Orthopaedic Surgery最新文献

Purpose: Curved intertrochanteric varus osteotomy (CVO) is a joint-preserving option for young patients with osteonecrosis of the femoral head (ONFH), but postoperative leg length discrepancy (LLD) remains a concern. This study investigated factors associated with leg shortening in both the early postoperative phase (P1) and the healing phase until bone union (P2).

Methods: This retrospective study included 48 patients (51 hips) with non-traumatic ONFH who underwent CVO. Radiographic evaluations were performed preoperatively, immediately postoperatively, and at bone union. Pearson's correlation coefficient was used to correlations between radiographic parameters and leg shortening in P1 and P2. Patients were divided into groups based on whether leg shortening ≥ 5 mm was observed in each phase, and statistical comparisons were conducted. Multivariate logistic regression analyses were performed to identify independent risk factors for leg shortening ≥ 5 mm.

Results: Leg shortening ≥ 5 mm occurred in 17.6% of hips in P1 and 47.1% in P2. Lateral shift of the osteotomy arc center correlated with leg shortening in P1 (r = 0.689, p < 0.0001). Varus angle and changes in femoral anteversion were also correlated in both P1 and P2 (P1: r = 0.362/0.322; P2: r = 0.404/0.754, all p < 0.05). Greater varus angle and lateral/distal shift of the osteotomy center were significantly associated with P1 shortening. In P2, greater changes in femoral anteversion, increased osteotomy distance from the midpoint of the lesser trochanter, and larger varus angle were significant factors. Multivariate analysis identified lateral shift of the osteotomy center as an independent predictor in P1 (OR, 1.30; 95% CI, 1.06-1.81; p = 0.004). In P2, change in femoral anteversion was an independent predictor of leg shortening ≥ 5 mm (OR: 1.24, 95% CI: 1.07-1.51; p = 0.003).

Conclusion: Leg shortening post-CVO progresses during surgery and bone healing. Careful surgical planning and postoperative management, particularly in cases requiring extensive varus correction or anteversion changes, is essential for minimizing LLD and optimizing outcomes.

Objectives: Cage retropulsion (CR) is a common complication following posterior lumbar interbody fusion (PLIF). Symptomatic patients with CR often require revision surgery. However, there is a lack of literature supporting the effectiveness of conservative treatment for CR. This study compares clinical and radiographic outcomes between conservative treatment and revision surgery in patients with CR after PLIF.

Methods: A total of 55 patients with CR after PLIF treated at our institution between 2016 and 2023 were retrospectively reviewed; postoperative radiographic data of follow-up were used to diagnose CR. Clinical outcomes were assessed before therapy and at the final follow-up using the visual analog scale (VAS) for lower back pain and leg pain, Oswestry Disability Index (ODI) scores, and Japanese Orthopedic Association 29 (JOA-29) scores. The treatment effectiveness was evaluated based on whether the score change reached the minimally clinically important difference (MCID). Radiographic indicators included the fusion rates, the extent of CR into the spinal canal, and the total displacement distance. Continuous variables were compared using independent samples t-tests or Mann-Whitney U tests, while categorical variables were analyzed using Chi-square or Fisher's exact tests, as appropriate. A p-value < 0.05 was considered statistically significant.

Results: The fusion rates at the final follow-up for the conservative treatment group and the revision surgery group were 87.5% and 84.6%, respectively. There were no significant differences in final follow-up fusion rates, lower back pain VAS scores, leg pain VAS scores, JOA scores, or ODI scores between the two groups (all p > 0.05). Additionally, there was no difference in the proportion of patients whose lower back pain VAS, ODI, and JOA scores achieved MCID between groups (all p > 0.05). However, in the revision surgery group, the proportion of patients whose leg VAS scores reached MCID was significantly higher than in the conservative group (p = 0.001). In the revision surgery subgroup analysis, patients who did not achieve leg VAS MCID demonstrated significantly more severe cage retropulsion distance compared to MCID achievers (p = 0.03).

Conclusions: Conservative treatment yields satisfactory outcomes in mild, symptomatic CR patients, particularly for low back pain. For patients with a CR distance less than 8.8 mm, conservative treatment and revision surgery showed comparable outcomes, whereas when the CR distance is ≥ 8.8 mm, revision surgery was recommended to improve clinical results. Both conservative treatment and revision surgery can yield favorable outcomes when appropriately indicated.

Objective: If the appropriate internal fixation surgical method is not adopted for femoral neck fractures in young people, it may lead to serious consequences such as poor fracture healing and femoral head necrosis, affecting the quality of life and working ability of young people. Therefore, it is crucial to conduct in-depth research on the internal fixation surgical methods. This study compared the therapeutic effects of triple cannulated screws combined with a bone graft sleeve for parallel implantation of DBM Crunch internal fixation (CCSBGS) and cannulated compression screws (CCS).

Methods: Medical records on the young and middle-aged patients with femoral neck fracture treated with two different internal fixation methods from January 2020 to June 2023 were collected and retrospectively analyzed in the Trauma Emergency Center of the Third Hospital of Hebei Medical University. Two internal fixation groups are: CCSBGS group with 50 patients, 35 males and 15 females, aged (42.44 ± 14.07) years; CCS group with 80 males and 39 females, aged (41.5 ± 13.48) years. This study compared the outcome measures of two groups of patients, including Garden alignment index, Operation duration time, Intraoperative blood loss, Length of hospital stay, Postoperative complications, Femoral neck shortening, Postoperative ambulation time, Walking with sticks, Barthel score, and Harris score.

Results: There was a statistically significant difference in blood loss between the CCS group and the CCSBGS group; at the same time, the amount of bleeding in the CCS group was lower than that in the CCSBGS group (p < 0.01). During the follow-up period, there was a statistically significant difference in the incidence of osteonecrosis of the femoral head among the two groups (p < 0.05), 20 patients in the CCS group and 2 patients in the CCSBGS group developed osteonecrosis of the femoral head. At the last follow-up, the average degree of femoral neck shortening in the CCSBGS group [(0.49 ± 0.28) cm] was significantly lower than that in the CCS group [(0.87 ± 0.35) cm] (p < 0.05). Meanwhile, the postoperative ambulation time of the CCSBGS group is earlier than that of the CCS group (p < 0.05). In addition, the CCSBGS group had the highest Barthel scores [(95.50 ± 2.90)] (p < 0.05). The average Harris score in the CCSBGS group [(92.52 ± 2.41)] was higher than that in the CCS group [(90.47 ± 2.88)] (p < 0.05).

Conclusions: Compared with CCSBGS and CCS, CCSBGS shows better efficacy in terms of quicker return to weight-bearing activities, preservation of femoral neck length, reduction of the rate of osteonecrosis of the femoral head, and overall enhancement of hip function.

Background: Anteromedial cortex reduction and accurate placement of the cephalomedullary nail is the key point to confront implant failure of intertrochanteric fractures. Existing intramedullary nails cannot compensate for femoral neck-shaft offset (FNSO), potentially undermining surgical outcome. This study aimed to investigate the effect of FNSO on anteromedial cortex reduction and accurate placement of the cephalomedullary nail for intertrochanteric fractures.

Methods: This retrospective study included patients with intertrochanteric fractures treated with short intramedullary nails at our institution from January 2014 to December 2016, who were divided into acceptable and unacceptable groups according to the anteromedial cortex reduction quality. We measured the femoral neck-shaft offset (FNSO) and offset angle (FNSOA) on the uninjured femur CT. Postoperative CT of the fractured femur was used to measure the offset between the femoral neck axis and the cephalic nail axis (FNCO) and the corresponding angular offset (FNCOA). Cephalic nail insertion alignment was classified into three types (oblique-forward/rear, coincident, and oblique-backward/front) based on FNCO/FNCOA values. Group differences were analyzed, and logistic regression identified predictors of poor reduction.

Results: Fifty-seven patients (mean age 78.10 ± 13.47 years; 74% women) were included. The median FNSO and FNSOA of unaffected femurs were 4.31 (IQR 1.50) mm and 4.85° (IQR 2.01). 42.1% of cases had acceptable anteromedial reduction, while 57.9% were unacceptable. Cephalic nail insertion types were: 43.9% oblique-backward/front, 28.1% coincident, and 28.1% oblique-forward/rear. The unacceptable reduction group had significantly different FNCO (-2.32 vs. 2.14 mm) and FNCOA (-3.5° vs. 0°) compared to the acceptable group (both p < 0.001), despite similar fracture types and devices. Cephalic nail insertion type differed between groups (p < 0.001): oblique-backward/front and coincident insertions were more common in poor reductions. Logistic regression showed that oblique-backward/front insertion (OR = 51.33, 95% CI 7.60-346.85) and coincident insertion (OR = 9.00, 95% CI 1.52-53.40) were strong independent predictors of unacceptable reduction (both p < 0.001). Among insertion types, oblique-forward/rear had the lowest median FNCO (3.59 mm) and FNCOA (0.69°) and only 12.5% unacceptable reductions, versus coincident (0 mm, 0°, 56.3%) and oblique-backward/front (-3.06 mm, -5.84°, 88.0%) (p < 0.001).

Conclusions: It is difficult for existing intramedullary nails to achieve both the reduction of the anterior medial cortex and the accurate implantation of intramedullary nails due to the presence of FNSO. Optimizing intramedullary nailing design and surgical strategy according to FNSO may improve the treatment outcome of intertrochanteric fractures.

Objectives: The treatment of extensive acetabular bone defects presents significant challenges in revision total hip arthroplasty (rTHA). Custom-made implants, tailored to patient-specific anatomy via 3D printing, offer potential advantages regarding implant stability and alignment. Precise positioning of these large-volume implants is crucial for primary stability and long-term fixation, but can be surgically demanding, especially when intramedullary iliac press-fit stems are used. In contrast to triflange custom-made implants, data on the implantation accuracy of custom-made acetabular components with iliac stem fixation remain limited. This study aimed to assess the accuracy of implant positioning by comparing preoperatively planned component positions with postoperative radiographic outcomes, focusing on anteversion (AV), inclination (INCL), and the center of rotation (CoR).

Methods: In this retrospective cohort study, 24 patients with large acetabular defects (Paprosky ≥ 3A) underwent rTHA with custom-made acetabular components with intramedullary press-fit iliac stem fixation between November 2022 and April 2024. Implantation accuracy was evaluated by comparing the planned positions on preoperative CT scans with the actual implant positions observed on 6-week postoperative radiographs using a previously validated methodology. Discrepancies in AV, INCL, and the CoR were analyzed.

Results: A high degree of alignment with preoperative plans was observed. The mean postoperative AV was 9.96° ± 6.4° (planned: 10.2°), and the mean INCL was 46.3° ± 3.2° (planned: 44.6°). The deviations were minor (Δ AV: -0.25°, Δ INCL: 1.7°), confirming the precision of implant placement. Four implants had CoR deviations exceeding 5 mm cranially (mean cranial shift: 1.77 ± 3.97 mm), and five exceeded 5 mm laterally. Most deviations were within clinically acceptable ranges.

Conclusions: Our findings demonstrate that custom-made acetabular components with iliac stem fixation can be implanted with high accuracy. Moreover, our results support the use of standard radiographs for the postoperative assessment of implant positioning precision. This study provides valuable insights into the accuracy of implant placement in complex rTHA cases, highlighting the role of patient-specific implant technologies in enhancing surgical outcomes.

Objective: In spinal surgery, precise identification of high-speed bur milling states is crucial for patient safety. This study investigates whether integrating tactile and auditory perception can enhance the accuracy of milling state detection in robot-assisted cervical laminectomy.

Methods: Based on the mathematical and physical model of vibration and sound in high-speed bur milling bone, the feasibility of employing vibration and sound characteristics to identify the milling states of high-speed bur is studied systematically. Cervical laminectomy was performed on the cervical spine of the sheep. During the signal acquisition process, acceleration sensors and microphones were installed to collect vibration and sound signals, respectively. Seven milling states were set up in the experiment: (1) Milling depths of cortical bone (CTB): 0.5, 1.0, and 1.5 mm; (2) Milling depths of milling of cancellous bone (CCB): 0.5, 1.0, and 1.5 mm; (3) Boundary conditions: high-speed bur idling or complete penetration of bone (PT). The milling speed was set at 0.5 mm/s, the milling angle was 45°, and the bur diameter was 4 mm. The vibration or sound was extracted by Fast Fourier Transform (FFT) in the frequency domain of the first nine harmonics to generate the feature vector in 9 dimensions (9-D) space. These vibration and sound features were combined to form an 18-D multi-perception spatial vector for subsequent analysis, including five machine learning algorithms: Support Vector Machine (SVM), K Nearest Neighbors (KNN), Naive Bayes (NB), Linear Discriminant Analysis (LDA), and Decision Tree (DT), and deep learning models: Long Short-Term Memory networks (LSTM).

Results: Based on the 18-D features of tactile and auditory multisensory fusion, the LSTM model is trained using 6600 sets of high-speed bur milling data. In order to achieve the best performance, a layer-by-layer parameter optimization strategy was used to determine the optimal parameter configuration, and finally, a single-layer LSTM with 12 memory units was constructed. In terms of accuracy and stability, the model is significantly superior to the machine learning algorithms (SVM, KNN, NB, LDA, and DT), and the accuracy of LSTM is 99.32% in the milling states identification of cervical lamina milling with high-speed bur.

Conclusion: Through theoretical analysis and experimental verification, the study built a multi-perception fusion framework based on tactile and auditory perception and accurately identified the cervical vertebra milling states through the LSTM model, which can provide perception means for operational spinal surgery robots in the future.

Pain is the main symptom of knee osteoarthritis (KOA) and the main cause for patients to seek medical treatment. Despite the development of various therapies to address pain, its efficacy often remains uncertain. According to the new classification of the International Association for the Study of Pain, pain is classified as nociceptive pain, neuropathic pain and nociplastic pain. This review sought to outline potential mechanisms and clinical manifestations within this new classification framework and provided tailored treatment recommendations for each type of pain. Moreover, we further divided nociceptive pain into three subgroups including Inflammatory Pain, Mechanical Pain, and BMLs-related Pain. We suggest: (1) For inflammatory pain, the use of anti-inflammatory medications such as NSAIDs and corticosteroids is recommended. (2) For mechanical pain, weight loss, adjustments to mechanical alignment of the lower limb, and rehabilitation training may significantly alleviate symptoms. (3) For BMLs-related pain, patients might benefit from treatment, such as reducing weight-bearing and implementing antiosteoporosis drugs. (4) For neuropathic pain, management may involve tricyclic antidepressants or anticonvulsants. (5) For nociplastic pain, we give priority to nonpharmacological therapies, with an emphasis on the biopsychosocial model, and encourage patients to adopt positive lifestyle changes, including physical activity, weight management, sleep hygiene, and self-management, as well as involvement in psychotherapy and intervention. In clinical practice, it is essential to recognize that many patients may present with a combination of these pain types. Thus, it becomes imperative to identify the primary pain type and craft precise and individual treatment strategies tailored to their specific needs.

Background: Lumbar spondylolisthesis (LS) is a spinal disorder that often necessitates surgical intervention. However, evidence on the comparative clinical value of robot-assisted full-endoscopic transforaminal lumbar interbody fusion (RA FE-TLIF) versus conventional FE-TLIF in early-grade (Grades I and II) LS remains limited, leaving uncertainty about its true clinical value in this patient population. This study aims to compare the clinical efficacy and safety of FE-TLIF with RA FE-TLIF in patients with Grade I and II LS.

Methods: A retrospective analysis was conducted on 47 patients who underwent surgical treatment for LS between April 2022 and April 2023 at our hospital. Patients were divided into two groups: 22 underwent RA FE-TLIF, and 25 underwent FE-TLIF. Key outcomes measured included operative time, intraoperative blood loss, postoperative recovery time, fusion rate, screw placement accuracy, Visual Analogue Scale (VAS), the Japanese Orthopaedic Association (JOA) scores, and the incidence of postoperative complications. Statistical analyses were performed using the independent-sample t test for continuous variables and the chi-square test for categorical variables, with a significance threshold of p < 0.05.

Results: The RA FE-TLIF group exhibited significantly shorter operative times and lower intraoperative blood loss compared to the FE-TLIF group (p < 0.05). Postoperative recovery, as measured by hospital stay, was also shorter in the RA FE-TLIF group (p = 0.001). VAS and JOA scores indicated greater pain relief and functional improvement in the RA FE-TLIF group, with statistically significant differences observed at both 1 month and final follow-up (p < 0.05). The incidence of postoperative complications was lower in the RA FE-TLIF group, though this difference was not statistically significant (p = 0.144). Complete fusion rates were 95.45% in the RA FE-TLIF group and 88.00% in the FE-TLIF group, with no significant difference (p > 0.05). Screw placement accuracy was higher in the RA FE-TLIF group (97.73%) than in the FE-TLIF group (89.00%), with a significant difference (p < 0.05).

Conclusion: RA FE-TLIF demonstrates superior clinical outcomes compared to FE-TLIF in the treatment of LS. These findings support the broader adoption of RA FE-TLIF as a preferred surgical technique for this condition.

Objective: Adult thoracolumbar kyphosis secondary to osteoporotic vertebral fractures (OVF) impairs the quality of life. Traditional 3CO provides correction but carries a high risk of complications, especially in the elderly. Minimally invasive anterior approaches may be safer. This study aims to compare the radiographic and clinical outcomes of septuagenarians with thoracolumbar kyphosis treated with single-position navigated lateral column realignment with anterior longitudinal ligament release (LCR-A) plus posterior column osteotomy (PCO) and posterior spinal fusion (PSF), or percutaneous pedicle screws (PPS) versus three-column osteotomy (3CO).

Materials and methods: This retrospective study included 21 patients with LCR-A and 54 with 3CO prospectively treated between March 2020 and April 2024. Radiographic parameters, the Oswestry Disability Index (ODI), SRS-22 scores, complications, and perioperative data were analyzed over a 2-year follow-up period.

Results: Although LCR-A patients were older, they had significantly reduced blood loss, shorter operative times, and fewer fused levels than 3CO patients. LCR-A achieved comparable deformity correction, with fewer complications, lower postoperative ODI, and better SRS-22 scores. The LCR-A group maintained radiographic correction, with fewer new neurological deficits and lower rates of infection, ileus, and delirium.

Conclusions: Single-position navigated LCR-A is a safer and less invasive alternative to 3CO in elderly patients with thoracolumbar kyphosis, offering effective deformity correction, fewer complications, improved functional outcomes, and enhanced recovery.

Level of evidence: IV.