Multilevel Schwab grade II osteotomies for sagittal plane correction in the management of adult spinal deformity

Background Context

Prior reports have compared posterior column osteotomies with pedicle subtraction osteotomies in terms of utility for correcting fixed sagittal imbalance in adolescent patients with deformity. No prior reports have described the use of multilevel Smith-Petersen Osteotomies (SPOs) alone for surgical correction in the adult spinal deformity (ASD) population.

腰椎间盘突出症Lasegue征与MRI定位区域的相关性分析

目的分析腰椎间盘突出症患者Lasegue征与MRI影像定位区域的关系。方法纳入自2015-04—2016-07诊治的50例腰椎间盘突出症。对Lasegue征影响因素进行分析,运用MUS分类法和胡有谷区域分类法对患者腰椎间盘突出节段的MRI片进行区域定位,共定位30个区域,分析Lasegue征与定位区域的关系。结果通过突出区域与Lasegue征的Logistic回归分析发现,椎间盘突出区域与Lasegue征有关(OR=1.007),但其敏感性和特异性并不高(AUC=0.5)。秩和检验发现,30个区域的Lasegue征阳性和阴性表现差异无统计学意义(P=1.0)。本组Lasegue征阳性多集中在18个突出区域,突出在Lesions(2A)+Ⅰ、Lesions(2A)+Ⅲ、Lesions(2AB)+Ⅲ和Lesions(3AB)+Ⅰ区域时,Lasegue征表现阳性的趋势更明显。结论 Lasegue征虽然是腰椎间盘突出症的一项特异性检查,突出在不同区域对其影响不显著,敏感性和特异性不高,但突出在某些固定的区域时,Lasegue征却有着呈阳性的趋势。     

The Effect of the Hip Flexion Angle in Osteonecrosis of the Femoral Head Based on China‐Japan Friendship Hospital Classification ‐ A Finite Element Study

Objective

The alteration in the mechanical environment of the necrotic area is the primary cause of the collapse observed in osteonecrosis of the femoral head (ONFH). This study aims to evaluate the biomechanical implications of the China-Japan Friendship Hospital (CJFH) classification system and hip flexion angles on the necrotic area in ONFH using finite element analysis (FEA). The goal is to provide valuable guidance for hip preservation treatments and serve as a reference for clinical diagnosis and therapeutic interventions.

Methods

Hip tomography CT scan data from a healthy volunteer was used to create a 3D model of the left hip. The model was preprocessed and imported into Solidworks 2018, based on the CJFH classification. Material parameters and boundary conditions were applied to each fractal model in ANSYS 21.0. Von Mises stresses were calculated, and maximum deformation values were obtained to evaluate the biomechanical effects of the load on the necrotic area and post-necrotic femur, as well as assess each fractal model's collapse risk.

Results

(1) At the same hip flexion angle, maximum deformation followed this order: M Type < C Type < L Type. The L3 type necrotic area experienced the most significant deformation at 0, 60, and 110° angles (1.121, 1.7913, and 1.8239 mm respectively). (2) Under the same CJFH classification, maximum deformation values increased with hip flexion angle (0 < 60 < 110°), suggesting a higher risk of collapse at larger angles. (3) Von Mises stress results showed that the maximum stress was not located in the necrotic area but near the inner and outer edge of the femoral neck, indicating decreased stiffness and strength of the subchondral bone after osteonecrosis.

Conclusion

The study found that femoral head collapse risk was higher when the necrotic area was located in the lateral column under the same stress load and flexion angle. Mechanical properties of the necrotic area changed, resulting in decreased bone strength and stiffness. Large-angle hip flexion is more likely to cause excessive deformation of the necrotic area; thus, ONFH patients should reduce or avoid large-angle hip flexion during weight-bearing training in rehabilitation activities.     

MGFA分型及QMG评分预测重症肌无力患者术后延迟拔管的价值

目的探讨美国重症肌无力协会基于定量测试的临床分型((MGFA分型)及定量评分(QMG评分)对重症肌无力(MG)患者胸腺切除术后延迟拔管的预测价值。方法以我院2007年1月至2012年2月确诊为MG行胸骨正中切口胸腺切除手术的61例患者为研究对象,根据术后情况分为正常拔管组(47例)和延迟拔管组(14例),比较两组性别、年龄、术前MGFA临床分型、QMG评分、肝肾功能、电解质、术前新斯的明及强的松用量等情况。绘制术前MGFA分型及QMG评分的受试者工作特征(ROC)曲线,计算QMG评分的最佳临界值,同时对MGFA分型及QMG评分预测术后延迟拔管的敏感度与特异度进行比较。结果延迟拔管组(14例)在术毕麻醉苏醒后需呼吸支持或拔管后48h内再次插管,延迟拔管率为22.95%。MGFA分型、QMG评分预测术后延迟拔管的ROC曲线下面积(AUC)分别为0.723、0.866,以QMG评分8.5为阈值,预测延迟拔管的灵敏度为78.6%,特异度为87.2%,而MGFA分型预测的灵敏度为78.5%,特异度为63.8%。结论术前MGFA分型、QMG评分可作为术后延迟拔管的预测指标。     

依据Paprosky分型股骨侧假体无菌性松动的处理策略

目的研究全髋关节置换术后假体无菌性松动的治疗方法及疗效,探讨股骨侧假体无菌性松动的治疗原则。方法回顾性分析自2000-01—2014-12诊治的24例股骨侧假体无菌性松动,记录手术前后VAS评分、Harris评分。影像学指标包括假体松动表现、Paprosky分型、假体内翻角、Barrack分级、植骨方式、内固定位置、并发症情况等。结果所有患者均获平均15.3(13~68)个月随访。术前VAS评分平均为8.9(7.2~10)分,末次随访VAS评分4.3(2~10)分,与术前有较大改善,差异有统计学意义(t=2.361,P=0.027)。术前Harris评分平均为32.5(12~54)分,末次随访时为60.8(36~82)分,差异有统计学意义(t=2.213,P=0.032)。所有患者初次置换为骨水泥型股骨柄假体,22例透亮线位于骨水泥-骨界面间。翻修手术采用生物型翻修假体,骨水泥残留1例。术前Paprosky分型,Ⅰ型4例(16.7%),Ⅱ型6例(25%),ⅢA型8例(33.3%),ⅢB型4例(16.7%),无Ⅳ型。术中根据不同分型应用结构性植骨及打压植骨,术后骨长入良好。结论股骨侧假体无菌性松动的处理原则需要对患者骨质缺损、初次置换方式及质量等方面因素进行综合考虑。其处理以翻修手术为主,需根据不同骨缺损类型选择植骨方式及翻修方法。     

Estudio observacional retrospectivo correlacionando las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile

IntroductionPelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification.MethodsRetrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016.ResultsA total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P=.032), and Tile B with sacral fractures (P=.033) and visceral injuries (P=.049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock.ConclusionsTile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.     

Primary Extracranial Meningiomas: An Analysis of 146 Cases

Primary extracranial meningiomas are rare neoplasms, frequently misdiagnosed, resulting in inappropriate clinical management. To date, a large clinicopathologic study has not been reported. One hundred and forty-six cases diagnosed between 1970 and 1999 were retrieved from the files of the Armed Forces Institute of Pathology. Histologic features were reviewed, immunohistochemistry analysis was performed (n = 85), and patient follow-up was obtained (n = 110). The patients included 74 (50.7%) females and 72 (49.3%) males. Tumors of the skin were much more common in males than females (1.7:1). There was an overall mean age at presentation of 42.4 years, with a range of 0.3–88 years. The overall mean age at presentation was significantly younger for skin primaries (36.2 years) than for ear (50.1 years) and nasal cavity (47.1 years) primaries. Symptoms were in general non-specific and reflected the anatomic site of involvement, affecting the following areas in order of frequency: scalp skin (40.4%), ear and temporal bone (26%), and sinonasal tract (24%). The tumors ranged in size from 0.5 up to 8 cm, with a mean size of 2.3 cm. Histologically, the majority of tumors were meningothelial (77.4%), followed by atypical (7.5%), psammomatous (4.1%) and anaplastic (2.7%). Psammoma bodies were present in 45 tumors (30.8%), and bone invasion in 31 (21.2%) of tumors. The vast majority were WHO Grade I tumors (87.7%), followed by Grade II (9.6%) and Grade III (2.7%) tumors. Immunohistochemically, the tumor cells labeled for EMA (76%; 61/80), S-100 protein (19%; 15/78), CK 7 (22%; 12/55), and while there was ki-67 labeling in 27% (21/78), <3% of cells were positive. The differential diagnosis included a number of mesenchymal and epithelial tumors (paraganglioma, schwannoma, carcinoma, melanoma, neuroendocrine adenoma of the middle ear), depending on the anatomic site of involvement. Treatment and follow-up was available in 110 patients: Biopsy, local excision, or wide excision was employed. Follow-up time ranged from 1 month to 32 years, with an average of 14.5 years. Recurrences were noted in 26 (23.6%) patients, who were further managed by additional surgery. At last follow-up, recurrent disease was persistent in 15 patients (mean, 7.7 years): 13 patients were dead (died with disease) and two were alive; the remaining patients were disease free (alive 60, mean 19.0 years, dead 35, mean 9.6 years). There is no statistically significant difference in 5-year survival rates by site: ear and temporal bone: 83.3%; nasal cavity: 81.8%; scalp skin: 78.5%; other sites: 65.5% (P = 0.155). Meningiomas can present in a wide variety of sites, especially within the head and neck region. They behave as slow-growing neoplasms with a good prognosis, with longest survival associated with younger age, and complete resection. Awareness of this diagnosis in an unexpected location will help to avoid potential difficulties associated with the diagnosis and management of these tumors.     

不同临床和病理分型对肝门部胆管癌切除术预后的影响

目的 研究临床和病理分型与肝门部胆管癌切除术疗效的关系。方法总结1993年至2004年在解放军总医院肝胆外科手术切除的肝门部胆管癌198例病例资料。结果临床分型Ⅰ型34例，Ⅱ型60例，Ⅲa型27例，Ⅲb型33例，Ⅳ型19例，Ⅴa型6例。Ⅴb型19例。病理高分化腺癌35例，中分化腺癌52例，低分化腺癌54例，三者的中位生存期分别为29．5、11、5．5个月；病理切缘阴性者与切缘阳性者生存率有显著性差异（P 〈0．05）。手术并发症出现率41．4％，围手术期死亡1例。结论肝门部胆管癌根据临床分型进行相应的手术治疗；病理切缘阴性是影响预后的主要因素之一；围手术期正确处理，是减少手术并发症，提高患者生活质量和延长生存期的关键。     

极外侧腰椎间盘突出症的临床分型及手术方式选择

目的 提出极外侧腰椎间盘突出症的新的临床分型,为手术方式的选择提供依据.方法 按照椎间盘突出的位置及其临床症状将极外侧腰椎间盘突出症分为椎管内椎间孔内型(Ⅰ型)、椎间孔内型(Ⅱ型)和椎间孔外型(Ⅲ型).据此对2002年1月至2007年1月收治的38例极外侧椎间盘突出症患者进行临床分型,并结合临床分型选择(1)经横突间椎间盘切除;(2)经椎管部分关节突切除、潜行椎间盘切除;(3)经椎管椎间盘切除+经后路椎体间融合(PLIF)等手术方式.38例患者中男性25例,女性13例;平均58.4岁.其中L_(3～4) 17例、L_ (4～5) 13例、L_5S_1 8例.单纯椎间盘突出23例,合并椎管狭窄15例.所有病例均表现为突出节段出口根受压的症状和体征,其中Ⅰ型中的7例同时伴有下位神经根受压的表现,15例合并椎管狭窄者存在间歇性跛行,21例有明确的腰痛症状.手术前后行根性疼痛VAS评分,术后采用MacNab方法进行临床疗效评定.结果 按照新的临床分型,38例患者中Ⅰ型10例、Ⅱ型19例、Ⅲ型9例.经横突间行椎间盘切除5例,经椎管部分关节突切除、潜行椎间盘切除7例,经椎管椎间盘切除+PLIF 26例.随访时间6个月～4年10个月,平均2年11个月.VAS评分术前平均为7.4分,术后2周为2.7分,末次随访为3.1分.末次随访MacNab评定结果:优20例、良12例、可5例、差1例,优良率为84.2%.并发症:伤口表浅感染1例、减压不满意者1例、脑脊液漏1例.未见内固定断裂、松动等.结论 新的临床分型,对认识极外侧腰椎间盘突出症的病理变化及选择手术方式等具有重要的意义.