Objective:To explore the efficacyof direct anterior approach (DAA) combined with direct posterior approach (DPA) for the treatment of Pipkin IV fracture.Methods:Data of 18 patients with Pipkin IV fracture treated through DAA combined with DPA from January 2016 to April 2019 was retrospectively analyzed. There were 13 males and 5 females, with an average age of 43.2 years (range,19-56 years). Fractures were caused by traffic accident in 15 and by falling in 3. The fracture lines of 13 cases were located below the fovea of the femoral head and 5 cases were located above the fovea. According to Letournel-Judet classification for acetabular fractures, there were 14 cases of posterior acetabular wall fractures, 2 cases of posterior wall fractures involving posterior column, and 2 transverse plus posterior wall fractures. The operation was performed through DAA approach to treat the femoral head fractures, and DPA approach was used to treat acetabular fractures. Radiographs and CT scans of the pelvis were reexamined after surgery, and fracture reduction, healing, and complications such as femoral head necrosis, sciatic nerve injury, superior gluteal neurovascular injury and heterotopic ossification were evaluated. Quality of acetabular reduction was evaluated according to the criteria proposed by Matta. Thompson-Epstein scoring system was used to evaluate hip function.Results:The average operation time was 133 min (range, 75-205 min). And the average blood loss was 371 ml (range, 240-600 ml). All 18 patients were followed up for 6 to 36 months, with an average period of 15.7 months. All fractures healed 10 to14 weeks after surgery. Three patients had symptoms of sciatic nerve injury after the injury, who recovered 6 to 12 weeks after the operation. All femoral head fractures were reduced. According to Matta criteria of reduction quality, anatomic reduction was gained in 13 cases, and satisfactory reduction was obtained in 3 cases, while unsatisfactory reduction was found in 2 cases, and the overall satisfactory rate was 88.9%(16/18). Two patients had Brooker I level heterotopic ossification. There was no iatrogenic vascular injury, avascular necrosis of femoral head, infection, internal fixation failure or other complications. According to the Thompson-Epstein scoring system at the latest follow-up, the functional results of the affected hip were excellent in 7 cases, good in 8, fair in 2 and poor in 1.Conclusion:Treatment of Pipkin IV fractures through DAA combined with DPA approach reduces surgical invasion. And it can directly reduce and fix the femoral head and posterior acetabular fracture, and protect the important structures such as the arteriae circumflexa femoris medialis, sciatic nerve and lateral femoral cutaneous nerve, and reduce the occurrence of complications such as femoral head necrosis and heterotopic ossification. Therefore, DAA combined with DPA is aneffective method for the treatment of Pipkin IV fractures.

Objective To evaluate the clinical outcome of bleeding control by preoperative embolization of internal iliac artery with DSA and intra?operative presetting abdominal aorta balloon, combine with the operation techniques of exposure, reduc?tion and internal fixation of pelvic fracture through lateral?rectus approach. Methods From March 2012 to May 2015, 7 patients with type C3 pelvic fractures admitted to our department from March 2012 to May 2015, treated with preoperative embolization of internal iliac artery under digital subtraction angiography 2 h before surgery and presetting abdominal aorta balloon were retrospec?tively reviewed. There were 3 males and 4 females, with an average age of 34 years (range, 16 to 61 years). According to AO classi?fication, all 7 cases belonged to type C3 (3.2:5 cases;C3.3:2 cases), including 5 cases with limb fracture, 2 cases with craniocere?bral trauma, 4 cases with pulmonary contusion, 2 cases with injury of abdominsal organs. Time from injury to operation was 19 days on average (10 to 33 days). Patients received damage control surgery treatment including bleeding control and temporary ex?ternal fixation, and ipsilateral tractions with heavy weight, intensive care and corrections of general situation before operation. The fracture model was manufactured by 3D printing and fracture reduction was simulated on computer preoperatively. Embolization of internal iliac artery was performed in the side of severe displaced sacroiliac joint with DSA 2 hours preoperatively. Reduction was performed to stabilize anterior-posterior pelvic ring and acetabular fractures via the intraoperative lateral?rectus approach. And 2 cases were performed by temporary balloon occlusion of abdominal aorta (≤60 min) for bleeding control in reduction of in the side of sacroiliac joint fractures. Results All the 7 cases had undergone the operations successfully, and the operating time was from 135-320 min with blood loss from 440-3 350 ml. According to Matta radiological evaluation postoperatively, reduction of pelvic fracture was rated as anatomic in 5 cases, satisfactory in 2, without complications. All 7 cases were complicated with lumbosacral plexus injury or lumbosacral trunk injury at different degrees (M0 2 cases, M1 2 cases, M2 2 cases, M3 1 case). According to the BMRC scoring system, 5 cases had well recovered and the other 2 cases had no improvement after three months (M4 2 cases, M5 3 cases). Conclusion Surgical management of pelvic fracture through preoperative internal iliac artery embolization and intra?oper?ative occlusion of abdominal aorta could effective control bleeding and achieve favorable conditions for reduction. Lateral?rectus approach can provide adequate exposure of the anterior and posterior ring, and this approach could also provide excellent visual control of reduction and fixation.

Objective: To investigate reduction and fixation of complex acetabular fractures using three-dimensional (3D) printing technique and personalized acetabular wing-plate via lateral-rectus approach. Methods: From March to July 2016, 8 patients with complex acetabular fractures were surgically managed through 3D printing personalized acetabular wing-plate via lateral-rectus approach at Department of Orthopedics, the Third Affiliated Hospital of Southern Medical University. There were 4 male patients and 4 female patients, with an average age of 57 years (ranging from 31 to 76 years). According to Letournel-Judet classification, there were 2 anterior+ posterior hemitransverse fractures and 6 both-column fractures, without posterior wall fracture or contralateral pelvic fracture. The CT data files of acetabular fracture were imported into the computer and 3D printing technique was used to print the fractures models after reduction by digital orthopedic technique. The acetabular wing-plate was designed and printed with titanium. All fractures were treated via the lateral-rectus approach in a horizontal position after general anesthesia. The anterior column and the quadrilateral surface fractures were fixed by 3D printing personalized acetabular wing-plate, and the posterior column fractures were reduction and fixed by antegrade lag screws under direct vision. Results: All the 8 cases underwent the operation successfully. Postoperative X-ray and CT examination showed excellent or good reduction of anterior and posterior column, without any operation complications. Only 1 case with 75 years old was found screw loosening in the pubic bone with osteoporosis after 1 month′s follow-up, who didn′t accept any treatment because the patient didn′t feel discomfort. According to the Matta radiological evaluation, the reduction of the acetabular fracture was rated as excellent in 3 cases, good in 4 cases and fair in 1 case. All patients were followed up for 3 to 6 months and all patients had achieved bone union. According to the modified Merle D′Aubigné and Postel scoring system, 5 cases were excellent, 2 cases were good, 1 case was fair. Conclusions Surgical management of complex acetabular fracture via lateral-rectus approach combine with 3D printing personalized acetabular wing-plate can effectively improve reduction quality and fixation effect. It will be truly accurate, personalized and minimally invasive.

Objective: To evaluate clinical efficacy and surgical techniques of customized variable-angle locking acetabular wing plates in treatment of complex acetabular fractures in the elderly through the lateral-rectus approach. Methods: Data of 11 elder patients of complex acetabular fractures (mean age 75 y, range: 60-93 y; 8 males, 3 females) admitted to our department from March 2016 to March 2017 were retrospectively analyzed. According to Judet-Letournel classification of acetabular fractures, there were 2 cases of anterior column and posterior hemitransverse fractures, 9 cases of both-column fractures. The customized variable-angle locking acetabular wing plates were designed by mimics software and then produced before surgery. During the operation, the customized variable-angle locking acetabular wing plate was applied to reduction and fixation via the anterior lataral-rectus approach. The effect of fracture reduction was assessed by Matta's criteria. The clinical effect was assessed by Harris Hip score and the modified Merle d' Aubigné-Postal score at the 6th month of postoperative follow-up. Results: The average time of designing and producing customized variable-angle locking acetabular wing plates was 4 d (3-5 d), the average operation time was 95 min (45-150 min), and the average intraoperative bleeding was 600 ml (250-1 400 ml). All patients were followed up, with an average follow-up of 18 m (6-24 m). All fractures were healed, with an average healing time of 8 weeks (6-12 weeks). Reduction quality: excellent in 8 cases, good in 2 cases, poor in 1 case, with an overall excellent and good rate of 90.9%. The result of Harris Hip scoring: excellent in 7 cases, good in 3 cases, and acceptable in 1 case, with a total excellent and good rate of 90.9%; Modified Merle d' Aubigné-Postal soring: excellent in 6 cases, good in 3 cases, and acceptable in 2 cases, with an overall excellent and good rate of 81.8%. There were 2 cases of obturator nerve injury, 1 case of fat liquefaction of incision, 3 cases of traumatic hip arthritis. During the follow-up, no complications such as ectopic ossification, plate fracture and screw loosening were found. Conclusion The customized variable-angle locking acetabular wing plates in treatment of complex acetabular fractures in the elderly via the lateral-rectus approach can achieve satisfactory reduction and firm fixtation.

Objective:To explore the surgical technique and the clinical efficacy of the lateral-rectus approach with traction reduction by the modified Starr pelvic reduction frame for Tile C pelvic nonunions and malunions.Methods:Data of 7 patients with Tile C pelvic nonunions and malunions from June 2017 to June 2018 who were treated via the lateral-rectus approach combined with traction reduction by the modified Starr pelvic reduction frame were retrospectively analyzed. There were 5 males and 2 females, aged from 22 to 53 (mean, 40 years). The injury mechanism included 3 cases of car accident injury, 3 of falling injury and 1 of crushing injury. The reasons for retreatment were pain in 7 cases, inability to walk and sit in 3, unequal length of lower limbs and lameness in 3. According to Tile classification, there were 4 cases of C1 type, 2 of C2 type and 1 of C3 type. A complete pelvic model with equal size as the patient’s pelvis was 3D-printed out according to three-dimensional reconstruction CT. The osteotomy or release site was designed, and the preoperative plan was detailed. Expose and release via the lateral rectus approach combined with traction reduction was conducted using the modified Starr pelvic reduction frame. Operative time, intraoperative blood loss and postoperative complications were collected. Visual analogue scale (VAS) at 6 months after surgery were recorded. Majeed score was used to evaluate the clinical efficacy. The quality of fracture reduction was evaluated by the Mears-Velyvis radiological evaluation criterion at the latest follow-up.Results:The operation time was 140-280 min, with an average of 190 min. The intraoperative blood loss was 700-2,800 ml, with an average of 1,250 ml. In 6 cases, the final fixation was performed at one time, while 1 case of Tile C3 type was performed in two stages. All patients were followed up for 10-22 months, and all the fractures healed. The mean time of bony union was 8 weeks (range, 6-12 weeks). The VAS of the 7 patients was improved from an average of 6.4 points to an average of 0.7 points during 6 months postoperative follow-up. The Majeed clinical efficacy score of the latest follow-up was improved from the average 60 points preoperative to 85 points postoperative. According to the Mears-Velyvis radiological evaluation criterion, the satisfaction rate reached 85.7%(6/7). After operation, 1 case occurred obturator nerve injury who recovered within 3 months, and 1 case remained limb shortening deformity of 1 cm. There was no fixation failure.Conclusion:The anterior osteotomy via the lateral-rectus approach can fully cut off nonunions and malunions of the pelvis, effectively release the soft tissues around the osteotomy site, with minimal surgical trauma and low risks of neurovascular injuries. Combined the modified Starr pelvic reduction frame, it can effectively correct pelvic deformities, lower limb rotation and unequal length deformities to achieve the expected effect of surgery.

Objective:To investigate the clinical efficacy of lateral-rectus approach(LRA) for vertical shear fracture of pelvis combined with lumbosacral plexus nerve injury.Methods:A retrospective study was conducted of the 37 patients who had been treated at Department of Orthopaedics, The Third Affiliated Hospital to Southern Medical University for vertical shear pelvic fracture combined with lumbosacral plexus nerve injury from August 2010 to August 2018. They were 25 males and 12 females, aged from 18 to 61 years (mean, 36.2 years). By the Tile classification, there were 31 cases of type C1.3, 5 cases of type C2 and one of type C3. LRA was used in all the patients to explore and release the lumbosacral plexus nerve and to reduce the sacral fracture. The posterior ring was fixated with an anterior iliac plate or sacral screws before fixation of the anterior ring and treatment of the acetabular fracture. The operation time, intraoperative bleeding volume, quality of fracture reduction, fracture union time and recovery of nerve and muscle strength were recorded.Results:For this cohort, the operation time ranged from 105 to 228 minutes (mean, 155.0 minutes) and the intraoperative bleeding volume from 680 to 2, 440 mL (mean, 1, 070 mL). Thefollow-up time ranged from 1 to 8 years (average, 2 years). According to the Matta criteria, the quality of fracture reduction was evaluated as excellent in 21 cases, as good in 12 cases and as fair in 4 cases, giving an excellent and good rate of 89.2%. Follow-ups revealed reduction loss in 4 patients, nonunion and reduction loss in one patient and bony union in the other 32 patients after 8 to 12 weeks (mean, 10.1 weeks). According to the criteria by the Nerve Injuries Committee of the British Medical Research Council (BMRC), the recovery of nerve and muscle strength achieved M5 (full recovery of neurological symptoms) in 22 cases, M4 (fine recovery of neurological symptoms) in 7 cases, M1, M2 and M3 (partial recovery of neurological symptoms) in 5 cases, and M0 (no recovery of neurological symptoms) in 3 cases.Conclusion:LRA is an ideal surgical approach for treatment of pelvic vertical shear fractures complicated with lumbosacral plexus nerve injury, because it can well expose the medial pelvic joint from the sacroiliac joint to the symphysis pubis, allow direct release of the lumbosacral plexus nerve compressed and stretched, and, together with traction of the lower limbs, lead to satisfactory fracture reduction.

Objective To explore the efficacy of the anterior lateral-rectus approach combined with preoperative simulation assisted by 3D printing for treatment of acetabular fractures in the elderly.Methods A total of 52 elderly patients with acetabular fracture were admitted to Department of Orthopaedics and Trauma,The Third Affiliated Hospital to Southern Medical University from January 2014 to December 2017.They were 36 males and 16 females,with an average age of 71.6 years (from 65 to 88 years).According to the Judet-Letournel classification,there were 5 anterior column fractures,6 transverse fractures,18 anterior and posterior hemi-transverse fractures,and 23 both-column fractures.For all cases a preoperative surgical simulation was implemented based on their 3D-printed acetabular models.A pre-bent reconstruction plate or a custom acetabular aliform plate was placed to fixate the fracture after reduction via the anterior lateral-rectus approach.The reduction quality,healing time,function of affected hip and complications were recorded.Results The operation time for this cohort ranged from 85 to 138 min (average,102 min);the intraoperative bleeding ranged from 280 to 750 mL(average,520 mL).Perioperatively,implant failure,wound infection or symptomatic lower extremity phlebothrombosis was observed in none of the patients.According to the Matta radiological evaluation,the postoperative reduction was rated as excellent in 40 cases,as good in 7 and as poor in 5 (an excellent and good rate of 90.4％).All cases were followed up for 6 to 18 (mean,10.6 months).All the acetabular fractures united after 8 to 20 weeks (average,12 weeks).According to the modified Merle d'Aubigne-Postal scoring at the final follow-up,the function of affected hip was categorized as excellent in 29 cases,as good in 12 and as fair in 11 (an excellent and good rate of 78.8％).Walking pain was experienced by 5 patients 6 months after operation,diagnosed by imaging examination as traumatic arthritis of the hip joint.Follow-ups observed no such complications as screw loosening or heterotopic ossification.Conclusion In the treatment of acetabular fractures in the elderly,the anterior lateral-rectus approach combined with preoperative simulation assisted by 3D printing can achieve effective reduction and fixation,decrease intraoperative hemorrhage,shorten operation time and reduce such complications as screw loosening caused by osteoporosis.

Objective:To explore the characteristics and short-term changes of high resolution CT (HRCT) in subclinical stage of COVID-19.Methods:The HRCT images of 17 COVID-19 patients in subclinical stage were analyzed retrospectively in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology and Wuhan Jinyintan Hospital from January 15 to 31, 2020. There were 4 males and 13 females, age ranged from 25.0 to 51.0 (39.8±7.5) years, who were closely contacted with other COVID-19 patients. The follow-up CT examination was performed within 3 to 6 days after the initial CT examination in all patients. Six patients were treated using anti-virus, anti-inflammation and symptomatic therapy, while the other 11 patients were untreated. The subclinical CT findings and short-term follow-up were analyzed, and the CT changes of short-term follow-up were summarized.Results:The lesions of 17 COVID-19 patients were mainly located at the lower lobes of bilateral lungs (at the left lower lobe in 9 cases and at the right lower lobe in 10 cases in the subclinical stage, at the left lower lobe in 9 cases and at the right lower lobe in 11 cases in the short-term follow-up). The number of involved lung segments increased from 46 in the subclinical stage to 90 in the short-term follow-up. In the subclinical stage, the multiple lesions were found in 13 cases, while in the short-term follow-up, the number of cases with multiple lesions decreased by 7, however the cases with focal lesions increased by 6 and diffuse lesions by 4. The lesions were mainly distributed under the pleura (13 cases) or along the bronchovascular bundle(10 cases). In the short-term follow-up, the lesion in 1 case expanded from the subpleural area to neighbouring bronchovascular bundle. There were 3 main types of the lesions, including ground glass nodule, ground glass opacity and crazy-paving pattern. In the subclinical stage and short-term follow-up, the ground glass opacities were seen in all the 17 cases. In the short-term follow-up, the number of cases with ground glass nodules decreased by 4 and crazy-paving pattern increased by 4. In 6 patients after treatment, the multiple ground glass nodules became single one in 3 cases, and in other 3 cases the multiple ground glass opacities were getting smaller. However, the scope of lesions in 11 patients without treatment enlarged.Conclusion:The HRCT features of the COVID-19 in subcilincal stage have some charicteristics, such as small ground glass nodule, ground glass opacity along the subpleural area or along the bronchovascular bundle, and the great changes can be seen in the short-term follow-up.

Objective:To investigate the safety and clinical efficacy of the lateral-rectus approach combined with the Pfannenstiel approach in the treatment of pelvic fractures complicated with urethral rupture.Methods:From January 2013 to June 2021, 20 patients with pelvic fracture complicated with urethral rupture were surgically managed through the lateral-rectus approach and the Pfannenstiel approach at Department of Traumatic Surgery, Center for Orthopaedic Surgery, the Third Hospital Affiliated to Southern Medical University. They were 15 males and 5 females, with an average age of 42 years (from 18 to 55 years). By the Tile classification, there were 11 cases of type B and 9 cases of type C. The first-stage urethral realignment was performed via the Pfannenstiel approach in the supine position after general anesthesia in conjunction with an urologist; at the second-stage, the lateral-rectus approach was used to reduce and fixate the acetabular or pelvic fractures. The operation time, intraoperative blood loss, fracture reduction quality, pelvic functional recovery and complications were documented.Results:In this cohort, the operation time ranged from 80 to 240 min, averaging 140.5 min; the time for simple urethral convergence ranged from 20 to 30 min; the intraoperative blood loss ranged from 400 mL to 2,000 mL, averaging 730 mL. According to the Mears andVelyvis evaluation for fracture reduction quality, anatomical reduction was achieved in 13 cases, satisfactory reduction in 6 cases, and unsatisfactory reduction in one. The 20 patients were followed up for 12 to 68 months (mean, 37 months) after surgery. One fracture got nonunited but the other fractures got united after 3.0 to 4.5 months (mean, 3.5 months). According to the Majeed scoring system, the pelvic function at 12 months after surgery was excellent in 12 cases, good in 6 and fair in 2, giving an excellent and good rate of 90% (18/20). Screw loosening was found in one patient, traction injury to the lumbosacral trunk nerve in another patient, varying degrees of dysuria which responded to periodic urethral dilation in 8 patients, urethral stricture in 3 patients and erectile dysfunction in 5 patients. No abdominal hernia or pelvic infection was observed.Conclusions:The lateral-rectus approach combined with the Pfannenstiel approach can be used effectively to reduce and fixate the pelvic and acetabular fractures, and to repair the urethral rupture in one stage as well. They are also safe due to a low incidence of such complications as abdominal wall hernia and pelvic infection.

Objective:To explore the surgical method and clinical efficacy of lateral-rectus approach (LRA) in the treatment of fragility fractures of the pelvis (FFP) in the elderly.Methods:A retrospective study was conducted for elderly FFP patients from January 2011 to December 2019. All the pelvic fractures should be exposed and reduced through LRA and fixed with pelvic reconstruction plates and channel screws. Then, a total of 30 elderly patients were included in the study, including 9 males and 21 females, with an average age of 72.5 years (range, 60-87 years). Fractures were caused by car accident in 5 cases, by falling from high places in 8 cases and by tumbling in 17 cases. According to the FFP classification, there were 6 cases of type IIc (6/30, 20%), 22 cases of type III (22/30, 73.33%, of which 13 cases were type IIIa, 7 cases were type IIIb, and 2 cases were type IIIc), 2 cases of type IVa (2/30, 6.67%). Among that, 2 cases suffered ipsilateral acetabular fractures, 17 suffered medical diseases such as hypertension, coronary heart disease, diabetes, etc., and none suffered extremities fractures or other types of injuries. Surgical field was exposed retroperitoneally through LRA, combined with lower limb traction to reduce the anterior and posterior pelvis ring fractures. Then, the reductions were done in direct visions and verified through X-ray fluoroscopy. After that, the posterior ring was fixed with reconstruction plate and/or sacroiliac screws, and the anterior ring was fixed with reconstruction plate or INFIX. The quality of fracture reduction was evaluated by Matta score and the postoperative function was evaluated by Majeed score.Results:All the 30 patients were surgical treated through LRA. The time from injury to operation was 5 to 20 days, with an average of 9.9 days. The operating time ranged from 35 to 150 min (mean, 73.5 min) and the intraoperative bleeding ranged from 220 to 2 400 ml (mean, 586.7 ml). Fractures were successfully reduced under direct vision and the positions of the plates and screws were monitored through X-ray fluoroscopy during the operation. Postoperative X-rays and CT scans showed satisfactory reduction of the pelvic ring. According to Matta criteria, the quality of fracture reduction was evaluated as excellent in 18 cases, good in 6 cases, fair in 4 cases and poor in 2 cases. The overall excellent and good rate was 80% (24/30). All patients were followed up for 6-24 months, the fractures were all healed, and all fractures healed for 2-5 months, with an average of 3.5 months. At the last follow-up, Majeed scores were 86.1±6.11 (range, 66-92), including 21 excellent cases, 7 good cases and 2 fair cases, with an excellent and good rate of 93.3% (28/30). As for complications, 1 patient developed deep venous thrombosis of the affected lower limb, and the thrombosis disappeared after thrombolytic therapy. One patient had fat liquefaction in the incision, and the wound healed after intensive dressing change. After INFIX fixation, 2 patients showed numbness on the lateral thigh of the affected side, and the symptoms were relieved after symptomatic treatment. Four patients were found to have internal fixation screws loosening during follow-up, but still achieved good fracture healing.Conclusion:The entire hemipelvic ring could be exposed through LRA without cutting the peritoneum, so that the sacroiliac joint, ilium wing and anterior ring fractures could be reduced under direct version. In the treatment of pelvis fragility fractures of the elderly, effective reduction and fixation could be achieved using reconstruction plates or channel screws through LRA.