A Biomechanical Evaluation to Optimize the Configuration of a Hinged External Fixator for the Primary Treatment of Severely Displaced Intraarticular Calcaneus Fractures with Soft Tissue Damage

The purpose of this investigation was to develop an optimized hinged external fixator for the primary treatment of dislocated, intra-articular calcaneus fractures with associated soft tissue damage. To this end, a calcaneus model was made out of a polyurethane block, and a steel cylinder served as the ankle joint and was connected to a synthetic model of the tibia via a metal clamp. A saw cut served as the fracture in the model. A Steinmann nail and Schanz screw were placed in defined positions in the model and connected medially and laterally with longitudinal support rods. The fixator allowed a total of 20 degrees of plantar- and dorsiflexion, with rotation in the virtual axis of the upper ankle joint. Changes in the model fracture were measured during cyclical strain, and at different screw positions in the model tibia and calcaneus. Miniature force sensors located on the longitudinal support rods, and a plantar tension spring, were used to measure pressure and tension. Reproducible values were determined and, with the optimal configuration, shifting within the osteotomy was minimal. In the experimental configuration, optimal tibial screw placement was 70 mm proximal to the rotation axis of the upper ankle joint, and optimal placement of the Steinmann nail was in the posterior surface of the calcaneus. These findings indicated that the hinged fixator allows 20 degrees of ankle movement without alteration of the rotation axis, and suggest that this type of external fixator can be used in all types of calcaneal fracture regardless of the soft tissue damage. ACFAS Level of Clinical Evidence: 5c.     

经皮撬拨复位螺钉内固定治疗跟骨关节内骨折

目的 探讨经皮撬拨复位微创螺钉内固定治疗跟骨骨折的疗效和技术要点.方法 2006年3月至2010年4月作者采用经皮撬拨复位微创空心拉力螺钉结合松质骨螺钉,部分患者联合注射高黏度液体人工替代骨或颗粒骨填充治疗21 例24侧跟骨骨折,男17 例,女4 例;年龄21～67 岁,平均年龄38.3 岁.其中18 例为单侧,3 例...     

The Treatment of Intra-articular Calcaneus Fractures with Severe Soft Tissue Damage with a Hinged External Fixator or Internal Stabilization: Long-term Results

We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhler's angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhler's angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.     

动力型外固定架结合有限内固定治疗Pilon骨折

目的探讨Orthofix动力型外固定支架结合有限内固定在治疗高能量Pilon骨折中的价值。方法2002年4月至2004年3月对11例高能量Pilon骨折采用Orthofix公司第四代跨关节外固定结合克氏针或螺钉有限内固定治疗,远端外固定螺钉固定于跟骨和距骨颈,外固定活动轴和踝关节运动的轴心位置保持一致。术后3周开始踝关节功能锻炼,2~5个月后去除外固定。结果11例均得到随访,随访6~18个月(平均13个月),骨折全部达骨性愈合,无切口感染、内植物外露等并发症。踝关节症状与功能评分按Mazur标准进行,临床评分68~97分(平均82分),其中优6例,良4例,可1例。结论Orthofix跨关节动力型外固定支架结合有限内固定治疗高能量Pilon骨折能促进骨折愈合,有利于踝关节早期活动,最大程度恢复踝关节功能,是治疗高能量Pilon骨折的一种理想方法。     

Experimental Study on the Prevention of Posttraumatic Osteoarthritis in the Rabbit Knee Using a Hinged External Fixator in Combination with Exercises

Abstract

Objective: To report the design and effect of our proprietary hinged external fixator, used in combination with treadmill exercise for rabbits with intra-articular inflammation and cartilage degeneration. Methods: Thirty-two white rabbits were randomly allocated into four groups: No treatment (NT), Distraction only (D), Exercise only (Ex), and Distraction plus exercise (D?+?Ex). Each rabbit underwent an anterior cruciate ligament transection on the right knee, with the contralateral knee used as a sham control (C). Results: In the D?+?Ex group, the levels of Interleukin (IL)-1β and Tumor necrosis factor (TNF)-α in synovium and TNF-α in joint effusion were significantly lower, while the expression of IL-10 in joint effusion and blood was significantly higher. The ratio of IL-10/TNF-alpha in blood was also the highest in the D?+?Ex group. The condition of collagen loss was examined: the D?+?Ex group had the lowest level of type II collagen in effusion and C-telopeptides of type II collagen (CTX-II) in blood. On the other hand, the D?+?Ex group had the highest expression of cartilage regeneration genes, including type II collagen, Aggrecan (AGN), and SRY-box 9 (SOX9). Finally, the histology showed an attenuation of cartilage degeneration with a lower OA score in the D?+?Ex group. Conclusion: Our hinged external fixator combined with treadmill exercise up-regulated cartilage regeneration genes, reduced synovial and intra-articular inflammation, and reduced type II collagen and proteoglycan loss, indicating the use of the fixator in combination with treadmill exercise could prevent progression of posttraumatic osteoarthritis of knee joint in rabbits.     

切复内固定治疗跟骨关节内骨折疗效观察及分析

目的：观察和分析跟骨关节内骨折早期进行切复内固定的治疗效果。方法：对36例42侧跟骨关节内骨折，经跟骨外侧入路在C形臂X线机监控下行切复内固定术。结果：34例40侧平均随访24个月，按Maryland足部评分系统评估术后功能，优20例，良14侧，可6侧，优良率85％。结论：跟骨关节内骨折经早期手术切复内固定可以取得满意的疗效。     

老年桡骨远端关节内骨折两种治疗方法的比较

目的分析手法复位石膏固定和克氏针结合外固定架治疗老年桡骨远端关节内骨折的疗效。方法选取2007年12月至2009年12月我院收治60岁以上的老年桡骨远端关节内骨折患者135例,手法复位石膏外固定80例,克氏针内固定结合外固定架固定55例,对上述两种治疗方法的疗效进行比较。结果所有患者均获得随访,随访时间6～18个月,平均10.5个月。采用Gartland and Werley腕关节功能评分评价疗效,手法复位石膏外固定组优良率72.5%,克氏针结合外固定架固定组优良率89.1%,克氏针结合外固定架固定组疗效优于石膏外固定组,差异具有统计学意义（P〈0.05）。PRWE评分两组差异不具有统计学意义（P〉0.05）。两组在患者满意度上差异也不具有统计学意义（P〉0.05）。结论老年桡骨远端关节内骨折,克氏针结合外固定架固定组疗效优于石膏外固定组。因为老年患者对上肢功能的要求减低,治疗的目标在于恢复患肢的功能达到可以接受的程度即可,如果患者对腕关节功能要求不高,保守治疗是一种适当的治疗措施。     

后环内固定加前环外固定治疗不稳定性骨盆骨折

目的探讨骨盆后环内固定术加前环外固定支架固定术治疗不稳定性骨盆骨折的疗效。方法 2005年1月至2008年7月共治疗不稳定性骨盆骨折17例,男14例,女3例,年龄16~57岁,平均34岁。腹股沟处骨折端外露1例,合并盆腔脏器损伤5例,股动脉损伤后血栓1例,腰骶神经损伤5例,下肢骨折4例,胸部外伤1例。均行快速复苏,12例同时行骨盆骨折外固定支架外固定术,复苏后行后环切开复位内固定术、继续前环外固定支架固定治疗;5例复苏后行后环切开复位内固定术、同时行前环外固定支架固定治疗。结果随访6~48个月,平均20.6个月,按照Co le等骨盆骨折效果评分表进行功能评价,17例中功能恢复优12例,良3例,可2例,差0例,优良率88.2%。无死亡病例,无切口感染,有2个钉道感染,无医源性损伤,腰骶神经损伤完全恢复3例,部分恢复2例。结论采取后环内固定术加前环外固定支架固定术治疗骨盆不稳定性骨折,可以获得稳定固定,疗效可靠,且手术操作简单、安全,创伤小、并发症少。     

The Results of Physical,Radiologic, Pedabarographic,and Quality-of-Life Assessments in Patients with Surgically Treated Intraarticular Calcaneus Fractures

Calcaneal fractures are complex injuries and have historically had a poor prognosis that results in substantial disability. However, no studies have been performed that analyze both the radiographic and plantar pressure changes after treatment of intraarticular calcaneus fracture. Patients with an intrarticular calcaneus fracture treated at our institution during the study period were identified from computerized hospital records. A total of 36 patients (34 males) completed physical examination and radiographic and dynamic pedobarographic assessments. The follow-up period was from 13 to 82 months (median 38 months). The mean pain score at rest was 3.7 and during activity was 4.0 on a 10-cm visual analogue scale. The mean range of motion of the subtalar joint was restricted. The mean American Orthopaedic Foot and Ankle Society function scale score was 68.1; the mean Short Form-36 physical score was 41.8; and the mental score was 44.9. Pedabarographic results showed that the mean maximum force in the midfoot, forefoot, and toes (p = .001; p = .04; p = .002) and peak pressure in the midfoot, forefoot (p = .001; p = .007), and contact area of the midfoot and toes (p = .038; p = .004) were significantly increased in the injured foot. Radiologic findings showed hindfoot varus, forefoot adductus, and an increase in the medial arch. Even after appropriate anatomic realignment with open reduction and internal fixation of calcaneus fractures, residual differences in plantar pressures and radiographic measures are noted compared to uninjured foot.     

股骨粗隆间骨折术后步行状态的生物力学特性

目的：研究单臂外固定架治疗股骨粗隆间骨折术后步行状态的生物力学特性。 方法：将 CT 数据文件经Simpleware 软件进行三维重建处理,得到股骨及外固定架的三维几何模型。在 Anybody 软件中建立正常人体股骨模型,并与股骨外固定架模型（stl 几何模型）一同导入 Geomagic Studio 软件中,将两组模型进行比对配准。将配准好的股骨外固定架模型导入 Anybody 软件中,通过 Simpleware 得到的网格模型（inp 格式）导入到 Abaqus 软件中,分析 1 个步态周期的应力分布情况。结果：以左侧为例,术后在行走过程中较大应力发生在不锈钢钉与股骨的连接处以及不锈钢钉与固定架的连接处,整体未见明显应力集中现象,在典型步态右足趾离地和左全足底着地中产生较大应力,在左足跟着地、右足跟着地产生一定应力集中现象,左足趾离地时应力最小。结论：单臂外固定架治疗股骨粗隆间骨折,安全、有效,符合人体步行状态的生物力学要求。     

内外固定治疗不稳定性骨盆骨折18例报告

18例不稳定性骨盆骨折采用切开复位内固定或骨盆外固定器治疗,其中旋转不稳型10例,垂直不稳型8例.平均随访17个月,疗效满意.认为旋转不稳型骨盆骨折宜首选外固定器治疗,垂直不稳型骨盆骨折应争取解剖复位,为此必须采用切开复位内固定治疗.     

动力髁螺钉治疗股骨近端及远端骨折的临床报告

目的介绍和评价动力髁螺钉治疗股骨近端及远端骨折的手术方法。方法1998年1月至2002年8月应用动力髁螺钉治疗股骨近端转子间骨折4例，转子下骨折15例，转子间、转子下混合骨折2例，股骨远端髁上骨折7例，髁间骨折5例，其中采用Maier改良技术治疗股骨远端骨折5例。结果术后随访4～32个月，平均15．1个月。骨折于3～5个月内临床愈合，关节功能恢复良好，未发现内固定物失效及其他并发症。结论动力髁螺钉设计科学合理，内固定坚强可靠，如适应证选择得当，是治疗股骨近端及远端骨折的理想内固定物。     

Tibial Fractures Treated with Hoffmann's External Fixation: A Comparative Analysis of Hoffmann Bilateral Frames and the Vidal-Adrey Double Frame Modification

The results after treatment of 50 open and comminuted tibial fractures with Hoffmann's external fixation were analysed. Half of the fractures were treated with bilateral Hoffmann frames, the other half with the Vidal-Adrey double frame modification. The groups were found to be comparable.

The results of the study confirm that Hoffmann's external fixation is a safe method for treating the bone and soft tissue lesions in such fractures. There was only one case of osteomyelitis, no definite pseudarthrosis and no leg amputation.

The considerably increased stability of the Vidal-Adrey double frame modification did not reduce the length of the healing period compared to fractures treated with bilateral Hoffmann frames. The duration of external fixation was on average 24 weeks, and the radiological healing time 27 weeks.

A slightly greater number of residual deformities were found in the group treated with bilateral Hoffmann frames. Most of the deformities were so minor, however, that they were of little practical consequence for the patients. Thus it seems that the original Hoffmann apparatus, if duplicated, is a stable enough fixation in most cases.     

锁定加压钢板与克氏针结合外固定支架治疗老年绝经期骨质疏松性桡骨远端复杂关节内骨折疗效分析

目的探讨锁定加压钢板与克氏针结合外固定支架治疗老年绝经期骨质疏松性桡骨远端复杂关节内骨折的疗效。方法 80例骨质疏松性桡骨远端复杂关节内骨折患者按手术方式分为两组,各40例:Ⅰ组骨折AO/ASIF分型:C1型11例,C2型15例,C3型14例,采用锁定加压钢板固定治疗,Ⅱ组骨折AO/ASIP分型:C1型12例,C2型13例,C3型15例,采用克氏针结合支架外固定治疗。术后比较两组患者骨折愈合情况、腕关节功能恢复情况和并发症发生率。结果两组患者均获随访,随访时间8~10个月,平均(8.3±1.4)个月。术后Ⅰ组愈合率为97.5(39/40),Ⅱ组愈合率为95.0%(38/40),两组愈合率比较差异无统计学意义(χ2=0.866,P=0.352)。两组患者骨折愈合时间、术后桡骨短缩距离比较差异亦无统计学意义(P0.05)。两组C1型、C2型骨折患者术后腕关节功能恢复情况比较差异无统计学意义(P0.05),而Ⅰ组C3型骨折患者术后Gartland-Werly评分显著高于Ⅱ组,差异具有统计学意义(P0.05)。Ⅰ组术后出现并发症3例(7.5%):碎骨片畸形愈合1例,手术切除后愈合;切口感染2例,予抗生素后得到控制;Ⅱ组术后并发症4例(10%):骨折延迟愈合2例,针道感染2例,予常规抗生素治疗后痊愈。结论对于C1型、C2型桡骨远端复杂关节内骨折患者,可以选择锁定加压钢板或克氏针联合外固定支架固定治疗;而对于严重的C3型骨折患者,克氏针联合外固定支架治疗效果更佳。     

Usability and Reliability of the Edinburgh Visual Gait Score in Children with Spastic Cerebral Palsy Using Smartphone Slow-Motion Video Technology and a Motion Analysis Application: A Pilot Study

BackgroundThe Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalities in children with cerebral palsy (CP) and has good psychometric properties. However, it is cumbersome to administer and requires multiple devices to record and measure its various components. We conducted this study to determine if a smartphone video protocol could be used to improve the usability and reliability of the EVGS for daily use in a clinic setting.MethodsWe used a handheld smartphone camera with slow-motion video technology and a motion analysis application to record and measure the EVGS of 30 ambulatory children with spastic CP. We tested the inter- and intra-rater reliability of various components of the EVGS between two observers.ResultsAverage age was 7 years 3 months (range 4–14 years). The mean (range) EVGS scores for the trunk, pelvis, hip, knee, ankle, and foot were 1.18 (0–3), 0.68 (0–3), 1.1 (0–4), 3.95 (1.5–7.5), 1.87 (0–4) and 4.13 (2–6.5) respectively. Total score was 12.92 (7–21.5). The mean (SD) scores for Gross Motor Function Classification System (GMFCS) levels II and III were 10.73 (3.86) and 14.96 (4.2) (p < 0.001). The intra-observer and inter-observer reliability using percentage of complete agreement was 65–98.3% and 61.7–92.5% respectively, with kappa values ranging from 0.15 to 0.87. Reliability was more for distal limb segments as compared to proximal segments.ConclusionWe have described a simple and reliable method for quantitative OGA of children with CP, using smartphone video technology and motion analysis application, which can be performed by every clinician in an office setting.Level of EvidenceLevel III.