A combined prone and supine approaches for complex three column tibial plateau fracture with posterolateral articular injury

IntroductionUpdated three column fixation of tibial plateau fractures (TPFs) arouse the importance of posterior column articular reduction. Complex TPFs with posterolateral (PL) articular injury is difficult to manage. We presented a strategy of combined positions and approaches to treat these injuries. Surgical technique was described and outcome of these were reported.Materials and MethodsFrom 2014 Jan to 2016 Dec, there were 132 patients of TPFs treated in our institute. Preoperative evaluation included plain films and 2D/3D CT scan to evaluate the involvement of articular surface and associated columns. Inclusion criteria were three column TPFs with PL corner injury. We put patients in prone position first with reverse L incision to manage PL articular impaction and posteromedial (PM) fractures. Then we repositioned the patients in supine to treat anterolateral fixation. Postoperative radiographic analysis, physical examination findings, and patient reported outcome scores from the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire were recorded.ResultsPatient demographic information was retrospectively reviewed with a mean follow-up time of 34.4 months (range 24–48 months). The average time to union was 5.2 months (range 4-8months). 13/16 (81%) of patients had satisfactory articular reduction by plain films (less than 2 mm articular step off). All patients demonstrated healed without secondary displacement or infection. All patients demonstrated satisfactory coronal (medial proximal tibia angle 84.68 degrees) and sagittal alignment (posterior proximal tibia angle 84.75 degrees). Condylar width averaged 3.93 mm. 3/16 (19%) of cases required posterolateral columnar plating in addition to posteromedial columnar plating. The knee range of motion averaged 115 degrees (ranged from 0 degrees of extension to140 degrees flexion). The average KOOS score was 83/100 (range 76–90). 3 patients in the series developed a surgical site superficial infection and resolved after debridement and oral antibiotics use. No patient eventually received total knee arthroplasty at the last follow up.ConclusionsOur strategy provides an effective method to treat three column tibial plateau fractures with PL articular injury.     

直接前入路和后外侧保留梨状肌入路全髋关节置换术的疗效对比

目的：前瞻性比较直接前入路（direct anterior approach,DAA）和后外侧保留梨状肌入路(posterolateral piriformis sparing approach,Mis-PLA)全髋关节置换的临床疗效。方法： 选自福建省立医院骨科2015 年 3 月至 2016 年2月收入院需行全髋关节置换术的患者,随机分为DAA和Mis-PLA两组。DAA 组（43例45髋）：男 27例 27髋,女16例 18 髋,平均年龄 （57.4±7.3）岁,术前 Harris 评分（41.4±8.7）分,体重指数（body mass index,BMI）为（24.3±2.2） kg/m2;Mis-PLA 组（39例42髋）：男 25 例 26 髋,女 14例 16 髋,平均年龄（59.2 ±7.3）岁,术前 Harris 评分 （39.6±8.4）分, BMI （24.7±2.5） kg/m2。分别对两组的切口长度、手术时间、术中出血量、术后Harris评分、关节功能恢复进行对比评估。结果：（1）两组患者手术切口均Ⅰ/甲级愈合。手术切口长度： DAA组（9.2±0.7） cm,Mis-PLA 组（9.5±0.6） cm,两者间差异无统计学意义（P=0.053）;手术时间：DAA 组(74.3±10.1) min,Mis-PLA组（37.5±4.3） min,两者间差异有统计学意义（P＜0.01）;出血量：DAA组（229.6±79.2） mL,Mis-PLA组（215.7±56.0） mL,两者之间差异无统计学意义（P=0.366）。（2）随访时间6～12个月,术后6 周 Harris 评分:DAA组(85.5±4.1)分,Mis PLA组(79.0±4.4)分,两组间差异有统计学意义(P＜0.01)。术后6个月Harris评分,DAA 组(94.3±2.7)分,Mis-PLA 组（95.2±1.9）分,两组间差异无统计学意义(P=0.125)。术后6周髋关节功能评估,DAA组和Mis-PLA组在直线步行速度上差异没有统计学意义（P=0.298）,Mis-PLA组上、下楼梯速度优于DAA组(P=0.047);在转弯速度、坐下、穿袜时,DAA组优于Mis-PLA组（P＜0.01,P=0.016,P＜0.01）。结论： 直接前入路和后外侧保留梨状肌入路的微创全髋关节置换术都能获得满意的临床疗效,后外侧入路的优势在于手术时间短、学习曲线短,直接前入路的主要优势在于术后早期没有体位限制的要求及髋关节功能恢复的更快。     

Efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 in posterolateral lumbar fusion: an open,active-controlled,randomized, multicenter trial

Background Context

The efficacy and safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) as a bone graft substitute in spinal fusion has been widely researched. However, no study of the efficacy and safety of Escherichia coli-derived rhBMP-2 (E.BMP-2) with a hydroxyapatite (HA) carrier has been proposed.

Epidermal growth factor enhances spinal fusion: Posterolateral lumbar fusion model on rats

ObjectiveThe aim of this study was to investigate the effects of human recombinant epidermal growth factor (EGF) on posterolateral lumbar fusion in a rat model.Methods36 male Sprague Dawley rats underwent posterolateral fusion at L4-5 level. They were randomly assigned to 3 groups: 1- Sham control group where no local augmentation was made, 2- Local Hydoxyapatite β-tricalcium phosphate (HA/β-TCP) augmentation group and 3- Local HA/β-TCP + EGF augmentation group. Rats were euthanized at 8 weeks post-surgery. 6 rats from each group were selected for manual palpation examination, micro-computed tomography analysis and histologic analysis; and the rest was used for biomechanical analysis.ResultsBased on manual palpation, there was no fusion in the sham control group. Fusion rate was 33.3% in the HA/β-TCP group and 66.7% in the HA/β-TCP + EGF group (p = 0.085). Micro-CT results revealed that new bone formation was higher in the HA/β-TCP + EGF group (BV/TV: 40% vs. 65%) (p = 0.004). Histologically newly formed bone tissue was more pronounced in the EGF group and compacted and bridging bone spicules were observed. The median maximum bending moment values were 0.51 Nmm (0.42–0.59), 0.73 Nmm (0.49–0.88) and 0.91 Nmm (0.66–1.03) in the sham control, HA/β-TCP and HA/β-TCP + EGF groups, respectively (p = 0.013). The median stiffness values were 1.69 N/mm (1.12–2.18), 1.68 N/mm (1.13–2.74) and 3.10 N/mm (1.66–4.40) as in the previous order (p = 0.087).ConclusionThis study demonstrates that EGF enhances posterolateral lumbar fusion in the rat model. EGF in combination with ceramic grafts increased the fusion rates. Our findings may provide insights to further studies, investigating EGF's clinical usage as an alternative fusion enhancer.     

A method to evaluate the in vivo behaviour of lumbar spine implants

The aim of the study was to design a method for evaluating the stabilizing effect of different lumbar spine implants in vivo, and to apply this method to a comparison of plates versus rods in lumbar spine posterolateral fusion using transpedicular screw fixation. Fourteen patients, seven operated on with transpedicular plates and screws (VSP), and seven operated on with rods and screws (Diapason), matched according to number of levels fused, had tantalum markers inserted in the vertebrae at surgery, enabling roentgen stereophotogrammetric analysis (RSA). Mean patient age was 45 (range 33–56) years. In each group, two patients underwent fusion between L4 and L5, three between L5 and S1, and two from L4 to S1. In three patients, concomitant nerve root decompression was performed using a facet joint preserving technique. RSA was performed 4 weeks after surgery. This interval was chosen to allow enough time for soft tissue healing, but not fusion healing, to occur. RSA was performed in supine and standing position without any mobility provocation, in line with the postoperative regimen given. Movements between the outermost vertebrae of the fusion were calculated along the transverse, vertical and sagittal axes. The method of measurement along these three axes has previously been determined to be accurate to 0.3, 0.6 and 0.7 mm, respectively. One patient stabilized with rods and screws between L5 and S1 displayed a sagittal translation of 1.01 mm but no mobility along the transverse or vertical axes. In the remaining 13 patients, positional change from supine to standing did not provoke any intervertebral mobility above the RSA accuracy along any of the axes. With the limited provocation described, in line with the postoperative regimen for lumbar fusion patients, plates with transpedicular screws and rods with transpedicular screws both seem to give adequate intervertebral stability in posterolateral lumbar fusions. Received: 15 July 1998 Revised: 4 December 1999 Accepted: 4 February 2000     

2D and 3D 3-tesla magnetic resonance imaging of the double bundle structure in anterior cruciate ligament anatomy

For anterior cruciate ligament (ACL) surgery using the anatomic approach of the double bundle concept it is helpful to describe the anteromedial (AM) and posterolateral (PL) bundle using Magnetic Resonance Imaging (MRI), since this is the most important preoperative parameter next to the physical examination. The aim of this study was to distinguish both bundles in MRI. In a prospective study we evaluated the double bundle structure in ACL anatomy with a 3-T ultra-high-field strength MR imaging of cadaver knees, which allows faster imaging times, increased resolution and increased signal-to-noise ratio. Using oblique sagittal and oblique coronal planes, we were able to distinguish the double bundle structure in each knee. The following arthroscopic evaluation of the knees confirmed our MRI findings. Our study demonstrates the possibility of distinguishing the two bundles in the native ACL with 3T MRI. Following examinations must study the value for clinical application by describing different rupture patterns of the bundles and correlating this to arthroscopy. It would be advantageous to know the rupture pattern in advance. Presurgical planning could be improved by reconstructing only the torn and preserving the intact bundle.     

Anatomical reconstruction of popliteofibular ligament using looped biceps femoris tendon: a case report

We describe a case of popliteofibular ligament (PFL) injury, successfully treated with a new anatomic reconstruction technique looping the biceps femoris tendon (BT). The anterior half of the BT was split longitudinally from the fibular insertion, cut at the proximal end and left attached at the insertion. The proximal end of the BT was looped back in a slit made in the popliteal tendon (PT) at the original anatomical insertion site of the PFL, and passed through the tunnel from the posterior and the baseball suture was tightened on the anterior cortex of fibular head.