Zhanle Zheng

Meta-analysis shows that highly comminuted bicondylar tibial plateau fractures treated by single lateral locking plate give similar outcomes as dual plate fixation

ObjectivesThis meta-analysis was conducted to compare the clinical outcomes of single lateral locking plate (SP) versus dual plate fixation (DP) for the repair of bicondylar tibial plateau fractures (AO/OTA type C or Schatzker type V and VI).MethodsPubMed, Embase, Medline, CNKI, Wanfang database and Chinese VIP information were searched to identify the randomized and prospective comparative clinical studies which concern the treatment of bicondylar tibial plateau fractures (AO/OTA type C or Schatzker type V and VI) both with SP and DP fixation before October 1, 2015. STATA version 11.0 (Stata Corporation, College Station, TX, USA) was used for data-analysis after the critical assessment of the methodological quality of the trials.ResultsFinally, nine trials comprising 559 patients were included for this meta-analysis after the filtration. There were no significant differences between SP fixation and DP fixation with regards to outcomes for bone graft, post-operative malalignment and post-operative malreduciton in surgical details; infection, venous thrombosis, implant irritation and loss of reduction in complications; knee motion range in final outcomes. Lower surgical time, hospital stay, union time and incision necrosis were found in SP fixation compared with DP fixation. High rate of loss of alignment and more satisfaction with 12-month HSS score were associated with SP fixation than with DP fixation.ConclusionsBoth SP fixation and DP fixation are acceptable strategies for managing this type of fracture. However, more high quality RCTs with large number of patients and long-term clinical evaluations are required to determine the optimal strategy for bicondylar tibial plateau fractures.

Axial view of acetabular anterior column: a new X-ray projection of percutaneous screw placement

IntroductionTo search for a new radiographic view/projection of the acetabular anterior column to provide a safe guide for percutaneous screw placement for acetabular fractures.Materials and methodsEight pelvic specimens taken from normal adult cadavers were positioned in a supine position on the operating table. First, the ipsilateral ilium-oblique view of the observed side was obtained on C-arm fluoroscopy by tilting the C-arm approximately 35° toward the contralateral hip joint. Then, the tilting angle of the C-arm was changed gradually until an oval track image (acetabular anterior column axial view) appeared. The oval shadow was clear only in one position as the angle of the C-arm was changed toward the caudal side of the operating table. A guide pin was put on the skin of the cadaver, and the location and tilting direction of the guide pin were adjusted under C-arm fluoroscopy until the pin’s shadow became a point in the center of the oval track. Then, the guide pin was inserted into the bone using a battery-powered drill. The degree of inclination of the guide pin in the cadaver in the frontal and sagittal planes was measured using computed tomography (CT).ResultsAxial views of the anterior column were found successfully in all of the pelvic specimens, and the guide pins were inserted accurately into the acetabular anterior column under C-arm fluoroscopic guidance. On the CT-reconstructed image, the average degree of angle between the guide pin and the sagittal plane was 33.6° (range 29.6°–36.5°). The average angle between the guide pin and the transverse plane was 59.1° (range 56.4°–63.2°).ConclusionThis axial view of the acetabular anterior column is a novel X-ray projection which provides an optimal method for guiding percutaneous insertion of anterior column screws for acetabular fractures.

Biomechanical Comparison of Two Kinds of Internal Fixation in a Type C Zone II Pelvic Fracture Model.

Background:Unstable pelvic fractures are complex and serious injuries. Selection of a fixation method for these fractures remains a challenging problem for orthopedic surgeons. This study aimed to compare the stability of Tile C pelvic fractures fixed with two iliosacral (IS) screws and minimally invasive adjustable plate (MIAP) combined with one IS screw. Methods:This study was a biomechanical experiment. Six embalmed specimens of the adult pelvis were used. The soft tissue was removed from the specimens, and the spines from the fourth lumbar vertebra to the proximal one-third of both femurs were retained. The pubic symphysis, bilateral sacroiliac joints and ligaments, bilateral hip joints, bilateral sacrotuberous ligaments, and bilateral sacrospinous ligaments were intact. Tile C pelvic fractures were made on the specimens. The symphysis pubis was fixed with a plate, and the fracture on the posterior pelvic ring was fixed with two kinds of internal fixation in turn. The specimens were placed in a biomechanical machine at a standing neutral posture. A cyclic vertical load of up to 500 N was applied, and displacement was recorded. Shifts in the fracture gap were measured by a grating displacement sensor. Statistical analysis used: Paired-samples t-test. Results:Under the vertical load of 100, 200, 300, 400, and 500 N, the average displacement of the specimens fixed with MIAP combined with one IS screw was 0.46, 0.735, 1.377, 1.823, and 2.215 mm, respectively, which was significantly lower than that of specimens fixed with two IS screws under corresponding load (P < 0.05). Under the vertical load of 500 N, the shift in the fracture gap of specimens fixed with MIAP combined with one IS screw was 0.261 ± 0.095 mm, and that of specimens fixed with two IS screws was 0.809 ± 0.170 mm. The difference was significant (P < 0.05). Conclusion:The stability of Tile C pelvic fractures fixed with MIAP combined with one IS screw was better than that fixed with two IS screws.

Femoral Condyles Tangential Views: An Effective Method to Detect the Screw Penetration of Femoral Condyles After Retrograde Nailing

Background: Postoperative knee soft tissue irritation is a common complication after retrograde nail fixation of femoral fractures. Distal locking screw prominence is one of the causes for soft tissue irritation. This study aimed to determine whether the use of the femoral condyles tangential views improve the diagnostic accuracy compared with anteroposterior (A-P) view in detecting distal locking screw penetrations during retrograde femoral nailing. Methods: The angle between the sagittal plane and lateral aspect of the condyle and the angle between the sagittal plane and medial aspect of condyle were measured on computed tomography (CT) images. After the angles were measured and recorded, cadaveric femurs were used in a simulated surgical procedure. The retrograde femoral nail was inserted into the femur and placed distal locking screws, which were left 2, 4, and 6 mm proud of the medial and lateral condyles for each femur. A-P view, lateral condyle tangential view and medial condyle tangential view were obtained. All fluoroscopic images were recorded and sent to three observers blinded to the experimental procedure to determine whether screws penetrated the condyle cortex or not. Results: According to the results of CT scan, the lateral condyle view was 20.88 ± 0.98° and the medial condyle view was 40.46 ± 3.14°. In the A-P view, we detected 0% at 2 mm penetration, 16.7% (lateral condyle screw) and 25.0% (medial condyle screw) at 4 mm, and 41.7% (lateral condyle screw) and 58.3% (medial condyle screw) at 6 mm. In the lateral tangential view, we detected 91.7% at 2 mm penetration of the lateral condyle and 100% at 4 mm and 6 mm. In the medial tangential view, we detected 66.7% at 2 mm penetration of the medial condyle and 100% at 4 mm and 6 mm. The femoral condyle tangential views provided significant improvement in detecting screw penetrations at all lengths (2, 4, and 6 mm) compared with the A-P view (P < 0.05). Conclusions: The femoral condyles tangential views increased the accuracy of detecting screw penetrations on the medial and lateral condyles. Routine clinical use of the femoral condyles tangential views has the potential to increase accuracy in detecting distal locking screw penetration during retrograde femoral nailing.

Unusual Combination of Posterior Femoral Head Dislocation With Anterior and Posterior Wall Fractures in the Ipsilateral Acetabulum

Although hip dislocation combined with acetabular fracture is not an uncommon injury, anterior acetabular wall fractures rarely occur in patients who have posterior fracture-dislocations of the hip. This article presents a unique case of anterior and posterior wall fractures of the ipsilateral acetabulum in a patient who sustained traumatic posterior hip dislocation that resulted from a high-speed motor vehicle accident. The initial imaging evaluation, which did not include the obturator oblique view, revealed no concomitant anterior acetabular wall fracture. Repeated manipulative reductions were unsuccessful in reducing the displaced hip joint. Pelvic computed tomography (CT) scans revealed the initially missed anterior acetabular wall fracture fragments incarcerated in the left hip joint in addition to the hip dislocation and the posterior acetabular wall fracture. The incarcerated bone fragments lay between the anterior wall and the femoral head, and between the posterior wall and the femoral head, which appeared to derive from both anterior and posterior acetabular walls, respectively. Open reduction and internal fixation was performed to manage the posterior dislocation and associated acetabular fractures. Intraoperatively, the major anterior wall fragment was used to reconstruct the defected posterior wall. This case highlights the necessity of suspicion and pre- and postoperative monitoring of the obturator oblique view and CT scans to detect the potentially existing anterior acetabular wall fracture. Early surgical intervention is important to guarantee satisfactory outcomes of such complex fracture-dislocation injuries.

Incidence and Radiological Predictors of Concomitant Meniscal and Cruciate Ligament Injuries in Operative Tibial Plateau Fractures: A Prospective Diagnostic Study

The aim of this prospective study was to determine the incidence of meniscal and cruciate ligament injuries in operative tibial plateau fractures detected using knee arthroscopy, and to identify the radiological predictors observed on CT images. From January 2016 to February 2017, a total of 102 closed tibial plateau fractures were enrolled in this prospective protocol. Each patient underwent arthroscopic examination following the tibial plateau internal fixation. Univariate analysis and multivariable logistic regression were used to assess the association between imaging parameters and soft-tissue injuries. The menisci were traumatically injured in 52.9% of subjects (54 of 102) and the cruciate ligaments injured in 22.5% (23 of 102). Significantly higher injury rates for bucket-handle meniscal tears were observed in Schatzker type VI fractures (P = 0.04). Greater risk of lateral meniscus injury was observed in patients with >6.3 mm of lateral joint depression. Greater risk of ACL injury when the volumetric lateral joint depression was ≤209.5 mm2 and/or with >5.7 mm lateral joint widening. Associated meniscal and ligament injuries were commonly seen among operative tibial plateau fractures. Preoperative CT measurements might help predict a higher risk of meniscus and ACL injury, providing guidance to the surgeon to look for and to be prepared to treat such injuries.

Percutaneous Reduction and Internal Fixation for Monocondylar Fractures of Tibial Plateau: A Systematic Review: Percutaneous Treatment of Tibial Plateau Fractures

Instead of extensive dissection of soft tissue around the fracture site, percutaneous techniques have unique advantages in managing displaced fragments, including preservation of soft tissues, less blood loss, lower risk of complications, and earlier functional rehabilitation. However, there are few systematic reviews on the effects of percutaneous reduction and internal fixation (PRIF) for tibial plateau fractures. A systematic search of Cochrane, EMBASE, and MEDLINE databases was performed for all publicly available data in March 2017 regarding the use of PRIF in treating monocondylar tibial plateau fractures. Basic information of included articles, surgical information, clinical outcomes, and concomitant soft tissue injuries were collected for analysis. Finally, a total of 20 articles including 561 patients were retrieved. Traffic accident was the most common cause of injury. Percutaneous techniques using bone tamp reduction were described in all studies. The majority (≥85%) of patients were classified as excellent or good according to clinical and radiological Rasmussen scores. The overall complication rate was 6.6%, with loss of reduction the most frequent complication with an incidence of 2.4%. This systematic review indicated that PRIF was an optimal alternative that physicians should consider for the treatment of monocondylar tibial plateau fractures.