Intertrochanteric valgus osteotomy for post-traumatic coxa vara after proximal femur fractures: A retrospective study

To investigate the clinical effects of a new intertrochanteric valgus osteotomy technique designed by the authors for treatment of post-traumatic coxa varus after proximal femur fractures. Retrospectively analyzed 11 patients who developed coxa vara after sustaining proximal femoral fractures were treated with intertrochanteric valgus osteotomy from December 2005 to December 2018 in our hospital. This study included 6 cases of intertrochanteric fracture deformity union, 3 cases of subtrochanteric fracture nonunion and 2 cases of femoral neck fracture nonunion. Measured the degree of coxa varus, the differences in the lower limb length and force line in all patients. Evaluated hip function with the Harris hip score. All injuries were treated with the authors’ intertrochanteric valgus osteotomy technique. The average follow-up period was 3 years and evaluated the clinical effects by radiological examination and the Harris hip score. The average neck–shaft angle increased 35.0° (99.1°–134.1°) and the average limb shortening lengthened 1.9 cm (2.9–1.0 cm) after surgery. The average operating time was 67.2 minutes and blood loss was 237.7 ml. The osteotomy position healed in all patients 3 months later. Union of the 2 old femoral neck fractures was achieved 4 and 6 months after surgery, respectively, and no femoral head necrosis occurred during follow-up. The Harris hip score increased an average of 49 points (44.1–93.1 points) at 1 year postoperatively. Our self-designed intertrochanteric valgus osteotomy technique showed a favorable clinical effect to treatment coxa vara and can be used in the clinical setting.     

Biomechanical analysis of the closed reduction internal fixation with cannulated screw of femoral neck fractures

The influencing factors in closed reduction internal fixation with cannulated screw of femoral neck fractures have not been well investigated. This study evaluated these factors in patients with femoral neck fractures.Fifty-seven patients (36 males and 21 females) diagnosed with femoral neck fracture with the average age of 52.44 ± 15.04 years who underwent closed reduction internal fixation with cannulated screw were included in this study. Data were collected through case report reviews, phone call follow-ups, and outpatient follow-ups to evaluate pre- and postoperative radiograph images. Statistical analysis was performed using Garden classification, binary and multinomial logistic regression analysis by including factors such as patient''s age, gender, fracture type, time to fixation, reduction quality, functional recovery period, removal of cannulated screw, and preoperative traction. Logistic regression analysis revealed that age and reduction quality was statistically significant (P < .05) to clinical outcome and other factors were not statistically significant.The main factors affecting clinical outcomes were functional recovery and reduction quality. The biomechanical effects of fixation provide a good foundation for fracture healing. Patient''s conditions should be carefully evaluated before selecting reduction procedures to reach an optimal surgical outcome.     

Titanium elastic nailing can be used in 6 to 10 years old pediatric with Delbet IV femoral neck fractures

The purpose of this study was to analyze the outcomes of titanium elastic nail (TEN) for the children in 6 to 10 years old who sustained a Delbet IV femoral neck fracture.A total of 56 children aged 6 to 10 years old with Delbet IV femoral neck fracture treated with TEN or cannulated screw (SC) were identified at our hospital from January 2009 to December 2019. Of which 24 were treated with TEN, and 32 with SC. All of them were followed up for 1 year after operation, and the differences in operation time, intraoperative blood loss, hospitalization time, hip joint function, and complication between the 2 groups were compared. Harris and Ratliff hip score were used to evaluate the hip function.All 56 fractures united properly. No major complications were noted in both groups. The intraoperative blood loss and operation time in TEN group and SC group were (11.42 ± 3.41) mL, (19.66 ± 4.05) mL (P = .000) and (33.58 ± 7.89) min, (40.22 ± 7.48) min (P = .002), respectively. There was no significant statistical difference between hip regarding range of motion and femoral neck-shaft angle in both groups, as well as Harris and Ratliff hip score between the 2 groups.TEN represent safe and effective methods in the treatment of Delbet IV femoral neck fracture in 6 to 10 years old children. TEN internal fixation is a minimal invasive and simpler technique and suitable for young children of Delbet IV femoral neck fracture.     

Treatment of Severely Displaced Radial Neck Fractures in Children With Percutaneous K-wire Leverage and Closed Intramedullary Pinning

To evaluate the efficacy and safety of percutaneous K-wire leverage (PKWL) reduction and closed intramedullary pinning (CIMP) for the treatment of pediatric radial neck fractures.From June 2010 to December 2013, a total of 50 children with Judet III and IV radial neck fractures were treated at our hospital. Manual closed reduction was first attempted to reduce the radial neck fractures. Upon successful closed reduction or the radial neck–shaft angle was reduced to <45°, radial intramedullary pinning or CIMP was performed for fixation. Unsuccessful manual reduction was corrected using percutaneous K-wire leverage and CIMP. The injured arm was fixed at the functional position using plaster for 4 to 6 weeks.Sixteen patients were treated with manual closed reduction and CIMP (group A). Percutaneous K-wire leverage and CIMP were performed for 30 patients (group B). Another 4 patients were treated with open reduction and CIMP (group C). Groups B and C showed no significant difference in the radial neck–shaft angle, fracture displacement, and angle/displace ratio (P > 0.05), but were significantly larger than group A in the radial neck–shaft angle and fracture displacement (P < 0.05). Group A and B had significantly shorter operation time than group C (58.4 ± 14.5 minutes, 55.2 ± 11.2 minutes, versus 81.4 ± 7.5 minutes, P < 0.05). Forty-five patients were followed up for a mean of 2 years. Bone union was achieved in all patients within a mean time of 4.1 months. The patients treated with manual reduction or percutaneous leverage reduction showed excellent results. Three patients, however, treated with open reduction showed 10 to 20° limitation in range of motion of the elbow. No other complications were seen.Percutaneous K-wire leverage and CIMP are safe and effective for the treatment of pediatric Judet III and IV radial neck fractures.     

A larger sized cup accelerates cartilage erosion of acetabulum after bipolar hemiarthroplasty in elderly with femur neck fracture

Bipolar hemiarthroplasty (BHA) is one of the common procedures done for the treatment of femur neck fracture. One of the frequently encountered complication with this surgery is erosion of the acetabular cartilage. This study was conducted to investigate acetabular erosion after BHA according to the difference in diameter between femoral head and implanted cup at minimum 10-year follow-up.We retrospectively reviewed 117 patients (117 hips) undergoing BHA with fracture of neck of the femur. Their mean age was 77.8 years (range, 65–96 years) and male: female ratio was 32:85. Patients were divided into 3 groups; Group A – bipolar cup size > actual head size, Group B – cup size < head size, Group C – cup size = head size. The degree of both superior and medial acetabular cartilage erosion was identified and calculated on postoperative radiographs using line of acetabular margin and Kohler line.The mean superior and medial acetabular erosion were 1.62 ± 1.6 mm (range, 0–4.4) and 4.15 ± 2.7 mm (range, 0–8.2) in Group A, 1.30 ± 1.3 mm (range, 0–3.8) and 4.11 ± 2.7 mm (range, 0–7.8) in Group B, and 0.90 ± 1.1 mm (range, 0–2.6) and 3.16 ± 2.9 mm (range, 0–7.9) in Group C (P = .039 and P = .187, respectively). The superior acetabular erosion showed significant difference between the 3 groups. During mean follow-up period of 12.3 years, 5 patients (5/117, 4.3%) underwent conversion to total hip arthroplasty due to superior acetabular erosion. All of 3 patient underwent BHA with a larger bipolar cup than the actual femoral head.A lager sized cup accelerated superior cartilage erosion of acetabulum after BHA. An optimal cup size should be considered when undergoing BHA in elderly patients.     

Treatment of tibial plateau fractures involving the posterolateral column using the extended anterolateral approach

To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31 months, with an average follow-up of 22.5 ± 3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38 ± 3.92°, a mean PA of 7.43 ± 2.68°, and a mean Rasmussen radiological score of 16.00 ± 2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91 ± 3.51°, a mean PA of 9.68 ± 4.01°, and a mean Rasmussen radiological score of 15.33 ± 2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (P > .05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37 ± 10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17 ± 10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.     

Analysis of Geometric Shifts and Proper Setup-Margin in Prostate Cancer Patients Treated With Pelvic Intensity-Modulated Radiotherapy Using Endorectal Ballooning and Daily Enema for Prostate Immobilization

We evaluate geometric shifts of daily setup for evaluating the appropriateness of treatment and determining proper margins for the planning target volume (PTV) in prostate cancer patients.We analyzed 1200 sets of pretreatment megavoltage-CT scans that were acquired from 40 patients with intermediate to high-risk prostate cancer. They received whole pelvic intensity-modulated radiotherapy (IMRT). They underwent daily endorectal ballooning and enema to limit intrapelvic organ movement. The mean and standard deviation (SD) of daily translational shifts in right-to-left (X), anterior-to-posterior (Y), and superior-to-inferior (Z) were evaluated for systemic and random error.The mean ± SD of systemic error (Σ) in X, Y, Z, and roll was 2.21 ± 3.42 mm, −0.67 ± 2.27 mm, 1.05 ± 2.87 mm, and −0.43 ± 0.89°, respectively. The mean ± SD of random error (δ) was 1.95 ± 1.60 mm in X, 1.02 ± 0.50 mm in Y, 1.01 ± 0.48 mm in Z, and 0.37 ± 0.15° in roll. The calculated proper PTV margins that cover >95% of the target on average were 8.20 (X), 5.25 (Y), and 6.45 (Z) mm. Mean systemic geometrical shifts of IMRT were not statistically different in all transitional and three-dimensional shifts from early to late weeks. There was no grade 3 or higher gastrointestinal or genitourianry toxicity.The whole pelvic IMRT technique is a feasible and effective modality that limits intrapelvic organ motion and reduces setup uncertainties. Proper margins for the PTV can be determined by using geometric shifts data.     

Dual-construct fixation is recommended in ipsilateral femoral neck fractures with infra-isthmus shaft fracture: A STROBE compliant study

The aim of this study was to evaluate the risk factors related to osteosynthesis failure in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age; smoking habit; comminuted fragments; infra-isthmus fracture; angular malreduction; unsatisfactory reduction (fracture gap >5 mm); and treatment with single construct.Patients over the age of 20 with concomitant ipsilateral femoral neck and shaft fractures diagnosed at a level one medical center between 2003 and 2019 were included. Treatment modalities included single construct with/without an antirotational screw for the neck and dual constructs. Radiographic outcomes were assessed from anteroposterior and lateral hip radiographs at follow-up. Fisher exact test was used to analyze categorical variables. The presence of avascular necrosis of the femoral head, delayed union, atrophic or hypertrophic nonunion of the femoral shaft fracture, and loss of reduction were identified as factors related to treatment failure.A total of 22 patients were included in this study. The average age was 58.5 years, and the majority was male (68.2%). The minimum radiographic follow-up duration was 12 months, and the median follow-up time was 12 (interquartile range 12–24) months.Femoral neck osteosynthesis failed in 3 patients, whereas femoral shaft osteosynthesis failed in 12 patients. Fisher exact test demonstrated the failure of femoral shaft osteosynthesis was significantly more frequent in the single-construct cohort in 16 infra-isthmus femoral fracture cases (P = .034).In ipsilateral femoral neck and infra-isthmus shaft fractures, it is better to treat the neck and shaft fractures with separate implants (dual constructs).In a dual-construct cohort, separate plate fixation of the femoral shaft achieved a better result in terms of bone union than retrograde nailing of the shaft (bone union rate: 4/8 vs 0/2).     

The Radiological Feature of Anterior Occiput-to-Axis Screw Fixation as it Guides the Screw Trajectory on 3D Printed Models: A Feasibility Study on 3D Images and 3D Printed Models

Anterior occiput-to-axis screw fixation is more suitable than a posterior approach for some patients with a history of posterior surgery. The complex osseous anatomy between the occiput and the axis causes a high risk of injury to neurological and vascular structures, and it is important to have an accurate screw trajectory to guide anterior occiput-to-axis screw fixation.Thirty computed tomography (CT) scans of upper cervical spines were obtained for three-dimensional (3D) reconstruction. Cylinders (1.75 mm radius) were drawn to simulate the trajectory of an anterior occiput-to-axis screw. The imitation screw was adjusted to 4 different angles and measured, as were the values of the maximized anteroposterior width and the left-right width of the occiput (C0) to the C1 and C1 to C2 joints. Then, the 3D models were printed, and an angle guide device was used to introduce the screws into the 3D models referring to the angles calculated from the 3D images.We found the screw angle ranged from α1 (left: 4.99 ± 4.59°; right: 4.28 ± 5.45°) to α2 (left: 20.22 ± 3.61°; right: 19.63 ± 4.94°); on the lateral view, the screw angle ranged from β1 (left: 13.13 ± 4.93°; right: 11.82 ± 5.64°) to β2 (left: 34.86 ± 6.00°; right: 35.01 ± 5.77°). No statistically significant difference was found between the data of the left and right sides. On the 3D printed models, all of the anterior occiput-to-axis screws were successfully introduced, and none of them penetrated outside of the cortex; the mean α4 was 12.00 ± 4.11 (left) and 12.25 ± 4.05 (right), and the mean β4 was 23.44 ± 4.21 (left) and 22.75 ± 4.41 (right). No significant difference was found between α4 and β4 on the 3D printed models and α3 and β3 calculated from the 3D digital images of the left and right sides.Aided with the angle guide device, we could achieve an optimal screw trajectory for anterior occiput-to-axis screw fixation on 3D printed C0 to C2 models.     

Intraoperative periarticular injection can alleviate the inflammatory response and enhance joint function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures

Purpose:This study aimed to investigate the potential beneficial effects of periarticular injection (PAI) of multimodal drugs on the inflammatory response and joint function after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.Methods:Fifty six elderly patients with unilateral osteoporotic femoral neck fractures were randomly allocated to 2 groups: the PAI group, which received the multimodal drug PAI intraoperatively before incision closure, and the control group, which received an injection of saline at the same time as placebo. The C-reactive protein (CRP), interleukin-1β (IL-1β), and IL-6 levels as well as the erythrocyte sedimentation rate (ESR) in peripheral venous blood samples were measured, along with the Visual Analogue Scale (VAS) score with activity and Harris hip score preoperation at 1, 2, 4, 7, and 14 days as well as 1 and 3 months post-operation.Results:The 2 groups were comparable in sex and age, and no significant differences were observed in the preoperative CRP, IL-1β, and IL-6 levels, ESR, VAS score, or Harris hip score between the 2 groups (all P > .05). However, during the postoperative period, the PAI group exhibited significantly lower levels of CRP, IL-1β, and IL-6 as well as a lower ERS and VAS score compared with the control group (P < .05), while the Harris hip score was significantly higher postoperatively in the PAI group (P < .05).Conclusion:Multimodal drug PAI can alleviate the inflammatory response and enhance hip function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.     

Comparison of the fixation ability of headless compression screws and locking plate for metacarpal shaft transverse fracture

Metacarpal shaft fractures are common hand fractures. Although bone plates possess strong fixation ability, they have several limitations. The use of headless compression screws for fracture repair has been reported, but their fixation ability has not been understood clearly.This study aimed to compare the fixation ability of locked plate with that of headless compression screw for metacarpal fracture repair.A total of 14 artificial metacarpal bones (Sawbones, Vashon, WA, USA) were subjected to transverse metacarpal shaft fractures and divided into 2 groups. The first group of bones was fixed using locked plates (LP group), whereas the second group was fixed using headless compression screws (HC group). A material testing machine was used to perform cantilever bending tests, whereby maximum fracture force and stiffness were measured. The fixation methods were compared by conducting a Mann–Whitney U test.The maximum fracture force of the HC group (285.6 ± 57.3 N, median + interquartile range) was significantly higher than that of the LP group (227.8 ± 37.5 N; P < .05). The median of the HC group was 25.4% greater. However, no significant difference in stiffness (P > .05) was observed between the HC (65.2 ± 24.6 N/mm) and LP (61.7 ± 19.7 N/mm) groups.Headless compression screws exhibited greater fixability than did locked plates, particularly in its resistance to maximum fracture force.     

Changes in tapered endotracheal tube cuff pressure after changing position to hyperextension of neck: A randomized clinical trial

Background:Endotracheal tube (ETT) with a tapered-shaped cuff had an improved sealing effect when compared to ETTs with a conventional cylindrical-shaped cuff. Positional change and neck movement typically displace an ETT and change the intracuff pressure. The aim of the current study was to compare the ETT cuff pressure in the TaperGuard ETT vs the conventional ETT after a change from the supine, neutral position to the extension of the neck and semi-Fowler position for thyroid surgery.Methods:This prospective, randomized clinical trial included 50 patients undergoing thyroidectomy. Patients were randomly allocated into one of the 2 groups: tracheal intubation with the TaperGuard ETT or with a conventional ETT. The ETT cuff was inflated with air and the ETT cuff pressure was set initially at 20 cmH₂O using a calibrated cuff manometer. ETT cuff pressure and distance from carina to ETT tip were measured at supine and semi-Fowler positions with neck extension.Results:After the position change, the ETT tip migrated cephalad and cuff pressure increased in the majority of cases. ETT cuff pressure was significantly higher in the TaperGuard group than the conventional group (28.0 ± 6.6 cmH₂O and 22.8 ± 4.5 cmH₂O, respectively, P = .001). The degree of cephalad displacement of the ETT tip was comparable between the 2 groups (19.4 ± 6.31 mm in TaperGuard group and 21.9 ± 6.9 mm in conventional group, P = .12).Conclusions:After the position change from supine to hyperextension of the neck, the ETT cuff pressure was higher in the TaperGuard ETT than in the conventional ETT, although the extent of displacement of the ETT was comparable between the 2 groups.     

Biomechanical Evaluation of Interfragmentary Compression At Tibia Plateau Fractures In Vitro Using Different Fixation Techniques: A CONSORT-compliant article

Reliable osteosynthesis of intraarticular fractures depends on lasting interfragmentary compression. Its amount differs in the applied fixation method. The interfragmentary compression of cancellous and cortical lag screws and angle stable locking plates was quantified in an osteoporotic and non-osteoporotic synthetic human bone model.A split fracture of the lateral tibia plateau (AO/OTA type 41-B1.1) was mimicked by an osteotomy in right adult synthetic human tibiae with hard or soft cancellous bone. Specimens were fixed with either two 6.5 mm cancellous, four 3.5 mm cortical lag screws, or 3.5 mm LCP proximal lateral tibia plate preliminary compresed by a reduction clamp (n = 5 per group). A pressure sensor film was used to register the interfragmentary compression. One-way analysis of variance (ANOVA) with Bonferroni post hoc correction was performed for statistical analysis (p < 0.05).Interfragmentary compression under reduction clamp was 0.59 ± 0.12 MPa in the non-osteoporotic and 0.55 ± 0.14 MPa in the osteoporotic group. The locking plate itself maintained the compression in non-osteoporotic (0.53 ± 0.11 MPa) and osteoporotic bone (0.50 ± 0.14 MPa). Four 3.5 mm cortical lag screws provided a compression of 1.69 ± 0.65 MPa in non-osteoporotic bone, being not significantly different to the osteoporotic bone group (1.43 ± 0.47 MPa, P = 1.0). Two 6.5 mm cancellous lag screws showed a significantly higher compression in non-osteoporotic (2.1 ± 0.59 MPa) compared to osteoporotic (0.77 ± 0.21 MPa, P < 0.01) bone.Angle stable locking plates maintained the compression preliminarily applied by a reduction clamp. Two 6.5 mm cancellous lag screws are especially suited for non-osteoporotic bone, whereas four 3.5 mm cortical screws exhibited comparable compression in both bone qualities.     

Postoperative hypoalbuminemia is an independent predictor of 1-year mortality after surgery for geriatric intertrochanteric femoral fracture: A retrospective cohort study

Preoperative hypoalbuminemia from malnutrition is associated with increased morbidity and mortality after geriatric hip fracture surgery. However, little is known regarding the correlation between postoperative hypoalbuminemia and mortality. This study aimed to evaluate whether postoperative hypoalbuminemia could predict 1-year mortality after intertrochanteric femoral fracture surgery in elderly patients.The medical records of 263 geriatric patients (age ≥65 years) who underwent intertrochanteric femoral fracture surgery between January 2013 and January 2016 in a single hospital were reviewed retrospectively. The patients were allocated to 2 groups based on lowest serum albumin levels within 2 postoperative days (≥3.0 g/dL [group 1, n = 46] and <3.0 g/dL [group 2, n = 217]. Data between the non-survival and survival groups were compared. Multivariable logistic regression analysis was conducted to identify the independent predictor for 1-year mortality.The 1-year mortality rate was 16.3% after intertrochanteric femoral fracture surgery. Multivariable logistic regression analysis revealed that postoperative hypoalbuminemia was significantly associated with 1-year mortality (adjusted odds ratio, 8.03; 95% confidence interval, 1.37-47.09; P = .021). The non-survival group showed a significantly increased incidence of postoperative hypoalbuminemia (95.4% vs 80.0%, P = .015) and intensive care unit admission (11.6% vs 2.7%, P = .020), older age (82.5 ± 5.8 years vs 80.0 ± 7.2 years, P = .032), lower body mass index (20.1 ± 3.2 kg/m² vs 22.4 ± 3.8 kg/m², P < .001), and increased amount of transfusion of perioperative red blood cells (1.79 ± 1.47 units vs 1.43 ± 2.08 units, P = .032), compared to the survival group.This study demonstrated that postoperative hypoalbuminemia is a potent predictor of 1-year mortality in geriatric patients undergoing intertrochanteric femoral fracture surgery. Therefore, exogenous albumin administration can be considered to improve postoperative outcomes and reduce the risk of mortality after surgery for geriatric hip fracture.     

Minimally invasive approach with external fixator for intra-articular calcaneal fractures in children

Calcaneal fractures are rare in pediatric population, with more displaced intra-articular fractures encountered due to the increasing number of high-energy trauma. Operative interventions are gaining popularity because of the unsatisfactory outcomes of traditional conservative methods. This study investigated the clinical outcomes of a minimally invasive technique using the sinus tarsi approach and external fixator in the treatment of intra-articular calcaneal fractures in pediatric patients.Patients who underwent open reduction between January 2010 and January 2018 at our institute were included in this study and reviewed retrospectively. Radiological and clinical parameters were all recorded and analyzed.Overall, 29 patients were included in the study, including 23 boys and 6 girls (10.2 ± 2.2 years old). The average follow-up was 29.5 months postoperatively (range, 26–72 months). Bohler angle was 15.2 ± 3.3° preoperatively, and 34.0 ± 3.8° postoperatively (P < .001); Gissane angle was 101.8 ± 6.2 degrees preoperatively, and 129.7 ± 6.2° postoperatively (P < .001). The average length of incision was 3.4 ± 0.7 cm. At the last follow-up, all patients showed satisfactory clinical outcomes and the score was 90.0 ± 2.3 according to American Orthopedic Foot and Ankle Society Scale.Minimally invasive approach with external fixator is an effective method for treating displaced intra-articular calcaneal fractures in pediatric patients, with a lower incidence of wound-related complications and good cosmetic outcomes.     

Modified Ilioinguinal Approach to Treat Pelvic or Acetabular Fractures: A Retrospective Study

The aim of this study was to evaluate the potential advantages and clinical results of a modified minimally invasive ilioinguinal approach for the treatment of acetabular or pelvic fractures to the results obtained using a standard ilioinguinal approach.Forty-six patients who were diagnosed as having anterior column acetabular fractures or anterior pelvic ring fractures underwent open reduction and internal fixation through 2 different surgical approaches between June 2008 to June 2012 in our trauma center was studied. The modified ilioinguinal group included 20 patients and the other 26 patients were in the standard ilioinguinal approach group. The clinical and radiographic results were recorded and compared between the 2 groups.There were no significant differences between 2 groups in the mean age, sex, fractures type, and causes of acetabular or pelvic fractures. The mean blood loss in the modified group was 560.0 ± 57.3 mL versus 850.0 ± 59.0 mL in the standard ilioinguinal group. The operative time was significantly reduced with modified ilioinguinal approach (86.0 ± 4.56 min vs. 101.9 ± 5.38 min). The mean hospital stay was 16.8 ± 0.58 days and 18.7 ± 0.52 days in the modified and standard ilioinguinal groups, respectively. According to the Matta score, the quality of reduction between the 2 groups was not significantly different. The complication rate was low in the modified group but not significantly different between the 2 groups. Forty-two patients were followed up with clinical examination and radiographs at a mean of 15.2 months. Solid union was observed in 42 cases at a mean time of 14.8 weeks. The mean Harris Hip Score and the Majeed scores at the time of evaluation were not significantly different between the 2 groups.On comparing the 2 surgical ilioinguinal approaches, it was found that using modified ilioinguinal approach decreased operative time and blood loss, and did not affect the quality of fracture reduction and fracture healing. This study demonstrates that the modified ilioinguinal approach is a simple and minimally invasive approach for anterior column acetabular fractures and pubic rami fractures comparing with the standard ilioinguinal approach.     

Experimental Study on the Fracture Parameters of Concrete

This study aimed to determine the influence of the volume fraction of steel fibers on the fracture parameters of concrete. Fifty notched steel-fiber-reinforced concrete (SFRC) beams and ordinary concrete beams with 100 mm × 100 mm × 515 mm were cast and tested via a three-point bending test. Among them, the type of steel fiber was the milling type (MF), and the volume fraction of steel fiber added was 0%, 0.5%, 1%, 1.5% and 2%, respectively. The effects of the steel fiber volume fraction (V_F) on the critical stress intensity factor (K_IC), fracture energy (G_F), the deflection at failure(δ₀), the critical crack mouth opening displacement (CMOD_C) and the critical crack tip opening displacement (CTOD_C) were studied. Through the analysis of test phenomena and test data such as the load-deflection (P-δ) curve, load-crack mouth opening displacement (P-CMOD) curve and load-crack tip opening displacement (P-CTOD) curve, the following conclusions are drawn: with the increase of the steel fiber volume fraction, some fracture parameters increase gradually and maintain a certain linear growth. The gain ratio of the fracture parameters increases significantly, and the gain effect is obvious. Through this law of growth, the experimental statistical formulas of fracture energy and the critical stress intensity factor are summarized.     

The Lumbar Spine as a Dynamic Structure Depicted in Upright MRI

Spinal canal stenosis is a dynamic phenomenon that becomes apparent during spinal loading. Current diagnostic procedures have considerable short comings in diagnosing the disease to full extend, as they are performed in supine situation. Upright MRI imaging might overcome this diagnostic gap.This study investigated the lumbar neuroforamenal diameter, spinal canal diameter, vertebral body translation, and vertebral body angles in 3 different body positions using upright MRI imaging.Fifteen subjects were enrolled in this study. A dynamic MRI in 3 different body positions (at 0° supine, 80° upright, and 80° upright + hyperlordosis posture) was taken using a 0.25 T open-configuration scanner equipped with a rotatable examination bed allowing a true standing MRI.The mean diameter of the neuroforamen at L5/S1 in 0° position was 8.4 mm on the right and 8.8 mm on the left, in 80° position 7.3 mm on the right and 7.2 mm on the left, and in 80° position with hyperlordosis 6.6 mm (P < 0.05) on the right and 6.1 mm on the left (P < 0.001).The mean area of the neuroforamen at L5/S1 in 0° position was 103.5 mm² on the right and 105.0 mm² on the left, in 80° position 92.5 mm² on the right and 94.8 mm² on the left, and in 80° position with hyperlordosis 81.9 mm² on the right and 90.2 mm² on the left.The mean volume of the spinal canal at the L5/S1 level in 0° position was 9770 mm³, in 80° position 10600 mm³, and in 80° position with hyperlordosis 9414 mm³.The mean intervertebral translation at level L5/S1 was 8.3 mm in 0° position, 9.9 mm in 80° position, and 10.1 mm in the 80° position with hyperlordosis.The lordosis angle at level L5/S1 was 49.4° in 0° position, 55.8° in 80° position, and 64.7 mm in the 80° position with hyperlordosis.Spinal canal stenosis is subject to a dynamic process, that can be displayed in upright MRI imaging. The range of anomalies is clinically relevant and dynamic positioning of the patient during MRI can provide essential diagnostic information which are not attainable with other methods.     

Dynamic Cerebral Autoregulation in Asymptomatic Patients With Unilateral Middle Cerebral Artery Stenosis

The aim of the study was to assess the capacity of dynamic cerebral autoregulation (dCA) in asymptomatic patients with unilateral middle cerebral artery (MCA) stenosis.Fifty-seven patients with asymptomatic mild, moderate, and severe unilateral MCA stenosis and 8 patients with symptomatic severe unilateral MCA stenosis diagnosed by transcranial Doppler were enrolled. Twenty-four healthy volunteers served as controls. The noninvasive continuous cerebral blood flow velocity and arterial blood pressure were recorded simultaneously from each subject in the supine position. Transfer function analysis was applied to determine the autoregulatory parameters (phase difference [PD] and gain).The PD values in the severe stenosis groups were significantly lower than those of the control group (60.71 ± 18.63°), the asymptomatic severe stenosis group was impaired ipsilaterally (28.94 ± 27.43°, P < 0.001), and the symptomatic severe stenosis group was impaired bilaterally (13.74 ± 19.21°, P < 0.001; 19.68 ± 14.50°, P = 0.006, respectively). The PD values in the mild and moderate stenosis groups were not significantly different than the controls (44.49 ± 27.93°; 48.65 ± 25.49°, respectively). The gain values in the mild and moderate groups were higher than in the controls (1.00 ± 0.58 cm/s/mm Hg vs 0.86 ± 0.34 cm/s/mm Hg, and 1.20 ± 0.59 cm/s/mm Hg vs 0.86 ± 0.34 cm/s/mm Hg, respectively). The gain values in the severe stenosis groups were significantly lower than that in the control group: the asymptomatic severe stenosis group was lower bilaterally (0.56 ± 0.32 cm/s/mm Hg, P = 0.003; 0.60 ± 0.32 cm/s/mm Hg, P < 0.05, respectively), whereas the symptomatic severe group was lower unilaterally (on the contralateral side) (0.53 ± 0.43 cm/s/mm Hg, P < 0.05).In asymptomatic patients with unilateral MCA stenosis, only the dCA of the severe stenosis was ipsilaterally impaired. Acute stroke may aggravate the impaired dCA and even spread contralaterally.     

Complication rates following all-epiphyseal ACL reconstructions in skeletally immature patients: A retrospective case series study

The aim was to evaluate the safety of a physeal-sparing anterior cruciate ligament reconstruction technique (ACLR), performed with Orthopediatrics (Warsaw, IN) equipment, by assessing complications.Skeletally immature patients who underwent all-epiphyseal ACLR between 2015 and 2017 with postoperative follow-up were included in this retrospective study. Complications, demographic, clinical, surgical, and imaging data was retrieved from an urban tertiary pediatric hospital database. Physeal status, limb-length discrepancies (LLD), and angular deformities were assessed on preoperative and postoperative radiographs, growth disturbances were reported, and initial and follow-up diameters of tunnels were compared.Nineteen ACLRs were included from 18 patients, 4 females and 14 males, with bone age at surgery of 13.3 ± 1.0 years. At a mean follow-up of 19.2 ± 10.1 months, there were no symptomatic growth disorders requiring intervention. There were: 2 (11.1%) unilateral early physeal closures, 2 (10.5%) new angular deformities (5°–10°), 4 (22.2%) LLD (1–2 cm), 1 (5.6%) contralateral ACLR, 1 (5.6%) femoral screw removal, 2 (10.5%) graft ruptures, and 1 meniscal tear (5.3%). Mean tunnel widening was 1.7 mm and 1.5 mm on the femoral and tibial side, respectively, and no massive osteolysis was recorded at the polyetheretherketone implant site.The complication rates were comparable to those in similar studies, with no growth-related complications at 19.2 months.