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 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 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 investigate the surgical treatment for ipsilateral fractures of femoral neck and shaft. Methods 26 cases of ipsilateral fractures of femoral neck and shaft treated from January 1996 to December 2002 were retrospectively reviewed. There were 22 males and 4 females, with an average of 28 years (range 17-50 years). The causes of fractures were traffic accident in 17 and fall in 9. The femoral neck fractures were diagnosed in emergency in 16 cases, and delayedly in 10 cases. The delayed time was 3-75 days, with an average of 13.1 days. All cases were divided into three types according to the site of femeral shaft fracture. Type Ⅰ: the proximal 1/3 femoral shaft fracture combined with neck fracture, in 3 cases; Type Ⅱ: the middle 1/3 femoral shaft combined with neck fracture, in 18 cases; Type Ⅲ: the distal 1/3 femoral shaft fracture combined with neck fracture in 5 cases. All cases were undergone surgical reduction and internal fixation. The femoral shaft fractures were stabilized with dynamic compression plate (DCP) in 13, with antegrade intramedullary locking nail in 2 cases, with retrograde intramudullary locking nail in 5 cases. The femoral neck fractures of these 20 patients were stabilized with cannulated lag screw. The femoral neck and shaft were stabilized with dynamic hip screw system (DHS) in 2, with constructive nail in 4. Results All of the patients were followed up for 3 to 9 years, with an average of 4.4 years. The femoral shaft fractures obtained rigid union at the latest follow-up study in 25. The duration for bone union ranged from 16 to 32 weeks, with an average of 20 weeks. The femoral neck fractures were united at the latest follow-up study in 25. The duration for bone union ranged from 12 to 28 weeks, with an average of 16 weeks. The complications included infection in 1, hardware failure in 1, nonunion of femoral neck fracture in 1 and osteonecrosis of femoral head in 1. Conclusion The ipsilateral fracture of femoral neck and shaft is rare, and the neck fracture is easy to miss diagnosis. The surgical treatment for ipsilateral fractures of femoral neck and shaft depends on the position of femoral shaft, and the situation of femoral neck.

Objective To research the operative methods and their comments on the lower leg, ankle and the foot soft tissue defects. Methods From June 1997 to December 2005, 43 cases of the lower leg, ankle and the foot soft tissue defects were treated with nine different kinds of pedicle flaps transplant. The patients included 38 males and 5 females, with an average age of 35 years (range from 7 to 63 years). The areas of flaps were from 4 cm?3 cm to 25 cm?15 cm. 9 kinds of flaps were underwent in all patients, which includes medial or lateral gastrocnemis myocutaneous pedical flaps in 2 cases; anteromedial cross leg flaps in 2 cases; medial cross leg flap with saphenous nerve in 1 case; medial reverse flow island leg flap with posterior tibial artery in 1 case; medial distal leg fascia flaps in 2 cases; reversed sural neurocutaneous island flaps in 17 cases; reversed saphenous neurocutaneous island flaps in 14 cases; supra extramalleolus reversed island flaps in 2 cases; and medial pedes distal island flaps in 2 cases. Results 37 flaps of 43 cases were completely survived, 1 case with superficial necrosis and 5 cases with distal edge partially necrosis and these 6 cases all healed after short time dressing change. All the cases were followed up 3 months to 7 years, with an average of 16 months, and none recurred. The flaps completely survived even in some special cases such as diabetes mellitus, dorsal artery of foot defect combined venous varicose, sural nerve injury, Gustilo ⅢC open fracture and serious degloving injury of lower leg and foot. Conclusion In order to achieve the desired results, it is important to grasp the surgical indications of various kinds of flaps and keys for the operation. The sural and saphenous neurocutaneous island flaps could be a satisfactory method to treat the soft tissue defects in lower leg, ankle and foot.

Objective To demonstrate the clinical results of the patients with failed cemented femoral component due to aseptic loosening with extensive porous-coated femoral implants. Methods Be-tween 1998 and 2003, twenty hips (20 patients) with a failed cemented femoral component were revised us-ing extensive porous-coated femoral components and allograft. There were 12 males and 8 females. The mean age of the patients at the time of revision was 64 years (41-77 years). All of the revised femoral com-ponents were cemented stems,with first-generation cement technique in 18 hips and second-generation ce-ment technique in 2 hips. The indications for hip arthroplasty included osteonecrosis of the femoral head in 14 hips and femoral neck fracture in 6 hips. The interval from primary hip arthroplasty to revision surgery ranged from 5 to 17 years, with an average of 11.5 years. There were 4 re-revisions in this group. Based on Paprosky classification for bone deficiency, 3 hips were of type I, 6 of type II and 11 of type IIIA. The com-ponents implanted included AML (DePuy) in 5 cases , Solution (DePuy)in 7, full-coated (Zimmer)in 6 and Perfecta Extend Stems (Wright Med) in 2. The postoperative stability was evaluated according to the Engh criteria. The patients were followed for an average of 40 months (18-60). Results At the latest fol-low-up, the mean Harris score was improved from 40 to 85 points postoperatively. The bony ingrowths were found in 17 hips and the fibrosis stability in 3 on postoperative radiographic evaluation. There were no re-revisions in this group. The bone remodeling was observed in all osteolytic zones. Conclusion In the pres-ence of bone loss in the proximal metaphyseal region of the femur, the extensive porous-coated femoral com-ponents may provide a bypass for the deficient proximal bone. It may further obtain initial optimizing pros-thesis-bone fitting and an axial anti-rotational stability in the relatively normal diaphyseal region of the fe-mur to allow the reliable biological fixation with bony ingrowths.