Orthopaedic Surgery最新文献

Objective: The selection of the lowest instrumented vertebra (LIV) is crucial in the surgical treatment of adolescent idiopathic scoliosis (AIS), particularly for thoracolumbar/lumbar curves. While traditional LIV selection strategies primarily rely on weight-bearing radiographs, the utility of supine imaging remains unclear. This study aimed to evaluate the feasibility of using the last touched vertebra identified in the supine position (LTV-supine) as the LIV for Lenke-5 AIS.

Methods: We conducted a retrospective review of Lenke-5 AIS patients who underwent posterior spinal fusion at Peking Union Medical College Hospital from 2010 to 2017, with a minimum 5-year follow-up. All patients underwent distal fusion to the LTV-supine. Radiographic parameters, including coronal and sagittal alignments and LIV-related measurements (LIV tilt, translation, rotation, and the subjacent disc angle), as well as the Scoliosis Research Society-22 (SRS-22) scores were compared across preoperative, postoperative, and final follow-up time points using the paired t-tests. Based on the positional relationship between the LTV-supine (the selected LIV) and the LTV-upright, patients were categorized into two groups: the short-fusion group (LIV at the first vertebra proximal to the LTV-upright) and the non-short-fusion group (LIV at LTV-upright). Radiographic parameters, SRS-22 scores, and the incidence of radiographic complications were compared between groups using independent t-test.

Results: Forty-five consecutive patients were included. Radiographic outcomes demonstrated significant improvements: the thoracolumbar/lumbar curve Cobb angle was corrected from 49.2° ± 10.8° preoperatively to 8.3° ± 5.6° at final follow-up (correction rate: 83.4% ± 10.9%; p < 0.05), and the coronal balance decreased from 20.3 ± 10.0 mm to 11.2 ± 6.9 mm (p < 0.05). All LIV-related parameters showed significant improvement at the final follow-up compared to preoperative values (p < 0.05). SRS-22 scores showed notable enhancements in self-image/appearance and mental health domains at final follow-up (p < 0.05). Fusion to LTV-supine saved 0.3 ± 0.5 distal vertebrae compared to the LTV-upright strategy (p < 0.05), resulting in shorter fusions in one-third of the patients (15/45). No significant differences were observed between the short-fusion (n = 15) and non-short-fusion (n = 30) groups in the final follow-up Cobb angle, correction rate, SRS-22 domain scores, nor in the incidence of adverse radiographic outcomes, such as sloped LIV, subjacent disc wedging, or coronal imbalance.

Conclusions: Supine imaging serves as a valuable adjunct for LIV selection in AIS. For Lenke-5 AIS, adopting the LTV-supine can yield comparable radiographic outcomes while potentially sparing additional distal segments in a subset of patients compared to the conventional upright radiograph-based approach.

Study design: Retrospective cohort study.

Objective: Mono-segmental thoracic and lumbar nonfusion (MTLN) can occur during spinal fusion in patients with ankylosing spondylitis (AS). This study aimed to summarize the clinical characteristics of AS-MTLNs, identify correlative variables for their occurrence, and propose a new classification system.

Methods: We retrospectively reviewed the clinical materials of patients with AS diagnosed between 2008 and 2023 in our institution, and 803 patients were included. The patients were divided into an AS-MTLN group (n = 155, 19.3%) and a non-AS-MTLN group (n = 648, 80.7%). Fifteen variables were collected, and the differences between groups were compared. The proposed new classification system included three main types and seven subtypes, including noninflammatory nonfusion (Type 1), inflammatory nonfusion without intervertebral destruction (Type 2), and inflammatory nonfusion with intervertebral destruction (Type 3).

Results: The prevalence of AS-MTLNs in descending order was lower thoracic spine (n = 84, 54.2%), lumbar spine (n = 62, 40.0%), and upper thoracic spine (n = 9, 5.8%). The computed tomography (CT) Hounsfield unit (HU) of the L1 vertebra was the only variable that showed a significant difference between two groups (p = 0.007), and the binary logistic regression model further confirmed its correlation with the occurrence of AS-MTLN (p = 0.005, odds ratio = 0.993, 95%). Regarding the new classification system, the AS-MTLN numbers of three types were (1) Type 1: 53 cases, 34.2%; (2) Type 2: 31 cases, 20%; (3) Type 3: 71, 45.8%. Type 1 was more common in lumbar spine (33 cases, 62.3%), Type 2 was more common in lower thoracic spine (20 cases, 64.5%), and Type 3 was also more common in lower thoracic spine (52 cases, 73.2%).

Conclusion: This study systematically described the clinical characteristics of AS-MTLNs and recognized that the CT HU of the L1 vertebra was correlated with the occurrence of AS-MTLN. The newly proposed classification system includes all types of AS-MTLNs, with value for clinical applications and popularization.

Objective: Hip fracture causes significant morbidity and mortality, necessitating the identification of biomarkers for risk stratification. This study aimed to evaluate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and incidence of postoperative complications and the 2-year all-cause mortality among hip fracture patients.

Methods: This retrospective cohort study involved 2595 patients aged from 45 years who received surgery for hip fracture between 2000 and 2022. Preoperative NT-proBNP levels were used to divide patients into three groups: low (< 123.27 pg/mL), moderate (123.27-349.93 pg/mL), and high (> 349.93 pg/mL) NT-proBNP group. Multivariate logistic regression and Cox proportional hazards models were used to evaluate the odds ratio (OR) for postoperative complications and the hazard ratio (HR) for mortality, after adjusting for potential confounders.

Results: Post-operative complications were reported in 171 (6.59%) patients with mortality of 226 (8.71%) during the 2-year follow-up. Compared to patients with low NT-proBNP group, the adjusted odds ratio for postoperative complications was 1.21 (95% CI 0.69-2.15) for those in the moderate NT-proBNP group and 2.33 (95% CI 1.35-4.03) for those in the high NT-proBNP group. Similarly, the adjusted hazard ratio for 2-year all-cause mortality was 1.51 (95% CI 0.91-2.50) for those in the moderate NT-proBNP group and 2.66 (95% CI 1.63-4.32) for those in the high NT-proBNP group. Higher pre-operative NT-proBNP levels were associated with an increased risk for postoperative complications and 2-year all-cause mortality (both p for trend < 0.001) among hip fracture patients. The results were consistent across various subgroup and sensitivity analyses.

Conclusion: Preoperative NT-proBNP is strongly associated with both postoperative complications and 2-year all-cause mortality among patients received hip fracture surgery. Higher levels of NT-proBNP before surgery may serve as a useful biomarker for risk stratification and guiding treatment decisions for this patient subpopulation.

Objectives: Wide surgical resection is the standard for primary malignant soft tissue and bone tumors, especially when the knee's intra-articular space is involved. Extraarticular Knee Joint Resection (EKJR) aims to remove the knee joint while preserving function. Considering the lack of literature present on these aspects, the purpose of this study is to analyze the data of a series of 30 patients affected by benign aggressive or malignant bone and soft tissue tumors who underwent EKJR with two different resection techniques.

Methods: The study involved all patients treated with EKJR for tumors between October 2006 and March 2023. Two EKJR techniques were analyzed: Type-A (complete extensor mechanism excision) and Type-B (patellar coronal osteotomy sparing the extensor mechanism). Clinical outcomes, tumor characteristics, and complications were compared between the two techniques. For statistical analyses, the Mann-Whitney test or Kruskal-Wallis test was employed to explore differences between continuous variables. Relationships between categorical variables were assessed using Pearson's Chi-square test or Fisher's exact test. Correlations were evaluated using Spearman's correlation coefficient. Survival analyses were conducted using the Kaplan-Meier method.

Results: The cohort included 13 males and 17 females (16 Type-A, 14 Type-B resections). Histologically confirmed intra-articular involvement was found in 26.7% of cases. Late complications included infections and amputations, more frequently in Type-A resections. The 5-year Local Recurrence-Free Survival was 91.5%, Metastasis-Free Survival was 39.5%, and Overall Survival was 47.9%. Type-A resections lead to higher complication rates, including amputation, due to extensive vascular and tissue disruption. Type-B resections, preserving the extensor mechanism, result in better functional outcomes and faster recovery despite some residual weakness.

Conclusion: EKJR is oncologically effective but carries significant functional and complication considerations. Type-B resection balances oncological safety and functional preservation, especially for benign aggressive tumors.

Objective: This study aims to investigate the role of Denosumab and its downstream target ST18 in wear particle-induced macrophage inflammation and osteolysis, and to explore the underlying mechanisms involved in aseptic loosening (AL) of prosthetic joints.

Methods: Macrophages were stimulated with titanium particles (TiPs), and inflammatory responses were assessed using qRT-PCR, western blot, flow cytometry, and immunohistochemistry. Denosumab's effects on inflammation and osteolysis were evaluated with the same approaches. Potential targets of Denosumab were screened via online databases and validated by qRT-PCR and western blot. ST18 was modulated in macrophages using lentiviral overexpression and knockdown systems. A mouse calvarial model of TiPs-induced osteolysis was established, and the roles of Denosumab and ST18 were examined in vivo using micro-CT, H&E staining, and tartrate-resistant acid phosphatase (TRACP) staining.

Results: Denosumab suppressed TiPs-induced macrophage inflammation by inhibiting NF-κB signaling and M1 polarization. We identified ST18 as a direct target of Denosumab, whose expression was upregulated by TiPs but downregulated by Denosumab. Lentivirus-mediated ST18 knockdown markedly attenuated TiPs-induced inflammation, whereas ST18 overexpression exacerbated it. Further analysis revealed that ST18 interacts with PARP1. In vivo, Denosumab significantly alleviated TiPs-induced osteolysis in mouse calvaria, an effect that was reversed by ST18 overexpression.

Conclusion: Denosumab attenuates TiPs-induced macrophage activation and osteolysis through suppression of the NF-κB pathway and M1 polarization, with ST18 serving as a key mediator. These findings highlight Denosumab as a promising therapeutic candidate for the prevention of prosthesis-related aseptic loosening.

Objective: Open tibial shaft fractures (OTSFs) pose significant therapeutic challenges due to high-energy trauma, extensive soft tissue damage, and contamination risks, complicating fracture stabilization and increasing infection rates. Conventional freehand closed reduction often requires multiple attempts, exacerbating soft tissue injury and radiation exposure. To address these limitations, this study evaluates a double reverse traction-assisted technique, hypothesizing that it could improve reduction accuracy and reduce complications in OTSFs managed with hexapod external fixators (HEFs).

Methods: This retrospective cohort study analyzed the records of 55 hospitalized patients with AO/OTA type 42-A or 42-B OTSFs treated with HEF between March 2020 and March 2023. Double reverse traction-assisted closed reduction was performed on 28 patients (DRTA group), while traditional freehand closed reduction was performed on 27 patients (Freehand group). We documented fracture reduction time, fluoroscopy time, external fixation time, radiographic results, electronic prescription count, and complications. Final clinical outcomes were assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria at a mean follow-up of 15.3 months. Statistical analysis was performed using independent samples t-tests or the chi-square test.

Results: DRTA group demonstrated significantly shorter fracture reduction time (12.13 ± 2.12 vs. 17.14 ± 3.43 min; p < 0.001) and fluoroscopy time (8.12 ± 1.78 vs. 13.75 ± 2.62; p < 0.001) compared to the Freehand group. External fixation time showed no significant difference (p > 0.05). DRTA group exhibited superior radiographic alignment, with significantly reduced residual translation and angulation on AP/lateral views (all p < 0.05). The electronic prescription count for postoperative correction was significantly lower in the DRTA group (0.9 ± 0.7 vs. 1.4 ± 1.0; p < 0.05). The complication rate was lower in the DRTA group (32.1%) than in the Freehand group (48.1%), but this difference was not statistically significant (p > 0.05). ASAMI scores were similar between both groups (p > 0.05). ASAMI bone and functional scores were similar between groups.

Conclusion: In this retrospective study, both reduction techniques achieved favorable therapeutic outcomes. However, the double reverse traction-assisted technique was associated with greater efficiency in fracture reduction, more accurate radiographic alignment, and a nonsignificant trend toward lower complications compared to traditional freehand reduction. These results indicate that the double reverse traction-assisted technique is a feasible and promising alternative, but its definitive advantages need to be confirmed by larger, prospective, randomized controlled trials.

Objective: Severe scoliosis is often accompanied by moderate-to-severe pulmonary dysfunction. Numerous surgical methods are available for the treatment of severe scoliosis, but the effect of each method on postoperative pulmonary function (PF) remains controversial. Apical region correction and global balance (ACGB) is an effective surgical strategy to treat severe scoliosis, using Schwab I-II osteotomies and simple one-stage surgery. Herein, we explore the effect of the ACGB surgical strategy on postoperative PF values in patients with severe scoliosis at 2-year follow-up.

Methods: Patients who underwent ACGB for scoliosis between 2015 and 2020 were enrolled, PF and radiological outcomes were evaluated preoperatively and at 2-year follow-up. PF values included forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and percent-predicted values (FVC% and FEV1%). Paired t-test, Pearson and Spearman correlation analyses, and multiple linear regression were used to analyze changes in PF values and associated factors.

Results: In total, 36 patients (12 male and 24 female; mean age, 20.1 years) who underwent ACGB surgery were enrolled. Preoperative PF values showed restrictive ventilatory dysfunction. At 2-year follow-up, the PF values showed significant improvements. FVC, FEV1, FVC%, and FEV1% showed mean increases of 0.72, 0.68 L, 10.3%, and 9.8%, respectively. Changes in PF values were significantly correlated with age, thoracic height, preoperative FVC%, and preoperative FEV1%.

Conclusion: ACGB significantly improves PF in patients with severe scoliosis at 2-year follow-up. The increased thoracic height may be crucial for improving PF values, while patients with poorer preoperative PF may show greater postoperative improvement.

Objective: Vertebroplasty with non-degradable polymethyl methacrylate bone cement is a common procedure in spine surgery. However, this bone cement reinforcement of the vertebral body could affect subsequent spinal surgeries, especially for pedicle screw insertion. This study proposes a novel method of inserting pedicle screws into bone cement-reinforced vertebral bodies through thermal softening via Kirschner wires (K-wires) drilling, and conducts preliminary in vitro experiments to assess its feasibility and safety.

Methods: This study includes bone cement block experiments and in vitro goat bone experiments. The bone cement block experiment utilized a CNC machine to drill into bone cement blocks with varying K-wire diameters, rotational speeds, and feed rates, followed by the insertion of pedicle screws. The highest temperature during the procedure and the pull-out strength of the pedicle screws were recorded for different groups. A two-way ANOVA was used for comparative analysis. The goat bone experiment consisted of an experimental group and a control group. The control group had screws inserted along the pedicle after drilling. In the experimental group, screws were inserted after softening the old bone cement within the vertebral body using a 3.5 mm K-wire for drilling. The highest temperature during the procedure was recorded for the experimental group, and pull-out tests were conducted on the screws of both groups after the procedure. The pull-out results from the goat bone experiment were analyzed using Student's t-test.

Results: Bone cement block experiment: Drilling with K-wires caused a significant temperature increase in the bone cement blocks, with temperature rises at 4 mm ranging from 28.1°C to 75.9°C. The maximum pull-out loads across all groups ranged from 2455.053 to 15201.94 N. In the goat bone experiment, the experimental group showed temperature increases of 8.38°C ± 3.07°C beneath the pedicle, 11.18°C ± 1.42°C in the spinal canal, and 8.26°C ± 3.46°C anterior to the vertebral body during drilling. The average maximum loads for the experimental and control groups were 910.5504 ± 221.6544 N and 294.229 ± 40.3475 N, respectively, indicating a statistically significant difference between the two groups (p = 0.0001).

Conclusion: The experimental results demonstrate that screws can be inserted into bone cement after thermal softening via K-wire drilling, achieving good pull-out resistance. In the goat bone experiment, the average temperature increase around the vertebral body was measured to be below 10°C, indicating a low risk of thermal damage to the surrounding tissues.

As a core minimally invasive technique for treating osteoporotic vertebral compression fracture (OVCF), percutaneous kyphoplasty (PKP) is widely employed clinically but continues to face significant technical challenges. These include uneven cement distribution, loss of vertebral height reduction, cement leakage, and adjacent vertebral re-fractures. To overcome these limitations, multi-dimensional technical refinements have emerged in recent years: innovations in surgical access and propping instruments (e.g., percutaneous curved kyphoplasty (PCKP), Sky system) optimize cement spatial distribution; intravertebral support implants (e.g., SpineJack, vertebral body stenting [VBS], stabilizing augmented Intervertebral Force [SAIF]) provide sustained mechanical support and mitigate loss of reduction height; and cement flow control techniques (e.g., Bone-filled bag systems, Kiva system), coupled with the use of high-viscosity bone cement, have significantly reduced leakage risks. This paper systematically reviews recent advancements in propping technology and intravertebral implants addressing these PKP challenges, aiming to provide an evidence-based foundation for optimizing the minimally invasive management of OVCF. Future development requires bioactive bone cements (e.g., magnesium/calcium phosphate-based composites) integrated with precise personalized design to advance PKP toward facilitating physiological bone remodeling.