Objective To evaluate the effect of the modified extended iliofemoral approach on treatingcomplex acetabular fractures. Methods Thirty-six cases of complex acetabular fractures were treated by the open reposition and internal fixation by a modified extended iliofemoral approach. Results Thirty-sixcases were followed up for 7-46 months, with an average of 23.8 months. According to the Matta standard, anatomical reposition was performed in 24 cases, perfect reposition in 8 cases, and unsatisfactory reposition in 4 cases. By the modified d’Aubignepostel score, among the 36 cases, 22 had an excellent result, 9 had a good result, and 5 had a poor result. Conclusion Themodified extended iliofemoral approach facilitates the operative exposure of the anterior and posterior walls and both columns of the acetabulum in the surgically-treated acetabular fractures by the open reposition and internal fixation.Because of the reconstruction, the functions of the abductor muscle mass managed by the lagscrew-fixed osteotomies of the iliac crest, and greater trochanter, the patients can achieve a rapid rehabilitation of the joint.
ObjectiveTo discuss the value of surgical hip dislocation approach in the treatment of femoral head fracture. MethodsA retrospectively analysis was made on the clinical data of 15 patients with femoral head fractures treated through surgical hip dislocation approach between January 2010 and February 2013. There were 11 men and 4 women with an average age of 30.8 years (range, 15-63 years). The causes included traffic accident injury in 9 cases, falling injury from height in 5 cases, and sports injury in 1 case. According to Pipkin typing, 2 cases were rated as type Ⅰ, 7 cases as type Ⅱ, 1 case as type Ⅲ, and 5 cases as type Ⅳ. The interval of injury and operation was 2-10 days (mean, 4.1 days). Reduction was performed in 10 patients within 6 hours after injury, and then bone traction was given for 4-6 weeks except 5 patients who received reduction in the other hospital. ResultsPrimary healing of incision was obtained in all patients after surgery without complications of dislocation and lower limbs deep venous thrombosis. The mean follow-up time was 29.9 months (range, 25-36 months). During follow-up, there was no infection, breakage of internal fixation, or nonunion of femoral greater trochanter fracture. In 3 patients having necrosis of the femoral head, 2 had no obvious symptoms[staging as Ⅱa and Ⅱb respectively according to Association Research Circulation Osseous (ARCO) staging system], and 1 (stage Ⅲb) had nonunion of the femoral neck fracture, who underwent total hip arthroplasty (THA). In 4 patients having myositis ossificans (2 cases of grade Ⅰ, 1 case of grade Ⅱ, and 1 case of grade Ⅲ based on Brooker grading), no treatment was given in 3 cases and the focus was removed during THA in 1 case. According to the Thompson-Epstein scale at last follow-up, the results were excellent in 9 cases, good in 3 cases, fair in 1 case, and poor in 2 cases, and the excellent and good rate was 80%. ConclusionSurgical hip dislocation approach can not only protect the residual vessels of the femoral head but also fully expose the acetabulum and femoral head, which is the ideal approach for the treatment of femoral head fractures.
Objective To evaluate surgical results of the titanium screwplate internal fixation in treatment of the lower cervical fracture dislocation. Methods From September 2001 to March 2006, 31 patients(24 males, 7 females; age range, 2063 years) with the lower cervical fracturedislocation were treated in our department. The injuries were caused by a road accident in 25 patients, a high crash in 4, and a heavy object crash in 2. The fracture dislocation occurred in the following cervical segments:C3(1 patient),C4(5 patients), C5(12 patients), C6(10 patients), and C7(3 patients). The disease course ranged from 1 to 23 days. The associated spinal nerve root injury occurred in 29 patients. The Frankle scaling revealed that 14 patients were at Grade A, 3 at Grade B, 7 at Grade C, 3 at Grade D, and 2 at Grade E (associated nerve root injury with hand and shoulder numbness). The 29 patients underwentthe spinal cord decompression, the grafting fusion of the small joints, and thelateral mass titanium screwplate internal fixation; 2 patients without nerve injury underwent only the grafting fusion of the small joints and the lateral mass titanium screwplate internal fixation. The bone fusion, cervical vertebra movement, and internal fixation condition were observed by the X-ray examinations postoperatively. The nerve function recovery was evaluated by the Frankle scaling system. Results The followedup in all the patients for 6months to 4 years revealed that the small joint fusion time was 36 months, with an average of 3.6 months. The cervical X-ray films showed that there was no instability or fracture looseness of the internal fixation at 6 months. Among the 29 patients with the spinal nerve root injury, 14 were at Grade A preoperatively but 13 were improved at Grade B and 1 at Grade C postoperatively; 3 were at Grade B preoperatively but 2 were improved at Grade C and 1 at Grade D postoperatively; 7 were at Grade C preoperatively but 3 were improved at Grade D and 4 at Grade E postoperatively; 3 at Grade D preoperatively but all the 3 were improvedat Grade E postoperatively; 2 were at Grade E preoperatively and remained unchanged postoperatively. In the 2 patients with only the nerve root injury, numbness disappeared soon after operation. Conclusion This posteriorapproach has two advantages: the mobility range of the cervical vertebra can preserved to the greatest extent because of the short segment fixation; the betterstability can obtained because of the titanium screwplate internal fixation on the cervical jointcolumn to prevent the hyperextension and hyperflexion. Therefore, the titanium screwplate internal fixation on the cervical lateral massis an effective treatment of the lower cervical fracture dislocation.
ObjectiveTo introduce the method of laparoscopic pancreaticoduodenectomy through an arterial approach, and to evaluate the clinical value of this technique. MethodsThe clinical data of 19 patients with periampullary carcinoma, distal bile duct cancer, and early-stage pancreatic head carcinoma that underwent laparoscopic pancreaticoduodenectomy through an arterial approach in the Department of Hepatobiliary and Pancreatic Surgery, Sun Yat-sen Memorial Hospital between September 2010 and July 2013 were retrospectively analyzed. The patients were followed-up until February 28, 2014. ResultsLaparoscopic pancreaticoduodenectomy were successfully performed in all 19 cases, there were no need to convert to open surgery. Open reconstruction was performed in 2 cases, and 17 cases underwent total laparoscopic reconstruction of the digestive tract. The duration of the operations ranged from 5-10.5 h(mean 6.3 h), and the intra-operative blood loss ranged from 170-430 mL(mean 250 mL). Post-surgical pathology detected a mean number of 13.7 lymph(9-21) nodes in all patients. No deaths occurred during the perioperative period. Complications were observed in 42.1%(8/19) of the subjects, including 5 cases with pancreatic fistula, 1 case with bile leak, 1 case with gastric emptying disorder, and 1 case with a gastroduodenal artery aneurysm. The mean length of hospital stay was 10.7 d(7-19 d). The mean followed-up period was 7.5 months(2-28 months), there were 6 patients died of tumor metastasis or recurrence during the followed-up. ConclusionLaparoscopic pancreaticoduodenectomy through an arterial approach simplifies pancreaticoduodenectomy and lymph node dissection procedures, and can completely remove lymph nodes.
Objective To explore a method of treating Madelung deformity. Methods Seven cases of Madelung deformity had been treated with the excision of ulnar carpi ulnaris segment and distal osteotomyof radius and tight constrict of extensor carpi ulnaris from Mar. 2000 to Nov. 2003. The angle of ulnar tilting was 37-70° and the angle of volar tilting wasover 16°. A longitudinal incision on each side of the radius and ulnar was made, the ulna was excised about 2-3 cm segment. Then the fracture of ulna was fixed by double across vertical steel wire and the radius was fixed with medullarywire. Lastly the extensor carpi ulnaris was shortened and sutured after the wrist was located restposition. Results After surgery, the deformity of wrist was improved and pain-free in the seven cases. The angle of ulnar tilting was reduced to 22-24°. The angle of volar tilting was reduced to 15° below. Follow-ups were conducted inthe 7 patients for 2 years in average. The activity of wrist joint and the rotation of forearm recovered from those before operation. The wrist joint could stretch fully. Conclusion This method of treating Madelung proves to be effective inrecovering deformity, releasing pain, improving function, and reducing traumatic osteoarthritics of the distal radioulnar joint.
ObjectiveTo summarize the tissue engineering techniques for cartilage repair on the combination fields of the three elements of tissue engineering:cells, scaffolds and signals. MethodsThe literature on cell-scaffold-based cartilage repair techniques, cell-free scaffolds, and scaffold-free approaches was reviewed and summarized. ResultsThe cell-scaffold-based cartilage repair techniques such as matrix-induced autologous chondrocyte implantation (chondrocytes are seeded on the scaffold) are able to enhance the survival of the cells; cell-free scaffolds can promote cell recruitment with chemoatractants; and scaffold-free approaches have better hyaline-like properties and can avoid the toxic effect of scaffold degradation products. ConclusionCombination fields of the three elements of tissue engineering provide a more biomimetic environment for cartilage repair and have broad prospects.
ObjectiveTo discuss the effectiveness of the modified Hueter direct anterior approach in treatment of Pipkin typeⅠ and Ⅱ femoral head fractures.MethodsBetween September 2014 and May 2016, 12 patients with Pipkin type Ⅰ and Ⅱ femoral head fractures were treated with the modified Hueter direct anterior approach. There were 8 males and 4 females, aged from 32 to 60 years (mean, 40.2 years). The disease causes included traffic accident injury in 9 cases and falling from height injury in 3 cases. According to Pipkin typing, 8 cases were rated as type Ⅰ and 4 cases as type Ⅱ. The interval of injury and admission was 2-28 hours (mean, 7.2 hours). Reduction was performed in all patients within 6 hours after admission, and then bone traction was given. The operation was performed in 3-7 days (mean, 4.3 days) after redution. The modified Hueter direct anterior approach was applied to expose and fix femoral head fractures by Herbert screws compressively. The operation time and intraoperative blood loss were recorded, and the effectiveness was evaluated according to the Thompson-Epstein scale at last follow-up.ResultsThe operation time was 80-130 minutes (mean, 97.5 minutes), and the intraoperative blood loss was 100-200 mL (mean, 130.2 mL). All fractures achieved anatomical reduction and successful fixation. All 12 patients were followed up 12-32 months (mean, 24.3 months). All patients achieved bone union in 15-20 weeks (mean, 16.3 weeks) and no wound infection, lateral femoral cutaneous nerve injury, osteonecrosis of the femoral head, or heterotopic ossification occurred. Traumatic arthritis occured in 3 patients. According to the Thompson-Epstein scale at last follow-up, the results were excellent in 5 cases, good in 5 cases, fair in 2 cases, and the excellent and good rate was 83.3%.ConclusionThe modified Hueter direct anterior approach has the advantages of clear anatomic structure, less trauma, and shorter operation time, and it can effectively expose and fix the Pipkin typeⅠ and Ⅱ femoral head fractures.
Objective To report our experience with enhanced recovery after surgery (ERAS) protocol in patients undergoing transapical transcatheter aortic valve implantation (TAVI) and to determine perioperative predictors for ERAS failure. Methods Between May 2018 and January 2019, 80 patients undergoing TAVI in our hospital were recruited. Among them, 40 patients (24 males, 16 females, aged 73.0±5.0 years) successfully received ERAS, defined as successful extubation in operating room (an ERAS group) and the other 40 patients (28 males, 12 females, aged 73.0±7.0 years, a non-ERAS group) failed to perform ERAS. Results Compared with the non-ERAS group, patients in the ERAS group were associated with a significantly lower incidence of postoperative complications (30.0% vs. 52.5%, P=0.04), shorter postoperative ICU stay (2.2±0.4 d vs. 4.0±4.8 d, P=0.00) and hospital stay (7.0±2.3 d vs. 9.5±4.8 d, P=0.00), and less medical cost (311±20 thousand yuan vs. 347±80 thousand yuan, P=0.00). Independent predictors of ERAS failure were poor preoperative heart function and elevated B-type natriuretic peptides. Conclusion ERAS protocol is feasible and effective in patients undergoing TAVI. Poor preoperative heart function is an independent predictor of failure in early extubation which, in turn, is associated with prolonged ICU and hospital stay and dramatic worsening of patient outcomes.
Objective To evaluate the effect of anterolateral approach in treating thoracolumbar disc protrusion. Methods From May 2004 to May 2008, 11 patients with thoracolumbar disc protrusion (T10-L3) underwent discectomy, autologous il iac bone graft, and internal fixation via anterolateral approach. There were 9 males and 2 females aged 26-57 years old (average 42.8 years old). The course of disease was 1 week-11 years (average 2.7 years). Nine patients showed the lower l imbs weakness, 8 had sensory disturbance, 6 presented with lumbodorsal pain, 5 had the lower l imb pain, 4 presentedwith sphincter muscle disturbance, 3 suffered from foot drop, and 5 had a history of lower back injury. X-ray, CT, and MRI test showed that 9 cases had the single-segmental protrusion, 2 cases had double-segmental protrusion, 2 cases were accompanied with ossification of the thoracic vertebra yellow l igament, 2 cases were combined with ossification of the vertebra posterior longitudinal l igament, and 1 was compl icated with Scheuermann disease. Preoperatively, the intervertebral height was (7.2 ± 1.3) mm and JOA score was 6.4 ± 2.8. Results The time of operation was 2.5-5.5 hours (average 3.5 hours); the blood loss during operation was 500-1 200 mL (average 750 mL). During operation, intraoperative pleural tear occurred in 1 patient, peritoneal tear in 1 patient, and dural laceration in 1 patient. Repairing was performed intraoperative and preventive suction drainage was used for 3-5 days. No postoperative hydropneumothorax and cerebrospinal fluid leakage occurred. All incisions healed by first intention. No postoperative compl ications of nerve system occurred. All the patients were followed up for 1-4 years (average 2.4 years). X-ray films showed that all the patients achieved bony fusion without the occurrence breakage and loosening of titanium plate and screw 6-9 months after operation. Three cases displayed subtle scol iosis (10-15°) without influence on spinal equil ibration. The intervertebral height increased to (12.3 ± 1.5) mm 2 weeks after operation, indicating there was a significant difference compared with preoperative value (P lt; 0.05). The intervertebral height 1 year after operation when the bony fusion was reached decreased to (7.5 ± 1.2) mm, indicating there was no significant difference compared to the preoperative value (P gt; 0.05). The JOA score increased to 7.6 ± 3.2 at 1 year after operation, indicating there was a significant difference compared with preoperative value (P lt; 0.05). The symptoms and signs of all the patients were improved to various degrees after operation. According to improvement rate evaluation system proposed by Hirabayashi t al., 4 cases were graded as excellent, 6 as good, 1 as fair, and the excellent and good rate was 90.9%. Conclusion Treating thoracolumbar disc protrusion via anterolateral approach is safe and effective.
ObjectiveTo explore the effectiveness of posteromedial and anterolateral approaches in the treatment of posterolateral tibial plateau collapsed and splited fractures. MethodsNineteen consecutive patients with posterolateral tibial plateau collapsed and splited fractures were treated between August 2010 and August 2013, and the clinical data were retrospectively analyzed. There were 13 males and 6 females, with an average age of 36.9 years (range, 25-75 years). All cases had closed fractures, involving 8 left sides and 11 right sides. Fractures involved posterior column according to the threecolumn classification based on CT scans; according to the Schatzker classification, all fractures were type Ⅱ; according to the AO/Association for the Study of Internal Fixation classification (AO/OTA), all fractures were type 41-B3.1.2. The interval between injury and operation was 7-14 days (mean, 9 days). The reduction of collapsed fractures and implantation of artificial bone allograft were supported by T-shaped distal radius plate via the posteromedial approach. The splited fractures was fixed by less invasive stabilization system (LISS) plate via the anterolateral approach. ResultsThe mean operation time was 69.0 minutes (range, 50-105 minutes). All incisions healed by first intention without neurovascular complications or wound infection. All patients were followed up 14-20 months (mean, 18.2 months). X-ray and CT examinations showed that collapsed tibial plateau and joint surface were completely corrected; bony union was obtained at 12 weeks on average (range, 10-16 weeks). No secondary collapsed fracture and knee varus or valgus occurred. The results were excellent in 12 cases, good in 5 cases, and fair in 2 cases with an excellent and good rate of 89.5% according to the Rasmussen's scoring system for knee function. ConclusionThe posteromedial approach combined with anterolateral approach for posterolateral tibial plateau fractures can fully expose the posterolateral aspects of the tibial plateau, and thus collapsed and splited fractures can be treated at the same time, which will lead to less operative time and good outcomes in the treatment of posterolateral tibial plateau collapsed and splited fractures.