Loss of the posteromedial support:a risk factor for implant failure after fixation of AO 31-A2 intertrochanteric fractures

Background:The purpose of this study was to analyze cases of AO31-A2 intertrochanteric fractures(ITFs)and to identify the relationship between the loss of the posteromedial support and implant failure.Methods:Three hundred ninety-four patients who underwent operative treatment for ITF from January 2003 to December 2017 were enrolled.Focusing on posteromedial support,the A2 ITFs were divided into two groups,namely,those with(Group A,n=153)or without(Group B,n=241)posteromedial support post-operatively,and the failure rates were compared.Based on the final outcomes(failed or not),we allocated all of the patients into two groups:failed(Group C,n=66)and normal(Group D,n=328).We separately analyzed each dataset to identify the factors that exhibited statistically significant differences between the groups.In addition,a logistic regression was conducted to identify whether the loss of posteromedial support of A2 ITFs was an independent risk factor for fixation failure.The basic factors were age,sex,American Society of Anesthesiologists(ASA)score,side of affected limb,fixation method(intramedullary or extramedullary),time from injury to operation,blood loss,operative time and length of stay.Results:The failure rate of group B(58,24.07%)was significantly higher than that of group A(8,5.23%)(χ2=23.814,P<0.001).Regarding Groups C and D,the comparisons of the fixation method(P=0.005),operative time(P=0.001),blood loss(P=0.002)and length of stay(P=0.033)showed that the differences were significant.The logistic regression revealed that the loss of posteromedial support was an independent risk factor for implant failure(OR=5.986,95%CI:2.667-13.432)(P<0.001).Conclusions:For AO31-A2 ITFs,the loss of posteromedial support was an independent risk factor for fixation failure.Therefore,posteromedial wall reconstruction might be necessary for the effective treatment of A2 fractures that lose posteromedial support.

Posteromedial approach of gastrocnemius for reduction and internal fixation of avulsed tibial attachment of posterior cruciate ligament

Objective： To introduce a posteromedial approach through the medial border of the medial head of gastrocnemius for reduction and reattachment of bony avulsiun of the posterior cruciate ligament （PCL） from the tibia. Methods ： Eleven patients with avulsed tibial attachment of the PCL underwent an operative reduction and internal fixation through the posteromedial approach of the gastrocnemius in our department from February 1998 to March 2000. The skin incision was reversed L-shaped along the medial border of the medial head of the gastrocnemius and the posterior capsule was exposed by dissecting the medial border and lateral retraction, avoiding the damage of the popliteal neurovascular structures. After that, the posterior capsule was vertically dissected a little medially to the posterior intercondylar sulcus and just on the posterior medial tibial eminence positioned by finger palpation. Then the PCL and its tibial attachment were easily accessible. In the delayed cases, PCL peripheral releasing was necessary to overcome the ligament retraction and to refresh the fracture bed for optimal reduction and bony healing. At last, one or two biodegradable screws were used to fix the avulsed bone segment and 30° flexion knee plaster cast immobilization was regularly applied after the wound was closed. The evaluation included X-ray, posterior sag sign and posterior drawer test compared with the contralateral side. The functional assessment of the low limbs was not available because of concomitant injuries. Results ： The posteromedial approach of the gastrocnemius used in repair of tibial attachment avulsed injury of the PCL could provide benefit of clear anatomical exposure, few blood loss （20 ml on average）, no need for detachment or reattachment of any structure. The patients were followed up for 11 months on an average （ranging from 6 months to 2 years ）. It demonstrated that bony healing was achieved within 4-6 weeks in cases of fresh injury and 7-9 weeks in cases of delayed injury. Six out of 8 fresh cases showed totally negative posterior sag sign or posterior drawer test but 2 had extra laxity for 1-2 mm. In 3 delayed cases, extra laxity for 3-4 mm was presented compared with the contralateral knee. Conclusions： The posteromedial approach of the gastrocnemius is ideal for internal fixation of avulsed tibial attachment of the PCL. It is fairly easy, safe, time-saving, applicable alternatives, in addition, the morbidity is rare and can also be used in management of posteromedial fracture of the medial femoral condyle and tibial plateau.

Analysis of the efficacy of a modified posteromedial approach for Klammer III posterior Pilon fractures

Purpose:To analyze the curative effect and technical points of a modified posteromedial approach in the treatment of Klammer III posterior Pilon fracture.Methods:A retrospective analysis of patients with Klammer III posterior Pilon fractures were conducted in our department from January 2018 to December 2019.Before the surgery,the patients were fully relieved of swelling and pain,and a comprehensive examination was carried out.The posteromedial approach exposed the posterior and medial fracture block of the distal tibia.According to the fracture of external malleolus,it is determined whether to combine a lateral incision and protect tendons and vascular nerves by a retractor,and then perform a fracture reduction and internal fixation.Postoperatively,the patients were treated with analgesia,detumescence,anticoagulation and rehabilitation exercise.The American orthopaedic foot and ankle society(AOFAS)score and visual analogue score were recorded at regular follow-up after surgery.A t-test was used for the comparison of the preoperative and final AOFAS score.Results:There were 7 male and 13 female(n=20)included in the study,aged 22 to 88 years(average age 54.2 years).The injury mechanisms were falling from a height(n=7),traffic accident(n=6),walking injury(n=2)and heavy injury(n=5).The postoperative follow-up duration was 12—24 months(mean 16.95 months).The AOFAS score of the 20 patients before and after surgery were compared.The preoperative AOFAS score was 38.90±3.91,and the final AOFAS score was 80.55±4.20,(p<0.001).The mean final visual analogue scores at rest,active and weight-bearing walking were 0.30,0.85 and 1.70,respectively.One patient reported poor postoperative wound healing and required a return to hospital for debridement and anti-infection treatment.Conclusion:In the treatment of Klammer III posterior Pilon fractures,the modified posteromedial approach can fully expose the fracture block and the collapsed articular surface of the medial malleolus,achieve good reduction and internal fixation with limited injury of the tendon and vascular nerves,and have a better prognosis.

Scoliocorrector Fatma-UI for correction of adolescent idiopathic scoliosis: Development, effectivity, safety and functional outcome

BACKGROUND Adolescent idiopathic scoliosis remains a major problem due to its high incidence,high risk,and high cost.One of the aims of the management in scoliosis is to correct the deformity.Many techniques are available to correct scoliosis deformity;however,they are all far from ideal to achieve three-dimensional correction in scoliosis.AIM To develop a set of tools named Scoliocorrector Fatma-UI(SCFUI)to aid threedimensional correction and to evaluate the efficacy,safety,and functional outcome.METHODS This study consists of two stages.In the first stage,we developed the SCFUI and tested it in finite element and biomechanical tests.The second stage was a single-blinded randomized clinical trial to evaluate the SCFUI compared to direct vertebral rotation(DVR).Forty-four subjects with adolescent idiopathic scoliosis were randomly allocated into the DVR group(n=23)and SCFUI group(n=21).Radiological,neurological,and functional outcome was compared between the groups.RESULTS Finite element revealed the maximum stress of the SCFUI components to be between 31.2-252 MPa.Biomechanical analysis revealed the modulus elasticity of SCFUI was 9561324±633277 MPa.Both groups showed improvement in Cobb angle and sagittal profile,however the rotation angle was lower in the SCFUI group(11.59±7.46 vs 18.23±6.39,P=0.001).Neurological and functional outcome were comparable in both groups.CONCLUSION We concluded that SCFUI developed in this study resulted in similar coronal and sagittal but better rotational correction compared to DVR.The safety and functional outcomes were also similar to DVR.

Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal

Arthroscopic surgery of the posterior compartment ofthe knee is difficult when only two anterior portals are used for access because of the inaccessibility of the back of the knee. Since its introduction, the posterior transseptal portal has been widely employed to access lesions in the posterior compartment. However, special care should be taken to avoid neurovascular injuries around the posteromedial, posterolateral, and transseptal portals. Most importantly, popliteal vessel injury should be avoided when creating and using the transseptal portal during surgery. Purpose of the present study is to describe how to avoid the neurovascular injuries during establishing the posterior three portals and to introduce our safer technique to create the transseptal portal. To date, we have performed arthroscopic surgeries via the transseptal portal in the posterior compartments of 161 knees and have not encountered nerve or vascular injury. In our procedure, the posterior septum is perforated with a 1.5-3.0-mm Kirschner wire that is protected by a sheath inserted from the posterolateral portal and monitored from the posteromedial portal to avoid popliteal vessel injury.

Symptomatic accessory soleus muscle:A cause for exertional compartment syndrome in a young soldier:A case report

BACKGROUND Accessory soleus muscle(ASM)is a rare congenital variation that is almost asymptomatic,but several papers have recently described symptomatic ASM.The clinical features of this condition are similar to tarsal tunnel syndrome(TTS)and include pain and numbness around the medial side of the ankle.ASM commonly originates from the fibula or soleus muscle and inserts into the Achilles tendon or calcaneus.Usually,it is identified as posteromedial swelling and definitely diagnosed by magnetic resonance imaging.In most cases,treatment is observation,but surgical excision can be considered if symptoms are severe.CASE SUMMARY A 23-year-old male Korean soldier presented with complaints of bilateral foot and ankle pain and a swelling medial to the Achilles tendon that was more pronounced on the right side.Symptoms first occurred after playing soccer 10 mo before this presentation,worsened after physical exertion,and were relieved by rest.He had no medical history,and no one in his family had the condition.Laboratory results were non-specific.Several tests were performed to exclude common diseases such as tumors or TTS.However,MRI revealed a bulky accessory soleus muscle in both feet,though the patient complained of more severe pain on the right side during physical activity.Accordingly,surgical resection was adopted.At surgery,a large accessory soleus muscle was noted anterior to the Achilles tendon with distinctive insertion from a normal soleus muscle.At 12 mo after surgery,there was no pain,numbness,or swelling of the right foot or ankle,no evidence of recurrence,and the patient could do all sports activities.CONCLUSION Accessory soleus muscle should be added to the list of differential diagnosis if a patient has pain,sole numbness or swelling of the posteromedial ankle.

Congenital Club Foot in Children Younger than 24 Months: Decancelous Cuboid Combined with Selective Soft Tissue Release

Purpose: To evaluate 2 surgical prosedures in treatment of congenital clubfeet in children younger than 24 months. Materials and methods: Data were analyzed on 319 patients (448 feet) from July 1990 to December 2005. Clinical and classification for all patients according to Diméglio. Operated patients were devided into two group: Group1, selective soft tissue release;and Group 2, selective soft tissue release combined with cuboid decancelation. Surgical result were classified according to McKay’s system. Results: There were 103 females (32.3%) and 216 males (67.7%) in this study. There were 192 patients (268 feet) in group 1, 127 patients (180 feet) in group 2. Bilateral involvement was found in 129 patients (40.4%), only the left foot affected in 65 patients (20.4%), and only the right in 125 patients (39.2%). According to the classification of Diméglio Grade II was seen in 32.4%, Grade III in 53,1%, and Grade IV in 14.5%. Postoperatively, in group 1, we got excellent result in 29.1%, good result in 49.2%, fair result in 18.3%, and poor result in 3.4%. In group 2, we attained excellent result in 50.6%, good result in 42.2%, fair result in 6.1% and poor result in 1.1%. The good to excellent result in group 2 was significantly higher in group 1 with p = 0.000042. There was no failure in both groups. Residual adduction of forefoot in frontal plane was seen in 78.0% of group 1, and 10.6% of group 2, which was also statistically significant with p ~ 0. Conclusion: Generally speaking, the procedure of selective soft tissue releases combined with cuboid decancelation showed an outstanding result with good to excellent result of 92.8%. Surgical procedure is simple, safe, and applicable for all patients with clubfeet’s deformyties.