Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years

Objective

Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture.

Methods

From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52–136 months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad–Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up.

Results

In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46–85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68–98 points) and 91.7 ± 0.4 (range: 76–100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18–52 points) and 38.4 ± 20.1 (range: 16–60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P ≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage.

Conclusions

The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.     

Safety and Efficacy of Cortical Bone Trajectory Screw Fixation Combined with Facet Fusion for the Treatment of Lumbar Degenerative Disease

Objective

The mainstream lumbar fusion surgeries have various shortcomings, such as complex operation, much invasion, and loss of lumbar function. How to minimize the surgical injury and to achieve better therapeutic effects has become the goal pursued by spine surgeons. This study introduces a cortical bone trajectory (CBT) screw fixation combined with facet fusion (FF), evaluates its safety and efficacy, and explores its advantages, in order to provide a reference for treatment of patients with single-level lumbar stenosis or grade I degenerative spondylolisthesis.

Methods

We retrospectively analyzed the clinical, radiological, and operative data of 167 patients with single-level lumbar stenosis or grade I degenerative spondylolisthesis who underwent FF or transforaminal lumbar interbody fusion (TLIF) from January 2013 to September 2019 in the spine surgery department of the Second Hospital of Shandong University. Patients were divided into four groups according to surgical method: group CBT-FF, CBT screw combined with FF; group PS-FF, pedicle screw (PS) combined with FF; group CBT-TLIF, CBT screw combined with TLIF; and group PS-TLIF, PS combined with TLIF. The operation time, estimated intraoperative blood loss, complications after surgery, visual analog scale (VAS), and Oswestry disability index (ODI) of the four groups were compared. The fusion was evaluated by anteroposterior and lateral X-ray, CT scan, and three-dimensional reconstruction.

Results

Twelve months after surgery, the fusion rate of four groups had no significantly statistical differences (p = 0.914). VAS and ODI scores were lower after surgery than before. Low back pain VAS scores 1 week after surgery in group CBT-FF and group CBT-TLIF were significantly lower than those in group PS-FF and group PS-TLIF (p_CF/PF = 0.001, p_CF/PT = 0.000, p_PF/CT = 0.049, p_CT/PT = 0.000). Low back pain VAS score 3 months after surgery was significantly lower in group CBT-FF than group PS-FF and group PS-TLIF (p_CF/PF = 0.045, p_CF/PT = 0.008). ODI score 1 week after surgery was significantly lower in group CBT-FF than group PS-FF, group CBT-TLIF, and group PS-TLIF (p_CF/PF = 0.000, p_CF/CT = 0.005, p_CF/PT = 0.000, p_CT/PT = 0.015). ODI score 3 months after surgery was significantly lower in group CBT-FF than group PS-FF, group CBT-TLIF, and group PS-TLIF (p_CF/PF = 0.001, p_CF/CT = 0.002, p_CF/PT = 0.000). Incidence of complications did not significantly differ among the groups.

Conclusion

CBT screw fixation combined with FF is a safe and efficacious procedure for patients with single-level lumbar stenosis or grade I degenerative spondylolisthesis. This minimally invasive approach of lumbar fusion can be simply and easily performed. Patients who undergo CBT screw fixation combined with FF recovered faster than TLIF.     

Preoperative Prevalence and Risk Factors For Calf Muscular Vein Thrombosis in Elderly Patients with Hip Fracture

Objective

Increasing evidence has shown that calf muscular vein thrombosis (CMVT) can develop into proximal deep vein thrombosis, even causing pulmonary embolism. However, opinions about the prevalence and risk factors are still controversial. This study aimed to investigate the prevalence and risk factors for CMVT in elderly patients with hip fractures to facilitate their preoperative management.

Methods

We included 419 elderly patients with hip fracture who were treated in the orthopaedic department of our hospital from June 2017 to December 2020. The patients were divided into CMVT and non-CMVT groups based on color Doppler ultrasound screening of the venous system in the lower extremities. Clinical data, such as age, sex, body mass index, time from injury to admission, and laboratory data were collected. Univariate and multivariate logistic regression analyses were performed to determine independent risk factors for CMVT. A receiver operating characteristic curve was used to analyze the predictive effectiveness of the model. Finally, the clinical utility of the model was analyzed using decision curve analysis and clinical impact curves.

Results

The prevalence of preoperative CMVT was 30.5% (128/419). Independent predictors of preoperative CMVT identified by univariate and multivariate logistic regression analyses were sex, time from injury to admission, American Society of Anesthesiologists (ASA) classification, C-reactive protein (CRP) level, and D-dimer level (p < 0.05). The area under curve (AUC) was 0.750 (95% CI: 0.699–0.800, p < 0.001) and the sensitivity and specificity were 0.698 and 0.711, respectively, which meant the prediction model has a good efficacy in the prediction of CMVT risk. In addition, the fitting degree of the prediction model was also good (Hosmer–Lemeshow χ² = 8.447, p > 0.05). The clinical utility of the model was verified using decision curve analysis and clinical impact curves.

Conclusion

Sex, time from injury to admission, ASA classification, CRP level, and D-dimer levels are independent preoperative predictors of CMVT in elderly patients with hip fractures. Measures should be taken for patients with these risk factors to prevent the occurrence and deterioration of CMVT.     

Risk Factors of Nonfusion after Anterior Cervical Decompression and Fusion in the Early Postoperative Period: A Retrospective Study

Objective

Although high fusion rates have been reported for anterior cervical decompression and fusion (ACDF) in the medium and long term, the risk of nonfusion in the early period after ACDF remains substantial. This study investigates early risk factors for cage nonfusion in patients undergoing single- or multi-level ACDF.

Methods

This was a retrospective study. From August 2020 to December 2021, 107 patients with ACDF, including 197 segments, were enrolled, with a follow-up of 3 months. Among the 197 segments, 155 were diagnosed with nonfusion (Nonfusion group), and 42 were diagnosed with fusion (Fusion group) in the early period after ACDF. We assessed the significance of the patient-specific factors, radiographic indicators, serum factors, and clinical outcomes. The Wilcoxon rank sum test, t-tests, analysis of variance, and stepwise multivariate logistic regression were used for statistical analysis.

Results

Univariate analysis showed that smoking, insufficient improvement in the C2-7 Cobb angle (p = 0.024) and the functional spinal unit Cobb angle (p = 0.022) between preoperative and postoperative stages and lower serum calcium (fusion: 2.34 ± 0.12 mmol/L; nonfusion: 2.28 ± 0.17 mmol/L, p = 0.003) β-carboxyterminal telopeptide end of type 1 collagen (β-CTX) (fusion: 0.51 [0.38, 0.71]; nonfusion: 0.43 [0.31, 0.57], p = 0.008), and N-terminal fragment of osteocalcin (N-MID-BGP) (fusion: 18.30 [12.15, 22.60]; nonfusion: 14.45 [11.65, 18.60], p = 0.023) are risk factors for nonfusion in the early period after ACDF. Stepwise logistic regression analysis revealed that poor C2-7 Cobb angle improvement (odds ratio [OR], 1.107 [1.019–1.204], p = 0.017) and lower serum calcium (OR, 3.700 [1.138–12.032], p = 0.030) are risk factors.

Conclusions

Patients with successful fusion after ACDF had higher preoperative serum calcium and improved C2-7 Cobb angle than nonfusion patients at 3 months. These findings suggest that serum calcium could be used to identify patients at risk of nonfusion following ACDF and that correcting the C2-7 Cobb angle during surgery could potentially increase fusion in the early period after ACDF.     

Treatment of Anterior Dislocation of the Sacroiliac Joint via the Lateral-rectus Approach: Surgical Techniques and Preliminary Outcomes

Objective

Anterior dislocation of the sacroiliac joint (ADSIJ) is caused by strong violence, and because of its low morbidity, there are no standardized diagnostic and therapeutical guidelines at this moment. This study aims to explore the surgical techniques and preliminary outcomes of the lateral-rectus approach (LRA) for treating ADSIJ.

Methods

A retrospective study was conducted of 15 patients with ADSIJ from January 2016 to January 2021. The patients' age ranged from 1.8 years old to 57 years old (37 ± 18 years old). All patients underwent open reduction and internal fixation (ORIF) through the LRA. Eight patients were combined with lumbosacral plexus injury and underwent neurolysis during operation. Patients' fracture type, mechanism of injury, associated injuries, operation time and intraoperative bleeding volume were accessed by reviewing medical history. Quality of fracture reduction was evaluated with the Matta score. At 1-year follow-up, the functional rehabilitation was evaluated by the Majeed rehabilitation criteria. For those with lumbosacral plexus injury, the neuromotor function was evaluated using muscle strength grading proposed by the British Medical Research Council (BMRC) and recovery was recorded.

Results

All 15 patients underwent the operation successfully. The surgical time ranged from 70 to 220 min (126 ± 42 min), and the intraoperative blood loss ranged from 180 to 2000 mL (816 ± 560 mL). Eighty percent of the cohort (12/15) were rated as excellent and good in the Matta score for fracture reduction quality after operation without surgical incision-related complications. At 1-year follow-up, the overall excellent and good rate was 73.3% (11/15) according to the Majeed criteria, the neuromotor function recovered completely in six cases and partially in two cases according to the BMRC muscle strength grading, and the recovery of sensory function was evaluated as excellent in six cases, good in one case and poor in one case, with an overall excellent and good rate of 87.5%.

Conclusion

The LRA can well expose the surrounding structures of the sacroiliac joint from the front, which helps surgeons reduce and fix the anterior dislocation of the sacroiliac joint under direct vision and effectively decompress the entrapment of the lumbosacral plexus to achieve better clinical efficacy.