly excellent, and the overall median score improved from 76 preoperatively to 95 postoperatively (p?<?0.0004). Bony union was achieved in all cases.Conclusion
The described screw post fixation technique results in an excellent outcome for these rare injuries.Level of evidence
Level IV, case series. 相似文献8.
9.
Background and purpose
The treatment of paediatric distal radius diaphyseal metaphyseal junction (DRDMJ) fractures is a challenge. The purpose of this study was to introduce a new operative approach at the proximal “safe zone” of the posterior interosseous nerve (PIN) to treat paediatric DRDMJ fractures and analyse the safety and efficacy of antegrade elastic stable intramedullary nail (ESIN) fixation.Methods
Thirty paediatric patients with unstable and displaced DRDMJ fractures were treated by antegrade ESIN fixation from November 2015 to September 2017. We created the entrance site at the posterolateral side of the proximal radius and 2?4?cm distal to the articular surface of the radius, using the ESIN to immobilise the fractures. In the study, we reviewed patient demographics, complications, time until removal, and intraoperative time for hardware removal.Results
Complete fracture healing was achieved between 6 and 12 weeks after surgery. Except for 3 patients presenting with irritation of the skin, we did not observe any complications. Radiologically, no secondary displacement, nail migration, loss of fixation, consolidation delay, non-union, or refracture was noted.Conclusions
The antegrade ESIN fixation is a minimally invasive, easy-to-learn, alternative operative method to treat paediatric DRDMJ fractures.Level of evidence
Therapeutic Level IV. 相似文献10.
Background
Few methods have been described for measuring hindfoot alignment from an anteroposterior view. The objective of this study was to compare two methods of angular measurement based on the views of Meary and Saltzman.Methods
Thirty asymptomatic volunteers were included. Four radiographs were performed: the views of Meary and Saltzman with parallel feet and with the Fick correction. The reproducibility was determined by the inter- and intraobserver variability (ICC).Results
Meary’s method revealed a mean valgus angulation of 3.9° (SD 3.47°). The reliability was extremely variable with a mean ICC of 0.59. The best reproducibility was obtained with Meary’s method with and without Fick correction.Conclusion
The results of this study show that the reliability of the angular measurements depends on the radiographic view and measurement method chosen. The lateral Fick correction did not counteract the influence of tibial rotation. The same method should be used consistently. 相似文献11.
Ichiro Tonogai Fumio Hayashi Yoshihiro Tsuruo Koichi Sairyo 《Foot and Ankle Surgery》2019,25(2):193-197
Background
The aims of this study were to identify the artery feeding the fifth metatarsal and determine how bunionette osteotomy could injure this vessel.Methods
The nutrient artery entering the fifth metatarsal was investigated in 10 adult cadaveric lower limbs by barium injection and enhanced computed tomography.Results
The nutrient artery entered the medial aspect of the fifth metatarsal around the junction of the middle and proximal thirds obliquely from a distal direction (mean?angle 36°) in the coronal plane in all cases; in the axial plane, the point of entry and direction of the artery was medial-plantar (mean?angle 49°).Conclusions
This report revealed direction and location of the nutrient artery entering the fifth metatarsal. 相似文献12.
Objective
To analyse whether early post-operative full weight bearing following syndesmotic ankle fixation affected radiographic outcomes suggestive of diastasis.Design
Retrospective comparative cohort study over a two year period.Setting
Level 1 trauma centrePatients/Participants
152 consecutive patients sustaining an unstable ankle fracture requiring syndesmotic stabilisation were included. Exclusions were 49 patients who had trimalleolar fixation without syndesmosis screws, one patient who had concomitant ankle and talar fracture. Five patients were lost to follow up and eleven patients were followed up in other centres. A total of 86 patients were analysedIntervention
Protected or full weight bearing.Main Outcome Measurement
The primary outcome measure was early diastasis. The secondary outcomes were late diastasis, wound complications and re-operation. Analysis of variance was used for the predictor variable of weight bearing status. We assumed a priori that p values of less than 0.05 were significant.Results
Median age was 36 (IQR 30), with 54 males and 32 females. Median follow up was 12 weeks (IQR 6). There was no significant difference when comparing weight bearing status and change in radiographic measurements intra-operatively compared to 6 and 12 week follow up radiographs (tibiofibular clear space p?=?0.799, tibiofibular overlap p?=?0.733 and medial clear space p?=?0.261).Conclusion
After surgical stabilization of an unstable syndesmotic injury, full weight bearing did not lead to syndesmotic diastasis in the early post-operative period. Full weight bearing is recommended following ankle fixation which includes syndesmotic fixation. 相似文献13.
K. Young A. Aquilina T.J.S. Chesser M.L. Costa S. Hettiaratchy M.B. Kelly C.G. Moran I. Pallister M. Woodford 《Injury》2019,50(2):497-502
Aims
To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network.Materials and methods
Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016.Results
Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3?h of admission, 82% were debrided within 24?h. Soft tissue coverage was achieved within 72?h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates.Conclusions
Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries. 相似文献14.
Michael M. Hadeed Cody L. Evans Brian C. Werner Wendy M. Novicoff David B. Weiss 《Injury》2019,50(2):503-507
Introduction
Tibial pilon fractures are often treated with initial external fixation followed by delayed definitive fixation. It has been postulated that the external fixator pin site may correlate with infection risk. The purpose of this study was to determine whether external fixator pin-site distance from definitive implants impacts the risk of deep infection in pilon fractures.Materials and methods
A retrospective cohort study was completed at a single level 1 trauma center. All patients ages 15–65 who underwent open reduction and internal fixation (ORIF) of a distal tibial fracture (AO/OTA Classification 43) from 2007 to 2013 were included. The final study population was 133 patients. The impact of external fixation pin location (relative to the definitive implant location) on postoperative infection was measured.Results
As a continuous variable, the distance between the closest pin site and plate was 62.1 ± 44.1?mm in the infected cohort and 62.2 ± 49.7?mm in the non-infected cohort (p?=?0.991). Further analysis was performed by grouping the distances into less than 0?mm (i.e. overlapping), >0.0 – 25.0?mm, >25.0 – 50.0?mm, >50.0 – 75.0?mm, >75.0 – 100.0?mm, and >100.0?mm of separation. No significant differences were noted with regards to the risk for infection.Conclusions
Staged care has been shown to be an effective treatment strategy for AO/OTA type 43 fractures. There are many variables to consider when placing an external fixator construct. In this cohort, pin site distance from definitive implant location was not associated with an increase in deep infections.Level of evidence
Level III. 相似文献15.
16.
Ángel Becerra Héctor Trujillo Lucía Valencia Aurelio Rodríguez‐Pérez 《Brazilian Journal of Anesthesiology》2019,69(2):200-203
Background and objectives
A prompt and effective management of trauma patient is necessary. The aim of this case report is to highlight the importance of intraoperative echocardiography as a useful tool in patients suffering from refractory hemodynamic instability no otherwise explained.Case report
A 41 year‐old woman suffered a car accident. At the emergency department, no abnormalities were found in ECG or chest X‐ray. Abdominal ultrasound revealed the presence of abdominal free liquid and the patient was submitted to urgent exploratory laparotomy. Nevertheless, she persisted suffering arterial hypotension and metabolic acidosis. Looking for the reason of her hemodynamic instability, intraoperative transthoracic echocardiography was performed, finding out the presence of pericardial effusion. Once the cardiac surgeon extracted pericardial clots, patient's situation improved clinically and analytically.Conclusion
Every anesthesiologist should be able to use the intraoperative echocardiography as an effective tool in order to establish the appropriate measures to promote the survival of patients suffering severe trauma. 相似文献17.
Nam Hoon Moon Won Chul Shin Jung Shin Kim Seung Hun Woo Seung Min Son Kuen Tak Suh 《Injury》2019,50(3):713-719
Background
The aim of this study was to investigate the postoperative outcomes of cementless Total hip arthroplasty (THA) following failed internal fixation for femoral neck and intertrochanteric fractures.Method
Ninety-six cementless THAs for failed internal fixation after femoral neck fracture (59, group I) and intertrochanteric fracture (37, group II) with a minimum follow-up of 3 years were analyzed. Clinical and radiologic evaluations were performed on all patients.Results
The intraoperative blood loss and operating time were significantly increased in group II (p?=?0.001, p?=?0.001, respectively). Harris hip score at last follow-up was significantly improved in group I (p?=?0.007) but, there were no differences in hospital stay, Koval score at last follow-up, and perioperative complications between both groups. Long femoral stems for diaphyseal fitting were frequently used in group II (32/37, 86%) (p?=?0.001). Radiographically, none of the acetabular cups showed evidence of migration, loosening. All cases showed stable fixation of the femoral stem at last follow-up.Conclusions
Outcomes of cementless THA following failed internal fixation for femoral neck and intertrochanteric fractures were satisfactory; increased intraoperative blood loss, operating time, and requirement of long femoral stem should be considered in the latter type of fracture. 相似文献18.
Background
The main purpose of this study is to introduce our surgical technique and report surgical outcomes for percutaneous cable fixation in the treatment of subtrochanteric femoral fractures.Methods
Between May 2013 and April 2017, 51 patients with subtrochanteric femoral fractures treated with closed intramedullary nailing and percutaneous cable fixation were enrolled in this study. Postoperative angulation, union rate, time from injury to union, and femoral shortening were also evaluated to assess radiologic outcomes. Clinical outcomes, including range of hip flexion, walking ability, and Harris hip score at the last follow-up were evaluated.Results
Average coronal and sagittal angulation after surgery were 0.9 (range 0–5) and 0.3 (range 0–5), respectively. There was no postoperative angulation of more than 5°. Average shortening of the femur at 1-year follow-up was 2.7?mm (range 0–15). Bone union was achieved in 50 patients (98.0%) and average time to union was 18.6 weeks (range 12–48). Hip flexion, walking ability and Harris hip score at the last follow up were 115.6° (90–120), 7.9 (5–9), and 88.3 (65–100), respectively.Conclusion
Percutaneous cerclage cable fixation can provide a greater likelihood of achieving anatomical reduction and increased stability of fracture, while preserving biology around the fracture site. Thus, percutaneous cerclage cable fixation can be an effective surgical technique for the treatment of complex subtrochanteric fractures. 相似文献19.
M.C. Liebensteiner B. Henninger C. Kittl R. Attal J.M. Giesinger C. Kranewitter 《Injury》2019,50(2):602-606
Purpose
To assess the visibility of both the anterolateral ligament (ALL) and the deep structures of the iliotibial tract (ITT) by means of MRI in paediatric patients. To determine reproducibility for such measurements.Methods
Knee MRI data from patients aged <18a without lesions of the capsule or ligaments, fractures, bone edemas, foreign material or motion artifacts were analyzed by two musculoskeletal radiologists separately and twice. The visibility of the different parts of the ALL was determined (femoral, meniscal, tibial parts). Similarly, the visibility of the different parts of the deep ITT was determined: deep attachments of the ITT to the distal femur (insertion near septum, supracondylar insertion and retrograde insertion) and capsulo-osseous layer of the ITT.Results
We studied 61 cases (36 female, 25 male). Age was 15 years (±2.3). Interobserver agreement was high. Cohen’s Kappa was 0.864 (95%CI: 0.715–1.000) for the tibial part of the ALL and 1.0 for the femoral part of the ALL. For the deep attachments of the ITT to the distal femur Kappa was 0.828 (95%CI: 0.685–0.971). Regarding intraobserver agreement, Cohen’s Kappa was 1.0 for the femoral part of the ALL and 0.955 (95%CI: 0.867–1.000) for the tibial part of the ALL. For the deep attachments of the ITT to the distal femur Cohen’s Kappa was 0.896 (95%CI: 0.782–1.000).Conclusion
On the basis of our findings it is concluded that the presence of the anterolateral structures of the knee can be determined by MRI in a pediatric population with substantial inter- and intraobserver agreement. This is true for both the ALL and the deep structures of the ITT.Level of evidence
Diagnostic study – Level 3. 相似文献20.