Application Of The Chinese Aircraft-shaped Sleeve System In The Treatment Of Tibial Shaft Fractures Using A Suprapatellar Approach For Tibial Intramedullary Nailing

Chapter Ⅰ Comparison between infrapatellar and suprapatellar approaches for intramedullary nailing of the fractures of the tibial shaftObjective: This study aimed to compare the clinical and functional outcomes of suprapatellar(SP)and infrapatellar(IP)approaches for intramedullary nailing in the tibial shaft fracture treatment.Methods: Patients who underwent tibial shaft fracture repair in our clinic between January2013 and January 2018 were reviewed.After applying the exclusion criteria,the study finally included 81 patients.Patients were categorized into two groups as per the nailing approach: 38 SP versus 43 IP.The mean time of follow-up was 15 months(12 to 20 months range).Intraoperative fluoroscopy time,operation time,blood loss,irrigation volume,postoperative X-ray alignment,Lysholm knee score,visual analog scores(VAS),incidence of anterior knee pain(AKP),range of motion(ROM)and complications were assessed one year after surgery.Results: The SP group exhibited significantly shorter intraoperative fluoroscopy time than that of the IP group(81.74 ± 14.49 s vs 122.00 ± 24.32 s,P < 0.001).The average irrigation volume was 976.32 ml in the SP group and more than 581.40 ml in the IP group,and this distinction was statistically significant(P < 0.001).A more accurate fracture reduction,both in terms of angulation(2.13° vs 3.05°,P < 0.05)and translation(0.61 mm vs 1.37 mm,P < 0.05)in the coronal plane,was seen in the SP group.However,there was no difference in reduction in the sagittal plane(P > 0.05).No significant difference was observed in the incidence of angulation(angulation > 5°)or translation(lateral displacement > 10 mm)in any plane between two groups(P > 0.05).A higher Lysholm knee score was found for the SP group than that of the IP group(86.66 vs.80.09;P < 0.05).The SP group exhibited lower average VAS score at significant value than that of the IP approach group(0.34 vs 1.26;P < 0.001).6 cases(15.79%)in the SP group and 16 cases(37.21%)in the IP group presented with AKP one-year post-operation(P < 0.05).No significant difference was observed between two groups in terms of ROM and incidence of complications(P > 0.05).Conclusion: Compared with the IP approach,the application of intramedullary nailing through the approach of SP in the treatment of fractures of tibial shaft can effectively shorten the intraoperative fluoroscopy time,correct coronal plane angulation and translation deformity,reduce the incidence of AKP and improve postoperative function.Chapter Ⅱ Significance of anatomical morphometry of patellofemoral joint for Chinese in intramedullary nail technique for tibial fracture via suprapatellar approachObjective: To obtain the anatomical parameters of the patellofemoral joint(PFJ)among Chinese and to compare the age,sex and race differences.In order to make a customized protective sleeve more suitable for the anatomical characteristics of Chinese,so as to increase the ease and safety of intramedullary nailing through SP approach.Methods: Adults(n = 212)normal lower limb function were selected for MRI(Magnetic resonance images)measurement and analysis.All the subjects were examined in the physical examination center of our hospital from January 2011 to January 2017.There were 101 males(47.6%)and 111 females(52.4%),aged 41.42 ± 13.91 years(range of age:18-73 years),and in total 106 each of left and right knees.Measurements include PA(patellar angle),SA(sulcus angle),SW(sulcus width),and SD(sulcus depth).Results: The SA,PA,SD,and SW were 142.37 ± 5.33 °,135.40 ± 6.20 °,4.29 ± 0.63 mm,and 33.37 ± 2.73 mm,respectively.No significant difference in the above parameters was observed among all age groups(P > 0.05).In women,PA,SW and SD were significantly smaller than that of men(P < 0.001),but not SA.PA and SA have a positive linear correlation(P < 0.01,r(the correlation coefficient)= 0.445(95% CI,or the confidence interval: 0.315-0.553)),SA and SD show a negative linear correlation(P < 0.01,r = 0.431(95% CI:-0.539--0.311)),and a positive linear correlation was observed between SW and SD(P < 0.01,r = 0.474(95% CI: 0.361-0.573)).No other linear correlation was found(P > 0.05).Compared with western studies,the SD of Chinese is significantly smaller than that of western races(P < 0.05).Conclusion: The anatomical parameters of PFJ in Chinese were obtained in this part of the study.The PA,SD and SW of women are significantly smaller than that of men,and the SD of Chinese is significantly smaller than that of westerners,indicating that the intramedullary nailing through SP approach may be more difficult and riskier for Chinese,especially for women with smaller stature.In the future,it is necessary to design special sleeves more suitable for the anatomical shape of Chinese patellofemoral joint to increase the safety and ease of this technique.Chapter Ⅲ The use of suprapatellar intramedullary nailing versus a suprapatellar Chinese Aircraft-shaped Sleeve System for tibial shaft fractures,a comparisonObjective: The safety and effecacy of the CASS(Chinese Aircraft-shaped Sleeve)system was compared with tibial intermedullary nailing applying a suprapatellar approach to treat the tibial fractures in a cohort of adult Chinese patients with a follow-up of a minimum of one-year.Methods: From January 2014 to July 2018,osteologically mature patients having type 42 Orthopaedic Trauma Association(OTA)tibial shaft fractures were randomly categorized into either a conventional SP approach group(34 patients)or a SP CASS group(33patients)after obtaining informed consent from them.Both groups absolutely followed research requirements and completed the follow-up of 12 months.There were 35 females and 32 males,with an average age of 38.42 years(22-69 years).Intraoperative arthroscopy and postoperative MRI were obtained to evaluate the PFJ and residual debris.The surgical time until the commencement of entry reaming,postoperative X-ray alignment,the irrigation time,Lysholm knee score,VAS,incidence of AKP,ROM and complications were assessed one year after surgery.Results: Intraoperative arthroscopic evaluation showed that the cartilage injury rate was3% in the CASS group and 26.5% in the conventional SP group.The two groups exhibited significant dissimilarity(P = 0.013),the relative risk(RR)was 0.114(95% CI:0.015-0.854),and the relative risk reduction rate(RRR)was 0.886.MRI evaluation one week after surgery showed that the CASS group exhibited lesser cartilage injury rate than that in the conventional SP approach group(6.1% vs 29.4%;P = 0.023,RR = 0.206(95%CI: 0.049-0.870),and RRR = 0.794).MRI evaluation one year after surgery showed that the cartilage injury rate was 0 vs 17.6% in the CASS and conventional SP groups,respectively.The cartilage injury rate of MRI one year after surgery was different at a significant value(P = 0.025(< 0.05)).Both intraoperative arthroscopy and MRI one week after surgery showed that the postoperative debris residual rate was 3% in the CASS group and 14.7% in the conventional SP group but was not significant(P > 0.05).MRI results one year after surgery showed that no debris remain or joint mouse in the articular cavity were found in all cases.In the CASS group,the time of surgery until the commencement of entry reaming and the irrigation time decreased significantly(P < 0.001).The Lysholm knee scores in the CASS group and the conventional SP group were 87.00 ± 5.80,and84.97 ± 6.88,respectively(P = 0.20).However,the CASS group exhibited significantly higher stair climbing score was than that of SP group(8.91 vs 7.41;P < 0.05).There was no significant difference in terms of postoperative X-ray alignment,VAS,incidence of AKP,ROM or complications.Conclusion: As per this study,the CASS system furnishes various advantages,including stability of the sleeve post-insertion,simplicity in the protective sleeve placement,minimal damage to the articular cartilage,shorter surgical time,convenient intraoperative irrigation,and improved clinical functions.This latest and practical improvement using the SP approach may impart beneficial outcomes in tibial shaft fractures during intramedullary nailing,particularly in treating smaller patients with fractures of tibial shaft.