Background Minimally invasive surgery has become popular because of the lower incidence of wound complications. However, achieving an anatomic reduction that provides a satisfactory outcome is difficult using minimally invasive surgery. Our study aimed to evaluate the reduction and clinical outcomes of closed reduction and percutaneous fixation treatment using a closed reduction traction device for displaced intra-articular calcaneal fractures compared with traditional open reduction plate fixation using an extended lateral approach. Methods A total of 40 patients and 45 feet with calcaneus fractures from 2012 to 2016 were studied. The open reduction plate fixation group (24 feet) was compared to the closed reduction percutaneous fixation group (21 feet) with a traction device. The reduction assessments included length, width, height, Bohler’s angle, Gissane’s angle, and varus or valgus angle before and after surgery. The clinical outcomes included the American Orthopaedic Foot and Ankle Society hindfoot score and the visual analog score for pain, length of stay, and complication rate. Results The patients were followed up for an average of 16.53 ± 3.95 months. No significant differences in reduction were observed between the open and closed groups ( P > 0.05). The American Orthopaedic Foot and Ankle Society scores of the two groups were 80.29 ± 6.15 and 83.62 ± 6.95 (open versus closed) ( P = 0.0957). The visual analog scores of the open and closed groups were 1.50 ± 1.22 and 0.81 ± 0.87 ( P = 0.0364). The lengths of stay in the open and closed groups were 9.63 ± 2.72 days and 6.71 ± 1.85 days ( P = 0.0002). The complication rates of the open and closed groups were 20.8% (5/24) and 4.8% (1/21) ( P < 0.0001). Conclusions The closed reduction percutaneous fixation with traction device method may provide equivalent reduction results and superior outcomes for the length of stay, VAS score, and complication rate for displaced intra-articular calcaneal fractures.
BackgroundProximal humeral fracture is a common fracture. Different approaches have been utilized in the surgical intervention of three-part fractures. Our study is to evaluate the clinical outcomes and effectiveness of a modified anterolateral approach and intra-osseous portal in minimally invasive treatment for three-part proximal humeral fractures in comparison to the traditional deltopectoral approach.MethodsFrom March 2015 to September 2016, 13 patients with three-part proximal humeral fractures were treated with internal fixation through the modified anterolateral minimally invasive approach (MIPO). These cases were compared to 20 additional cases using the deltopectoral approach (DP). Clinical and radiographic evaluations were performed, including the constant score (CS) and range of motion in abduction, flexion/extension and external/internal rotation. Complications were recorded as well.ResultsAll patients were followed up for a mean time of 12.12 ± 4.01 months. At the latest follow-up, no significant differences (p < 0.05) were observed in terms of length of stay, range of motion for abduction, flexion or internal/external rotation of the shoulder, Constant score or visual analog scors (VAS) for pain. Elbow flexion (142.31 ± 8.32 vs. 123.00 ± 10.18), posterior shoulder extension (41.92 ± 5.22 vs. 35.50 ± 5.83) and postoperative VAS (4.38 ± 1.04 vs. 6.15 ± 0.99) were significantly better in the MIPO group than in the DP group (p < 0.05). No significant differences were detected in the radiographic evaluation, and complications including axillary nerve injury were not present.ConclusionThe use of the modified anterolateral approach and intra-osseous portal is safe and effective for minimally invasive reduction and plating treatment for three-part proximal humeral fractures.
BackgroundSacral fracture and sacral nerve injury remain problems in orthopedics, especially in a sacral fracture combined with an anterior sacral nerve injury. Treating a sacral nerve injury with open reduction neurolysis or more conservative treatment cannot meet the clinical needs. Open reduction sacral nerve neurolysis will increase the number of severe, life-threatening injuries, regardless of whether the anterior or posterior approach is used. In recent years, computer- and robot-assisted orthopedic surgery has emerged as part of many clinical treatments.MethodsFor an unstable pelvic fracture with an anterior sacral nerve injury, we established a comprehensive and integrated solution. To achieve closed reduction, minimally invasive fixation, and minimally invasive anterior sacral nerve neurolysis, the Starr Frame, navigation robot, and Da Vinci robot were jointly applied.ResultsThe Starr Frame is very helpful for closed reduction percutaneous fixation in complex pelvic fractures. In this study, a minimally invasive fixation technique for the navigation robot in the pelvic fracture was explored. Although the patient had delayed anterior sacral nerve compression pain after surgery, we developed an approach and surgical method using the Da Vinci robot to explore the sacral nerve by celiac decompression. The patient was relieved of nerve pressure and pain.ConclusionsThis treatment method could be an alternative treatment for pelvic fractures and sacral nerve injury. The application of this treatment is a safe and feasible option that can be employed to manage early and late nerve repair with sacral fractures when open surgery or conservative treatment is unsuitable.
Objective To compare the biomechanical stability of transsacral-transiliac screw fixation and lumbopelvic fixation for “H”- and “U”-type sacrum fractures with traumatic spondylopelvic dissociation. Methods Finite element models of “H”- and “U”-type sacrum fractures with traumatic spondylopelvic dissociation were created in this study. The models mimicked the standing position of a human. Fixation with transsacral-transiliac screw fixation, lumbopelvic fixation, and bilateral triangular fixation were simulated. Biomechanical tests of instability were performed, and the fracture gap displacement, anteflexion, rotation, and stress distribution after fixation were assessed. Results For H-type fractures, the three kinds of fixation ranked by stability were bilateral triangular fixation > lumbopelvic fixation > transsacral-transiliac screw fixation in the vertical and anteflexion directions, bilateral triangular fixation > transsacral-transiliac S1 and S2 screw fixation > lumbopelvic fixation in rotation. The largest displacements in the vertical, anteflexion, and rotational directions were 0.57234 mm, 0.37923 mm, and 0.13076 mm, respectively. For U-type fractures, these kinds of fixation ranked by stability were bilateral triangular fixation > lumbopelvic fixation > transsacral-transiliac S1 and S2 screw fixation > transsacral-transiliac S1 screw fixation in the vertical, anteflexion, and rotational directions. The largest displacements in the vertical, anteflexion, and rotational directions were 0.38296 mm, 0.33976 mm, and 0.05064 mm, respectively. Conclusion All these kinds of fixation met the mechanical criteria for clinical applications. The biomechanical analysis showed better bilateral balance with transsacral-transiliac screw fixation. The maximal displacement for these types of fixation was less than 1 mm. Percutaneous transsacral-transiliac screw fixation can be considered the best option among these kinds of fracture fixation.
BackgroundTo place the magic screw more simply, we established a set of reproducible fluoroscopic views and a standardized procedure of magic screw insertion.Materials and methodsThis study on the magic screw tunnel uses a three-dimensional reconstruction model and a skeleton projection. The 3D model of the pelvis was made to be transparent and it was rotated to the place where the ischial spine was just sheltered by the posterior wall of the acetabulum. The angles of this view projection were recorded in the transverse plane and coronal plane. Six cadaveric pelvises (three males, three female) were used to validate the proper projection angle of the C-arm fluoroscopy. The skeleton specimens were all positioned latericumbent on a radiolucent table.ResultIn all pelvis 3D models, all magic cylinders with a 7.3 mm diameter were successfully inserted along the bone structure tunnel in 30 3D pelvic models. The average angle of the transverse view rotated by the C-arm fluoroscopy was 162° in males and 157° in females, the angle of the coronal plane was 22° in males and 24° in females. The average distance between the front wheel of the C-arm machine and the middle axial line of the radiolucent bed was 43 cm in males and 43 cm in females. In skeleton pelvis research, all the screws were safely inserted using this method.ConclusionThe magic screw technique could be a good choice for the treatment of acetabular fractures, especially quadrilateral plate fractures. If the proper fluoroscopy view technique is used properly, the magic screw can be inserted rapidly and safely.
Background: It is difficult for the surgeon to measure pelvic displacement in the closed reduction operation for unstable pelvic fracture. We therefore developed a pelvic deformity measurement software program based on standardized radiographs. The objectives of the present study were to evaluate the inter-observer reliability of the program for measuring specific fracture types on preoperative pelvic films and to assess the validity of the measurement software program by comparing it with a gold standard. Methods: Twenty-five patients diagnosed with AO/OTA type B or C pelvic fractures with the unilateral pelvis fractured and dislocated were included in this study. Four separate observers repeatedly determined the translational and rotational patterns and outcomes using the software program and hand measurement, and calculated the displacement using computed tomography (CT) coupled with a three-dimensional (3D) CT model. The validity of the measurement software was calculated by assessing the consistency between the software measurements and the gold standard. Additionally, inter-observer reliability was assessed for the software. The software was also applied in preliminary clinical practice for closed reduction procedures. Results: The overall inter-observer reliabilities of the software program, CT coupled with 3D reconstruction, and hand measurements were high, with kappa values of 0.956, 0.958, and 0.853, respectively. The software showed validity similar to that of CT coupled with 3D reconstruction (0.939 vs. 0.969), and better than that of hand measurement (0.939 vs. 0.858). A preliminary clinical application demonstrated that the software is effective for guiding closed reduction of pelvic fractures. Conclusions: Our newly established pelvic deformity measurement program is a reliable and accurate tool for analyzing pelvic displacement patterns and can be used for guidance of closed reduction and planning of the reduction pathway.
Background: Pelvic fractures in trauma patients can be associated with substantial massive hemorrhage. Mainly hemostasis interventions consist of pelvic packing (PP) and endovascular intervention (EI), such as angiography-embolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA). Whether PP or EI should be given priority for the management of hemodynamic unstable patients with pelvic fractures is still under debate. This meta-analysis aims to find out the evidence-based recommendations to fill the gap in literature. Materials and Methods: PubMed, CENTRAL, and EMBASE was searched for articles published from Jan 1st, 2000 to Jan 31st, 2022. Eligible studies, such as retrospective cohort study, propensity score matching studies, prospective cohort study, observational cohort study, quasi-randomized clinical trial evaluating PP and EI (AE or REBOA) managing patients with hemodynamically unstable pelvic fractures, were included. Mean Difference (MD), relative risk (RR), and 95% confidence intervals (CI) were calculated employing fixed- or random-effects models depending on the heterogeneity of included trials. This meta-analysis was performed to compare the effectiveness of the two methods in terms of mortality, unstable fracture pattens, Injury Severity Score (ISS), systolic blood pressure (SBP), lactate (LA), base deficiency (-BE), hemoglobin preoperatively, blood transfusion requirement, the time to and of operation, the complications.Results: 15 trials enrolling 1,136 patients were analyzed with the total mortality of 28.4% (323/1136). In our study, there was no effect of PP preference on the ISS (PP 36.4±10.4 vs. EI 34.5±12.7,), SBP (PP 81.1± 24.3 mmHg vs. EI 94.2±32.4 mmHg), LA (PP 4.66±2.72 mmol/L vs. 4.85±3.45 mmol/L), BE (PP 8.14±5.64 mmol/L vs. 6.66±5.68 mmol/L), unstable fracture pattens (RR=1.10, 95% CI [0.63, 1.92]). The application of PP was associated with lower preoperative hemoglobin level(PP 8.11±2.28 g/dl vs. EI 8.43±2.43 g/dl, p<0.05), more preoperative transfusion(MD=2.53, 95% CI [0.01, 5.06]), less postoperative transfusion within first 24 hours(MD=-1.09, 95% CI [-1.96, -0.22]), shorter waiting time to intervention(MD=-0.93, 95% CI [-1.54, -0.31]), shorter operation time of intervention(MD=-0.41, 95% CI [-0.52, -0.30]). PP has lower mortality rate due to uncontrolled hemorrhage in the acute phase (RR= 0.41, 95% CI [0.22, 0.79]). There is neither difference on mortality due to other complications (RR=1.60, 95% CI [0.79, 3.24]), nor total mortality (RR=0.92, 95%CI [0.49, 1.74]) (p>0.05).Conclusions: We firstly reached a conclusion that PP, a reliable hemostatic method, had advantages of reducing the amount of postoperative transfusion, shortening the time of waiting and operating and decreasing the mortality due to uncontrolled hemorrhage in the acute phase, without raising the odds of mortality due to complications. PP should be given a high priority in resuscitating the most pelvic fractures with hemodynamically unstable, especially in case of bleeding from veins and fracture sites, as well as inadequate EI. Sometimes AE should be regarded as a complementary treatment in case of the relative stable branch artery injury, the recurrent hypotension and ongoing hypotension after PP. REBOA is recommended in temporally transporting the hemorrhagic shock patients and stopping fatal bleeding from the main artery or multiple-sources.
Objective: To compare the biomechanical stability of transsacral-transiliac screw fixation and lumbopelvic fixation for “H”- and “U”-type sacrum fractures with traumatic spondylopelvic dissociation.Methods: Finite element models of “H”- and “U”-type sacrum fractures with traumatic spondylopelvic dissociation were created in this study. The models mimicked the standing position of a human. Fixation with transsacral-transiliac screw fixation, lumbopelvic fixation, and bilateral triangular fixation were simulated. Biomechanical tests of instability were performed, and the fracture gap displacement, anteflexion, rotation, and stress distribution after fixation were assessed.Results: For H-type fractures, the three kinds of fixation ranked by stability were bilateral triangular fixation > lumbopelvic fixation > transsacral-transiliac screw fixation in the vertical and anteflexion directions, bilateral triangular fixation > transsacral-transiliac S1 and S2 screw fixation > lumbopelvic fixation in rotation. The largest displacements in the vertical, anteflexion and rotational directions were 0.57234 mm, 0.37923 mm and 0.13076 mm, respectively. For U-type fractures, these kinds of fixation ranked by stability were bilateral triangular fixation > lumbopelvic fixation > transsacral-transiliac S1 and S2 screw fixation > transsacral-transiliac S1 screw fixation in the vertical, anteflexion and rotational directions. The largest displacements in the vertical, anteflexion and rotational directions were 0.38296 mm, 0.33976 mm and 0.05064 mm, respectively.Conclusion: All these kinds of fixation met the mechanical criteria for clinical applications. The biomechanical analysis showed better bilateral balance with transsacral-transiliac screw fixation. The maximal displacement for these types of fixation was less than 1 mm. Percutaneous transsacral-transiliac screw fixation can be considered the best option among these kinds of fracture fixation.
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