Spine‐Pelvis‐Hip Alignments in Degenerative Spinal Deformity Patients and Associated Procedure of One‐Stage Long‐Fusion with Multiple‐Level PLIF or Apical‐Vertebra Three Column Osteotomy–a Clinical and Radiographic Analysis Study

ObjectiveTo explore the spine‐pelvis‐hip alignments in degenerative spinal deformity (DSD) patients, and compare the outcomes in the procedure of long‐fusion with posterior lumbar inter‐body fusion (PLIF) or single‐level three‐column osteotomy (STO) at lower lumbar level (LLL, L₃‐S₁) and thoracolumbar levels (TLL, T₁₀‐L₂) for those patients.MethodsThis is a retrospective study. Following institutional ethics approval, a total of 83 patients (Female, 67; Male, 16) with DSD underwent long‐fusion with PLIF or STO surgery between March 2015 and December 2017 were reviewed. All of those patients were assigned into LLL and TLL groups. The average age at surgery was 65.2 years (SD, 8.1). Demographic (age, gender, BMI, and comorbidities), radiographs (both coronal and sagittal parameters) and health‐related quality of life (HRQOL) assessments were documented. The radiographic parameters and HRQOL‐related measurements at pre‐ and post‐operation were compared with paired‐samples t test, and those variables in the two groups were analyzed using an independent‐sample t test. The relationships between pelvic incidence (PI) and other sagittal parameters were investigated with Pearson correlation analysis. The Pearson χ² or Fisher''s exact was carried out for comparison of gender, incidence of comorbidities and post‐operative complications.ResultsThere were 53 and 30 patients in the LLL and TLL groups respectively. Those spino‐pelvic radiographic parameters had significant improvements after surgeries (P < 0.001). The patients in the two group with different pre‐operative thoracolumbar kyphosis (TLK, P = 0.003), PI (P = 0.02), and mismatch of PI minus lumbar lordosis (PI‐LL, P = 0.01) had comparable post‐operative radiographic parameters except PI (P = 0.04) and pelvic‐femur angle (PFA, P = 0.02). Comparing the changes of those spine‐pelvic‐hip data during surgeries, the corrections of TLK in TLL group were significant larger (P = 0.004). Pearson correlation analysis showed that there were negative relationship between PI and TLK (r = −0.302, P = 0.005), positive relationship between PI and LL (r = 0.261, P = 0.016) at pre‐operation. Those patients underwent the surgical procedure that long‐segment instrumentation and fusion with STO would have higher incidence of complications involving longer operative timing (P = 0.018), more blood loss (P < 0.001), revision surgery (P = 0.008), and cerebrospinal fluid leakage (P = 0.001). All the HRQOL scores significantly improved at final follow‐up (P < 0.001), with no difference of intra‐group.ConclusionPatients suffered de‐novo scoliosis or hyper‐kyphosis with low PI would be vulnerable to significant thoracolumbar degeneration, and have more changes of spine‐pelvis‐hip data after long‐fusion surgery, however, those with high PI would be closed to significant lumbar degeneration. Although spine‐pelvis‐hip alignments in DSD patients can be restored effectively after long‐fusion with PLIF or STO, the incidence of complications in patients underwent STO was significant higher than that in patients performed multi‐level PLIF.     

Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Systematic Review of the Literature and Meta‐analysis of Single‐arm Studies

PurposeThis article aims to summarize the incidence of these complications through a meta‐analysis, analyze the causes of complications and provide clinical promotion and recommendations.MethodsDatabases and retrieval platform including PubMed, Web of science, Springer link, Cochrane clinical trials, ProQuest, ScienceDirect, Europe PMC, Wiley online, OVID, Clinical trials, CNKI and WanFang, and supplement the literature through Google Scholar, collect all the unilateral biportal endoscopy (UBE) controlled trials and non‐controlled trials of UBE in the treatment of lumbar spinal stenosis (LSS). The search time limit is from January 1, 2000 to December 25, 2021. After two reviewers independently screened the literature, extracted data and evaluated the risk of bias in the included studies, meta‐analysis was performed using Stata 15.1 software.ResultsFinally, 24 studies were included, including 999 patients. The results of a single‐arm rate meta‐analysis showed that the overall complication rate of UBE treatment of LSS was 6.27% [95% CI (0.0412, 0.0876)], and the incidence of dural tear was 2.49% [95% CI (0.0133, 0.0390)], the incidence of transient paresthesia was 0.14% [95% CI (0.0000, 0.0072)], the incidence of postoperative spinal epidural hematoma was 0.27% [95% CI (0.0000, 0.0096)], the incidence of postop headache, inadequate decompression, root injury and infection was 0.00%.ConclusionCurrent evidence shows that the complication rate of UBE in the treatment of LSS is low, mainly due to dural tears. Limited by the number and quality of included studies, the above conclusions still need to be confirmed by more studies.     

Simplified Chinese Version of the Spinal Instability Neoplastic Score in Evaluating Patients with Metastatic Spinal Tumor: A Cross‐Cultural Adaptation and Validation

ObjectiveTo translate the original English version of the Spinal Instability Neoplastic Score (SINS) into simplified Chinese, adapt it cross‐culturally, validate its psychometric properties in measuring spinal instability in patients with metastatic spinal tumors in the Chinese mainland, examine the reliability and validity to demonstrate its accuracy and applicability in clinical practice.MethodsPatients diagnosed with metastatic spinal disease between January 2016 and January 2020 were recruited. The number of participants was advised to be at least 50 for appropriate analysis of reliability, construct validity, as well as ceiling or floor effects, and recruitment of 100 patients was advised for internal consistency analysis. The study was conducted in two phases: first, the SINS was translated into simplified Chinese; second, the factor structure, internal consistency, test–retest reliability, validity, and floor and ceiling effects of the SC‐SINS were assessed. The internationally recognized cross‐cultural adaptation guidelines were followed. Internal consistency was evaluated with Cronbach''s alpha. Test–retest reliability was examined among the patients with a 4‐week interval. The validity of the Chinese version of SINS (SC‐SINS) was assessed by examining its relationship with Kostuik classification. Principal component analysis was conducted to confirm the factor structure of each subscale.ResultsA total of 160 participants (88 males and 72 females) were enrolled. No major difficulties occurred in the forward and backward translations of SINS. The internal consistency of SC‐SINS was excellent (Cronbach''s α =0.857, ranging from 0.68 to 0.85). Test–retest reliability was also excellent with a value of 0.89, ranging from 0.86 to 0.95. Validity analyses indicated that the SC‐SINS was positively and significantly correlated with Kostuik classification. The correlation between “Posterolateral Involvement of Spinal Elements” and “1‐2 Partial Damage” was the highest with a correlation value of 0.792. The correlation between “Pain” and “1–2 Partial Damage” was the lowest with a value of 0.341. All items showed principal component coefficients greater than 0.4. The values of Factor 1 ranged from 0.523 to 0.681; Factor 2 ranged from 0.591 to 0.731; Factor 3 ranged from 0.613 to 0.754; Factor 4 ranged from 0.461 to 0.711; Factor 5 ranged from 0.513 to 0.701; and Factor 6 ranged from 0.501 to 0.668. In addition, neither floor nor ceiling effects were seen in the SC‐SINS.ConclusionThe SC‐SINS demonstrated high internal consistency and test–retest reliability, which has been proven valid and reliable to measure spinal stability in patients from the Chinese mainland with metastatic spinal tumor.     

Comparisons between Direct Anterior Approach and Lateral Approach for Primary Total Hip Arthroplasty in Postoperative Orthopaedic Complications: A Systematic Review and Meta‐Analysis

The direct anterior approach (DAA) are attracting increasing attention from orthopedic arthroplasty surgeons, due to the less blood loss, mild soft tissue invasion, rapid rehabilitation and shorter length of stay. However, the longer learning curve in DAA can give rise to several complications, such as intraoperative femoral fracture, lateral femoral cutaneous nerve injury, wound‐healing problem, premature revision and so on. This meta‐analysis was performed to compare the rate of postoperative orthopedic complications between the DAA and the lateral approach (LA). All studies involving the comparison of postoperative orthopedic complications after THA between the DAA and LA group were searched in 7 databases prior to October 2020. The odds ratio (OR) with the 95% confidence intervals (CI) for each outcome was calculated by using the RevMan 5.3. The methodological bias of included studies was evaluated and the potential heterogeneity sources were analyzed. Thirteen comparative studies including a total of 24853 hips (9575 hips in the DAA group and 15278 hips in the LA group) were eligible for this meta‐analysis. There was no significant difference in the rate of surgical site infection [2.59% vs 2.14% (OR = 0.98; 95% CI: 0.59‐1.61, P = 0.93)], heterotopic ossification [12.16% vs 26.47% (OR = 0.46; 95% CI: 0.20‐1.07, P = 0.07)] and reoperation [2.70% and 2.11% respectively (OR = 0.93; 95% CI: 0.68‐1.26, P = 0.64)] between the DAA and LA groups. Although a lower rate in prosthesis malposition [36.19% vs 54.86% (OR = 0.50; 95% CI: 0.35‐0.73, P = 0.0003)], leg length discrepancy [1.87% vs 2.37% (OR = 2.35; 95% CI: 1.30‐4.25, P = 0.005)] and Trendelenburg gait [1.68% vs 4.78% (OR = 0.29; 95% CI: 0.13‐0.65, P = 0.003)] was observed in the DAA group, a higher rate in dislocation [0.77% vs 0.18% (OR = 3.73; 95% CI: 2.35‐5.94, P< 0.00001)], periprosthetic fracture [1.05% vs 0.41% (OR = 2.38; 95% CI: 1.58‐3.58, P< 0.0001)], prosthesis loosening [0.61% vs 0.37% (OR = 1.66; 95% CI: 1.05‐2.62, P = 0.03)] and nerve injury [0.95% vs 0% (OR = 7.12; 95% CI: 1.66‐30.48, P = 0.008)] was found in the DAA group. This meta‐analysis demonstrated several evidences indicating that the DAA exhibited the advantages in the accurate prosthesis placement and less damage of surrounding hip musculature. However, a higher rate in dislocation, periprosthetic fracture, prosthesis loosening and nerve injury in the DAA group should be paid more attention, due to the limited exposure and a longer learning curve, compared to the LA.     

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.     

Failure of Posterior Lower Lumbar/Lumbosacral Hemi‐Vertebra Resection: An Analysis of Reasons and Revision Strategies

ObjectiveTo investigate the causes of failed primary surgery and the revision strategies for congenital scoliosis (CS) patients with lower lumbar/lumbosacral (LL/LS) hemi‐vertebra (HV).MethodsFifteen CS patients with LL/LS HV (seven females and eight males) with a mean age of 20.4 ± 10.4 years undergoing revision surgery in our center were retrospectively reviewed. The radiographic parameters including Cobb angle, distance between C₇ plumb line and center sacral vertical line (C₇PL‐CSVL), thoracic kyphosis (TK), lumbar lordosis (LL) and sagittal vertical axis (SVA) were assessed at pre‐revision, post‐revision and the last follow‐up. The causes of failure in primary operation, and radiographic and clinical outcomes of revision procedures were analyzed.ResultsThe revision rate of patients undergoing LL/LS HV resection and correction surgery was 11.4%. The average time interval between primary surgery and revision surgery was 18.2 ± 10.6 months. The operation duration and estimated blood loss of revision surgery were 194 ± 56 min and 326 ± 74 ml, respectively. Reasons for failed primary operations were as follows: internal fixation fracture in 10 cases, curve progression in two cases, implant loose in two cases and post‐operative coronal imbalance in one case. The post‐revision Cobb angle was significantly improved from 29.9° ± 8.3° to 18.7° ± 6.7° (P < 0.001) with a correction rate of 37.5% ± 12.6%. At the final follow‐up, the average Cobb angle was 18.9° ± 6.2° and the correction was well maintained (P = 0.788). The C₇PL‐CSVL at pre‐revision, post‐revision and at last follow‐up were 23.2 ± 9.3 mm, 14.8 ± 4.8 mm and 14.9 ± 5.4 mm, respectively. Significant improvements (P = 0.004) were observed after revision surgery and there was no evident loss of correction (P = 0.703). There was no significant difference in TK, LL and SVA before and after revision surgery (all P > 0.05). At the last follow‐up, no significant correction loss of above coronal and sagittal parameters were observed (all P > 0.05). The revision methods were individualized according to the primary surgical procedures and the reasons for revision. The recommended revision strategies include incision of pseudarthrosis with sufficient bone graft, fixation of satellite rods, thorough residual HV excision, prolonged fusion to S₂ and transforaminal lumbar interbody fusion at lumbosacral region. Solid bony fusion and no implant‐related complication were detected during the follow‐up.ConclusionsThe causes of revision surgery for patients with congenital scoliosis (CS) due to lumbosacral HV were verified and implant failure with pseudarthrosis was the main reason for failed primary operation.     

Risk Factors for the Drift Phenomenon in O‐arm Navigation‐Assisted Pedicle Screw Placement during Spinal Deformity Surgery

ObjectiveIntraoperative O‐arm navigation systems improve the accuracy of spinal instrumentation placement. However, deviation of the pedicle screw from the guide line might occur. The aim of the present study was to explore the causes of and countermeasures for the drift phenomenon during pedicle screw implantation with the aid of an O‐arm three‐dimensional navigation system in spinal deformity surgery.MethodsThis was a retrospective analysis of 341 patients with spinal deformity who underwent O‐arm navigation system‐assisted pedicle screw placement from July 2015 to June 2019. The patient''s general condition, Cobb angle, apical vertebra position, softness index, spinal release status, fixed reference frame position, and distance between the navigation vertebral body and the reference frame were collected and compared by independent‐samples t test or Pearson''s chi‐square analysis. The potential risk factors for the drift phenomenon were identified using binary logistic regression analysis.ResultsThe drift phenomenon occurred in 57 patients during the first navigation‐assisted pedicle screw placement, for an incidence of 16.7% (57/341). There were significant differences in factors such as the apical vertebra position, softness index, spinal release status, and distance between the vertebral body and the reference frame when the drift phenomenon occurred (P < 0.05). Binary logistic regression analysis showed that the softness index, spinal release status, and distance between the vertebral body and the reference frame when drifting occurred were independent risk factors for the drift phenomenon during O‐arm navigation‐assisted pedicle screw placement.ConclusionDuring the use of an O‐arm navigation system to assist with pedicle screw placement, pedicle screws should not be placed away from the reference frame, and spinal osteotomy and release should be performed after pedicle screw placement. In addition, the accuracy of O‐arm navigation‐assisted pedicle screw placement will be affected more in those with larger softness indices.     

Reduction with Pre‐Drilling Combined with a Finger Reduction Tool in Difficult‐to‐Reduce Intertrochanteric Fracture

ObjectiveTo investigate the feasibility of pre‐drilling combined with a finger reduction tool for the reduction of difficult‐to‐reduce intertrochanteric fractures.MethodsPatients diagnosed with complicated intertrochanteric fractures during the period from July 2016 to May 2021 at the Affiliated Hospital of our College were enrolled in this study. All patients underwent reduction by pre‐drilling combined with a finger reduction tool followed by fixing with proximal femoral nail antirotation. The outcome of reduction was evaluated by intraoperative fluoroscopy. The operation time, intraoperative fluoroscopy frequency, and incidence of postoperative complications (including infection in the incision area, coxa vara, nail withdrawal, nail breakage, blade cut‐out, lower limb vein thrombosis, and pulmonary embolism) were recorded to evaluate the speed of the operation, the difficulty of the operation, and the prognosis of the patient, respectively. The Harris hip score at 9 months after surgery was used to evaluate the hip recovery.ResultsA total of 52 patients (17 men and 35 women), 61–88 (77.54 ± 7.40) years of age were included in the study. There were 14 patients with cardiovascular or cerebrovascular disease, ten patients with diabetes, three patients with Parkinson''s disease, and three patients with respiratory diseases. The fractures included in the study were classified according to the Orthopedic Trauma Association 31 classification system as type A2.2 (n = 36) or type A2.3 (n = 16). The time from injury to surgery was 1–11 (3.35 ± 1.78) days, and the operation time ranged 31–101 (65.67 ± 14.17) min. The intraoperative blood loss ranged from 40 to 100 (67.69 ± 18.24) mL, and the number of intraoperative fluoroscopy images obtained was 12 to 32 (20.42 ± 5.27). The Harris hip score at 9 months after surgery ranged from 84 to 94 (90.06 ± 2.15). Patients were followed for 9–16 (10.63 ± 1.61) months. One patient died of acute myocardial infarction at 9 months after surgery. One patient suffered from nail withdrawal 5 months post‐operation and thus underwent hemiarthroplasty.ConclusionsSatisfactory reduction can be achieved using a pre‐drilling femoral trochanter combined with a finger reduction tool for the management of difficult‐to‐reduce complex intertrochanteric fractures. This technique does not increase surgical trauma and also reduces the dose of radiation administered to the patient.     

Destination Joint Spacers: A Similar Infection‐Relief Rate But Higher Complication Rate Compared with Two‐Stage Revision

ObjectiveTo evaluated the clinical outcomes of periprosthetic joint infection (PJI) patients with destination joint spacer compared with that of two‐stage revision.MethodsFrom January 2006 to December 2017, data of PJI patients who underwent implantation with antibiotic‐impregnated cement spacers in our center due to chronic PJI were collected retrospectively. The diagnosis of PJI was based on the American Society for Musculoskeletal Infection (MSIS) criteria for PJI. One of the following must be met for diagnosis of PJI: a sinus tract communicating with the prosthesis; a pathogenis isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; four of the following six criteria exist: (i) elevated ESR and CRP; (ii) elevate dsynovial fluid white blood cell (WBC) count; (iii) elevated synovial fluid neutrophil percentage (PMN%); (iv) presence of purulence in the affected joint; (v) isolation of a microorganism in one periprosthetic tissue or fluid culture; (vi) more than five neutrophilsper high‐power fields in five high‐power fields observed from histological analysis of periprosthetic tissue at ×400 magnification. Age, sex, body mass index (BMI), and laboratory test results were recorded. All patients were followed up regularly after surgery, the infection‐relief rates were recorded, Harris hip score (HHS) and knee society score (KSS) were used for functional evaluation, a Doppler ultrasonography of the lower limb veins was performed for complication evaluation. The infection‐relief rates and complications were compared between destination joint spacer group and two‐stage revision group.ResultsA total of 62 patients who were diagnosed with chronic PJI were enrolled, with an age of 65.13 ± 9.94 (39–88) years. There were 21 cases in the destination joint spacer group and 41 cases in the temporary spacer group, namely, two‐stage revision group (reimplantation of prosthesis after infection relief). The Charlson comorbidity index (CCI) in the destination joint spacer group was higher than that in the temporary spacer group, and this might be the primary reason for joint spacer retainment. As for infection‐relief rate, there were three cases of recurrent infection (14.29%) in the destination joint spacer group and four cases of recurrent infection (9.76%) in the two‐stage revision group, there were no significant differences with regard to infection‐relief rate. Moreover, there two patients who suffered from spacer fractures, three cases of dislocation, one case of a periarticular fracture, and three cases of deep venous thrombosis in destination joint spacer group, while there was only one case of periprosthetic hip joint fracture, one case of dislocation, and one patient suffered from deep venous thrombosis of the lower extremity in two‐stage revision. The incidence of complications in the destination joint spacer group was higher than that of two‐stage revision.ConclusionsIn summary, the present work showed that a destination joint spacer might be provided as a last resort for certain PJI patients due to similar infection‐relief rate compared with two‐stage revision.     

Freehand S2‐Alar‐Iliac Screw Placement Technique in Lumbosacral Spinal Tumors: A Preliminary Study

ObjectiveS2‐alar‐iliac (S2AI) screw technique is widely used in spinal surgery, but it is rarely seen in the field of spinal tumors. The aim of the study is to report the preliminary outcomes of the freehand S2AI screw fixation after lumbosaral tumor resection.MethodsThe records of patients with lumbosacral tumor who underwent S2AI screw fixation between November 2016 to November 2020 at our center were reviewed retrospectively. Outcome measures included operative time, blood loss, complications, accuracy of screws, screw breach, and overall survival. Mean ± standard deviation or range was used to present continuous variables. Kaplan–Meier curve was used to present postoperative survival.ResultsA total of 23 patients were identified in this study, including 12 males and 11 females, with an average age of 47.3 ± 14.5 (range,15–73). The mean operation time was 224.6 ± 54.1 (range, 155–370 min). The average estimated blood loss was 1560.9 ± 887.0 (600–4000 ml). A total of 46 S2AI screws were implanted by freehand technique. CT scans showed three (6.5%) screws had penetrated the iliac cortex, indicating 93.5% implantation accuracy rate. No complications of iatrogenic neurovascular or visceral structure were observed. The average follow‐up time was 31.6 ± 15.3 months (range, 13–60 months). Two patients'' postoperative plain radiography showed lucent zone around the screw. One patient underwent reoperation for wound delayed infection. At the latest follow‐up, eight patients had tumor‐free survival, 11 had survival with tumor, and four died of disease.ConclusionThe freehand S2AI screw technique is reproducible, safe, and reliable in the management of lumbosacral spinal tumors.     

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.     

Biomechanical Evaluation of the Cross‐link Usage and Position in the Single and Multiple Segment Posterior Lumbar Interbody Fusion

ObjectivePrevious studies have neither explored the usage of cross‐links nor investigated the optimal position of the cross‐links in posterior lumbar interbody fusion (PLIF). This study evaluates biomechanical properties of cross‐links in terms of different fixation segments and optimal position in single‐ and multi‐segment posterior lumbar interbody fusion.MethodsTwo finite element (FE) models of instrumented lumbosacral spine with single‐(L4/5) and multi‐segment (L3‐S1) PLIF surgery were simulated. On the basis of the two models, the benefits of the usage of cross‐links were assessed and compared with the status of no application of cross‐links. Moreover, the effects of position of cross‐links on multi‐segment PLIF surgery were studied in Upper, Middle, and Lower positions.ResultsNo significant difference was found in the range of motion (ROM), intersegmental rotational angle (IRA) of adjacent segments, and intradiscal pressure (IDP) regardless of the usage of cross‐links in the single‐segment PLIF surgery, while the cross‐link increased the maximum von Mises stress in the fixation (MSF) under the axial rotation (53.65 MPa vs 41.42 MPa). In the multi‐segment PLIF surgery, the usage of cross‐links showed anti‐rotational advantages indicated by ROM (Without Cross‐link 2.35^o, Upper, 2.24^o; Middle, 2.26^o; Lower, 2.30^o) and IRA (Without Cross‐link 1.19^o, Upper, 1.08^o; Middle, 1.09^o; Lower, 1.13^o). The greatest values of MSF were found in without cross‐link case under the flexion, lateral bending, and axial rotation (37.48, 62.61, and 86.73 MPa). The application of cross‐links at the Middle and Lower positions had lower values of MSF (48.79 and 69.62 MPa) under the lateral bending and axial rotation, respectively.ConclusionThe application of cross‐links was not beneficial for the single‐segment PLIF, while it was found highly advantageous for the multi‐segment PLIF. Moreover, the usage of cross‐links at the Middle or Lower positions resulted in a better biomechanical stability.     

Effect of Resistance Training Combined with Beta‐Hydroxy‐Beta‐Methylbutyric Acid Supplements in Elderly Patients with Sarcopenia after Hip Replacement

ObjectivesTo evaluate the efficacy of resistance training (RT) combined with beta‐hydroxy‐beta‐methylbutyric acid (HMB) in the treatment of elderly patients with sarcopenia after hip replacement.MethodsFrom January 1, 2018 to December 31, 2018, 200 elderly patients (68 men, mean age 76.3 years and 137 women, mean age 79.1 years) who experienced femoral neck fracture with sarcopenia after hip arthroplasty were assigned to four groups: RT + HMB group, RT group, HMB group, and negative control group. Baseline data, body composition, grip strength, Barthel index (BI), Harris hip score (HHS), and visual analog scale score (VAS) were compared among the four groups before and 3 months after surgery.ResultsA total of 177 participants completed the trial, including 43 in the HMB + RT group, 44 in the HMB group, 45 in the RT group, and 45 in the negative control group. At the 3‐month follow‐up, the body composition and grip strength of the HMB + RT group and RT group were significantly improved compared with those before operation. The HMB group had no significant change, while the measures in the negative control group significantly decreased. Postoperative BI and HSS did not reach pre‐injury levels in any of the four groups, but postoperative VAS score was significantly improved. However, there was no significant difference in BI, HSS, or VAS among the four groups.ConclusionRT, with or without HMB supplementation, can effectively improve body composition and grip strength in elderly patients with sarcopenia after hip replacement at short‐term follow‐up. Simultaneously, use of exclusive HMB supplementation alone may also help to prevent decreases in muscle mass and grip strength in these patients.     

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.     

Application of Spinal Robotic Navigation Technology to Minimally Invasive Percutaneous Treatment of Spinal Fractures: A Clinical,Non‐Randomized,Controlled Study

ObjectiveTo introduce a new robotic navigation system that assists pedicle screw implantation and verify the accuracy and stability of the system.MethodsPedicle screw placements were performed on the thoracic vertebrae (T)9–Lumbar vertebrae (L)5 thoracolumbar vertebrae of cadavers using robotic guidance. The operative duration, puncture success, correction, and correction time were assessed. Additionally, a total of 30 thoracolumbar fractures from September 2017 until June 2019 were included in a clinical study. Two groups were evaluated: the robotic guidance group and freehand group. Both sexes were evaluated. Mean ages were 47.0 and 49.1 years, respectively, in the robotic and freehand groups. Inclusion criteria was age >18 years and a thoracolumbar fracture. Intervention was the operative treatment of thoracolumbar fractures. Outcome parameters were the operation time, intraoperative bleeding, and fluoroscopic data. The accuracy of the pedicle screw placement and screw penetration rate of the two groups were compared using intraoperative fluoroscopic axial images.ResultsThe success rate for 108 one‐time nail placements in cadavers was 88% and two‐time nail placement was 100%. Vertebral punctures at L5 took the longest to perform and achieve correction. Clinically, there were no significant differences in patients'' sex, body mass index, age distribution, or intraoperative bleeding between the groups. The average X‐ray exposure time for patients and operators were 37.69 ± 9.24 s and 0 s in the robotic group (significantly lower than in the freehand group: 81.24 ± 6.97 s vs 56.29 ± 7.93 s, respectively). Success rates for one‐time screw placements were 98.64 and 88.46% in the robotic and freehand groups, respectively, which is significant. Screw penetration rates (1.36% vs 11.54%, robotic vs freehand), were significantly different.ConclusionsThe robotic system improved the accuracy and safety of pedicle screw internal fixation and reduced patients'' and operators'' intraoperative radiation exposure.     

Application of Oblique Lateral Interbody Fusion in Treatment of Lumbar Spinal Tuberculosis in Adults

ObjectiveThe purpose of the present paper was to evaluate the safety and clinical efficacy of mini‐open retroperitoneal oblique lumbar interbody fusion (OLIF) for the treatment of lumbar spinal tuberculosis.MethodsA total of 115 patients who suffered from lumbar spinal tuberculosis from June 2014 to December 2017 were included in this research. A total of 59 patients underwent OLIF and percutaneous pedicle screw fixation (OLIF group) and 56 patients underwent the anterior‐only approach (anterior‐only group). All patients were followed up for at least 24 months. Operation time, blood loss, and rate of complications were used to assess the safety of these two techniques. The visual analog scale (VAS) and the Oswestry disability index (ODI) were used to evaluate the relief of neurological and functional symptoms. The erythrocyte sedimentation rate (ESR) and C‐reactive protein (CRP) were measured to investigate the activity and recurrence of spinal tuberculosis. The Cobb angle, the sagittal vertical axis of the spine (SVA), the pelvic tilt (PT), the sacral slope (SS), the pelvic incidence (PI), and postoperative Frankel classification were also used to assess the efficiency of the spine deformity correction and the recovery of long‐term neurological function.ResultsMost patients were successfully treated with OLIF and the anterior‐only technique and attained satisfactory clinical efficiency during the 24‐month follow‐up period. In the perioperative period, the mean operative time (154.68 ± 23.64 min, P < 0.001), the mean blood loss (110.57 ± 87.67 mL, P < 0.001), and the mean hospital stay (9.55 ± 3.62 days, P < 0.001) of the OLIF group were all significantly lower than in the anterior‐only group (172.49 ± 25.67 min, 458.56 ± 114.89 mL, and 14.89 ± 3.89 days, respectively). A total of 10 patients (16.95%) experienced complications in the OLIF group, including neurological injury, segmental artery and iliac vein lacerations, peritoneal injury, instrument failure, and infection of incisions; this rate of complications was lower than in the anterior‐only group (37.50%, P = 0.013). Regard to spinal deformity correction, the Cobb angle (9.42° ± 1.72°, P = 0.032), the SVA (2.23 ± 1.07 cm, P = 0.041), the PT (14.26° ± 2.37°, P = 0.037), and the SS (39.49° ± 2.17°, P = 0.042) of the OLIF group at last follow‐up were all significantly different when compared to the anterior‐only group (14.75° ± 2.13°, 3.48 ± 0.76 cm, 18.58° ± 1.45°, and 36.78° ± 1.96°, respectively). The VAS and the ODI of the OLIF group at 1 week postoperatively (3.15 ± 0.48, 21.85 ± 3.78, P = 0.032, 0.037) and at the last follow‐up (2.12 ± 0.35, 16.70 ± 5.25, P = 0.043, 0.035) were both lower than for the anterior‐only group (5.18 ± 0.56, 29.83 ± 5.42 and 3.67 ± 0.62, 20.68 ± 6.23). The Frankel classification was improved for both OLIF and anterior‐only patients; however, there were 35 cases (59.32%) classified as Frankel grade E in the OLIF group and 22 cases (39.29%, P = 0.021) in the anterior‐only groupConclusionThe OLIF surgical technique for single lumbar (L₂–L₅) spinal tuberculosis is less invasive, has lower complication rates, and is more efficient than the anterior‐only approach. However, the long‐term effects of this surgical technique still need to be explored.     

Decreased expression of miR‐204‐3p in peripheral blood and wound margin tissue associated with the onset and poor wound healing of diabetic foot ulcers

To investigate the relationship between small non‐coding RNA‐204‐3p (miR‐204‐3p) and the onset and wound healing of diabetic foot ulcers (DFU) and the underlying molecular mechanism, sixty four newly diagnosed patients with T2DM without DFU (T2DM group), 82 T2DM patients with DFU (DFU group), and 60 controls with normal glucose tolerance (NC group) were included. Quantitative real‐time PCR (qRT‐PCR) method was used to determine miR‐204‐3p expression levels in peripheral blood and wound margin tissue of subjects, and to analyse the relationship between the expression of miR‐204‐3p and wound healing. In vitro experiments were also performed to understand the effect of miR‐204‐3p on high glucose induced injury of HaCaT cells (human keratinocytes). The results showed that miR‐204‐3p expression level of peripheral blood in the T2DM group was marked lower than that in the NC group [2.38 (1.31‐5.04) vs 3.27 (1.51‐6.98)] (P < .05). Similarly, the miR‐204‐3p expression level of peripheral blood in the DFU group was significantly lower than the T2DM group [1.15 (0.78‐2.89) vs 2.38 (1.31‐5.04)] (P < .01). The expression level of miR‐204‐3p in peripheral blood and wound margin tissues of DFU patients was positively correlated with the healing rate of foot ulcers after 8 weeks (P < .05). Multifactorial logistic regression analysis showed that decreased expression of miR‐204‐3p in peripheral blood was an independent risk factor for DFU (OR = 2.95, P < .05). The results of in vitro experiments showed that miR‐204‐3p could improve the proliferation and migration of HKC cells and reduce the proportion of apoptosis of HKC cells by targeted regulation of zinc finger protein Kruppel like factor 6 (KLF6) in high glucose environment. Therefore, the decreased expression of miR‐204‐3p in peripheral blood and wound tissue of T2DM patients is closely related to the occurrence and poor wound healing of DFU. The down‐regulated expression of miR‐204‐3p can reduce its ability to antagonise the functional damage of keratinocytes induced by high‐glucose conditions. These results will provide potential targets for the treatment of DFU.     

Effectiveness and Feasibility of Injectable Escherichia coli‐Derived Recombinant Human Bone Morphogenetic Protein‐2 for Anterior Lumbar Interbody Fusion at the Lumbosacral Junction in Adult Spinal Deformity Surgery: A Clinical Pilot Study

ObjectiveTo explore the effectiveness and feasibility of injectable Escherichia coli‐derived recombinant human bone morphogenetic protein‐2 (injectable E‐rhBMP‐2, a combination of E. coli‐derived recombinant human bone morphogenic protein‐2 and a hydrogel type beta‐tricalcium phosphate carrier) as a bone substitute for anterior lumbar interbody fusion (ALIF) of the lumbosacral junction in adult spinal deformity (ASD) patients.MethodsA prospective single‐institution therapeutic exploratory trial was conducted. Twenty patients (average age: 69.1 years; 19 female and one male; average fusion level: 7.95) diagnosed with ASD with sagittal imbalance who underwent surgical treatment including ALIF at the lumbosacral junction from December 2017 to January 2019 were evaluated. Injectable E‐rhBMP‐2 was prepared by dissolving 3 mg of E. coli‐derived recombinant human bone morphogenetic protein‐2 in 1.5 ml H₂O and mixing in situ with 9 g hydrogel type beta‐tricalcium phosphate. This bone graft substitute was loaded onto a metal ALIF cage and L₅–S₁ ALIF was performed in routine manner. Then posterior column osteotomy with multilevel oblique lumbar interbody fusion or pedicle subtraction osteotomy with accessory rod technique was performed to restore sagittal balance. Patients were followed up for 12 months. CT‐based fusion rates were examined at 6 and 12 months after surgery. Also, clinical outcomes (Oswestry Disability Index [ODI], Visual Analog Scale [VAS] score of the back and leg) were evaluated at 6 and 12 months after surgery. All postoperative adverse events were evaluated for the association with injectable E.BMP‐2.ResultsOf the 20 patients, loss to follow‐up occurred with one patient at 6 months after surgery and one patient at 12 months after surgery, resulting in a total of 18 patients who were available for follow‐up. Six months after surgery, 68.4% patients achieved solid fusion. Twelve months after surgery, 100% fusion rate was achieved. Compared to baseline values, ODI scores improved to 45.8% and 63.7%, VAS (back) improved to 69.2% and 72.8%, and VAS (leg) improved to 49.2% and 64.8%, respectively, at 6 and 12 months after surgery (p < 0.001 for all). Ten cases of adverse events occurred. But no adverse events were associated with injectable E‐rhBMP‐2.ConclusionInjectable E‐rhBMP‐2 will be an effective bone graft substitute when achieving solid interbody fusion in the lumbosacral junction.     

Factors Associated with Shoulder Range of Motion After Arthroscopic Rotator Cuff Repair: A Hospital‐Based Prospective Study

ObjectiveTo assess the factors associated with outcomes of arthroscopic surgical repair of rotator cuff tears (RCTs).MethodThis prospective study recruited patients, at least 18 years old, who underwent arthroscopic rotator cuff repair for full‐thickness RCTs at the First People''s Hospital of Hangzhou Xiaoshan between July 2019 and October 2020. Patient demographics, lifestyle habits, and medical histories were collected preoperatively; RCT sizes and affected tendons were determined intraoperatively. Outcomes were assessed by shoulder range of motion (ROM) determinations 1.5 and 3 months postoperatively. The factors associated with ROM were determined using a binary logistic regression analysis, and the results were expressed as adjusted relative risks (RRs) and 95% confidence intervals (CIs).ResultsA total of 132 patients with RCTs underwent arthroscopic surgery. Five were lost to follow‐up, leaving 127 patients (mean age, 59 years; 58.3% women) who were included in the study analysis. The majority of the patients (54.5%) had RCTs that were classified as large or massive, and approximately 20% had tears involving multiple tendons; 80.3% of the patients had tears involving only a single tendon. Moreover, 29.9% of the patients had hypertension and 11.0% had diabetes. Among the patients, 23.0% were smokers and 34.6% drank alcohol. According to the multivariate analysis, none of the assessed factors were associated with shoulder ROM at the 1.5‐month follow‐up. At the 3‐month follow‐up, RCTs involving a single tendon demonstrated 3‐fold better abduction (RR = 4.00; 95% CI, 1.30–12.33; P = 0.016) and 3.15‐fold better internal rotation (RR = 3.15; 95% CI, 1.19–8.36; P = 0.021) than did RCTs involving multiple tendons. Patients who did not drink alcohol demonstrated 6.08‐fold better anteflexion (RR = 7.08; 95% CI, 2.11–23.73; P = 0.002) and nearly 4‐fold better abduction (RR = 4.97; 95% CI, 1.62–15.23; P = 0.005) than patients who drank alcohol.ConclusionTo improve outcomes, the results indicate that more targeted measures should be directed toward patients with multiple‐tendon RCTs and that preoperative alcohol abstinence education is needed for patients with RCTs.