Bone Nails Research Articles

A facile fabrication of novel stuff with antibacterial property and osteogenic promotion utilizing red phosphorus and near-infrared light

Bone-implant materials are important for bone repairing and orthopedics surgery, which include bone plates and bone nails. These materials need to be designed not only considering its biostability and biocompatibility, but also their by-products induced infection after therapy or long-time treatment in vivo. Thus, the development of novel implant materials is quite urgent. Red phosphorus has great biocompatibility and exhibits efficient photothermal ability. Herein, a red phosphorus/IR780/arginine-glycine-asparticacid-cysteine (RGDC) coating on titanium bone-implant was prepared. The temperature sensitivity of Staphylococcus aureus biofilm is enhanced in the presence of ROS produced by IR780 with 808 nm light irradiation. With keeping the cells and tissues normal, a high antibacterial performance can be realized by near-infrared (808 nm) irradiated within 10 min at 50 °C. Besides the high effective antibacterial efficacy provided by photothermal therapy (PTT) and photodynamic therapy (PDT), the RGDC decorated surface can also possess an excellent performance in osteogenesis in vivo.

Treatment of unstable pelvic fractures with sacroiliac screwing assisted by 3D printing technique in combination with front ring nail-rod system

Objective To explore the clinical efficacy of 3D printing technique in assisting sacroiliac screwing in combination with front ring nail-rod system for treatment of unstable pelvic fractures. Methods From July 2015 to June 2017, 3D printing technique was used to assist the sacroiliac screwing in combination with front ring nail-rod system for 16 patients with unstable pelvic fracture at Orthopaedic Center, The Fourth People's Hospital of Zigong. They were 9 males and 7 females, aged from 19 to 60 years (average, 39.8 years). By the Tile classification, 5 cases were type B1, 6 type B2, 3 type B3 and 2 type C. Their operation duration, bleeding, fluoroscopy frequency, incision length, postoperative fracture reduction, success rate of sacroiliac screwing, accuracy of sacroiliac screwing, perioperative complications, weight-bearing exercise time, fracture healing time and the Majeed scores at the last follow-up were documented. Results All the 3D models and navigation templates were successfully designed and printed. Surgery succeeded in all the patients. Follow-ups ranged from 6 to 18 months, averaging 13.3 months. The bleeding ranged from 100 to 250 mL, averaging 162.4 mL; the operation duration ranged from 60 to 120 min, averaging 73.2 min; the intra-operative fluoroscopy frequency ranged from 13 to 31 times, averaging 17.4 times; the incision length ranged from 16 to 32 cm, averaging 21.1 cm. All the incisions healed by the first intention and all the fractures obtained osseous union after 90 to 120 d (average, 102.3 d). No significant complications like neurovascular injury or pulmonary embolism happened. The weight-bearing exercise time ranged from 25 to 40 d, averaging 31.5 d. According to the Matta imaging scores, the reduction was rated as excellent in 12 cases and good in 4. Altogether 28 screws were inserted with a success rate of 100%. Compared with the preoperative simulated screwing, the actual screwing angle deviated postoperatively by 0.12°±0.32°, the X axis by 0.36±1.24 mm, the Y axis by 0.36±1.24 mm and the Z axis by 0.22±1.26 mm, showing no statistically significant difference between the actual 3D deviations and the test value of 0 (P>0.05). Conclusion In the treatment of unstable pelvic fractures, 3D printing technique can be used in preoperative preparation of the connecting rod in the front ring nail-rod system to assist the sacroiliac screwing, significantly shortening the operation duration, reducing bleeding, ensuring safe and accurate screwing, and facilitating functional recovery. Key words: Pelvis; Fracture fixation, internal; Bone nails; 3D printing technique

Clinical observation of proximal femoral anti-rotation nail internal fixation in the treatment of intertrochanteric fracture

Objective To evaluate the clinical effect of proximal femoral nail anti-rotation Ⅱ(PFNA Ⅱ) internal fixation in the treatment of intertrochanteric fracture. Methods From September 2012 to April 2016, the clinical data of 37 patients with intertrochanteric fracture who were treated by PFNAⅡ internal fixation in Yuehua Hospital were retrospectively analyzed. Results All 37 patients were successfully operated, and the operation time was 40~120 min, with an average of 66 min.The amount of blood loss was 30~110 mL, with an average of 50 mL.During operation and after operation, X ray showed a good position and steady internal fixation.Three days after operation, patients exercised diseased side hip joint.Seven days after operation, patients exercised sitting on the bed.Fourteen days after operation, suture was dismantled and patients could get out of bed and walk with no weight or some weight.Lower limb deep venous thrombosis(DVT) was not observed.Through operative multiple reexamination, the fracture was healed and hip joint function was good. Conclusion PFNA Ⅱ has advantages of convenient operation, less trauma, stronger internal fixation, rapid recovery.It is an ideal method to treat intertrochanteric fracture. Key words: Femoral fractures; Fracture fixation, intramedullary; Bone nails; Haemorrhage; Complication

Comparison of the clinical effects of proximal femoral anti-rotation nail and dynamic hip screw internal fixation in the treatment of elderly patients with intertrochanteric fracture

Objective To compare the effects of proximal femoral nail anti-rotation (PFNA) and dynamic hip screw (DHS) internal fixation in treating senile intertrochanteric fractures. Methods From January 2014 to March 2016, 100 elderly patients with intertrochanteric fracture in the Second People's Hospital of Yaodu District were selected and randomly divided into two groups according to the digital table, with 50 patients in each group.The PFNA group and DHS group were treated with PFNA and DHS internal fixation, respectively.The curative effect, fracture healing, complications and hip function scores were compared between the two groups. Results The treatment excellent rate of the PFNA group (92%) was significantly higher than 76% of the DHS group (χ2=4.762, P<0.05). The fracture healing time of the PFNA group was (15.37±6.29)weeks, which was significantly shorter than (23.64±8.17)weeks of the DHS group (t=5.671, P<0.05). The incidence rate of complications of the PFNA group (6%) was significantly lower than 22% of the DHS group ( χ2=5.316, P<0.05); .After surgery, the Harri hip scores of the PFNA group and DHS group were significantly higher than those before surgery (t=11.330, 5.788, all P<0.05), and the Harri hip score of the PFNA group after surgery was higher than that of the DHS group (t=5.147, P<0.05). Conclusion Compared with DHS, the clinical effect of PFNA internal fixation in the treatment of elderly patients with femoral intertrochanteric fractures is more significant. Key words: Femoral fractures; Fracture fixation, intramedullary; Internal fixators; Bone nails; Aged

Individualized treatment of aseptic femoral nonunion after intramedullary nailing

Objective To evaluate individualized treatment of aseptic femoral nonunion after interlocking intramedullary nailing based on the morphology of each nonunion and nailing stability in each specific patient. Methods This study reviewed 108 patients who had been treated and followed up for more than one year for aseptic femoral nonunion following interlocking intramedullary nailing between February 2012 and February 2016. They were 89 men and 19 women, aged from 23 to 65 years (average, 45.5 years). The classification and corresponding treatments were as follows: Type Ⅰ (15 cases), characterized by callus (+)/bone defect (-) and nailing stability (+), were treated by augmentation plating; Type Ⅱ (43 cases), characterized by callus (+)/bone defect (-) and nailing stability (-), were treated by exchange for larger nailing/larger nailing with poller screws; Type Ⅲ (23 cases), characterized by callus (-)/bone defect (+) and stability of nailing (+), were treated by augmentation plating with bone grafting; Type IV (27 cases), characterized by callus (-)/bone defect (+) and stability of nailing(-), were treated by double plating and bone grafting. The healing of bone nonunion, complications and assessments for bone and function were followed up. Results All these patients received follow-up for 12 to 14 months (average, 12.5 months). All the nonunions were healed with no postoperative complications. Bone healing was achieved after 4 to 8 months (average, 5.5 months). The good to excellent rates for bone and function were 100%. Conclusion To achieve better surgical outcomes, the treatment of aseptic femoral nonunion after interlocking intramedullary nailing should be individualized according to the morphology of each nonunion and nailing stability in each specific patient. Key words: Femur; Fractures, ununited; Bone nails

Kirschner wire combined with external fixator for open comminuted distal tibiofibular fractures according to the concept of damage control orthopaedics

Objective To report the clinical efficacy of Kirschner wire combined with external fixator in the treatment of open comminuted distal tibiofibular fractures according to the concept of damage control orthopaedics. Methods A case series study was done on the clinical data of 15 open comminuted distal tibiofibular fractures which had been treated with kirschner wire combined with external fixation from January 2015 to August 2018 at Department of Orthopedics, Affiliated Hospital to Logistics College of Chinese People's Armed Police. They were 12 men and 3 women, aged from 27 to 62 years (mean, 46.5 years). By the Gustilo classification, there were one case of type Ⅰ, 4 cases of type Ⅱ, 7 cases of type ⅢA, 2 cases of type ⅢB and one case of type ⅢC. All the patients were treated with emergency debridement, tibial fixation using external fixator and fibular fixation using kirschner wire, followed by vacuum sealing drainage(VSD). Effective anti-inflammatory and other comprehensive treatments were given postoperatively. Regular follow-up was conducted to observe fracture healing and complications like osteomyelitis and bone disconnection. At the final follow-up, the American Orthopaedic Foot Ankle Society (AOFAS) ankle-hindfoot scale was used to evaluate the ankle function. Results All the patients were followed up for 12 to 18 months (mean, 12.8 months). Primary bone union was achieved in 13 cases (86.7%), delayed healing observed in one case (6.7%) and bone nonunion in one case (6.7%). No osteomyelitis occurred. By the AOFAS ankle-hindfoot scale, the ankle function was rated as excellent in 9 cases, as good in 4, as fair in one and as poor in one. Conclusions For patients with open comminuted distal tibiofibular fracture, treatment should be conducted according to the concept of damage control orthopaedics. After early thorough debridement, the tibia should be fixated using external fixator and the fibula using kirschner wire, followed by VSD, leading to economical cost and satisfactory clinical efficacy. Key words: Tibial fractures; Fibular fractures; External fixators; Bone nail; Damage control orthopaedics

Projection marking to optimize antegrade femoral intramedullary nailing

Objective To evaluate the projection marking which was designed to improve the surgical efficiency of antegrade femoral intramedullary nailing for femoral intertrochanteric and shaft fractures. Methods A total of 198 patients (158 femoral intertrochanteric fractures and 40 femoral shaft fractures) were analyzed retrospectively who had been treated at Department of Orthopedics, The First Affiliated Hospital to Wenzhou University from January 2012 to January 2016. They were 61 males and 137 females, aged from 13 to 95 years (mean, 65.4±14.6). By AO classification, there were 55 cases of type 31-A1, 103 cases of type 31-A2, 21 cases of type 32-A2 and 19 cases of type 32-A3. The intertrochanteric fractures which had been treated from January 2012 to May 2013 with no projection marking were assigned into group A1 (n=61) while the shaft fractures which had been treated in the same period with no projection marking into group B1 (n=12); the intertrochanteric fractures which had been treated from May 2013 to January 2016 with projection marking were assigned into group A2 (n=97) while the shaft fractures which had been treated in the same period with projection marking into group B2 (n=28). Comparisons were made between groups A1 and A2, and between groups B1 and B2 in terms of total operative time, total number of fluoroscopy, complications, Harris hip score (HHS), and pain and symptoms scores in Knee Injury and Osteoarthritis Outcome Score (KOOS) 3 months after operation. Results The 198 patients were followed up for 3 to 18 months (average, 7.0 months). The total operative time (56.5±6.6 min) and the total number of fluoroscopy (26.6±6.2 times) in group A2 were significantly less than those in group A1 (59.2±9.2 min and 31.4±9.9 times) (P 0.05). Conclusion The self-designed designed method of projection marking can reduce operative time and number of intraoperative fluoroscopy in the antegrade femoral intramedullary nailing for femoral intertrochanteric and shaft fractures. Key words: Femoral fractures; Fracture fixation, internal; Bone nails; Projection marking

Lateral decubitus intramedullary nailing for femoral subtrochanteric fractures

Objective To investigate the efficacy of lateral decubitus intramedullary nailing for treatment of subtrochanteric fractures of the femur. Methods From January 2012 to December 2015, 23 patients with simple femoral subtrochanteric fracture were treated at Department of Orthopedic Trauma, Changhai Hospital. They were 15 males and 8 females, aged from 19 to 77 years (average, 48.3 years). According to the Seinsheimer classification, there were 6 cases of type ⅡB, 8 cases of type ⅡC, 6 cases of type ⅢA, and 3 cases of type ⅢB. Their injuries were caused by traffic accident in 10 cases, falling from a height in 5 cases, and sprain in 8 cases. All patients were treated by closed reduction and anterograde intramedullary nailing at lateral decubitus. Their operative time, bleeding volume, fluoroscopic frequency, fracture healing time, functional recovery and complications were recorded and analyzed. Results Their operative time ranged from 55 to 80 min, averaging 65.7 min; their bleeding volumes ranged from 240 to 420 mL, averaging 304.3 mL; their fluoroscopic frequency ranged from 30 to 60 times, averaging 42.7 times. This cohort was followed up for 12 to28 months (average, 17.9 months). Their fracture healing time ranged from 4 to 10 months, averaging 5.5 months. Nonunion occurred in one patient but was cured by secondary operation. The HSS evaluation at the final follow-ups showed 17 excellent cases and 6 good ones, yielding an excellent to good rate of 100%. All the wounds healed by the first intention. No infection, deep vein thrombosis or implant failure was observed. Conclusion As lateral decubitus intramedullary nailing can achieve satisfactory clinical efficacy for subtrochanteric fractures of the femur, the body position of lateral decubitus may be a good alternative. Key words: Posture; Fracture fixation, intramedullary; Bone nail; Lateral decubitus; Subtrochanteric fracture

Vertical Neck angle and long-term outcomes of femoral neck fractures treated with cannulated screws

Objective To analyze the associations between long-term outcomes of fresh femoral neck fractures treated with cannulated screws and the classification based on vertical neck (VN) angle. Methods A retrospective study was conducted of the 162 fresh femoral neck fractures treated with 3 cannulated screws at Department of Orthopaedics, The Sixth People’s Hospital of Shanghai from January 2012 to December 2014. The relationships were analyzed using Logistic Regression between long-term complications and VN classification, including fixation failure, fracture nonunion and osteonecrosis of femoral head (ONFH). Results All the patients were followed up for an average of 25.7 months (from 6 to 36 months). Of them, 151 obtained fracture union after an average of 4.5 months (from 3 to 9 months). Internal fixation failure occurred in 23 cases, nonunion of femoral neck in 11, ONFH in 21 and femoral neck collapse in 13. Logistic Regression analysis showed no significant associations between internal fixation failure, nonunion or ONFH and gender, age or reduction method (P>0.05) but significant associations of VN classification with fixation failure (P<0.001) and nonunion (P=0.001) and insignificant association of VN classification with ONFH (P= 0.109). Conclusion VN classification, a new classification method for femoral neck fractures, may be closely related with incidences of fixation failure and nonunion. Key words: Femoral neck fracture; Bone nails; Prognosis; Vertical neck angle; Classification

Three-dimensional navigation assisted percutaneous sacroiliac screw combined with external fixator for Tile B and C pelvic fractures

Objective To evaluate the clinical outcomes of three-dimensional navigation assisted percutaneous sacroiliac screw combined with external fixator for the treatment of the Tile B and C pelvic fractures. Methods A retrospective case-control study was conducted on 43 patients with Tile B and C pelvic fractures from January 2014 to June 2017. There were 25 males and 18 females, with an average age of 44.6 years (range, 21-68 years). According to the AO typing, there were seven cases of type B1, 13 type B2, six type B3, 15 type C1, and two type C2. The duration from injury to operation ranged from 4 to 14 days (mean, 8.0 days). Based on the operation method, patients were divided into Group A (n=20) treated by three dimensional navigation assisted percutaneous sacroiliac screw combined with external fixator, and Group B (n=23) treated by anterior open reduction and plate internal fixation. The two groups were compared in terms of operation time, blood loss, reduction quality by Matta score, Majeed pelvic fractures function score at the last follow up, and postoperative complications. Results All patients were followed up for 6-24 months (mean, 12.7 months). The operation time [(27.5±1.6)minutes] and intraoperative bleeding [(26.3±3.9)ml] in Group A were significantly less than those in Group B [(166.2±3.6)minutes and (128.0±8.9)ml](P 0.05). The incidence of postoperative complication in Group A (10%) was significantly lower than that in Group B (39%)(P<0.05). Conclusion Compared with open reduction and plate internal fixation, three dimensional navigation assisted percutaneous sacroiliac screw combined with external fixator is preferable to unstable pelvic fractures due to the shorter operation time, less intraoperative bleeding, and fewer postoperative complications. Key words: Pelvis; Surgery, computer-assisted; Bone nail; External fixators

Comparative study on digital orthopedic three-dimensional visualization technology combined with image-based computer navigation and simple image-based computer navigation in percutaneous screw fixation for sacroiliac joint complex injury

Objective To compare the clinical effect of digital orthopedic three-dimensional visualization technology combined with image-based computer navigation and simple image-based computer navigation in percutaneous screw fixation for the treatment of sacroiliac joint complex injury. Methods A retrospective case-control analysis was conducted on 49 cases of sacroiliac complex injury from January 2015 to May 2017. There were 27 males and 22 females, with an average of 39.3 years old (range, 21-66 years). According to AO typing, there were 10 cases of type B1, 19 type B2, and 20 type C1. The duration from injury to operation ranged from 5 to 11 days (mean, 6.5 days). Based on the application of three-dimensiona digital programming, the 49 cases were assigned to Group A (n=24) which used Mimics computer assisted surgery software to simulate screw placement on the healthy side of sacroilic joint before operation and Group B (n=25) without the simulation programming. Screw placement time, intraoperative fluoroscopy frequency, and intraoperative bleeding were compared between two groups. Fracture reduction was evaluated by modified Matta standard score, and the function of hip joint by Majeed pelvic fracture function score at the last follow-up. Fracture healing and complications were observed. Results All patients were followed up for an average of 10.4 months (range, 6-24 months). The time of sacroiliac joint screw placement [(18.4±3.0)min] and the intraoperative fluoroscopy frequency [(12.9±3.8)times] in Group A were significantly less than those [(26.4±3.8) min, (19.4±1.5) times] in Group B (P 0.05). According to the modified Matta reduction standard, the good and excellent rate of Group A was 92% (22/24), and that of Group B was 92% (23/25). At the last follow up, the Majeed pelvic function score was 96% (23/24) in Group A and 92% (23/25) in Group B (P>0.05). Bone healing was seen in all patients 4 months after operation, and no complications such as wound infection, deep venous thrombosis, or screw loosening were observed. Conclusion The digital orthopedic three-dimensiona visualization technology in preoperative planning can reduce the time of sacroiliac screw placement and the intraoperative fluoroscopy frequency. It is an effective adjuvant technique for the percutaneous screw fixation under navigation in the treatment of sacroiliac joint. Key words: Sacroiliac joint; Imaging, three-dimensional; Surgery, computer-assisted; Bone nail

Comparison of fixations with dynamic hip screw, percutaneous compression plate and proximal femoral nail anti-rotation for intertrochanteric femoral fractures with paries medialis defect

Objective To compare the effects of fixations with dynamic hip screw (DHS), percutaneous compression plate (PCCP) and proximal femoral nail anti-rotation (PFNA) for treatment of intertrochanteric femoral fractures with paries medialis defect. Methods We reviewed the 82 patients with femoral intertrochanteric fracture and paries medialis defect who had been treated at our department from January 2011 to July 2016. They were 42 men and 40 women, aged from 27 to 91 years (average, 73.0 years). According to the AO classification, 72 cases belonged to type 31-A2.2, 10 to type 31-A2.3. Of them, 9 cases were treated with DHS, 17 cases with PCCP and 56 cases with PFNA-Ⅱ. The 3 groups were compared in terms of intraoperative blood loss, blood infusion, fluid infusion, operation duration, time for fracture union, postoperative complications and Functional Recovery Score (FRS) of the hip 12 months after operation. Results The fluid infusion [1,100 (850, 1,100) mL] and intraoperative blood loss [60 (5, 100) mL] in the PCCP group were significantly less than in the PFNA group [1,100 (1,000, 1,700) mL and 150 (50, 300) mL] and the operation duration (91.4±29.2 min) in the former was significantly shorter than in the latter [121 (85, 185) min] (P 0.05). Of the patients, 57 (8 DHS, 12 PCCP and 37 PFNA ones) were followed up for an average of 47 months (from 15 to 85 months). There were no statistically significant differences between the 3 groups in time for fracture union, complications, or average FRS score of the hip 12 months after operation (P>0.05). Conclusions For unstable intertrochanteric fractures with paries medialis defect, it is not clear that intramedullary nails are superior to extramedullary fixation. Intramedullary nails like PFNA may be suggested for patients with better preoperative conditions while extramedullary fixation like PCCP suggested for those with poor general conditions. Key words: Hip fractures; Fracture fixation, internal; Bone plates; Bone nails

Digital analysis and certification of osseous pathway for anterograde screwing in acetabular posterior column

Objective To analyze and determine the optimal osseous pathway for anterograde screwing in the acetabulum posterior column. Methods Recruited for this study were 40 healthy adult volunteers, 20 males and 20 females, aged from 18 to 56 years (average, 34.6 years). Firstly, their abdomen CT scanning images were transformed into Materialise Mimics Innovation Suite 16.0 software to obtain the 3D reconstruction images of the pelvis (.stl file). The Imageware 12.0 software (EDS, USA) was used to produce the optimal osseous pathway for anterograde screwing in the acetabulum posterior column. The diameter and length of the pathway were measured and statistically analyzed. Secondly, after 10 adult fresh pelvic specimens were scanned, the optimal osseous pathway for anterograde screwing in the acetabulum posterior column was determined in the same way as the above. A navigation template for anterograde screwing in the acetabular posterior column was manufactured. The screwing in the posterior column of the acetabulum was conducted using Kirschner wire with the aid of the navigation template. Imaging evaluation was performed after fixation. Results The projection of the safe zone in the acetabular posterior column was irregularly triangle; there were no significant differences regarding the projection size between different ages (P>0.05). The maximum diameter and the maximum length of the left optimal pathway in males were respectively 22.37±1.42 mm and 131.27±3.63 mm, and those of the right optimal pathway in males respectively 23.16±1.39 mm and 129.23±3.27 mm. The maximum diameter and the maximum length of the left optimal pathway in females were respectively 17.58±1.83 mm and 112.56±2.77 mm, and those of the right optimal pathway in females respectively 16.92±1.66 mm and 114.41±2.98 mm. There were no significant differences between the left and right sides for the same item in the same gender (P>0.05).There were significant differences between males and females for the same item in the same side (P<0.05). No penetration into the cortex or the hip joint happened. Conclusion The optimal osseous pathway for anterograde screwing in the acetabulum posterior column can be determined by digital techniques, leading to a simple and safe procedure for the treatment of fractures of the acetabular posterior column. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone nails; Imaging, three-dimensional

Internal fixation with proximal femoral nail anti-rotation for intertrochanteric fracture involving lateral wall: a finite element analysis

Objective To study the biomechanical performance of proximal femoral nailing anti- rotation (PFNA) in the treatment of femoral intertrochanteric fracture involving the lateral wall using finite element analysis and the significance of the lateral wall. Methods A healthy senior volunteer, male, 80 years of age, was recruited for this study.The CT data of his proximal femur were used to establish a three-dimensional finite element model of proximal femur by software Mimics17.0 and Geomagic Stusio. After the intertrochanteric fracture of AO-type 31-A1.2 was simulated together with coronal displacement of the lateral wall fracture, it was assembled with PFNA into the three-dimensional finite element model. Finite element analysis was performed on the femoral head, neck, fracture ends, lateral wall, and internal components of the model to observe the stress values of various parts of the model under the same load, with different degrees of fracture reduction (no displacement, anterior displacement of 5%, 10%, 15% and 20%, posterior displacement of 5%, 10%, 15% and 20%) and with or without the lateral wall. Results The stress values for internal components at the femoral head, neck, fracture ends, main nail with anatomical reduction of fracture ends and integrity of the lateral wall were 0.40 MPa, 30.05 MPa, 74.35 MPa and 121.68 MPa, respectively. The respective stress values of the above with lateral wall fracture were 0.82 MPa, 47.32 MPa, 151.92 MPa and 266.88 MPa, increased by about 100%. With every horizontal reduction loss increased by 5% forward or backward, the stress exerting on the corresponding spots would see a 10% progressive growth, plus 20% lateral wall fracture and reduction loss. The stress of the main nail (468.43 MPa) was thrice that (121.68 MPa) of the stress posing on the complete lateral wall with the fracture ends 100% reduced. Conclusions When PFNA is used in the treatment of femoral intertrochanteric fractures involving the lateral wall, stresses on the internal components may be doubled. Loss of coronal reduction may lead to the most significant increase in stress on the bonding site between the main nail and screw blade. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails; Finite element analysis; Lateral wall

Factors associated with screw penetration after plating for proximal humerus fractures of Neer types II & III

Objective To analyze the factors that influence screw penetration after plating for proximal humerus fractures of Neer two- or three-part. Methods We reviewed the patients with proximal humerus fracture of Neer types Ⅱ & Ⅲ who had been treated from January 2006 to June 2017. The data were documented regarding gender, age, Neer classification, osteoporosis, surgical procedure, cephalic screw number, type of medial support and screw penetration. They were divided into 2 groups according to the presence or absence of screw penetration. χ2 test and independent samples t test were used with software IBM SPSS 22.0. The multivariate logistic regression was used to identify the independent risk factors when there were two or more statistically significant factors. The two-side test was used and significance was set to P< 0.05. Results Altogether 78 patients were included in our analysis, including 27 males (34.62%) and 51 females (65.38%) with an average age of 57.41 years (from 18 to 85 years).Their average follow-up time was 7.7 months (from 3 to 24 months). There were 54 Neer two-part fractures (69.23%) and 24 Neer three-part ones (30.77%). Screw penetration was observed in 18 patients (23.08%) but not in the other 60 ones (76.92%). The χ2 test and independent samples t test revealed that screw penetration was significantly associated with gender (P=0.003), osteoporosis (P=0.003) and cephalic screw number (P=0.003) but not with age (P=0.256), Neer classification(P=0.754), surgical procedure( (P=0.308) or type of medial support (P=0.186). The multivariate logistic regression revealed that osteoporosis (P=0.027) and cephalic screw number (P=0.026) were independent risk factors for screw penetration. Conclusions After plating for proximal humerus fractures of Neer two- or three-part, the patients with osteoporosis and those receiving more than 5 cephalic screws may face a higher risk of screw penetration than those without osteoporosis and those receiving 4 cephalic screws. Key words: Shoulder fractures; Postoperative complications; Bone nails; Osteoporosis

Application of locking intramedullary nail and locking plate in traumatic extraarticular proximal tibial fractures

Objective To investigate the application of locking intramedullary nail and locking plate in traumatic extraarticular proximal tibial fractures. Methods 150 patients with traumatic extraarticular proximal tibial fractures were chosen in the research.According to the internal fixation program, the patients were divided into observation group and control group, with 75 cases in each group.The observation group was treated with multifunctional locking intramedullary nail, the control group was treated with locking plate.After treatment for 3 months, the fracture repairing effects, blood loss, operation time, bleeding duration and adverse reaction between the two groups were compared. Results The patients were followed up after operation, the average fracture healing time of the observation group was (9.17±2.84) months, which of the control group was (9.25±2.65) months, there was no statistically significant difference between the two groups(t=0.252, P>0.05). The repairing effect of the observation group was better than that of the control group, the difference was statistically significant(u=4.341, P 0.05). Conclusion Multifunctional locking intramedullary nail can reduce the incidence rate of adverse reaction and blood loss in traumatic extraarticular proximal tibial fractures, the fracture repairing effect is better than locking plate internal fixation. Key words: Tibial fractures; Fracture fixation, internal; Bone nails

Treatment of femoral intertrochanteric fractures by reduction without a traction table in a special position and fixation with proximal femoral nail antirotation (PFNA)

Objective To study the treatment of femoral intertrochanteric fractures by reduction without a traction table in a special position and fixation with proximal femoral nail antirotation (PFNA). Methods From May 2016 to May 2017, 34 patients with femoral intertrochanteric fracture were treated with PFNA. They were 20 men and 14 women, from 36 to 89 years of age (average, 69.9 years). The left side was affected in 15 cases and the right side in 19. By AO classification, there were 10 cases of type AO 31-A1, 13 ones of type 31-A2, and 11 ones of type 31-A3. Two cases were complicated with other fractures, and 5 with internal system disease, 3 of whom had more than 2 concomitant diseases. Preoperative deep venous thrombosis was found in 2 cases. Surgery was performed for them between 2 and 8 days after injury (average, 3.7 days). Reduction was performed in a special position without a traction table. The duration of anesthesia, operation time, intraoperative hemorrhage, postoperative complications and hip function by Harris scores were recorded. Results For the 34 patients, the anesthesia time ranged from 57 to 85 min (average, 67.5 min), the operation time ranged from 28 to 65 min (average, 40.9 min), and the intraoperative hemorrhage from 80 to 150 mL (average, 110.6 mL). They received effective follow-up for 6 to 12 months (average, 8.4 months). All the fractures healed after 6 to 12 months(average, 7.2 months). No failure of internal fixation was observed during follow-ups. By the Harris scores at the final follow-up, the function of the affected hip was rated as excellent in 9 cases, as good in 21 and as fair in 4, giving an excellent to good rate of 88.2%. Conclusion In the treatment of femoral intertrochanteric fractures, reduction without a traction table in a special position and PFNA fixation may reduce anesthesia time, leading to satisfactory clinical outcomes. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails; Non-traction table; Special position

Euthyphoria reduction combined with percutaneous iliosacral screw fixation for irreducible sacroiliac dislocation

Objective To evaluate euthyphoria reduction combined with percutaneous iliosacral screw fixation in the treatment of irreducible sacroiliac dislocation. Methods From March 2012 to May 2015, 29 patients with irreducible sacroiliac dislocation were treated using euthyphoria reduction followed by percutaneous iliosacral screw fixation. They were 18 men and 11 women, aged from 25 to 68 years (average, 37.9 years). According to the Tile classification, there were 7 cases of type C1, 9 cases of type C2, and 13 cases of type C3. The intervals from injury to surgery ranged from 6 to 32 days (average, 11.3 days). Results The operation time for this cohort ranged from 40 to 125 minutes (average, 76.2 minutes). The intraoperative bleeding ranged from 50 to 360 mL (average, 148.6 mL). Their follow-ups ranged from 24 to 41 months (average, 28.9 months). According to the Matta criteria for reduction, 20 cases were rated as excellent and 9 as good, yielding an excellent to good rate of 100%. Their Majeed scores at the final follow-up averaged 90.1 points (range, from 67 to 100 points), giving 20 excellent, 7 good and 2 fair cases (with an excellent to good rate of 93.1%). No screw loosening or lameness of the affected limb was observed during follow-ups. Conclusions Euthyphoria reduction combined with percutaneous iliosacral screw fixation can lead to satisfactory outcomes in the treatment of irreducible sacroiliac dislocation. Additionally it may improve operative safety. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Bone nails; Reduction

Application of micro screws in holistic management of comminuted fracture of posterior acetabular wall combined with posterior hip dislocation

Objective To explore the application of micro screws in holistic management of comminuted fracture of posterior acetabular wall combined with posterior hip dislocation. Methods From October 2013 to March 2016, 38 patients (38 hips) were managed for comminuted fracture of posterior acetabular wall combined with posterior hip dislocation. They were 29 males and 9 females, aged from 15 to 71 years (average, 38.6 years). According to the Letournel-Judet classification, there were 35 simple fractures of posterior acetabular wall and 3 complex fractures (2 fractures of posterior column plus posterior wall and one transverse plus posterior wall fracture). All fractures were comminuted and involved the posterior wall. The posterior Kocher-Langenbeck approach was selected for all the patients. Intraoperative exploration revealed the comminuted posterior walls were complicated with broken acetabular rims and ruptured glenoid rims to various degrees. Micro screws or micro screw-plate system were used to repair the comminuted fractures and broken acetabular rims, bridge support fixation with a locking plate followed pelvic reconstruction, and at the same time the ruptured glenoid rims were sutured so that the whole posterior articular structure around the posterior wall was repaired and reconstructed in a holistic manner. Results All the 38 patients were followed up for 12 to 36 months (average, 17.6 months). By the Matta assessment, the reduction was excellent in 36 cases and fine in 2, giving an excellent to good rate of 100%. All fractures got united after 9 to 14 weeks (average, 10.2 weeks). By the improved Merle d'Aubigne & Postel criteria, the clinical outcome was excellent in 35 cases and good in 3, giving an excellent to good rate of 100%. After surgery, heterotopic ossification occurred in one case, and transient paralysis of the sciatic nerve in 3 cases. No infection, necrosis of the femoral head, joint pain, joint malfunction or unstable walking was observed. Conclusion In the management of comminuted fracture of posterior acetabular wall combined with posterior hip dislocation, the lesions of the whole posterior wall can be repaired primarily in a holistic manner by repairing the shattered posterior wall of the acetabulum wth micro plate and screw system and simultaneous suture and fixation of the broken actabular rim and ruptured glenoid rim. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone plates; Bone nails

Internal fixation with elastic intramedullary nail versus plate-screw system for treatment of fibular diaphyseal fracture

Objective To compare elastic intramedullary nail (EIN) and plate-screw (P+S) system in the treatment of fibular diaphyseal fractures. Methods From January 2014 to April 2017, 48 tibiofibular fractures were treated with internal fixation using EIN (21 cases) or plate-screw (27 cases) . The 2 groups were compared in terms of intraoperative blood loss, operative time, fibular healing time, fibular union rate, ankle function and postoperative complications. Results All the patients were followed up for 3 to 24 months (average, 14.0 months) .The intraoperative blood loss (17.9±4.9 mL) , operative time (23.2±5.8 min) and fibular healing time (10.3±1.8 weeks) for the EIN group were significantly less than those for the plate-screw group (28.9±9.6 mL, 30.0±10.7 min and 11.6±2.0 weeks) (P 0.05) . The AOFAS ankle-hindfoot scoring revealed 12 excellent, 8 good and one fair cases (91.0±5.3 points on average) in the EIN group, and 14 excellent, 10 good and 3 fair cases (90.1±6.1 points on average) in the plate-screw group, showing no significant difference between the 2 groups (P=0.594) . Conclusions Compared with plate-screw system, elastic intramedullary nail for fibular diaphyseal fractures may be in line with the biomechanical characteristics of the fibula and with the basic principles of minimally invasive surgery. It may be advantageous in blood loss, operative time and fracture healing but not in fibular union rate or functional recovery of the ankle. An appropriate way of internal fixation for a fibular diaphyseal fracture should be chosen according to the specific conditions of the patient. Key words: Fibula; Fractures, Bone; Fracture fixation, internal; Bone nails; Bone plate