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.     

Risk Factors for Tracheostomy after Traumatic Cervical Spinal Cord Injury: A 10‐Year Study of 456 Patients

ObjectivesTo explore the difference between tracheostomy and non‐tracheostomy and identify the risk factors associated with the need for tracheostomy after traumatic cervical spinal cord injury (TCSCI).MethodsThe demographic and injury characteristics of 456 TCSCI patients, treated in the Xinqiao Hospital from 2010 to 2019, were retrospective analyzed. Patients were divided into the tracheostomy group (n = 63) and the non‐tracheostomy group (n = 393). Variables included were age, gender,smoking history, mechanism of injury, concomitant injury, American Spinal Injury Association (ASIA) Impairment Scale, the neurological level of injury, Cervical Spine Injury Severity Score (CSISS), surgery, and length of stay in ICU and hospital. SPSS 25.0 (SPSS, Chicago, IL) was used for statistical analysis and ROC curve drawing. Chi‐square analysis was applied to find out the difference of variables between the tracheostomy and non‐tracheostomy groups. Univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA) were used to identify risk factors for tracheostomy. The area under the ROC curve (AUC) was used to evaluate the performance of these risk factors.ResultsOf 456 patients who met the inclusion criteria, 63 (13.8%) underwent tracheostomy. There were differences in age (χ² = 6.615, P = 0.032), mechanism of injury (χ² = 9.87, P = 0.036), concomitant injury (χ² = 6.131, P = 0.013),ASIA Impairment Scale (χ² = 123.08, P < 0.01), the neurological level of injury (χ² = 34.74, P < 0.01), and CSISS (χ² = 19.612, P < 0.01) between the tracheostomy and non‐tracheostomy groups. Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as potential risk factors for tracheostomy by ULRA. Smoking history (OR = 2.960, 95% CI: 1.524–5.750, P = 0.001), CSISS ≥ 7 (OR = 4.599, 95% CI: 2.328–9.085, P = 0.000), AIS A (OR = 14.213, 95% CI: 6.720–30.060, P = 0.000) and NLI ≥ C5 (OR = 8.312, 95% CI: 1.935–35.711, P = 0.004) as risk factors for tracheostomy were determined by MLRA. The AUC for the risk factors of tracheostomy after TCSCI was 0.858 (95% CI: 0.810–0.907).ConclusionsSmoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as risk factors needing of tracheostomy in patients with TCSCI. These risk factors may be important to assist the clinical decision of tracheostomy.     

Potential Link between Ossification of Nuchal Ligament and the Risk of Cervical Ossification of Posterior Longitudinal Ligament: Evidence and Clinical Implication from a Meta‐Analysis of 8429 Participants

ObjectiveThe aim of the present paper was to evaluate the strength and the magnitude of the association between ossification of the nuchal ligament (ONL) and the risk of cervical ossification of the posterior longitudinal ligament (COPLL) and to determine whether there is a direct association or whether COPLL is a consequence of shared risk factors.MethodsMedline, Web of Science, Cochrane Library, and Embase databases were searched for studies evaluating the association of COPLL‐ONL published before July 2020. Eligible studies were selected based on certain inclusion and exclusion criteria. Two investigators independently conducted the quality assessment and extracted the data, including study designs, countries, patients'' age, gender, body mass index (BMI), and the risk of COPLL between individuals with and without ONL. A meta‐analysis of homogenous data, a sensitivity analysis, a publication bias assessment, and a subgroup analysis were performed using Stata 12.0 software.ResultsA total of 10 cohort studies involving 8429 participants were incorporated into this analysis. Pooled results demonstrated a statistically significant association between the presence of ONL and the increased COPLL risk (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.68–5.52, P < 0.001). Furthermore, subgroup analyses indicated that this association was independent of study design (6.36‐fold in case‐control studies vs 3.22‐fold in cross‐sectional studies), sex (6.33‐fold in male–female ratio >2.5 vs 2.91‐fold in male–female ratio <2.5), age (4.28‐fold in age ≥55 years vs 3.45‐fold in age <55 years), and BMI (3.88‐fold in BMI ≥ 25 kg/m² vs 2.43‐fold in BMI < 25 kg/m²), which also indicated that obese, older male patients with ONL had a higher risk of OPLL. Moreover, combined two articles revealed that patients with larger‐type ONL had a significantly higher risk of long‐segment COPLL compared with controls (OR 1.86; 95% CI 1.41–2.47, P < 0.001).ConclusionThis is the first meta‐analysis to demonstrate a strong and steady association between ONL and higher risk of COPLL. This association was independent of sex, age, and BMI. Considering that ONL is generally asymptomatic and easily detectable on X‐ray, our findings implied that ONL might serve as an early warning sign of the onset of COPLL and provide clinicians an opportunity for early detection and early intervention.     

Surgery or Conservative Treatment of Forearm in Patients Diagnosed with Pediatric Floating Elbow? Retrospective Analysis of 60 Consecutive Cases

BackgroundThe coexistence of supracondylar humerus fracture and forearm fracture is a rare trauma (3–13%) and it is called floating elbow. The aim of this study is to clinically compare the treatment outcomes of the patients diagnosed with floating elbow who underwent surgical treatment and who were followed up forearm with immobilization with splint.Materials and MethodsWhen scanned retrospectively, 60 patients who were treated with the diagnosis of floating elbow due to traumatic causes and followed up for at least 1 year were included in our study. Surgical treatment was performed on 42 patients for forearm fracture. Eighteen patients followed up with immobilization with a long arm splint. The results were evaluated according to the criteria modified by Templeton and Graham, in comparison with the patient’s intact side.ResultsIn the patients whose forearms were followed up conservatively, the mean age was 5.67 ± 2.25 years, and the mean follow-up period was 62.17 ± 45.91 months. In the patients who underwent surgery for the forearm, the mean age was 8.79 ± 2.01 years, and the mean follow-up was 47.14 ± 34.25 months. Eighteen patients whose forearms followed up conservatively, 12 had excellent and good clinical results and 6 had poor and moderate clinical results. Excellent and good clinical results in 27 patients who underwent surgical treatment for their forearms, moderate and poor clinical results obtained in 15 of them. There was no significant difference between the two groups (p = 0.357).ConclusionsIn conclusion, satisfactory clinical and radiological outcomes can be obtained with immobilization of the forearm fracture with splint, if acceptable reduction can be provided for the forearm following fixation of the supracondylar humerus fracture with the K-wire for treatment of floating elbow injury.     

Personality Traits Affect the Cost‐Effectiveness of Total Knee Arthroplasty

ObjectiveTo assess the clinical benefit and compare the cost‐effectiveness of total knee arthroplasty (TKA) in patients with different personality traits.MethodsThe present study was retrospectively conducted from January 2017 to May 2018. A total of 232 patients between 46 and 71 years old who underwent unilateral, primary TKA with the diagnosis of knee osteoarthritis were interviewed. Three types of data were required to compare the cost‐effectiveness differences among groups: personality traits, postoperative clinical outcomes about health‐related quality of life, and costs associated with TKA. Personality was assessed using the Eysenck Personality Questionnaire, functional outcome was assessed through the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, and costs were evaluated. Besides, the marginal cost‐effectiveness ratio (MCER) as the primary outcome, which relates the direct costs to the associated patient benefit as assessed by the clinical endpoint ($/quality‐adjusted life years [QALY]), was compared among different personality traits. All information for this study was acquired by directly interviewing the patients and reviewing the medical computer records at our hospital.ResultsTwo hundred and eleven patients completed the final analysis with an average of 24.6 months follow‐up postoperatively. The choleric group, sanguine group, melancholic group, and phlegmatic group has 41, 70, 46, and 54 patients, respectively. A statistically significant difference in MECR, QALYs, and postoperative WOMAC existed among different personality traits (all P < 0.05). There was no significant difference in mean age (P = 0.588), body mass index (BMI) (P = 0.790), smoking (P = 0.934), heavy drinking (P = 0.994), chronic comorbidities (all P > 0.05), preoperative albumin <3.5 g/dL (P = 0.991), and American Society of Anaesthesiologists (ASA) score (P = 0.687) among personality traits. More women tend to be melancholic in comparison to other personality traits (P = 0.016). Melancholic patients attested inferiority of TKA compared with other personality traits, who would pay for the same QALYs at the highest costs (P < 0.05). By contrast, sanguine patients have a more cost‐effective TKA than other personality traits, as they pay the least money for the same QALYs (P < 0.05). Although phlegmatic and choleric patients seemingly have moderate gains from TKA, in general, the extroversion (measured by the extroversion subscale) and stability (measured by the neuroticism subscale) displayed more pleasurable QALYs in comparison with introversion and instability (P < 0.05). Sensitivity analysis showed that the results mentioned above appeared not to be sensitive when varying key parameters (prosthesis survival and life expectancy) in a one‐way sensitivity analysis. Sanguine and melancholic patients still have the lowest and highest MCER in comparison with choleric and phlegmatic traits (P < 0.05). The multivariate logistic regression showed that RA (adjusted OR = 1.3, 95% CI = 1.2–1.4, P < 0.01), ASA Class I–II (adjusted OR = 0.9, 95% CI = 0.8–1.0, P < 0.001), sanguine (adjusted OR = 0.8, 95% CI = 0.7–0.9, P < 0.001) and melancholic (adjusted OR = 1.2, 95% CI = 1.1–1.3, P < 0.001) were significantly associated with MCER.ConclusionsBefore surgery, screening the melancholic patients would significantly reduce the economic burden, avoid unnecessary suffering, and shorten the recovery period.     

Comparison of Arthroscopic Debridement and Repair in the Treatment of Ellman Grade II Bursal‐side Partial‐thickness Rotator Cuff Tears: A Prospective Randomized Controlled Trial

ObjectiveTo compare the effects of arthroscopic debridement and repair in treating Ellman grade II bursal‐side partial‐thickness rotator cuff tears.MethodsThis is a single‐center, prospective, randomized controlled trial. From September 2017 to April 2019, 78 patients underwent arthroscopic debridement (35 patients) or repair (43 patients) due to Ellman grade II bursal‐side partial‐thickness rotator cuff tears. Twenty‐six men and 52 women were included in the study, with an average age of 56.31 years (range, 42 to 74 years). After the acromioplasty was formed, the debridement group only performed stump refreshing and surrounding soft tissue cleaning, while the repair group converted the partial tears into full‐thickness tears and then sutured them by single row or suture bridge technique. The visual analogue scale (VAS), Constant‐Murley shoulder (CMS), American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) scores were used to evaluate clinical results preoperatively and at 6, 12, and 18 months postoperatively. Magnetic resonance imaging was used to assess the integrity of the rotator cuff, muscle atrophy, and fat infiltration.ResultsA total of 85 patients met the inclusion criteria and were randomly divided into the debridement group (41 patients) and the repair group (43 patients). During the 18‐month follow‐up period, a total of seven patients were lost to follow‐up. The functional scores of both groups were significantly improved: the VAS score decreased 5.06 and 4.63 in the debridement group (5.77 preoperative to 0.71 postoperative) and the repair group (5.49 to 0.86) (P < 0.05). Moreover, the CMS, ASES, UCLA scores increased 51.63, 58.24, 20.57 in debridement group (39.46 to 91.09, 34.14 to 92.38, 13.29 to 33.86), and increased 48.14, 60.53, 20.93 in repair group (43.63 to 91.77, 33.10 to 93.63, 12.58 to 33.51) (P < 0.05). No significant differences were found in functional scores between the two groups at 6, 12, and 18 months postoperatively (P > 0.05). The magnetic resonance imaging showed no re‐tears, and no difference was observed in the degree of muscle atrophy and fat infiltration between the two groups (P > 0.05). Except for four cases of shoulder stiffness, no other obvious surgery‐related complications were found.ConclusionFor Ellman grade II bursal‐side partial‐thickness rotator cuff tears, both the debridement and repair groups achieved good results during 18‐month follow‐ups, with no difference between the two groups.     

Subclinical Hypothyroidism Affects Postoperative Outcome of Patients Undergoing Total Knee Arthroplasty

ObjectiveThe aim of this study was to investigate whether subclinical hypothyroidism could increase the risk of postoperative complications in patients undergoing primary total knee arthroplasty (TKA).MethodsA prospective case‐control study of 796 patients undergoing primary TKA between January 2015 and January 2020 was performed. A total of 700 patients (87.9%) were female and the average age of included patients was 65.0 years, with a standard deviation of 5.6. The participants who had subclinical hypothyroidism were referred to as the case group, while those without abnormal thyrotropin (TSH) were included in the control group (matched for age and gender). The fasting plasma levels of TSH were tested in the morning in all patients. The diagnosis of subclinical hypothyroidism was completed by a senior endocrinologist based on laboratory tests; namely, a serum TSH ≥ 5 mu/L and normal free thyroxine (FT4). Subclinical hypothyroidism was further described as mild (TSH < 10 mu/L) or severe (TSH ≥ 10 mu/L). The incidence of 90‐day postoperative complications was compared between two cohorts. Logistic regression analysis was used for the risk factors of 90‐day postoperative complications following TKA.ResultsA total of 398 patients had a diagnosis of subclinical hypothyroidism. Among them, 275 cases (69.1%) were described as mild (79 patients [19.8%] with low FT4 and 196 patients [49.2%] with normal FT4 in the repeated test) and 123 cases (30.9%) as severe subclinical hypothyroidism. Of the 196 patients (49.2%) with mild subclinical hypothyroidism and normal FT4, 63 patients (15.8%) had symptoms before surgery. Patients were followed up for an average duration of 25.4 months (6 to 43 months). A total of 265 patients (66.6%) received preoperative treatment for subclinical hypothyroidism, with an average therapy time of 9.2 months. There were 162 patients (40.7%) with positive autoantibodies to thyroid peroxidase (anti‐TPO). There were no statistically significant differences in baseline data between cohorts (all P > 0.05). As for the cumulative 90‐day outcomes, subclinical hypothyroidism increased the incidences of both medical and surgical complications following primary TKA compared to those without this condition (11.6% vs 7.2%, OR = 1.55, 95% confidence interval [CI] = 1.47–1.62, P < 0.05). Subclinical hypothyroidism caused patients to suffer increased total incidence of readmission within the first 90 days after discharge when compared to those without this condition (20.61% vs 14.15%, OR = 1.45, 95% CI = 1.41–1.49, P < 0.001). Controlling for preoperative and intraoperative variables, the patients with TSH ≥ 10 mu/L and positive anti‐TPO and those without corrected subclinical hypothyroid and thyroid hormone supplementation were more likely to experience postoperative complications within 90 days of TKA.ConclusionSubclinical hypothyroidism might increase the risk of postoperative complications within 90 days of TKA, especially for the patients with TSH ≥ 10 mu/L and positive anti‐TPO and those without corrected subclinical hypothyroid and thyroid hormone supplementation.     

Knee Scores of Patients with Non‐Lateral Compartmental Knee Osteoarthritis Undergoing Mobile,Fixed‐Bearing Unicompartmental Knee and Total Knee Arthroplasties: A Randomized Controlled Trial

ObjectiveTo evaluate knee scores and clinical efficacies of patients with non‐lateral unicompartmental knee osteoarthritis (OA) who randomly underwent mobile‐bearing (MB) unicompartmental knee arthroplasty (UKA), fixed‐bearing (FB) UKA, and total knee arthroplasty (TKA).MethodsFrom September 2015 to February 2017, a prospective, randomized, parallel, single‐center trial of 180 patients (78 males and 102 females; 63.3 ± 6.9 years) with non‐lateral compartmental knee OA was performed in the first author‐affiliated hospital. The patients were randomly divided into three groups (each group included 60 patients) and received medial cemented Oxford phase 3 MB UKA, medial cemented Link FB UKA, or cemented DePuy Sigma PFC TKA, respectively. A similar perioperative management and fast‐track surgery program was carried out for all patients. The knee scores at 3‐year follow‐up after operation and clinical efficacies of these three groups of patients were recorded, investigated, and compared.ResultsPrimarily, compared to the TKA group, the UKA groups (MB UKA and FB UKA) had shorter operative time (median 63.2 < 67.1 min), less bleeding (8.6 < 30.0 mL), earlier resumption of walking without crutches (3.0 < 8.0 days) and walking up and down the stairs (5.0 < 10.0 days) (P < 0.001), higher FJS scores (78.0 > 74.5) (P = 0.007), better results in all knee scores (except VAS and KSS function scores) (P < 0.05), and a larger maximum flexion angle of the knee at the 3‐year follow‐up (123.0° > 96.0°) (P = 0.001). Secondarily, compared to the TKA group, the MB UKA group showed better results in the Western Ontario and McMaster Universities index (WOMAC) stiffness (83.6 > 79.6), WOMAC total (86.3 > 83.2), Oxford knee score (OKS) (20.0 < 23.0), Forgotten Joint Score (FJS) (78.5 > 74.5), and a larger maximum flexion angle of the knee (123.0 > 96.0) (P < 0.05). Moreover, the FB UKA group showed higher Hospital for Special Surgery Knee Score (HSS) (91.0 > 88.5), WOMAC stiffness (84.3 > 79.6), WOMAC function (85.2 > 81.7), WOMAC total scores (87.6 > 83.2), and a larger maximum flexion angle of the knee (119.0° > 96.0°) than the TKA group (P < 0.05). Overall, there was no significant difference in all knee scores and maximum flexion angles of the knee for the MB UKA and FB UKA groups (P > 0.05). There was one case with original bearing dislocation in MB UKA group. One patient with displacement of the femoral component caused by a fall injury, and another patient, who lost his life in a car accident, were involved in the FB UKA group. There was an infection case and an intermuscular vein thrombosis case in TKA group.ConclusionUKA showed more advantages than TKA; however, there was no significant difference between the MB UKA and FB UKA groups for treatment of non‐lateral compartmental knee OA.     

Correlation of Acetabular Anteversion and Thoracic Kyphosis Postoperatively with Proximal Junctional Failure in Adult Spinal Deformity Fused to Pelvis

ObjectivesTo investigate whether the immediate thoracic kyphosis (TK) and acetabular anteversion (AA) postoperatively are correlated with proximal junctional failure (PJF) in adult spinal deformity (ASD) patients underwent surgical treatment.MethodsThis is a retrospective study. Following institutional ethics approval, a total of 57 patients (49 Female, eight Male) with ASD underwent surgery fused to sacroiliac bone (S1, S2, or ilium) from March 2014 to January 2019 were included. All of those patients were followed up for at least 2 years. Demographic, radiographic and surgical data were recorded. The maximum range of flexion motion (F‐ROM) and extension motion (E‐ROM) actively of hip joints was measured and recorded at pre‐ and postoperation. The sum of F‐ROM and E‐ROM was defined as the range of hip motion (H‐ROM). Receiver operating characteristic (ROC) curve analysis was used to obtain the cut off value of parameters for PJF. A Kaplan–Meier curve and log‐rank test were used to analyze the differences in PJF‐free survival.ResultsIn all, 14 patients developed PJF during follow‐up. Comparisons between patients with and without PJF showed significant differences in immediate TK (P < 0.001) and AA (P = 0.027) postoperatively. ROC curve analysis determined an optimal threshold of 13° for immediate AA postoperatively (sensitivity = 74.3%, specificity = 85.7%, area under the ROC curve [AUC] = 0.806, 95% CI [0.686–0.926]). Nineteen patients with post‐AA ≤13° were assigned into the observational group, and 38 patients with post‐AA >13° were being as the control group. Patients in the observational group had smaller H‐ROM (P = 0.016) and F‐ROM (P < 0.001), but much larger E‐ROM (P < 0.001). There were 10 patients showing PJF in the observational group and four in the control group (10/9 vs 4/34, P < 0.001). PJF‐free survival time significantly decreased in the observational group (P = 0.001, log‐rank test). Furthermore, patients in the observational group had much larger TK (post‐TK, P = 0.015). The optimal threshold for post‐TK (sensitivity = 85.7%, specificity = 76.7%; AUC = 0.823, 95% CI [0.672–0.974]) was 28.1° after the ROC curve was analyzed. In the observational group, those patients with post‐TK ≥28.1° had significantly higher incidence of PJF (9/2 vs 1/7, P < 0.001) than those with post‐TK < 28.1°. Moreover, PJF‐free survival time in those patients significantly decreased (P = 0.001, log‐rank test).ConclusionsASD patients with acetabular anteversion of ≤13° at early postoperation may suffer significantly restricted hip motion and much higher incidence of PJF during follow‐up, moreover, in those patients, postoperative TK ≥28.1° would be a significant risk factor for PJF developing.     

What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

BackgroundTerrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation.Questions/purposes(1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries?MethodsBetween January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow.ResultsOf the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]).ConclusionThe reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options.Level of EvidenceLevel III, therapeutic study.     

Comparison of Tri‐Lock Bone Preservation Stem and the Conventional Standard Corail Stem in Primary Total Hip Arthroplasty

ObjectiveTo compare the clinical and radiographic outcomes between the Tri‐Lock Bone Preservation Stem (BPS) and the conventional standard Corail stem in primary total hip arthroplasty (THA).MethodsFrom March 2012 to May 2014, we retrospectively reviewed 84 patients (104 hips) who received Tri‐Lock (BPS) and 84 patients (115 hips) who received conventional standard Corail stem in THA. Their mean ages were 53.12 ± 2.32 years and 52.00 ± 2.11 years, respectively. The clinical outcomes were assessed by Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Pain Visual Analogue Scale (VAS) and Harris Hip Score (HHS). The radiological outcomes were evaluated by the radiological examination. Accordingly, Intraoperative and postoperative complications were observed as well.ResultsThe mean follow‐up time was 48.23 ± 2.91 months in the Tri‐Lock (BPS) group and 49.11 ± 2.11 months in the Corail group, respectively. The bleeding volumes in two groups were comparable (169.22 ± 58.11 mL vs 179.30 ± 59.14 mL, P = 0.003), with more bleeding volume in Corail group patients, while no statistically significance with respect to operation time was observed (65.41 ± 6.24 min vs 63.99 ± 6.33 min, P = 0.567). The rates of intraoperative fracture was 8% for the Corail group while 1% for the Tri‐Lock (BPS) group (8% vs 1%, P = 0.030). At final follow‐up, no statistical differences in regard to HHS, WOMAC, and Pain VAS were revealed between the two groups (P > 0.05). The rate of thigh pain was higher in Corail group than in Tri‐lock (BPS) group (5% vs 0%, P = 0.043). However, incidence of stress shielding in grade 1 was higher in Tri‐Lock (BPS) than in the Corail group (76% vs 23%, P < 0.01), while those in grade 2 and 3 were lower compared to the Corail stem (15% vs 28%, P < 0.01; 9% vs 16%, P = 0.008, respectively). Intriguingly, other assessments in relation to radiographic outcomes and postoperative complications were not comparable between the two groups. The Kaplan–Meier survival rate (revision surgery performed for any reason was defined as the end point) was similar between the two groups (P = 0.57), with 98.8% (95% confidence interval, 92.3%–100%) in Tri‐lock (BPS) group and 97.6% (95% confidence interval, 94.6%–100%) in Corail group.ConclusionsThe Tri‐Lock (BPS) has similar clinic performances compared to the Corail stem. Furthermore, the Tri‐lock (BPS) stem has some advantages in achieving lower incidence of thigh pain, stress shielding and intra‐operative fracture. Therefore, we recommend the Tri‐lock (BPS) stem as a good alternative in primary total hip arthroplasty, especially taking into account patient factors, including bone deficiency and convenience of extraction of the stem in hip revision.     

Hypotensive Anesthesia Combined with Tranexamic Acid Reduces Perioperative Blood Loss in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Cohort Study

ObjectiveTo assess the efficacy and safety of hypotensive anesthesia (HA) combined with tranexamic acid (TXA) for reducing perioperative blood loss in simultaneous bilateral total hip arthroplasty (SBTHA).MethodsIn this retrospective cohort study, a total of 183 eligible patients (15 females and 168 males, 44.01 ± 9.29 years old) who underwent SBTHA from January 2015 to September 2020 at our medical center were enrolled for analysis. Fifty‐nine patients received standard general anesthesia (Std‐GA group), the other 85 and 39 patients received HA with an intraoperative mean arterial pressure between 70 and 80 mmHg (70–80 HA group) and below 70 mmHg (<70 HA group), respectively. TXA was administrated to all patients. Perioperative blood loss (total, dominant, and hidden), transfusion rate and volume, hemoglobin and hematocrit reduction, duration of operation and anesthesia, length of hospitalization, range of hip motion as well as postoperative complications were collected from hospital''s electronic records and compared between groups.ResultsAll patients were followed for more than 3 months. Total blood loss in the two HA groups (1390.25 ± 595.67 ml and 1377.74 ± 423.46 ml, respectively) was significantly reduced compared with that in Std‐GA group (1850.83 ± 800.73 ml, P < 0.001). Both dominant and hidden blood loss were dramatically decreased when HA was applied (both P < 0.001). Accordingly, the transfusion rate along with volume in 70–80 HA group (14.1%, 425.00 ± 128.81 ml) and <70 HA group (12.8%, 340.00 ± 134.16 ml) were reduced in comparison with those in Std‐GA group (37.3%, 690.91 ± 370.21ml; P = 0.001 and P = 0.014, respectively). The maximal hemoglobin and hematocrit reduction in both HA groups were significantly less than those in Std‐GA group (both P < 0.001). Of note, 70–80 and <70 HA groups exhibited comparable efficacy with no significant differences between them. Besides, significant difference in duration of surgery was found among groups (P = 0.044 and P < 0.001), while no differences in anesthesia time and postoperative range of hip motion were observed. Regarding complications, the incidence of both acute kidney injury and postoperative hypotension in <70 HA group was significantly higher than that in 70–80 HA and Std‐GA groups (P = 0.014 and P < 0.001). Incidence of acute myocardial injury was similar among groups (P = 0.099) and no other severe complications or mortality were recorded.ConclusionThe combination of HA with a mean arterial pressure (MAP) of 70–80 mmHg and TXA could significantly reduce blood loss and transfusion during SBTHA, in addition to shortening operation time and length of hospitalization, and with no increase in complications.     

Low Grip Strength Associated with Clinical Outcomes after Total Hip Arthroplasty ‐ A Prospective Case–Control Study

ObjectiveTo assess whether low grip strength (GS) is associated with clinical outcomes after total hip arthroplasty (THA).MethodsA prospective case–control study was designed to assess 231 cases of primary THA between January 1, 2015 to May 1, 2018, at an urban tertiary care hospital. Patients were placed into two cohorts based on preoperative GS levels. Low GS in the present study was defined as GS lower than 26 kg for men and 16 kg for women in the dominant hand. Baseline data were prospectively collected and included patient demographics (age, sex, body mass index [BMI]), the surgeon''s diagnoses, medical history, length of stay, and American Society of Anaesthesiologists'' (ASA) score. Clinical outcomes included surgery‐ and prosthesis‐related variables. The Harris hip score (HHS) and the Short Form Health Survey (SF‐12) were completed at the baseline visit and at 1 and 2 years postoperatively in the outpatient department to assess the hip''s function and quality of life. Differences in baseline data, length of study (LOS), 90‐day postoperative complications, and hospital readmissions were compared. Besides, the correlations between GS and Harris hip score (HHS) and Short Form score (SF‐12) were tested.ResultsA total of 202 participants have completed records for analysis finally. The patients were followed up for an average of 24.8 months postoperatively (24–26 months). Eighty‐two patients (40.6%) had low GS before THA. Patients with low GS were more likely to be female, older, fracture of femoral head or neck as the primary cause, albumin <3.5 g/dL, and have a lower BMI, higher ASA score, increased rates of the pressure sore, blood transfusion, and LOS compared to normal GS (all P < 0.05). Also, patients in the low GS cohort showed a statistically significant increased unplanned hospital readmissions and decreased discharge home compared to normal GS (both P < 0.05). There was an increasing rate of complications between the two cohorts, for cardiac complications, pressure sore after THA, respiratory complications, urinary tract infection, stroke, and DVT (all P < 0.05). A partial correlation test by controlling medical comorbidities and demographic factors was used to determine the correlation between GS and HHS. There was a significant correlation between them (r = −0.673; P = 0.002). A similar condition was detected in the correlation between GS and SF‐12 (r = 0.645; P = 0.001).ConclusionsClinicians should be encouraged to include GS assessment in their evaluation of patients who planned to undergo THA in order to optimize the treatment of high‐risk individuals.     

Non‐Anatomical Arthroscopic All‐Inside Repair of Medial Meniscus Posterior Root Tear to Posterior Cruciate Ligament for Patients with Normal Lower Limb Alignment

ObjectiveTo describe a non‐anatomical arthroscopic all‐inside repair of medial meniscus posterior root tear (MMPRT) to posterior cruciate ligament (PCL) technique for patients with normal lower limb alignment and to evaluate the short‐term clinical and radiologic outcomes.MethodsMMPRT directly to PCL was repaired with all‐inside horizontal mattress suturing technique rather than by the transtibial pullout suture technique or anchor suturing repair technique in 20 Laparade Type II MMPRT patients with normal lower limb alignment during 2018–2019. The clinical and radiological outcomes were evaluated retrospectively for at least 2 years follow‐up. The VAS score, Lysholm score, Tegner activity score were evaluated preoperatively and at the final follow‐up. The status of the medial meniscus posterior root were assessed on magnetic resonance imaging (MRI) preoperatively and at the final follow‐up.ResultsTwenty patients (mean age 54.5 ± 19.5 years) were included in the present study. The mean follow‐up duration was 32.5 ± 5.8 months. The VAS score was significantly decreased from preoperative 6.5 ± 1.5 to 2.1 ± 1.4 at the final follow‐up (P < 0.01). The mean Lysholm score was significantly improved from 43.7 ± 10.9 preoperatively to 85.7 ± 10.8 (P < 0.01). The median Tegner activity score was improved from 1.0 (range 1–4) to 3.0 (range 2–4, P < 0.01). On MRI, a total of 12 cases (60%) had complete healing, while eight cases (40%) had partial healing.ConclusionNon‐anatomical arthroscopic all‐inside repair of MMPRT to PCL may yield beneficial clinical outcomes and a higher rate of clinical healing in Type II MMPRT patients with normal lower limb alignment. It is an easy and reliable alternative technique to the transtibial pullout suture or anchor suture repair technique.     

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.     

Management of Locked Posterior Shoulder Dislocation with Reverse Hill–Sachs Lesions via Anatomical Reconstructions

ObjectiveTo evaluate the outcomes of locked posterior shoulder dislocation with reverse Hill–Sachs lesions in patients treated with anatomical reconstructions.MethodsPatients who were treated at our institution between January 2016 and June 2020 were retrospectively reviewed. The demographics of the patients including gender, age, occupation, and dominant arm were recorded. Eleven cases from 10 patients qualified in this study. Nine males and one female were included. The mean age of the patients was 44.8 years (range, 33–54 years). Mechanism of injury, duration between injuries and definitive diagnosis, misdiagnosis, size of humeral head impaction, treatment maneuver, and details of operation performed were reviewed. Plain radiographs and computed tomography (CT) scan were taken to determine the size of defects preoperatively and fracture healing during follow‐up. During surgery, the deltopectoral approach was employed. Anatomical reconstruction procedure including reduction, disimpaction, bone grafting, and fixation were sequentially performed. Either cancellous autograft from iliac crest or allograft were used and the fractures were anatomically reduced and stabilized by screws or plates. Visual Analog Scale (VAS) and Constant–Murley score were recorded to determine the functional outcomes preoperatively, at 3 months and 6 months postoperatively, and at the last follow‐up. The range of motion in forward flexion was recorded at 6 months follow‐up postoperatively.ResultsCauses of injuries included epileptic seizure in four cases, fall in three cases, and road traffic accident in three cases. Misdiagnoses occurred in five out of 10 patients. The mean time between injury and definitive treatment among those misdiagnosed was 112 days. The mean size of the impacted reverse Hill–Sachs lesions was 33.95% (range, 19.1%–42.6%). All patients received surgical management with anatomical reconstruction approach, including open reduction, disimpaction, bone grafting, and internal fixation. The mean amount of bleeding during operation was 450 mL. The mean follow‐up period was 22.6 months. Fracture healing was observed by 8 weeks in all cases postoperatively and evidence of bone grafting could not be further detected on CT scan at 6 month during follow‐up. VAS was significantly lower at the last follow‐up (0.68 ± 0.21) in comparison to preoperative scores (4.96 ± 0.97) (P < 0.05). Constant–Murley was improved significantly at the last follow‐up (91.7 ± 8.3) in comparison to that preoperatively (40.6 ± 10.3) (P < 0.05). The mean range of motion in forward flexion was 38.25° ± 9.36° preoperatively and significantly improved to 162.48° ± 12.68° at 6‐month follow‐up (P < 0.05).ConclusionThe anatomical reconstruction procedure by open reduction and bone augmentation for the treatment of locked posterior shoulder dislocation with reverse Hill–Sachs lesion was promising in both fracture healing and functional outcomes.     

Changes in Serum Prealbumin and Incision Complications Following Spinal Tuberculosis Surgery: A Preliminary Study

ObjectivesTo explore the trend of changes in the serum prealbumin (PA) level in patients with spinal tuberculosis during the perioperative period and its relationship with postoperative incision complications.MethodsA retrospective study was performed by enrolling 162 patients (82 men and 80 women) with spinal tuberculosis who had been admitted to the Tianjin Haihe Hospital from June 2013 to June 2017. The included patients were then assigned to the elderly group (≥65 years of age, n = 35) and the non‐elderly group (<65 years of age, n = 127). The chemotherapy regimen was 3HREZ/9HRE, in combination with nutritional support for 3–4 weeks, as well as one‐stage debridement and (or) bone graft fusion and internal fixation. The serum PA levels of patients with spinal tuberculosis at admission, prior to surgery, and at 2 and 4 weeks after surgery were collected, and incision healing and sinus formation were observed for 3 months. Changes in serum PA levels of all patients at different time points were observed using one‐way analysis of variance. Pairwise comparison at different time points was performed using the least significant difference method and comparison of serum PA levels between different groups at the same time points was subjected to t‐test. The χ²‐test was used for comparison of the incidence of incision complications between different groups and between different subgroups based on different PA levels.ResultsThere was a gradual increased trend in the PA level from admission to 4 weeks after surgery in all patients [(0.14 ± 0.03) g/L < (0.16 ± 0.04)g/L < (0.22 ± 0.04) g/L < (0.25 ± 0.04) g/L]. The increase in the non‐elderly group was higher than that in the elderly group (P < 0.01). Furthermore, the incidence of incision complications in the elderly group was higher than in the non‐elderly group (14.29% > 1.78%, P < 0.01). The serum PA level was graded in accordance with NRS2002. There were 88 patients with preoperative grade 0–1 serum PA level (≥0.16g/L) who had no incision complications. The incidence of incision complications in patients with grade 3 serum PA level (<0.10 g/L, 9 patients) was higher than in patients with grade 2 (0.100–0.159 g/L, 66 patients) (44.44% > 6.06%, P < 0.01).ConclusionChanges in serum PA level in patients with spinal tuberculosis during the perioperative period are consistent with the trend of inflammation control and nutrition improvement, and are correlated with the incidence of incision complications after surgery. The relationship between the changes and the timing of surgery is worthy of future research.     

Risk factors for heel pressure injury in cardiovascular intensive care unit patients

This study analyzed the risk factors for heel pressure injury in cardiovascular intensive care unit patients with the aim of laying the groundwork for preventive nursing interventions. We conducted a retrospective case‐control study of 92 patients who were admitted to the cardiovascular surgical or medical intensive care unit of a university hospital in South Korea between January and December 2017. Of these patients, 31 and 61 were included to the heel pressure injury group and the non‐heel pressure injury group, respectively. Data on their demographic, disease‐related, and intensive care unit treatment characteristics, as well as the degree of pressure injury, were collected from the hospital''s electronic medical records using a standardized form. Cardiac surgery (P < .001), operation time (P = .001), use of a mechanical ventilator (P < .001), use of vasoconstrictors (P < .001), use of sedative drugs (P < .001), and extracorporeal membrane oxygenation treatment (P < .001) were identified as significant risk factors for heel pressure injury. A total of 22 patients (71%) from the heel pressure injury group developed deep tissue injury, and 16 patients (51.6%) who received extracorporeal membrane oxygenation treatment developed heel pressure injury.     

Adverse Tissue Reactions and Metal Ion Behavior After Small‐Head Metasul Hip Arthroplasty: A Long‐Term Follow‐Up Study

ObjectiveTo investigate the long‐term survivorship, incidence of adverse reactions to metal debris (ARMD), and metal ion behavior in patients who underwent small‐head Metasul metal‐on‐metal (MoM) total hip arthroplasty (THA).MethodsBetween February 1998 and September 2003, a retrospective study was performed on 43 consecutive patients (43 hips) who underwent unilateral cementless Metasul MoM THAs at our institution. Of them, 35 patients (nine males and 26 females) who were available for follow‐up more than 15 years after THA were enrolled in this study and underwent metal artifact reduction sequence magnetic resonance imaging (MARS‐MRI) to identify ARMD. The mean age at surgery of the patients was 59.7 years old (range, 31–83). Clinical and radiographic outcomes were evaluated retrospectively. Clinical examinations were conducted using the Harris Hip Score (HHS). Serum cobalt (Co) and chromium (Cr) ion levels and Co/Cr ratio were assessed at different postoperative periods of <5, 5–10, 11–14, and ≥15 years.ResultsThe mean follow‐up period for the 35 patients included was 18.1 years (range, 15–22). The mean HHS significantly improved from 44.6 ± 11.3 points preoperatively to 89.4 ± 7.9 points at the final follow‐up (P < 0.0001). ARMD was found in 20% of the patients using MARS‐MRI. No signs of stem loosening were found clinically or radiographically, whereas cup loosening and ARMD were observed in three patients (9%), for whom revision THAs were performed. The Kaplan–Meier survival rates with revision for any reason as the endpoint were 90.9% at 5 years, 84.8% at 10 years, 84.8% at 15 years (95% CI, 67.1–93.6), and 70.3% at 20 years (95% CI, 43.6–87.0). The survival rates with revision for ARMD as the endpoint were 100% at 5 years, 96.6% at 10 years, 96.6% at 15 years (95% CI, 77.2–99.7), and 80.1% at 20 years (95% CI, 45.3–95.2). Serum Co ion level peaked at 5–10 years after THA, which was significantly higher than that <5 years; however, it decreased to the initial level after 15 years. In contrast, serum Cr ion level significantly increased at 5–10 years and then remained almost constant. Significant differences in Cr ion levels (1.0 vs 2.0 μg/L, P = 0.024) and Co/Cr ratio (1.3 vs 0.9, P = 0.037) were found between non‐ARMD and ARMD patients at >11 years postoperatively.ConclusionOur results suggest that increased Cr ion levels and decreased Co/Cr ratio may be signs of ARMD in patients who underwent small‐head Metasul MoM THA.     

Reconstruction of Paprosky Type III Acetabular Defects by Three‐Dimensional Printed Porous Augment: Techniques and Clinical Outcomes of 18 Consecutive Cases

ObjectiveTo introduce the surgical technique of reconstruction of Paprosky type III acetabular defects by 3D printed porous augments.MethodsFirst, CT scans of pelvis were obtained to establish the 3D reconstruction model of 3D printed porous augment. Then, a nylon pelvis model was printed to simulate operation with the surgeons. At this time, the augment was designed and modified according to the surgeon''s suggestions and the 3D printing principles. Eighteen patients with Paprosky type III acetabular defects receiving reconstructive surgery by 3D printed porous augments were included in current study. Their data, including general information, intra‐operative findings, imaging results, functional scores, and complications were retrospectively analyzed.ResultsThe mean follow‐up time lasted 33.3 ± 2.0 (24–56) months. The average limb‐length discrepancy (LLD) was 31.7 ± 4.2 (3–59) mm preoperatively, 7.7 ± 1.4 (1–21) mm postoperatively (P < 0.0001), and 7.5 ± 1.2 (0–18) mm at the latest follow‐up. The mean vertical position of hip center of rotation (HCOR) from the interteardrop line changed from preoperative 50.7 ± 3.9 (23.3–75.3) mm to postoperative 22.9 ± 1.9 (10.1–40.3) mm (P < 0.0001), with the latest follow‐up revealing an HCOR of 22.3 ± 1.7 (11.0–40.5) mm. Follow‐up study showed that no hip had radiolucencies and radiological loosening of the acetabular components and augment. The average Harris hip score (HHS) improved from 40.3 ± 4.5 (10.5–71) before operation to 88.4 ± 1.9 (75–97) at the last follow‐up (P < 0.0001). Moreover, follow‐up exhibited that no periprosthetic joint infection, hip dislocation, fracture, and re‐revision occurred.ConclusionSurgical treatment of Paprosky type III acetabular defect with 3D printed porous augment was simple, achieved good match between porous augment and the defect bone surface and the acetabular component, ideally restored LLD and HCOR after operation, significantly improved HHS and attained good early clinical outcomes. It is a promising personalized solution for patients with severe acetabular bone defect.