Objective To retrospectively reviewed the operative therapy of the terrible triad of the elbow. Methods From October 2003 to September 2007, 10 cases of terrible triad were treated, with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. There were 3 males and 7 females with the age of 18-66 years. The injury was caused by traffic accidents in 4 cases, fall ing from a height in 4 cases, and tumbl ing in 2 cases. The coronoid process fractures of the patients were 5 cases of type I, 3 cases of type II and 2 cases of type III according to Regan- Morrey classification. The radial head fractures of the patients were 1 case of type I, 6 cases of type II and 1 case of type IIIaccording to Mason classification, and their radial heads of the other 2 patiants were resected before they were in hospital. The general approach was to repair the damaged structures sequentially from deep to superficial, from coronoid to anterior capsule to radial head to lateral l igament complex to common extensor origin. And selected cases were repaired of the medial collateral l igaments and assisted mobile hinged external fixation to keep the forearm fixed in functional rotation position. The function of the elbows were evaluated with the criteria of the HSS2 score system. Results The other wounds healed by first intention except 1 case which had infection 7 days after operation and whose soft tissue defect in posterior elbow were repaired with the pedicle thoracoumbil ical flap. The patients were followed up 6 to 51 mouths (mean 24.9 mouths). The fracture heal ing time was 6 to 20 weeks (mean 9.6 weeks). Six mouths postoperatively, the mean flexion-extension arc of the elbow was 106.5° (85-130°), and the mean pronation-supination arc of the forearm was 138°( 100-160°) respectively. According to the criteria of the HSS2 score, the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases. No compl ications such as stiffness and ulnohumeral arthrosis occurred. The radial nerve injury was found in 1 patient 1 day after operation who was treated with neurolysis, and the nerve function was recovered after 4-6 months. And heterotopic ossification occurred in 6 patients 6 months after operation and radiographic subluxation developed in 1 patient 36 months after operation, and conservative treatment weregiven. Conclusion The terrible triad of the elbow can lead to serious elbow instabil ity and should be treated with operationto restore the anatomic structures, to repair the articular capsule and the collateral l igament, using the adjuvant hinged external fixation and early exercise to avoid immobil ization and recover the articular function.
Objective To investigate the method and effectiveness of operative treatment of anterior olecranon fracture-dislocation. Methods Between January 2007 and December 2010, 10 cases of anterior olecranon fracture-dislocation were treated. There were 6 males and 4 females with an average age of 46.1 years (range, 27-68 years). The injury was caused by traffic accident in 7 cases, falling from height in 2 cases, and falling in 1 case. Nine cases were fresh fracture and 1 case was old fracture. There were 9 cases of ulnar olecranon comminuted fracture and 1 case of simple oblique fracture. Associated fractures were Regan-Morrey type III coronoid process fractures in 5 cases, Mason type II radial head fracture in 1 case, and Mason type III radial head fracture in 1 case. Open reduction and internal fixation were performed in all cases: reconstruction plates were used in 4 cases, tension band and reconstruction plates in 5 cases, and tension band and one-third tubular plate in 1 case; bone graft was performed in 2 cases. Results All incisions healed by first intention. The patients were followed up 12-26 months (mean, 19.8 months). The X-ray films showed that fractures healing was achieved at 12-24 weeks (mean, 16.4 weeks). No failure of internal fixation, ulnohumeral joint instability, or traumatic arthritis occurred. At last follow-up, the elbow function score was 69-100 (mean, 89.1) according to the Broberg-Morrey evaluation criteria; the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases with an excellent and good rate of 80%. The Disability of Arm-Shoulder-Hand (DASH) score was 0-22 (mean, 9). The visual analogue score (VAS) was 0-3 (mean, 0.5). Conclusion For anterior olecranon fracture-dislocation, an early and stable anatomic reconstruction of the trochlear notch of the ulna with plates and early active mobilization are given, the good functional results can be obtained.
Objective To simulate anterosuperior instabil ity of the shoulder by a combination of massive irreparable rotator cuff tears and coracoacromial arch disruption in cadaveric specimens, use proximally based conjoined tendon transfer forcoracoacromial l igament (CAL) reconstruction to restrain against superior humeral subluxation, and investigate its feasibility and biomechanics property. Methods Nine donated male-adult and fresh-frozen cadaveric glenohumeral joints were applied to mimic a massive irreparable rotator cuff tear in each shoulder. The integrity of the rotator cuff tendons and morphology of the CAL were visually inspected in the course of specimen preparation. Cal ipers were used to measure the length of the CAL’s length of the medial and the lateral bands, the width of coracoid process and the acromion attachment, and the thickness in the middle, as well as the length, width and thickness of the conjoined tendon and the lateral half of the removed conjoined tendon. The glenohumeral joints were positioned in a combination of 30° extension, 0° abduction and 30° external rotation. The value of anterosuperior humeral head translation was measured after the appl ication of a 50 N axial compressive load to the humeral shaft under 4 sequential scenarios: intact CAL, subperiosteal CAL release, CAL anatomic reattachment, entire CAL excision after lateral half of the proximally based conjoined tendon transfer for CAL reconstruction. Results All specimens had an intact rotator cuff on gross inspection. CAL morphology revealed 1 Y-shaped, 4 quadrangular, and 4 broad l igaments. The length of the medial and lateral bands of the CAL was (28.91 ± 5.56) mm and (31.90 ± 4.21) mm, respectively; the width of coracoid process and acromion attachment of the CAL was (26.80 ± 10.24) mm and (15.86 ± 2.28) mm, respectively; and the thickness of middle part of the CAL was (1.61 ± 0.36) mm. The length, width, and thickness of the proximal part of the proximally based conjoined tendon was (84.91 ± 9.42), (19.74 ± 1.77), and (2.09 ± 0.45) mm, respectively. The length and width of the removed lateral half of the proximally conjoined tendon was (42.67 ± 3.10) mm and (9.89 ± 0.93) mm, respectively. The anterosuperior humeral head translation was intact CAL (8.13 ± 1.99) mm, subperiosteal CAL release (9.68 ± 1.97) mm, CAL anatomic reattachment (8.57 ± 1.97) mm, and the lateral half of the proximally conjoined tendon transfer for CAL reconstruction (8.59 ± 2.06) mm. A significant increase in anterosuperior migration was found after subperiosteal CAL release was compared with intact CAL (P lt; 0.05). The translation after CAL anatomic reattachment and lateral half of the proximally conjoined tendon transfer for CAL reconstruction increased over intact CAL, though no significance was found (P gt; 0.05); when they were compared with subperiosteal CAL release, the migration decreased significantly (P lt; 0.05). The translation of lateral half of the proximally conjoined tendon transfer for CAL reconstruction increased over CAL anatomic reattachment, but no significance was evident (P gt; 0.05). Conclusion The CAL should be preserved or reconstructed as far as possible during subacromial decompression, rotator cuff tears repair, and hemiarthroplasty for patients with massive rotator cuff deficiency. If preservation or the insertion reattachment after subperiosteal release from acromion of the CAL of the CAL is impossible, or CAL is entirely resected becauseof previous operation, the use of the lateral half of the proximally based conjoined tendon transfer for CAL reconstruction isfeasible.
ObjectiveTo investigate the effectiveness of total elbow arthroplasty (TEA) with preservation of triceps brachii insertion approach.MethodsBetween January 2012 and September 2017, 17 patients with elbow disease were treated with TEA with preservation of triceps brachii insertion approach. There were 3 males and 14 females, with an average age of 65.2 years (range, 48-85 years). The injuries located on left elbow in 5 cases and on right elbow in 12 cases. There were 11 cases of distal humerus fracture (AO type C1 in 2 cases and type C3 in 9 cases); the interval between fracture and operation was 3-10 days (mean, 4.1 days). There were 3 cases of osteoarthritis and 3 cases of rheumatoid arthritis, with the disease duration of 2-26 years (mean, 8.7 years). The postoperative elbow function and pain was assessed by Mayo elbow performance score (MEPS) and visual analogue scale (VAS) score, respectively. The prosthesis position, heterotopic ossification, and periprosthetic fracture were observed by X-ray films.ResultsAll incisions healed by first intention. Sixteen patients were followed up 18-69 months (mean, 40.6 months). Intraoperative ulnar nerve injury occurred in 2 cases, and healed after symptomatic treatment. At last follow-up, the MEPS score was 55-100 (mean, 90.3). The results were excellent in 11 cases, good in 2 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 81.3%. The VAS score was 0-2 (mean, 0.4). X-ray reexamination showed that no polyethylene wear, prosthesis loosening and fracture, abnormal prosthesis position, periprosthetic fracture occurred during the follow-up period, and the prosthesis survival rate was 100%. Heterotopic ossification occurred in 2 and 3 months after operation in 2 cases, respectively.ConclusionThe triceps on approach for TEA are satisfactory for distal humerus fracture, osteoarthritis, and rheumatoid arthritis.
ObjectiveTo construct a model for predicting prognosis risk in patients with pancreatic malignancy (PM).MethodsThe clinicopathological data of 8 763 patients with PM undergone resection between 2010 and 2015 were collected and analyzed by SEER*Stat (v8.3.5) and R software, respectively. The univariate and multivariate Cox proportional hazard regression analysis were used to analyze the factors for predicting prognosis outcome risk and constructed the nomograms of patients with PM, respectively. Kaplan-Meier method was used to evaluate the survival of patients according to relevant factors and the high risk group and low risk group of patients with PM. The discriminative ability and calibration of the nomograms to predict overall survival were tested by using C-index, area under ROC curve (AUC) and calibration plots.ResultsThe multivariate Cox proportional hazard regression analysis showed that age, T staging, N staging, M staging, histological type, the differentiation, number of regional lymph node dissection, chemotherapy, and radiotherapy were independent factors for predicting the prognosis of patients with PM (P<0.05). Based on regression analysis of patients with PM, a nomograms model for predicting the risk of patients with PM was established, including age, T staging, N staging, M staging, histological type, the differentiation, tumor location, type of surgery, number of regional lymph node dissection, chemotherapy, and radiotherapy. The discriminative ability and calibration of the nomograms revealed good predictive ability as indicated by the C-index (0.747 for modeling group and 0.734 for verification group). The 3- and 5-year survival AUC values of the modeling group were 0.766 and 0.781, and the validation group were 0.758 and 0.783, respectively. The calibration plots showed that predictive value of the 3- and 5-year survival were close to the actual values in both modeling group and the verification group. ConclusionsIndependent predictors of survival risk after curative-intent surgery for PM were selected to create nomograms for predicting overall survival. The nomograms provide a basis for judging the prognosis of PM patients.