2012年 · 第15卷第04期

Abstract：Objective:Total hip arthroplasty (THA)and hemiarthroplasty (HA) are effective methods currendy used to treat femoral neck fracture in elderly patients,but the two options remain controversial in patients over 70 years old.The main purpose of our study was to determine whether THA or HA is a superior treatment of femoral fractures involving a displaced neck in patients who are over 70 years of age.Methods:A computer-based online search of Medline (1970-2011),PubMed (1977-2011),and the Cochrane Central Register of Controlled Trials (2002-2011) was conducted.Six relevant randomized controlled trials with a total of 739 patients were included for the final analysis.The analysis was performed with software RevMan 5.0.Results:We found that compared with THA,HA needed shorter average time and lost less blood.While over the long-term follow-up,THA patients exhibited significantly less pain and better function and were less likely to require a revision hip surgery.Postoperative infection was equally common among HA and THA patients.Conclusions:The significant differences in outcomes suggest that THA is a valuable treatment option for active elderly hip fracture individuals.However,patients who are older,impaired or institutionalized benefit from HA。

Abstract：Objective:Interphalangeal joint contracture is a challenging complication of hand trauma,which reduces the functional capacity of the entire hand.In this study we evaluated the results of soft tissue distraction with no collateral ligament transection or volar plate removal in comparison with traditional operation of contracture release and partial ligament transection and volar plate removal.Methods:In this prospective study,a total of 40 patients in two equal groups (A and B) were studied.Patients suffering from chronic flexion contracture of abrasive traumatic nature were included.Group A were treated by soft tissue distraction using pentagonal frame technique and in Group B the contracture release was followed by finger splinting.Results:Analyzed data revealed a significant difference between the two groups for range of motion in the proximal interphalangeal joints (P＜0.05),while it was not meaningful in the distal interphalangeal joints (P＞0.05).There was not a significant difference in the degrees of flexion contracture between groups (P＞0.05).Regression analysis showed that using pentagonal frame technique significantly increased the mean improvement in range of motion of proximal interphalangeal joints (P＜0.001),while the higher the preoperative flexion contracture was observed in proximal interphalangeal joints,the lower improvement was achieved in range of motion of proximal interphalangeal joints after intervention (P＜0.001).Conclusion:Soft tissue distraction using pentagonal frame technique with gradual and continuous collateral ligament and surrounding joint tissues distraction combined with skin Z-plasty significantly improves the range of motion in patients with chronic traumatic flexion deformity of proximal and/or distal interphalangeal joints。

Abstract：Objective:To detail our early experience and technique of a modified two-stage reimplantation protocol using antibiotic-loaded articulating cement spacers (ALACSs) for treatment of late periprosthetic infection after total knee arthroplasty (TKA).Methods:From January 2006 to February 2009,a series of 21 patients (21 knees) with late infected TKAs were treated by radical debridement and removal of all components and cement,and then articulating spacers were implanted using antibiotic-impregnated bone cement.For this purpose,4 g vancomycin powder was mixed with per 40 g cement.Graduated knee motion and partial weight beating activity were encouraged in the interval period.Each patient received an individual systemic organism-sensitive antimicrobial therapy for 4.9 (range,2-8) weeks followed by a second-stage TKA revision.All the patients were regularly followed up using the American Knee Society Scoring System.Results:Each case underwent a successful two-stage exchange and had infection eradicated,none had recurrent infection after an average of 32.2 (range,17-54) months of follow-up.Preoperatively,the mean knee score was 53.5 points,function score was 27.3 points,pain score was 25.7 points,range of motion (ROM) was 82.0°,extensor lag was 2°.Between stages,the mean knee score was increased to 61.3 points,function score to 45 points,pain score to 35 points,ROM to 88.2°,and extensor lag to 3.4°.At final follow-up,the mean knee score was further increased to 82.1 points,function score to 74.5 points,pain score to 42.1 points,ROM to 94.3°,and knee extension lag to 1.9°.Theinterval period was 11.5 (range,6-32) weeks.The amount of　bone loss was unchanged between stages.No patient developed noticeable dysfunction of the liver or kidney or　other complications such as impaired wound healing,deep　venous thrombosis,pulmonary embolism,cerebrovascular　accidents,etc.Conclusions:Treating infected TKA with ALACS　avoids spacer-related bone loss,preserves knee function　between stages,and eradicates infection effectively without significant complications.The early clinical results are　inspiring.The authors believe that radical and repeated (if　needed) debridement,individual application of systemic　antibiotics,and reasonable timing judgement upon the secondary revision are all key factors related to a successful　outcome with two-stage reimplantation procedure for infected TKA。

Abstract：Objective:To identify the main characteristics of victims of motorcycle accidents in Fars Province,Iran.Methods:This cross-sectional study was conducted in Fars Province which has the fourth largest population of all 31 provinces in lran from March 2009 to June 2010.We included data from all 542 recorded cases of fatalities due to motor vehicle accidents.Data were recorded from the forensic medicine registry consisting of demographic and accident-related information.Demographic information consisted of name,age,sex,status of fatal victim (motorcycle driver vs passenger) and educational level.Results:Of the 2 345 autopsy records from the forensic medicine archives,542 (23.1％) gave the cause of death as motor vehicle accidents.Mean age of these victims was (31.4± 16.5) years,and the male to female ratio was 28.Head injury was the most common cause of death in these victims,and overall they tended to have a low level of education.Motorcycle accidents frequently involved younger age groups (15-35 years),and head trauma related with non-use of a helmet was the most common cause of death.Conclusions:Head injury is frequent among victims in the province we studied.This situation may be related to the victims' low socioeconomic status and little education regarding traffic laws leading to speeding and disregard of these laws along with their weak enforcement。

Abstract：Objective:To elucidate the therapeutic effect of subtemporal decompressive craniotomy with large flap resection on serious craniocerebral injury associated with cerebral infarction.Methods:Forty-eight cases of serious head injury accompanied by cerebral infarction were classified into two groups with each having 24 cases:treatment group,in which large bone-flap decompressive craniotomy was performed;control group,in which routine craniotomy and hematoma evacuation were adopted.The status of cerebral infarction pre- and post-operation,as well as the curative effect 3 months after operation were comparatively analysed between the two groups.Results:There was no significant difference regarding the status of cerebral infarction on the first day after operation; while one week after operation,the size of cerebral infarction was significantly smaller in treatment group than control one (P＜0.05).Postoperative 3 months,the mortality rate was 20.8％ in treatment group,being evidently superior to that of control group (33.3％,P＜0.05).The moderate disability (good and fair) rate was 41.7％ in treatment group,significantly higher than that in control group (25.0％,P＜0.05).Conclusion:Large bone-flap decompressive craniotomy is confirmed effective and hence it offers us a preferable alternative of treatment by which to reduce disability and fatality rates for patients with serious head injury accompanied by cerebral infarction。

Abstract：Dynamic hip/compression screw (DHS/DCS) is one of the most commonly performed surgeries in orthopaedic practice.Sliding barrel plate over the DHS/DCS lag screw is one of the very crucial and at times uncomfortable and time consuming steps of DHS/DCS surgery especially when it comes to inexperienced surgeons and residents.Also in developing countries where not all standard instrumentation is always available,this crucial step becomes more time consuming.Here we present a case report of 58-year-old male patient with intertrochanteric fracture,in which we used a new device for insertion of barrel plate over DHS/DCS lag screw and found that a small DHS/DCS lag screw extension (sliding jig of barrel plate)can be very helpful to slide barrel plate over the DHS/DCS lag screw。

Abstract：We present an unusual case of an unstable pelvic fracture during pregnancy period,who suffered fetal death and splenic rupture simultaneously which developed massive delayed hemorrhage in abdomen.When considering potential causes of fetal death,direct trauma to the uterus,placenta,or fetus was not associated with a higher fetal mortality rate,compared with maternal hemorrhage.A cesarean section and splenectomy could rescue the maternal life from the hemorrhage situation.Successful treatment of these rare cases is possible with careful pre-,peri-,and post-operative evaluation of the mother and fetus by a multidisciplinary team。

Abstract：Hoffa fracture is an uncommon injury.In the literature,lateral condylar Hoffa fracture is mentioned as a more common injury pattern than medial condylar Hoffa fracture.The mechanism of injury and method of treatment is not very well described in the literature.We are presenting a rare case of comminuted medial condylar Hoffa fracture with ipsitateral patellar fracture.The mechanism of injury has not been described in the literature.Lag screw fixation,which is the most acceptable method of treatment,is not possible due to comminution.We explain the possible mechanism of injury and fix the fracture with L-buttress plate。

Abstract：Penetrating injury to the rectum,vertebral body and spinal cord by a steel rod is a rare condition.Treatment of this kind of injury is very challenging.Rectal injury requires repair and fecal diversion,while debridement of the spine is difficult,especially when the injury site is very long.Here we report a case of penetrating injury of rectum and sacral vertebra by a steel rod after falling onto the ground from 1 m height.The abscess cavity was irrigated with 3％ hydrogen peroxide and physiological saline repeatedly.The bony canal was carefully debrided,curetted and bony fragments were removed.Spinal irrigation and drainage lasted for 2 months and sensitive antibiotic (amikacin sulfate) was given 7 days after surgery,but abscess was still formed in the vertebral canal.At 6-month follow-up,the patient was paralyzed without any neurological improvement,and the pain in low back and lower limb still continued。

Abstract：A very rare and serious complication of shoulder dislocation is a lesion to the axillary artery in the elderly population,whose vascular structures have become less flexible.Axillary artery injury secondary to anteroinferior shoulder dislocation is much rarer,especially in the young people.Proper recognition and treatment of this entity offers a full recovery to the patient.Present report highlights the possibility of axillary artery injury with anteroinferior shoulder dislocation.A few case reports and small case series of this injury have been reviewed.And recommendations for management have been brought up to date,in line with current thinking。

Abstract：This case report presents a 25-year-old female patient with anterior dislocation of right shoulder secondary to seizures as a complication of eclampsia.This is an unusual mechanism of injury,but similar to other uncontrolled muscular contractions caused by electroconvulsive therapy,etc.To the best of our knowledge only one such case has been reported in the English literature.Closed reduction under general anaesthesia was successfully achieved.High suspicion in patients complaining of pain over shoulder joint is necessary for early diagnosis of this condition。

Abstract：Reactive arthritis or Reiter's syndrome characteristically affects the joint of the lower limb in an asymmetrical pattern.Usually it does not affect the axial skeleton or upper limbs.Although cases of atraumatic atlantoaxial subluxations have been reported,no case of spontaneous sternoclavicular dislocation in Reiter's syndrome has been reported.This paper describes a case of a 26 year old male patient who developed a spontaneous posterior sternoclavicular joint dislocation.No attempt of reduction was made and the patient was managed conservatively with good results。

Abstract：We present the technical report for treatment of comminuted fracture of the capitate with ligamentotaxis.The base of third metacarpal was found to be fractured with comminution of the capitate.The decrease in carpal height index and comminution of the third metacarpal base lead to dilemma between conservative treatment and surgical management of this particular injury.The surgical management was chosen to maintain the carpal height index of the wrist to prevent the late degenerative changes.The patient was applied with external fixator in distraction mode expanning the wrist joint for six weeks,and the wrist was mobilised after removal of the fixator.It is shown that the external fixator in distraction mode expanning the wrist joint is a good alternative method for treatment of capitate fracture。

Abstract：Objective:Fractures of the capitellum and trochlea constitute less than 1％ of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarely reported.Type IV capitellum fracture is still controversial in regard to its radiographic appearance,surgical approach and osteosynthesis.We report 10 cases of type IV capitellum fracture with a view to elucidating its clinical features and treatment outcome.Methods:We treated 10 patients of type IV capitellum fracture with a mean age of 32 years.A uniform surgical approach and postoperative rehabilitation were followed.Results:Nine patients presented to us after a mean of 4 days of injury and one patient was nonunion after 6 months of injury who had been treated conservatively by a bone setter.Double arc sign was absent in 6 cases.Intraoperatively 6 capitellotrochlear fragments were devoid of soft tissue attachments.By Mayo Elbow Performance Score evaluation,7 patients got excellent,2 good and l fair results.One patient with associated elbow dislocation developed heterotopic ossification.There was no case of avascular necrosis,osteoarthrosis or fixation failures.Conclusions:Type IV capitellum fractures are rare and belong to complex articular injuries.A good functional outcome can only be achieved with open reduction and stable internal fixation followed by early mobilization.Preoperative radiographic assessment and computed tomography help surgeons in choosing the right surgical approach and implants.Good surgical technique and stable internal fixation are the keys to early mobilization and good functional outcome。