Objective To evaluate the curative effects of Hybrid external fixator in the treatment of severely comminuted and open fractures of the distal or proximal tibia. Methods From March 2004 to December 2008,we treated 27 patients with severely comminuted and open fractures of the distal or proximal tibia with the Hybrid frame purchased from Orthofix Co.in combination with limited internal fixation if necessary.The internal fixation was done with screws in 6 cases,with absorbable interference serews in 4 and with wire in 3.There were 16 males and 11 females,with an average age of 56.2(13 to 80)years.Accordins to Gustilo-Anderson classification,there were 10 cages of typeⅡ,12 cases of type Ⅲ A and 5 cases ofⅢB.The injuries were mostly caused by traffic accident and fall.Postoperative ankle and/or knee funetions were evaluated by Johner-Wrubs system.Results The patients were followed up for 7 to 58 months(average,27 months).Averagely the patients obtained bone union at 6.7 months and fixator removal at 6 months after operation.The postoperative JohnerWruhs score was excellent in 17 cases.good in 8 and fair in 2.The total exceHent to good rate was 92.6%,without wound infection or complications of nerve and vessel injury.There were only 5 cages of local superficial pin tract infection which responded to oral antibiotics and disinfectants. Conclusion In treatment of severely comminuted and open fractures of the distal or proximal tibia,Hybrid frame fixation may lead to limited invasion,reliable fixation,low rate of complications,and early recovery of joint function.

Objective To explore the proliferation and differentiation of osteoblasts from 2 sources co-cultured with SD rat Schwann cells(SCs) . Methods Bone marrow stromal cells (BMSCs) were obtained by washing the femoral and tibial bone marrow cavities in SD rats. Osteoblast differentiation of the third passage of BMSCs was induced by incubation in osteogenic medium. Primary rat calvarial osteoblasts were obtained by digestion of the calvarial bone in one day old SD rats. The cells were cultured in DMEM supplemented with 10% fetal bovine serum(FBS) . SCs of passage 2 were obtained by digestion of sciatic nerve. The SCs were identified by S-100. The proliferation of 2 kinds of osteoblasts co-cultured with SCs was tested using 96 co-culture plate by methyl thiazdyl tetrazolium(MTF). Real-time PCR was used to test the osteoblast differentiation through co-culturing with SCs in 3 d and 7 d. The osteoblasts were implanted in the subtus chamber. The SCs were implanted in the superior chamber. Results SCs enhanced significantly the proliferation of calvarial osteoblasts at 7 time points. The expression levels of OPN mRNA, OCN mRNA, ALP mRNA, and BMP-2 mRNA of the osteoblasts were significantly lower in the experiment group than in the control group in 3 d and 7 d. SCs also enhanced significantly the proliferation of the induced osteoblasts in 5 d, 7 d and 9 d. The expression levels of OPN mRNA, OCN mRNA, ALP mRNA, and BMP-2 mRNA of the induced osteoblasts were significantly higher in the experiment group than in the control group in 3 d and 7 d, except the level of ALP mRNA in 7 d.Conclusions The BMSCs-induced osteoblasts cocultured with SCs may be used as seed cells to construct neurotized tissue engineered bone.

Objective To investigate the causes and treatment of postoperative nonunion of the intercondylar fracture of humerus. Methods Twenty-six patients suffering from postoperative nonunion of the intercondylar fracture of humerus, 14 males and 12 females, were analyzed in this study. Four cases underwent total elbow arthroplasty(TEA), and the other 22 received refixation and autografting, 4 of whom healed only after 2 operations. The causes of postoperative nonunion were analyzed. Results This group had 28 unstable fixations, 16 postoperative plaster external fixations and 21 significant bone defects. On average, they had a follow-up of 11.4 months (4 to 41 months). In the 4 TEA cases, the average flexion was 112° (90° to 130°) and the extension 18° (0 to 35°). Their average MEPS score was 85(80 to 90 points). The other 22 cases achieved bone union ultimately, with an average flexion of 97.7°± 10. 0° (70° to 110°),an average extension of 30. 9°± 12.8°(0 to 60°), and an average motion arc of 66. 8°± 10. 5° (50° to 90°).Their average MEPS score was 81.4 ± 11. 1 points (65 to 100 points). Conclusions Inadequate internal fixation, elbow stiffness due to plaster external fixation and significant bone defects are the main causes for postoperative nonunion of the intercondylar fracture of humerus. 90-90 plate fixation and parallel plate fixation, together with constructive bone grafting, can achieve bone union in most cases, though the motion arc of the elbow is still unsatisfactory.

Objective To compare the posterior midline approach and the combined lateral and medial approach usually used in elbow arthrolysis. Methods From January to December in 2009, 41 cases of elbow stiffness were treated and fully followed up by the same team in our hospital. The posterior midline approach was used in 21 cases, 15 males and 6 females, with an average age of 35.8 years (16 to 70 years). In this group, the total flexion-extension arc was ＜ 30° in 12 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Eight cases had ulnar symptoms. The combined lateral and medial approach was applied in 20 cases, 8 males and 12 females, with an average age of 38. 8 years (16 to 51 years). In this group, the total flexion-extension arc was ＜ 30° in 11 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Five cases had ulnar symptoms. Results The 41 cases were followed up for 4 to 15 months (average, 7.9 months). In the posterior approach group, the mean preoperative flexion-extension ROM (27.6°± 25.7°) was improved to the postoperative 111.4°± 25.6°, the mean preoperative rotation ROM ( 152.9°± 46. 9°) to the postoperative 168.1°± 19. 1°, and the mean preoperative MEPS score (65.5 ± 11.5) to the postoperative 95.7 ±6.4. In the combined approach group, the mean flexion-extension ROM was improved from 35.5°± 25.0° preoperatively to 116. 5°± 19.1° postoperatively, the mean rotation ROM from 138.0°±55.7° preoperatively to 148.5°± 45.6° postoperatively, and the mean MEPS score from 66. 3 ± 13.0 preoperatively to 97.3 ± 7.0 postoperatively. The differences were statistically significant between preoperation and postoperation in both groups ( P ＜ 0. 05), but not statistically different between the 2 groups in the preoperative or postoperative values ( P ＞ 0. 05). In the posterior approach group, 5 patients had huge hematoma, 3 had wound dehiscence at the posterior elbow, and the others all had mild hematoma. But in the combined approach group, no wound complications were noted. Conclusion The combined lateral and medial approach should be used as far as possible in the elbow arthrolysis to avoid the likely complications when the posterior midline approach is used.

Objective To explore the feasibility and application of determining the center of the inferior portion of the glenoid on a standard anteroposterior view of the normal glenoid. Methods Seventy shoulders of 35 mature adults were measured in this study. A 64-slice CT 3D reconstruction was performed for each glenoid. A standard anteroposterior view and the scale of glenoid were made at a 3D workstation by one radiologist, and then transferred to software AutoCAD as 2D images. The 2D images were analyzed with AutoCAD respectively by 3 radiologists. The line was drawn between the most anterior and the most inferior points of the glenoid bony rim. On the same image, another line was drawn between the most posterior and the most inferior points of the glenoid bony rim. Two perpendicular bisectors of the 2 lines were drawn. The cross point of the 2 perpendicular bisectors was regarded as the circle center of the inferior part of the glenoid. The distances from the circle center to the anteroinferior and the posteroinferoir rims of the glenoid and the most posterior point were measured. Measurements were expressed as the mean ± standard deviation. Several related samples Friedman rank sum test was used to compare the measurements (the distance from the circle center to the most posterior point) by the 3 radiologists. Paired t tests were used to compare the differences between the left and right glenoids. Results The mean distance from the circle center to the most posterior point was ( 14. 1 ± 1.6) mm, the anteroinferior rim was ( 14. 0 ± 1.7) mm, and the posteroinferoir rim was ( 14. 1 ±1.6) mm. No significant differences were found ( P>0. 05) between measurements by the 3 radiologists. No significant differences were found ( P>0. 05) between the measurements of the both-side glenoids. Conclusions The method of determining the center of the inferior portion of the glenoid based on the most anterior,posterior and inferior points of the glenoid on a standard 3D anteroinferior view of the normal glenoid is easy,practical and highly repeatable. The radius of the left glenoid is comparable to the radius of the right side in normal shoulders. This method can be used to quantify a glenoid bone defect precisely.

Objective To compare extramedullary fixation (EF), intramedullary fixation (IF) and dipolar femoral replacement(DFR) in the treatment of intertrochanteric fractures in the elderly patients. Methods From July 1999 to December 2008, 172 old patients with intertrochanteric fractures were treated by either EF, or IF or DFR. The operative procedures, complications and therapeutic effects were compared between the 3 methods. Results The patients included in the present study were followed up for 8 to 36 months (average, 19. 6 months). There were significant differences ( P<0. 05) in incision length, operation time, intraoperative blood loss, functional recovery and complications between the 3 methods. IF had the shortest incision length and the least intraoperative blood loss. DFR had less blood loss than EF. IF had the least operation time, followed by DFR. DFR had the best functional recovery one year postoperatively. IF had shorter rehabilitation and healing time than EF. Conclusions EF is the first choice for intertrochanteric fractures of A 1.1, A 1.2, A 1.3 and A2. 1. IF is more appropriate for the aged and unhealthy patients with intertrochanteric fractures of A1. 1, A1. 2, A1. 3, A2. 1, A2. 2, A3. 1 and A3.2. DFR is fit for the elderly patients with severe comminuted fractures and osteoporosis.

Objective To investigate the classification and its application in one-stage repair of massive posttraumatic bone defects which are infection-induced and refractory in lower extremities. Methods From March 2002 to December 2008, we treated 42 patients with massive posttraumatic refractory infection-induced bone defects in lower extremities. We classified the defects into 3 types: simple massive infection-induced bone defects (type Ⅰ), massive infection-induced bone and soft-tissue defects (type Ⅱ) and massive infection-induced bone defects plus limb shortening (type Ⅲ). After thorough debridement, various types of vascularized fibular grafts were used to repair the 3 kinds of defects accordingly. Simple fibular grafts were used in 6 cases, transplantation with fibular and skin flaps was used in 31 cases, fibular grafts combined with anterior lateral thigh flap in 4 cases, and one-stage limb lengthening and fibular graft in one. Results The follow-ups of 6 to 41 (average, 26. 3) months revealed that the refractory bone defects were repaired successfully in 38 cases, amputation due to necrosis of fibular grafts in 2 cases and uncontrolled infection in 2 cases. In the 38 cases, infections were controlled effectively, circulation of the traumatic limbs was good,contour and function were restored satisfactorily, and no obvious complication was found in donor limbs. By Johner-Wruhs evaluation, 17 cases were excellent, 18 cases good, 3 cases fair and 4 cases poor, with a total excellent and good rate of 83.33%. Conclusions Refractory and massive posttraumatic infection-induced bone defects in lower extremities can be classified into 3 types. They can be repaired using various types of vascularized fibular grafts according to the defect types at one-stage.

Objective To discuss the effects of triangle limited fixation by Russian external fixator for proximal and distal tibiofibular fractures. Methods From December 2005 to December 2007, 54 patients with tibiofibular fractures were managed with close reduction and triangle limited fixation by Russian external fixator. They were 48 males and 6 females, aged from 18 to 54 years (average, 34 years). By AO classification, there were two cases of type 41-C3 (one complicated with type 43-B2 and one with type 43-A3), 17 cases of 42-A, 13 cases of 42-B, 12 cases of 42-C, 5 cases of 43-B, and 5 cases of 43-C.Twenty-six cases were open injury (by Gustilo classification, type Ⅱ in 13, type ⅢA in 10, type ⅢC in 3),and 28 closed injury (by Tscherne classification, grade Ⅰ in 8 and grade Ⅱ in 20). Results Follow-ups of 50 patients revealed that the fractures healed from 2 to 6 months (average, 3 months). Swelling subsided in just one week in the 28 patients with close injury. Of the 26 patients with open injury, 24 obtained primary healing of wounds, one obtained wound healing 4 weeks after changes of dressing, and one suffered amputation. No malfunctions were found in this group. One case had nonunion which was healed after change to single-ann external fixation. Conclusion Triangle limited fixation by Russian external fixator can be applied in the treatment of complex tibiofibular fractures.

Objective To investigate the estradiol (E2) prolactin (PRL) levels in young females with cerebral trauma combined with extremity long tubular bone fracture. Methods E2 and PRL were detected in 39 young females with cerebral trauma combined with extremity long tubular bone fracture (experimental group) and 42 young females with just extremity long tubular bone fracture (control group) at 1 to 3, 5 to 7, 10 to 14, 28 to 30, and 56 to 60 days after injury. Results E2 levels in the experimental group were significantly higher than in the control group at 1 to 3, 5 to 7, 10 to 14, and 28 to 30 days after injury (P < 0.05), but there was no significant difference in the E2 level between the 2 groups at 56 to 60 days after injury (P > 0.05) . Compared with 1 to 3 days, the E2 level was significantly decreased in the experimental group at other time points (P < 0. 05), while there was no significant difference in the E2 level in the control group among each time point (P > 0. 05). PRL level in the experimental group was significantly higher than in the control group at all time points. In particular, the PRL level in the experimental group was significantly increased at 5 to 7, 10 to 14 and 28 to 30 days after injury, compared with that at 1 to 3 days after injury (P<0.05), but there was no significant difference in the PRL level between 56 to 60 days and 1 to 3 days (P > 0. 05). Additionally, the PRL level did not change in the control group at all time points (P > 0.05). Time of fracture healing in the experimental group was significantly shorter than in the control group, while the time of hospital stay in the experimental group was significantly longer than in the control group (P<0.05). Conclusion E2 and PRL levels increase remarkably in the young females with cerebral trauma combined with extremity long tubular bone fracture at an early onset stage.

Objective To explore an effective prevention and management of nonunion and malunion due to insidious infection after fracture internal fixation. Methods From January 2001 to January 2006,we treated 26 patients with nonunion and malunion due to insidious infection after fracture internal fixation.They were 15 cases of femoral fractures, 2 cases of ulna fractures, 3 cases of radial fracturos, 3 cases of humerus fractures, and 3 cases of tibial fractures. The patients were treated with irrigation after debridement.In 23 fractures, the internal fixation was dislodged and changed into external fixation. In the 3 cases whose internal fixation remained, instillation and drainage were conducted after debridement. Bone grafting was performed for 20 cases after replacement of internal fixation, and for 3 cases after removal of external fixation.Three patients received no bone graft. Results The preoperative X-ray findings confirmed the diagnosis of insidious infection in 21 cases, while the other 5 cases were diagnosed by bacterial culture or pathological examination of the pus and inflammatory granulation tissue found during surgery. The bacterial culture was positive in 17 cases, including 6 cases of Staphylococcus epidermidis, 8 cases of Staphylococcus aureus, and 3 cases of Escherichia coli. All the patients were followed up for 8 to 48 months, with an average of 23.5 months. Of the 26 cases, 22 obtained bony union, 2 partial union and 2 nonunion. Complications included fistula in 2 patients and infection relapse in 3 patients. Conclusions Insidious infection may be related to the bacterial toxicity, anatomical sites and surgical methods. X-ray changes may help the diagnosis of insidious infection. Surgery is necessary for management of nonunion and malunion due to insidious infection after fracture internal fixation.