2014年 · 第17卷第02期

Abstract：Objective:To compare the clinical effects between closed reduction and internal fixation (CRIF) and total hip arthroplasty (THA) for displaced femoral neck fracture.Methods:In this prospective randomized study,285 patients aged above 65 years with hip fractures (Garden Ⅲ or Ⅳ) were included from January 2001 to December 2005.The cases were randomly allocated to either the CRIF group or THA group.Patients with pathological fractures (bone tumors or metabolic bone disease),preoperative avascular necrosis of the femoral head,osteoarthritis,rheumatoid arthritis,hemiplegia,long-term bed rest and complications affecting hip functions were excluded.Results:During the 5-year follow-up,CRIF group had significantly higher rates of complication in hip joint,general complication and reoperation than THA group (38.3％ vs.12.7％,P＜0.01; 45.3％ vs.21.7％,P＜0.01; 33.6％ vs.10.2％,P＜0.05 respectively).There was no difference in mortality between the two groups.Postoperative function of the hip joint in THA group recovered favorably with higher Harris scores.Conclusion:For displaced fractures of the femoral neck in elderly patients,THA can achieve a lower rate of complication and reoperation,as well as better postoperative recovery of hip joint function compared with CRIF。

Abstract：Hemorrhage is the second most common cause of death among trauma patients and almost half of the deaths occur within 24 hours after arrival.Damage control resuscitation is a new paradigm for patients with massive bleeding.It consists of permissive hypotension,hemostatic resuscitation and transfusion strategies,and damage control surgery.Permissive hypotension seems to have better results before the bleeding is controlled.The strategy of fluid resuscitation is minimizing crystalloid infusion and increasing early transfusion with a high ratio of fresh frozen plasma to packed red cells.Damage control surgery is done when the patient's condition is unfit for definitive surgery.Hemorrhage and contamination control with temporary abdominal closure is performed before transferring the patients to intensive care unit and the operating room for a permanent laparotomy。

Abstract：Traumatic arteriovenous fistula between the axillary artery and vein may present a difficult problem in treatment.There are few reports demonstrating the endovascular repair of this challenge.Herein,we present such a case of endovascular repair of traumatic arteriovenous fistula between the axillary artery and vein with false aneurysm formation.The patient was discharged 1 1 days after successful operation.Oral clopidogrel and aspirin were administerted for 18 months.At one year follow-up,the patient was in good condition and showed no evidence of neurological deficit in the left upper limb。

Abstract：Objective:Trauma in India is an increasingly significant problem,particularly in light of rapid development and increasing motorization.Social changes are resulting in alterations in the epidemiology of trauma.The aim of the study was to assess the various epidemiological parameters that influence the cause of injury in the patients admitted to a major trauma centre in northern India.Methods:An observational study of 748 patients chosen by random assortment was carried out over a period of 1 year (August 2008 to July 2009).Age,sex,injury type and pattern were noted.Injury mode of upper and lower limbs was also noted.Results:Injuries occur predominately in the age group of 15-30 years.Males incurred more injury with male to female ratio of 6:1.The most vulnerable group was motorcycle users.Among the injured,farmers were the most commonly involved.Blunt injuries (94.92％) were much more common than penetrating injuries.Among patients with head injury,two wheelers related accidents were the most common (40.3％).Most spinal cord injuries were caused by falls from height (51.09％).Most lower limb fractures were simple type.Compound fractures of the lower limb were more common than upper limb fractures.Conclusion:Strict enforcement of traffic rules,combined with improved infrastructure and behavior change can decrease the burden of road traffic accidents in India and other developing countries.This study could assist in raising the profile of road traffic accidents as a public health problem which needs to be addressed as a preventable cause of mortality and morbidity,and planning appropriate interventions for this major challenge.Preventive strategies should be made on the basis of these epidemiological trends。

Abstract：Both delayed posttraumatic intracerebral hemorrhage and epidural hematoma have been well described in the neurosurgical literatures.However,delayed posttraumatic acute subdural hematoma which happens more than a week with a rapid progress after mild traumatic brain injury and causes death of patient is rarely reported.We show two such cases and briefly review the literature and discuss the probable pathogenesis of their rapid progress。

Abstract：Fracture of femoral shaft in adults is common and mostly managed with intramedullary interlocking nails.Complications during closed intramedullary femoral nailing are uncommon,and mostly of them are caused by technical reasons.We describe a case of closed nailing for a femoral shaft fracture in which a jammed intramedullary guide wire,due to an incarcerated bone fragment at the nail tip,was inadvertently advanced across the knee.Forceful attempt of nail insertion caused this complication,which was probably attributed to nail design。

Abstract：Anterior cruciate ligament (ACL) reconstruction is usually recommended for young patients.Several recent articles have however reported comparable outcomes of ACL reconstruction between youth and patients in fourth or fifth age group.But in the literature there are not many reports about ACL reconstruction in patients over 70 years old.We report a case of a successful arthroscopic ACL reconstruction (using single bundle quadrupled hamstring graft) in an active 75-yearold medical practitioner.Successful outcome after ACL reconstruction can be achieved in selected older patients;chronological age is no barrier。

Abstract：Objective:To discuss the indications,surgical procedures,and curative effect of dynamic hip screw (DHS) in the treatment of femoral neck fracture in the elderly.Methods:A retrospective study was conducted to analyse the clinical data of 42 elderly patients who had been treated for femoral neck fracture with DHS in our department between June 2009 and November 2011.There were 21 males and 21 females with a mean age of 68.5 years (range 60-75 years).According to the Garden Classification,there were 19 cases of type Ⅱ,21 cases of type Ⅲ and 2 cases of type Ⅳ fractures.By the Singh Index Classification,there were 3 cases of level 2,19 cases of level 3 and 20 cases of level 4 fractures.The Harris criterion,complications and function recovery after operation were analysed.Results:The average hospitalization time in 42 patients was 11.2 days (range 7-21 days).All patients were followed up for 12-26 months (mean 18 months).No lung infection,deep venous thrombosis or other complications occurred.Partial backing-out of the screws was found in 2 cases.The internal fixation device was withdrawn after fracture healing.Intemal fixation cutting was found in 1 case,and he had a good recovery after total hip arthroplasty.The time for fracture healing ranged from 3-6 months (average 4.5 months).According to Harris criterion,15 cases were rated as excellent,24 good,2 fair and 1 poor.The Harris scale was significantly improved from 30.52±2.71 preoperatively to 86.61±2.53 at 6 months postoperatively (P＜0.05).Conclusion:DHS,being minimal invasive,allowing early activity and weight-bearing,is advisable for treatment of elderly patients with femoral neck fracture.In addition,it can avoid complications seen in artificial joint replacement.It is especially suitable for patients with mild osteoporosis。

Abstract：Objective:To analyze the extent of postoperative hip abductor insufficiency in primary total hip arthroplasty (THA) patients undergoing anterolateral minimally invasive (ALMI) approach,and to investigate whether the clinical outcomes are more favorable in femoral neck fracture (FNF) patients than in non-femoral neck fracture (nFNF) patients.Methods:A total of 48 patients were enrolled in this study.Each patient underwent a clinical examination preoperatively and 6,12,24 and 48 weeks postoperatively.The abductor torque,Trendelenburg's sign,gait velocity,Harris hip score,Oxford hip score,Westren Ontario and McMaster Universities (WOMAC) score and visual analog scale pain score were recorded.Statistical evaluation was performed with SPSS software version 18.0.The significance level was set at P＜0.05.Results:The abductor torque of the operated hip and the recovery ratio showed a gradual improving tendency from 6 weeks postoperatively until the last follow-up.Gait velocity,Harris hip score,Oxford hip score and WOMAC score improved significantly after the operation until 24 weeks postoperatively.In the FNF group,the abductor torque of the operated side and the recovery ratio were significantly higher than in nFNF group at 6 weeks postoperatively,however,as time passed,this trend tended to disappear.Conclusion:This study demonstrates that patients can obtain good abductor strength and function in the early postoperative period and the hip abductor function of patients who suffer from hip osteoarthritis,rheumatoid arthritis,avascular necrosis of the femoral head could be significantly improved following ALMI THA。

Abstract：Objective:To analyze the early clinical and radiographic outcomes of Hoffa fractures treated by a standard protocol of open reduction and internal fixation using headless compression screws combined with back buttress plate in a consecutive series of 8 Chinese patients.Methods:Open reduction and internal fixation was performed on all patients.The fractures were anatomically reduced and held temporarily by K-wire.If the ends of fractures were atrophic,autologous bone graft from the ipsilateral iliac crest was packed between the ends.Then the fracture fragments were fixed with AO 6.5 mm headless compression cannulated screws.At least two screws were used to provide rotational stability.One pre-contoured reconstruction plate was placed on the nonarticular surface posteromedially or posterolaterally as back buttress plate.Results:All the patients were followed up for at least 12 months (range 12-25 months).All fractures achieved anatomical reduction and healed clinically and radiographically.At recent follow-up,the mean flexion degree was 120.6° (range 110°-135°) and the mean extension degree was 2.5° (range 0°-5°).The average visual analogue scale score was 1.6 points (range 0-3).Six patients were assessed as excellent and 2 as good according to the hospital for special surgery knee score system.There were no superficial or deep infections,or hardware breakages.No patient had giving way or locking of the knee,though some had intermittent pain and swelling after strenuous exercise.Injury mechanism had significant influence on the functional outcome (P=0.046).Conclusion:Headless compression screws combined with back buttress plate and/or autologous bone grafting to treat old Hoffa fracture is one of effective measures.It would be conducive to not only fracture healing but also early exercise and functional recovery。

Abstract：Objective:Tibial shaft fractures are straightforward to treat but when associated with soft tissue injury particularly at the nail entry/plate insertion site or there is significant comminution proximally or a large butterfly fragment/a second split component in the posterior coronal plane,it is a challenge to the treating surgeon.The aim of the present report is to describe the technique of posterior coronal plating in such a scenario and its advantages.Methods:Between July 2008 and June 2011,12 patients were prospectively treated by this approach using 4.5 mm broad dynamic compression plates.Results:The time of bony consolidation and full weight bearing averaged 21.7 weeks (range,16-26 weeks).Patients were followed up for at least 24 months (range,24-48 months).At 1 year postoperatively,no loss in reduction or alignment was observed.Mean Hospital for Lower Extremity Measurement Functional Score was 72.8 (range,64-78).All patients were satisfied with their treatment outcomes.Conclusion:Direct posterior approach and fixation using prone position helps to visualise the fracture fragments and provide rigid fixation.The approach is simple and extensile easily,apart from advantages of less soft tissue and hardware problems compared to standard medial or lateral plating。

Abstract：Objective:Dynamic hip screw (DHS) is recommended for the fixation of stable intertrochanteric fractures.Its postoperative cut-out rate ranges from 1％ to 6％.In osteoporotic bone,normal screws in DHS blade provide less anchorage compared to locking screws.This study aims to compare DHS with locking side plate and conventional side plate.Methods:Fifty consecutive patients with intertrochanteric fractures were randomly allocated for fixation with a standard DHS (group A) and locking DHS (Combi plate,group B).We compared the clinical and radiological outcomes for the conventional DHS and locking DHS in intertrochanteric fractures.Functional outcome was evaluated using the Parker mobility score.Results:Coxa valga was found more frequently in group A than in group B (12％ vs.0％,P=0.42).Coxa vara showed the same trend (12％ vs.8％,P=0.81).Rate of restoration of postoperative neck-shaft angle within 20° of sound side was higher in group B (8％ cases) than in group A (4％ cases,P=0.98).The rate of anteversion angle restoration within 10° of sound side was also higher in group B (100％ vs.88％,P=0.85).The average lag screw slippage in group A and group B was 3.2 mm and 4.2 mm,the average fracture union duration was 17.1 weeks and 16.4 weeks,and the mean Parker score was 5.6 and 5.8 respectively.Screw cut-out was seen in one patient in group A.No cut-out was seen in any of the patient in group B.No patient developed deep infection,avascular necrosis,deep vein thrombosis or any other significant complications.Conclusion:The present study demonstrated that treating intertrochanteric fracture with a locking DHS allows sound bone healing and is not associated with any major complications.Although this report is promising,it should be interpreted with caution because only a prospective study with a large sample size would allow definitive conclusion。

Abstract：Objective:One of the most common joint dislocations presented to the emergency department (ED) is anterior shoulder dislocation (ASD).Various techniques for the treatment of this abnormality have been suggested.In this study,we evaluated the efficacy and success rate of modified scapular manipulation (MSM) as a painless procedure compared to traction-countertraction (TCT) for reduction of ASD.Methods:Patients with ASD who were presented to ED of Baqiyatallah Hospital,Tehran during 2011 were included.They were randomly divided into MSM group or TCT group and then pain at reduction,time of reduction,duration of hospitalization,and success rate were compared.In TCT group,reduction was performed using sedative and antipain medications.Results:Ninety seven patients (81.6％ male) with a mean age of 34.15 years±13.48 years were studied.The reduction time between both groups showed a significant difference (470.88 seconds±227.59 seconds for TCT group,79.35 seconds±82.49 seconds for MSM group,P＜0.001).The success rate in MSM group in the first and second effort were 89％ and 97％ whereas 73％ and 100％ in the TCT group respectively (P＜0.001).Conclusion:It seems that the manipulation technique can be more successful than the TCT method at the first effort whilst the second effort has the opposite results.Also MSM can be safer,cheaper and more acceptable for patients than TCT as a standard traditional method。