Indications and limitations of locked plating

The goal of fracture fixation is to achieve bone healing and restore the function of the injured limb in the shortest possible time without compromising safety. Newer technologies such as the locking compression plate (LCP) and its derivatives are valuable additions to the orthopaedic traumatologist's armamentarium. As with any emerging technology, the indications will be extended until a threshold is reached and the limitations of the technology are seen. It is vital that surgeons involved in fracture care are aware of when locked plating is superior to other methods and also when they should use another treatment modality.This paper reviews the use of locked plating as a fixation method. Five topics covered in this review are: a historical perspective on locked plating, general indications, specific modes and techniques, patterns of failure, and an anatomical overview of current indications for locked plating.     

Results of non-operative treatment following hip fracture compared to surgical intervention

We followed all consecutive hip fracture patients admitted between 2004 and 2006, identified cases in which the intention was to treat non-operative and compared their functional outcome and mortality with a similar cohort treated surgically over the same period. We recorded length of hospital stay, place of discharge, pre and post-fracture mobility and residence, 30 days and 1 year mortality, re-admission due to same fracture and delayed surgery. The group treated surgically was recruited and matched for age, gender, pre and post-fracture mobility, mental confusion and independence. 25 patients were treated non-operative. 22 patients treated surgically over the same time period matched the patient characteristics of the non-operative arm. The mean hospital stay was 13 days in both groups. There were 4 extra-capsular fractures (3 displaced) and 21 intra-capsular fractures (5 displaced) in the non-operative arm and 11 extra-capsular fractures and 9 intra-capsular fractures in the surgically treated arm. 4 patients from the non-operative treatment group underwent late surgery because of persisting hip pain 20 days-2 months after the index event (2 cannulated screws, 1 hemiarthroplasty, 1 total hip arthroplasty). 11 patients in the surgical treatment arm underwent dynamic screw fixation, 1 had cannulated screw, 1 had total hip replacement and 7 had hemiarthroplasty. 14 of the non-operative treated patients were mobile independently or with aid before fracture but only 9 patients retained their pre-fracture mobility following treatment, compared to 16 patients pre-fracture and 11 patients post-fracture after surgery. 16 patients treated non-operative were living independently prior to injury but only 7 went back to their own residence. Of the operatively treated patients 14 patients were living independently and 10 patients went back to their previous residence. 1 month and 1 year mortality in the non-operative treated group was 4/21 and 7/21 respectively compared to 1/20 and 5/20 in the operative fixation group. There was no statistically significant difference in mobility, residence or mortality between the two groups (Fisher exact test, p > 0.05). Non-operative management after hip fracture is suitable for medically unfit patients and does not result in statistically significant difference in functional outcome or mortality compared to patients treated surgically.     

髂深血管蒂髂骨-腹内斜肌同蒂双岛状瓣修复下颌复合组织缺损

目的评价以髂深血管为蒂的髂骨—腹内斜肌双岛状瓣（简称同蒂双岛状瓣）修复下颌复合组织缺损的临床应用价值。方法2005年1月至2006年10月,应用同蒂双岛状瓣修复10例下颌骨复合组织缺损（包括下颌骨体部、下颌角和下颌骨升支及其周围软组织,其中有7例还包含髁突的缺损）。结果10例同蒂双岛状瓣移植均获成功,仅1例出现局部轻度感染,换药后二期愈合。术后随访3～24个月,均无肿瘤复发,颌面外形两侧基本对称,咬合关系恢复正常,且供区未见明显的并发症。结论同蒂双岛状瓣具有切口隐蔽、单一,对供区功能影响小,软硬组织复合缺损同期修复效果好等特点,是半侧下颌骨复合周围软组织大型缺损功能重建的较好方案。     

腰椎后路非融合固定系统的临床应用

复习腰椎后路非融合固定系统的设计原理、临床应用及治疗效果等相关文献,与传统的脊柱融合术相比,应用非融合系统可获得很好的疗效,并可以减少邻近节段退变的发生率。     

距骨骨折的手术治疗

目的探讨距骨骨折的特点、类型、手术方法及影响疗效的相关因素。方法1998年12月至2004年12月,共治疗距骨骨折39例,根据Hawkins分型方法,型骨折5例,型骨折25例,型骨折9例。型骨折采用松质骨拉力螺钉内固定;、型骨折行急诊手术,其中型骨折采用前外侧切口暴露,解剖复位,2枚松质骨拉力螺钉交叉内固定;型骨折采用踝前内侧切口暴露,解剖复位,松质骨拉力螺钉内固定,伴有内踝骨折时同时复位内固定,并以自体髂骨块跨骨折线嵌入植骨。术后短腿管形石膏外固定12~24周,X线片示骨折线模糊后拆石膏行不负重下踝关节活动,骨折线消失后恢复伤前活动。结果除2例失访外,37例获得随访。随访时间1.5~6年,平均3年。根据Hawkins疗效标准判定,优12例(32.4%),良17例(45.9%),可6例(16.2%),差2例(5.4%),优良率为78.4%。结论距骨骨折虽然并发症多且后果严重,但是通过急诊手术、解剖复位、有效内固定、自体髂骨块嵌入植骨、局部封闭、理疗等综合治疗,可降低病残率。     

The relational underpinnings of quality internal auditing in medical clinics in Israel

Internal auditing is a key mechanism in enhancing organizational reliability. However, research on the ways quality internal auditing is enabled through learning, deterrence, motivation and process improvement is scant. In particular, the relational underpinnings of internal auditing have been understudied. This study attempts to address this need by examining how organizational trust, perceived organizational support and psychological safety enable internal auditing. Data collected from employees in medical clinics of one of the largest healthcare organizations in Israel at two points in time six months apart. Our results show that organizational trust and perceived organizational support are positively related to psychological safety (measured at time 1), which, in turn, is associated with internal auditing (measured at time 2).     

Mechanical Testing of Seven Fixation Methods for Generation of Compression Across a Midtarsal Osteotomy: A Comparison of Internal and External Fixation Devices

The purpose of this study was to assess 7 methods of fixation for a midtarsal osteotomy. Polyurethane foam models (N = 6) and cadaver specimens (N = 4-7) were used to examine the force generated by the different constructs of fixation. A midtarsal osteotomy was performed on each specimen in the test groups. The osteotomies were fixated either with 2 parallel 0.062-in Kirschner wires and 40-mm-long, 4-mm partially threaded, cancellous, cannulated titanium screws, an external ring fixator (frame), a frame with wires tensioned (tension), a frame with wires tensioned and compressed toward the osteotomy (tension and compression), a frame with tension, compression, and parallel Kirschner wires, or a frame with tension, compression, and two 4.0 cannulated parallel screws, respectively. Each model was fixated, and the force generated by the construct across the osteotomy was recorded via the use of pressure-sensitive film. Statistical analysis of the data in the polyurethane foam group determined that the use of frame with tension, compression, and two 4.0 parallel cannulated screws was statistically superior to 1) frame, 2) frame with tension, 3) 2 parallel Kirschner wires, 4) two 4.0 cannulated parallel screws, and 5) frame with tension and compression. A cadaver study determined that the frame with tension, compression, and 2 parallel Kirschner wires was statistically superior to 1) frame and 2) two parallel Kirschner wires. These findings suggest that there is a difference in the force generated by the type of fixation construct across a midtarsal osteotomy.     

两种微创方法治疗股骨颈骨折的临床对照试验

目的分别应用三针锁针加压器外固定和空心拉力钉内固定疗法治疗股骨颈骨折,探讨股骨颈骨折最佳治疗方法.方法应用三针锁针加压器外固定治疗股骨颈骨折63例,其中男24例,女39例;年龄55～89岁,平均(64.5±3.2)岁;Garderl Ⅰ型2例,Ⅱ型15例,Ⅲ型38例,Ⅳ型8例.应用空心拉力钉内固定治疗63例,其中男29例,女34例;年龄45～76岁,平均(62.2±2.9)岁;Garden Ⅰ型4例,Ⅱ型24例,Ⅲ型28例,Ⅳ型7例.对其疗效进行分析.结果126例除2例死亡外均得到随访.115例愈合,其中10例股骨头坏死.外固定组愈合58例,股骨头坏死4例,死亡1例;内固定组愈合57例,股骨头坏死6例,死亡1例.根据Harris功能评定标准评价疗效,外固定组62例中优24例,良26例,可8例,差4例,优良率80.65%;内固定组62例中优23例,良27例,可6例,差6例,优良率80.65%.Harris评分外固定组平均(80.40±1.21)分,内固定组平均(79.14±1.47)分,两组Harris评分比较差异无统计学意义(P＞0.05).结论采用内外固定治疗股骨颈骨折疗效无明显差异,但外固定创伤小、费用低、可早期离床;而采用拉力钉内固定器医疗成本高,卧病时间相对较长,且需二次手术取内固定钉.     

切开复位内固定治疗骨盆桶柄样Tilt骨折

目的探讨骨盆桶柄样Tilt骨折手术治疗方法。方法切开复位内固定治疗52例骨盆桶柄样Tilt骨折。前骨盆经Plan—nenstiel入路固定9例，Pfannenstiel入路结合部分髂腹般沟入路固定43例。37例行骨盆重建钢板固定，骨盆重建钢板固定结合耻骨上支髓内螺钉固定9例，6例2块骨盆重建钢板固定。后环37例经患侧髂嵴入路以骨盆重建钢板固定。8例骶骨骨折行骶髂关节螺钉固定。7例未行后骨盆固定。结果平均随访18个月。全部骨性愈合，无下肢不等长，骨盆畸形基本纠正。按Majeed疗效评定标准优良率为93．8％。结论通过前后联合入路，切开复位治疗骨盆桶柄样Tilt骨折疗效满意，并可防止远近期并发症的发生。     

有限内固定结合外固定支架治疗胫骨远端骨折

目的探讨有限内固定结合Hybrid外固定支架治疗胫骨远端骨折的疗效。方法从2003年1月～2005年7月,使用Hybird外固定支架治疗胫骨远端骨折21例,按AO分类:A1型4例;A2型5例;A3型4例;C1型2例;C2型3例;C3型3例,其中开放性骨折8例,手术采用有限切开,骨片钉固定,Hybrid外固定支架不跨踝关节固定。结果术后21例均获随访,平均随访时间12.3个月,骨折平均愈合时间7.6个月。功能评定采用Bone的踝关节活动度进行评价,优良率达76%。结论Hybrid外固定支架设计合理并能维持骨干的轴线,骨片钉能很好的固定骨折块,同时避免了软组织的并发症,可使踝关节早期活动,防止踝关节僵硬,因而是治疗胫骨远端骨折有效的方法之一。