Objective To compare the efficacy of anterior-posterior and posterior-anterior screw fixation for posterior malleolar fractures surgery.Methods A retrospective analysis of 376 cases of posterior malleolar fractures treated with lag screws from January 2011 to October 2022 with more than 12 months of follow-up period was conducted.The patients were divided into two subgroups based on the thickness of the fracture fragment,with 167 cases in the small fracture subgroup having a fracture fragment thickness＜17 mm(screw thread length)and 209 cases in the large fracture subgroup having a fracture fragment thickness ≥ 17 mm.Each subgroup was further divided into anterior-posterior and posterior-anterior groups based on the direction of screw fixation in the posterior malleolar fracture surgery.In the small fracture subgroups,there were 74 cases in the anterior-posterior group and 93 cases in the posterior-anterior group.In the large fracture subgroup,there were 88 cases in the anterior-posterior group and 121 cases in the posterior-anterior group.The American Orthopaedic Foot and Ankle Society(AOFAS)ankle-hindfoot score was measured at the last follow-up.The displacement of the fracture fragment in the direction of the fracture line(Dn)and perpendicular to the fracture line(Dt)were measured on the first day after surgery and at the last follow-up,and the displacement of the fracture fragment was calculated,which was the difference between Dn+Dt at the last follow-up and Dn+Dt on the first day after surgery.Results On the first day after surgery,X-ray showed no significant difference in Dn and Dt between the anterior-posterior and posterior-anterior groups in both of the small and large fracture subgroups(P＞0.05).The entire group was followed up for 12-85 months,with an average of 19.3 months.In the small fracture subgroup,the displacement of the fracture fragment in the posterior-anterior group[(0.11±0.19)mm]was superior to that in the anterior-posterior group[(0.19±0.21)mm;P=0.011],and the AOFAS score was also superior to that in the anterior-posterior group[(80.2±8.4)points vs.(76.2±8.6)points,P=0.003].In the large fracture subgroup,there was no significant difference in fracture displacement between the posterior-anterior group[(0.11±0.18)mm]and the anterior-posterior group[(0.12±0.19)mm;P=0.630],and there was also no significant difference in AOFAS scores[(84.1±7.8)points vs.(82.8±7.6)points,P=0.246].Conclusions There is no significant difference in the reduction effect between anterior-posterior and posterior-anterior lag screw internal fixation for posterior malleolar fractures in trimalleolar fractures.For patients with fracture thickness＜17 mm,posterior-anterior fixation is superior to anterior-posterior fixation;for patients with fracture thickness ≥17 mm,there is no significant difference in the efficacy between anterior-posterior and posterior-anterior fixation.

Objective:To compare the short-term outcomes of femoral neck system (FNS) and dynamic hip screw (DHS) in the treatment of femoral neck fractures.Methods:A retrospective analysis was performed of the 105 patients with fresh femoral neck fracture who had been treated by FNS fixation from September 2019 to October 2020 or by DHS fixation from January 2018 to October 2020 at Department of Orthopaedics, The Third Hospital Affiliated to Peking University. In the FNS group of 54 cases, there were 18 males and 36 females with a mean age of (60.7±15.2) years; in the DHS group of 51 cases, there were 14 males and 37 females with a mean age of (63.3±13.2) years. The 2 groups were compared in terms of hospital stay, operation time, intraoperative blood loss, incision length, intraoperative fluoroscopy frequency, qualify of reduction, and femoral neck shortening length, Harris hip score and complications at the last follow-up.Results:The 2 groups were comparable due to insignificant differences in their preoperative general data or follow-up time ( P>0.05). In the FNS group, the median operation time [45.0 (40.0, 59.0) min], intraoperative blood loss [30.0 (20.0, 50.0) mL], incision length [4.0 (4.0, 5.0) cm], intraoperative fluoroscopy frequency [10.5 (9.0, 12.0) times] and hospital stay [2.0 (2.0, 4.0) d] were significantly superior to those in the DHS group [72.0 (55.0, 89.0) min, 50.0 (30.0, 50.0) mL, 7.0 (6.0, 8.0) cm, 18.0 (15.0, 19.0) times, and 3.0 (3.0, 6.0) d] (all P<0.05). There were no statistical differences between the 2 groups in quality of reduction, length of femoral neck shortening, failure rate of internal fixation or Harris hip score at the last follow-up ( P>0.05). There were no such surgical complications as deep infection or femoral head necrosis in either of the 2 groups. Conclusions:In the fixation of femoral neck fractures, both FNS and DHS may lead to fine short-term outcomes. However, compared with DHS, FNS exhibits advantages of simplicity, minimal invasion, less surgical trauma and intraoperative fluoroscopy frequency, and reduced operation time and hospital stay.

Objective: To identify the risk factors for failure of internal fixation with proximal femoral nail antirotation (PFNA) for reverse intertrochanteric hip fractures. Methods: A retrospective study was conducted of the 45 patients with reverse intertrochanteric hip fracture who had been treated with PFNA fixation from January 2006 through January 2018 at the Department of Traumatic Orthopaedics, The Third Affiliated Hospital to Peking University. They were 19 males and 26 females, aged from 19 to 97 years (average, 71.9 years). According to the AO/OTA classification, there were 7 cases of type 31-A3.1, 4 cases of type 31-A3.2 and 34 cases of type 31-A3.3. Fracture healing was judged according to the X-ray at the time of last follow-up. The patients were assigned into a healed group and a failed group. The 2 groups were compared in terms of gender, age, body mass index (BMI), mechanism of injury, AO classification, type of main fracture line, reduction method, reduction quality, status of lateral femoral wall and tip-apex distance. A multivariate logistic regression model was designed to analyse the dependent variable 'implant failure’ with a set of independent variables as risk factors. Results: The 45 patients were followed up for 12 to 62 months (average, 28.4 months). Implant failure was observed in a total of 6 patients (13.3%), 3 of whom had helical blade perforation, 2 main screw breakage, and one cut-out of helical blade. The single factor analysis revealed significant differences in reduction quality and type of main fracture line between the patients with successful fixation and those with failed fixation (P<0.05). The multiple logistic regression analysis identified poor reduction quality (OR=30.809, 95%CI: 1.052~902.298, P=0.047) and a transverse fracture line (OR=25.639, 95%CI: 1.636~401.917, P=0.021) as risk factors for implant failure. Conclusion Poor reduction quality and a transverse fracture line may be predictors of implant failure in reverse intertrochanteric hip fractures treated with PFNA fixation.

Treatment of extremity bone defects,especially large segmental ones,is a difficult problem encountered by orthopedic surgeons in the clinic.Despite a variety of treatment techniques available,lack of uniform protocols causes patients to suffer enormous physical and psychological pain during their medical treatment.Now that new materials and new techniques are constantly evolving and patients' requirements for functional and morphological recovery of the injured limb become more demanding,it has become a great challenge for orthopedic surgeons to provide an optimal individualized treatment protocol for each patient.This review intends to help surgeons with brief update information on the research progress in the treatment of extremity bone defects.

Objective To analyze the iatrogenic fractures following treatment of type 12-A humeral shaft fractures with antegrade intramedullary nails. Methods We reviewed the patients who had been treated with antegrade intramedullary nails for type 12-A humeral shaft fracture from October 2006 to March 2017. They were 13 males and 13 females with an age range from 22 to 76 years and an average age of 44. 5 years. Six of them were complicated with other fractures or radial nerve injury. We divided the patients into an iatrogenic fracture ( IF ) group and a non-iatrogenic fracture ( NIF ) group and compared gender, age, fracture type, reaming and nonunion between the 2 groups. Results The follow-up time for the 26 patients ranged from 13 to 182 weeks ( 63. 8 weeks on average ) . Of them, 7 suffered iatrogenic fracture and 4 nonunion. The union time for the other 22 patients ranged from 9 to 29 weeks ( 14. 6 weeks on average ) . All the 7 patients in the iatrogenic fracture group were treated with reaming while only 9 of the 19 patients in the non-iatrogenic fracture group were treated with reaming. Nonunion occurred in 3 patients in the iatrogenic fracture group but in only one patient in the non-iatrogenic fracture group. All the above comparisons were statistically significant between the 2 groups ( P < 0. 05 ) but there were no significant differences in comparisons between the 2 groups regarding gender, age, nail diameter, fracture type, way of locking proximal and distal screws or rate of secondary surgery ( P > 0. 05 ) . Conclusions Antegrade intramedullary nailing may cause an iatro-genic fracture in the treatment of type12-A humeral shaft fractures. The iatrogenic fracture may affect fracture union. Intraoperative reaming may be the risk factor for the iatrogenic fracture.

Objective To analyze the factors that influence screw penetration after plating for proximal humerus fractures of Neer two-or three-part.Methods We reviewed the patients with proximal humerus fracture of Neer types Ⅱ & Ⅲ who had been treated from January 2006 to June 2017.The data were documented regarding gender,age,Neer classification,osteoporosis,surgical procedure,cephalic screw number,type of medial support and screw penetration.They were divided into 2 groups according to the presence or absence of screw penetration.x2 test and independent samples t test were used with software IBM SPSS 22.0.The multivariate logistic regression was used to identify the independent risk factors when there were two or more statistically significant factors.The two-side test was used and significance was set to P ＜ 0.05.Results Altogether 78 patients were included in our analysis,including 27 males (34.62％) and 51 females (65.38％) with an average age of 57.41 years (from 18 to 85 years).Their average follow-up time was 7.7 months (from 3 to 24 months).There were 54 Neer two-part fractures (69.23％) and 24 Neer three-part ones (30.77％).Screw penetration was observed in 18 patients (23.08％) but not in the other 60 ones (76.92％).The x2 test and independent samples t test revealed that screw penetration was significantly associated with gender (P =0.003),osteoporosis (P =0.003) and cephalic screw number (P =0.003) but not with age (P =0.256),Neer classification(P =0.754),surgical procedure((P =0.308) or type of medial support (P =0.186).The multivariate logistic regression revealed that osteoporosis (P =0.027) and cephalic screw number (P =0.026) were independent risk factors for screw penetration.Conclusions After plating for proximal humerus fractures of Neer two-or three-part,the patients with osteoporosis and those receiving more than 5 cephalic screws may face a higher risk of screw penetration than those without osteoporosis and those receiving 4 cephalic screws.

Objective:To evaluate the rate of basicervical fractures and document their diagnosis and treatment.Methods: From January 2005 to May 2016,28 basicervical fractures of the 832 trochanteric fractures were collected and evaluated.The patients were treated with multiple screws,dynamic hip screw (DHS),intramedullary nail.Via the operation time,postoperative hospitalization,loss of blood duration the operation,hidden blood loss,total blood loss,mean union time and the final follow-up Harris hip score,the characteristics of different internal fixations were compared and analyzed.Results: The incidence of basicervical fractures was 3.37％ (28/832) in our study.In the intramedullary nail group (16 patients),the operation time was 55 (20,120) min,the postoperative hospitalization was 3(2,7) d,the intraoperative blood loss was 50(5,100) mL,the hidden blood loss was 533.37 (376.19,987.15) mL,and the total blood loss 627.35 (406.19,1037.16) mL.The union time and final follow-up Harris score were 6 (3,9) months and 90.25 (74,100) min.In the DHS group (8 patients),the operation time was 87.5 (65,115) min,the postoperative hospitalization was 5.5 (2,17) d,the intraoperative blood loss was 100 (50,300) mL,the hidden blood loss was 278.11 (202.43,849.97) mL,and the total blood loss 580.19 (368.55,899.97) mL.The union time and final follow-up Harris score were 5.5 (4,12) months and 85.5 (84,87) min.In the multiple screws group (4 patients),the operation time was 47.5 (35,75) min,the postoperative hospitalization was 5 (2,12) d,the intraope-rative blood loss was 20 (2,70) mL,the hidden blood loss was 150 (100.00,412.01) mL,and the total blood loss 195.00 (120.00,414.01) mL.The union time and final follow-up Harris score were 4 (4,6) months and 80 (61,97) min.The patients treated with multiple screws and intramedullary nail had a shorter operation time than the DNS group,but no obvious difference was found between the other two groups (P=0.367).Postoperative hospitalization had no significant difference among the three groups.The intraoperative bleeding was more in the DHS group,the other two groups had no significant difference (P=0.100).However,the hidden blood loss was more in the intramedullary nail group,the other two groups had no significant difference (P=0.134).The total blood loss in the intramedullary nail group was more than multiple screw group,similar to the DHS group (P=0.483).One patient treated with multiple screws underwent internal fixation failure three months after operation.The mean union time and final follow-up Harris scores had no significant difference among the three groups (P>0.05).Conclusion: Through this study,we found that the incidence of basicervical fractures is low.Fractures with no shift can be confirmed by preoperative X-ray.For displaced fractures,preoperative CT + 3D reconstruction is recommended.Surgical treatment by closed reduction and internal fixation with DHS or intramedullary nail is shown to be very effective.

Objective To evaluate the correlation between 3 different instruments,SF-36 Health Survey,Hospital for Special Surgery (HSS) knee score and Rasmussen Score,for measurement of surgical outcomes of tibial plateau fractures,and their clinical significances as well.Methods Included in this study were 94 patients with tibial plateau fracture who had been consecutively treated and followed up from January 2009 through February 2015 at our department.Their surgical outcomes were measured by SF-36 Health Survey,HSS-knee score and Rasmussen Score respectively for health-related quality of life (HRQL),knee function,and reduction of fracture.Pearson correlation test was used to determine the correlation between the 3 measurement instruments.Results 94 cases eventually finished their following-ups.The mean follow-up was 41.2 months (range,from 12 to 75 months).The Rasmussen scores for their first postoperative X-ray films averaged 14.7 ± 2.1 points,their HSS-knee scores at the final follow-up averaged 81.0 ± 13.7 points,and their SF-36 scores at the final follow-up averaged 85.5 ± 10.0 points.Statistical analysis showed that the HSS-knee score was positively related to the SF-36 score and Rasmussen score (P ＜ 0.05) but not to the Rasmussen score (P ＞ 0.05).Conclusions Fine reduction may be the basis for good functional recovery of the knee and good functional recovery may benefit the HRQL of the patients,but merely good fracture reduction does not promise a high HRQL for patients with tibial plateau fracture.In the treatment of tibial plateau fractures,it is not enough to take care of fracture reduction and functional recovery,and the HRQL of patients should be taken into consideration.More attention should be paid to other important factors influencing the HRQL of patients.

[Summary] Acute acromioclavicular joint dislocation is a common injury of the shoulder .Its surgical treatment is various .In recent years , with the promotion of arthroscopic techniques , arthroscopic treatment has gradually become a hot spot in the field of minimally invasive treatment for acute acromioclavicular joint dislocation .There are various types of internal fixation .The overall treatment effect is satisfactory .In this review we summarized minimally invasive treatment for acromioclavicular joint dislocation .

Objective:To study the effectiveness of inferior pole fracture of patella treating by the new tension band.Methods:From Dec.2011 to Dec.2013, 21 patients with inferior pole fracture of patella were treated with the new tension band which consisted of cannulated screw, titanium cable and shims. There were 21 patients[10 males, 11 females, the average age was 54 years(21 to 79)],of whom,all were“fell on knees”.Results:The average operation time was 89 min (57-197 min),the follow-up visits were done from 7-31 months ( average 18 months) , the bone healing time was from 8-12 weeks (average 10.5 weeks).The post operation assessment was done by Bostman score, from 20 -30 (average 27),10 excellent,and 11 good.No complication occurred.Conclusion:The new tension band is the effective treatment for inferior pole fracture of patella.The internal fixation is reliable, it is simple to operate, and patients can take exercises as early as possible.Therefore, the new tension band has a bet-ter clinical value.