Objective To investigate whether combining use of platelet-rich plasma (PRP) and decalcified bone matrix (DBM) has synergistic action on promoting bone consol idation and heal ing. Methods Forty male New Zealand rabbits (weighing 2.2-2.8 kg) were randomly divided into 4 groups (n=10). The whole blood was extracted from the central aural artery and PRP was prepared with the Landesberg’s method. An 1 cm-defect was made below the tibiofibular joint of the lefttibia through osteotomy. In group A, defect was repaired by distraction osteogenesis (1 cm); in group B, defect was repaired with 0.5 cm DBM and then by distraction osteogenesis (0.5 cm); in group C, defect was repaired by distraction osteogenesis (1 cm) and local injection of 1 mL PRP; in group D, defect was repaired by 0.5 cm DBM combined with 1 mL PRP and then by distraction osteogenesis (0.5 cm). Then lengthening started at 7 days after operation, at a rate of 1 mm/day and 0.5 mm every time for 10 days (groups A and C) or for 5 days (groups B and D). After the lengthening, the consolidation was performed. The X-ray films were taken at 0, 12, 17, 27, and 37 days after operation. At 37 days after operation, the tibial specimens were harvested for Micro-CT scanning, three-dimensional reconstruction and biomechanical test. Results The X-ray films showed that new bone formation in groups B and C was obviously better than that in groups A and D at 37 days. The bone mineral density (BMD), bone mineral content (BMC), and bone volume fraction (BVF) of groups B and C were significantly higher than those of groups A and D (P lt; 0.05); the BMD and BMC of group C were significantly higher than those of group B (P lt; 0.05); the BVF had no significant difference between groups B and C (P gt; 0.05). There was no significant difference in BMD, BMC, and BVF between groups A and D (P gt; 0.05). The trabecula number (Tb.N) of group C was significantly more than that of other groups (P lt; 0.05), and the trabecula spacing (Tb.Sp) of group C was significantly smaller than that of other groups (P lt; 0.05), but no significant differencewas found among other groups (P gt; 0.05). There was no significant difference in the trabecula thickness among 4 groups (P gt; 0.05). The ultimate angular displacement had no significant difference among 4 groups (P gt; 0.05). The maximum torque of groups B and C was significantly higher than that of groups A and D (P lt; 0.05); the maximum torque of group C was significantly higher than that of group B (P lt; 0.05); no significant difference was found between groups A and D (P gt; 0.05). Conclusion In the rabbit bone defect/lengthening model, local injection of PRP can enhance bone consol idation effectively during consol idation phase. In normal distraction rate, DBM can promote bone consol idation during distraction osteogenesis. In the early stage of distraction osteogenesis, combining use of DBM and PRP can not further promote bone consolidation and healing.
Objective To evaluate the effectiveness of posterior malleolus fixation on the function of ankle in patients with ankle fracture. Methods Between June 2007 and June 2009, 110 patients with ankle fracture were treated with posteriormalleolus fixation in 59 patients (fixation group) or without fixation in 51 patients (non-fixation group). In fixation group, there were 31 males and 28 females with an average age of 62.6 years (range, 19-75 years); the causes of injury included traffic accident (20 cases), falling (18 cases), and sprain (21 cases) with a disease duration of 1-3 days (2.2 days on average); and the locations were left ankle in 32 cases and right ankle in 27 cases, including 6 cases of type I, 23 of type II, 19 of type III, and 11 of type IV according to the ankle fracture clssification. In non-fixation group, there were 38 males and 13 females with an average age of 64.5 years (range, 16-70 years); the causes of injury included traffic accident (15 cases), falling (12 cases), and sprain (24 cases) with a disease duration of 1-3 days (2.5 days on average); and the locations were left ankle in 22 cases and right ankle in 29 cases, including 8 cases of type I, 16 of type II, 19 of type III, and 8 of type IV according to the ankle fracture clssification. There was no significant difference in general data between 2 groups (P gt; 0.05). Results All patients of 2 groups achieved wound heal ing by first intention. The patients were followed up 12-18 months (16 months on average). X-ray films showed that fractures healed at 8-12 weeks (10 weeks on average) in fixation group and at 10-14 weeks (12 weeks on average) in non-fixation group. There were significant differences in the cl inical score (89.28 ± 8.62 vs. 86.88 ± 9.47, P lt; 0.05), postoperative reposition score (33.34 ± 2.15 vs. 31.24 ± 2.89, P lt; 0.05), and osteoarthritis score (13.22 ± 1.66 vs. 12.46 ± 2.03, P lt; 0.05) according to Phill i ps ankle scoring system between 2 groups at last follow-up. There was no significant difference in cl inical score of type I and II patients between 2 groups (P gt; 0.05), but significant differences were found in cl inical score and osteoarthritis score of type III and IV patients between 2 groups (P lt; 0.05). There were significant differences in the postoperative reposition score between 2 groups in all types of fractures (P lt; 0.05). Conclusion The posterior malleolus fixation may provide satisfactory cl inical functional outcomes for ankle fracture. Proper fracture classification and correct method of internal fixation are important for achieving good reduction and improving the long-term results.
Objective To review the recent advances in treatment of aseptic femoral shaft nonunion. Methods The clinical studies about the treatments of aseptic femoral shaft nonunion in recent years were widely reviewed and analyzed. Results There are several surgical methods for aseptic femoral shaft nonunion. Due to uncertain clinical outcome, dynamization of nail should be carefully selected. The exchange nailing is suitable for the hypertrophic nonunion of the isthmal femoral shaft fracture. The exchange lateral plating is suitable for nonunion with obvious malformation. However, wave plate or dual plate should be chosen when the bone nonuinon is combined with the medial defect. The augmentation plating improves the success rate of nailing for femoral shaft nonunion, but it should be carefully selected for patients with obvious deformity or bone defect. Ilizarov technique is suitable for various bone nonunion, especially with complicated or large segmental bone defects. Induced membrane technique is also an important method for the treatment of bone nonunion with large bone defects. The clinical efficacy of the blocking screw remains to be supported by further evidence. Biological stimulants are mainly used for atrophic nonunion, and the clinical efficacy of them alone are still controversial. Conclusion Due to lack of comparative studies between different surgical methods, the orthopedist should choose the appropriate treatment according to the individual situations of the patient and the types of bone nonunion.
ObjectiveTo summarize the evolving concept in treatment of intertrochanteric fractures and the development of internal fixation devices. MethodsRelated literature concerning the implant devices to treat intertrochanteric fractures was reviewed and analyzed in terms of the biomechanical characteristics, clinical application, and complications. ResultsThe treatment of intertrochanteric fractures has undergone an evolving concept from conservative treatment to surgical treatment. Surgery strategies include extramedullary fixation and intramedullary fixation. Intramedullary fixation has gradually become the main treatment of intertrochanteric fractures due to its minimally invasive and biomechanical advantages. However, the current intramedullary fixation system still can not reconstruct the medial cortical support of the proximal femur, which leads to some failures in the treatment of unstable fractures. ConclusionThe development of internal fixation of intertrochanteric fractures is based on the deep understanding and biomechanical theory of intertrochanteric fractures in clinical practice. In the future, the updated design of internal fixation devices will depend on the treatment principle of reconstruction of medial support and secondary stabilization of intertrochanteric fractures, and finally the purpose of improving success rate and reducing postoperative complications of intertrochanteric fracture will achieved.
ObjectiveTo review the literature about the clinical application and research progress on medial support augmentation of plate osteosynthesis for proximal humeral fractures, and to provide reference for clinical treatment.MethodsThe literature concerning medial support augmentation of plate osteosynthesis for proximal humeral fractures in recent years was extensively reviewed, as well as the biomechanical benefit and clinical advantage were analyzed thoroughly.ResultsMedial support augmentation of plate osteosynthesis for proximal humeral fractures is very important, especially in osteoporotic and/or comminuted fractures. Many medial support augmentation methods have been proposed which can be divided into extramedullary support and intramedullary support. It can also be divided into autogenous bone support and allogenic bone support according to the material and source, divided into medial column support, calcar support, and humeral head support according to the support site, and divided into fibular shaft support, femoral head support, anatomic fibula support according to the shape of the augmented fixation. At present, clinical and biomechanical researches show that medial support augmentation is an effective treatment for proximal humeral fractures.ConclusionAs an important treatment strategy for the treatment of proximal humeral fractures, the medial support augmentation of plate osteosynthesis gets the focus from the biomechanical studies and clinical treatment. However, there are still widespread controversies among orthopedic surgeons regarding the support mode, site, implant shape, and material of medial column support for augmentation of proximal humeral fractures. More high-quality clinical trials and biomechanical researches as well as multi-disciplinary integration, are needed to provide better strategy treatment for the treatment of proximal humeral fractures.
Objective To evaluate the effectiveness of the AO anatomical locking compression plate in treating type C distal humeral fracture. Methods Between July 2008 and April 2009, 13 cases of type C distal humeral fracture were treated with the AO anatomical locking compression plates. There were 5 males and 8 females with an average age of 52.1 years (range, 24-80 years). Fractures were caused by tumbl ing in 7 cases, by traffic accident in 4 cases, and by fall ing from height in2 cases. According to Association for Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) classification, there were 3 cases of type C1, 6 cases of type C2, and 4 cases of type C3. Two cases compl icated by ulnar nerve injuries, 1 by radial nerve injury, 2 by fractures of ulnar olecranon, 3 by fractures of other parts of extremities, and 6 by osteoporosis. The time from injury to hospital ization ranged from 3 hours to 4 days (0.9 day on average). Results All the incisions achieved heal ing by first intention. Thirteen cases were followed up 12 to 21 months with an average of 15.9 months. According to the X-ray films, unions were achieved both at fracture site and the olecranon osteotomy site with a heal ing time of 8 to 13 weeks (10 weeks on average). The function of elbows recovered from 3 to 32 weeks (10 weeks on average). No fixation failure, myositis ossifican, delayed union, or malunion occurred during the follow-up. The Mayo Elbow Performance score ranged from 75 to 100 with an average score of 95.8; the results were excellent in 9 cases, good in 3 cases, and fair in 1 case with an excellent and good rate of 92.3%. Conclusion The AO anatomical locking compression plate has a good fixation in treating type C distal humeral fracture. Through the approach of olecranon osteotomy, it is easy to get anatomical reduction, stable fixation, and early exercise.
ObjectiveTo develop an artificial intelligence based three-dimensional (3D) preoperative planning system (AIHIP) for total hip arthroplasty (THA) and verify its accuracy by preliminary clinical application.MethodsThe CT image database consisting of manually segmented CT image series was built up to train the independently developed deep learning neural network. The deep learning neural network and preoperative planning module were assembled within a visual interactive interface—AIHIP. After that, 60 patients (60 hips) with unilateral primary THA between March 2017 and May 2020 were enrolled and divided into two groups. The AIHIP system was applied in the trial group (n=30) and the traditional acetate templating was applied in the control group (n=30). There was no significant difference in age, gender, operative side, and Association Research Circulation Osseous (ARCO) grading between the two groups (P>0.05). The coincidence rate, preoperative and postoperative leg length discrepancy, the difference of bilateral femoral offsets, the difference of bilateral combined offsets of two groups were compared to evaluate the accuracy and efficiency of the AIHIP system.ResultsThe preoperative plan by the AIHIP system was completely realized in 27 patients (90.0%) of the trial group and the acetate templating was completely realized in 17 patients (56.7%) of the control group for the cup, showing significant difference (P<0.05). The preoperative plan by the AIHIP system was completely realized in 25 patients (83.3%) of the trial group and the acetate templating was completely realized in 16 patients (53.3%) of the control group for the stem, showing significant difference (P<0.05). There was no significant difference in the difference of bilateral femoral offsets, the difference of bilateral combined offsets, and the leg length discrepancy between the two groups before operation (P>0.05). The difference of bilateral combined offsets at immediate after operation was significantly less in the trial group than in the control group (t=−2.070, P=0.044); but there was no significant difference in the difference of bilateral femoral offsets and the leg length discrepancy between the two groups (P>0.05).ConclusionCompared with the traditional 2D preoperative plan, the 3D preoperative plan by the AIHIP system is more accurate and detailed, especially in demonstrating the actual anatomical structures. In this study, the working flow of this artificial intelligent preoperative system was illustrated for the first time and preliminarily applied in THA. However, its potential clinical value needs to be discovered by advanced research.
ObjectiveTo review the research progress of different surgical approaches in the treatment of acetabular both-column fractures.MethodsThe domestic and foreign related research literature on surgical approaches for acetabular both-column fractures was extensively consulted. The anatomical characteristics, exposure ranges, advantages, disadvantages, and indications of various common surgical approaches for both-column fractures were mainly summarized.ResultsThe ilioinguinal approach is more suitable for both-column fractures if the anterior column fracture is complicated or combined with the anterior wall fracture while the posterior column fracture is simple and stable. The modified Stoppa approach or the lateral (para) rectus abdominal approach is the preferred choice when both-column fractures are combined with a quadrilateral fracture or femoral head dislocation. What’s more, the Kocher-Langenbeck approach is required when the posterior column fractures are complicated or combined with posterior wall fractures. In addition, the simultaneous ilioinguinal and Kocher-Langenbeck approaches are the first choices when the both-column fractures possessing extremely severe and obvious displacement.ConclusionThe reasonable choice of surgical approach is extremely important for acetabular both-column fractures. Each surgical approach has its advantages and limitations. It is necessary to take the precise reposition of the acetabular joint surface as the principle, and comprehensively judge the fracture types and severity of anterior column, posterior column, and square area, and then select the optimal surgical approach for surgical treatment.
ObjectiveTo explore the effectiveness of triangular stabilization system in the treatment of postoperative nonunion of femoral neck fracture.MethodsThe clinical data of 30 patients with postoperative nonunion of femoral neck fracture who met the selection criteria between December 2014 and December 2019 were retrospectively analyzed. There were 21 males and 9 females with an average age of 40.7 years (range, 15-65 years). The Pauwels angle at the time of injury was 51°-79°, with an average of 63.6°. According to the Pauwels classification, they were all type Ⅲ. The time from the first operation to this revision operation was 5-24 months, with an average of 9.7 months. The preoperative visual analogue scale (VAS) score was 4.2±1.3, the Harris score was 31.2±5.3, the neck-shaft angle was (116.3±7.9)°, and the lower limb shortening length was (1.73±0.53) cm. Triangular stabilization system, which was made of dynamic condylar screw and medial anatomical buttress plate, combined with the window bone grafting at the fracture site was used for bone nonunion revision. The postoperative lower limb shortening length, neck-shaft angle, fracture healing time, and complications were recorded; the Harris score was used to evaluate the hip joint function, and the VAS score was used to evaluate the pain improvement before and after operation.ResultsAll patients were followed up 12-60 months, with an average of 27.7 months. There was no clear sign of femoral head necrosis and collapse after operation; 1 patient developed infection at 4 months after operation, and the incision healed after debridement and removal of internal fixator. All patients achieved bone healing, and the healing time was 2.8-6.0 months, with an average of 3.9 months. At last follow-up, the lower limb shortening length was (0.30±0.53) cm, which was significantly corrected when compared with preoperative one (t=16.721, P=0.000); the neck-shaft angle was (133.9±5.7)°, which was significantly recovered when compared with preoperative one (t=−11.239, P=0.000). The VAS score was 0.7±0.9, the Harris score was 88.3±5.9, both of which were significantly improved when compared with preoperative scores (t=16.705, P=0.000; t=−40.138, P=0.000).ConclusionTriangular stabilization system combined with window bone grafting can provide a stable and balanced mechanical environment, promote fracture healing, and achieve satisfactory effectiveness in the treatment of postoperative nonunion of femoral neck fracture.
Objective To explore the value of wide-awake local anesthesia no tourniquet (WALANT) technique in the treatment of acute Achilles tendon rupture. MethodsIn a prospective randomized controlled trial, 48 patients with acute Achilles tendon rupture who met the criteria between March 2020 and October 2020 were randomly divided into two groups according to 1∶1 distribution, with 24 cases in each group. The study group used WALANT technique and the control group used epidural anesthesia with tourniquet for channel-assisted minimally invasive repair (CAMIR). There was no significant difference between the two groups in gender, age, injured side, cause of injury, distance from broken end of Achilles tendon to calcaneal tubercle, and time from injury to hospitalization (P>0.05). The operating room use time (from patients entering the operating room to leaving the operating room), intraoperative blood loss, hospital stay, and the highest pain score [using Numerical Rating Scale (NRS)] during operation and at 1 day after operation were recorded and compared between the two groups. The tourniquet adverse reactions in the control group were recorded. The functional recovery was evaluated by the scoring method of American Orthopedic Foot and Ankle Society (AOFAS) at 12 months after operation. ResultsThe operation was successfully completed in both groups. The operating room use time and hospital stay in the study group were significantly less than those in the control group (P<0.05), but the difference in the intraoperative blood loss between the two groups was not significant (t=0.429, P=0.670). There was no significant difference in the highest NRS score during operation between the two groups (t=1.671, P=0.101); the highest NRS score in the study group at 1 day after operation was significantly lower than that in the control group (t=−6.384, P<0.001). In the control group, 13 patients had different degrees of tourniquet adverse reactions, including tourniquet regional pain, local swelling, blisters, thigh numbness, and discomfort. The patients in both groups were followed up 12-18 months, with an average of 13.9 months. The motor function of all patients returned to normal at 12 months after operation. The difference in AOFAS scores between the two groups was not significant (t=0.345, P=0.731). There was no complication such as sural nerve injury, local infection, and secondary rupture in both groups. ConclusionThe application of WALANT combined with CAMIR technique in the treatment of acute Achilles tendon rupture has good anesthetic and effectiveness, avoids the adverse reactions of tourniquet, and reasonably saves social medical resources.