2013年 · 第16卷第02期

Abstract：Objective:The effect of tranexamic acid (TA) on patients receiving total knee arthroplasty (TKA) has been reported in many small clinical trials.But single trials are not sufficient enough to clarify the effectiveness and safety of TA.So,we carried out a meta-analysis of randomized controlled trials to investigate the efficacy and safety of the intravenous use of TA in TKA.Methods:Literatures were retrieved in Cochrane Library,OVID,PubMed,EMBASE,CNKI and Wanfang Data.All the related literatures were checked by two independent investigators and only the high quality randomized controlled trials were enrolled.Relevant data were analyzed using RevMan 5.1 to compare the difference of blood loss,transfusion and complications between TA group and control group.Results:There were 353 related literatures and only 22 randomized controlled trials met the inclusion criteria.The use of TA in TKA significantly reduced total blood loss by a mean of 435.41 ml (95％ CI300.62-570.21,P＜0.01),postoperative blood loss by a mean of 406.69 ml (95％ CI333.16-480.22,P＜0.01).TA also significantly lowered the transfusion rate (risk difference 0.30,95％ CI0.21-0.39,P＜0.01) and transfusion volume (mean difference 0.95 unit,95％ CI0.53-1.37,P＜0.01).The risks between TA group and control group in developing deep vein thrombosis and pulmonary embolism were not statistically significant.Conclusion:TA is beneficial for patients undergoing TKA,which can significantly reduce total blood loss,postoperative blood loss,transfusion rate,and transfusion volume.Meanwhile TA is recommended to reduce deep vein thrombosis and pulmonary embolism following TKA。

Abstract：Phalangeal neck fractures occur almost exclusively in children.We present the case of a 49 years old man with a dislocated fracture of the neck of the middle phalanx with the distal fragment rotated at 180°,due to a traumatic circular saw injury to the left index,which was solved by anatomical reduction and bone fixation with two 1.5 mm Synthes screws and a temporary transarticular Kwire at the distal interphalangeal joint.Zone I flexor digitorum profundus repair was performed using a modification of the Kessler 4-strands core suture and a full-thickness skin graft from the hypothenar eminence was taken to cover the skin gap.At 6-month follow-up the patient was pain-free and with a total active movement equivalent to 190°.No radiological signs of avascular necrosis of the head of the middle phalanx or nonunion of the distal fragment was detectable with recovery to the previous manual work.Owing to the position of the phalangeal head maintained in position by the collateral ligaments an anatomic reduction from dorsal approach is difficult to be performed and a longitudinal traction can render the reduction harder too.The volar approach permits an easier reduction of the fracture through a derotation of the distal fragment facing palmar。

Abstract：Objective:To introduce bipolar hemiarthroplasty with a two-step osteotomy technique and observe its clinical result for unstable intertrochanteric fractures in senile patients.Methods:Fifteen consecutive patients with unstable intertrochanteric fractures aged from 81 to 92 years with a mean of 85 years were treated in our hospital from August 2006 to October 2011 (Evans type Ⅲ in 4 cases,Evans type Ⅳ in 11 cases),who received bipolar hemiarthroplasty with a two-step osteotomy technique performed by a senior orthopedic surgeon through posterior approach under general anesthesia.All cases were evaluated by Zuckerman functional recovery score (FRS) and operative risk assessment software 1,based on the patients' physical and laboratory examinations preoperatively.The duration and blood loss have been recorded.There were 4 male cases (4 hips) and 11 female cases (11 hips).All prostheses consisted of Link SP Ⅱ femoral stem and bipolar femoral head.All patients were followed up for more than 1 year.Results:The average preoperative FRS,predictive value of operative morbidity and mortality were 83.7 (81.7-85.9),9.3％ (7.3％-15.0％) and 3.5％ (2.3％-4.2％),respectively.The average operation time was 50 minutes with a mean intraoperative blood loss of 310 ml.There were no operative or anesthetic complications or deaths within 30 days after operation.Sitting up was permitted 3 to 4 days,and partial weight bearing was allowed 5 to 7 days after operation.The average FRS was 79.3 at 30 days and 84.9 at 1 year postoperatively.Three patients died of unrelated causes (one due to myocardial infarction and the others due to cerebral hemorrhage during at least one-year follow-up).Conclusion:Bipolar hemiarthroplasty with a two-step osteotomy technique for unstable intertrochanteric fractures in the senile patients is a good choice for early ambulation and good hip function。

Abstract：Concomitant dislocation of the tarsometatarsal and metatarsophalangeal joints of foot is an extremely rare injury.Such injuries presenting in a single or adjacent dual rays have been described in few cases previously.We describe such an injury in adjacent three metatarsals of a polytrauma patient.These injuries are likely to be missed in the initial assessment of a polytrauma patient.These patients are at risk of an overlooked diagnosis but the consequences of missing this type of injury may be quite severe.This case is presented in view of its uniqueness along with possible mechanism of injury,the sequence of reduction and follow-up.Knowledge of such injury and its proper management may be useful to the trauma surgeons。

Abstract：Femoral neck stress fractures (FNSFs) are rare,constituting only 5％ of all stress fractures in young adults.These fractures are usually seen in athletes,military recruits and patients with underlying metabolic diseases.The treatment of FNSFs is still controversial because of the inherent complications associated with the treatment procedure.We came across 4 cases of bilateral FNSFs in non-athletic individuals who were manual labourers without underlying bony disorders.Two patients with FNSFs and coxa vara deformity on both sides were managed by subtrochanteric valgus osteotomy and dynamic hip screw fixation.One of the remaining two patients was treated by cannulated cancellous screw fixation on one side and subtrochanteric valgus osteotomy on the other side.The fourth patient received subtrochanteric valgus osteotomy on one side and bipolar hemiarthroplasty on the other side after failed cannulated screw fixation.All the fractures healed without any complications.No evidence of avascular necrosis or arthritis was noted in our series.Subtrochanteric valgus osteotomy restores normal neck-shaft angle in patients suffering from FNSFs combined with coxa vara deformity.Moreover,it helps to bring the forces acting around the hip to normal biomechanical levels,leading to fracture union and better results.Replacement arthroplasty is recommended to patients who fail to achieve bony union after fixation。

Abstract：Nonunion in tibial plateau fractures is very rare.Limited literature is available on Pubmed search on intraarticular tibial nonunion.Most of the cases reported have been following failed surgical treatment and none was neglected fractures.Three patients of isolated and neglected medial tibial plateau nonunion with almost similar demographic profile are reported in this paper.All the three patients were managed by minimally invasive compression fixation using lag screws supplemented with limb realignme nt procedure of high tibial osteotomy.We discussed theinjury mechanism,management and rehabilitation in such cases and reviewed the available literature regarding such a presentation。

Abstract：Hip dislocation in children can occur congenitally in isolation or in conjunction with other congenital abnormalities.Traumatic hip dislocations in children are relatively uncommon and anterior dislocation of hip joint is even rarer.We report such a case following unusual mode of injury in a 12-year-old child.The patient underwent successful emergent closed reduction of left hip.The clinical course and follow-up assessment of the patient was otherwise uneventful.At 2 years' follow-up there was no evidence of osteoarthritis,coxa magna,heterotrophic calcification,in congruency of the joints or avascular necrosis of the head of femur。

Abstract：Simultaneous bilateral fractures of the femoral necks are rare injuries,especially when there is no underlying pathological condition.We report a 20-year-old man who sustained bilateral femoral neck fractures resulting from an accidental electric shock with 440 Ⅴ direct current.Simultaneous bilateral femoral neck fractures after electrical shock injury without falling from a height are rather uncommon in clinic.The main cause of the fracture may be muscle contraction.This case highlights that even in the absence of primary and secondary bone disease,bilateral fractures of the femoral necks can occur following electric shock injury.We successfully managed this case with bilateral cannulated screw fixation without bone grafting.Surgeons caring for patients with electrical injury should be aware of the possibility of skeletal injuries which can go unnoticed,leading to delay in diagnosis and increased risk of complications。

Abstract：Objective:Fractures of the femur are the most incapacitating fractures.For children aged 6-14 years,there is no clear consensus as to the preferred treatment.The conventional treatment of traction and casting is no longer recommended.We report our experience in titanium elastic nailing for treatment of paediatric femoral diaphyseal fractures.Methods:Thirty patients in the age group of 6-16 years with displaced diaphyseal femoral fractures were stabilized with titanium elastic nails.Patients were followed up clinically and radiologically for a minimum period of 1 year.The final results were evaluated using Flynn's criteria.Technical difficulties and complications associated with the procedure were also analysed.Results:Overall results were excellent in 20 cases and satisfactory in 10 cases.No patient had poor result.The average hospital stay was 9 days.All the fractures healed with an average time to union of 6.86 weeks.The most common complication encountered was soft tissue irritation at the nail entry site seen in 6 cases.Clinically,lengthening was noticed in 4 cases,while no patient had shortening.Malalignment was seen in only 6 cases.Perioperative difficulties encountered were failure of closed reduction seen in 6 cases and corkscrewing of nails in one case.Conclusion:Titanium elastic nails are a relatively easy to use,minimally invasive,physeal-protective implant system with high rate of good and excellent outcomes in children aged 6-16 years.Technical pitfalls can be eliminated by adhering to the basic principles。

Abstract：Objective:To analyze the time factor in road traffic accidents (RTAs) in Fars Province of Iran.Methods:This study was conducted in Fars Province,Iran from November 22,2009 to November 21,2011.Victims'information consisted of age,sex,death toll involving drivers or passengers of cars,motorcycles and pedestrians,and site of injury etc.Accidents were analyzed in relation to hour of the day,season of the year,lighting condition including sunrise,sunset,daytime and nighttime.Results:Atotal of 3 642 deaths (78.3％ were males,and the ratio of males to females was about 3.6:1) were studied regarding their autopsy records.There was a steady increase in fatal accidents occurring at midnight to 15:59.The risk of being involved in a fatal traffic accident was higher for those injured between 4:00 to 7:59 than at other times (OR=2.13,95％ CI 1.85-2.44).The greatest number of fatal RTAs took place in summer.Mortalities due to RTA during spring and summer were more pronounced at 20:00 to 23:59and midnight to 3:59,whereas mortalities in fall and winter were more pronounced from 12:00 to 15:59.Conclusion:The high mortality rate ofRTAis a major public health problem in Fars Province.Our results indicate that the time is an important factor which contributes to road traffic deaths。

Abstract：Objective:Cardiac injuries are one of the most challenging injuries in the field of trauma surgery.Their management often requires immediate surgical intervention,excellent surgical technique and the ability to provide excellent postoperative critical care to patients.The aim of this study was to evaluate the outcome and survival rate of patients with penetrating cardiac injury in southern Iran,Shiraz.Methods:From January 2001 to June 2007,medical records of all patients suffering from penetrating cardiac injuries were reviewed and their outcomes were investigated.The inclusion criterion was the presence of a confirmed penetrating cardiac injury intraoperatively or by autopsy.Patients with blunt cardiac injuries were excluded from the study.Results:The study consisted of 37 patients,including 1 gunshot wound (2.7％),35 stab wounds (94.6％) and 1 (2.7％)shotgun wound.The overall survival rate was 76％ (28 in 37) and that in stab wound patients was 80％.The collected data of 9 expired patients revealed 11％ death on arrival,67％ hypotensive,and 22％ normotensive considering physiologic presentation.Paired sample test showed significant correlation between mortality and electrocardiographic changes,amount of retained blood in pericardium,clinical stage and physiologic condition at presentation,as well as associated injury type (gunshot more than stab wound).Conclusion:Our results show that injury mechanism and initial cardiac rhythm are significant predictors of outcomes in patients with penetrating cardiac injuries.Besides,gunshot injury and exsanguination are the most important predictive variables of mortality。

Abstract：Objective:To define the preoperative and intraoperative variables which may affect the immediate postoperative outcome in surgically managed patients with unstable pelvic fractures.Methods:This study was performed prospectively from January 2009 to June 2011 on 36 consecutive patients admitted to the trauma ward of Postgraduate Institute of Medical Education and Research,Chandigarh,with unstable pelvic injuries.Results:In the present study of 36 patients,29 were managed surgically.Surgical duration was 2 hours in patients operated on within 1 week and 3.4 hours in those operated on after 1 week.The blood loss was 550 ml when surgery was done after a week,but when done within a week it was 350 ml.The average blood loss through Pfanenstial approach was 360 ml,through posterior approach was 408 ml and through combined approach was 660 ml which was significantly high.Conclusion:Anterior approach to the pelvis would cause significantly more amount of blood loss than posterior approach and external fixation.Surgical approaches do not have any influence on the surgical duration or the infection rate.The blood loss significantly increases when the surgical time is more than 1 h.The infection rate is not influenced by the duration of surgery.Presence or absence of associated injuries to the head,chest or abdomen is the main determinants of patient's survival and it greatly influences the duration of hospital stay。