Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis

It has been reported that in patients undergoing posterolateral lumbar fusion (PLF), the fusion status is not related to the short-term operative results. To determine whether the fusion status influences the long-term operative results of PLF, we retrospectively examined the surgical outcomes of uninstrumented PLF for a minimum of 8 years (average, 9.5 years), by comparing cases exhibiting union with those exhibiting nonunion. Uninstrumented PLF was performed for the treatment of lumbar canal stenosis (LCS) with degenerative spondylolisthesis. Since nine patients were lost to final follow-up, the study included 42 patients, and the follow-up rate was 82.4%. The mean age of the patients was 64.1 years (range 46–77 years). Eight patients exhibited fusion at the L3–4 level and 34 patients, at the L4–5 level. The fusion status was assessed using plain radiographs. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scores. Nonunion was noted in 26% (11/42) of the patients. There were no statistically significant differences between the groups exhibiting union and nonunion with respect to age, sex, preoperative JOA score, or preoperative lumbar instability. The union group achieved better operative results than the nonunion group at the 5-year and final follow-up (P = 0.006 and 0.008, respectively) although there was no significant difference in the percent recovery at 1 and 3-year follow-up (P = 0.515 and 0.506, respectively). A stepwise regression analysis revealed that the best combination of predictors for percent recovery at the time of final follow-up included the fusion status and the presence of comorbid disease. The results indicate that the fusion status following PLF is a critical factor influencing the long-term but not short-term operative results in the treatment of LCS with degenerative spondylolisthesis.     

自体中1/3股二头肌腱和股薄肌重建膝关节后外侧角韧带复合体损伤

目的 探讨采用自体中1/3股二头肌腱和股薄肌重建膝关节后外侧角韧带复合体(PLC)的技术及近期的疗效. 方法 本组21例,均为联合型的直向外侧+后外侧旋转＞Ⅱ度不稳定,重建范围:胭肌腱、外侧副韧带、胭腓韧带.术中单独提取健侧或患侧股薄肌重建膕肌腱.切取股二头肌肌腱中1/3部,折叠后对折端拉入股骨外髁骨隧道固定,分出的前束重建外侧副韧带(LCL),后束重建胭腓韧带. 结果 术后随访6～24个月,平均16个月.Lyshohn膝关节功能评分,术前为(43±2)分,术后半年为(90±3)分,有明显改进. 结论 PLC损伤可造成患肢功能受损,采用自体中1/3股二头肌腱和股薄肌修复重建韧带手术可获得良好预后.     

直接前路与后外侧入路人工股骨头置换治疗老年移位性股骨颈骨折的临床疗效对比

目的比较直接前路与后外侧入路人工股骨头置换术治疗老年移位性股骨颈骨折的临床治疗效果。方法选取2013年6月至2015年6月我科诊治的老年单侧移位性股骨颈骨折患者73例,其中采用直接前路36例(直接前路组),后外侧入路37例(后外侧入路组),分析其手术用时、切口长短及愈合时间、手术出血及伤口引流量、下床时间及住院天数,术后3天、7天疼痛视觉评分(VAS),术前、术后1、3、6、9、12个月及末次随访时髋关节Harris评分,术后脱位发生率及其他并发症发生情况。采用欧洲生活质量评分(EQ-5D评分)评价末次随访时患者健康生活质量。结果患者均获得随访,随访时间12~17个月,平均13.6个月。直接前路组的手术用时、切口长度、术中出血量及术后引流量小于后外侧入路组(P0.05),两组下地行走时间、伤口愈合时间无统计学差异(P0.05);直接前路组术后3天、7天疼痛视觉评分优于后外侧入路组;术后1月、3月、6月直接前路组Harris评分高于对照组,术后9、12个月及末次随访时两组Harris评分基本接近。两组患者术后末次随访时健康生活质量无统计学差异(P0.05)。直接前路组1例患者出现伤口局部红肿,后外侧入路组1例患者出现假体脱位,1例出现切口周缘麻木,两组患者无肺栓塞、下肢静脉血栓形成并发症。结论直接前路和后外侧入路均能有利于髋关节运动功能的恢复,早期临床疗效较好。直接前路手术创伤小,出血少,假体脱位发生率低,术后早期疗效好等优势,但直接前路手术对术者的手术技术要求较高。     

Lumbar posterolateral fusion inhibits sensory nerve ingrowth into punctured lumbar intervertebral discs and upregulation of CGRP immunoreactive DRG neuron innervating punctured discs in rats

Degeneration of lumbar intervertebral discs is thought to be a cause of low back pain. Studies have found that a cause of discogenic low back pain is intervertebral disc inflammation and axonal growth of afferent fibers innervating the disc. Lumbar spine fusion for chronic discogenic low back pain is considered an effective procedure. However, no study has investigated the mechanism of pain relief. We did this by applying Fluoro-Gold (FG) to the ventral aspect of the L4–L5 intervertebral discs of 40 rats. We exposed the nucleus pulposus to the annulus fibrosus in a disc punctured model. Rats were divided into 4 groups. Group A: Punctured intervertebral disc with sham posterolateral fusion (PLF) (n = 10), Group B: Punctured intervertebral disc with PLF (n = 15), Group C: Normal intervertebral disc (no puncture) with PLF (n = 10), and Group D: Normal disc (no disc puncture) with sham PLF (n = 5). Four weeks after surgery, bilateral L1–L5 dorsal root ganglia (DRGs) were stained with growth-associated protein 43 (GAP43), a marker of axonal growth, and calcitonin gene-related peptide (CGRP), a neuropeptide marker of pain. Bone union was evaluated using X-ray imaging. Of the FG-labeled neurons, the proportions of GAP43- and CGRP-immunoreactive (IR) neurons in Group A were significantly higher than in Group D (P < 0.05). The proportions of GAP43- and CGRP-IR neurons in bone union rats in Group B were significantly lower than in nonunion rats in Group B and in the rats in Group A (P < 0.05). No significant differences in GAP43- and CGRP-IR neurons were observed between bone union and nonunion rats in Group C and the rats in Group D (P > 0.05). PLF is strongly related to the downregulation of GAP43 and CGRP expression. Therefore, PLF may suppress the increase of inflammatory neuropeptides and the process of axonal growth. Moreover, these results may explain, in part, the mechanism of pain relief following lumbar spinal fusion for chronic discogenic low back pain in humans.     

Posterolateral corner anatomy and its anatomical reconstruction with single fibula and double femoral sling method: anatomical study and surgical technique

This paper reports a novel method for reconstructing the posterolateral structures [lateral collateral ligament (LCL), popliteus tendon, popliteofibular ligament] based on an anatomical study of a cadaveric dissection. The popliteus tendon was found to always be attached to the anterior–inferior portion of the femoral attachment site of the LCL, and the average distance from the origin of the popliteal tendon in the femoral side to that of the LCL was 18.5 mm (17–20). The insertion site of the LCL in the fibular side was located anterior–inferior-superficially and the popliteofibular ligament was inserted into the posterior–superior-deep portion around the styloid process. Two femoral tunnels and one fibular head tunnel were made at the proximal and distal portion of the anatomical insertion sites.     

后外侧小切口入路全髋关节置换术的近期疗效观察

目的探讨小切口全髋关节置换术的手术技术要点及临床近期疗效。方法髋关节疾病患者18例,男7例,女11例,年龄53-82岁,平均73.5岁,术前Harris评分39.6分。采用后外侧入路,行小切口人工全髋关节置换术。对病例的切口长度、术中髋关节囊处理、围手术期出血量、术后早期功能恢复情况及假体的位置进行评价。结果本组病例手术切口均小于10cm,手术过程中均未行关节囊切除,对关节囊行缝合修整,围手术期出血量312±113.6ml,假体的安放和固定较常规手术未因手术切口的改变而改变,术后扶拐下床时间5.3±2.2天,术后6周均脱拐行走,术后3个月Harris评分94.3分。术后1例出现下肢静脉血栓,经对症处理后缓解,无一例出现关节脱位、感染。结论后外侧小切口全髋关节置换术具有创伤小、围手术期出血少、术后并发症少及术后早期功能恢复快的优点,对于多数病例能替代传统手术,但手术要掌握好手术适应证,手术医师需具有丰富的关节置换经验,减少软组织的损伤和关节囊的保护至关重要。     

A case of delayed recurrent hemarthrosis after posterolateral reconstruction of the knee with a staple fixation at the lateral femoral epicondyle

We present a case of delayed recurrent hemarthrosis after posterolateral reconstruction of the knee with staple fixation of the tendon graft at the lateral femoral condyle. A 20-year-old man had undergone a reconstructive surgery of the knee with allogeneic Achilles tendon aimed to reinforce lateral collateral ligament and popliteofibular ligament. At 4 months after surgery, recurrent swelling of the operated knee after minor exertion developed. The radiographs showed prominent staples at the lateral side of lateral femoral condyle. The arthroscopy revealed that the staples were salient intra-articularly at lateral gutter of the knee, and the adjacent lateral capsule seemed abraded, through which the longitudinal fibers of iliotibial band were seen. Iatrogenic iliotibial band syndrome owing to the prominent staple was speculated. The staples were removed under arthroscopic guidance, and there has been no recurrence thereafter. A staple fixation over bony prominence is not advisable and the interference screw might be a better alternative method of fixation.     

Anatomical variations in the anatomy of the posterolateral corner of the knee

This cadaveric study of 22 knees described the anatomy of the deeper structures of the posterolateral corner, the popliteus–tendon complex, arcuate ligament complex, the popliteofibular ligament, and the coronary ligament. Most variations occurred in the popliteofibular ligament; the variations and the different nomenclatures used in the literature for these structures make it difficult to diagnose and repair injuries to them. Untreated injuries may result in chronic functional instability to the posterolateral corner of the knee.     

A comparison of modified Larson and ‘anatomic’ posterolateral corner reconstructions in knees with combined PCL and posterolateral corner deficiency

Different methods to reconstruct damaged posterolateral structures are available, but there has been little work studying their relative performance in combined PCL plus posterolateral corner (PLC) deficiency. We hypothesized that an ‘anatomic’ reconstruction with three graft bundles crossing the joint line would restore knee laxity closer to normal than a modified two-bundle Larson reconstruction. In a controlled laboratory study, the kinematics of cadaveric knees were measured electromagnetically with posterior drawer, external rotation, or varus rotation loads applied, with the knee at sequential stages: intact, PCL-deficient; PCL plus PLC-deficient; modified Larson reconstruction; anatomic PLC reconstruction. The graft bundles were tensioned sequentially to restore specific degrees of freedom to intact values of laxity at specific angles of knee flexion. A significant difference was not found between the two reconstructions. Both reconstructions restored external rotation and varus laxity to normal. Both restored posterior drawer to that caused by isolated PCL deficiency, but did not restore posterior laxity to normal. It was concluded that, with appropriate graft tensioning, both PLC reconstructions could restore both external rotation and varus laxity to normal, but not posterior drawer. The three-stranded anatomical reconstruction did not perform better than the modified two-strand Larson technique. Both of these isolated PLC reconstructions in knees with combined PCL plus PLC deficiency restored the knees to the laxity condition of an isolated PCL-deficiency, they could not reduce posterior drawer to normal.     

水平带状钢板治疗胫骨平台后外侧象限骨折的生物力学研究

目的　比较胫骨平台后外侧象限骨折不同内固定方式的力学稳定性效果。 方法　采用Synbone人工合成胫骨18个,切割构建孤立的胫骨平台后外侧象限骨折模型,随机分为3组,分别采用外侧水平带状钢板固定、外侧低切迹解剖锁定钢板固定、后侧直形重建钢板固定。将固定好的骨折模型置于万能水压材料测试机进行测试,分别进行静态加载、疲劳测试和极限加载,检测骨块的相对空间位移。 结果　以10 mm/min加载至总载荷1050 N,重复加载10000次后,带状钢板组骨折块的纵向位移(2.77±1.79) mm,外侧锁定钢板组的纵向位移为(2.69±1.14) mm;后方重建钢板组骨折块的纵向位移为(1.62±0.60) mm,组间差异无统计学意义（P>0.05）。施加载荷到骨或内固定的结构破坏后,带状钢板组的极限支撑力为(2055±263) N,外侧锁定钢板组的为（1968±209）N,后方重建钢板组的极限支撑力为(2272±130) N,组间差异具有显著的统计学意义（P<0.05）。 结论　治疗孤立的胫骨平台后外侧象限骨折,侧方带状钢板水平固定能取得满意的效果。