Hsuan-Ti Huang

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus.

BACKGROUND Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures. METHODS The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation. RESULTS The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001). CONCLUSION On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeons ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.

The Efficacy of Combined Use of Intraarticular and Intravenous Tranexamic Acid on Reducing Blood Loss and Transfusion Rate in Total Knee Arthroplasty

The purpose of this study is to investigate the effect of preoperative intravenous (IV) and intraoperative topical administration of tranexamic acid (TXA) in total knee arthroplasty (TKA). A total of 120 patients were and randomly allocated to either topical group, combined group, or control group. The mean total blood loss was lower in the combined and topical groups (705 mL and 579 mL, respectively) in comparison with control group (949 mL, P < 0.001). There was a significant difference in transfusion rate among groups (P = 0.009). The postoperative hemoglobin drop and total drain amount were significantly less in the combined group compared to other groups. In conclusion, combining preoperative IV injection and topical administration of TXA can effectively reduce blood loss and transfusion rate.

Indirect reduction and bridge plating of supracondylar fractures of the femur

Between October 1995 and December 1998, 16 patients with A-O type A3, C2 or C3 supracondylar femoral fractures were treated by open reduction and internal fixation using indirect reduction and bridge plating. Seven (44%) patients had open fractures. The patients were followed for a mean of 46 months (range 24-71). All fractures healed. The average time for fracture healing was 18.5 weeks (range 12-28). Four primary bone grafts and three secondary bone grafts were performed. By using the modified Schatzker rating scale, the result of 13 patients (81%) were rated as excellent or good. Complications included two implant failures that were due to full weight bearing before bone healing, and one superficial delayed wound healing. No deep infections were found in this series. The open fracture group needed longer time to heal and had a higher rate of receiving bone grafts. We conclude that indirect reduction and bridge plating with a 95 degrees dynamic condylar screw (DCS) or condylar blade plate can produce favourable results for complex distal femoral fractures. We suggest primary bone grafts or early secondary bone grafts for comminuted open fractures using an indirect reduction technique.

Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman: a case report.

Objective Bisphosphonates are used as first-line therapy for postmenopausal osteoporosis owing to their potent inhibition of bone resorption. Long-term use of bisphosphonates may lead to low-energy femoral subtrochanteric or shaft fractures in a very few patients. The aim of this study was to describe the clinical course of a patient treated with alendronate for 3 years who developed an atypical femoral fracture and to hypothesize the beneficial effects of teriparatide on the healing of the patient’s atypical femoral fracture. Methods A 63-year-old Asian woman had a lumbar osteoporotic fracture and received 70 mg of alendronate for 3 years. Pain and soreness in the thigh presented initially and exacerbated thereafter. X-ray revealed a right femoral diaphysis stress fracture. She then received teriparatide for the treatment of osteoporosis and the femoral atypical fracture. Results Pain and tenderness improved remarkably after teriparatide treatment for 1 month, and these symptoms disappeared after teriparatide treatment for 9 months. The patient also received raloxifen as further therapy, and the fracture line had completely disappeared by 15 months after treatment. Conclusions Even though a previous study has reported that teriparatide healed stress fractures in a rat model and even with the time course of fracture healing in our patient, we are still not certain that teriparatide played a primary role in the positive response to therapy. Vitamin D therapy, calcium, and alendronate discontinuation may have played secondary roles. This case report may serve to introduce a direction for future research into the pharmacological treatment of atypical femoral fractures. Surgical treatment of incomplete atypical femoral fractures may be a safer method.

Pioglitazone and dexamethasone induce adipogenesis in D1 bone marrow stromal cell line, but not through the peroxisome proliferator-activated receptor-γ pathway

Osteoblasts and adipocytes share a common progenitor in bone marrow. Peroxisome proliferator-activated receptor-gamma (PPAR-gamma) plays a critical role in adipogenesis. Using a mouse pluripotent mesenchymal cell, D1, as a model, several reports have demonstrated that dexamethasone, a glucocorticoid, can induce adipogenesis. We first examined whether adipogenesis induction in D1 cells is initiated by activation of PPAR-gamma. The results revealed that pioglitazone induces adipogenesis in D1 cells in a dose-dependent manner and decreases alkaline phosphatase activity in D1 cells. Interestingly, this adipogenesis was not blocked by bisphenol A diglycidyl ether, a PPAR-gamma antagonist. A PPAR-gamma-mediated reporter gene assay showed no response to pioglitazone. We then asked whether dexamethasone-induced adipogenesis can be repressed by mifepristone (RU486), an antagonist of glucocorticoid receptor. The results disclosed that mifepristone cannot counteract dexamethasone-induced adipogenesis, and mifepristone itself induced adipogenesis in D1 cells. Moreover, glucocorticoid receptor-mediated reporter gene assay was not responsive to dexamethasone or mifepristone. We concluded that the adipogenesis induced by pioglitazone and dexamethasone in D1 cells may not occur via a PPAR-gamma and glucocorticoid receptor pathway. Finally, we analyzed the gene expression profile of D1 by cDNA microarray after treatment with dexamethasone. We found that the expression of several adipogenesis-related genes is highly provoked by this agent.

An Alternative Technique for the Management of Phalangeal Enchondromas With Pathologic Fractures

PURPOSE Enchondroma of the hand with a pathologic fracture is generally treated by tumor curettage and bone grafting after the fracture has healed. However, delayed surgery postpones definitive diagnosis and prolongs the period of disability. We have treated pathologic fractures in a single stage through a modified lateral surgical approach with curettage of the tumor and stabilization using injectable calcium sulfate cement. The aim of this study was to report the outcomes of treatment with this material and the modified approach. METHODS Between 2006 and 2010, we enrolled 8 patients with solitary hand enchondromas and pathologic fractures. The surgical procedure involved a lateral approach, an extended lateral cortical window, thorough tumor evacuation, and reconstruction of the bone defects using commercially available injectable calcium sulfate cement. We performed evaluations before surgery and in the postoperative follow-up series by radiographs and clinical assessments, including measurement of joint motion by goniometry and a visual analog pain scale. RESULTS The average time of follow-up was 19 months (range, 12-36 mo). The pathologic fractures of all patients healed clinically and radiographically within 8 weeks after surgery, and the mean active motion arcs of the metacarpophalangeal joints and proximal interphalangeal joints of the involved digit were 90° and 94°, respectively at 3-month follow-up. All patients returned to ordinary daily activities without obvious pain by 3 months postoperatively. We found no major complications, such as unacceptable alignment, nonunion, infection, or tumor recurrence, during follow-up. CONCLUSIONS This study demonstrated the outcomes of early management of phalangeal enchondromas with pathologic fractures using a lateral approach and injectable calcium sulfate cement for reconstruction. This combined approach avoided the need for supplemental internal fixation, allowed early mobilization, and resulted in minimal joint stiffness. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Open reduction and internal fixation of acute intra-articular displaced calcaneal fractures: A retrospective analysis of surgical timing and infection rates

The choice of surgical timing in open reduction for calcaneal fractures has been proposed to be associated with soft-tissue complications and infection. This study analysed the correlation between surgical timing and postoperative infection rates. We performed a retrospective single-surgeon single-facility study (Kaohsiung Medical University Hospital, KMUH) between January 2006 and January 2010. Fifty patients with 53 close intra-articular calcaneal fractures were included. They received open reduction and internal fixation via the extensile lateral L-shaped approach. We assessed the duration between heel trauma and operation from the medical records and sorted our patients into early (within 3 days), intermediate (from 3 to 10 days) and delayed (over 10 days) surgical groups. The mean follow-up period was 13 months. Only one of the 50 patients, a 74-year-old female with diabetes mellitus, developed deep infection requiring hardware removal and serial debridement. Overall, we did not find a statistical difference in postoperative infection rates in the different timing groups. Our conclusion is that in experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication. Therefore, early operation may be helpful to these patients.

Bicondylar tibial plateau fracture treated by open reduction and fixation with unilateral locked plating

The management of bicondylar tibial plateau fractures is challenging. A lateral locking plate offers an alternative method to traditional dual plating to avoid further stripping of soft tissue. Nevertheless, the rate of malreduction and fixation loss remains high. From 2007 to 2009, we performed open reduction and fixation with unilateral locked plating to directly reduce the fracture in 15 patients with bicondylar plateau fracture. The average follow‐up duration was 16.2 months (range: 12–30 months), and the average age of the patients was 43 years (range: 19–64 years). All fractures were Orthopaedic Trauma Association type 41‐C. Postoperative radiographic alignment was evaluated immediately and at 2–4 weeks, 8–12 weeks, 5–7 months, and 11–13 months. Both Oxford knee score and Hospital for Special Surgery knee score were used to evaluate functional outcomes. The average duration within which union was achieved was 4.8 months (range: 2–10 months). One patient incurred wound dehiscence; however, there was no case of deep infection. Malreduction occurred in one patient (6.7%) while fixation loss occurred in three patients (20%) with subsidence of the posteromedial fragment and varus malalignment. Despite the malreduction rate being lower in our study than in previous studies involving unilateral locked plating, a high rate of fixation loss was recorded. Per our limited experience, we believe that unilateral locked plating may have limitations in patients with selective patterns of bicondylar tibial plateau fractures.

Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty

AIMS AND OBJECTIVES The aim of this study was to evaluate the effects of continuous passive motion on the range of motion, postoperative pain and life quality of patients undergoing total knee arthroplasty within six months after the operation. BACKGROUND Total knee arthroplasty reduces pain and improves range of motion of the osteoarthritic knee joint. Continuous passive motion increases postoperative movement, but there is some controversy regarding whether aggressive continuous passive motion can improve range of motion or life quality, and whether it induces more pain. DESIGN A prospective controlled study was conducted in a medical centre in Taiwan from January to December 2006. METHODS One hundred and seven patients were recruited. The patients underwent the basic rehabilitation protocols (the control group) or the basic rehabilitation protocols and additional daily use of continuous passive motion for more than six hours per day (the experimental group). The range of motion, modified Short Form-36 (SF-36) and semi-quantitative visual analogue scale were recorded. Results.  Range of motion increased from 109° preoperatively to 125° at six months postoperatively in the treatment group and from 111° preoperatively to 125° at six months postoperatively in the control group. Visual analogue scale decreased from 7·78 preoperatively to 0·37 at six months postoperatively in the treatment group and from 7·92 preoperatively to 0·21 at six months postoperatively in the control group. The SF-36 improved from 3·76 preoperatively to 1·77 at six months postoperatively in the treatment group and from 3·68 preoperatively to 1·83 at six months postoperatively in the control group. There was no significant difference in range of motion, visual analogue scale and SF-36 between groups at each visit. CONCLUSION With the advances in total knee arthroplasty surgical technique, aggressive continuous passive motion does not provide obvious benefits. RELEVANCE TO CLINICAL PRACTICE Total knee arthroplasty can alleviate pain and improve range of motion, but aggressive continuous passive motion does not provide additional benefits.

Minimally invasive total hip arthroplasty using a posterolateral approach: technique and preliminary results.

Minimally invasive total hip arthroplasty (THA) has become popular over the past few years. The advantages of this technique include reduced soft tissue damage. On the other hand, there are new risks related to reduced visualization. The widespread introduction of minimally invasive THA is still controversial. Here, we present our experiences and early results with a posterolateral approach to minimally invasive THA. Between August 2005 and July 2006, 85 hips from 79 consecutive patients were operated on using posterolateral minimally invasive THA. The outcomes were assessed on the basis of clinical and radiographic parameters. The mean operative time was 55 minutes. The mean length of hospital stay was 5.3 days. Average postoperative Harris hip score was 92.0 at 3 months postoperatively Complications included only one (1.18%) intraoperative nondisplaced calcar split. There were no cases of dislocation, neurovascular injury or postoperative infection. Our study indicates an early result of low complication rate and good functional recovery following minimally invasive THA using a posterolateral approach. This minimally invasive THA technique provides short‐term safety and efficacy.