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

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

Age‐ and Gender‐Specific Epidemiologic Characteristics of Major Intra‐Articular Fractures: Five‐Year Data from a Level 1 Trauma Center

ObjectiveTo investigate the epidemiological characteristics of major intra‐articular fractures.MethodsThis retrospective study enrolled patients with major intra‐articular fractures who were treated in the Third Hospital of Hebei Medical University from January 2015 to December 2019. A total of 11,084 patients (7,338 [66.20%] males and 3,746 [33.80%] females) meeting the inclusion and exclusion criteria were included. The distribution characteristics of intra‐articular fractures involving shoulder, elbow, wrist, hip, knee, ankle, and subtalar joints were identified.The potential associations between fractures and various other factors, such as age, gender, sites, were explored.ResultsThere were 74 cases (0.67%) of shoulder fractures, 1,941 cases (17.51%) of elbow fractures, 1,155 cases (10.42%) of wrist fractures, 520 cases (4.69%) of hip fractures, 3,118 cases (28.13%) of knee fractures, 2,156 cases (19.45%) of ankle fractures, and 2,120 cases (19.13%) of subtalar fractures. The overall male‐to‐female ratio was 1.96:1. The highest proportion age group of major intra‐articular fractures included the ages 45–54 years. For males, the highest proportion age group was 45–54 years, for females, it was 55–64 years. The knee joint fracture was the most common type, accounting for 28.13%. For male and female patients, knee fractures accounted for 26.19% and 31.93%, respectively, with a male to female ratio of 1.13:1. The proportion of shoulder fractures was the smallest among this investigation, accounting for 0.67%. For male and female patients, shoulder fractures accounted for 0.44% and 1.12%, respectively, with a male to female ratio of 0.76:1. The age group with the highest proportion of shoulder joint fractures was ≥65 year olds (41.89%), with a male to female ratio of 0.76:1. The age group with the highest risk of elbow, wrist, hip, knee, ankle, and subtalar joint fracture was 5–14 year olds (33.59%) with a male to female ratio of 3.29:1, 5–14 year olds (23.98%) with a male to female ratio of 6.91:1, 45–54 year olds (26.92%) with a male to female ratio of 5.67:1, 45–54 year olds (24.60%) with a male to female ratio of 1.68:1, 25–34 year olds (20.36%) with a male to female ratio of 2.30:1, 45–54 year olds (27.41%) with a male to female ratio of 9.02:1, respectively. The most common site of intra‐articular fractures in different age groups was corresponding as follows: 0–4 year olds (elbow), 5–14 year olds (elbow), 15–24 year olds (ankle), 25–34 year olds (subtalar joint), 35–44 year olds (subtalar joint), 45–54 year olds (knee), 55–64 year olds (knee), 65–74 year olds (knee), and ≥75 year olds (knee).ConclusionThe current study revealed the age‐ and gender‐specific epidemiological characteristics of major intra‐articular fractures, providing a basis for clinical evaluation and practices.     

Comparison of Robot‐Assisted Percutaneous Cannulated Screws Versus Open Reduction and Internal Fixation in Calcaneal Fractures

ObjectiveAccurate placement of the screws is challenging in percutaneous cannulated screw fixation of calcaneal fractures, and robot‐assisted (RA) surgery enhances the accuracy. We investigated the outcome of percutaneous cannulated screw fixation of Sander''s type II and III calcaneal fractures.MethodsThis retrospective study analyzed clinical data of 26 patients with fresh closed calcaneal fractures (28 fractures) who were admitted to our center from January 2022 to July 2022. All fractures were divided into the RA group and the open reduction and internal fixation (ORIF) group according to the surgeries performed. RA surgery was performed by closed reduction or open reduction combined with a tarsal sinus approach. Age, sex, operation time, preoperative waiting time, length of postoperative hospital stay, wound complications, and American Orthopaedic Foot and Ankle Society Ankle Hindfoot Scale (AOFAS) at 3 months postoperatively were compared. Preoperative and postoperative radiographic parameters (calcaneal length, width, height, Böhler angle, and fixation rate of the sustentaculum tali) were documented. The chi‐square test, one‐way analysis of variance, and Wilcoxon test were used for the comparison of categorical, normally distributed, and nonnormally distributed continuous variables, respectively.ResultsThe calcaneal width, height, and Böhler angle were significantly corrected postoperatively in both groups. The postoperative calcaneal lengths in both groups were also corrected. However, no significant difference was found. No significant differences in calcaneal length, width, height, and Böhler angle were observed between the two groups. The operation time (p < 0.001), preoperative waiting time (p < 0.001), and length of postoperative hospital stay (p = 0.003) in the RA surgery group were significantly shorter than those in the ORIF group. The fixation rate of the sustentaculum tali (p < 0.001) in the RA surgery group was significantly superior to that in the ORIF group. All wound complications occurred in the ORIF group. All fractures healed within 3 months. The AOFAS scores at 3 months postoperatively were not significantly different.ConclusionRA percutaneous screw fixation of the calcaneal fracture is a safe, effective, rapid, and minimally invasive surgical option for surgeons.     

Management of Failed External Fixation by Two‐Staged Internal Osteosynthesis in the Lower Limb

ObjectiveThis study aims to evaluate the result of a two‐stage (delayed conversion) management of nonunion after failed external fixation of the lower limb.MethodsA case series of 25 patients (19 males and six females) enrolled in this study between February 2008 and October 2016, mean age 33.4 years (range, 22–65 years). Eight had femoral fractures, and 17 had tibial fractures. All were due to high‐energy trauma and were open fractures. All cases were presented by non‐union after external fixation in the lower limb long bones. All patients were managed by two stages (delayed conversion) osteosynthesis. The patients have been assessed for rate and time for union, range of motion of adjacent joints, the Modified functional outcome score of Karlstrom‐Olerud, and Trauma outcomes measure score.ResultsThe mean follow‐up was 36.5 months (range 24–54 months). Twenty‐two cases (88%) were fully united on an average of 5.3 months. According to the Karlstrom‐Olerud scores, the final functional outcome score was excellent 12 cases, good 9 cases, accepted 2 cases, and poor in two cases. As regards the trauma outcome measure score, the mean TOM after 3 months was 26.1 (25.3–27.3), 30.4 (29.3–32.1) after 12 months, and 33.4 (32.3–40) after 24 months.ConclusionsThe technique of two‐stage treatment of nonunions of long bone after external fixation is a successful tool to achieve bony union. It could be a favorable option with a low risk of complications and a high level of functional outcomes.     

Three‐Dimensional Printing‐Assisted Masquelet Technique in the Treatment of Calcaneal Defects

ObjectiveThe aim of the present study was to summarize the clinical efficacy of three‐dimensional (3D) printing technology combined with the Masquelet technique in the treatment of calcaneal defects.MethodsFrom January 2018 to April 2019, 3D printing combined with induced masquelet technology was used to treat four patients with calcaneal defects, including two men and two women. The patients were aged 22–52 years old, with an average age of 36 years. There were two cases of traffic accident injuries, there was one case of a fall from height, and there was one case of crush injury. CT scans were used to reconstruct the bilateral calcaneus, mirror technology was used to construct the bone defect area, and Materialise 3‐matic software was used to design the calcaneus shaper mold and 3D print the mold. During the operation, the mold was used to shape the bone cement and fill the bone defect. In the second stage, the bone cement was removed and autologous bone was implanted to repair the bone defect. All patients were followed up to observe the effect.ResultsAll four patients were followed up for 14 months (range, 10–18 months). There were three cases of infectious bone defects: two cases of Escherichia coli and one case of Pseudomonas aeruginosa. The 3D printed mold was used to shape the bone cement. During the operation, it was found to have a high degree of matching with the defect area of calcaneus. There is no need to adjust it again, and the wound healed well after the first stage. In the second stage of surgery, it was found that the induced membrane formed was complete and of appropriate size; the bone cement was easily removed during the operation. The fracture healing time was 3–6 months, with an average of 4 months. At the last follow up, there was no pain and the patients walked with full weight bearing. The Maryland score was 94 points (range, 88–98 points); three cases were excellent and one case was good. The AOFAS score ranged from 86 to 98, with an average of 92.8 points; three cases were excellent and one case was good.ConclusionThree‐dimensional printing technology combined with induced membrane technology is an effective approach for treating calcaneal bone defects.     

外固定支架结合闭合复位有限内固定微创治疗桡骨远端AOC3型骨折的比较研究

目的比较闭合复位有限内固定结合外固定支架与单纯石膏外固定治疗桡骨远端AO C3型骨折的临床疗效。方法随访2005年6月～2010年10月36例桡骨远端AO C3型骨折,其中18例予以单纯石膏固定（石膏组）,18例采用外固定支架结合闭合复位有限内固定（支架组）。随访至术后24周,比较两组患侧临床功能（改良Gartland-Werley功能评分）及X线表现（改良Lidstrom-Radiographic评分系统）。结果所有患者均骨性愈合,无明显感染等严重并发症。术后24周,临床疗效（改良Gartland-Werley功能评分）：支架组腕关节屈（45.06±3.04）°,伸（52.83±2.94）°,桡偏（22.83±2.33）°,尺偏（36.33±5.29）°,旋前（51.67±4.16）°,旋后（44.89±4.13）°;石膏组屈（41.56±3.01）°,伸（49.56±3.58）°,桡偏（20.61±2.17）°,尺偏（31.22±5.35）°,旋前（46.33±4.12）°,旋后（41.33±2.93）°。X线表现（改良Lidstrom-Radiographic评分系统）：支架组桡骨高度（9.11±1.23）mm,掌倾角（16.00±2.40）°,尺偏角（16.39±1.79）°,关节面台阶（1.11±0.76）mm;石膏组桡骨高度（7.61±1.65）mm,掌倾角（13.44±2.48）°,尺偏角（12.67±3.83）°,关节面台阶（2.22±0.94）mm。各项指标支架组均显著优于石膏组（P〈0.01）。结论对于桡骨远端AO C3型粉碎性骨折,采用外固定支架结合闭合复位有限内固定是一种微创有效的方法,但需要注意桡神经浅支损伤等并发症。     

Comparison of Three‐Dimensional Navigation‐Guided Percutaneous Iliosacral Screw and Minimally Invasive Percutaneous Plate for the Treatment of Zone II Unstable Sacral Fractures

ObjectiveThe percutaneous IS screws and the minimally invasive percutaneous plate are the most popular internal methods for Zone II unstable sacral fractures. However, the choice of fixation remains controversial for orthopaedic surgeons. The purpose of study was to evaluate and compare the clinical results of percutaneous iliosacral (IS) screw fixation under three‐dimensional (3D) navigation and minimally invasive percutaneous plate fixation in the treatment of Zone II unstable sacral fractures.MethodsA retrospective study was performed, including 64 patients with Zone II unstable sacral fractures who underwent percutaneous IS screw fixation under 3D navigation (navigation group) and minimally invasive percutaneous plate fixation (plate group) from January 2011 and March 2021 in our department. The age, gender, fracture type, mechanism of injury, injury severity score (ISS), time from admission to operation, operative time, intraoperative blood loss, hospital stay, incision length, follow‐up time, time to clinical healing, and complications were recorded and analyzed. Matta standard was used to assess fracture reduction outcomes. The Majeed function system assessed functional outcomes at the last follow‐up.ResultsThe average follow‐up time was (14.42 ± 1.57) months in the navigation group and (14.79 ± 1.37) months in the plate group. No statistical difference between the two groups in age, gender, fracture type, mechanism of injury, ISS, time from admission to operation, and time to clinical healing. However, significant differences were detected in operative time, intraoperative blood loss, hospital stay, and incision length (p < 0.001). According to Matta standard at 2 days postoperatively, the excellent and good rate was 91.42% in the navigation group, and it was 93.10% in the plate group. There was no significant difference between the two groups (p = 0.961). According to Majeed function system at the follow‐up, the excellent and good rate was 97.14% in the navigation group, and 93.10% in the plate group. The difference between the two groups was not statistically significant (p = 0.748). There were no neurovascular injuries associated with this procedure. The incidence of complications was 44.82% (13/29) in the plate group, while 14.28% (5/35) in the navigation group (p = 0.007).ConclusionThis study found that compared with minimally invasive percutaneous plate fixation, percutaneous IS screw fixation under 3D navigation is a suitable option for the treatment of Zone II unstable sacral fractures. This approach is characterized by its shorter operation time, less surgical trauma, less bleeding, less hospital time, and fewer complications.     

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.     

经皮微创内侧锁定板固定治疗胫骨下段骨折

目的观察经皮微创钢板固定（minimally invasive percutaneous plate osteosynthesis,MIPPO）技术治疗胫骨下段骨折的临床疗效。方法对2009年1月至2011年2月收治的29例胫骨下段骨折病例采用MIPPO技术结合锁定加压接骨板（locking compression plate,LCP）治疗,其中男23例,女6例;年龄20~71岁,平均47.7岁。对临床疗效进行回顾性分析。结果其中26例获得随访,时间12~24个月,平均14个月。1例软组织感染,骨折均愈合,愈合时间3~6个月,平均4.2个月。按Johner-Wruhs评分标准评定疗效,其中优23例,良2例,可1例,优良率为96.2%。结论采用MIPPO技术结合LCP治疗胫骨下段骨折,具有创伤小、手术时间短、骨折愈合率高、功能好的优点,是治疗胫骨下段骨折的理想方法。但需重视小腿内侧软组织条件,严格掌握适应证,避免软组织并发症。     

Clinical Outcomes of the Modified Stoppa Combined with Iliac Fossa Approach for Complex Acetabular Fractures: A Medium‐ and Long‐term Retrospective Study

ObjectiveThe modified Stoppa combined with iliac fossa approach has gained increasing popularity. Although early clinical outcomes have been satisfactory, extensive long‐term clinical outcomes are relatively scarce. The purpose of this study was to evaluate the medium‐ and long‐term outcomes of this approach for complex acetabular fractures.MethodsThis was a retrospective study involving 57 patients with complex acetabular fractures from January 2009 to January 2016. All fractures were treated with the modified Stoppa combined with iliac fossa approach. Follow‐up was at least 5 years. Primary outcome measures, including quality of reduction and clinical outcomes, were recorded by an independent observer. Secondary outcome measures included time to surgery, surgical time, intraoperative blood loss, and perioperative complications.ResultsFifty‐seven patients (range, 18–80 years) included 46 males and 11 females. There were 32 cases on the left side and 25 cases on the right side. The most common associated injury was pulmonary contusion. According to the Judet–Letournel classification, there were 27 both‐column fractures, 16 anterior column with posterior hemitransverse fractures and 14 T‐type fractures. The average time from injury to surgery was 7.3 days. The average intraoperative blood loss and transfusion were 750.9 ml and 564.3 ml, respectively. All fractures healed within 6 months after surgery. The average follow‐up time was 7.7 years, and there was no loss of follow‐up. The quality of reduction was graded as anatomical in 23 cases (40.4%), imperfect in 22 cases (38.6%), and poor in 12 cases (21.0%). According to grading system of Merle d’ Aubigne and Postel, clinical outcomes at 1 year follow‐up were excellent in 17 cases (29.8%), good in 25 cases (43.9%), fair in four cases (7.0%), and poor in 11 cases (19.3%). The excellent and good rate was 73.7% and the difference was not statistically significant compared with the clinical outcomes at the last follow‐up. Intraoperative complications included four cases of obturator nerve injury and two cases of vascular injury. Postoperative complications included one case of wound delayed healing, two cases of deep vein thrombosis, two cases of avascular necrosis of femoral head, three cases of heterotopic ossification and five cases of post‐traumatic arthritis. Only one of these patients underwent reoperation for femoral head necrosis.ConclusionsThe modified Stoppa combined with iliac fossa approach can achieve satisfactory reduction quality and hip function. It might be a valuable alternative to the ilioinguinal approach for the surgical management of acetabular fractures.     

Clinical Observations of Kümmell Disease Treatment Through Percutaneous Fixation Combined with Vertebroplasty

ObjectiveTo explore the safety and efficacy of percutaneous pedicle screw fixation combined with vertebroplasty for the treatment of stage III Kümmell disease.MethodsThe clinical data and follow‐up results of 22 patients with Kümmell disease who were admitted to our department from 2014 to 2018 were analyzed. There were 14 females and eight males, and the Age range was 58–81 years. All patients were followed up for 24 months. The treatment method was percutaneous pedicle screw fixation combined with vertebroplasty. The patient general information such as age, gender, bedrest time and location of fracture vertebrae were recorded. The clinical symptoms and imaging data of visual analogue scale (VAS), bone cement leakage, Oswestry Disability Index (ODI), Cobb angle, anterior, middle and posterior height of the diseased vertebral body, and complications were recorded before operation and during follow‐up.ResultsFor patients enrolled, no bone cement leakage was observed during the operation; no patients developed infections after operation. The operation was safe and resulted in a short bedrest time. The VAS score and ODI index at 3 and 24 months postoperative (2.86 ± 0.83, 31.68% ± 6.21%; 3.0 ± 0.82, 32.78% ± 6.05%) were significantly lower than that recoded preoperatively (7.59 ± 0.59, 71.5% ± 8.84%) (P < 0.05). Additionally, there was no significant difference between the records at 3 and 24 months after operation (P > 0.05). Imaging data showed that the bone cement and screws were in good position and did not move during postoperative and follow‐up. The anterior, middle and posterior height of the diseased vertebral body measured 2 days after surgery (23.46 ± 4.72, 23.12 ± 3.05, 25.81 ± 2.22) and at last follow‐up (20.83 ± 4.48, 21.78 ± 2.74, 24.74 ± 1.93) were higher than that recorded preoperatively (13.08 ± 4.49, 12.93 ± 3.53, 19.32 ± 2.73) (P < 0.05), and the Cobb angle measured 2 days and 24 months after operation (9.57 ± 4.63, 10.68 ± 3.97) were lower than that recorded preoperatively (28.24 ± 8.95) (P < 0.05), and no significant difference was found between the values recorded at 2 days and 24 months after operation (P > 0.05). Follow‐up for 24 months, there was no re‐fracture of the diseased vertebrae and internal fixation loosening, but two cases of adjacent vertebral refracture complications occurred, and the effect was good after PVP treatment.ConclusionShort‐segment percutaneous pedicle screw fixation combined with vertebroplasty in the treatment of stage III Kümmel disease can effectively restore the height of the diseased vertebrae, kyphosis correction, reduce trauma, prevent the diseased vertebral body from collapsing again, and effectively improves clinical symptoms.     

Intra‐Articular Biomechanical Changes of the Meniscus and Ligaments During Stance Phase of Gait Circle after Different Anterior Cruciate Ligament Reconstruction Surgical Procedures: A Finite Element Analysis

ObjectiveThe debate on the superiority of single‐ or double‐bundle for anterior cruciate ligament reconstruction has not ceased. The comparative studies on intra‐articular biomechanics after different surgical reconstructions are rare. This study is to evaluate the biomechanical stress distribution intra‐knee after single‐ and double‐bundle anterior cruciate ligament reconstruction by three‐dimensional finite element analysis, and to observe the change of stress concentration under the condition of vertical gradient loads.MethodsIn this study, magnetic resonance imaging data were extracted from patients and healthy controls for biomechanical analysis. Patients included in the three models were matched in age and sex. The strength and distribution of induced stresses were analyzed in two frequently used procedures, anatomical single‐bundle anterior cruciate ligament reconstruction and anatomical double‐bundle anterior cruciate ligament reconstruction, using femoral‐graft‐tibial system under different loads, to mimic a post‐operation mechanical motion. The three‐dimensional finite‐element models for normal ligament and two surgical methods were applied. A vertical force simulating daily walking was performed on the models to assess the interfacial stresses and displacements of intra‐articular tissues and ligaments. The evaluation results mainly included the stress of each part of ligament and meniscus. The stress values of different parts of three models were extracted and compared.ResultsThe stress of ligament/graft at femoral side of three finite‐element models was significantly higher than at tibial side, while the highest level was observed in single‐bundle reconstruction finite‐element model. With the increase of force, the maximum stress in the medial (7.1–7.1 MPa) and lateral (4.9–7.4 MPa) meniscus of single‐bundle reconstruction finite‐element model shifted from the anterior horn to the central area (p = 0.0161, 0.0479, respectively). The stress was shown to be at a lower level at femoral side and posterior cruciate ligament of intra‐knee in two reconstruction finite‐element models than that in normal finite‐element models, while presented higher level at the tibial side than normal knee (p = 0.3528). The displacement of the femoral side and intra‐knee areas in reconstruction finite‐element models was greater than that in normal finite‐element model (p = 0.0855).ConclusionCompared with the single‐bundle technique, the graft of double‐bundle anterior cruciate ligament reconstruction has better stress dissipation effect and can prevent postoperative meniscus tear more effectively.     

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.     

Comparison of Outcomes between Robot‐Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single‐Level Lumbar Spondylolisthesis

ObjectiveTo compare the safety and effectiveness of robot‐assisted minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single‐level lumbar degenerative spondylolisthesis (LDS).MethodsThis is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single‐level lumbar degenerative spondylolisthesis and treated with robot‐assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot‐assisted Mis‐TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient''s satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively.ResultsThere were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis‐TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis‐TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow‐ups. ODI score was also significantly lower in OLIF group than Mis‐TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis‐TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis‐TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis‐TLIF, P = 0.263).ConclusionRobot‐assisted OLIF and Mis‐TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.     

Treatment of Delayed Acetabular Fractures by Periacetabular Osteotomy through the Lateral‐Rectus Approach

ObjectiveThere has been a controversy in the surgical approach for delayed acetabular fracture. The objective of the present study is to investigate the feasibility, surgical techniques, safety, and efficacy of periacetabular osteotomy using the single lateral‐rectus approach (LRA) for the surgical treatment of delayed acetabular fracture.MethodsThe retrospective study included 22 patients (16 males and six females, with an average age of 45 years) with delayed acetabular fractures from June 2012 to June 2019. For all cases, periacetabular osteotomy was performed through the single LRA. Fracture classification, mechanism of injury, associated injury, time to surgery, operation time, intraoperative blood loss, and complications were recorded and analyzed. The quality of the reduction was assessed based on Matta radiographic criteria. Potential impact factors affecting the quality of reduction were analyzed. Functional outcome was evaluated at the final follow‐up according to a modified Mere D''Aubigne‐Postel scoring system for each patient.ResultsAll patients were followed up for at least 12 months. The duration of surgery was 140 min on average (110–205 min) and the mean intraoperative blood loss was 1250 ml (500–2100 ml). According to Matta radiographic criteria, the accuracy of reduction was “anatomical” in seven patients, “imperfect” in 11 patients, and “poor” in four patients, with an excellent and good rate of 81.8%. The time to surgery in poor reduction group was significantly longer than anatomical or imperfect reduction group (p < 0.05). All the acetabular fractures united after 8–12 weeks. The average modified Merle D''Aubigne‐Postel score evaluated at the final follow‐up was 14.6 (6–18), and the clinical outcomes were rated as excellent in six patients, good in 10 patients, fair in four patients, and poor in two patients, with an excellent and good rate of 72.7%. There were two cases of osteonecrosis of the femoral head (9%). No other complication was found for all cases.ConclusionThe LRA is an effective and minimally invasive approach in the treatment of delayed acetabular fractures excluding posterior wall fracture and posterior dislocation.     

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.     

The Short‐ and Mid‐term Follow‐Up of Single‐Column Fixation in Transverse and Posterior Wall Acetabular Fractures

ObjectiveTo evaluate the radiological and clinical outcomes of the surgical treatment for transverse and posterior wall fractures using single‐column posterior fixation.MethodsFrom January 2009 to January 2018, a total of 24 patients with transverse and posterior wall acetabular fractures in our center were included in this retrospective study, including 17 males and seven females with a mean age of 47 years and a minimum follow‐up of 1 year. All cases were closed fractures. All fractures were fixed with single‐column fixation via the Kocher–Langenbeck approach. Primary outcome measures, including quality of reduction and clinical outcomes, were recorded by an independent observer, who also noted secondary outcome measures, including time to surgery, surgical time, intraoperative blood loss, and postoperative complications.ResultsTwenty‐four patients (range, 26–74 years) included 17 males and seven females. There were 14 cases on the left side and 10 cases on the right side. The mean time from injury to surgery was 7.1 days. Mean intraoperative blood loss and surgical time were 405.4 mL and 135.8 min, respectively. The mean follow‐up time was 29.5 months (range 12–96 months). All the acetabular fractures united within 5 months after surgery. The quality of reduction was graded as anatomical in 17 cases (70.8%), imperfect in three cases (12.5%), and poor in four cases (16.7%). According to grading system of Merle d’ Aubigne and Postel, clinical outcomes at the final follow‐up were excellent in 10 cases (41.7%), good in six cases (25.0%), fair in five cases (20.5%), and poor in three cases (12.5%). The excellent and good rate was 66.7%. There was a significant relation between the quality of reduction and clinical outcomes (P < 0.05). At follow‐up, there were one case of sciatic nerve injury, one case of wound infection, two cases of deep vein thrombosis, two cases of avascular necrosis, three cases of heterotopic ossification, and five cases of postoperative traumatic arthritis. Three of these patients underwent reoperation, including one with heterotopic ossification affecting hip movement and two with femoral head necrosis.ConclusionsOur study shows that single‐column posterior fixation of transverse and posterior wall acetabular fracture through the Kocher–Langenbeck approach can obtain satisfactory radiological and clinical outcomes if there is adequate indirect reduction of the anterior column.     

两种后路手术方式治疗胸腰椎爆裂性骨折的疗效比较

目的比较胸腰椎爆裂性骨折后路固定直接与间接减压两种手术方式的疗效,指导手术方案的合理选择。方法选取我院2007年1月~2011年1月收治的192例胸腰椎爆裂性骨折患者,随机分为直接减压组及间接减压组,各96例,分别接受后路固定直接及间接减压。比较两组患者手术及恢复情况。结果两组手术时间、术中出血量及24 h引流量比较均无统计学差异(P0.05),且均未见术后椎管内血肿、截瘫平面上升等严重神经功能损伤并发症;两组患者术后3个月伤椎高度丢失率、伤椎Cobb角及邻近椎间高度较术前均得到显著改善,差异具有统计学意义(P0.05),但两组间比较差异无统计学意义(P0.05);两组患者术后3个月Frankel分级比较差异无统计学意义(P0.05)。两组患者均获得有效随访,平均时间(1.7±0.4)年,直接减压组ODI评分为13.5%±2.9%,间接减压组为8.3%±1.6%,组间比较差异具有统计学意义(t=6.339,P0.05)。结论两种后路手术方式治疗胸腰椎爆裂性骨折均可有效改善患者的临床症状,且术中损伤小、术后并发症少,疗效及安全性均理想;直接减压易导致患者术后腰背功能恢复受到影响,治疗中应首选后路间接减压,在保证患者生活质量的前提下达到良好复位效果。     

微创经皮钢板骨桥接术联合锁定加压钛板治疗胫骨远端骨折

目的探讨微创经皮钢板骨桥接术（minimallyi nvasive percutaneous plate osteosynthesis，MIPPO）联合锁定加压钛板（locking compression plate，LCP）治疗胫骨远端骨折的近期疗效。方法2004年6月～2006年3月采用MIPPO联合LCP治疗胫骨远端骨折16例，AO分型：43A1型7例，43A3型5例，43B1型2例，43C3型2例。采用3种方法复位胫骨骨折后插入LCP，用锁定螺钉固定。结果16例随访5～20个月，平均11，5月。16例切口一期愈合，骨折无延迟愈合、畸形愈合、断钉、断板等并发症。术后X线检查4～12周（平均7．6周）骨痂形成并开始部分负重，8～20周骨性愈合（平均16周），此时开始完全负重。3例出现胫骨远端内植物局部不适。根据美国足踝骨科学会评分系统对踝关节功能评分，优14例（87．5％），良2例（12，5％）。结论MIPPO具有创伤小、固定牢靠、可早期功能锻炼等优点，近期疗效满意，是治疗胫骨远端骨折的有效方法。