Anterior and posterior approach for total sacrectomy for tumors

Surgical Principles A transperitoneal approach will allow the ligation of vessels feeding the tumor. After a blunt separation of the tumor from the intestines the intervertebral disc will be cut transversely. The anterior approach will be closed and the sacrum removed through a posterior approach.     

3D打印全骶骨假体在全骶骨切除患者腰-髂稳定性重建中的应用

目的:评估3D打印全骶骨假体在全骶骨切除患者腰-髂稳定性重建中的应用价值。方法 :回顾性分析2015年1月～2018年12月于我中心接受全骶骨切除术的42例患者资料。根据重建方式将患者分为3组:假体重建组(14例)采用3D打印全骶骨假体重建,联合重建组(19例)采用包含前方椎体重建的联合重建方案,脊柱骨盆(SPF)重建组(9例)采用单纯SPF重建。比较三组患者的腰-髂稳定性(疼痛及运动功能评分)、内置物生存情况(内置物失败率及生存期)、手术安全性(手术时间、术中出血量及围手术期并发症发生率)。结果:术后平均随访时间为33.6±14.2个月。假体重建组手术平均耗时394.6±128.0min,术中出血量平均为3250.0±1711.4ml,共2例患者发生围手术期并发症。末次随访时,13例患者无需拐杖等辅助行走,12例患者无需使用止痛药。共4例患者发生影像学内置物失败,其中2例需行二次手术,1例因严重疼痛并伴有肿瘤复发接受二次手术,术中因假体与周围骨融合牢固而未取出假体;1例因严重疼痛及运动功能明显受损接受二次手术取出假体。假体重建组平均内置物生存期为49.3(95%CI 40.8～57....     

Anterior corpectomy versus posterior laminoplasty for multilevel cervical myelopathy: a systematic review and meta-analysis

Background

Surgical strategy for multilevel cervical myelopathy resulting from cervical spondylotic myelopathy (CSM) or ossification of posterior longitudinal ligament (OPLL) still remains controversial. There are still questions about the relative benefit and safety of direct decompression by anterior corpectomy (CORP) versus indirect decompression by posterior laminoplasty (LAMP).

Objective

To perform a systematic review and meta-analysis evaluating the results of anterior CORP compared with posterior LAMP for patients with multilevel cervical myelopathy.

Methods

Systematic review and meta-analysis of cohort studies comparing anterior CORP with posterior LAMP for the treatment of multilevel cervical myelopathy due to CSM or OPLL from 1990 to December 2012. An extensive search of literature was performed in Pubmed, Embase, and the Cochrane library. The quality of the studies was assessed according to GRADE. The following outcome measures were extracted: pre- and postoperative Japanese orthopedic association (JOA) score, neurological recovery rate (RR), surgical complications, reoperation rate, operation time and blood loss. Two reviewers independently assessed each study for quality and extracted data. Subgroup analysis was conducted according to the mean number of surgical segments.

Results

A total of 12 studies were included in this review, all of which were prospective or retrospective cohort studies with relatively low quality. The results indicated that the mean JOA score system for cervical myelopathy and the neurological RR in the CORP group were superior to those in the LAMP group when the mean surgical segments were <3, but were similar between the two groups in the case of the mean surgical segments equal to 3 or more. There was no statistical difference in the surgical complication rate between the two groups when the mean surgical segments <3, but were significantly higher incidences of surgical complications and complication-related reoperation in the CORP group compared with the LAMP group in the case of the mean surgical segments equal to 3 or more. Besides, the operation time in the CORP group was longer than that in the LAMP group, and the average blood loss was significantly more in the CORP group compared with the LAMP group.

Conclusion

Based on the results above, anterior CORP and fusion is recommended for the treatment of multilevel cervical myelopathy when the involved surgical segments were <3. Given the higher rates of surgical complications and complication-related reoperation and the higher surgical trauma associated with multilevel CORP, however, it is suggested that posterior LAMP may be the preferred method of treatment for multilevel cervical myelopathy when the involved surgical segments were equal to 3 or more. In addition, taking the limitations of this study into consideration, it was still not appropriate to draw a strong conclusion claiming superiority for CORP or LAMP. A well-designed, prospective, randomized controlled trial is necessary to provide objective data on the clinical results of both procedures.     

Surgical techniques for sciatica due to herniated disc, a systematic review

Introduction

Disc herniation with sciatica accounts for five percent of low-back disorders but is one of the most common reasons for spine surgery. The goal of this study was to update the Cochrane review on the effect of surgical techniques for sciatica due to disc herniation, which was last updated in 2007.

Materials and methods

In April 2011, we conducted a comprehensive search in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDRO, ICL, and trial registries. We also checked the reference lists and citation tracking results of each retrieved article. Only randomized controlled trials (RCT) of the surgical management of sciatica due to disc herniation were included. Comparisons including chemonucleolysis and prevention of scar tissue or comparisons against conservative treatment were excluded. Two review authors independently selected studies, assessed risk of bias of the studies and extracted data. Quality of evidence was graded according to the GRADE approach.

Results

Seven studies from the original Cochrane review were included and nine additional studies were found. In total, 16 studies were included, of which four had a low risk of bias. Studies showed that microscopic discectomy results in a significantly, but not clinically relevant longer operation time of 12 min (95 % CI 2–22) and shorter incision of 24 mm (95 % CI 7–40) compared with open discectomy, but did not find any clinically relevant superiority of either technique on clinical results. There were conflicting results regarding the comparison of tubular discectomy versus microscopic discectomy for back pain and surgical duration.

Conclusions

Due to the limited amount and quality of evidence, no firm conclusions on effectiveness of the current surgical techniques being open discectomy, microscopic discectomy, and tubular discectomy compared with each other can be drawn. Those differences in leg or back pain scores, operation time, and incision length that were found are clinically insignificant. Large, high-quality studies are needed, which examine not only effectiveness but cost-effectiveness as well.     

Use of INFIX for managing unstable anterior pelvic ring injuries: A systematic review

IntroductionSubcutaneous screw rod system which is popularly known as Pelvic internal fixator (INFIX) has emerged as an alternative to external fixators in management of unstable pelvic injuries. INFIX has shown various advantages over external fixation such as reduced infection rate and patient morbidity. However, it has its own set of complications such as lateral femoral cutaneous nerve injury, heterotopic ossification, femoral nerve palsy etc. We intended to conduct a systematic review of the current literature to assess outcomes and complications with INFIX technique of fixation.MethodsA comprehensive search of literature was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and online database of EMBASE, PubMed, Medline and Scopus was searched for all studies in English language till March 2020. Included studies were reviewed for demographic data, fracture type/classification, radiological outcome and functional outcomes. The inclusion criteria were: 1. Studies in English language 2. Clinical studies reporting use of INFIX technique in pelvis fracture where clinical and radiological outcomes were reported.ResultsTwenty-two studies fulfilling inclusion and exclusion criteria were included in this systematic review with total of 619 patients. Radiographic parameters and outcome measures were infrequently reported. Fixation with INFIX in these fractures leads to 87% excellent to good radiological results and 84% excellent to good functional results. Complications include lateral femoral cutaneous nerve irritation (25.3%), heterotopic ossification (24.7%), infection (3%), and femoral nerve palsy (1.6%); which is likely related to placing the bar and screws too deep.ConclusionThis analysis supports the use of INFIX in management of unstable pelvis fractures where anterior fixation is required.     

Use of INFIX for managing unstable anterior pelvic ring injuries: A systematic review

IntroductionSubcutaneous screw rod system which is popularly known as Pelvic internal fixator (INFIX) has emerged as an alternative to external fixators in management of unstable pelvic injuries. INFIX has shown various advantages over external fixation such as reduced infection rate and patient morbidity. However, it has its own set of complications such as lateral femoral cutaneous nerve injury, heterotopic ossification, femoral nerve palsy etc. We intended to conduct a systematic review of the current literature to assess outcomes and complications with INFIX technique of fixation.MethodsA comprehensive search of literature was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and online database of EMBASE, PubMed, Medline and Scopus was searched for all studies in English language till March 2020. Included studies were reviewed for demographic data, fracture type/classification, radiological outcome and functional outcomes. The inclusion criteria were: 1. Studies in English language 2. Clinical studies reporting use of INFIX technique in pelvis fracture where clinical and radiological outcomes were reported.ResultsTwenty-two studies fulfilling inclusion and exclusion criteria were included in this systematic review with total of 619 patients. Radiographic parameters and outcome measures were infrequently reported. Fixation with INFIX in these fractures leads to 87% excellent to good radiological results and 84% excellent to good functional results. Complications include lateral femoral cutaneous nerve irritation (25.3%), heterotopic ossification (24.7%), infection (3%), and femoral nerve palsy (1.6%); which is likely related to placing the bar and screws too deep.ConclusionThis analysis supports the use of INFIX in management of unstable pelvis fractures where anterior fixation is required.     

Long-term clinical outcome of sacral chondrosarcoma treated by total en bloc sacrectomy and reconstruction of lumbosacral and pelvic ring using intraoperative extracorporeal irradiated autologous tumor-bearing sacrum: a case report with 10 years follow-up

Background contextPrimary malignant tumors of the sacrum are rare. Chondrosarcoma is one of the common malignant tumors arising from the sacrum. Chondrosarcoma is often invasive, and there is a high propensity for local recurrence. Surgical resection is often the only effective treatment; however, the treatment of malignant sacral tumors can be challenging, both because of the anatomy of the spinopelvic complex and the frequently large tumor size.PurposeWe report a case of sacral chondrosarcoma that was successfully treated by total en bloc sacrectomy and reconstruction of the lumbosacral and pelvic ring using intraoperative extracorporeal irradiated autologous tumor-bearing sacrum.Study designA case report with 10 years follow-up.MethodsA 51-year-old man presented with right lower leg pain. Plain radiographs and computed tomography (CT) showed an osteolytic lesion at the sacrum that extended to the sacroiliac joint. Magnetic resonance imaging demonstrated that the tumor mass was localized from S1 to S2 with an epidural lesion at L5–S1 disc level. Histopathologic evaluation by open biopsy revealed that the lesion was chondrosarcoma. Total en bloc sacrectomy of the tumor-bearing sacrum was performed. The removed tumor-bearing sacrum was extracorporeally irradiated at 200 Gy during the operation and returned to the original position as a bone graft and fixed with instruments thereafter.ResultsWe needed two revision surgeries during the first 3 years because of the implant failures; however, 10 years after the initial surgery, CT revealed that the irradiated sacrum had remodeled into living bone and integrated with surrounding iliac bone without radiological evidence of tumor recurrence. The patient ambulates without any support and there was no clinical and radiological evidence of tumor recurrence.ConclusionsThe advantages of our method include the availability of high dose of radiation because of extracorporeal irradiation, excellent fit between graft and host bone, reduction of the dead space, no immunological rejection, no need for a bone bank, availability of the sacrum not only for the augmentation of the large defect but also for the scaffold for the other bone grafts. Our report is of only one case; however, we consider that it could be one option for the treatment of sacral malignant bone tumors, such as chondrosarcoma.     

Safety and efficacy of total ankle arthroplasty versus ankle arthrodesis for ankle osteoarthritis: A systematic review and meta-analysis

Osteoarthritis is the most common joint disease-causing pain and disability, and its management keeps creating a debate. So, we aimed to compare the safety and efficacy of total ankle arthroplasty and ankle arthrodesis for ankle osteoarthritis. We searched PubMed, Cochrane, Scopus, and Web of Science till August 2021. The outcomes were pooled as Mean difference (MD) or Risk Ratio (RR), and 95% confidence interval. We included 36 studies. The results showed a significantly lower risk of infections in total ankle arthroplasty (TAA) than ankle arthrodesis (AA) (RR= 0.63, 95% CI [0.57, 0.70], p < 0.00001), amputations (RR= 0.40, 95% CI [0.22, 0.72], p = 0.002), postoperative non-union (RR= 0.11, 95% CI [0.03, 0.34], p = 0.0002), and a significant increase of overall range of motion in TAA than AA. Our results preferred total ankle arthroplasty over ankle arthrodesis in terms of lowering the rates of infections, amputations, and postoperative non-union, with better change in the overall range of motion.     

Nail or plate fixation for A3 trochanteric hip fractures: A systematic review of randomised controlled trials

Continuing controversy exists for the choice of implant for treating A3 trochanteric hip fractures so we undertook a systematic review of randomised controlled trials from the year 2000 onwards that have compared an intramedullary nail with an extramedullary fixation implant for the treatment of these fractures. Data on the occurrence of any fracture healing complications was extracted and the results combined to calculate Peto odd ratio. Nine studies involving 370 fractures were identified. Three studies involving 105 fractures compared an intramedullary nail with a static fixation (condylar, blade or locking plate). Plate fixation was associated with a fivefold increase risk of fracture healing complications (19/52(36.6%) versus 4/53(7.5%), odds ratio 0.14, 95% Confidence intervals 0.04–0.45). Six studies involving 265 fractures compared an intramedullary nail with a sliding hip screw. No statistically significant difference was found in the occurrence of facture healing complications between implants (13/137(9.5%) versus 11/128(8.6%) odds ratio 0.28, 95% Confidence intervals 0.50–2.80). Bases on the evidence to date from randomised trials, the use of fixed nail plates for surgical fixation of this type of fracture cannot be justified. Intramedullary nail fixation and the sliding hip screw have comparable fracture healing complication rates.     

Surgical management of anal fistulae: a systematic review

Objective  The anal fistula has been a common surgical ailment reported since the time of Hippocrates but little systematic evidence exists on its management. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. Method  Studies were identified from PubMED, EMBASE, Cochrane Controlled Trials Register, ClinicalTrials.Gov and Current Controlled Trials. All uncontrolled, nonrandomized, retrospective studies, duplications or those unrelated to the surgical management of anal fistulas were excluded. Results  The search strategy revealed 443 trials. After exclusions 21 randomized controlled trials remained evaluating: fistulotomy vs fistulectomy (n = 2), seton treatment (n = 3), marsupialization (n = 2), glue therapy (n = 3), anal flaps (n = 3), radiosurgical approaches (n = 2), fistulotomy/fistulectomy at time of abscess incision (n = 5) and intra‐operative anal retractors (n = 1). Two meta‐analyses evaluating incision and drainage alone vs incision + fistulotomy were obtained. Conclusion  Marsupialization after fistulotomy reduces bleeding and allows for faster healing. Results from small trials suggest flap repair may be no worse than fistulotomy in terms of healing rates but this requires confirmation. Flap repair combined with fibrin glue treatment of fistulae may increase failure rates. Radiofrequency fistulotomy produces less pain on the first postoperative day and may allow for speedier healing. Major gaps remain in our understanding of anal fistula surgery.     

Surgical correction of equinus deformity in children with cerebral palsy: a systematic review

Purpose  

Equinus is the most common deformity in cerebral palsy. However, despite the large volume of published studies, there are poor levels of evidence to support surgical intervention. This study was undertaken to examine the current evidence base for the surgical management of equinus deformity in cerebral palsy.     

Minimally invasive anterolateral approach versus lateral transmuscular approach for total hip arthroplasty: A systematic review and meta-analysis

BackgroundTotal hip arthroplasty (THA) using a minimally invasive (MI) approach is a commonly performed procedure, and several approaches are now being used clinically. The MI anterolateral (MIAL) approach is one of the MI approaches used in clinical practice. Whether the MIAL approach is superior to non-MI approaches remains controversial. To resolve this controversy, we performed a systematic review and a meta-analysis of results of THA procedures that used the MIAL approach. We assessed whether the MIAL approach was superior to the lateral transmuscular (LT) approach in terms of operative time, operative blood loss, radiological parameters, and clinical outcomes.MethodsWe performed a methodical search for all literature published on PubMed, Web of Science, and the Cochrane Library, and pooled data using the RevMan software. A p value < 0.05 was considered statistically significant. We calculated the mean differences (MD) for continuous data with 95% confidence intervals (CI) for each outcome.ResultsThis meta-analysis included 6 studies. Pooled results indicated no statistically significant differences between the groups in terms of operative time (MD = 5.13, 95% CI -2.49 to 12.75, p = 0.19), cup abduction angle (MD = 1.64, 95% CI -1.32 to 4.60, p = 0.28), and cup anteversion angle (MD = 0.75, 95% CI -1.09 to 2.59, p = 0.43). Operative blood loss was significantly greater in those who underwent THA via the MIAL approach than those who underwent THA via the LT approach (MD = 68.01, 95% CI 14.69 to 121.33, p = 0.01). The postoperative Harris hip score (HHS) assessed at the time of final follow-up was significantly higher in those who underwent THA via the MIAL approach than those who underwent THA via the LT approach (MD = 1.41, 95% CI 0.50 to 2.33, p = 0.002).ConclusionWe conclude that the MIAL approach is superior to the LT approach in terms of clinical outcomes.Level of evidenceLevel Ⅱ     

Mentorship in surgical training: a systematic review

Objective  

This review systematically examines the literature regarding mentor–mentee relationships in surgery.     

Influence of osteoporosis on fracture fixation - a systematic literature review

Summary The goal of our systematic literature search was to prove whether the experimentally shown influence of osteoporosis on fracture fixation could be confirmed in clinical studies. Despite significant effects in several studies, this is not supported by pooled data due to lack of accurate osteoporosis assessment and complication definitions. Introduction The fact that osteoporosis causes fractures is well-known; the assumption that it aggravates their orthopaedic treatment has not been proven. The goal of our systematic literature search was to find out whether the experimentally proven influence of osteoporosis on fracture fixation could be confirmed in clinical studies. Methods A systematic electronic database search was performed identifying articles that evaluated complications after fracture fixation among patients suspected of having osteoporosis as measured by BMD or surrogates including Singh index or risk factors. To determine complications risks (relative risk within 95% confidence interval) data were pooled across studies, weighted by sample size and stratified by treatment type. Results Ten studies out of 77 randomized controlled trials (51 hip, 23 distal radius and three proximal humerus studies) and three systematic reviews finally met eligibility criteria. Despite significant differences of the relative complication risk between osteoporotic and non-osteoporotic patients in several studies, this could not be proven in the pooled data. Conclusions In contrast to biomechanical evidence that local osteoporosis affects anchorage of implants, this could not be reproduced in clinical studies, due to the lack of accurate osteoporosis assessment, missing complication definitions and heterogeneous inclusion criteria in these studies. Prospective studies are required that address specifically the correlation between local bone status and the risk of fixation failure.     

Surgical fixation of isolated greater tuberosity fractures of the humerus- systematic review and meta-analysis

ObjectivesA systematic review was undertaken based on PRISMA guidelines to study the results of surgical treatment of Greater Tuberosity fractures of the Humerus by different techniques (Open, Percutaneous or Arthroscopic) and using different fixation devices (Sutures, Screws and Plates).Data sourcesLiterature searches were performed for studies in English on four online databases (MEDLINE®, Embase®, Ovid® Emcare and CINAHL®) using a pre-planned search strategy.Study selectionStudies were screened against pre-decided inclusion and exclusion criteria. 24 articles were eligible for inclusion involving 562 patients in all.Data extractionA template was used for collection of relevant data regarding the study design, demographics, fracture characteristics, surgical techniques and implants used, outcomes, complications and re-operations. Methodological quality was assessed using a modified Coleman Methodology Score.Data synthesisPooled analysis was conducted for (1) complications/reoperations of different devices; and (2) reported results using standard outcome measures of various techniques. Results were pooled using inverse variance method. When pooling proportions, we used arcsine transformation to account for zero events.ConclusionUse of screws was associated with higher rates of total complications (23.7%) as well as reoperations (13.2%), compared to sutures (14.2%; 2.6%) and plates (10.6%; 4.1%). In a subgroup analysis, use of low-profile plates (LPPs) was associated with the lowest rates of total complications (4.97%). The superiority of any surgical technique could not be established using the pooled Constant or ASES scores because there was lack of uniformity in the reporting of outcome measures. Our analysis of complications of the various fixation devices dissuades the use of screws and favours the use of low-profile plates. There is a need for prospective studies comparing arthroscopic suture fixation with open low-profile plate fixation of GT fractures.     

Artificial total disc replacement versus fusion for the cervical spine: a systematic review

Cervical total disc replacement (CTDR) has been increasingly used as an alternative to fusion surgery in patients with pain or neurological symptoms in the cervical spine who do not respond to non-surgical treatment. A systematic literature review has been conducted to evaluate whether CTDR is more efficacious and safer than fusion or non-surgical treatment. Published evidence up to date is summarised qualitatively according to the GRADE methodology. After 2 years of follow-up, studies demonstrated statistically significant non-inferiority of CTDR versus fusion with respect to the composite outcome ‘overall success’. Single patient relevant endpoints such as pain, disability or quality of life improved in both groups with no superiority of CTDR. Both technologies showed similar complication rates. No evidence is available for the comparison between CTDR and non-surgical treatment. In the long run improvement of health outcomes seems to be similar in CTDR and fusion, however, the study quality is often severely limited. After both interventions, many patients still face problems. A difficulty per se is the correct diagnosis and indication for surgical interventions in the cervical spine. CTDR is no better than fusion in alleviating symptoms related to disc degeneration in the cervical spine. In the context of limited resources, a net cost comparison may be sensible. So far, CTDR is not recommended for routine use. As many trials are ongoing, re-evaluation at a later date will be required. Future research needs to address the relative effectiveness between CTDR and conservative treatment.     

股骨近端髓内钉与滑动髋螺钉固定治疗成人股骨转子间骨折的系统评价

目的 系统评价股骨近端髓内钉(PFN)与滑动髋螺钉(SHS)固定治疗成人股骨转子间骨折的疗效差异. 方法 计算机检索Cochrane图书馆、MEDLINE数据库、EMBASE数据库、中国生物医学文献数据库,手工检索相关文献的参考文献及4种中文主要骨科杂志.收集PFN与SHS固定比较治疗成人股骨转子间骨折的随机对照试验,严格评价纳入研究的方法学质量并提取资料.统计软件采用RevMan4.2.10. 结果 共纳入3个随机对照试验,1个半随机对照试验.资料分析显示,PFN固定与SHS固定比较,在平均手术时间、平均术中失血量、病死率、术后股骨干骨折发生率、拉力螺钉切出率、骨折不愈合率、再次手术率和伤口感染率方面,两者间无显著差异. 结论 目前尚没有足够的证据表明PFN固定治疗成人股骨转子间骨折优于SHS,还需要开展更多高质量、大样本的临床随机对照试验以增加证据的强度.