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Hoffa fracture: the CT classification system

Chinese Journal of Orthopaedic Trauma.2013;15(9):737-741. doi:10.3760/cma.j.issn.1671-7600.2013.09.001

Objective To introduce a new CT classification system we designed for Hoffa fractures and compare the interrater reliability between the CT and X-ray classification systems.Methods A total of 20 isolated Hoffa fractures from January 2008 to December 2011 were randomly selected for the present analysis of their imaging data (anteroposterior and lateral X-ray films of the knee joint and three-dimensional CT reconstruction of the femoral condyle).At the same time,a total of 20 independent observers (clinicians with junior,intermediate and senior professional qualifications) were selected for classification of the Hoffa fractures in the same manner respectively according to the Letenneur's X-ray system and our self-designed CT system.We used Kappa statistics to evaluate the interrater reliability among the clinicians between the 2 classification systems for Hoffa fractures.Results According to the CT classification of the 20 Hoffa fractures by the 20 clinicians,type Ⅰ,Ⅱ and Ⅲ fractures accounted for 66.0％,30.5％ and 3.5％ respectively.In type Ⅰ fractures,type Ⅰb involving zone b accounted for the most (50.0％),next by type Ⅰc(31.0％) and type Ⅰa (19.0％).In type Ⅱ comminuted fractures,fracture fragments were mostly seen in zone b.The overall incidence of fractures involving zone b by CT classification was 67％.According to the X-ray classification,type Ⅰ,Ⅱ,Ⅲ and Ⅳ fractures accounted for 31.4％,14.3％,28.0％ and 26.3％,respectively.The interrater reliability for CT classification agreement (Kappa =0.681) among clinicians was higher than that for X-ray agreement (Kappa =0.261).Conclusion For Hoffa fractures,communicated ones in particular,our CT classification system may be better than the X-ray classification system.

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Ilizarov technique for treatment of congenital brachymetatarsia

Jianzhong GE ; Sihe QIN

Chinese Journal of Orthopaedic Trauma.2013;15(10):867-870. doi:10.3760/cma.j.issn.1671-7600.2013.10.010

Objective To evaluate the clinical therapeutic effectiveness of Ilizarov technique for the treatment of congenital brachymetatarsia.Methods We retrospectively analyzed the 5 patients who had been treated in our department for congenital brachymetatarsia (12 metatarsal bones in 10 feet) from January 2008 to January 2011.All of them were female,aged from 22 to 26 years (mean,24.2 years).All cases were bilaterally involved.Three of them suffered from bilateral brachymetatarsia of the first metatarsal bone,one from bilateral brachymetatarsia of the fourth metatarsal bone,and the other one from bilateral brachymetatarsia of the first and fourth metatarsal bones.Bone transport was conducted with a monolateral mini-fixator in 3 patients and with a modified semi-ring Ilizarov fixator in the other 2.Dorsal incision was used for all osteotomy before the external fixator was mounted.Bone transport began 7 days after surgery at a rate of 0.3 mm/d and was completed in 3 times.Results The 5 patients were followed up from 12 to 48 months (mean,22.0 months).The metatarsal bones were lengthened by 13.5 mm(12 to 17 mm) on average.The functions of the toe and ankle joint were normal without skin necrosis,vascular or nerve injury,tylosis of the footplate,or walking pain.The lengthened segments were mineralized well,with an average lengthening index of 48 d/cm(45 to 53 d/cm) and average time of external fixation of 64.8 days.At the last follow-up,the average AOFAS score was 92.2 points (90 to 95 points).Conclusions Although the Ilizarov technique necessitates a patient's prolonged fixation with an external fixator in the treatment of congenital brachymetatarsia,it has advantages of simplicity,minimal invasion,and satisfactory correction of brachymetatarsia.Consequently it is a good treatment for this disease.

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Osteoporotic fracture of proximal humerus treated with Spatial Subchondral Support(S3) locking plate of proximal humerus

Yimin CHAI ; Wenqi GU ; Guohua MEI

Chinese Journal of Orthopaedic Trauma.2014;16(1):43-46. doi:10.3760/cma.j.issn.1671-7600.2014.01.010

Objective To evaluate the surgical techniques and clinical outcomes of treating osteoporotic fracture of proximal humerus with Spatial Subchondral Support (S3) locking plate of proximal humerus.Methods From July 2010 to July 2011,21 patients with osteoporotic fracture of proximal humerus,12 males and 9 females,were treated in our department.They were 66.0 years old on average (from 58 to 80 years old).According to the Neer classification system,13 cases were 3-part fractures,8 4-part fractures,and 2 combined with shoulder dislocation.All cases were evaluated carefully with routine CT scans pre-operatively to define the type of fracture and the involvement of articular surface.Open reduction and internal fixation with S3 locking plate of proximal humerus was performed 2 to 7 days after injury (average,4.0 days).Regular X-ray follow-ups were taken and complications recorded as well.Overall function evaluation was carried out according to the modified Constant-Murley score system (CMS) and visual analogue scale (VAS).Results The 18 cases were followed up for a mean duration of 18.0 months (from 12 to 24 months).No complications of wound infection,implant failure or impingement were observed during the follow-ups.Bone union was achieved after an average of 12.0 weeks (from 10 to 14 weeks).On average,the Modified CMS score was 80.2 and the VAS score 1.5.At the post-operative 10th and 13th months,X-ray manifested avascular necrosis of the humeral head respectively in 2 cases of 4-part fractures,who suffered from moderate pain which was relieved after conservative treatment.Conclusion Fixation with S3 locking plate of proximal humerus is a safe and effective treatment of osteoporotic fracture of proximal humerus,because it is rigid and avoids plate-related impingement.

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Hip arthroplasty versus internal fixation for displaced femoral neck fractures in the elderly patients: a Meta-analysis

Zhenhui SUN ; Yueju LIU ; Heng LI

Chinese Journal of Orthopaedic Trauma.2014;16(2):115-121. doi:10.3760/cma.j.issn.1671-7600.2014.02.005

Objective To compare hip arthroplasty versus internal fixation for treatment of displaced femoral neck fractures in the elderly patients in terms of reoperation,surgery-related complications and postoperative 1-2-year mortality.Methods All the randomized controlled trials (RCTs) up to May 2013 on hip arthroplasty versus internal fixation for displaced femoral neck fractures in the elderly were electronically searched for in Pubmed/Medline,EMBASE,Cochrane CENTRAL,CNKI,WanFang and VIP databases.The 2 treatments were compared in terms of reoperation,surgery-related complications and postoperative 1-2-year mortality.The Meta analysis was performed with RevMan 5.2.5 software.Results Five eligible RCTs involving 1 288 cases were included for this review.The rate of reoperation (including implant removal and other operations),either within 2 years or over 2 years,in the internal fixation group was significantly higher than that in the arthroplasty group (P ＜ 0.05).The surgery-related complications in the internal fixation group was significantly higher than that in the hip arthroplasty group [OR =8.82,95％ CI (6.45,12.07),P ＜0.001].No significant difference was found in the postoperative 1-2-year mortality between the 2 groups (P ＞0.05).Conclusion In the treatment of displaced femoral neck fractures in the elderly,compared with internal fixation,arthroplasty should be recommended as the first choice,because it can significantly reduce surgery-related complications and reoperations though it cannot decrease the postoperative 1-2-year mortality.

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Clinical effects and helical blade positions in the treatment of senile intertrochanteric fractures with proximal femoral nail antirotation

Hongwei TANG ; Yong YIN

Chinese Journal of Orthopaedic Trauma.2014;16(2):93-97. doi:10.3760/cma.j.issn.1671-7600.2014.02.001

Objective To compare the clinical effects of 2 common installation positions of the helical blade in the treatment of senile intertrochanteric fractures with proximal femoral nail antirotation (PFNA).Methods From January 2010 to December 2012,166 old patients with intertrochanteric fracture were treated by PFNA.According to the installation position of the helical blade in the femoral head on the postoperative X-ray films,they were divided into a C/C group (87 cases) where the helical blade was at the center of the femoral head in both anteroposterior and lateral views and an I/C group (79 cases) where the helical blade was at the inferior one-third of the femoral head in anteroposterior view and at the center in lateral view.There were no significant differences between the 2 groups in general data preoperation (P ＞ 0.05).The 2 groups were compared in terms of reduction quality,tip-apex distance (TAD),full weight bearing time,fracture healing time,and Harris Hip Score(HHS) at the last follow-up.Results C/C group had 83 patients followed for an average of 13.6 months and I/C group had 76 patients followed for an average of 13.3 months.There were no significant differences between the 2 groups regarding the good-to-excellent reduction rate [94.0％ (78/83) versus 94.7％ (72/76)],full weight bearing time (9.4 ± 1.5 weeks versus 9.3 ± 1.3 weeks),fracture healing time (17.8 ±2.3 weeks versus 17.2 ±2.3 weeks),or HHS (89.6 ±4.6 points versus 89.3 ±4.7 points) (P ＞ 0.05).There was a significant difference in TAD (21.14 ± 3.17 mm versus 24.96 ± 3.48 mm) between the 2 groups(t =-7.242,P =0.000).No infection or cut-out or other related complications of the helical blade occurred in either group.Conclusion The helical blade may lead to satisfactory clinical effects in the treatment of senile intertrochanteric fractures with PFNA no matter at which of the 2 positions it is installed.

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Early histopathological changes in explosive wounds at canine limbs following seawater immersion

Jianming HONG ; Min LIU ; Xuefeng HU

Chinese Journal of Orthopaedic Trauma.2011;13(10):956-959. doi:10.3760/cma.j.issn.1671-7600.2011.10.014

Objective To observe early histopathological changes in explosive wounds at canine limbs after seawater inmersion.Methods Forty adult dogs,weighing 10 to 15 kg each,were assigned into 2 equal groups.The left hind limb of each dog in both groups was injured by a man-made explosion.The explosive wound was first washed by normal sodium.The 20 injured limbs in the experimental group (EG)were immersed in seawater for one hour while those in the control group (CG) were only exposed naturally for one hour without seawater immersion.All the wounds were covered with sterile dressing without suture.The pus and soft tissue at the wound were taken for pathological examination,bacterial culture and drug sensitivity test on day 3.The time of wound healing was recorded.Tissue sections were taken from the wounds for pathological examination at 4 and 8 weeks.Results Fifteen wounds (75％) were infected in the EG,significantly more than the 8 wounds infected (40％) in the CG( P ＜ 0.05).The wounds healed in a mean time of 38.4 days in the EG,significantly longer than the mean time for wound healing (23.1 days) in the CG ( P ＜ 0.05).In the EG,Vibrio infection caused more serious tissue necrosis and inflammatory reaction than Bacillus and coccus did.At 4 and 8 weeks,tissue necrosis and inflammatory reaction in the EG were worse than those in the CG.Conclusion Seawater immersion can lead to increased infective tissue necrosis and inflammatory reaction in an explosive wound,as well as longer time for wound healing.

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Clinical assessment of cancellous bone content in the humeral head

Liang CHENG ; Xuhua WU ; Yimin CHAI

Chinese Journal of Orthopaedic Trauma.2011;13(10):933-936. doi:10.3760/cma.j.issn.1671-7600.2011.10.008

Objective To measure the cancellous bone contents at different parts of the humeral heads of different ages and genders for data helpful for humeral head fixation.Methods Thirty-six patients with proximal humeral fracture were selected for this study who had been treated at our department with locking proximal humerus plate from June 2008 to April 2010.They were 18 men and 18 women,aged from 20 to 86 years (average,51.6 years).They were grouped according to age:group A ( ＜ 40 years),group B (40 to 60 years),and group C (＞ 60 years).A GE Sensation 16 CT scanner (GE Healtbcare,USA) was used to scan both of their affected and healthy humeral heads preoperation,with slices one mm thick.The bone density of cancellous bone was assessed by the CT value expressed in Hounsfield units.The maximum,minimum,and mean CT values were calculated for the cancellous bone in the humeral head in each image.CT images were processed by computer with custom software (Xiphoid 1.3,Image J 1.4g and Image-Pro Plus 6.0).All the data were analyzed with SPSS16.0.Results We found 4 weak point.s at the cortical bone of proximal humerus,correspondent with the 4 clinic CT types of proximal humeral fracture.The cancellous bone was the densest in the medial humeral head.The mean cancellous bone content was significantly lower in group C than in group A and B( P ＜ 0.05).There was a significant difference between men and women in group A in the BMD of cancellous bone ( t =4.744,P =0.001 ).Conclusions The cancellous bone content in the humeral head is related with age and gender.Since there is more cancellous bone in the medial part than in other parts of the humeral head,it is a reliable part for humeral head fixation.

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The assistant medial approach in treatment of intraarticular fractures of calcaneus

Zhijie WANG ; Yanchen CHU ; Yunwen ZOU

Chinese Journal of Orthopaedic Trauma.2011;13(10):924-928. doi:10.3760/cma.j.issn.1671-7600.2011.10.006

Objective To evaluate the assistant medial approach used in the surgical management of intraarticular fractures of calcaneus.Methods From January 2005 to December 2009,33 patients with intraarticular fracture of calcaneus were treated by open reduction and internal fixation through the expanded lateral L-shape approach and the assisted medial approach.They were 27 men and 6 women,aged from 18 to 62 years (average,36 years).There were 15 left sides and 18 right sides.According to Sanders' classification system,there were 27 patients with type Ⅲ displaced calcaneal fracture and 6 with type IV.Four cases were complicated with fracture of lumbar vertebra,one with pilon fracture and one with fracture of acetahulun.Fracture healing was observed and the Bǒhler and Gissane angles were measured.The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale system was used to evaluate the functional recovery.Results All patients were followed up postoperatively to assess their functional outcome.The follow-up duration was 6 to 24 months (mean,12 months).All incisions healed primarily and all fractures obtained bony union in an average of 8 weeks (from 6 to 24 months).All the Bǒhler and Gissane angles were corrected and AOFAS scores were improved.There were significant differences between preoperation and pestoperation in all indexes( P ＜ 0.05).Conclusion As the medial approach can be used to assist the expanded lateral L-shape approach in treatment of the intraarticular fractures of the calcaneus,the reduction and insertion of internal implants can be improved to achieve satisfactory functional outcome.

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Long term outcome of patella fractures:open reduction and internal fixation with stainless steel wire vs.non-absorbable braided polyester suture

Emmanuel ILLICAL ; Richard E.BUCKLEY

Chinese Journal of Orthopaedic Trauma.2011;13(11):1052-1059. doi:10.3760/cma.j.issn.1671-7600.2011.11.012

Objective To determine the long term outcome of patella fractures managed surgically with two different types of fixation:stainless steel wire or non-absorbable,braided,polyester suture.Design A prospective trial where patients were recruited in a consecutive fashion between the years 2000 and 2005 and randomized into 2 treatment groups through random number generation and number assignments in sealed envelopes.Patients were blinded to the treatment group assigned.Surgical technique and post-operative protocol was the same for each group.Subjects Patients were over the age of 16 and medically fit who presented with a displaced patella fracture requiring operative fixation.Patients were able to give consent and could follow post-operative rehabilitation requirements.Interventions In the 2 groups,open reduction and internal fixation of the patella fractures was standardized with 2 longitudinal K-wires and a figure of eight tension band using either 18 G stainless steel wire or 2 #5 ethibond sutures.Outcome Measures The primary outcome measure was re-operation rate.Secondary outcomes included surgical procedure time,the presence of clinical and radiographic union,and validated functional outcome measures (knee questionnaire,Euroqol EQ-SD,SF-36)collected from patients at final follow up.Results Almost all patients were followed to clinical and radiographic union(20/22).Average follow-ups for the stainless steel wire and suture groups were 4 and 2.3 years respectively.The re-operations in the wire and suture groups was 4 (of 11)and 5(of 11)respectively.The majority of re-operations were due to longitudinal K-wire related irritation (6/9).The wire group had a slightly shorter average surgical time than the suture group(33 vs.44 minutes),which was not statistically significant.Long term functional outcome scores indicated that there was some residual disability in patellar fracture patients,although this was not debilitating.Conclusions We suggest that a major determinant of re-operation for patella fracture fixation in a tension band technique is unnecessary longitudinal K-wire length.Suture can be as good as wire in achieving clinical and radiographic union of patella fractures.Patients with patellar fractures can achieve a reasonable functional outcome but will have a high chance of re-operation during their recovery period.

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Treatment of open to the tarsometatarsal joint injury

Wenqi GU ; Zhongmin SHI ; Yimin CHAI

Chinese Journal of Orthopaedic Trauma.2012;14(9):748-751. doi:10.3760/cma.j.issn.1671-7600.2012.09.003

Objective To discuss the treatment and clinical outcome of open to the tarsometatarsal joint injury. Methods From April 2009 to April 2010,14 patients,10 males and 4 females,with open to the tarsometatarsal joint injury were treated in our department.They were 45 years old on average (from 21 to 67 years old).Five of them had the tarsometatarsal complex involved.According to Chiodo and Myerson's classification,all the injuries were of three-column type. Medial and lateral column shortening was respectively concomitant in 2 cases.Two patients had combined soft tissue defects and one patient degloved dorsal skin.A thorough debridement and Kirschner wire fixation following reduction were performed for all patients in the emergency room.A mini external fixator was applied in patients with medial or lateral column shortening.The degloved skin was thinned and grafted in situ,followed by vacuum sealing drainage (VSD) to cover the wound.The soft tissue defect was covered by VSD after debridement.All the patients had a definitive internal fixation after the soft tissue condition improved, and 3 of them had soft tissue coverage simultaneously.Functional outcomes were scored by American Orthopedic Foot Ankle Society (AOFAS) system. Results One patient with degloving injury had partial skin necrosis which was treated by debridement,definitive internal fixation and local flap transfer on the 13th day after emergency operation.A definitive internal fixation and skin graft were performed in 2 patients with soft tissue defects respectively on the 7th or 11th day post-operation.No wound infection or necrosis occurred in other patients.Twelve patients were followed up for an average period of 18 months (from 13 to 25 months).Solid union was obtained 12 weeks on average (from 10 to 16 weeks) after the secondary surgery.No flap necrosis,infection,nonunion or osteomyelitis occurred during the follow-up.Two patients had tarsometatarsal arthrodesis at the 12th or 14th month respectively due to severe pain and function limitation caused by post-traumatic arthritis.The mean AOFAS midfoot score at the last follow-up was 72 (from 61 to 89). ConclusionsAs tnanagement of open to the tarsometatarsal joint injury is a great challenge,surgeons must take soft tissue condition into consideration.Tenporary Kirschner wire fixation or in combination with external fixation after early thorough debridement,reduction and alignment restoration,followed by secondary definitive internal fixation until soft tissue condition improves is a safe and effective treatment strategy to decrease soft tissue complications and obtain stable fixation.

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