胫骨中上段骨折合并胫骨平台骨折手术治疗48例

目的：探讨胫骨中上段合并胫骨平台骨折有效治疗方法。方法：胫骨中上段合并胫骨平台骨折患者48例，21例胫骨中上段骨折合并单纯外侧平台骨折患者，采取胫骨上段前外侧切口，2例合并单纯内侧胫骨平台骨折患者，采用内侧切口，选择胫骨近端段解剖型钢板内固定，合并髁问棘骨折的加用钢丝固定。25例合并双髁胫骨平台骨折患者中，9例骨折偏中前部则采取正中直切口或Y形切口，16例平台骨折部位位于偏后部采取两侧切口，内固定选择胫骨外侧放置长L形支持钢板，内侧放置短T形支持钢板。结果：共随访47例，随访时间12～24月。根据H S S膝关节临床功能评分，优30例，良12例，可4例，差l例，优良率89．36％。结论：对于胫骨中上段合并胫骨平台骨折手术治疗，首先选择好手术治疗时机，其次要具备良好的复位、稳定的内固定。合并单纯外侧平台骨折患者内固定选择胫骨近端段解剖型钢板，合并双髁胫骨平台骨折应选择双钢板内固定，可收到较好疗效。

双钢板内固定治疗胫骨平台双髁骨折30例疗效分析

目的：探讨双钢板内固定治疗胫骨平台双髁骨折的疗效。方法：对30例双髁骨折患者采用双钢板内固定治疗，并评价疗效。结果：术后随访1-3年，平均1．8年。Rasmussen临床评分：优20例，良6例，中4例，优良率86．7％；Rasmussen放射学评分：优18例，良10例，中2例，优良率93．3％。结论：双入路内外侧切开锁定钢板固定治疗胫骨平台双髁骨折可达到解剖复位、坚强内固定，早期行功能锻炼，且未发生软组织并发症，术后疗效满意。

AIRCAST加压冷疗系统在Pilon骨折术后应用疗效分析

目的:探讨AIRCAST加压冷疗系统在Pilon骨折术后的临床疗效。方法:将40例Ⅱ、Ⅲ型Pilon骨折术后患者随机分为两组,每组20例,A组(试验组)术后采用AIRCAST加压冷疗系统进行冷疗,B组(对照组)运用自制冰块冰敷。比较两组患者术后疼痛、肿胀程度及引流量。结果:两组研究对象术后6、24、48hVAS评分及踝关节周径减少值、术后6、24、48h切口引流量的变化差异有统计学意义。结论:Ⅱ、Ⅲ型Pilon骨折术后,AIRCAST加压冷疗系统较自制冰块冰敷更能早期缓解踝关节疼痛,减轻肿胀,减少切口出血,使患者能早期进行功能锻炼,促进踝关节功能早期康复。

支撑钢板固定后侧Pilon骨折45例疗效观察

目的:探讨支撑钢板固定后侧Pilon骨折的临床疗效。方法:收集的Pilon骨折患者90例,根据对患者所采用的固定方法的不同,将其分为对照组和试验组,每组各45例。试验组患者采取后侧支撑钢板固定,对照组的患者采取常规的钢板固定。结果:两组患者经过不同的固定手术治疗后,对照组的平均愈合时间和完全负重时间均明显长于试验组,两组间比较差异显著;对两组患者在手术后的并发症进行比较,对照组出现的并发症明显多于试验组。对照组出现7例切口感染、5例积血和5例肿胀;试验组出现1例切口感染,无积血和水肿现象发生。患者的切口感染、积血和水肿在两组间差异显著。结论:使用后侧入路支撑钢板固定方法治疗Pilon骨折,具有治疗效果显著、患者的愈合时间快、负重时间短,患者的切口感染、积血和水肿等并发症少。

A BIOMECHANICAL ANALYSIS OF UNILATERAL HOOKED-SULCATED EXTERNAL FIXATOR ON OSTEOMINED TIBIA

Four tibiae removed from 30-40 years males, who died of accidents in less than 12 hours, were os- teomized at medium part. Then these tibiae were fixed by an unilateral hooked-sulcated external fixator (UHSEF), and the bone-fixator system was used as a model of external fixation of tibial fracture. The axial compression, distraction, torsion, antero-posterior and lateral bending rigidly and the strain of the pins were determined in this system. Based on the results, we found that compared with the configuration of four paralled pins, the rigidity of the fan-like configuraton didn’t decrease significantly if the angle between lateral and medium pins was less than 45’. But the reverse was true when the frame separation increased from 5 to 8 cm. What’ more, the pin strain decreased if the rigidity of the system was improved. These data provided a theoretical basis of biomechanics for the improvement of UHSEF.

PERCUTANEOUS REDUCTION AND STABILIZATION OF COMPLEX TIBIAL PLATEAU FRACTURES

Mechanical traction and percutaneous reduction by leverage and fixation by a bilateral groove externalfixator were performed on 23 patients with complex tibial plateau fractures involving a depressed and splitfragments. The fixator is composed of two long groove frames, three to five nuts, hooked bolts and Stein-manns pins.All fractures united in good position in three months with no incision (only pinpricks), llttle operativetrauma and no significant complications but pintract infection, and the flexion-extension range of kneemovement was excllent in all patients, so that this technique is particularly advisable for complex tibialplateau fractures.

Classification to guide internal fixation for tibial fracture

Objective： To explore a classification method which can provide the clinical guidance for internal fixation of tibial fracture. Methods： The different fractures were fixed according to their mechanical classification. Totally, 71 cases of tibial plateau fracture, tibial proximal fracture, tibial distal fracture and Pilon fracture were analyzed to test this selective principle. Results： All 71 patients were followed up for 6-32 months. The displacement was seldomly observed in cases treated acccording to the classification principle, while some cases against the principle had postoperative displacement.The difference was statistically significant （P〈0.05）. It was proved that there was remarkable correlation between tibial fracture classification, internal fixator and fixation methods. Conclusion： Types Ⅲa3, Ⅲb 1 and Ⅲb2 fractures without eccentric moment should be fixed with double plates or angle-stable materials combined with locking structure, otherwise displacement may occur.

Comparative study on treatment of midshaft tibial fracture with expandable and interlocking intramedullary nails

Objective ： To evaluate the clinical results of treatment of midshaft tibial fracture with expandable intramedullary nails compared with interlocking intramednilary nails. Methods： From June 2003 to August 2005, 46 patients （27 males and 19 females, aged 20-74 years, mean =38.4 years ） with midshaft tibial fracture were treated surgically in our department. The causes of fractures were traffic injury in 21 patients, fall injury in 6, tumbling injury in 11 and crushing injury in 8. According to AO/ ASIF classification, Type A fracture was found in 16 patients, Type B in 11, Type C1 in 5, and Type C2 in 2. Open fractures were found in 12 patients, according to Gustilo classification, Type Ⅰ in 9 patients and Type Ⅱin 3 patients. Based on the patients＇consent, 24 patients were treated with expandable intramedullary nails （Group A ） and 22 with interlocking intramedullary nails （Group B ）. The operation time, blood loss during operation, X-ray fluoroscopic times, hospitalization time, weight bearing time after operation, healing time of fracture and complications of all the patients were recorded. The clinical effects of all the cases were evaluated according to the criteria of Johner-Wruhs. Results： All the patients were followed up for 12,34 months （ mean = 16.2 months）. The time of operation, the blood loss, X-ray fluoroscopic times, hospitalization time and healing time of fracture of Group A significantly decreased （P 〈 0.05 ） compared with those of Group B, but the time for weight bearing after operation, the Johner- Wruhs degree of clinical effects and complications had no significant difference between Group A and Group B （P〉0.05）. Conclusions： Expandable intramedullary nail can shorten operation time, decrease blood loss and reduce invasion, which is a safe and effective treatment method for tibial midshaft fracture.

Orthopaedic surgeon＇s nightmare： iatrogenic fractures of talus and medial malleolus following tibial nailing

Intramedullary interlocking nailing is the gold standard for treatment of tibial shaft fractures. The growing use of intramedullary nailing has resulted in an increased number of tibial nailing in daily clinical practice. Despite adequate surgeon experience, tibial nailing is not without complications if proper techniques are not followed. A case of iatrogenic talar neck and medial malleolus frac- tures during intramedullary nailing of tibia in a 24-year-old male is reported. It is believed to be caused by forceful hammering of insertion zig with foot dorsiflexed. To the best of our knowledge, no such case has been reported in the literature. It is possible to reduce the risk of this complication by adoption of preventive measures.

Triple plating of tibia in a complex bicondylar tibial plateau fracture

High-energy tibial plateau fracture poses a significant challenge and difficulty for orthopaedic surgeons. Fracture of tibial plateau involves major weight bearing joint and may alter knee kinematics. Anatomic reconstruction of the proximal tibial articular surfaces, restoration of the limb axis （limb alignment） and stable fixation permitting early joint motion are the goals of the treatment. In cases of complex bicondylar tibial plateau fractures, isolated lateral plating is frequently associated with varus malalignment and better results have been obtained with bilateral plating through dual incisions. However sometimes a complex type of bicondylar tibialplateau fractures is encountered in which medial plateau has a biplaner fracture in posterior coronal plane as well as sagittal plane. In such fractures it is imperative to fix the medial plateau with buttressing in both planes. One such fracture pattern of the proximal tibia managed by triple plating through dual posteromedial and anterolateral incisions is discussed in this case report with emphasis on mechanisms of this type of injury, surgical approach and management.

Influence of distal tibiofibular synostosis on ankle function

Objective： To study the influence of distal tibiofibular synostosis on ankle function. Methods： Prom October 1998 to October 2004, a total of 281 consecutive patients underwent operations because of ankle fractures or distal fractures of the tibia and fibula. Distal tibiofibular synostosis occurred after operation in 8 patients. The duration of follow-up averaged 20.6 months （14-44 months）. The ankle function was assessed on the basis of functional rating system described by Mazur. Results： According to Mazur＇s ankle evaluation system, 4 patients achieved an excellent result, 2 a good result and 2 a fair result. The dorsiflexion of the synostosis ankle reduced by 8.26 degrees as compared with that of the contralateral ankle, and there was little influence on the plantar flexion. All the patients had a normal gait. Conclusion： The distal tibiofibular synostosis after the operation of ankle fractures or distal fractures of the tibia and fibula usually gives rise to few symptoms and needs no specific treatment.

Octyl-a-cyanoacrylate adhesive in the treatment of tibial transverse fracture in rabbits

Objective: To observe the effect of octyl-a-cyanoacrylate upon bone healing and its degradation in vitro after middle tibial transverse fracture in rabbits, and to establish treatment of higher efficacy with the application of octyl-a-cyanoacrylate.Methods: Middle tibial transverse fracture model of New Zealand rabbits was established. In the experimental group, internal fixation with 2 mm Kirschner wires was performed and the broken ends were fixed with octyl-a-cyanoacrylate. In the control group, only internal fixation with 2 mm Kirschner wires was conducted. Animals were killed at preset time intervals of 2, 4, 6, 8, 10 and 12 weeks postoperatively and samples were harvested.Results: Two weeks after operation, clear fracture lines were observed in both the experimental and the control groups. Fibrous soft tissue connection was noted between the broken ends and there was soft tissue adhesion around the fracture site. There was no callus formation and the broken ends were surrounded by adhesive soft tissues. Obvious external callus formation was confirmed at 8 weeks after operation in both groups with partial disappearance of fracture lines. Ten and twelve weeks after the operation, fracture lines disappeared completely and there was obvious external callus formation and bone union. In the fourth week, fibrous cells and chondrocytes were found to grow into the colloid and surround it at the 6th week. The adhesive material was degraded and gradually absorbed at the 8th week. Chondrification was observed.Conclusions: Two weeks after fixation for tibial fracture in rabbits, octyl-a-cyanoacrylate begins in vivo degradation. Chondrocytes and fibrocytes gradually grow into the degradation area and surround the adhesive material, which broke into pieces at 8 weeks. Complete degradation and disappearance of the adhesive material is present between 10 and12 weeks. No barrier effect hampering fracture healing is noted.

A two-choice strategy through a medial tibial approach for the treatment of pilon fractures with posterior or anterior fragmentation

Objective： The anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. For complex fracture patterns a com- bined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported. In our retro- spective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment of pilon fractures with anterior or posterior fragmentation. Methods： Based on an anatomic study oftibial pilon fractures, we retrospectively analyzed the fractures with primary posterior, posterior-lateral or anterior, anterior-lat- eral （Tillaux-Chaput） involvement of the distal tibia. This retrospective study consisted of 18 patients with a closed tibial plafond fracture. The inclusion criteria were： （1） pre- sence of an anterior/anterolateral type fragment or a poste- rior （Volkmann） type fragment involving 〉25% of the articu- lar surface, （2） a minimum follow-up of 12 months, （3） a fibula fracture associated with a medial colunm fracture of the distal tibia, and （4） soft tissue conditions at the time of opera- tion that did not compromise the choice of surgical access （Tscheme classification for closed fractures： grade 0 and grade 1）. Tibial plafond fractures were classified into two groups： one presenting anterior and the other with poste- rior rim （Volkmann） fragments. Results： Most patients achieved a good clinical re- covery in terms of range of motion and Olerud-Molander scale scores. Only three patients presented a grade 2 os- teoarthritis at the 12 month follow-up. Conclusion： Our two-choice strategy highlights con- cepts which have been previously debated and described in the literature. But a new extended protocol for surgical approach to the distal tibia, including more fracture pat- terns and their association should be further investigated.

Hoffa fracture associated with femoral shaft and proxi-mal tibial fractures： report of two cases

Solitary coronal shear fractures of femo- ral condyle, such as Hoffa＇s fracture, are usually associated with supracondylar or intercondylar fractures of the femur. These fractures are rare and seen in the context of high energy mechanism leading to multiple injuries; therefore a thorough workup of the patient is required to rule out other significant injuries. Hoffa＇s fracture associated with femo- ral shaft and proximal tibial fractures is extremely rare and no such injury has been reported previously. We report two such cases which were managed with standard operativefixation techniques and demonstrated good to excellent func- tional outcome after a follow-up of one year. This report emphasizes that high index of suspicion is required for di- agnosis of these injuries and a thorough workup is manda- tory to rule out other associated injuries. We also propose a possible mechanism of injury.

Timing of internal fixation and effect on Schatzker IV-VI tibial plateau fractures

Objective： To study the effect of internal fixation performed at different times on therapeutic outcomes of Schatzker IV-VI tibial plateau fractureS. Methods： The clinical data of 42 cases ofSehatzker IV- VI tibial plateau fractures treated in our department were analyzed retrospectively. Among these 42 patients, 21 re- ceived surgical treatment within 12 h after injury, （Group I）, the other 2 [ were first treated by traction or piaster fixation followed by a delayed internal fixation after soft tissue swell- i ing subsided （Group II）. The surgical time, comPlications, length of hospital stay, cost of hospitalization, and time for i fracture union, as well as functional recovery were analyzed and compared between the two groups. Results： After 10-28 months follow-up （mean 16.5 months）, except 5 cases who lost to follow-upl no differ-ences were found between the two groups regarding surgi- cal time, preoperative and postoperative complications, heal- ing time or the Hospital for Special Surgery （HSS） score at the end of follow-up, but significant differences were found in the length of hospital stay, cost of hospitalization and HSS score at 3 months after operation （P〈0.05）. Conclusion： Under certain conditions, early internal fixation for Schatzker IV-VI tibial plateau fracture is feasible, which can shorten the length of hospital stay, decrease the cost of hospitalization and promote early functional rehabilitation.

Indirect reduction technique using a distraction support in minimally invasive percutaneous plate osteosynthesis of tibial shaft fractures

Purpose： To describe an indirect reduction technique during minimally invasive percutaneous plate osteosynthesis （MIPPO） of tibial shaft fractures with the use of a distraction support. Methods： Between March 2011 and October 2014, 52 patients with a mean age of 48 years （16-72 years） sustaining tibial shaft fractures were included. All the patients underwent MIPPO for the fractures using a distraction support prior to insertion of the plate. Fracture angular deformity was assessed by goniometer measurement on preoperative and postoperative images. Results： Preoperative radiographs revealed a mean of 7.6°（1.2°-28°） angulation in coronal plane and a mean of 6.8°（0.5°-19°） angulation in sagittal plane. Postoperative anteroposterior and lateral radio graphs showed a mean of 0.8°（0°-4.0°） and 0.6°00-3.6°） of varusvalgus and apex anterior/posterior angulation, respectively. No intraoperative or postoperative complications were noted. Conclusions： This study suggests that the distraction support during MIPPO of tibial shaft fractures is an effective and safe method with no associated complications.

Complications in the management of closed high-energy proximal tibial plateau fractures

Purpose： To report complications in the management of complex closed proximal tibial fractures. Method： A retrospective study was conducted to analyze the infectious and noninfectious complications encountered in the management of high-energy Schatzker type V and VI tibial plateau fractures. All patients were treated at the level 1 trauma centre between January 20tl and March 2014. Sixty two patients were included in the study. The mean patient age was （43.16 ±11.59） years with 60 males and 2 females. Infectious complications like superficial and deep infection, wound dehiscence, malalignment in the immediate postoperative period and in follow-up period were noted. Results： The overall complication rate was 30.65% （19 out of 62）. Infectious complications were noted in 20.97% cases （13162）. In majority of the cases （8113）, superficial infection was seen which managed with regular dressing and antibiotic administration. The patients （5/13） who had developed deep-seated infection were subjected to repeated debridements, flap coverage, implant removal or amputation depending upon the host response. Thirteen patients had experienced noninfectious complications. Hardware related complications were noticed in six patients and four among them received a secondary procedure. Malalignment was observed in seven patients but only single patient underwent subsequent operative intervention. Conclusion： Proximal tibial plateau fractures especially Shatzker type V and VI are associated with extensive soft tissue damage even in closed injuries. The complications encountered in the management of these fractures can be minimized with appropriate patient selection and minimal soft tissue dissection.

aseudoarthrosis of medial tibial plateau fracture role of alignment procedure

Nonunion in tibial plateau fractures is very rare. Limited literature is available on Pubmed search on intraarticular tibial nonunion. Most of the cases reported have been following failed surgical treatment and none was neglected fractures. Three patients of isolated and neglected medial fibial plateau nonunion with almost similar demo- graphic profile are reported in this paper. All the three pa- tients were managed by minimally invasive compressionfixation using lag screws supplemented with limb realign- ment procedure of high tibial osteotomy. We discussed the injury mechanism, management and rehabilitation in such cases and reviewed the available literature regarding such a presentation.

Internal fixation and bone grafting for intraarticular nonunion of tibial plateau： a report of four cases

Intraarticular nonunion of tibial plateau is rare. In the literature, only 9 patients were found to be treated for intraarticular tibial plateau nonunion and they got varying results. Internal fixation along with bone grafting was done as a standard treatment in all cases. We treated 4 different profile cases of intraarticular tibial plateau nonunion in our institution by 4 different methods. We treated these cases with plaster of paris cast, internal fixation along with bone graft, arthrodesis with K-nail and total knee replacement. Case 1 was treated with plaster of paris （POP） cast as the patient refused surgery. The fracture was united and the patient was fully satisfied with full range of motion despite valgus malalignment. Case 2 was managed with open reduction internal fixation along with bone grafting. Thepatient had a good union and got full range of motion at the knee joint. Case 3 was treated with total knee arthroplasty due to her old age and got satisfactory result. Case 4 was an infected nonunion. Arthrodesis was done and the patient could walk with full weight bearing independently. We conclude that internal fixation along with bone grafting may not be suitable in all cases of intraarticular nonunion of tibial plateau. Causes of nonunion, present condition and range of motion of the knee joint, as well as the age of patient should be all considered and the treatment should be individualised according to each patient＇s situation.