Comparison of Early Clinical Results for Femoral Neck System and Cannulated Screws in the Treatment of Unstable Femoral Neck Fractures

ObjectiveTo compare early clinical effects of the femoral neck system (FNS) and three cannulated screws for the treatment of patients with unstable femoral neck fractures.MethodsA retrospective analysis with pair matching of 81 patients who received FNS or cannulated screw internal fixation for Pauwels type‐3 femoral neck fracture in our hospital from January 2019 to December 2019 was conducted. Patients who received FNS were the test group, and those who received cannulated screws comprised the control group. Matching requirements were as follows: same sex, similar age, and similar body mass index (BMI). A total of 30 pairs were successfully matched at a 1:1 ratio, including 12 males and 18 females. The average age of the patients in the FNS group was 54.53 ± 6.71 years. In the cannulated screw group, the average age of the patients was 53.14 ± 7.19 years. The operation time, intraoperative blood loss, hospital stay, hospitalization cost, postoperative visual analog scale (VAS) score, time to walking without crutches, Harris score, femoral head necrosis rate, and complication rate were compared between the groups.ResultsPostoperative re‐examination of radiographs showed satisfactory reduction in all patients, and all patients were followed up for 10–22 months. Those in the FNS group had lower postoperative VAS scores, earlier times to walking without crutches, higher Harris scores at the last follow‐up, and lower complication rates (P < 0.05). VAS scores were lower in the FNS group (3.13 ± 1.07 scores) than in the cannulated screw group (3.77 ± 1.04 scores) (P = 0.018). Patients in the FNS group (5.23 ± 1.33 months) recovered to walking without crutches earlier than did those in the cannulated screw group (6.03 ± 1.45 months) (P<0.001). In addition, a statistically higher postoperative Harris score was detected in the FNS group (86.16 ± 7.26) than in the cannulated screw group (82.37 ± 7.52) (P = 0.039). Overall, a higher incidence of complications was observed in the cannulated screw group (9/30) than in the FNS group (2/30) (P = 0.042). However, intraoperative blood loss and hospitalization costs were greater in the FNS group (P < 0.05). Intraoperative blood loss was greater in the FNS group (99.73 ± 4.69) than in the cannulated screw group (30.27 ± 9.04) (P<0.001). In addition, patients in the FNS group (46976 ± 2270 ¥) spent more on hospitalization costs than did those in the cannulated screw group (15626 ± 1732 ¥) (P<0.001). No statistically significant difference in operation time, hospital stay, or femoral head necrosis rate was observed between the two groups (P > 0.05).ConclusionFor patients with unstable femoral neck fractures, FNS has better clinical efficacy than cannulated screws, though it is also more expensive.     

Medial Buttress Plate and Allograft Bone‐Assisted Cannulated Screw Fixation for Unstable Femoral Neck Fracture with Posteromedial Comminution: A Retrospective Controlled Study

ObjectiveTo investigate the outcomes of open reduction and internal fixation combined with medial buttress plate (MBP) and allograft bone‐assisted cannulated screw (CS) fixation for patients with unstable femoral neck fracture with comminuted posteromedial cortex.MethodsIn a retrospective study of patients operated on for unstable femoral neck fractures with comminuted posteromedial cortex from March 2016 to August 2020, the clinical and radiographic outcomes of 48 patients treated with CS + MBP were compared with the outcomes of 54 patients treated with CS only. All patients in the CS + MBP group were fixed by three CS and MBP (one‐third tubular plates or reconstructive plates) with bone allografts. The surgery‐related outcomes and complications were evaluated, including operative time, blood loss, union time, femoral head necrosis, femoral neck shortening, and other complications after the operation. The Harris score was evaluated at 12 months after the operation.ResultsAll patients were followed up for 12–40 months. The average age of patients in the CS‐only group (54 cases, 22 females) and CS + MBP group (48 cases, 20 females) was 48.46 ± 7.26 and 48.73 ± 6.38 years, respectively. More intraoperative blood loss was observed in the CS + MBP group than that of patients in CS‐only group (153.45 ± 64.27 vs 21.86 ± 18.19 ml, t = 4.058, P = 0.015). The average operative time for patients in the CS + MBP group (75.35 ± 27.67 min) was almost double than that of patients in the CS‐only group (36.87 ± 15.39 min) (t = 2.455, P < 0.001). The Garden alignment index of patients treated by CS + MBP from type I to type IV was 79%, 19%, 2%, and 0%, respectively. On the contrary, they were 31%, 43%, 24% and 2% for those in the CS‐only group, respectively. The average healing times for the CS‐only and CS + MBP groups were 4.34 ± 1.46 and 3.65 ± 1.85 months (t = 1.650, P = 0.102), respectively. Femoral neck shortening was better in the CS + MBP group (1.40 ± 1.73 mm, 9/19) than that in the CS‐only group (4.33 ± 3.32 mm, 24/44). Significantly higher hip function was found in the CS + MBP group (85.60 ± 4.36 vs 82.47 ± 6.33, t = 1.899, P = 0.06). There was no statistical difference between femoral head necrosis (4% vs 11%, χ ² = 1.695, P = 0.193) and nonunion (6% vs 9%, χ ² = 0.318, P = 0.719).ConclusionFor unstable femoral neck fractures with comminuted posteromedial cortex, additional MBP combined with bone allografts showed better reduction quality and neck length control than CS fixation only, with longer operative time and more blood loss.     

Micro‐Computed Tomography Analysis of Femoral Head Necrosis After Long‐Term Internal Fixation for Femoral Neck Fracture

ObjectiveTo analyze necrotic femoral head after long‐term internal fixation for femoral neck fractures using micro‐computed tomography (CT) for bone histomorphometry.MethodsThe experimental group included six patients (two men and four women; mean age 62.00 ± 9.36 years) who underwent hip arthroplasty at 47.67 ± 14.22 months after internal fixation. Surgery was performed because of femoral head necrosis after femoral neck fracture between October 2018 and October 2020. The control group included three patients (two men and one woman; mean age 69.33 ± 4.62 years) who underwent hip arthroplasty for femoral neck fracture. In the experimental group, micro‐CT quantitative analysis of the whole femur, sclerotic region around screws, screw paths, sclerotic region and screw paths, and relatively normal region was performed. The bone volume fraction (BV/TV), number of bone trabeculae (Tb.N), connection density (Conn.D), thickness of bone trabeculae (Tb.Th), separation of bone trabeculae (Tb.SP), structural model index (SMI), and bone mineral density (BMD) of each part were quantitatively analyzed.ResultsThe BV/TV (0.3180 ± 0.0617), Conn.D (6.9261 ± 2.4715/mm³), Tb.Th (0.3262 ± 0.0136 μm), and BMD (298.9241 ± 54.2029 g/cm³) of the sclerotic region around the screws were significantly higher in the experimental group than the BV/TV (0.1248 ± 0.0390), Conn.D (2.5708 ± 0.5187/mm³), Tb.Th (0.1713 ± 0.0333 μm), and BMD (66.5181 ± 43.0380 g/cm³) in the control group (P < 0.05). The BV/TV (0.2222 ± 0.0684), Tb.Th (0.2775 ± 0.0326 μm), and BMD (195.0153 ± 71.8509 g/cm³) in the collapsed region were significantly higher in the experimental group than in the control group (P < 0.05). In the experimental group, the volume ratio of the sclerotic region around screws and screw paths to the entire femoral head was 0.4964 ± 0.0950.ConclusionAfter internal fixation for femoral neck fracture, a large number of sclerotic plate‐like trabeculae were observed around the long‐term retained implant. The screw paths and surrounding sclerotic comprise approximately 50% of the femoral head volume.     

Comparison of the Effect of Rhombic and Inverted Triangle Configurations of Cannulated Screws on Internal Fixation of Nondisplaced Femoral Neck Fractures in Elderly Patients

ObjectiveTo investigate whether four‐screw fixation in rhombic configuration could improve the clinical outcomes and decrease the complication rate compared with three‐screw fixation in inverted triangle configuration in elderly patients with nondisplaced femoral neck fractures.MethodFrom January 2018 to January 2019, 91 elderly patients with nondisplaced femoral neck fractures who were treated with a cannulated screw system were reviewed retrospectively. The inverted triangle configuration was applied in 51 patients and rhombic configuration in 40 patients. The demographic and perioperative information of the patients were extracted from medical records and surgical records. Variables including incision size, surgical blood loss, surgical time, fluoroscopy time, hospital stays, fracture union time, postoperative visual analogue scale (VAS) scores, and complications were compared between the two groups. Also, Harris hip score at the final follow‐up was used to evaluate the functional outcomes.ResultsAll patients were followed up from 24 to 36 months, with an average of 29.75 months. The average age of patients was 72.37 ± 7.16 years. No significant differences were found between the two groups with regard to patients'' age, gender, affected side, Garden classification, Pauwels classification and comminution of posterior wall (P > 0.05). We found shorter incision size (P < 0.001), less blood loss (P = 0.020), less surgical time (P = 0.026), and shorter fluoroscopy time (P < 0.001) in inverted triangle configuration group. However, shorter hospital stays (P = 0.001) and fracture union time (P = 0.002) were found in the rhombic configuration group. The VAS scores were lower in the rhombic configuration group at the first (P < 0.001) and third months (P = 0.010), but no significant difference was found at the sixth month (P = 0.075). Meanwhile, the total complication rate was relatively lower in the rhombic configuration group compared to the inverted triangle configuration group (P = 0.041). Harris hip score presented no significant difference between the two groups at final follow‐up (P = 0.078). No wound infection or cortical perforation occurred in either group.ConclusionFour‐screw fixation in rhombic configuration was superior to three‐screw fixation in inverted triangle configuration in the treatment of nondisplaced femoral neck fractures in elderly patients in terms of less early postsurgical pain, shorter fracture union time, and lower complication rate.     

Oxidative Stress Induced Osteocyte Apoptosis in Steroid‐Induced Femoral Head Necrosis

ObjectiveTo investigate the effect and mechanism of Glucocorticoids (GCs) induced oxidative stress and apoptosis on necrosis of the femoral head in patients and rats.MethodsEight patients with steroid‐induced avascular necrosis of the femoral head (SINFH) and eight patients with developmental dysplasia of the hips (DDH) were enrolled in our study. In animal model, twenty male Sprague‐Dawley rats were randomly divided into two groups (SINFH group and NS group). The SINFH model group received the methylprednisolone (MPS) injection, while control group was injected with normal saline (NS). MRI was used to confirm SINFH rat model was established successfully. Then, the rats were sacrificed 4 weeks later and femoral head samples were harvested. Histopathological staining was preformed to evaluate osteonecrosis. TUNEL staining was performed with 8‐OHdG and DAPI immunofluorescence staining to evaluate oxidative injury and osteocyte apoptosis. Immunohistochemistry staining was used to detect Nox1, Nox2, and Nox4 protein expression.ResultsMRI showed signs of typical osteonecrosis of femoral head in SIHFH patients. Histopathological staining showed that the rate of empty lacunae in SINFH patients was significantly higher (56.88% ± 9.72% vs 19.92% ± 4.18%, T = −11.04, P < 0.001) than that in DDH patients. The immunofluorescence staining indicated that the TUNEL‐positive cell and 8‐OHdG‐positve cell in SINFH patients were significantly higher (49.32% ± 12.95% vs 8.00% ± 2.11%, T = −7.04, P = 0.002, 54.6% ± 23.8% vs 9.75% ± 3.31%, T = −4.17, P = 0.003) compared to the DDH patients. The immunohistochemistry staining showed that the protein expression of NOX1, NOX2 and NOX4 in SINFH patients were significantly increased (64.50% ± 7.57% vs 37.58% ± 9.23%, T = −3.88, P = 0.018, 90.84% ± 2.93% vs 49.56% ± 16.47%, T = −5.46, P = 0.001, 85.46% ± 9.3% vs 40.69% ± 6.77%, T = −8.03, P = 0.001) compared to the DDH patients. In animal model, MRI showed signs of edema of femoral head in MPS group, which represents SINFH rat model was established successfully. Histological evaluation showed the rate of empty lacunae in MPS group was significantly higher (25.85% ± 4.68% vs 9.35% ± 1.99%, T = −7.96, P < 0.001) than that in NS group. The immunofluorescence staining indicated that the TUNEL‐positive cell and 8‐OHdG‐positve cell (in MPS group were significantly increased (31.93% ± 1.01% vs 11.73% ± 1.16%, T = −32.26, P < 0.001, 47.59% ± 1.39% vs 22.07% ± 2.45%, T = −22.18, P < 0.001) compared to the NS group. The immunohistochemistry staining showed that the expression of NOX2 in MPS group was significantly increased (76.77% ± 8.34% vs 50.32% ± 10.84%, T = −4.74, P = 0.001) compare with NS group.ConclusionOur findings indicated that GC‐induced NOXs expression may be an important source of oxidative stress, which could lead to osteocyte apoptosis in the process of SINFH     

Factors Associated with Femoral Neck Shortening After Closed or Open Reduction and Screw Fixation

PurposeThis study aimed to evaluate the incidence of femoral neck shortening (FNS) after the treatment of displaced and non-displaced femoral neck fractures with closed or open reduction internal fixation, and determine the independent factors associated with this condition.MethodThe study included 81 patients who underwent internal fixation by closed or open reduction with multiple screws between 2013 and 2018 due to femoral neck fracture (FNF) and were followed up for at least 1 year. Patients were divided into two groups as with and without FNS. The patient, fracture, and surgical parameters compared between the two groups, and the factors affecting development of FNS were investigated.ResultsInternal fixation was applied by closed reduction in 56 patients (69.1%) and open in 25 (30.9%). FNS was detected in 41 patients (50.6%), with the mean shortening 6.3 ± 6.4 mm. Fracture union achieved in 72 patients (89%). The mean time to fracture union was 4.3 ± 2.3 months.No statistically significant relationship found between FNS and the parameters of gender, age, smoking, reduction type, number, type and orientation of screws, Singh index, and Garden fix index (p > 0.05).However, there was significant difference between two groups regarding energy of the fracture, fragmentation, coronal angulation, Garden type, and fixation with medial buttress plate (p < 0.05)ConclusionFNS is an expected condition in FNF fixed by screws. Patients with high-energy traumas and advanced Garden types are more likely to have FNS. The use of medial plate may be effective in preventing FNS.     

The Evaluation of Sagittal Pelvic‐Femoral Kinematics in Patients with Cam‐Type Femoracetabular Impingement

ObjectiveTo investigate the sagittal hip‐pelvic kinematics in symptomatic cam‐type femoroacetabular impingement (FAI) patients in the process of sitting down and compare their difference between patients with sitting pain complaint and those without.MethodsTwenty‐nine symptomatic cam‐type FAI patients were recruited from our clinic between May 2018 and October 2018. Patients were categorized into two groups depending on whether they complain of pain in prolonged sitting or not. The pelvic‐femoral measurements were assessed with a set of lateral pelvic radiography in sitting and standing respectively. Pelvic incidence (PI), sacral slope (SS), and proximal femoral shaft angle (PFSA) were measured on lateral pelvic radiography, and then pelvic tilting, apparent hip flexion, true hip flexion, and the pelvic‐femoral ratio were calculated to investigate the kinematic change from standing to sitting position. Demographic measurements, hip morphology measurements, functional measurements, visual analog scale (VAS), and pelvic‐femoral measurements were compared between the two groups.ResultsThirteen cases without sitting pain complaint and 16 cases with sitting pain complaint were stratified to Group N and Group P respectively. No was significant difference in age, body mass index (BMI), and gender between the two groups. Hip morphology measurements (α angle and lateral center‐edge angle) and functional measurements (iHOT‐12) showed no significant difference between the two groups. However, the mean VAS of pain while sitting was 0.5 ± 0.4 and 1.6 ± 0.6 in Group N and Group P respectively (P = 0.005). Patients with sitting pain complaint have increased pelvic PI compared to those without (50.1° ± 6.5° and 44.2° ± 7.6°, P = 0. 042). The changes in SS (pelvic tilting) from standing to sitting in Group N was significantly larger than that in Group P (21.8° ± 7.0° and 15.1° ± 6.5°, P = 0.012). Although no significant difference in apparent hip flexion and true hip flexion was found. Patients without sitting pain complaint demonstrated a higher pelvic‐femoral ratio (22.8% ± 7.9% and 16.1% ± 7.5%, P = 0.010) compared to those with sitting pain complaint.ConclusionSagittal pelvic‐femoral kinematics could have an influence on the symptomology of cam‐type FAI. The small PI and insufficient sagittal pelvic tilting in the process of sitting down could be related to the complaint of sitting pain in patients with symptomatic cam‐type FAI.     

Repair Versus Non‐Repair of Lateral Ulnar Collateral Ligament in Elbow Varus Posteromedial Rotatory Instability Treatment: A Comparative Study

ObjectiveTo compare the effects of repairing and not repairing the lateral ulnar collateral ligament (LUCL) when surgically treating elbow varus posteromedial rotatory instability (PMRI).MethodsIn this retrospective study spanning June 2014 to February 2019, 24 patients with elbow PMRI who were treated surgically were assigned to group RL (Repair LUCL) or group NL (Non‐repair LUCL) depending on whether the LUCL was repaired. Hospitalization time, operation time, intraoperative blood loss, and related complications were reviewed. The elbow range of motion (ROM), the visual analog scale (VAS), the Mayo elbow performance score (MEPS), and the disabilities of the arm, shoulder, and hand (DASH) score were used for functional assessment.ResultsAmong the 24 patients with PMRI, 15 were assigned to group RL and nine were assigned to group NL. The mean blood loss (184.66 ± 20.3 vs 207.33 ± 19.447, P < 0.001), the operation time (98.88 ± 12.693 min vs 184.66 ± 20.3 min, P < 0.001) were significantly lower in group RL compared to group NL. There were no significant differences between the two groups in time until surgery and follow‐up time (6.66 ± 1.838 vs 6.11 ± 1.900 days, 25.53 ± 2.099 vs 26.11 ± 2.891 months, P = 0.577, P = 0.486). All of the patients achieved bone union. The elbow flexion‐extension ROM (122.00° ± 3.162°vs 121.11° ± 3.333° at 12 months, P = 0.520) and pronation‐supination ROM (154.53° ± 3.335° vs 155.55° ± 4.639° at 12 months, P = 0.537). Both groups achieved similar results in MEPS score (90.53 ± 2.695 vs 89.77 ± 3.865, P = 0.578) and DASH (9.77 ± 1.897 vs 9.99 ± 1.550, P = 0.772) score at the final follow‐up. And the MEPS score revealed excellent results (87% in group RL, 89% in group NL).The VAS scores decreased significantly in group RL (from 6.13 ± 0.990 to 1.93 ± 0.593) and group NL (from 5.77 ± 1.481 to 1.88 ± 0.781), and no significant differences in preoperative or final follow‐up were observed between the two groups (P = 0.487, P = 0.876). Complications observed in group NL with one patient occurred cubital tunnel syndrome 3 months after the operation, the patient underwent ulnar nerve simple neurolysis and the symptoms were relieved after 3 weeks.ConclusionFor patients with elbow PMRI, satisfactory functional outcomes can be yielded with non‐repair of the LUCL as long as the stable elbow joint is performed during operation.     

Cervical Transdural Discectomy with Laminoplasty for the Treatment of Multi‐segment Cervical Spinal Stenosis Accompanied with Cervical Disc Herniation: Technical Note and Clinical Outcome

ObjectiveTo describe the surgical technique of cervical transdural discectomy with laminoplasty (CTDL) for the treatment of multi‐segment cervical spinal stenosis (CSS) accompanied with cervical disc herniation (CDH) and investigate its surgical outcomes and complications.MethodsThis was a clinical study. Between 2012 and 2018, 31 patients (13 males and 18 females) with multi‐segment CSS (over two cervical segments) accompanied with huge CDH and underwent CTDL were enrolled in this study. The details of CTDL technique with general anesthesia was described by the authors. The average follow‐up period of patients was 65.03 months (range from 24 to 126 months). Perioperative parameters such as age, sex, operative level, operative time, estimated blood loss, ambulation time, and operative complications were recorded. The results of clinical metrics such as the visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores in the preoperative and during the follow‐up period were obtained and used to evaluate clinical outcomes. Radiographic improvement was evaluated by the compression ratio, sagittal maximum spinal cord compression (SMSCC), and cervical range of motion (ROM). The preoperative and postoperative follow‐up parameters (VAS, JOA, Compression ratio, SMSCC, and ROM) were assessed with paired t test. A P‐value <0.05 was considered statistically significant.ResultsIn the study, the mean age of the 31 patients was 55.23 ± 10.97 years. The mean operative time was 192.45 ± 24.17 min (ranging from 150 to 245 min), and intraoperative blood loss was 322.58 ± 129.00 mL (ranging from 150 to 600 mL). The VAS neck pain was improved significantly over the follow‐up period (P < 0.05, respectively). The VAS arm pain improved significantly from 6.26 ± 0.93 preoperatively to 1.74 ± 0.63 at 24 months postoperatively (P < 0.001). There was no significant difference in improvement of VAS arm pain between 24 months postoperatively and final follow‐up (P = 0.180). Compared with preoperative JOA score, JOA score was significantly improved at 24 months postoperatively (14.79 ± 1.84 vs 9.66 ± 2.81, P < 0.001). Meanwhile, there were no statistically significant differences between the final follow‐up and the postoperative JOA scores (15.08 ± 1.71 vs 14.79 ± 1.84, P = 0.051). Postoperative patients showed significantly higher index of compression ratio (58.30 ± 8.51 vs 27.17 ± 3.89, P < 0.001) and lower SMSCC (25.12 ± 5.67 vs 33.66 ± 5.38, P < 0.001). In addition, there was no significant difference between preoperative and postoperative cervical ROM (P = 0.740). One patient observed postoperative symptom of C₆ nerve root injury, which was resolved within 24 months after the surgery; meanwhile, the neurological monitoring also reflected the intraoperative stretching of the C₆ nerve root. Two cases involved postoperative cerebrospinal fluid (CSF) leakage which may have been related to laceration of dura mater.ConclusionsThis study suggested that CTDL technique could acquire satisfactory surgical outcomes for patients with multi‐segment CSS accompanied with CDH, but the surgical indications of the patients need to be selected strictly.     

The Significance of Evaluating the Femoral Head Blood Supply after Femoral Neck Fracture: A New Classification for Femoral Neck Fractures

ObjectiveTo compare a new classification with the Garden classification by exploring their relationships with vascular injury.MethodsThis retrospective study enrolled 73 patients with subcapital femoral neck fracture from July 2015 to November 2018, including 32 males and 41 females with an average age of 47.2 years. All patients were classified by the Garden classification using anteroposterior X‐ray imaging and by a new classification system based on three‐dimensional CT imaging. The blood supply of the affected femoral head in these patients was evaluated based on DSA images. Correlations between the two classifications and the degree of vascular injury were assessed.ResultsThe results of the DSA examination indicated that eight patients had no retinacular vessel injury, 20 patients had one retinacular vessel injury, 35 patients had two retinacular vessel injuries, and 10 patients had three retinacular vessel injuries. The degree of vascular injury was used to match the two fracture classifications. Forty‐nine Garden classifications (Type I‐IV: 8, 12, 23, 6, respectively, 67.12%) and 66 new classifications (Type I‐IV: 8, 20, 32, 6, respectively, 90.41%) corresponded to the degree of vascular injury (p < 0.05). The Garden classification showed moderate reliability, and the new classification showed near perfect agreement (Interobserver agreement of k = 0.564 [0.01] in Garden classification vs. Garden classification k = 0.902 [0.01] for the five observers).ConclusionsThe new classification system can accurately describe the degree of fracture displacement and judge the extent of vascular injury.     

Core Decompression Prevents Progression of Asymptomatic Type C Osteonecrosis of Femoral Head According to the Japanese Investigation Committee Classification: A Retrospective Study

ObjectiveTo evaluate whether core decompression could prevent progression of asymptomatic type C osteonecrosis of the femoral head (ONFH) according to the Japanese Investigation Committee (JIC) classification.MethodsThis retrospective cohort study included 124 hips (117 patients) with asymptomatic type C ONFH. Seventy‐one hips (67 patients) received core decompression (core decompression group) and 53 hips (50 patients) received no surgical treatment (control group). Clinical and radiological follow‐up was conducted at 6 and 12 months, then annually until 5 years. Clinical outcomes were evaluated in terms of the Oxford hip score and UCLA Activity Level rating. Radiological outcomes were evaluated using X‐ray and magnetic resonance imaging. Survival analysis was performed based on collapse of the femoral head as the first endpoint and total hip arthroplasty (THA) as the second endpoint.ResultsThere were no significant differences in clinical outcomes between the core decompression group and the control group within 2 years after surgery. Patients in the core decompression group had significantly better Oxford hip score and UCLA Activity Level from year 3 to the end of follow‐up (P < 0.05). In year 5, the absolute difference in Oxford hip score (5.3 points) exceeded the reported minimal clinically important difference (MCID, 5.2 points). In years 3–5, the absolute difference in UCLA Activity Level rating (0.95 points, 0.95 points, and 0.99 points, respectively) exceeded the reported MCID (0.92 points). By 5‐year follow‐up, significantly fewer patients in the core decompression group had experienced femoral head collapse (40.8% vs 62.3%, P = 0.011) or received THA (26.8% vs 45.3%, p = 0.022).ConclusionsCore decompression can prevent progression of asymptomatic type C ONFH according to the JIC classification, leading to better medium‐term hip function and activity levels than no surgical treatment. Core decompression is recommended for early intervention against asymptomatic type C ONFH.     

Hallux Valgus Correction Comparing Percutaneous Oblique Osteotomy and Open Chevron Osteotomy at a 2‐year Follow‐up

ObjectiveThis study aimed to compare the percutaneous oblique osteotomy (POO) and the open chevron osteotomy technique for correction of hallux valgus deformity at a 2‐year follow‐up.MethodsThis is a retrospective study of consecutive patients undergoing operative correction of hallux valgus using one of two techniques (POO vs open chevron osteotomy) from 2014 to 2018. Forty eight feet (41 patients) that underwent the POO was compared with 64 feet (58 patients) that underwent open chevron osteotomy. The hallux valgus angle (HVA), intermetatarsal angle (IMA) and American Orthopedic Foot & Ankle Society Hallux Metatarsophalangeal‐Interphalangeal scores (AOFAS‐HMI) were assessed preoperatively and postoperatively at the 1, 2‐year follow‐up. The Manchester–Oxford Foot Questionnaire (MOXFQ) were assessed preoperatively and postoperatively at the 2‐year follow‐up. The VAS score was collected preoperatively and on 2 weeks,1 year and 2‐year follow‐up.ResultsBoth groups achieved significant correction of the hallux deformity. The HVA in the POO group during the follow‐up period were 12.5 ± 2.22 and 17.9 ± 9.31, respectively, and in the open chevron group were 14.1 ± 6.78 and 14.8 ± 7.83, respectively. The IMA in the POO group during the follow‐up period were 7.61 ± 1.63 and 6.94 ± 1.53, respectively, and in the open chevron group were 6.89 ± 3.06 and 6.97 ± 2.95, respectively. Postoperative MOXFQ scores in all domains were significantly improved in both groups, however there was no significant difference in the improvement of any domain between POO and open groups at a 2‐year follow‐up. The AOFAS HMI scores in the POO group during the follow‐up period were 86.5 ± 10.7 and 85.2 ± 13.8, respectively, and in the open chevron group were 88.2 ± 10.8 and 79.5 ± 23.7, respectively. The VAS scores in the POO group during the follow‐up period were 2.00 ± 0.98, 2.00 ± 0.99 and 1.55 ± 1.11, respectively, and in the open chevron group were 5.51 ± 1.45, 2.56 ± 2.88 and 2.56 ± 2.88 respectively. The 1‐year and 2‐year follow‐up outcomes between POO and open groups showed no significant difference regarding AOFAS HMI scores and VAS scores, however the POO group showed statistically significant improvement of VAS scores in the postoperative 2 weeks (P < 0.001). There was no statistical significance between the POO and open group in terms of complications rates (8.3% vs 12.5%, P = 0.480).ConclusionThe POO technique is reliable and shows a comparable outcome to the open chevron osteotomy. However, the POO technique shows significantly less pain in the first 2 weeks after surgery.     

Surgical Treatment of Internal Fixation Failure of Femoral Peritrochanteric Fracture

ObjectiveTo investigate the factors, surgical treatment methods and clinical effect of internal fixation failure of intertrochanteric and subtrochanteric fractures.MethodsFrom June 2015 to May 2019, arthroplasty and internal fixation revision were used to treat 18 cases of internal fixation failure of intertrochanteric and subtrochanteric fractures. There were 10 males and eight females, with an average age of 67.3 years (38–92 years). The 16 cases of initial intertrochanteric fractures were classified according to AO/OTA:13 cases of A2 and 3 cases of A3, the other 2 cases were subtrochanteric fractures (Seinsheimer type IV). The internal fixation failure was treated with total hip arthroplasty (6 cases), bipolar hemiarthroplasty (4 cases), revision with proximal femoral lockingplate (4 cases) and extend intramedullary nail (4 cases).ResultsAll patients were followed up for an average of 24.7 months (range, 12 to 36 months). The average operative time was 111.4 min (range, 72 to 146 min) and the average intraoperative blood loss was 403.6 mL (range, 200 to 650 mL). The average time of fracture union was 6.9 months (range, 5 to 9 months) for cases of internal fixation revision. The operative time of the arthroplasty group was shorter than the revision group (P < 0.001), and the intraoperative blood loss of the arthroplasty group was less than the revision group (P = 0.001). The affected limb shortening of postoperative (0.21 ± 0.19 cm) was better than preoperative (2.01 ± 0.60 cm) (P < 0.001), while the limb shortening of the arthroplasty group (0.11 ± 0.21 cm) was less than the revision group (0.33 ± 0.09 cm) (P = 0.015). At the last follow‐up, all injured limbs regained walking function, and the Harris hip score was 81.3 ± 9.4 points. The Harris score of postoperative was better than preoperative (33.4 ± 5.9 points) (P < 0.001), while there were no significant differences between the arthroplasty group and the revision group at 3 months (76.5 ± 8.5 vs 71.1 ± 10.6, P = 0.249), 6 months (80.9 ± 7.9 vs 78.9 ± 12.9,P = 0.687) postoperative and the last follow‐up (80.5 ± 8.3 vs 82.3 ± 11.7, P = 0.716) respectively.ConclusionFor internal fixation failure of peritrochanteric fractures, young patients could accept internal fixation revision to restore normal anatomical structure, correct varus deformity and autograft; while elderly patients and patients with damaged femoral head could be treated with arthroplasty to restore walking function.     

Longitudinal Spinous‐Splitting Laminoplasty with Coral Bone for the Treatment of Cervical Adjacent Segment Degenerative Disease: A 5‐Year Follow‐up Study

This study was designed to analyze the causes of cervical adjacent segment degenerative disease (ASDis), evaluate the surgical outcomes of longitudinal spinous‐splitting laminoplasty with coral bone (SLAC) during cervical reoperation, and accumulate data on reoperation with SLAC in a primary hospital. Based on the inclusion and exclusion criteria, we conducted a retrospective study involving 52 patients who underwent cervical reoperation for ASDis using SLAC at the spinal surgery department of the Beijing Jishuitan Hospital from 1998 to 2014. Among them, 39 were treated with anterior cervical fusion and internal fixation during the first operation (anterior cervical corpectomy with fusion [ACCF], n = 24; anterior cervical discectomy and fusion [ACDF], n = 11; and cervical disc arthroplasty [CDA], n = 4). Outcomes were the Japanese Orthopaedic Association (JOA) score, neck disability index (NDI) score, upper limb/neck and shoulder evaluated using a visual analogue scale (VAS), and rates of ASDis. In patients who underwent an anterior cervical approach in the first instance, the incidence of ASDis was significantly higher in the C_3/4 gap than in the other gaps. In the ACCF group, the lateral radiograph of the cervical spine revealed that the distance between the anterior cervical plate and the adjacent segment disc was <5 mm in 15 (62.5%) cases and five (12.8%) cases, respectively, the internal fixation screws broke into the annulus of the adjacent segment. After the first SLAC, ASDis developed at C_2/3 and C_3/4 in four (30.8%) and eight (61.5%) cases, respectively. After reoperation, all cases were followed up for >5 (average, 6.2) years. The pre‐reoperation and last follow‐up values were as follows: mean Japanese Orthopaedic Association score, 10.2 ± 1.5 vs 15.5 ± 0.7 (P = 0.03); neck disability index, 26.2 vs 13.6 points (P = 0.01); upper‐limb visual analog scale (VAS) score, 6.1 vs 2.6 points (P = 0.04); and neck and shoulder VAS score, 6.6 vs 2.1 points (P = 0.03). SLAC is a simple technique in which the local anatomy is clearly visible and satisfactory clinical outcomes are obtained.     

Anterior Cervical Discectomy and Fusion Combined with Foraminotomy Assisted by High‐Definition 3‐Dimensional Exoscope in the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis

ObjectiveTo evaluate the outcomes of cervical spondylotic radiculopathy secondary to bony foraminal stenosis treated with anterior cervical discectomy and fusion (ACDF) combined with anterior cervical foraminotomy (ACF) assisted by High‐Definition 3‐Dimensional Exoscope.MethodsIn this retrospective study, a total of 19 consecutive patients (12 males and seven females, with an average of 49.2 years, range from 40 to 59 years) with spondylotic radiculopathy caused by bony foraminal stenosis underwent ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope in our hospital between January 2019 and December 2019 were included in this study. All patients signed the consent form before the surgery. The patient baseline information such as gender, age, body mass index (BMI), surgery time, blood loss, hospital stay, lesion segment, side, follow‐up time and postoperative complications were recorded. The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were measured and compared before surgery, 1 months and final follow‐up after surgery. The radiographic outcomes were evaluated using the C₂‐C₇ angel, disc height, foraminal height, superior diagonal distance, inferior diagonal distance, and foraminal area.ResultsThe involved levels included C₄‐C₅ (six cases), C₅‐C₆ (10 cases), C₆‐C₇ (three cases). The mean duration of the surgery, mean blood loss, mean hospital stay, and mean follow‐up were 100 ± 11.10 min, 19.4 ± 7.05 mL, 7.1 ± 0.99 days, and 12.1 ± 2.25 months, respectively. The average preoperative JOA score was 11.9 ± 1.31, then improved to 15.7 ± 0.73 (t = −13.45, P < 0.001) and 16.2 ± 0.74 (t = −14.39, P < 0.001) at 1 month after operation and at last follow‐up, respectively. The average preoperative NDI score was 27.3 ± 3.36, then decreased to 5.1 ± 1.79 (t = 20.63, P < 0.001) and 4.5 ± 1.21 (t = 25.53, P < 0.001) 1 month after operation and at last follow‐up, respectively. The average preoperative VAS score was 6.7 ± 0.93, then decreased to 2.4 ± 0.69 (t = 15.05, P < 0.001) and 1.9 ± 0.78 (t = 16.40, P < 0.001) 1 month after operation and at last follow‐up, respectively. As compared with the condition before surgery, there was a significant improvement in the C₂‐C₇ angel, disc height, foraminal height, and foraminal area (P < 0.05). None of the patients developed postoperative vascular injury, nerve injury, loosening and rupture of the internal fixation, displacement of interbody fusion cage, and pseudarthrosis.ConclusionACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope is effective and safe for the treatment of CSR caused by secondary to bony foraminal stenosis.     

Posteromedial Corner Release with the Knee in Figure‐of‐Four Position vs Conventional Position for Varus Knee Arthroplasty

ObjectiveTo introduce posteromedial corner release with the knee in the figure‐of‐four position versus the conventional position for varus knee arthroplasty.MethodsThis is a retrospective study. From March 2015 to September 2019, a series of 123 patients (139 knees) with varus knee were randomly and blindly allocated to experimental group (60 patients; 68 knees) and control group (57 patients; 65 knees). Patients in experimental group underwent posteromedial corner release with the knee in the figure‐of‐four position; and patients in control group with the knee in the conventional position. If soft tissue balance was not completely achieved or the medial gap was still tight, an additional loosening technique were used to achieve symmetric medial and lateral space in both groups. Time for soft tissue balancing was defined as the time from the start of the spacer test to the end of the balance test. Length of release was defined as the distance from the osteotomy surface of the tibial plateau to the farthest structures released. The rating system of Hospital for Special Surgery (HSS) knee score was used to evaluate the clinical results. Quantitative variables were described as mean and standard deviation, and compared by one‐way analysis of variance.ResultsThe mean age of experimental group and control group was 70.2 ± 8.7 years and 68.7 ± 6.2 years, respectively (P > 0.05). Preoperatively, the mean HSS score of the groups was 38.2 ± 11.3 and 39.1 ± 10.7, respectively (P > 0.05). The mean varus knee angle was 19.7° ± 9.3° and 19.3° ± 10.7°, respectively (P > 0.05). The mean time for soft tissue balancing was 8.4 ± 3.3 min and 11.3 ± 6.9 min in experimental and control group, respectively (P < 0.05). The mean length of releasing posteromedial corner structures was 35.5 ± 13.4 mm and 27.3 ± 9.7 mm in experimental and control group, respectively (P < 0.05). Additional special loosening techniques were performed in eight knees in experimental group and seven knees in control group. The HSS scores 5 years after surgery were 95.1 ± 16.9 and 94.8 ± 17.2 respectively (P > 0.05). No complications were found during the follow‐up time, and the clinical symptoms were observed to be significantly improved in the patients.ConclusionThe posteromedial corner can be released more extensively and thoroughly when the knee is placed in the figure‐of‐four position during varus knee arthroplasty.     

Comparison of the Wiltse Approach and Percutaneous Pedicle Screw Fixation Under O‐arm Navigation for the Treatment of Thoracolumbar Fractures

ObjectivesThe aim of this study was to evaluate the clinical outcomes of the Wiltse approach and percutaneous pedicle screw placement under O‐arm navigation for the treatment of thoracolumbar fracture.MethodsWe enrolled a total of 54 patients with neurologically intact thoracolumbar fracture who received minimally invasive treatments between October 2014 and October 2018 in this retrospective study. Among these, 28 patients (22 males and six females, with a mean age of 48.6 ± 9.6 years) were treated with pedicle screw fixation through the Wiltse approach (WPSF), and another 26 (15 males and 11 females, with a mean age of 45.7 ± 10.6 years) received percutaneous pedicle screw fixation under O‐arm navigation (OPSF). Statistical methods were used to perform a detailed comparison of clinical outcomes, radiologic findings, and complications between the two groups obtained preoperatively, postoperatively, and at last follow‐up.ResultsAll patients underwent surgery successfully and finished a follow‐up of more than 12 months. No serious complications, such as infection, blood vessel injury, or spinal cord or nerve root injury occurred. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, local Cobb angle (LCA), vertebral wedge angle (VWA), and R value were notably improved after surgery, though there was no clear discrepancy between the groups at each time point (P > 0.05). During the follow‐up period, no patients developed neurological impairment or implant‐related complications, and no patients underwent revision surgery. The WPSF group had a significantly shorter operation time than the OPSF group (68.1 ± 9.8 vs 76.1 ± 9.0 minutes, P = 0.005). Moreover, the WPSF group showed less cost of surgery than the WPSF group (48142.1 ± 1430.1 vs 59035.4 ± 1152.7 CNY, P < 0.001). There were no significant differences between the two groups in terms of the intraoperative bleeding, length of incision, or postoperative hospitalization time (P > 0.05). The accuracy of pedicle screw placement was 95.2% (160/168) in the WPSF group and 96.8% (151/156) in the OPSF group, with no significant difference between the groups (P = 0.432).ConclusionBoth WPSF and OPSF were safe and effective for the treatment of thoracolumbar fracture. Although the two groups showed favorable clinical and radiologic outcomes through to final follow‐up, we recommended the minimally invasive WPSF given its shorter operation time and lower cost of surgery.     

The effects of combined microwave ablation and open surgery for the treatment of lung cancer‐derived thoracolumbar metastases

ObjectiveTo investigate the clinical effects of microwave ablation (MWA) in addition to open surgery for the treatment of lung cancer‐derived thoracolumbar metastases.MethodsThis was a single‐institution, retrospective, cohort study. From January 2019 to December 2020, a total of 47 patients with lung cancer‐derived thoracolumbar metastases underwent posterior spinal canal decompression and fixation surgery in our hospital. Two independent surgical teams treated these patients. One group underwent open surgery combined with MWA therapy, while the other had open surgery only (control). The pre‐ and post‐operative visual analog scale (VAS) scores and the overall survival (OS) were compared between the MWA and control groups. The Frankel Grade classification was applied for the evaluation of the post‐surgical spinal cord function. Improvement was defined as an increase of at least one rank from the pre‐operative scores. Each patient was evaluated pre‐ and post‐operatively at 48 h, 1 month, and 3‐month intervals. Data on surgical‐related complications were recorded.ResultsThirty men and 17 women were included, with an average age of 57.9 ± 11.4 years (range, 26–81 years). Twenty‐eight patients underwent MWA and were in the MWA group, and 19 patients were included in the control group. Post‐operatively all patients were followed up regularly; the median follow‐up time was 12 months (range, 3–24 months), and their median OS was 14 months. Patients in the MWA group had a lower VAS score than those in the control group at the 48‐h (1.75 ± 1.01 vs 2.47 ± 0.96, P = 0.01) and 1‐month (1.79 ± 0.92 vs 2.53 ± 1.35, P = 0.048) check‐ups. At the 3‐month evaluation, the VAS score differences between the two groups were not significant (P = 0.133). After surgery, spinal cord function improvement was not significantly different between the MWA and control groups (P = 0.515). MWA therapy combined with open surgery was not associated with increased OS compared with the control group (P = 0.492).ConclusionMWA can be an effective and safe pain‐relief method but may not extend the OS of patients with lung cancer.     

Effects of Platelet‐Rich Plasma on Tendon‐Bone Healing After Anterior Cruciate Ligament Reconstruction

ObjectiveTo investigate the effect of platelet‐rich plasma on tendon‐bone healing after anterior cruciate ligament reconstruction.MethodsThis retrospective study included 85 patients (range, 18–50 years; mean age, 33.95 ± 10.53 years; male/female, 49/36) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between August 2017 and June 2019 at our institute. The participants in the study group (n = 42) were injected with platelet‐rich plasma at both ends of the tendon graft, while those in the control group (n = 43) received an injection of normal saline. Magnetic resonance imaging signal/noise quotient values of the femoral and tibial ends, knee Lysholm scores, and International Knee Documentation Committee scores were compared at 3, 6, and 12 months postoperatively.ResultsThe signal/noise quotient values of the femoral and tibial ends in both groups were higher at 6 months than at 3 and 12 months postoperatively. The signal/noise quotient values of the tibial end were significantly lower in the platelet‐rich plasma group than in the normal saline group at all follow‐up time points (P < 0.05). The signal/noise quotient values of the tibial and femoral ends in both groups were significantly different at 3, 6, and 12 months postoperatively (P < 0.05). Additionally, the signal/noise quotient values of the tibia were significantly lower than those of the femur in both groups (P < 0.05). The Lysholm and International Knee Documentation Committee scores were significantly better in the platelet‐rich plasma group than in the normal saline group only at 3 months postoperatively. No complications, such as knee joint infection or vascular and nerve injuries, occurred in any of the 85 patients. The knee flexion of all patients were more than 90°, and the straight degree was 0°. No joint stiffness was observed in all patients.ConclusionPlatelet‐rich plasma can promote tendon‐bone healing in grafts and can improve early postoperative knee joint function.     

Comparing the Bridge‐Type Zero‐Profile Anchored Spacer (ROI‐C) Interbody Fusion Cage System and Anterior Cervical Discectomy and Fusion (ACDF) with Plating and Cage System in Cervical Spondylotic Myelopathy

ObjectiveTo compare the clinical efficacy and radioactivity of the bridge‐type zero‐profile anchored spacer (ROI‐C) interbody fusion cage and anterior cervical discectomy and fusion with plating and cage system (ACDF) for cervical spondylotic myelopathy (CSM).MethodsThis is a retrospective contrastive study. We recruited 35 patients who received ROI‐C (ROI‐C group) and 34 patients who received ACDF (ACDF group), between January 2014 to January 2019, at our treatment center. The ROI‐C group comprised of 11 males and 24 females with a mean age of 61.59 ± 8.21 years (range, 51–71 years). The ACDF group comprised of 12 males and 22 females with a mean age of 60.15 ± 7.52 years (range, 52–74 years). Neck Disability Index (NDI), Japanese Orthopaedic Association score (JOA), Odom''s score, cervical Cobb angle, fusion rate, adjoining ossification, and dysphagia.ResultsA total of 69 patients met the inclusion criteria, and these patients received more than two years of follow‐up. There were significant differences in surgical duration (101 ± 22 min vs. 118 ± 29 min) and blood loss (102 ± 46 ml vs. 145 ± 58 ml) between two groups (P < 0.05). The JOA and NDI of these two groups of patients significantly improved, when compared with those before the operation (P < 0.05). Twenty‐nine of 35 patients in the ROI‐C group and 27 of 34 patients in ACDF group achieved good or excellent outcomes according to Odom''s criteria. The cervical lordosis of both two groups significantly increased, when compared with those before the operation (P < 0.05). In the ROI‐C group, the postoperative fusion rate was 85.7% at the 3‐month follow‐up and 100% at the final follow‐up. In the ACDF group, the postoperative fusion rate was 82.4% at the 3‐month follow‐up and 100% at the final follow‐up. The dysphagia incidence of the ACDF group was higher than that of the ROI‐C group postoperatively and at the one month after surgery (P < 0.05), but no significant difference was found in the incidence of dysphagia at final follow‐up (P > 0.05).ConclusionBoth ROI‐C and ACDF achieved good therapeutic effects. However, ROI‐C can reduce the operation time and postoperative complications.