Objective To introduce a new fluoroscopic method for assessing the quality of medial and lateral joint surface reduction during internal fixation of patellar fractures and to summarize the clinical outcomes of patients treated using this method. Methods A retrospective analysis was conducted on the clinical data of 52 patients with patellar fractures treated between January 2018 and January 2022 who met the inclusion criteria. There were 27 male and 25 female patients, aged 21-75 years, with an average age of 62 years. The types of patellar fractures included 9 transverse fractures, 37 comminuted fractures, and 6 longitudinal fractures. According to the AO/Orthopaedic Trauma Association (AO-OTA)-2018 fracture classification, there were 21 cases of type 34A, 6 cases of type 34B, and 25 cases of type 34C. The time from injury to operation ranged from 1 to 5 days, with an average of 2.3 days. Treatments included internal fixation with hollow screws or hollow screw tension bands, with or without anchor repair. During operation, the medial and lateral joint surfaces of the patella were observed using the tangential fluoroscopic method to assess the smoothness of reduction of the median ridge, lateral joint surface, medial joint surface, and lateral joint edge. Patients were followed up regularly, and X-ray films were taken to observe fracture healing. Knee joint range of motion, Böstman score, and Lysholm score were used to evaluate functional recovery. Results The tangential fluoroscopic method for the medial and lateral joint surfaces of the patella during operation showed satisfactory reduction of the joint surfaces and good positioning of the implants. All patients were followed up 12-16 months, with an average of 13.4 months. During the follow-up, fracture displacement occurred in 1 case and titanium cable breakage in 1 case. All patella fractures healed successfully, with a healing time of 8-16 weeks (mean, 11.4 weeks). At last follow-up, knee joint range of motion ranged from 120° to 140°, with an average of 136°. The Böstman score ranged from 20 to 30, with an average of 28, yielding excellent results in 45 cases and good results in 7 cases. The Lysholm score ranged from 88 to 100, with an average of 93, yielding excellent results in 40 cases and good results in 12 cases. Conclusion The intraoperative application of the tangential fluoroscopic method for the medial and lateral joint surfaces of the patella can quickly determine the fluoroscopic plane of the patella, accurately assess the quality of fracture reduction and the position of internal fixator, thereby improving effectiveness.
ObjectiveTo explore effectiveness of reduction and internal fixation via modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column.MethodsBetween January 2016 and September 2018, 19 patients diagnosed as tibial plateau fractures involving posterolateral column were treated with reduction and internal fixation via modified anterolateral supra-fibular-head approach. There were 11 males and 8 females with an average age of 43.2 years (range, 28-65 years). The causes of tibial fracture were traffic accident (12 patients), falling injury (5 patients), and falling from height (2 patients). According to the Schatzker typing, the tibial fractures were rated as type Ⅱ in 9 cases, type Ⅲ in 4 cases, type Ⅴ in 4 cases, and type Ⅵ in 2 cases. The time from injury to operation was 5-13 days (mean, 8.5 days). There were 2 patients with osteoporosis. The operation time, intraoperative blood loss, and postoperative complications were recorded. The knee X-ray film was reviewed regularly to observe the fracture healing. At last follow-up, the fracture reductions were evaluated by Rasmussen radiological score. The knee joint function was evaluated by Hospital for Special Surgery (HSS) score system.ResultsThe average operation time was 95 minutes (range, 65-130 minutes). The average intraoperative blood loss was 220 mL (range, 150-350 mL). All incisions healed by first intention. No complications such as infection or deep venous thrombosis occurred. All patients were followed up 12-20 months (mean, 15.4 months). X-ray films showed that the fractures healed with the healing time of 12-20 weeks (mean, 14.5 weeks). No complications such as loosening or breakage of internal fixation occurred. At last follow-up, according to the Rasmussen radiological score, the fracture reductions were evaluated as excellent in 13 cases, good in 4 cases, fair in 1 case, and poor in 1 case. HSS scores of knee joint function were excellent in 14 cases, good in 3 cases, fair in 1 case, and poor in 1 case. The knee joint range of motion was 90°-135°, with an average of 113.4°.ConclusionApplication of modified anterolateral supra-fibular-head approach in reduction and internal fixation for tibial plateau fractures involving posterolateral column has the advantages of full exposure, less trauma, safety, and reliable reduction and fixation.
ObjectiveTo introduce the reduction concept of anteromedial cortical support in the treatment of intertrochanteric fracture, summarize the history, characteristics, biomechanics, and clinical applications, discuss the unsolved problems and prospect the future directions.MethodsRelevant domestic and foreign studies on cortical support reduction of intertrochanteric fracture in recent years were reviewed. Conclusions were drawn combined with clinical experience.ResultsThe positive cortical supportive reduction of intertrochanteric fracture, as a stable non-anatomical fracture reduction technique, has dual effects on mechanical buttress and biological bone healing. It does not increase the difficulty of doctors’ surgical procedure. For patients, it decreases the loss of femoral neck length, the loss of neck-shaft angle, the incidence rate of coxa vara, and maintains stable mechanical structure of the pelvis. It also shows a lower rate of instrument-related complications, and higher limb function scores. The mechanical stability of medial cortex apposition is more important than that of anterior cortex. For the best stability of the fracture, both sides should get positive support reduction pattern.ConclusionAnteromedial cortical support reduction can improve the postoperative stability of intertrochanteric fracture, enable better imaging and functional prognosis. As a kind of non-anatomic form of functional reduction, it can be used as a suboptimal choice secondary to anatomic reduction.
Objective To investigate the feasibility and effectiveness of the novel bone hook combined with finger-guided technique in the treatment of irreducible intertrochanteric femoral fractures in elderly. Methods Between January 2021 and August 2023, 23 elderly patients with irreducible intertrochanteric femoral fractures were treated with the novel bone hook combined with finger-guided technique. There were 10 males and 13 females; the age ranged from 68 to 93 years (mean, 76.2 years). The time from injury to operation ranged from 36 to 76 hours (mean, 51.2 hours). According to the classification standard proposed by TONG Dake et al in 2021, there were 10 cases of typeⅠA, 1 case of typeⅠB, 6 cases of type ⅡA, 4 cases of type ⅡB, and 2 cases of type ⅡC. The operation time, intraoperative blood loss, intraoperative fluoroscopy frequences, and quality of fracture reduction were recorded. The fracture healing time and occurrence of postoperative complications were observed during follow-up. At last follow-up, the Harris scoring system was used to evaluate the hip joint function. Results The operation time was 42-95 minutes (mean, 52.1 minutes). The intraoperative blood loss was 40-420 mL (mean, 126.5 mL). Intraoperative fluoroscopy was performed 14-34 times (mean, 20.7 times). According to the criteria proposed by Chang et al, the quality of fracture reduction was rated as good in 20 cases and acceptable in 3 cases. All patients were followed up 6-20 months (mean, 10.2 months). X-ray film showed that all fractures healed with the healing time of 3.0-5.5 months (mean, 4.0 months). At last follow-up, the Harris score of the hip joint ranged from 82 to 97 points (mean, 90.4 points). Among them, 14 cases were rated as excellent and 9 cases as good. No complication such as coxa vara, cutting of the cephalomedullary nail, nail withdrawal, or nail breakage occurred during follow-up. Conclusion The treatment of elderly patients with irreducible intertrochanteric femoral fractures by using the novel bone hook combined with finger-guided technique can achieve high-quality fracture reduction and fixation, and has a good effectiveness.
Objective To design a new extracorporeal reduction device for percutaneous pedicle screw fixation of thoracolumbar fractures (short for “new reduction device”), and to evaluate its effectiveness. Methods According to the mechanism of thoracolumbar fractures and biomechanics characteristic of reduction, a new reduction device was designed and used in a combination with long U-shaped hollow pedicle screw system. Between January 2014 and January 2016, 36 patients (group A) with single segment thoracolumbar fracture without neurological complications underwent percutaneous pedicle screw fixation, and the clinical data were compared with those of another 39 patients (group B) with thoracolumbar fracture underwent traditional open pedicle screw fixation. There was no significant difference in gender, age, cause of injury, classification of fractures, segments of fractures, injury to operation interval, height percentage of injury vertebrae, and kyphotic angle between 2 groups (P>0.05). The 2 groups were compared in terms of operation time, length of incision, intraoperative blood loss, drainage volume, visual analogue scale (VAS) at postoperative 24 hours, fluoroscopy frequency, ambulation time, height percentage of injury vertebrae, kyphotic angle and correction. Results Group A was significantly better than group B in the operation time, length of incision, intraoperative blood loss, drainage volume, VAS score at postoperative 24 hours, and ambulation time (P<0.05). However, fluoroscopy frequency of group B was significantly less than that of group A (P<0.05). All patients were followed up 11.2 months on average (range, 7-15 months). There was no intraoperative and postoperative complications of iatrogenic nerve injury, infection, breakage of internal fixation. Mild pulling-out of pedicle screws occurred in 1 case of group A during operation. The kyphotic angle and height percentage of the fractured vertebral body were significantly improved at 3 days after operation when compared with preoperative ones (P<0.05), but no significant difference was found between 2 groups at 3 days after operation (P>0.05). Conclusion Minimally invasive extracorporeal reduction device for percutaneous pedicle screw fixation is an effective and safe treatment of thoracic vertebrae and lumbar vertebrae fractures, because of little trauma, less bleeding, and quicker recovery.
Objective This review summarized the first 10-year progresses and controversies in the concept of anteromedial cortical support reduction, to provide references for further study and clinical applications.Methods Relevant domestic and foreign literature on cortical support reduction was extensively reviewed to summarize the definition of positive, neutral, and negative support, anteromedial cortices at the inferior corner, intraoperative technical tips for fracture reduction, radiographic assessment at different periods, comparison between positive versus neutral and medial versus anterior support, and the clinical efficacy of Chang reduction quality criteria (CRQC) and postoperative stability score. Results Anteromedial cortical support reduction was only focused on the cortex of anteromedial inferior corner, with no concern the status of lateral wall or lesser trochanter. Anteromedial cortex was seldom involved by fracture comminution, it was thicker, denser, and stronger, and was the key for mechanical buttress of the head-neck fragment to share compression load. Positive, neutral, and negative support were also called “extramedullary, anatomic, and intramedullary reduction”, respectively. There was hardly seen parallel cortical apposition, but characterized by some kinds of head-neck rotation, for example 10°-15° flexed rotation for positive cortical contact and support. Due to intraoperative compression and postoperative impaction, the status of cortical support may be changed at different time of radiographic examination. The positive medial cortex support was more reliable with less reduction loss than its neutral counterpart, and the anterior cortex contact was more predictive than the medial cortex for final results. As incorporation the bearing of cortex apposition and using a 4-point score, CRQC demonstrated more efficacy and was gradually accepted and applied in the evaluation of trochanteric fracture reduction quality. Postoperative stability score (8 points) provided a assessment tool for early weight-bearing in safety to prevent mechanical failure. Conclusion Anteromedial cortical support reduction is a key point for stability reconstruction in the treatment of trochanteric femur fractures. Evidence has definitely shown that non-negative (positive and neutral) is superior to negative (loss of cortical support). There is a tendency that positive cortex support is superior to neutral, but high quality study with large sample size is needed for a clear conclusion.
ObjectiveTo explore effectiveness of intermediate screw assisted reduction and fixation technique in the treatment of Schatzker type Ⅴ and Ⅵ tibial plateau fractures. Methods A clinical data of 22 patients with Schatzker type Ⅴ and Ⅵ tibial plateau fractures, who were admitted between June 2022 and December 2023 and met the selection criteria, was retrospectively analyzed. During operation, the intermediate screw assisted reduction and fixation technique was used. There were 14 males and 8 females with an average age of 46.3 years (range, 17-65 years). The fractures were caused by traffic accident in 13 cases, by falls in 5 cases, and by falling from height in 4 cases. According to Schatzker classification criteria, 9 cases were type Ⅴ and 13 cases were type Ⅵ. The interval between injury and operation was 5-12 days (mean, 7.9 days). The operation time, intraoperative fluoroscopy times, and length of hospital stay were recorded. The range of motion of knee joint and Hospital for Special Surgery (HSS) score were recorded at last follow-up. X-ray films were taken to review the fracture healing. Rasmussen score, tibial plateau varus angle (TPVA), and posterior tibial slope (PTS) were estimated before operation, at immediate after operation, and at last follow-up in order to evaluate the fracture reduction effect and postoperative outcome. Results The operation time was 85-140 minutes (mean, 103.9 minutes). Intraoperative fluoroscopy was performed 7-15 times (mean, 10.1 times). All incisions healed by first intention after operation, and no complication such as nerve or blood vessel injury occurred. The length of hospital stay ranged from 8 to 17 days (mean, 12.4 days). All patients were followed up 10-22 months (mean, 14.8 months). At last follow-up, the range of motion of knee joint was 110°-140° (mean, 125°). HSS score was rated as excellent in 16 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 95.5%. X-ray films reexamination showed that all fractures healed with the healing time of 12-17 weeks (mean, 14.8 weeks). No internal fixation failure occurred. Rasmussen score, TPVA, and PTS at immediate after operation and at last follow-up were significantly superior to those before operation (P<0.05). And there was no significant difference between immediately after operation and last follow-up (P>0.05). Conclusion The treatment of Schatzker type Ⅴ and Ⅵ tibial plateau fractures with intermediate screw assisted reduction and fixation technique is reliable, which can reduce the difficulty of reduction and fixation, improve the efficiency of reduction and fixation, reduce the operation time, achieve satisfactory reduction and fixation effect and postoperative prognosis, and achieve good recovery of knee joint function.
ObjectiveTo review and evaluate the basic principles and advantages of orthopedic robot-assisted technology, research progress, clinical applications, and limitations in the field of traumatic orthopedics, especially in fracture reduction robots. Methods An extensive review of research literature on the principles of robot-assisted technology and fracture reduction robots was conducted to analyze the technical advantages and clinical efficacy and shortcomings, and to discuss the future development trends in this field. Results Orthopedic surgical robots can assist orthopedists in intuitive preoperative planning, precise intraoperative control, and minimally invasive operations. It greatly expands the ability of doctors to evaluate and treat orthopedic trauma. Trauma orthopedic surgery robot has achieved a breakthrough from basic research to clinical application, and the preliminary results show that the technology can significantly improve surgical precision and reduce surgical trauma. However, there are still problems such as insufficient evaluation of effectiveness, limited means of technology realization, and narrow clinical indications that need to be solved. ConclusionRobot-assisted technology has a broad application prospect in traumatic orthopedics, but the current development is still in the initial stage. It is necessary to strengthen the cooperative medical-industrial research, the construction of doctors’ communication platform, standardized training and data sharing in order to continuously promote the development of robot-assisted technology in traumatic orthopedics and better play its clinical application value.
Objective To evaluate the safety and effectiveness of reducing posterior malleolar fractures via the modified Rammelt transfibular approach. Methods A retrospective analysis was conducted on 26 patients with ankle fractures who met the selection criteria and were admitted between September 2023 and May 2024. There were 13 males and 13 females, aged from 14 to 59 years (median, 43.5 years). Causes of injury included traffic accident (1 case), falls (7 cases), and sprains (18 cases). Time from injury to operation ranged from 1 to 13 days (mean, 3.9 days). According to the Lauge-Hansen classification, there were 5 supination-external rotation type Ⅲ fractures and 21 supination-external rotation type Ⅳ fractures. According to the Bartoníček classification for posterior malleolar fractures, there were 12 type Ⅱ fractures, 10 type Ⅲ fractures, and 4 type Ⅳ fractures. During operation, the fracture was exposed via the modified Rammelt transfibular approach; then, the fracture reduction was achieved under direct vision using techniques such as towel clip traction, posterolateral compression, and lifting with a posterior transverse periosteal elevator; finally, the fracture was fixed using anteroposterior cannulated screws or Kirschner wires. The incision healing was observed after operation. At 4 months after operation, X-ray film and CT were reviewed to evaluate the quality of fracture reduction. The medial clear space, tibiofibular clear space, and the anterior/posterior tibiofibular syndesmotic distances were measured. At last follow-up, the ankle function was assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the range of motion. Results The marginal necrosis occurred in 2 lateral malleolar incisions, and superficial infection occurred in 1 lateral malleolar incision; the remaining incisions healed by first intention. All 26 patients were followed up 13-21 months (mean, 15.6 months). X-ray films showed that fractures in 25 patients achieved clinical union within 3-8 months (mean, 5.4 months); 1 case had delayed union of the lateral malleolus. At 4 months after operation, no significant difference was found between the injured and healthy sides in the medial clear space, tibiofibular clear space, or the anterior/posterior tibiofibular syndesmotic distances (P>0.05). No malreduction of the posterior malleolus or the tibiofibular syndesmosis occurred. At last follow-up, the AOFAS score ranged from 80 to 100 (mean, 91.9). The range of motion ranged from 17° to 22° (mean, 21.0°) in active ankle dorsiflexion and from 40° to 49° (mean, 44.6°) in plantar flexion. Internal fixator was removed in 12 patients at 1 year after operation, with no ankle instability occurring. Ankle joint degeneration was observed in 1 patient at last follow-up. Conclusion The modified Rammelt transfibular approach is a safe and reliable technique. It enables precise reduction under direct vision, improves the quality of reduction for the distal tibial articular surface and the tibiofibular syndesmosis, and provides satisfactory ankle functional recovery in short-term follow-up.
Objective To summarize the morphological characteristics of sagittal beak-like deformity of head-neck fragment in femoral intertrochanteric fractures and to investigate the technical skills in fracture reduction. Methods A clinical data of 31 patients with femoral intertrochanteric fractures between May 2021 and April 2023 was retrospectively analyzed. The fractures had sagittal beak-like deformity of head-neck fragment in all patients. There were 13 males and 18 females, with an average age of 76.2 years (range, 68-83 years). The time from injury to operation was 36-76 hours (mean, 51.2 hours). Fractures were classified as type A1.2 in 10 cases, type A1.3 in 11 cases, type A2.2 in 6 cases, and type A2.3 in 4 cases according to the AO/Orthopaedic Trauma Association (AO/OTA)-2018 classification; and as type A1.3 in 10 cases, type A2.1 in 11 cases, type A2.2 in 6 cases, type A2.3 in 2 cases, and type A2.4 in 2 cases according to a novel comprehensive classification for femoral intertrochanteric fractures proposed by the “Elderly Hip Fracture” Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association. Based on preoperative X-ray films, CT scan and three-dimensional reconstruction, the fractures were classified into two types: type 1 (14 cases), with uncomplicated fracture morphology, severe bone interlocking and (or) soft tissue incarceration; type 2 (17 cases), with severe fracture crushing, obvious dissociation between bone blocks, and severe soft tissue hinge destruction. After the failure of the closed reduction, all patients underwent fracture reduction assisted with instrument via anterior minimal incision and proximal femoral nail antirotation nails internal fixation. The operation time, intraoperative fluoroscopy, intraoperative visible blood loss, length of hospital stay, and incidence of complications were recorded. The fracture reduction quality and stability score were assessed at immediate after operation under fluoroscopy. The fracture healing was evaluated and healing time was recorded by X-ray films. The pain visual analogue scale (VAS) score was performed at 48 hours after operation and Parker-Palmer activity score at 3 months after operation for function evaluation. ResultsThe operation time was 39-58 minutes (mean, 46.3 minutes); fluoroscopy was performed 13-38 times (mean, 23.5 times) during operation; the intraoperative visible blood loss was 45-90 mL (mean, 65.3 mL). The fracture reduction quality and stability score were rated as good in 29 cases and acceptable in 2 cases. The pain VAS score was 2-6 (mean, 3.1) at 48 hours after operation. Eleven patients developed deep vein thrombosis of the lower limbs after operation. Patients were hospitalized for 6-10 days (mean, 7.3 days). All patients were followed up 5-8 months (mean, 6.5 months). All fractures healed at 3.5-8.0 months after operation (mean, 4.5 months). Parker-Palmer activity score at 3 months after operation was 9 in 28 cases and 6 in 3 cases. Conclusion The femoral intertrochanteric fracture with sagittal beak-like deformity of head-neck fragment is difficult to manually reduce. The pin combined with cannulated screw insertion to the neck cortex can hold the fragment and assist fracture reduction, which is a simple and effective technique.