Internal Fixation Group Research Articles

Effectiveness of Ilizarov external fixation in elderly patients with pilon fractures

BackgroundPilon fractures are associated with soft tissue complications such as skin necrosis, and deep infections have been reported very often. This study retrospectively compared the treatment effects of Ilizarov external fixation and of internal fixation methods in elderly patients with pilon fractures. MethodsA total of 37 patients >60 years old with pilon fractures (AO classification type 43) were investigated. Patients were treated either with internal fixation (n = 15) or Ilizarov external fixation (n = 22). The patients' mean age was 74.2 (range, 60–78) years in the internal fixation group and 76.1 (range, 60–82) years in the Ilizarov external fixation group. Many patients in the internal fixation group received toe-touch to 1/3 partial weight-bearing at 2–4 weeks postoperatively and full weight-bearing by 6–8 weeks postoperatively. Many patients in the Ilizarov external fixation group received partial weight-bearing (as tolerated) 1 day postoperatively, 1/2 partial weight-bearing at 2 weeks postoperatively, and full weight-bearing at 4 weeks postoperatively. ResultsThe mean duration of hospitalization was 79.1 ± 30.1 days for the internal fixation group and 29.1 ± 18.8 days for the Ilizarov external fixation group (p < 0.05). Bone mineral density (T-score) was 2.6 ± 0.7 for the internal fixation group and 3.6 ± 1.2 for the Ilizarov external fixation group (p < 0.05). The incidence of skin disorders that required additional surgical treatment was 33.3% (5/15 patients) in the internal fixation group and 0% (0/22 patients) in the Ilizarov external fixation group (p < 0.05). ConclusionsIn elderly patients with periarticular fractures of the ankle, those who underwent Ilizarov external fixation had a shorter duration of hospitalization and fewer complications than those who underwent internal fixation.

A Word of Caution: Success May Be Limited to 2 Years and Highly Displaced OTA/AO B2 and C2 Injuries: Commentary on an article by Alexander Nilsskog Fraser, MD, et al.: "Reverse Total Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly. A Multicenter Randomized Controlled Trial".

Commentary I would like to congratulate Fraser et al. on a well-conducted study from which we are able to draw a narrow but strong conclusion: for the displaced anatomic neck fracture with involvement of the lesser and greater tuberosities, a reverse total shoulder arthroplasty (TSA) yields improved outcome at a 2-year follow-up across a population of patients. It is important to acknowledge that results are superior at 2 years and superior in this injury pattern, not generally superior postoperatively or for other broad definitions of proximal humeral fracture. There was a mean difference in the Constant score of 13.4 points overall and 18.7 points for C2 fractures for this modest timeframe and in these fracture patterns. Both exceeded the minimal clinically important difference of 10 points, according to the article by Fraser et al. This article is well organized and written, easy to understand, and comprehensive. The strengths of the investigation include a well-powered cohort for the primary outcome variable, the Constant score, although it was underpowered for secondary outcomes and subgroup analysis. Additionally, the inclusion and exclusion criteria were well established, and I like that Fraser et al. stuck to the controversial treatment groups of the OTA B2 and C2 fractures and, at that, only those with severely angulated and displaced parameters of >45° valgus or >30° varus on an anteroposterior radiographic view or >45° angulation on a scapular Y radiographic view. Although there was a high percentage of excluded patients (54% [146 of 270 patients] with OTA/AO B2 and C2 fractures), most exclusions were due to the patients not meeting displacement criteria, ultimately leaving 60 patients in the open reduction and internal fixation (ORIF) group and 64 patients in the reverse TSA group. It was outstanding that the physiotherapists performing measurements were blinded to the procedure during the measurement of outcome parameters and were different from those physiotherapists rendering treatment. Further, in this study, the same surgeons performed the arthroplasties and ORIF, which has the advantage of consistency of technique and protocol in each treatment arm. However, the possible downside is that this circumstance may also introduce bias for 1 treatment arm given that the operating surgeons were likely shoulder surgeons by training. We should not conclude that, for every patient and every surgeon, improved results can be expected with one modality over another. The randomized controlled trial (RCT) helps to give us a guideline for a population of patients treated by a population of surgeons; therefore, it should be obvious that within those populations there exist patients who will outperform the mean in both treatment groups, and the same is true for the surgeon. This RCT does not tell us what the optimal outcome is at the onset of treatment for any individual patient, nor even whether optimal reverse TSA is better than optimal ORIF; therefore, we must be circumspect in counseling our patients, taking into consideration variables that could make them better candidates for a particular technique or that may make the surgeon more facile with another technique. What would not be appropriate is to conclude that reverse TSA is better than ORIF for proximal humeral fractures. We must beware; it is only a 2-year study. If there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics again. I commend the authors for an excellent study, and I am pleased to learn that this study group is in the midst of mining longer-term results that would elevate our understanding further regarding this very important fracture for which excellent treatment results have been hard to find.

Internal fixation versus hemiarthroplasty for displaced femoral neck fractures in the elderly: A cost-effectiveness analysis

BackgroundThere is little information on the cost and outcome of different treatments for femoral neck fractures. This study aimed to evaluate the cost-effectiveness of internal fixation compared with hemiarthroplasty (HA) for elderly patients with displaced femoral neck fractures. Materials and MethodsA total of 121 patients ≥ 65 years old were divided into internal fixation (n = 58) or HA group (n = 63). Clinical outcome was evaluated by the EuroQol 5 dimensions (EQ-5D) score at 3, 12, and 24 months. The total costs including medical and non-medical expense were collected through hospitalisation information, cost diaries, and telephone interviews. A cost-utility analysis of the total costs in combination with quality-adjusted life years (QALYs) calculated by EQ-5D and survival time was conducted. Results were expressed in incremental cost-effectiveness ratio (ICER). ResultsThe mean EQ-5D index score in the HA group were higher at the early follow-up (p<0.05). At 24 months there were no differences in EQ-5D between the 2 treatment groups (p>0.05). Over the 2-year period, patients treated with HA gained 0.09–0.10 more QALYs than those treated with internal fixation, while the mean total costs for internal fixation (CNY 55,676) were significantly lower than for HA (CNY 80,297) (P<0.001). ICER indicated that internal fixation may be more cost-effective than HA. ConclusionHA is associated with better outcome than internal fixation in the treatment of displaced femoral neck fractures in elderly patients. However, internal fixation may be more cost-effective because of less total cost.

Ilizarov versus internal fixation in management of complex tibial plateau fracture. Which is better?

Abstract Back ground In this prospective randomized clinical study, we report results of management of complex tibial plateau fracture shatzker five and sex (type 41C) by Ilizarov external fixator in comparison with internal fixation according to three column classification with average follow up 18 months Patients and Methods In this study we managed 40 cases with complex tibial plateau fracture shatzker five and sex (type 41c). Twenty cases were surgically managed by Ilizarov technique and the other twenty cases were surgically managed by double internal fixation. We compare between both group as regard clinical, radiological results and rate of complications. Results while using Knee society score, the results are the following Regarding ilizarov group the range of knee society score is 31-90 with Mean±SD 76.05±14.86 (11 excellent, 4 good, 3fair, 2 poor) while group with internal fixation the range of knee society score is 44-93 with Mean±SD 73.95±13.38 (8 excellent, 5 good, 3 fair, 4 poor).According to these results; p value is 0.641 with no significant difference between two groups. Conclusion ilizarov is superior when compared with internal fixation as by ilizarov we can achieve more biological fixation especially when there highly comminuted fractures Complications rate was higher in internal fixation group (7cases) while external fixation group complications were presented in (3 cases).

Management of Complex Distal Femur Fractures: Comparative Study between Ilizarov External Fixation and Double Plating

Abstract Background In this prospective randomized clinical study, we report results of management of type C2 and C3 distal femur fractures by Ilizarov external fixator in comparison with double plating through separate medial and lateral approaches with a mean of 42.8 ± 6.84 weeks follow-up. Patients and Methods In this study we managed 30 cases with highly comminuted distal femoral fractures AO classification type C2 or C3. Fifteen cases were surgically managed by Ilizarov technique and the other fifteen cases were surgically managed by double plating technique. We compare between both group as regard clinical, radiological results and rate of complications. Results while using Knee society score, the results are the following: In Ilizarov group: 7 cases (46.67%) are excellent, 4 cases (26.67%) are good, 3 cases (20.00%) had fair results while 1 case (6.67%) had poor results. In internal fixation group, 8 cases (53.33%) had excellent results, 3cases (20%) had good results, 2 cases (13.33%) had fair results while 2 cases (13.33%) had poor results. Conclusion In fixation of complex distal femur fracture, both Ilizarov and double plating methods had no significant difference in clinical outcome by knee society score and in rate of complications. Ilizarov allow earlier weight bearing and less blood loss while double plating gives better ROM of knee joint and rapid radiological healing. Level of Evidence Level I Randomized controlled study.

Comparison of conservative and operative management for unstable extra articular proximal phalanx fracture of hand: A prospective study

BACKGROUND: Hand injuries are often overlooked and are not given the importance that they deserve. Decision-making in the management of phalangeal fractures is crucial rather more difficult than long bone fractures; as no treatment will lead to deformity and over treatment will cause stiffness. AIM OF THE STUDY: Compare the results of both conservative and operative managements of proximal phalangeal fractures for decision making while dealing with these innocent looking injuries. SUBJECTS AND METHODS: This was a prospective study of 60 patients of unstable extra articular proximal phalangeal fractures over 2 years. Fifty percent of the patients managed conservatively and 50% surgically. Results were analyzed by the assessment of total range of movements (TROM); functional score of Belesky et al.; grip strength; time of return to work and complications associated with each methods. RESULTS: There was no statistically significant difference between conservative and operative group (TROM P 0.063; Belesky score P = 0.135). Among all modalities best results was achieved with Close Reduction and Internal Fixation (CRIF) with percutaneous k wires which was statistically and clinically significant as compared to conservative and Open Reduction and Internal Fixation (ORIF) group (TROM P = 0.012; Belesky score P = 0.024]. Complications were mostly malunion with conservative methods and infection; implant failure; CRPS were more common in operative methods. CONCLUSION: Conservative management is preferred over surgery for unstable proximal phalangeal fractures. If surgery is needed for stability than close reduction (CRIF) with percutaneous k wire is preferred over open techniques (ORIF).

Cemented modular bipolar in unstable femur intertrochanteric fracture in osteoporotic elderly patients- its functional outcomes

Introduction: Intertrochanteric femur (IT) fracture is a common fracture in old age. The cause of long morbidity and mortality in I/T femur is malunions, nonunions, respiratory tract infection and bed sores etc., As we routinely do treatment modality like DHS and PFN are time tested but with availability of better cemented modular bipolar techniques and implant mortality and morbidity can be reduced. Aims and objectives: To study functional outcome of cemented modular bipolar for management of unstable intertrochanteric fracture femur in elderly osteoporotic patients. Method and Materials: 60 yrs. and above 30 patients who were admitted and operated between november 2017 to march 2019 and had fulfilled the inclusion criteria were enrolled for this study. Cemented modular bipolar was done, Total numbers of patient 30, of mean age of 70.2 yrs and F:M ratio is 19:11. A follow up period of total 1 years. Follow up was done at 6 week, 3 months, 6 months and at 1 year by Harris Hip Scoring System assessed post operatively. x ray and bone scan was done to asses osteoporosis. Result: For result assessment and evalution we use, Harris hip score, Chi- square test, T-test, and statistical analysis. Our P value< 0.05 was considering significant. In our study we get 1 had superficial wound infection, no one had deep infection or pulmonary infection. Over all very less post operative complication and early mobilisation and ambulation was done, excellent result at the end of 1 yr patient who follow up all had good to excellent results. Conclusion: Functional recovery and early post operative Harris hip score were excellent in osteoporotic patients treated with cemented modular bipolar as compared to routine internal fixation group. Post operative complications were more with DHS and PFN due to osteoporotic bone than cemented modular bipolar group and were comparable with other studies. Thus in conclusion, primary cemented modular bipolar does provide a stable, pain-free, and early mobile joint with acceptable less complication rate as seen in our study; however a larger prospective randomised study comparing the use of dynamic hip screwand proximal femur nail devices against primary cemented modular bipolar for unstable intertrochantric fractures in osteoporosis will be needed.

Percutaneous fixation assisted by O-arm-based navigation for thoracolumbar fractures without neurologic deficits

Objective To investigate the clinical efficacy of percutaneous fixation assisted by O-arm-based navigation for thoracolumbar fractures without neurologic deficits. Methods A retrospective case control study was conducted to analyze the clinical data of 35 thoracolumbar fracture patients without neurologic deficits admitted to Henan Provincial People's Hospital from January 2018 to December 2018. There were 26 males and 9 females, aged 17-51 years, with an average age of 30.4 years. The injured segments were distributed at T11 in 10 patients, T12 in 15, L1 in 11, and L2 in 4 patients. A total of 19 patients (22 vertebrae, 98 pedicle screws) were treated with O-arm guided navigation assisted percutaneous internal fixation (Group A), and 16 patients (18 vertebrae, 82 pedicle screws) were treated with C-arm guided percutaneous internal fixation (Group B). The operation time, accuracy rate of nail placement, complications, Cobb angle of fracture vertebral body, visual analogue score (VAS) and Japanese Orthopaedic Association (JOA) score were recorded and compared before operation, 7 days after operation and at the last follow-up. Results The patients were followed up for 2-12 months [(7.2±2.9)months] in Group A and 3-13 months [(7.1±3.3)months] in Group B. The operation time was (70.5±11.2)minutes in Group A and (81.3±10.9)minutes in Group B (P 0.05). The VAS at day 7 after operation was (2.3±1.1)points and (2.8±1.0)points in Group A and Group B, respectively, while the VAS at the final follow-up was (0.7±0.7)points and (0.8±0.7)points in Group A and Group B respectively. The postoperative VAS was significantly decreased compared with the preoperative VAS (P 0.05). The JOA at day 7 after operation was (21.1±2.2)points and (21.8±2.5)points in Group A and Group B respectively, while the JOA at the final follow-up was (24.9±2.2)points and (23.8±1.9)points in Group A and Group B respectively. The postoperative JOA was significantly increased compared with the preoperative JOA (P 0.05). Conclusion For thoracolumbar fractures without neurologic deficits, percutaneous fixation assisted by O-arm-based navigation can shorten the operation time and deliver a higher accuracy rate in the placement of pedicle screws, in addition to the similar effects with percutaneous fixation assisted by C-arm in pain relief, function improvement and correction of fracture vertebral kyphosis. Key words: Spinal fractures; Fracture fixation, internal; Navigation

Treatment of Monosegment Spinal Tuberculosis via Posterior Unilateral Vertebral Lamina Fenestration Debridement and Bone Grafting Fusion Combined with Laminar Reconstruction and Internal Fixation: A Retrospective Case-Control Study with a Minimum 5-Year Follow-Up

To investigate the clinical and imaging outcomes of posterior unilateral vertebral lamina fenestration debridement and bone grafting fusion combined with laminar reconstruction and instrumentation compared with the traditional posterior-only method for treating monosegment spinal tuberculosis. Fifty-four patients underwent posterior unilateral vertebral lamina fenestration debridement and bone grafting fusion combined with laminar reconstruction and internal fixation (group A), and 60 patients underwent 1-stage posterior debridement, laminectomy decompression, bone grafting fusion and instrumentation (group B). The clinical and radiographic outcomes of these groups were analyzed and compared. Group A had less intraoperative blood loss, shorter hospitalization, and a shorter fusion time than did group B (P < 0.05). At 3 months postoperatively, group A had a lower mean Oswestry Disability Index than did group B (P < 0.05). At the final follow-up, group A had a lower mean visual analog scale pain score and a lower mean ODI than did group B (P < 0.05). Group A had a smaller kyphotic angle loss (1.2° ± 0.6°) and loss rate (4.8% ± 2.5%) than did group B (P < 0.05). The procedure of posterior unilateral vertebral lamina fenestration debridement and bone grafting fusion combined with laminar reconstruction and internal fixation is safe and effective in treating monosegment spinal tuberculosis. Compared with the conventional posterior-only approach, this method maximizes the retention and reconstruction of the posterior column and is minimally invasive, achieving faster postoperative recovery with fewer complications.

Comparison of four different internal fixation methods in the treatment of distal clavicle fractures

This study compared the clinical efficacy of four internal fixation methods in the treatment of distal clavicle fractures, in an effort to guide appropriate selection and application in the clinic. Eighty-four patients with distal clavicle-comminuted fractures were treated with a distal clavicle anatomic plate (group A), clavicular hook plate (group B), double-plate vertical fixation (group C), or T-shaped steel plate internal fixation (group D). The Constant-Murley scoring system was used to evaluate the shoulder joint function. The fracture healing time, VAS, and postoperative complications were compared and analyzed among the four groups. According to the Constant-Murley evaluation standard, the excellent and good rates of the four groups were 94.4, 73.1, 95 and 80% in groups A-D, respectively. The excellent and good rates of Constant-Murley evaluation standard in groups A and C were significantly better than those in groups B and D (P<0.05). VAS in the distal clavicle anatomic plate group (group A), double-plate vertical fixation group (group C), and T-shaped steel plate internal fixation group (group D) were significantly better than the clavicular hook plate group (group B) (P<0.05). The incidence of postoperative complications in the clavicular hook plate group (group B) was 15.4% and in the T-shaped steel plate internal fixation group (group D) was 15%, which were significantly higher than those of the distal clavicle anatomic plate group (group A) and double-plate vertical internal fixation group (group C) (P<0.05). The treatment of distal clavicle fractures using either one of the four internal fixation techniques can obtain better clinical results. The distal clavicle anatomic plate and double-plate vertical internal fixation techniques are associated with a decreased incidence of shoulder pain, an increase in the range of motion of the shoulder, and a reduction in complications, and thus, are preferable for the early functional recovery of limbs.

Outcomes of internal fixation versus hemiarthroplasty for elderly patients with an undisplaced femoral neck fracture: a systematic review and meta-analysis

BackgroundAlthough internal fixation has been the main treatment option for elderly patients with an undisplaced femoral neck fracture, it is associated with a high reoperation rate. Some surgeons have discussed the use of hemiarthroplasty, but there is limited literature comparing these two treatment modalities. In this study, we compared the perioperative results of hemiarthroplasty with internal fixation for undisplaced femoral neck fractures.MethodsWe performed a comprehensive review of literatures on PubMed, Web of Science, Embase, and the Cochrane Library for randomized controlled trials and comparative observational studies. Of the 441 studies initially identified, 3 met all inclusion criteria. Two reviewers independently graded study quality and abstracted relevant data including reoperation rate, mortality rate, Harris Hip Score (HHS), length of hospital stay, and operation duration.ResultsOur results revealed that hemiarthroplasty was associated with a lower reoperation rate than the internal fixation group (OR 4.489; 95% CI 2.030 to 9.927). Mortality rate at postoperative 1 month and 1 year and HHS at postoperative 1 year and 2 years were not different. Length of hospital stay (SMD − 0.800, 95% CI − 1.011 to − 0.589) and operation duration (SMD − 2.497, 95% CI − 2.801 to − 2.193) were shorter in the internal fixation group.ConclusionsCompared with the internal fixation group, patients that underwent hemiarthroplasty had a lower reoperation rate and an equivalent overall mortality rate. Our meta-analysis suggests that hemiarthroplasty might be a better treatment choice than internal fixation in treating elderly patients with an undisplaced femoral neck fracture.

Outcome of fracture calcaneum managed by conservative versus operative methods a randomized comparative study

Background: Calcaneal fracture is a complex injury that represents 1%–2% of all fractures. However, they make up 60% fractures of the midfoot bones. Due to challenging management of calcaneal fractures, we decided to evaluate the long term outcome of the same. Method: In this series of 61 calcaneal fractures 11 fractures were treated by open reduction and internal fixation method, 16 fractures by percutaneous reduction technique and 34 were treated conservatively, Creighton-Nebraska scoringhas been chosen, being based on results rather than radiographic criteria. Our average duration of follow is 18 months.Results: In this study total 61 feets of 50 patients. Com90. 9%) had excellent results with 1 fair result in open reduction group with internal fixation group. 5 excellent (31. 2%) with 10 good (62. 5%) and 1 fair (6. 3%) result were obtained in percutaneous reduction group. No patient from operative group and percutaneous reduction group showed poor result. There were Only 3 excellent (8. 8%) results with 10 good (29. 5%), 13 fair (38. 3%), and 8 poor (23. 5%) results in conservative group of patients plication included infection, plantar fascitis, subtalar arthritis.Conclusion: our conclusion is that intra articular fractures of calcaneum should be approached in more practical and scientific manner so that normal anatomy of the subtalar joint and overall shape of the calcaneum can be restored with early range of motion.

Outcomes of Hindfoot and Ankle Arthrodesis in Neuropathic Patients

Category:Ankle Arthritis, Diabetes, HindfootIntroduction/Purpose:Charcot neuropathy of the ankle and hindfoot is a progressive and destructive process that can lead to instability and ulceration resulting in significant morbidity which can end with amputation. The foot and ankle surgeon’s aim is to reconstruct the high risk foot with the creation of a stable plantigrade foot, while reducing the risk of ulceration and allowing the patient to mobilize in commercially available footwear. There are numerous techniques for the reconstruction of the neuropathic hindfoot, but the most utilized of these include multiplanar external fixation or internal fixation with a plate or intramedullary nail. It is our goal to further elucidate outcomes of Charcot patients undergoing corrective ankle and hindfoot fusion comparing internal versus external fixation.Methods:We retrospectively collected 377 patients undergoing hindfoot and ankle arthrodesis at our institution from 2006- 2017. 77 patients were identified that underwent arthrodesis for Charcot arthropathy, 56 of which met our inclusion and exclusion criteria. This included 47 who had internal fixation as their primary procedure and 9 patients who underwent external fixation with a multi-planar external fixator. Our median follow up time was 3.4 years (IQR .5 to 12.9). Preoperatively we collected basic demographic variables, reasons for neuropathy, and ulcer status. Postoperatively we collected complications including infection, hardware failure, ulceration, recurrent deformity, and radiographic outcomes including union and hardware backout. Reoperation numbers and indications were also collected. Our primary outcome was limb salvage at final follow up.Secondarily, we collected final ambulatory and footwear status.Results:The limb salvage rate was 82% with 10 patients undergoing amputation, which did not vary between groups (p=.99). The primary reasons for amputation were persistent infection (4 of 10) and nonunion (4 of 10). Thirteen (24%) patients developed an infection. The median number of reoperations per patient was 1 (IQR 0-2) with the patients who underwent amputation undergoing a median of 2 (IQR 2-4) reoperations. The rate of union was 54%, occurring at a median of 26.5 (IQR 12-47) months. 44% (4/9) of patients in the external fixation group had a preoperative ulceration versus 19% (9/47) of the patients in the internal fixation group (p=.19). Preoperative ulceration was not a risk factor for amputation. Forty-two (75%) patients were ambulatory at final follow up.Conclusion:We report on the single largest series of Charcot patients undergoing hindfoot and ankle arthrodesis. The surgical management of this population has a high rate of complications with infection and reoperation being common. Despite a high nonunion rate most patients are able to ambulate in a brace or orthotic. Limb salvage can be expected with either internal or external fixation techniques.

Computed Tomographic Image Analysis of Proximal Femoral Nail Antirotation and Dynamic Hip Screw in the Treatment of Intertrochanteric Fractures

Objective: Based on the observation of Computed Tomography (CT) image analysis technique, the efficacy of Proximal Femoral Nail Antirotation (PFNA) and Dynamic hip screw (DHS) in the treatment of intertrochanteric fractures in the elderly was analyzed. Methods: Thirty-nine elderly patients with unstable intertrochanteric fractures were randomly divided into two groups: 19 patients in the DHS internal fixation group and 20 patients in the PFNA group. They were treated with DHS and PFNA internal fixation, and were observed based on CT image analysis techniques. The patient performs follow-up testing of the procedure before and after surgery. Results: There was a statistically significant difference in mean operative time and intraoperative blood loss between the groups (P &lt; 0.01). The incidence of intraoperative and postoperative complications was statistically different between the two groups (P &lt; 0.05). The incidence of postoperative and postoperative complications in the PFNA group was lower than that in the DHS group. The excellent and good rates of DHS group and PFNA group were 89.47% and 95.00%, respectively. There was no significant difference between the two groups (P &gt; 0.05). There was a significant difference in fracture healing time between the PFNA group and the DHS group (P &lt; 0.01). Discussion: Compared with DHS, PFNA has the advantages of short operation time, low bleeding volume and short hospital stay. There were 7 cases of internal fixation failure or non-union in the DHS group and 1 case of delayed healing in the PFNA group. Conclusion: DHS and PFNA were used to treat intertrochanteric fractures in the elderly. After observation by CT image analysis technique, there was no significant difference in efficacy. The average operative time of PFNA was the shortest, the intraoperative blood loss was the least, the incidence of intraoperative and postoperative complications was low, and the fracture healing time was short. PFNA has a lesser effect on the blood circulation and bone destruction at the fracture end, and it is more secure. It is a reasonable surgical method for the treatment of senile osteoporotic intertrochanteric fractures.

Clinical and Radiological Outcomes After Surgical Treatment of Lower Limb Fractures in Patients With Spinal Cord Injury.

Study Design:Retrospective observational study.Objectives:To analyze the clinical and radiological outcomes of lower limb fractures following surgical treatment in patients with chronic spinal cord injury (SCI).Methods:Between January 2003 and December 2015, 102 chronic SCI patients with a lower limb fracture were surgically treated at our hospital. A total of 58 patients met the inclusion criteria and were recruited for final analysis. Patients with 2-stage procedure or incomplete clinical records with lost-to-follow-up were excluded from the study. Patients were divided into 2 groups (group 1= internal fixation; group 2 = external fixation). Primary outcome measures were to identify the number of nonunions via Kaplan-Meier analysis and the time to bone consolidation. The diagnosis of a pseudarthrosis was made after more than 180 days of consolidation time. Considering the Kaplan-Meier analysis, pseudarthrosis was interpreted as treatment failure. Secondary outcome measure was to evaluate the complication rate with special focus on heterotopic ossification.Results:A total of 58 chronic SCI patients with closed bone fractures were included in this study. Fifty-two fractures (88%) were simple and 7 (12%) were complex (type C) fractures according to AO classification. The majority of patients (34 cases, 59%) developed femur fractures followed by 24 tibial fractures (41%). Seventeen patients received an external (29%) and 41 an internal fixation (71%). Bone consolidation was reported in 31 patients (53%) with a mean time interval of bone consolidation after 97 days (range from 45 to 160 days; SD = 30). The reported nonunion (pseudarthrosis) rate was 47%. Comparing the internal group (n = 15 patients) versus the external group (n = 14), we could not find any significant difference (P = .939) concerning the bone consolidation time. The Kaplan-Meier analysis showed a 75% cumulative survivorship at 120 days (internal group) versus 111 days (external group). Most common postoperative complications occurred in the internal fixation group with Wound infections being predominantly observed (10%), followed by heterotopic ossifications (8%).Conclusions:Our results show that surgical treatment of lower limb fractures in chronic SCI patients is a challenging treatment with a high pseudarthrosis rate in both groups. The complication rate seems to be lower in the patients treated with external fixation. As a clinical recommendation, longer implants should be used for a stable osteosynthesis since SCI patients seem to have a higher load on the osteosynthesis material due to missing sensomotoric feedback.

Comparison between non-fusion and fusion internal fixation with posterior pedicle screw for odontoid fracture

Objective To investigate the clinical efficacy of non-fusion and fusion internal fixation with posterior pedicle screw for odontoid fractures. Methods A retrospective case control study was conducted to analyze the clinical data of 46 patients with odontoid fractures admitted to Henan Provincial People's Hospital from January 2013 to June 2015. There were 35 males and 11 females, aged 19-62 years [(36.9±1.6)years]. The preoperative odontoid fractures were classified as type IIA in five patients, type IIB in eight, type IIC in 22, shallow type III in six according to Anderson and D'Alonzo typing. The fractures of five patients were not classified. According to the ASIA grading, the preoperative spinal cord function was graded as D or E in the 46 patients. Among the patients, 15 underwent posterior pedicle screw non-fusion internal fixation (Group A), with 60 pedicle screws removed 12-29 months after operation. A total of 31 patients were treated with fusion internal fixation with posterior pedicle screw (Group B), with 124 pedicle screws free from removal after operation. The follow-up time, operation time, intraoperative fluoroscopy time, intraoperative blood loss as well as visual analog scale (VAS), cervical rotation degree, and neck disability index (NDI) before operation, 1 year after surgery (when no internal fixation was removed) and at the last follow-up were compared between the two groups. Results There were no significant differences between the two groups in the follow-up time, operation time, intraoperative fluoroscopy time, intraoperative blood loss, VAS score, neck rotation degree, NDI score before operation and at 1 year after operation (P>0.05). There were significant differences between two groups in VAS scores, neck rotation degree, NDI scores indicating driving and walking and recreational activities at the last follow-up (P 0.05). Conclusions Posterior pedicle screw internal fixation for odontoid process fracture has good curative effect. Non-fusion internal fixation with posterior pedicle screw is more conducive to the recovery of cervical spine rotation function, the relief of neck and back pain, and the improvement of patients' driving, walking and entertainment activities. Key words: Odontoid process; Fracture fixation, internal; Pedicle screw

Preliminary application of Starr reduction framecombined with O-arm navigation systemin the treatment ofcomplex pelvic fractures

Objective To investigate the feasibility and short term clinical efficacy of early minimally invasive treatment of complex pelvic trauma with Starr reduction frame combined with O-arm navigation system. Methods From June 2017 to December 2018, thirty two patients with Tile C complex pelvic fractures were prospectively divided into two groups according to the random number table. The open treatment group included 17 cases (open reduction and internal fixation group; 10 males and 7 females, age 24-60 years, average 37±6.5 years; according to Tile classification, 8 cases of C1 type, 8 cases of C2 type and 1 case of C3 type; according to the Denis classification of sacral fractures, 9 cases in zone I, 6 cases in zone II and 2 cases in zone III). The combined treatment group included 15 cases (Starr reduction frame group combined with O-arm navigation system, 8 males and 7 females, age 32-57 years, average 40±5.2 years; according to Tile classification, 8 cases of C1 type, 6 cases of C2 type and 1 case of C3 type; according to the Denis classification of sacral fractures, 8 cases in zone I, 5 cases in zone II and 2 cases in zone III). The ilioinguinal and Stoppa approaches were used in the open treatment group, and the anterior and posterior ring injuries were fixed with reconstruction plate screws and hollow screws, respectively. In the combined treatment group, starr frame was used to assist reduction, combined with O arm navigation technique, infix internal fixation frame, superior pubic branch screw, sacroilium screw were used to fix the anterior and posterior ring injury. The quality of pelvic fracture reduction was evaluated by the Matta scoring system, and the Majeed score was used to evaluate the clinical efficacy. Results All patients were followed up for 6 to 12 months. The hospitalization time (45±11 d), operation time (220.0±49.4 min) and fracture healing time (24.0±5.6 weeks) in the open treatment group were longer than those in the combined treatment group (21±9 d, 180.0±24.2 min, 16.1±3.8 weeks), and the intraoperative blood loss (820.0±140.4 ml) was significantly higher than that in the combined treatment group (24.0±10.4 ml)(t=6.651, 2.772, 6.128, 22.874; all P< 0.05). According to Matta scoring system, in the open treatment group, there are 8 excellent cases, 6 good cases, 2 fair cases, 1 poor case, thus the excellent and good rate was 82.4%(14/17). While 9 cases were excellent, 5 good, 1 fair, and the excellent and good rate was 93.3% (14/15) in the combined treatment group. At the latest follow-up, Majeed score was 51-85 points in the open treatment group, including excellent in 8 cases, good in 6 cases, fair in 2 cases, poor in 1 case, thus the excellent and good rate 82.4% (14/17), and the Majeed score was 75-95 points in the combined treatment group, including excellent in 9 cases, good in 5 cases, fair in 1 case, thus excellent and good rate 93.3% (14/15). There was a statistically significant difference between the two groups of Matta score and Majeed score (χ2=0.034, 0.040; P< 0.05). Surgical infection occurred in 4 cases in the open treatment group and healed after debridement and treatment with sensitive antibiotics. The incidence of complications was 23.5% (4/17). In the combined treatment group, 2 cases had anterolateral thigh skin sensory loss after operation, and the symptoms were relieved after mannitol, mecobalamine treatment and removal of internal fixations. One patient had hematoma of the gluteus maximus muscle after operation. The result of angiography showed that the INFIX screw was too long and perforated near the foramen of the ischium, resulting from the injury of the superior gluteal artery. After stopping the use of anticoagulant, intravenous infusion of tranexamic acid, blood transfusion, etc., the patient was cured and discharged from hospital. The incidence of complications was 20.0% (3/15). There was no significant difference in the incidence of complications between the two groups. Conclusion With the help of starr reduction frame, the early reduction and minimally invasive treatment of pelvic fracture can be realized, and the amount of intraoperative bleeding can be reduced. The combined application of o arm navigation can improve the accuracy and safety of sacroiliac screw and anterior column screw placement, reduce the radiation dose and frequency of operators and patients, shorten the operation time and improve the curative effect. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Surgery, computer-assisted

Closed reduction and internal fixation versus transtarsal sinus small incision internal fixation for Sanders type II calcaneal fractures

To compare the clinical effects of closed reduction and internal fixation with limited transtarsal sinus incision in the treatment of Sanders type II calcaneal fractures. From June 2015 to February 2018, 60 patients with Sanders type II calcaneal fractures were treated by minimally invasive method. According to the different treatment methods, they were divided into two groups: closed prying reduction and internal fixation with hollow nails(group A) and limited transtarsal sinus incision internal fixation (group B). There were 34 cases in group A, including 22 males and 12 females, aged 21 to 60(38.90±3.25) years old, 14 cases of Sanders type IIA, 14 cases of Sanders type IIB and 6 cases of Sanders type IIC. There were 20 cases in group B, including 14 males and 6 females, aged 20 to 59(39.20±2.96) years old, 8 cases of Sanders type IIA, 9 cases of Sanders type IIB and 3 cases of Sanders type IIC. Calcaneal height, calcaneal width, Gissane angle and Bohler angle were measured before and after operation. The complications, hospitalization time and cost were compared. Functional evaluation was performed by AOFAS score system one year after operation. Fifty-four cases were followed up for 6 to 16(11.40±2.55) months and 6 cases were lost. All the wounds healed in grade A without complications such as skin infection and necrosis. There were 1 case of nerve injury in group A, 2 cases of tendon entrapment, 2 cases of nerve injury in group B, there was no significant difference(P>0.05). There was no significant difference in calcaneal width, height, Bohlers angle and Gissane angle between group A and group B (P>0.05). There was no significant difference in AOFAS score between group A and group B(89.2±4.7 vs 88.7±4.8, P>0.05). The hospitalization expenditure and length of stay in group A were(5 021.25±1 047.19) yuan, (6.31±4.75) d, and those in group B were(13 591.35±1 975.21) yuan, (9.65±3.42) d, respectively, with significant difference(P<0.05). Closed reduction and internal fixation is as effective as transtarsal sinus incision reduction and internal fixation for Sanders typeIIfracture. It has the advantages of less trauma and fewer complications. Closed reduction and hollow nail fixation group can significantly shorten hospitalization time, reduce hospitalization costs, and is more economical. It is worth recommending, but attention should be paid to avoid choosing to comminute serious calcaneal fracture.

Comparison of Fragment Removal Versus Internal Fixation for Treatment of Pipkin I Femoral Head Fractures: A Finite Element Analysis

Fragment removal and internal fixation are the principle treatments for Pipkin type I femoral head fractures. The aim of this study was to compare, using a finite-element method, changes in stress on the femoral head after 2 different operation types. A three-dimensional (3D) finite-element model of a Pipkin type I femoral head fracture was generated with MIMICS and ABAQUS software. A 3D numerical screw model was reconstructed based on data from BIOFIX and using SOLIDWORKS software. The screw was implanted in the fragment and femoral head to reconstruct the implantation. Stress changes on the femoral head after removal of the fragment and internal fixation were investigated. Mean stresses along 13 points were 16.94 ± 16.79 MPa in the fragment removal group and 14.17 ± 14.08 MPa in the internal fixation group (P &amp;lt; 0.05). Random tests indicated that the mean stresses along 50 randomly determined points were 25.41 ± 12.12 MPa in the fragment removal group and 19.45 ± 14.62 MPa in the internal fixation group (P &amp;lt; 0.05). Compared with internal fixation, fragment removal led to greater stress that was more concentrated in the femoral head.

Minimally invasive surgical techniques for the therapy of far lateral disc herniation in middle-aged and elderly patients.

To examine the clinical results of different minimally invasive techniques for the therapy of far lateral disc herniation in middle-aged and elderly patients. Percutaneous endoscopic lumbar discectomy, MIS-TLIF combined with contralateral translaminar screw and MIS-TLIF combined with bilateral pedicle screws were evaluated via a retrospective chart review. Data from 74 consecutive middle-aged and elderly patients with far lateral disc herniation were analyzed. All patients underwent surgery; 19 with PELD, 24 with MIS-TLIF CTS, and 31 with MIS-TLIF BPS. Clinical data included the length of the incision, duration of the operation, blood loss, hospitalization time, operation cost, recurrence rate, and fusion rate. Preoperative and postoperative patient outcomes including the VAS, ODI scores and MacNab criteria were assessed and recorded. The mean follow-up time was 26.4 months (range from 14 to 46 months). Compared with the internal fixation groups, the length of the incision, duration of operation, blood loss, and hospitalization time were obviously lower in the PELD group. The difference in operation cost among the three methods was statistically significant. The postoperative VAS scores for LBP and LP decreased significantly as compared with those recorded preoperatively. The postoperative ODI scores were lower than those recorded preoperatively. MacNab criteria rating excellent, good and fair results were in 27, 37 and 10 patients, respectively. PELD, MIS-TLIF CTS, and MIS-TLIF BPS are all effective minimally invasive techniques for the therapy of single segment far lateral lumbar disc herniation in middle-aged and elderly patients. PELD had a shorter operation time and less surgical trauma, being a less invasive and more economical method; however, there was no recurrence of disc herniation after fixation. Compared with MIS-TLIF BPS, MIS-TLIF CTS obtained a similar fusion rate and certain costs were saved.