肱骨骨折锁定钢板内固定术后失败原因分析

目的探讨肱骨干骨折使用锁定钢板术后失败原因。方法回顾4例肱骨骨折锁定钢板固定后钢板断裂、螺钉拔出及不愈合的原因,其中钢板断裂2例,螺钉拔出1例,不愈合1例,均给予相应二次手术治疗。结果二次手术后均骨性愈合。结论术后患者过早大强度活动、固定材料选择不当等原因是导致锁定钢板固定术后失败的主要原因。     

胫骨内固定术后非感染性骨不连的原因分析及治疗

目的观察胫骨内固定术后非感染性骨不连手术与非手术治疗的效果。方法自2006年5月至2012年12月．对29例胫骨内固定术后非感染性骨不连患者采用骨端清理＋髓内钉、钢板、外固定支架固定联合自体植骨手术治疗或金葡液骨折断端注射方法的非手术治疗。结果29例均获随访,随访时间10～24个月,X线片均见骨折愈合。依据采用Johner—Wmh评定标准：优15例,良12例,一般2例。半年内愈合者8例,1年内愈合者18例,大于1年愈合者3例;所有患者均于骨折愈合后取除固定物,恢复正常工作。结论胫骨内固定术后非感染性骨不连可根据其类型选择非手术或手术治疗方式达到满意的治疗效果。     

自制一次性止血带在静脉输液中的新应用

目的:探讨自制一次性止血带用于输液固定及替代人工按压止血的效果.方法:将600例静脉输液的患者随机分为对照组和实验组,2组在静脉穿刺时均使用自制一次性止血带,穿刺后按常规方法固定,对照组撤去止血带,实验组再用松开的止血带固定针头硅胶管和输液管末端,观察一次静脉输液的成功率;拔针时对照组按常规方法压迫止血,实验组利用止血带固定棉签压迫止血,观察按压部位的出血率、淤血率,并与对照组进行比较.结果:实验组一次静脉输液的成功率明显高于对照组,P＜0.05;局部出血率、淤血率明显低于对照组,P＜0.05.结论:自制一次性止血带用于输液固定能提高输液的成功率,用于压迫止血能替代人工按压,值得临床推广使用.     

Biomechanical comparison of pedicle screws versus spinous process screws in C2 vertebra: A cadaveric study

Background:

Biomechanical studies have shown C2 pedicle screw to be the most robust in insertional torque and pullout strength. However, C2 pedicle screw placement is still technically challenging. Smaller C2 pedicles or medial localization of the vertebral artery may preclude safe C2 pedicle screw placement in some patients. The purpose of this study was to compare the pullout strength of spinous process screws with pedicle screws in the C2.

Materials and Methods:

Eight fresh human cadaveric cervical spine specimens (C2) were harvested and subsequently frozen to −20°C. After being thawed to room temperature, each specimen was debrided of remaining soft tissue and labeled. A customs jig as used to clamp each specimen for screw insertion firmly. Screws were inserted into the vertebral body pairs on each side using one of two methods. The pedicle screws were inserted in usual manner as in previous biomechanical studies. The starting point for spinous process screw insertion was located at the junction of the lamina and the spinous process and the direction of the screw was about 0° caudally in the sagittal plane and about 0° medially in the axial plane. Each vertebrae was held in a customs jig, which was attached to material testing machine (Material Testing System Inc., Changchun, China). A coupling device that fit around the head of the screw was used to pull out each screw at a loading rate of 2 mm/min. The uniaxial load to failure was recorded in Newton''st dependent test (for paired samples) was used to test for significance.

Results:

The mean load to failure was 387 N for the special protection scheme and 465 N for the protection scheme without significant difference (t = −0.862, P = 0.403). In all but three instances (38%), the spinous process pullout values exceeded the values for the pedicle screws. The working distances for the spinous process screws was little shorter than pedicle screws in each C2 specimen.

Conclusion:

Spinous process screws provide comparable pullout strength to pedicle screws of the C2. Spinous process screws may provide an alternative to pedicle screws fixation, especially with unusual anatomy or stripped screws.     

A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma

Introduction

Non-union rate in forearm fractures is generally less than 2% when a proper technique is used; this rate increases when ulnar lesions are involved.

Patients and methods

We present a case series of seven young patients whose average age was 14 years (range 11–19 years) at the time of surgery and who presented with a forearm post-traumatic non-union that was previously treated in different ways (three isolated ulnar non-union, two isolated radial non-union and two combined). Average follow-up was 34 months (range 9–72 months).Surgical treatment began with the removal of the previous synthesis and with curettage of the non-union area. The Acumed ulnar rod, Acumed radial rod and Thalon elastic nail (all of them are unreamed and locked nails) together with autologous platelet-rich plasma (PRP) obtained with the Biomet System (concentration of 158.2 × 10⁴ platelets/μL) were chosen to treat the patients.X-rays and clinical controls were conducted every 30 days until recovery.

Results

All patients recovered: average recovery was 23 weeks from operation (range 16–36 weeks) and nails were removed 3 months after complete healing. Six patients had excellent results and one patient had a good result (Patient 2, forearm pronosupination 60–0–40 degrees).

Discussion

The purpose of the case series was to establish a better way of treatment and to find a technique that could avoid the use of bone grafts, because obtaining autologous bone requires a further surgical procedure that can be really invasive depending on the amount of bone needed.

Conclusion

All patients in the study showed complete recovery, with excellent clinical outcomes. Although there were only seven patients in this case series, and there is a need to analyse more patients, this study showed that the use of a specific locking nail system can provide proper stability to ulnar or radial atrophic non-union despite rotational forces, and when combined with autologous growth factors (PRP) is sufficient to promote bone healing in young patients without the necessity to take autologous bone grafts.     

Femoral malrotation after intramedullary nailing in obese versus non-obese patients

Objective

Intramedullary nailing (IMN) of obese patients with femoral fractures can be difficult due to soft tissue considerations and overall body habitus. Complications including malrotation can occur and have significant impact on postoperative function. The purpose of this study was to evaluate femoral rotation after intramedullary nailing of obese and non-obese patients to see if there was a difference in rotation, complications and any risk factors for malrotation.

Materials and methods

Between 2000 and 2009, 417 consecutive patients with femur fractures treated with IM nail at Level I trauma and tertiary referral center. Of these, 335 with postoperative computed tomography (CT) scanogram of the bilateral lower extremities were included in this study. Baseline demographic, perioperative and postoperative femoral version calculations were included in the dataset. Statistical analysis included chi-squared test for categorical data, t-test for continuous data, and univariate and multivariate regression analysis. Significance was set at p < 0.05.

Results

Of the 417 patients with femur fractures between 2000 and 2009, 335 met criteria for this study. There were 111 patients with a BMI <25, 129 with BMI 25–29.9, and 95 patients with a BMI >30. When BMI was categorised into 3 groups (<25, 25–29.9, or 30+), none of these groups were predictive of version in univariate or multivariate regressions. Among only obese patients (BMI 30+), BMI of 35+ was not a significant predictor of version when compared to BMI 30–34.9. There were no significant differences in femoral version based on entry point (antegrade vs. retrograde) in any BMI category. There were also no significant difference between groups of patients with a DFV of >15? (p = 0.212).

Conclusions

Based on this study, BMI did not have an effect on postoperative difference in femoral version. In fact, in our multivariate regression analysis, BMI of over 30 was actually predictive of significantly lower difference in femoral version. While other studies have documented the intraoperative difficulties encountered with obese patients with femur fractures, the outcome of femoral rotation is not affected by an increasing BMI.     

Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation – An anatomical study

Introduction

The antegrade intramedullary Locking Blade Nail (Marquardt, Germany) is a device aimed at improving purchase in the humeral head and reducing varus displacement by providing medial buttress support and triangular stability within the humeral head. The aim of this study is to measure the relationship of the proximal fixation screws to the axillary nerve.

Methods

13 whole cadavers underwent insertion of an antegrade proximal humeral blade nail via a deltoid split approach to both shoulders. The anatomic proximity of the anterior branch of the axillary nerve to the screws was measured following soft tissue dissection and inspection of the nerve.

Results

The mean distance of the nerve from the anterolateral acromion was 62 mm (range 45–81 mm). The nerve lay closest to the distal blade fixation screw 4.9 mm (range 0–19 mm). In three cases the nerve lay directly underneath the washer and in all three cases there was macroscopic evidence of damage to the nerve. In 5 cases the nerve travelled obliquely in a cranial direction to lie 1.8 mm (range 0–3 mm) from the distal blade fixation screw, in 2 of these cases the nerve lay beneath the washer.

Conclusion

The anterior branch of the axillary nerve is placed at risk during insertion of the locking screws despite use of protection sleeves and trocars. We advocate that when using antegrade intramedullary nails that incorporate an inferomedial calcar screw an extended anterolateral acromial approach is undertaken.     

Factors associated with outcome of spinopelvic dissociation treated with lumbopelvic fixation

Spinopelvic dissociation is a rare high-energy injury, which is frequently associated with lumbosacral plexus and cauda equina deficits. During an 18-year period, 36 consecutive patients with a H-type sacral fracture and spinopelvic dissociation were treated using lumbopelvic fixation with a minimum follow-up of 18 months. We evaluated factors prognostic of outcome after standardised surgical fixation and neural decompression. Neurological recovery was assessed by Gibbons’ criteria. Pelvis Outcome Scale (POS clinical score) was used to evaluate the clinical outcome. Despite excellent or good radiological results in the vertical components of the sacral fractures having been achieved in all patients, 15 patients (42%) had a poor clinical outcome. The degree of initial translational displacement in the transverse sacral fracture was significantly associated with neurological recovery (as defined by a change in Gibbons score) (p = 0.038) and final POS clinical score (p < 0.001). Both neurological recovery and clinical outcome were worse in patients with completely displaced fractures than in patients with a partially displaced sacral fracture. The degree of residual translational displacement and kyphosis in the transverse sacral fracture were also associated with clinical outcome (POS clinical score) (p = 0.011 and p = 0,018, respectively). However, Roy-Camille classification (type 2 vs. type 3), age, gender, ISS, timing of surgery, and sacral laminectomy did not have a statistically significant association with the outcome. Based on the results, Roy-Camille sacral fracture classification (type 2 vs. type 3) was not prognostic of neurological impairment. Thus further categorisation of the transverse sacral fractures as partially displaced or completely displaced could be used to predict the rate of neurological recovery following lumbopelvic fixation. Accurate reduction of all sacral fracture components seems to be associated with better clinical outcome.     

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

Introduction

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

Methods

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

Results

The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigné score, functional outcome was good to excellent in all patients.

Discussion and conclusion

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.     

内固定手术治疗多发性肋骨骨折的疗效与安全性的随机对照试验

目的 探讨肋骨内固定手术对多发性肋骨骨折患者的疗效与安全性。 方法 新疆医科大学第六附属医院胸外科2010年1月至2013年1月收治的多发性肋骨骨折患者,选取胸部创伤评分（AIS-ISS评分） 9～20 （16±2）分的患者141例,采用SPSS软件产生的随机序号将患者分为内固定组［69例,男41例、女28例,年龄25～61 （37±4）岁］ 和对照组［72例,男43例、女29例,年龄24～63 （35±5）岁］,分别行肋骨内固定手术和保守治疗。观察患者血浆C反应蛋白（CRP）水平变化、胸廓外观满意度、肺部炎症发生率、止痛有效率,以及闭式引流时间和住院时间。结果 内固定组CRP水平在伤后1～3 d与对照组差异无统计学意义（P＞0.05）,在伤后4～12 d内明显低于对照组（P＜0.05）。内固定组胸廓外观满意度（97.1% vs. 48.6%,P＜0.05）、肺部炎症发生率（11.6% vs. 37.5%,P＜0.01）和止痛有效率（91.3% vs. 68.1%, P＜0.05）均优于对照组,胸腔闭式引流时间［（3±2） d vs. （7±4） d,P＜0.05］和住院时间［（9±4） d vs. （15±7） d,P＜0.05］均短于对照组。 结论 对多发性肋骨骨折患者,在生命体征平稳的前提下,采用肋骨内固定手术有利于缩短住院时间和缓解胸痛程度,胸廓外观明显改善,从减轻肺部炎症反应和增加手术安全性的角度提高了多发性肋骨骨折的治疗效果。