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.     

Correlation Analysis between Tibial Tuberosity‐Trochlear Groove Distance and Other Patellar Stability Parameters in Young and Middle‐aged Populations

ObjectiveThe exact mechanism of patellofemoral instability has not been clearly clarified. The current study aims to explore the correlation between the tibial tuberosity‐trochlear groove (TT‐TG) distance and other patellar stability parameters.MethodsA total of 60 individuals aged 18 to 40 years who underwent knee computed tomography (CT) examination between September 2014 and December 2017 were retrospectively recruited. Five reference sites were selected on the femoral trochlear articular surface in every CT image. The TT‐TG distance and the trochlear groove angles (TGA) at the five reference sites were measured. The patellar ligament length (PLL), patellar length (PL), medial patellar retinaculum length (MPRL) and lateral patellar retinaculum length (LPRL) were quantitatively analyzed. The TT‐TG distances on different knee sides or in different sexes were compared. The relationships between the TT‐TG distance and TGA, PLL/PL, MPRL, and LPRL were analyzed by Spearman''s method. Comparison analysis among patellar stability parameters was analyzed using ANOVA or two‐tailed Student''s t test.ResultsVariance analysis revealed no significant differences in the TT‐TG distances among the five positions of the femoral trochlea (F = 0.67, P = 0.62) but significant differences among the five femoral TGAs at the five reference sites (F = 380.37, P < 0.01). Notably, an increasing tendency of the TT‐TG distance was observed in the sexes (male, range 16.61–19.68 mm; female, range 14.37–17.38 mm) and knee sides (left knee, range 14.37–18.43 mm; right knee, range 15.80–19.68 mm). The TGA at site 1 of the femoral trochlear cartilage was the largest, with an angle of 151.97° ± 10.4°, and then gradually decreased to the smallest when the cartilage disappeared at site 5, with an angle of 92.05° ± 10.01°. Interestingly, there was a positive relationship between the TT‐TG distance at site 1 and TGA in the right knees of males (r = 0.490, P = 0.033) as well as LPRL in the left knees of males (r = −0.420; P = 0.046). There were no correlations between the TT‐TG distance and the other patellar stability parameters, including TGA, PLL/PL, MPRL, and LPRL.ConclusionAmong young and middle‐aged populations, patella surgeries should be carefully determined based on the comprehensive consideration of these patellar stability parameters rather than the TT‐TG distance alone. Differences in sex and knee side should also be considered.     

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.     

Fourth‐Generation Ceramic‐on‐Ceramic THA in Patients with Ankylosing Spondylitis: A Minimum 10‐Year Follow‐Up

ObjectiveTo report the long‐term outcomes of total hip arthroplasty (THA) with fourth‐generation ceramic‐on‐ceramic (CoC) bearing in patients with ankylosing spondylitis (AS).MethodsWe retrospectively identified 180 primary THAs performed in 110 patients with AS, including 100 (90.9%) men and 10 women (9.1%), from 2009 to 2011.The mean age of the patients at surgery was 33 years (range, 16 to 65 years). Cementless prostheses with fourth‐generation CoC bearings were used in all patients. Survivorship of the implants and postoperative complications were calculated. Functional improvement was assessed by the hip flexion‐extension range of motion (ROM) and Harris hip score (HHS). A special noise assessment questionnaire was performed at the last follow‐up. The cumulative incidence of noise was calculated by the Kaplan–Meier method with 95% confidence intervals (CIs). Clinical characteristics and functional outcomes were compared in the hips with noise to those without noise.ResultsThe mean follow‐up was 11 years (range, 10 to 12 years), and survivorship of the implants was 99.4% at the most recent follow‐up. The complications included dislocation (one hip, 0.6%), periprosthetic joint infection (one hip, 0.6%), mild to moderate pain (five hips, 2.8%), heterotopic ossification (12 hips, 6.7%), and noise (52 hips, 28.9%). The flexion‐extension ROM improved significantly with a median from 10° (range, 0 ~ 130°) to 100° (30 ~ 130°) after THA (p < 0.001), and the HHS increased significantly from 41 ± 20 to 90 ± 8 (p < 0.001). The cumulative incidence of noise at 0.5, 5, and 10 years was 6.1% (95% CI, 2.6 ~ 9.6), 16.7% (95% CI, 11.2 ~ 22.1), and 28.9% (95% CI, 22.2 ~ 35.5), respectively, and that of squeaking at 0.5, 5, and 10 years was 4.4% (95% CI, 1.4 ~ 7.4), 13.3% (95% CI, 8.4 ~ 18.3), and 23.9% (95% CI, 17.6 ~ 30.1), respectively. None of the patients with noise generation in the hip reported it affecting daily activities or causing dissatisfaction. No differences in age, sex, BMI, disease duration, bilateral THA, the frequency of bony ankylosis, the proportion of using a 36‐mm‐diameter femoral head, pre/postoperative flexion‐extension ROM, or pre/postoperative HHS were found between hips with noise and those without noise (p > 0.05).ConclusionTHAs with fourth‐generation CoC bearings exhibit excellent long‐term survival and clinical outcomes in patients with AS, with a very low dislocation rate. The incidence of noise associated with CoC bearings in THA performed in patients increases over time, but it does not affect postoperative hip function or daily activities.     

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.     

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.     

Effect of Orthogeriatric Co‐Management on Geriatric Hip Fractures in China

ObjectivesAlthough geriatric hip fracture is a serious public health problem in China, the result of orthogeriatric co‐management (OGC) is rarely reported. This study aimed to evaluate the effect of OGC in Chinese patients aged ≥65 years.MethodsIn this single‐centre, pre‐post intervention, retrospective study, traditional orthopaedic care (TOC) was used until OGC was implemented in May 2015, a multidisciplinary team was organized, and clinical protocol was designed. Consecutive hip fracture patients who were ≥65 years and injured within 3 weeks were included in this study. Demographic characteristics, comorbidities, fracture patterns, surgical procedure, time to surgery, length of hospital stay, inpatient complications, and in‐hospital mortality were extracted and examined. At 1‐year after surgery, data on patients'' mobility and mortality were collected. The time to surgery, incidence of inpatient complications, mortality and functional outcomes were compared between the groups.ResultsThere were no significant differences in sex, fracture type, and surgical pattern between OGC (n = 434) and TOC (n = 452) groups. Patients in OGC group were significantly older (P < 0.001) and had a higher age‐adjusted Charlson comorbidity index (P < 0.001). However, waiting time between admission and operation was significantly lower in OGC group (P < 0.001). There was no significant difference in the mortality rate at the time of the patient being in‐hospital and at 1, 3, and 6 months after surgery. Although 1‐year mortality was higher in OGC group (P = 0.036), Cox regression analysis showed no significant correlation of OGC with 1‐year mortality. There was no significant difference in pre‐injury mobility and 1‐year follow‐up mobility assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility level.ConclusionOGC significantly shortens time to surgery for geriatric hip fractures compared with TOC. However, there is no significant effect on mortality rate within 1 year and functional status at 1 year of follow‐up.     

A Comparative Study of a New Retractor‐Assisted WILTSE TLIF,MIS‐TLIF,and Traditional PLIF for Treatment of Single‐Level Lumbar Degenerative Diseases

ObjectivesTo compare the clinical efficacy of a new retractor‐assisted Wiltse transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS‐TLIF), and traditional posterior lumbar interbody fusion (PLIF) in treating single‐level lumbar degenerative diseases.MethodsA retrospective study was conducted by analyzing the clinical and imaging data of consecutive patients with single‐level lumbar degenerative diseases who underwent the new retractor‐assisted Wiltse TLIF, MIS‐TLIF, or traditional PLIF. This study enrolled 87 concurrent patients between June 2016 and December 2019 (Wiltse TLIF 29 cases; MIS‐TLIF 28 cases; PLIF 30 cases). The three groups were compared for perioperative indicators (including intraoperative blood loss, postoperative drainage volume, operation time, intraoperative fluoroscopy time, bedridden time), creatine kinase (CK), visual analog score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral fusion rate, muscle atrophy, and fatty infiltration (including ratio of multifidus atrophy and ratio of lean‐to‐total cross‐sectional area [CSA]).ResultsIntraoperative blood loss (F = 62.628, p < 0.001), postoperative drainage volume (F = 72.048, p < 0.001), and bedridden time (χ² = 62.289, p < 0.001) were significantly lower in the MIS‐TLIF and Wiltse groups than in the PLIF group. The operative and intraoperative radiation times of the MIS‐TLIF group were significantly longer than those of the Wiltse and PLIF groups. The CK concentration in the Wiltse and MIS‐TLIF groups were significantly lower than those in the PLIF group 1 day (F = 9.331, p < 0.001) and 3 days after surgery (F = 15.967, p < 0.001). The PLIF group''s back pain VAS score was higher than those of the Wiltse and MIS‐TLIF groups. The PLIF group had a higher ODI 6 months (F = 3.282, p = 0.042) and 12 months (F = 5.316, p = 0.007) after surgery and a lower JOA score than the Wiltse and MIS‐TLIF groups 6 months (F = 3.234, p = 0.044) and 12 months (F = 3.874, p = 0.025) after surgery. The ratio of multifidus atrophy in the PLIF group (41.70 ± 8.84%) was significantly higher than those of the Wiltse group (24.13 ± 6.82%) and the MIS‐TLIF group (22.35 ± 5.03%). The ratio of lean‐to‐total CSA in the PLIF group was lower than those of the Wiltse and MIS‐TLIF groups after surgery (F = 8.852, p < 0.001). MIS‐TLIF group showed longer operation time (169.11 ± 29.38 min) and intraoperative fluoroscopy time (87.61 ± 3.13 s) than the Wiltse group.ConclusionWiltse TLIF assisted by the new retractor is a more convenient and minimally invasive surgical method than the traditional PLIF and MIS‐TLIF methods, which are linked to a long learning curve and long operation and fluoroscopy time.     

Long‐term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6‐Year Follow‐up Study

ObjectiveTo assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis.MethodsThis single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females).ResultsThe data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m² and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (r _s = −0.515, P < 0.05) and the sagittal rotation (r _s = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (r _s = 0.637, P < 0.01) and the pelvic incidence (r _s = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (r _s = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires.ConclusionsThe surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.     

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.     

Efficacy of One‐stage Paravertebral Approach using a Micro‐Tubular Technique in Treating Thoracic Dumbbell Tumors

ObjectiveThe aim of the present study was to investigate the feasibility and efficacy of one‐stage surgical resection of thoracic dumbbell tumors using a paravertebral approach and a micro‐tubular technique.MethodsClinical data of thoracic dumbbell tumors resected using a paravertebral approach and a micro‐tubular technique (14 mm, non‐expandable type) in the Department of Neurosurgery at our hospital from July 2014 to July 2019 were retrospectively analyzed. Tumors were found between T1 and T12 vertebrae. Operation time, blood loss, hospitalization, recovery of neurological function, complications, the Japanese Orthopaedic Association (JOA) score, and the visual analogue scale (VAS) score were used to evaluate clinical efficacy.ResultsIn all 31 cases, tumors were completely resected in one operation, with a mean blood loss of 53.23 ± 33.08 mL (20–150 mL) and a mean operation time of 95.16 ± 20.31 min (60–180 min). According to the Eden classification, there were four type II cases, 16 type III cases, and 11 type IV cases. The incidence of tumors in the lower thoracic segment (T8–T12) was 51.6% (16/31 cases), while the incidences in the upper thoracic segment (T1–T4) and middle segment (T5–T8) were 25.8% (8/31 cases) and 22.6% (7/31 cases), respectively. Pathological diagnoses were schwannoma (n = 22), gangliocytoma (n = 4), metastatic tumor (n = 2), neurofibroma (n = 1), granuloma (n = 1), and lipoma (n = 1). After surgery, symptoms were relieved in all patients. VAS and JOA scores significantly improved (P < 0.001). There was no pleural or lung injury, and there were no complications, such as cerebrospinal fluid leakage. The average follow‐up duration was 29 months (13–59 months), during which time no tumor recurrence or spinal instability occurred. The group of Eden type II tumors had lower JOA scores at 12 months postoperatively, longer operation times, and more estimated blood loss compared with other groups (P < 0.05). There were no significant influences on VAS scores at 12 months postoperatively and postoperative hospital stay from the different types of tumors.ConclusionThe paravertebral approach with a micro‐tubular technique is a safe and effective minimally invasive surgical approach for thoracic dumbbell tumors that allows one‐stage tumor resection using a single incision. Using this approach significantly reduces intraoperative blood loss and postoperative complications, shortens hospital stay, and reduces the rates of postoperative spinal instability.     

Validation of CT‐Based Three‐Dimensional Preoperative Planning in Comparison with Acetate Templating for Primary Total Hip Arthroplasty

ObjectiveThis study aims to compare the accuracy of CT‐based preoperative planning with that of acetate templating in predicting implant size, neck length, and neck cut length, and to evaluate the reproducibility of the two methods.MethodsThis prospective study was conducted between August 2020 and March 2021. Patients who underwent elective primary total hip arthroplasty by a single surgeon were assessed for eligibility. The included patients underwent both acetate templating and CT‐based planning by two observers after the operation. Each observer conducted both acetate templating and CT‐based planning twice for each case. The outcome measures included the following: (1) the accuracy of surgical planning in predicting implant size, calcar length, and neck length, which was defined as the difference between the planned size and length and the actual size and length; (2) reproducibility of the two planning techniques, which were assessed by inter‐observer and intra‐observer reliability analysis; (3) the influence of potential confounding factors on planning accuracy, which was evaluated using generalized estimating equations.ResultsA total of 57 cases were included in the study. CT‐based planning was more accurate than acetate templating for predicting cup size (93% vs 79%, p < 0.001) and stem size (93% vs 75%, p < 0.001). When assessed by mean absolute difference, the comparison between acetate templating and CT‐based planning was 4.28 mm vs 3.74 mm (p = 0.122) in predicting neck length and 3.05 mm vs 2.93 mm (p = 0.731) in predicting neck cut length. In the inter‐observer reliability analysis, an intraclass correlation coefficient (ICC) of 0.790 was achieved for predicting cup size, and an ICC of 0.966 was achieved for predicting stem size using CT‐based planning. In terms of intra‐observer reliability, Observer 1 achieved an ICC of 0.803 for predicting cup size and 0.965 for predicting stem size in CT‐based planning. Observer 2 achieved ICC values of 0.727 and 0.959 for predicting cup and stem sizes, respectively. The average planning time was 6.48 ± 1.55 min for CT‐based planning and 6.12 ± 1.40 min for acetate templating (p = 0.015).ConclusionThe CT‐based planning system is more accurate than acetate templating for predicting implant size and has good reproducibility in total hip arthroplasty.     

Original Designed Uniportal‐Bichannel Spinal Endoscopic System (UBiSES) for Foraminoplasty in Percutaneous Endoscopic Transforaminal Discectomy

ObjectiveThe study introduced uniportal‐bichannel spinal endoscopic system (UBiSES) and explored the feasibility of applying UBiSES to conduct lumbar foraminoplasty in percutaneous endoscopic transforaminal discectomy (PETD).MethodsThis is a cohort study. 36 patients confirmed as L5/S1 lumbar disc herniation (LDH) in our hospital from March, 2019 to November, 2019 were enrolled. 36 patients were divided into two groups named the UBiSES group (n = 18, male: female = 8:10) and the TESSYS group (n = 18, male: female = 10:8). The average age of the UBiSES group and the TESSYS group were 40.94 ± 12.39 years old and 39.78 ± 13.02 years old respectively. PETD via uniportal‐bichannel foraminoplasty assisted by UBiSES was adopted on the UBiSES group while PETD via conventional foraminoplasty was performed on the TESSYS group. One experienced surgeon with more than 4000 cases of lumbar surgery performed PETD on all patients. The demographic data, the duration of working cannula placement (minutes), decompression time (minutes), radiation exposure time (seconds), complications, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores and modified MacNab criteria were recorded and analyzed. The magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to evaluate the radiographic improvement.ResultsPETD via lumbar foraminoplasty was successfully performed in all cases. The follow‐up points were 3 months, 6 months, and 12 months. The average follow‐up period of all patients was 15.78 ± 2.29 months. There was no statistic difference in age (P = 0.81), sex (P = 0.51) and follow‐up (P = 0.14) between two groups. The duration of working cannula placement was 19.08 ± 2.30 min in the UBiSES group and 24.90 ± 4.71 min in the TESSYS group and there was significant difference between two groups (P < 0.05). There was no statistic difference in decompression time between the UBiSES group (44.18 ± 5.70 min) and the TESSYS group (47.46 ± 5.96 min) (P = 1.70). The radiation exposure time was 28.00 ± 4.70 s in the UBiSES group and 40.50 ± 5.73 s in the TESSYS group respectively, and has significant difference between two groups (P < 0.05). Furthermore, there was significant different in the duration of working cannula placement and radiation exposure time in male or female between the UBiSES group and the TESSYS group (P < 0.05). For male or female, no difference observed in decompression time and follow‐up period between two groups. Postoperative VAS of low back and leg at every follow‐up point (1 day, 3 months, 6 months, 12 months) was improved significantly in both groups compared with their preoperative VAS (P < 0.05). The postoperative ODI (3 months, 6 months, 12 months) has decreased significantly in both the UBiSES group and the TESSYS group compared with their preoperative ODI (P < 0.05). 94.44% patients received an excellent or good recovery in the UBiSES group and 88.89% for the TESSYS group. There was no poor result reported in both groups. The radiographic images showed satisfactory foraminoplasty and sufficient decompression of nerve in both groups. No postoperative complications were observed during follow‐ups in the UBiSES group. Two patients in the TESSYS group experienced postoperative dysesthesia and the symptom was disappeared in 5 days and 7 days respectively with dexamethasone and neurotrophic drugs treatment.ConclusionsThe original designed UBiSES could effectively and safely enlarge the foramen with an extensive surgical view and space under full‐time and real‐time visualization and get satisfactory efficacy.     

Mid‐ and Long‐Term Follow‐Up Efficacy Analysis of 3D‐Printed Interbody Fusion Cages for Anterior Cervical Discectomy and Fusion

ObjectiveTo evaluate the safety and stability of 3D‐printed interbody fusion cages (3D‐printed cages) in anterior cervical discectomy and fusion (ACDF) by investigating the mid‐ and long‐term follow‐up outcomes.MethodsIn this prospective study, the clinical data of 30 patients with CSM admitted to the Second Hospital of Shanxi Medical University from May 2012 to May 2014 were analyzed. The cohort comprised 18 males and 12 females with an average age of 60.22 ± 3.2 years. All patients were examined by X‐ray, CT and MRI before the operation. A total of 30 cases of CSM were treated by ACDF with 3D printed cage implantation. Mid‐ and long‐term follow‐ups were performed after the surgery. Clinical efficacy was evaluated by comparing the JOA score, SF‐36 score, change in neurological function, cervical curvature index (CCI), vertebral intervertebral height (VIH) and fusion rate before the operation, 6 months after the operation, and at the last follow‐up.ResultsTwo of the 30 patients were lost to follow‐up. The remaining patients were followed up for 48–76 (65.23 ± 3.54) months. The patients recovered satisfactorily with a significant clinical effect. The JOA score increased meanfully and the improvement rate was 89.4% at the final follow‐up. The SF‐36 score increased significantly from pre‐ to postoperatively. The height of the intervertebral space at the last follow‐up was not statistically significantly different from that at 6 months after surgery (P > 0.05), showing that the height of the intervertebral space did not change much and the severity of cage subsidence (CS) decreased. The CCI improved from pre‐ to postoperatively. The CCI did not change much from the 6‐month follow‐up to the last follow‐up. and the cage rate (CR) was 100% at the 6‐month and last follow‐ups. No severe complications, such as spinal cord injury, esophageal fistula, cerebrospinal fluid leakage, cervical hematoma or wound infection, occurred in any of the patients.ConclusionThe clinical and radiological results show that the application of 3D‐printed cages in ACDF can significantly relieve symptoms. Moreover, 3D‐printed cages can restore the curvature of the cervical spine, effectively maintain the intervertebral height for a long time, and prevent complications related to postoperative subsidence.     

The Application of H‐Loop in Arthroscopic Knotless Double‐Row Rotator Cuff Repairs

ObjectiveTo determine the functional outcomes after a novel method of H‐loop knotless double‐row technique in patients with rotator cuff tears.MethodFrom June 2020 to September 2020, a total of six patients (five women, one man) with arthroscopic rotator cuff repair using the H‐loop knotless double‐row technique were enrolled in our study. The average age is 54 years (range: 50–61 years). The preoperative and final follow‐up clinical outcome were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS), University of California Los Angeles (UCLA) score, and Constant–Murley score. The active shoulder range of motion (ROM) was also collected preoperatively and postoperatively at the final follow‐up (forward flexion and abduction). Accordingly, intraoperative and postoperative complications were observed as well.ResultThere were six patients that underwent arthroscopic rotator cuff repair using the H‐loop knotless double‐row technique. The average follow‐up period was 7.52 ± 0.70 months. The VAS, UCLA, ASES, and Constant–Murley scores improved from 5 ± 2.45, 15.67 ± 3.44, 47.67 ± 17.41 and 49.17 ± 8.98 preoperatively, to 0.83 ± 0.75, 36.27 ± 3.83, 91.67 ± 10.76 and 85.83 ± 4.31 at the final follow‐up, with statistical significances of P = 0.009, P < 0.001, P = 0.006, and P = 0.001, respectively. Meanwhile, the active shoulder ROM (forward flexion and abduction) improved from 135.00 ± 46.80 and 125 ± 56.48 preoperatively, to 173.67 ± 4.13 and 172 ± 3.27 at final follow‐up, respectively (P = 0.082, P = 0.088). During the follow‐up, there were no postoperative complications such as wound‐site infection, nerve or vessel damage, subcutaneous hematoma, and suture anchor problems.ConclusionWith the benefit of reducing the possibility of strangulation and blood supply affection for the rotator cuff, The H‐loop knotless double row technique may be an alternative method to significantly improve subjective functional outcomes and increase the healing rate of medium‐sized rotator cuff tears with degeneration issues and poor tissue quality.     

Expansion of Spinal Canal with Lift‐Open Laminoplasty: A New Method for Compression Cervical Myelopathy

ObjectiveThis study is to introduce lift‐open laminoplasty and verify the increase of the spinal canal area following this surgical technique according to the preoperative anatomical measurement.MethodsThere are 82 patients (43 male and 39 female) analyzed in our study from January 2019 to December 2020. The average age was 63.2 ± 3.21 years (from 41 to 84 years). All of them were treated with open‐door laminoplasty, with a decompression segment range from C3 to C6. The increase of the spinal canal area after open‐door laminoplasty was measured on postoperative CT images of the patients, and the distances between both lamina‐facet junctions and lamina length was measured on preoperative CT images. Using the Pythagorean theorem for the equation of calculation area after the expansile open‐door laminoplasty. Based on previous measurement parameters, spinous process length, lateral mass width, distance between osteotomy line and lamina‐facet junctions line were additionally measured on preoperative CT images. Pythagorean theorem was used for calculating the area after the expansile lift‐open laminoplasty. The results were recorded and a statistical analysis was undertaken. Then, there were six patients (five male and one female) treated with lift‐open laminoplasty on C6, open‐door on C3–C5, who suffer from cervical spondylotic myelopathy from December 2020 to January 2021. The average age was 60.3 ± 1.7 years (from 56 to 71 years). Operation time, blood loss, and Japanese Orthopaedic Association (JOA) score recovery rate were recorded. Intraoperative and postoperative complications were observed.ResultsThe increase of the spinal canal area after open‐door laminoplasty measured on postoperative CT images was 123.01 ± 17.06 mm² and the calculation of the increase of the spinal canal areausing the Pythagorean theorem after open‐door laminoplasty was 122.86 ± 15.86 mm². A comparison of the actual value with calculative value showed no significant difference (T value = 0.057, P value = 0.955). The calculation of the increase of the spinal canal area after lift‐open laminoplasty was 183.57 ± 62.99 mm², which was larger than that after open‐door laminoplasty (T value = 8.462, P value < 0.001). Mean operation time was 153.3 min and operative blood loss was 600 mL of the six patients treated with lift‐open laminoplasty. At 1 month follow‐up, all patients had recovered well. JOA score recovery rate was 37.6% and no intraoperative and postoperative complications occurred.ConclusionLift‐open laminoplasty could preserve nearly 100% of extensor muscle, avoid damaging C7 paraspinal muscles and C6‐7 posterior muscle‐ligament complex, reconstruct the spinous process firmly in the midline, and expand adequate spinal canal area after operation. These advantages could reduce the incidence rate of complications and bring better clinical results than traditional laminoplasty.     

Onion extract gel is not better than other topical treatments in scar management: A meta‐analysis from randomised controlled trails

To evaluate the efficacy and safety of onion extract (OE) gel on scar management, a systematic review was performed by searching Embase, PubMed, Medline, and the Cochrane Library databases, and a meta‐analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement guidelines. Finally, 13 randomised controlled trails were enrolled for meta‐analysis. OE gel increased the total improvement scores assessed by investigators (P < .00001) and patients (P < .00001) than no treatment, but no differences were detected between OE gel and other commonly used topical treatments assessed by investigators (P = .56) and patients (P = .39). Moreover, OE in silicone gel increased the total improvement scores assessed by investigators (P < .00001) and patients (P = .0007) than other treatments. OE gel increased the incidence of total adverse effects compared with no treatment (P < .0001) and other treatments (P = .008) by a fixed‐effects model, and increased the incidence of dropping out caused by intolerance of treatments (P = .0002). OE gel not only has no superiority to commonly used topical treatments, but also has the potential to increase the incidence of adverse effects on scar management; OE in silicone gel might be the optimal topical choice for scar treatment; however, more evidences are needed to strength these conclusions.     

Factors Associated with Postoperative Respiratory Complications following Posterior Spinal Instrumentation in Children with Early‐onset Scoliosis

ObjectiveTo investigate the incidence and risk factors of postoperative respiratory complications (PRCs) in children with early‐onset scoliosis (EOS) following posterior spine deformity surgery (PSDS) based on growth‐friendly techniques, so as to help improve the safety of surgery.MethodsA retrospective study of children with EOS admitted for PSDS based on growth‐friendly techniques from October 2013 to October 2018 was reviewed at a single center. There were 73 children (30 boys, 43 girls) who fulfilled the criteria in this research. The mean age of the patients was 7 ± 6.2 years. Patients were divided into the groups with and without PRCs. Variables that might affect the PRCs during the perioperative period, including general factors, radiographic factors, laboratory factors and surgical factors, were analyzed using univariate analysis to evaluate the potential risk factors. The variables that were significantly different were further analyzed by binary logistic regression analysis to identify the independent factors of PRCs.ResultsAll the 73 children included 42 idiopathic scoliosis (57.5%), 12 congenital scoliosis (16.4%), 10 syndromic scoliosis (13.7%) and nine neuromuscular scoliosis (12.3%). PRCs were detected in 16 children (21.9%) with nine different PRCs. The total frequency of detected PRCs was 54, including pleural effusion (25.9%), postoperative pneumonia (20.4%), hypoxemia (18.5%), atelectasis (14.8%), prolonged intubation with mechanical positive pressure ventilatory support (PIMPPVS) (7.4%), bronchospasm (3.7%), reintubation (3.7%), delayed extubation (3.7%) and pneumothorax (1.9%). Results of univariate testing demonstrated that the following six variables were statistically different (P < 0.05): nonidiopathic scoliosis, combined with pulmonary comorbidities, pretransferrin < 200 mg/dL, prealbumin < 3.5 g/dL, anesthesia time ≥ 300 min and blood loss to total blood volume ratio (BL/TBV) ≥ 15%. Binary logistic regression analysis confirmed that BL/TBV≥15% (odd ratio OR = 29.188, P = 0.010), combined with pulmonary comorbidities (OR = 19.216, P = 0.012), pretransferrin < 200 mg/dL (OR = 11.503, p = 0.024), and nonidiopathic scoliosis (OR = 7.632, P = 0.046) were positively linear correlated with PRCs in children with EOS following PSDS.ConclusionPRCs has a higher incidence in children with EOS following PSDS. BL/TBV ≥15%, combined with pulmonary comorbidities, pre‐transferrin < 200 mg/dL, and nonidiopathic scoliosis play an important role for the development of PRCs in this population.     

A multi‐country cross‐sectional study to assess predictors of daily versus on‐demand oral pre‐exposure prophylaxis in youth from South Africa,Uganda and Zimbabwe

IntroductionSub‐Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre‐exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on‐demand PrEP among AYP in South Africa, Uganda and Zimbabwe.MethodsA cross‐sectional survey was conducted in 2019 among 13‐ to 24‐year olds, capturing socio‐demographics, HIV risk behaviours and preferences for daily or on‐demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age.Results and discussionA total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17–22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on‐demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On‐demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18‐ to 24‐year‐olds vs. 47% in 13‐ to 15‐year‐olds). After adjusting for site, sex and age group, preference for on‐demand PrEP decreased as sex frequency over the past month increased (p‐trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on‐demand PrEP (p‐trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on‐demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on‐demand PrEP (p = 0.05).ConclusionsOur data show that AYP in four SSA communities prefer on‐demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio‐demographic differences and designed in conjunction with AYP.