Long-term Knee Joint Function And Imaging Studies Of The Surgical Treatment Of Patellar Fracture And The Surgical Treatment Of Proximal Humerus Comminuted Fracture

As the largest sesamoid bone in human body, patella plays an importantrole in the knee extension movements. Patella is located subcutaneously of theanterior knee joint, and it is easy to get direct or indirect violent injury. Hencethe patellar fracture is one of the most commonly observed fractures,accounting for2.21%of the total body fracture. As a type of intra-articularfracture, patellar fracture will result in destroying the continuous of the kneeextension system and evenness of the patellofemoral joint surface. Therefore,the prognosis of patients’ patellar fracture will result in significant impact onthe knee function and even life quality. To restore knee function as soon aspossible and avoid or reduce traumatic arthritis, the treatment principles forpatella fractures include anatomical reduction, strong fixation, and earlymobilization. With the continuous development of orthopedic fixationtechnology, a large number of newly discovered surgical techniques andfixation materials has been applied into the treatment of patellar fracture andmade the treatment results improved significantly. Before the20th century, thetreatment of patella fractures was controversial; the most commonly usedtreatments were non-operative methods like extension splinting and rest.Dowd etc. thought the traditional treatment had a bad prognosis with a lowersymphysis possibility and a higher disability expectation. As a result twosurgical plans were proposed with the improvement of sterile surgicaltechniques: patellar fracture open reduction and internal fixation with steelwire, and patellectomy. Later, the patellar fracture open reduction and internalfixation with steel wire became the primary choice for the treatment of patellafracture.As a treatment of the extreme comminuted patella fracture, patellectomyis often applied. However taking the long term efficacy and prognosis into consideration, this resection treatment is controversial. Some scholars believedthat under the condition that the comminuted patella fractures cannot be stablyfixed, patellectomy can be applied as the treatment. And under this conditionthe satisfaction rate was about80%. However after the1980s, with theprogress of internal fixation techniques, a discussion on this operation wasbrought up believing that the clinical results of the patellectomy were not ideal.And this patellectomy can only be served as the final treatment. The previousfindings have only been focusing on the prognostic features of the patellarfractures, but the long term impact of the ipsilateral patellectomy on thefunction of the contralateral knee and the imaging changes has been rarelyreported. By comparing and analyzing the ipsilateral and contralateral side ofthe comminuted fractured patella with patellectomy and patella internalfixation treatments, our study is focusing on the function recovery andimaging changes in the two situations.The requirement for clinical treatments on patellar fracture is increasing;in principle the treatment should maximally retain the patella and restore itsfunction. Most displaced patella fracture can be treated with open reductionand internal fixation. Partial patellectomy are usually applied for seriouspatella fracture, particularly severe fracture of the interior patella. Thelong-term efficacy of partial resection and degeneration of petallofemoral jointare rarely reported in publications. This study will evaluate the long-termefficacy of partial patellectomy by MRI scoring and the knee function scoring.As China entering the aging society, the population of the aged people isincreasing rapidly, as a result the number of aged patients with patella fractureis also increasing. However, due to the problem from osteoporosis and poorbone quality of the aged patients, when applying the reduction and fixationtreatment, the fractured fragments were easy to be broken and internalfixations are easy to loosen. All these result in a non-or delayed close up ofthe fractured bones. Most of the aged patients with patella fracture need anadditional several weeks’ Kirschner wire plus tenson bend after the operationperformed. However, the long-term applied external fixation equipment during the treatment will result in the extreme unfavorable impact on the jointfunction recovery, as result, the cause of joint stiffness and impact on the kneefunction restore. This study is mainly discussing the effects of early functionalexercise and plaster fixation on the aged patients with patella fractures, via thescoring the early functional exercise and plaster fixation and analyzing thepostoperative complication during the recovery.PART ONE: Gender determination from the patella CT threedimensional reconstruction measurement from Han adults in the NorthChinaObjective: The objective of this part is to determine adults’ gender, byapplying discrimination analysis to the received computed tomography (CT)three-dimensional reconstruction from257Han adults.Method: The257Han adults were patients in Hebei Province TraumaCare Centers volunteered to participate in the test, from January2011toDecember2013. CT scans were applied to the volunteers and thethree-dimensional reconstructions were composed of the height and width,thickness, and the lateral patellar articular surface of the patella. After appliedto statistical analysis, the discriminant analysis functions and determinecompliance rates of mono-and multi-indicators were identified.Result: In patella of the Han adults in the North China, the fiveindicators showed significant (P <0.01) larger mean values in men than inwomen. Discriminant analysis functions of medial articular surface of thepatella as a mono-indicator were Y1=-82.08+7.95X4and Y2=-60.29+6.78X4, with a determine compliance rate of83.33%. Discriminant analysisfunctions of multi-indicators were Y1=-296.24+2.94X1+6.78X2+0.119X3+3.01X4+4.70X5; Y2=-261.06+2.82X1+6.72X2+0.07X3+2.08X4+4.33X5, with a determine compliance rate of89.10%.Conclusion: The determine compliance rate was83.33%when usingmedial articular surface of the patella as the mono-indicator in thediscriminant analysis; while the determine compliance rate was89.10%whenusing the multiple discriminant analysis. A reliable way of determining gender was figured out by a morphological measurement study on patella.PART TWO: Long-term functional and imaging changes in patients’knees with partial patellectomyObjective：To investigate long-term functional and imaging changes inpatients’ knees with partial patellectomy.Methods:29cases of patients with partial patellectomy in our hospitalfrom January1987to January2002were retrospectively reviewed. There were21males and8females, with an average age of45.8(range29-71years). Meanfollow-up was13years (range,8-13years). In order to analysis the functionof patients’ knee, such examinations as MRI, physical examination andquestionnaire. As well as the KOOS score and Bostman score and modifiedWORMS score, were carried out in the study.Result:The average Modified WORMS score in29cases of affectedknee was13.79±5.80points, included mild arthritis24cases, moderate5casesand severe0; score of unaffected sides was12.31±5.48, included mildarthritis26cases, moderate3cases and severe0. no statistical differencesshowed in the two groups (P=0.321). The average KOOS score of pain was88.0±6.37points, symptom was86.9±5.65points, daily life was89.9±5.15,entertainment and sports was83.6±7.55points and the quality of life related toknee joint function was80.5±8.46.The average Bostman score was27.41±3.621points, included20patients reached excellent,9good and0bad.Flexion degree of involved sides was128.34°±5.50°, the uninvolvedknee was128.76°±4.223°, no statistical differences showed in the two groups(P=0.173). Flexion degree of involved sides was105.35±12.18Nm, theuninvolved knee was106.59±9.09Nm, no statistical differences showed in thetwo groups (P=0.175).Conclusion: partial patellectomy does not cause serious jointdegeneration and traumatic arthritis; Function score of knee shows finecurative effect. Partial patellectomy can be used for patellar fractures thatreplacement is difficult or malreduction. PART THREE: ORIF contrast patellectomy treatment of comminutedfracture of the patella forward bilateral knee function and radiographicmanifestationsObjective: By comparing and analyzing the evaluations of imaging andfunctional scores between patellectomy of comminuted patella fracture andcontralateral and ipsilateral knee patella of internal fixed fractured patella, thisstudy mainly focus on the function recovery and imaging changes in the twosituations.Method: Review analysis on the52patients accepting treatments ontheir comminuted fractured patella from January1987to January2002in ourhospital, including24patellectomy patients (resection group) and28patellaORIF patients (fixed group). MRI was performed on all patients at the finalfollow-up along with a knee function test and recovery surveys. A modifiedWhole-Organ Magnetic Resonance Imaging Score (WORMS) was performedin the patients MRI imaging analysis and American Knee Society Score (AKS)was applied to the knee function evaluation. The Biodex-II (USA) iso-kineticdynamometer system was applied for measuring knee joints’ extension peaktorque and buckling angle.Result: The24patients in patellectomy group got11to26yearfollow-ups (mean was17.3years). The28patients in fixed group got12to22year follow-ups (mean15.5years). In the final follow-up of the patellectomygroup, the mean WORMS’s scores were6.58±1.05at ipsilateral side, and4.71±0.53at contralateral side. While the mean scores for the fixed group were8.11±1.21at ipsilateral side, and4.43±0.28at contralateral side. There wasno significant difference between the two groups at ipsilateral andcontralateral sides. The mean AKS’s scores were152.75±2.87at ipsilateralside and165.08±2.23at contralateral side of the patellectomy group; whilethe mean AKS’s scores for the fixed group were149.14±2.66at ipsilateralside, and165.08±2.23at contralateral side. There was no significantdifference between the two groups at ipsilateral and contralateral sides. Themean knee buckling angels were119.9°±3.01°at ipsilateral side and123.5°±2.71°at contralateral side of the resection group; while the angels for the fixed group were115.32°±3.11°at ipsilateral side, and127.14°±1.6°atcontralateral side. There was no significant difference between the two groupsat ipsilateral and contralateral sides (overall P=0.238, ipsilateral P=0.298, P>0.05, see Table1). The mean knee joints’ extension peak torque were96.08±2.32N m at ipsilateral side and106.46±1.8N m at contralateral side ofthe patellectomy group; while those for the fixed group were99.18±1.98N m at ipsilateral side, and105.25±1.63N m at contralateral side. There wasno significant difference between the two groups at ipsilateral andcontralateral sides.Conclusion: After a long rehabilitation and compensation, patients withpatellectomy and internal fixation showed no functional difference within theipsilateral and contralateral sides. The patients in patellectomy group showedslightly lower muscle force at their quadriceps. However knee degenerationwas observed at the ipsilateral side within the patients in fixation group. Theincrease of functional compensatory increase at both side of the knee joint isthe major reason for this accelerated degeneration.PART FOUR: Study of functional rehabilitation and complication ofpostoperative knee patella fracture in aged patients with early exerciseversus auxiliary external fixation.Objective: Discussing the effects of early functional exercise and plasterfixation on the aged patients with patella fractures, via scoring the earlyfunctional exercise and external plaster fixation and analyzing thepostoperative complication during the recovery.Method: Review analysis on the119aged patients accepting treatmentson their patella from January1987to January2002in our hospital, including99male cases and20female cases. Among these patients64were treated withexternal plaster fixation (plaster group) and55were applied to early functionalexercise (exercise group) after the surgical treatment. KOOS and Bostmanscoring were applied to all patients in their final follow-up as an evaluation ofthe patients’ knee function. Additionally, the complications including woundinfection, venous thrombosis, failure internal fixation, etc. were recorded and analyzed with the Electronic Medical Recording System.Result: The follow-up time ranged from36months to98months, withan average of53months. There was no significant difference in age, gender,injury mechanism, injury type, time from injury to surgery, and hospitalizationtime between the two groups. According to Bostman standard, exercise groupgot a higher score than the plaster group, but no statistically significantdifference was observed (P=0.721). The excellent-to-good rates were79.69%(51/64) for exercise group and81.82%(45/55) for plaster group, no significantdifference was observed either. The KOOS score of exercise group wasslightly higher than that of plaster group without a significant difference. Themean knee buckling angels were116.36°±18.60°(54°~135°) for theexercise group and114.64°±18.31°(59°~135°) for the plaster group, nosignificant difference was observed (P=0.612). Extension activity was notlimited in either group. No internal fixation failure occurred in the plastergroup, but14cases of internal fixation failure occurred in the exercise group.A secondary ORIF was applied to10of the14patients with an external plasterfixation or brace; while the other four were treated with a plaster fixation untilfracture healing. There were14patients got wound infection;9were in theplaster group and5in the exercise group. Among the14infected patients,12got superficial infections (8in the plaster group and4in the exercise group),2got deep infections (1patient per group). Superficial infection was controlledby applying medication change and antimicrobial agents, and the wound washealed in all cases with no significant difference in two groups. There were13patients developed venous thrombosis and1developed deep vein thrombosisin plaster group; while in the exercise group5patients developed venousthrombosis and no deep vein thrombosis development.Conclusion: The aged patients with good bone quality and stronginternal fixation can get good functional rehabilitation and low fixation failurerate by applying early post-surgical exercise rather than external plasterfixation, under the condition that the fracture was non-comminuted fracture.The aged patients with less poor internal fixation should be treated with fracture. External plaster fixation can reduce fixation failure rate with littleaffect on the knee function; however, the patients treated with external plasterfixation has a higher possibility in developing vein thrombosis. For agedpatients with higher risk of vein thrombosis development and patella fractures,anti-thrombotic therapy and lower limb exercise should be applied as soon aspossible.PART FIVE: Locking plate fixation combined with iliac crest boneautologous graft for proximal humerus comminuted fractureObjective: The aim of this study was to evaluate the clinical andradiographic outcomes of a locking plate and crest bone autologous graft fortreating proximal humerus comminuted fractures.Method: We assessed the functional outcomes and complication rates in40patients with proximal humerus comminuted fractures. Eighteen patientswere treated with a locking plate and an autologous crest bone graft(experimental group), and22were treated with only the locking plate and nobone graft (control group). Postoperative assessments included radiographicimaging, range of motion analysis, pain level based on the visual analoguescale (VAS), and the SF-36(Short Form (36) Health Survey), as well aswhether patients could return to their previous occupation.Result: All fractures healed both clinically and radiologically in theexperimental group. There was no more than2mm collapse of the humeralhead, and no osteonecrosis or screw penetration of the articular surface. Incontrast, two patients had a nonunion in the control group, and they eventuallyaccepted total shoulder replacements. The average time from surgery toradiographic union was significantly shorter in the experimental group((4.66±1.63) months) compared with the control group ((5.98±1.57) months)(P<0.05). For the experimental versus controls groups, the mean shoulderactive flexion (148.00±18.59vs.121.73±17.20) degrees, extension (49.00±2.22vs.42.06±2.06) degrees, internal rotation (45.00±5.61vs.35.00±3.55) degrees,external rotation (64.00±9.17vs.52.14±5.73) degrees, and abduction (138.00±28.78vs.105.95±15.66) degrees were all significantly higher (allP<0.001). The median SF-36in the experimental group ((88.00±5.71) points)was significantly higher than that of the control group ((69.45±9.45) points;P<0.001). The median VAS pain level (mean rank,10.50) in the experimentalgroup was lower than that (mean rank,47.19) of the control group (P<0.001).All but one patient (17of18,94.4%) in the experimental group returned totheir previous activities or occupations, and that one patient changed to adifferent occupation because of slight restrictions to activities. On the otherhand, four patients could not return to their previous activities or occupationsin the control group.Conclusion: Locking plate fixation combined with an iliac crest bonegraft is an effective technique for treating proximal humerus comminutedfractures.