With the rapid development of the tra ffic,acetabular fractures and open fractures resulted from high energy injuries occur more freq uently.A combined examination of ro entgenogram,CT scanning and the three-dimensional imaging of the spiral CT helps make an accurate diagnosis of a cetabulum fractures.At present,the fracture is usually classified a ccording to the Letournel classific ation and AO classification.The ind ications for conservative treatment of this frac ture are limited,while surgical tre atment is more often the choice.In th e treatment,good reduction,rigid in ternal fixation and early functional recovery are essential.Much care,however,should be given to the selection of th e operation approach,prevention of complications such as damage to the sciatic nerve,heterotopic ossific ation and venous thrombus.As for the open fracture,thorough debridemen t,fixation,and suturing of the wound a t a possibly early stage are generally recommended.Care should also be given to proper administration of antibio tics and early functional recovery i n order to promote the union of the fra cture and the recovery of the functions.[

A treatment process of fractures consists of diagnosis, reduction, fixation and rehabilitation. Advances made in techniques of open reduction and internal fixation, typing of fractures, and standardization and humanization of treatment, as well as development of four AO principles of fracture treatment have led to constant improvement of therapeutic effects. In treatment of fractures not only biomechanical factors but also biological ones should be taken into consideration. Although operative and non operative treatments have indications of their own, they are supplementary to each other in clinical treatment. Orthopedists must master techniques of both open reduction and close reduction, and pay enough attention to scientific rehabilitation after operation.

Objective To analyze the reasons of internal fixation failure for subtrochanteric fractures of the femur and indicate the methods for avoiding the complications. Methods Thirty-nine patients with internal fixation failure for subtrochanteric fractures of the femur were treated from January 1993 to January 2004. There are 34 males and 5 females with an average age of 37 years (range from 21 to 65 years). The causes of injury included falls from bicycle in 3 cases, pedestrain injury in 1 case, traffic accident in 28 cases and falls from heights in 7 cases. The pattern of the fractures included Seinsheimer ⅡA type in 5 cases,ⅡB type in 2 cases,ⅡC type in 1 case,ⅢA type in 18 cases,ⅢB type in 1 case,Ⅳ type in 3 cases,Ⅴ type in 9 cases. The initial operation included open reduction and fixed with cerclage wires in 1 case, open reduction and fixed with Kuntscher nail and cerclage wire in 13 cases, closed reduction and fixed with Russell-Taylor reconstruction nail in 1 case, open reduction and fixed with 135? DHS in 6 cases, open reduction and fixed with plate in 18 cases. Two cases failed in 8 weeks postoperation, 26 cases failed in 6 months postoperation and 11 cases failed over 6 months. The pattern of failure of internal fixation include varus deformity of fracture in 35 cases, cutout of the lag screw from the femoral head in 2 cases and over medial migration of the distal femoral shaft in 2 cases. The reasons of internal fixation failure were nonanatomically reduction of fractures, unrigid interal fixation, over early weight bearing and poor placement of lag screw. Results The internal fixtion of fractures were revised, including open reduction and fixed with kuntscher nail in 2 cases, fixed with interlocking nail in 23 cases, fixed with 135? DHS in 6 cases, fix with plate in 4 cases, total hip replacement in 4 cases. The mean duration of follow up was 23 months (range from 19 to 37 months). The average time of fracture healing was 11.5 months (range from 11 to 13 months). Conclusion There are higher bending loads at the subtrochanteric area of the femur due to the eccentric loading. If extramedullary implant is selected, the stability at the medial cortex of the femur must be reconstructed intraoperatively and bone grafting is required.

Objective To investigate the management of limb length discrepancy during total hip replacement. Methods Forty-four hips of 44 patients undergone unilateral primary total hip replacement between July 1997 and July 2000 were included in this study. There were 30 males and 14 females. The ages of the patients at the surgery ranged from 42 to 80 years(mean, 65.8 years). Evaluation of the limb length discrepancy through clinical measurements and radiographic templates was done preoperatively to anticipate the optimal implantation position of the components and determine the level of expected femoral neck cut to maintain the equality of the limbs. During the surgery, the distance between two reference points made at pelvis and femur were measured before femoral neck osteotomy was performed based on preoperatively estimated parameters. The distance between the two points was measured again after insertion of the trail components in order to adjust the offsets of the femoral neck and head. Results Of the 30 patients with shortened limb ranging 1.5 to 5 cm preoperatively, only 4 had limb length discrepancy between 1.5 and 2 cm after surgery. Of the 14 patients with equal limb length preoperatively, only one limb had been lengthened more than 1.0 cm postoperatively compared with its contralateral limb. Conclusion The preoperative measurements, templating and intraoperative corrections are helpful in minimizing limb length discrepancy during total hip replacements and correcting preoperative limb length discrepancy as well.

Objective To elucidate the clinical characteristics and diagnostic outline of ipsilateral femoral neck and shaft fractures.Methods A retrospective study was carried ou t on 7patients with ipsi-lateral femoral neck and shaft fractures associated injuries of the knee;the duration of delay in diagnosis o f the femoral neck fractures,the managem ent of treatment and final clinical o utcomes were reviewed.Results All of the femoral shaft fractures occur red in the middle third and the femora l neck fractures in the base of the neck.Two patients were associated w ith knee injuries.The duration of delay in diagnosis of the femoral neck fractures ranged from 1to 75days.Si x femoral shaft fractures and 5neck f ractures were treated operatively.The mean follow-up period was 15.6mo nths,and all of the shaft and neck fra ctures were eventually healed without the evidence of avascular necrosis of the femoral head in spite of2mal-unions of the femoral neck.Conclusion In case of femoral shaft fracture resulting from high-energy trauma,an A-P pelvic film should be routinely taken.The patients with negative findings on the hip radiographs continue to complain of hip pain following open reduction and intern al fixation of the femoral shaft fractures should undergo CT or MR imaging examination.Once the femoral neck f racture is recognized,operative re duction and fixation should be em-ployed immediately.The outcome of o perative treatment is much superior to that of non-operative.

Objective To evaluate the early and middle outcome of deep circumflex iliac arterial vascularized iliac bone grafting to delayed femoral neck fractures in young patients. Methods Thirty-one delayed femoral neck fractures were treated from January 1997 to December 2003. Complete data were available in 26 cases (19 males and 7 females). The patients' age ranged from 15 to 38 years old with the average of 25 years old. 17 cases suffered from traffic accidents and 9 cases from falling injury. There were 11 cases in Garden type Ⅲ and 15 cases in type Ⅳ. 11 cases exhibited nonunion after conservative treatment and another 15 nonunion cases had previous surgery history. The initial operation included closed reduction and steinmann pin fixation or open reduction and threaded pin or steinmann pin fixation. The average duration from injury to the second operation was 8.5 months (range from 6 to 17 months). Most of the patients presented shorten limbs and limited hip function in difference degree. Open reduction, deep circumflex iliac artery vascularized iliac bone grafting and cannulate screw fixation were performend. Partial weight bearing started on 6 to 8 months postoperatively and full weight bearing on 11 months postoperatively. Results The mean duration of follow up was forty-one months (range from 28 to 69 months). Fracture healed successfully in 26 cases. The average time of fracture healing was 12.5 months (range from 11 to 15 months). Two femoral head necroses were noted during the follow-up period. The 5 cases of obvious shortened limbs stop progressing after surgery. Harris hip joint function score was on average 82.8. Conclusion Deep circumflex iliac artery vascularized iliac bone grafting can improve the blood supply to fractured femoral head. As a result, it's an effective way to enhance delayed femoral neck fracture.

Objective To explore the operative methods of open reduction and fixation for the old trimalleolus fractures. Methods Fifty-eight patients of the old trimalleolus fractures were treated from January 2000 to January 2004. There are 41 males and 17 females with an average age of 43 years (ranged from 19 to 61 years). The average time of postinjury was 48 days (ranged from 29-76 days). The fractures were classified by Lauge-Hansen system. Supination-external rotation type in 37 cases. Pronation-external rotation type in 21 cases. The anterior-medial approach and anterior-lateral approach were chosen. Explore the original fracture line of medial and lateral malleolus sharply, resect scar tissue at the fagment and ankle mortise, make the ankle joint valgus, expose the posterior malleolus fragment directly and explore the original fracture line. Reducted and fixed the posterior malleolus. According to the fibular crest, the normal length and alignment were recovered. The fracture was fixed with 1/3 tubular plate or ordinary plate. Medial malleolus was fixed with screw or tention band. The time of partial weight bearing was 10-12 weeks. Results The mean duration of follow up was 37 months (range from 18-65 months). Superficial skin necrosis was in 2 cases. The wound delayed union in 4 cases. The average time of fracture healing was 25 weeks(range from 21-29 weeks). The fibula malalignment in 2 cases. 6 cases developed arthrosis. 2 cases in this 6 patients had a good reduction of fractures. The average time of the operation in this 6 patients was 58.5 d after injury. According to the AOFAS scoring system, excellent in 31 cases, good in 22 cases, fair in 5 cases. The total rate of good results was 91.4%. The pain score was up to 20 in 5 cases. 9 cases had restriction of dorsiflexion with less than 10?. Conclusion The excellent reduction and clinical results were obtained by explore the original fracture line sharply, reduct posterior malleolus fragment directly and maintain normal length of the fibula, rotation and alignment for the old trimaleolus fractures which injuried within 76 days.

Objective To investigate the characteristics of the reversed sural neurocutaneou s island flap in clinical application.Methods From June 1997to March 2002,13cases of soft tissue defect in the lower leg,or around the ankle and the heel were repaired with the reversed sural neurocutaneous island flaps.The largest flap size was 15cm ?9cm,while the smallest was 5cm ?6cm.Results11of the flaps survived well and had primary healing,while 2flaps had distal partial necrosis and healed after dressing change.The follow-u p from3months to 4years showed that all fla ps were satisfactory.Conclusion Since the blood supply of the reverse d sural neurocutaneous island flap is reliable,even in patients with insufficient blood supply,and the flap is easy and quick to get without sacrificing the major arteries,it is an ideal method to use this flap to repair the soft tis sue defect in the lower leg and around the malleolus,the heel and the Achilles tendon.[

Objective To analyze the clinical characteris tics and diagnostic outline and to elucidate the effects of different managements of femoral shaft fractures with ipsila teral femoral neck fractures.Methods A retrospective study was carried out in 18patients with ipsilateral femo ral neck and femoral shaft fractures from 1998to 2001,and their managements and final clinical outcomes were reviewed.Results The follow -up ranged from8to 40months with an average of 16mon ths.All the fractures united except one femoral shaft fracture and one femoral neck fracture.Conclusion Retrograde intramedullary nailing with multiple cancellous screws to t reat ipsilateral femoral neck and femora l shaft fractures has been proved an e ffective technique.For the cases overlooked initially,treatment with multiple nailing around the intramedullary n ail is a good choice.[

Objective To describe the method of treating so ft tissue defects of the lower 1/3of l egs with the reversed saphenous neurocu taneous island flaps.Methods From June 1998to December 2000,eight cases of soft tissue defects or unstable scars of the lower one third of the legs,or around the ankle and th e heels were treated with reversed sap henous neurocutaneous island flaps.The size of the flaps were from 6cm ?5cm to 15cm ?9cm,averaging 9cm ?6.3c m.In 3cases in order to avoid the inju ry of the blood vessels of the flap pedicle when it passed thr ough the subcutaneous tunnel,a skin fascial bridge was designed in width of 1.5cm as the pedicle of the island f lap and to form the roof of an open tunnel.Results Seven cases had the flaps survived,one case had partially necrosis of the flap.After 6mo nths to 2years follow-up,all of the8cases were evaluated as satisfacto ry.Conclusion The blood supply of the reversed saph enous neurocuta-neous island flap is reliable,even i n patients with insufficienct arterial supply of the distal one third of t he lower limb.The flap does not sacrifice the major arteries and is easy to be perfomed.[