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Periprosthetic fracture of femur is the most common postoperative complication after total knee arthroplasty (TKA). Risk factors for periprosthetic fractures include female sex, osteoporosis/osteopenia, rheumatoid arthritis, osteoarthritis, neuromuscular disease, cognitive disorder, chronic use of corticosteroids, obesity, advanced age, infection, osteolysis around the prosthesis, knee joint ankyloses, notching of the anterior femoral cortex, etc. According to epidemiological research, the incidence of femoral periprosthetic fractures following TKA ranges from 0.3% to 2.5%. Lewis and Rorabeck classifications, the most commonly used classification of periprosthetic fractures of the femur, introduce the concept of prosthesis loosening and emphasize the ecessity of revision surgery. Other classifications include Su typing, Universal Typing System, and Rhee typing, the latest of which is the Kim typing proposed in 2022. Treatment strategies for periprosthetic femoral fractures after TKA include nonsurgical treatment, external fixation techniques, single-plate fixation, double-plate fixation, intramedullary nail fixation, and revision TKA and distal femur replacement. The purpose of this paper is to better guide the prevention and treatment of periprosthetic fractures after TKA by searching and analyzing relevant literature on periprosthetic fractures after TKA.

A classical Monteggia fracture is defined as an ulnar fracture with dislocation of the proximal radioulnar joints. If combined with posterior dislocation of the radial head (posterior dislocation of the radiocapitellar joints), it is called a posterior Monteggia fracture. And for those without dislocation of the proximal radioulnar joints, it should not be defined as the posterior Monteggia fracture, but as the posterior dislocation of the proximal ulna fracture. For dislocation of the proximal radioulnar joints, the Monteggia fractures, clinical are relatively rare. The coronoid process fracture is comminuted, the proximal radioulnar joints are destroyed, the membrane and the annular ligament is injured. After restoring osseous structure and repairing the lateral ligament complex, we must also pay attention to the stability of proximal radioulnar joints, and the prognostic efficacy not sure. However, posterior dislocation of proximal ulna fractures is relatively common in clinical practice, and the coronal process fracture is usually complete, with the annular ligament and interosseous membrane intact. In treatment, the bone structure is mainly restored, and the lateral ligament complex of elbow joint is treated at the same time, with good prognosis. Through anatomical basis, imaging characteristics, injury characteristics, treatment and prognosis, we can distinguish with the posterior Monteggia fracture and posterior dislocation of proximal ulna fracture.

Objective To assess the clinical value of cross raft screws technique in preventing postoperative collapse of tibial plateau fracture.Methods From September 2014 to November 2017,data of 14 patients with tibial plateau fracture who were treated by cross raft screws technique were retrospectively analyzed.There were 9 males and 5 females aged from 30-65 years old (average,44.4± 1.7 years).There were 8 patients that the thickness of subchondral cancellous bone measured preoperatively by CT data was less than 4 mm,and 6 patients that the thickness of subchondral cancellous bone measured intraoperatively was less than 4 mm.1/4 tubular plate was placed along the anterior rim of lateral tibial plateau,and the 3.5 mm cortical bone screws were fixed as bamboo raft from anterior to posterior through the plate.The collapse of tibial plateau after surgery were measured by CT scan after union of the fracture.The function of knee was evaluated by Rasmussen Anatomical and Functional Grading.Results The time of tubular plate procedure was 18 to 35 min (average,24.1±5.4 min).All 14 patients were successfully followed-up for 13.8±5.1 months.The height of collapse preoperatively by CT scan was 5-21 mm (average,8.00± 1.40 mm).3 days after the operation,the height between articular line and lateral articular surface was 0-2 mm (average,0.80±0.06 mm).Compared with CT data preoperatively,the collapse was corrected postoperatively that was proved by CT scan (P＜ 0.05).After the fracture was healed,according to CT data,the height between articular line and lateral articular surface was 0-2 mm (average,0.70±0.08 mm).Compared with CT data postoperatively,there was no postoperative collapse happened (P=0.466).The position and length of nails were placed appropriately.The average healing time of fracture was 3.6 months.There were no infection,nonunion and pain of tendon happened.The plate could be touched subcutaneously in 2 patients,who had no discomfort feelings.The patient's postoperative Rasmussen Anatomical Grading were 13-18 (average,16.7),including 8 cases excellent and 6 cases good.The postoperative Rasmussen Functional Grading was 18-28 (average,25.7),including 11 cases excellent and 3 cases good.Conclusion The cross raft screws technique is a good way to prevent the postoperative collapse of the lateral articular surface of tibial plateau.

Objective To evaluate clinical outcomes of treating displaced intra-articular calcaneal fractures with Orthofix external fixation (EF) in comparison with open reduction and internal fixation (ORIF).Methods Between February 2013 and December 2014,39 patients with 41 calcaneal fractures were treated operatively and fully followed up at our department.They were 27 men and 12 women,aged from 27 to 56 years(average,42.5 years).The left foot was affected in 15 cases and the right in 26.By the Sanders classification,there were 11 cases of type Ⅱ,22 ones of type Ⅲ and 8 ones of type Ⅳ.The 5 open fractures were Gustilo type Ⅰ (2 cases) and Gustilo type Ⅱ (3 cases).Of the 11 fractures complicated with soft tissue injury,4 were Tscherne-Oestern type Ⅰ and 7 Tscherne-Oestern type Ⅱ.The patients were divided into group EF (25 cases) and group ORIF (16 cases) according to the operation they had received.The 2 groups were compared in intraoperative indexes and follow-up radiological data.The American Orthopaedic Foot and Ankle Society (AOFAS) scores for ankle and hindfoot were recorded at the final follow-up for every patient.Results The mean duration of surgery,intraoperative bleeding,time for hospitalization and bone healing in group EF were significantly less than in group ORIF (P ＜ 0.05).There were no significant differences between the 2 groups in follow-up duration,AOFAS score,Bthler angle,Gissane angle,calcaneal axis,calcaneal horizontal length,tuberosity height,hillock calcaneal height,calcaneal width,or talar inclination angle (P ＞ 0.05).According to the AOFAS scores at the final follow-ups,15 cases were rated as excellent,8 as good and 2 as fair in group EF while 10 were rated as excellent,5 as good and one as fair in group ORIF.Conclusions All types of calcaneal fracture can be treated using Orthofix external fixation which may lead to advantages of earlier surgery regardless of soft tissue condition,minimal invasiveness with less devascularization to the calcaneus and decreased risk of complications,and good clinical outcomes.

Objective To investigate the results and complications in the treatment of the mechanically unstable fractures of the distal femur when Less Invasive Stabilization System (LISS) is used.Methods From September 2011 to July 2014,81 patients with mechanically unstable fractures of the distal femur were treated with the LISS,according to the inclusion criteria and exclusion criteria,59 patients meet the condition including 31 male and 28 female.The mean age of the patients was 49.8 years (range 18-80 years).The fractures occurred on the left side in 40 cases and on the right side in 19 cases.According to AO classification,27 type 33A2,14 type 33A3,13 type 33C2,5 type 33C3.2 cases combined with ipsilateral fractures of the femoral shaft,according to AO classification,1 type 32A1,1 type 32C1.The mechanism of injury was a fall from the height in 8 cases,a traffic accident in 18 cases,a crush injury in 7 cases,a fall injury in 26 cases.55 fractures were closed,and 4 were open.According to the Gustilo-Anderson classification,there were 3 type Ⅰ,1 type Ⅱ.Results The 7-hole plate were used in 21 patients,9-hole plate in 26 patients and 13-hole plate in 12 cases.The 3.5 mm or 6.5 mm lag screw were placed around the LISS plate to stabilized the articular fracture fragment in 11 cases.The mean operation time was 105.2 min (85-145 min),the mean bleeding volume was 203 ml (130-315 ml).All patients were followed up 11-27 months (average 13.2 months).1 delayed union(13 months),the average time to union was 16 weeks (range 12-21 weeks).The average flexion of the knee was 116 degree,0 degree in extension.The functional outcome:32 had an excellent result,19 had a good result and 8 had a fair result,with 86.4％ excellent and good results.No deep infections occurred.No loss of reduction.3 cases had malalignment,2 failed fixation,4 patients with symptomatic hardware irritation.27 cases underwent implants removal after union,cold-welding occurred in 4 cases (9 screws) which resulted in difficult removal.Conclusion LISS is one of the reliable and effective methods in fixation of mechanically unstable fractures of the distal femur.However,its operation indications and operating instructions should be strictly followed.

Objective To investigate the feasibility of a noval anterior cubital approach for the coronoid via flexor?prona?tor teres interval and assess the clinical result. Methods Five formalin?fixed adult cadaver elbows were used. Through a single universal anteromedial longitudinal skin incision, the coronoid tip was exposed via pronator and flexor carpiradialis interval, and coronoid anteromedial facet and base via palm longus and flexor carpi ulnaris interval. The distances from the entry point to the muscles or branching point of the nerves to the line passing through medial and lateral epicondyles, as well as the length were mea?sured with regard to the motor nerve branches arising from median nerve to pronator teres, flexor carpiradialis, palm longus and flexor digiti superficialis, as well as the most proximal two motor branches to flexor carpi ulnaris arising from ulnar nerve. From September 2013 to August 2014, 4 male patients with ulnar coronoid fracture were treated operatively through the above anterior cubital approach in our hospital. They were all left side involved, with an average age of 32 years (range, 16-42 years). According to O’Driscoll classification, there were two cases of type Ib and two cases IIb respectively. They were all treated by open reduction and internal fixation through flexor?pronator teres interval. Results At cubital fossa, there were 2-3 branches to the pronator teres mostly, 1 branch to flexor carpiradialis and palm longus arising from median nerve. The branch to the flexor digiti superficia?lis usually was long and thick, and divided into 2-5 short twigs near muscle. The branch to palm longus had the same trunk with that to flexor digiti superficialis. The branch to flexor digiti superficialis was the most proximal among those passed through the in?terval of pronator teres and flexor carpiradialis, and its entry point to the muscle had an averaged distance of 37.22 mm to the line passing through medial and lateral humeral epicondyles. It was optimal to expose coronoid tip through the interval of pronator teres and flexor carpiradialis. It was safe to expose coronoid proximal to the branch to flexor digiti superficialis. While, it was better to expose the anteromedial facet and base of corocoid through the interval of palm longus and flexor carpiulnaris via median and ul?nar nerve interface. All of the four patients were followed up for an average period of 9 months. They all achieved bone union from 6 weeks to 3months (mean, 9 weeks). All the patients obtained excellent result according to the modified An&Morrey elbow per?formance index with scores from 94 to 100. Conclusion The novel anteromedial cubital approach via flexor?pronator teres is opti?mal for exposure of coronoid.

Objective To evaluate the causes of complications of patients with femoral Intertrochanteric fractures after gamma3 nail fixation.Methods A retrospective analysis was conducted to summarize the treatment of intertrochanteric fractures in 186 cases with Gamma3 nail from May 2006 to July 2011.Complications occurred in 24 cases during the operations.19 were males,5 females,with the age from 42 to 81,the average age of 69.00±3.27 years.According to AO/OTA classification,8 cases were type A1,1 case were type A2.1,15 cases were type A3.All patients included were acute fractures,while pathological fractures were excluded.Supine position were selected during operation,close reduction were performed in traction bed.Gamma3 nail made by Stryker Company was used to fix fractures through small incisions.Operational times were from 45 to 160 minutes,averaged by 80 min.Blood lose were 300-800 ml in average.No patient need blood transfusion.The procedure from hospitalized to operation is from 3 to 12 days,6 days in average,discharged from 3 to 16 days after operation.According to the intraoperative and postoperative follow-up evaluation of the X-ray and Harris evaluation criteria,Gamma3 nail complications were summarized in the application.Results Time of surgery in 24 cases were 45-160 min,average 80 min.Blood loss were 300-800 ml,average 600 ml,walking time 35-106 d.Harris evaluation were 75-91 point,average 81 point.The anti-spiral nail dropped into inner thigh muscles occurred in 1 case,causing defects of femoral lateral wall in 3 cases.Splitting fractures occurred in the proximal femoral shaft during the operations in 5 cases,poor fracture reduction during closed reduction in 6 cases.Fracture site were shifted lately postoperative in 5 cases,lag screw cut-out in 3cases and refracture in the site of distal femoral interlocking nail in 1 case.Conclusion Higher incidence of complications were occurred in some special types of AO classification when using close reduction and short Gamma3 nail.The reduction method,wrong indication selection and unreasonable application of equipment may result in the occurence of complications.We,therefore,should use long or short Gamma nail according to their respective induction method and scope of its application,aiming to avoid complications.

Objective To investigate surgical outcomes of anterolateral plus posteromedial approaches for treatment of complex tibial plateau fractures.Methods We reviewed 68 patients with tibial plateau fractures of Schatzker types Ⅴ and Ⅵ who had been treated from January 2008 to December 2011 and fully followed up in our department.They were 42 men and 26 women,22 to 64 years of age (average,42.3 years).Fractures occurred at the left side in 24 cases and at the right side in 44 cases.Intervals between injury and operation ranged from 3 to 15 days,7.4 days on average.All of them were operated on through anterolateral plus posteromedial approaches.T-or L-shaped steel plates were used laterally while reconstruction plates or T-shaped plates for distal radius were used medially.Results In this cohort the operation time averaged 3.13 hours,intraoperative blood loss 562.7 mL and hospital stay 20.4 days.All cases were followed up for an average of 18.8 months (range,12 to 38 months).Fractures healed from 4 to 8 months,6.7 months on average.The average tibial plateau angle,posterior slope angle and femorotibial angle immediately postoperation were respectively 87.3°± 1.5°,12.0°± 2.5° and 170.0°± 2.5°,not significantly different from those at one year postoperation (86.8° ± 1.2°,13.0° ± 1.8° and 171.0° ± 1.7°) (P ＞ 0.05).According to The Hospital for Special Surgery Score,the outcomes were excellent in 36 cases,good in 24 cases,fair in 6 cases and poor in 2 cases,with a good to excellent rate of 88.2％.No neural or vascular injury,deep infection,or implant failure was found in this group.Conclusion Anterolateral plus posteromedial approaches are effective for complex tibial plateau fractures,leading to anatomic reduction,stable fixation and early functional rehabilitation.

Objective To discuss methods and clinical efficacy of patients treated with arthrolysis for posttraumatic elbow stiffness with heterotopic ossification.Methods The study involved 16 patients with posttraumatic elbow stiffness combined with heterotopic ossification treated by arthrolysis between June 2007 and June 2011.There were 11 males and 5 females,at average age of 29.6 years (range,18-53 years).Time from injury to surgery averaged 10.7 months (range,8-14 months).Other than medial approach for only one patient,the rest adopted medial to lateral approaches to have a complete clearance of periarticular heterotopic ossification tissue and hyperplastic tissue as well as partial resection of articular capsules and ligaments.Besides,seven patients were fixed using hinged external fixators.After surgery,three weeks of oral celecoxib was given for the patients.Rehabilitation was started immediately after operation.Range of motion (ROM) of the elbow and Mayo elbow pcrformance score (MEPS) were used to determine clinical results.Results All patients were followed up for 8-17 months (mean 13.4 months).ROM of the elbow (extension lag,flexion,pronation and supination)showed an improvement from (45.2-3.5)° to (27.2 ±8.4)°,(68.1-11.8)° to (106.8 ± 16.4)°,(55.8 ± 8.2) ° to (80.5 ± 3.3) °,and (53.7 ± 6.3) ° to (83.1 ± 5.3) ° respectively (P ＜ 0.01).MEPS increased from (46.8 ±7.0) points to (83.2 ±9.4) points after operation (P ＜0.01).According to MEPS criterion,the results were excellent in seven patients,good in five and fair in four.Conclusion With respect to posttraumatic elbow stiffness with heterotopic ossification,satisfactory therapeutic results can be achieved by thorough preoperative evaluation,strict control of surgical indications,appropriate selection of intraoperative techniques and early systematic rehabilitation.