Orthopaedic Surgery最新文献

Objectives: In patients with lumbar spinal stenosis (LSS) undergoing unilateral biportal endoscopic unilateral laminotomy for bilateral decompression (UBE-ULBD), damage to the epidural venous plexus often leads to bleeding, increasing the risk of surgical complications. Surgiflo Hemostatic Matrix (SHM) is a gelatin extracted from porcine skin, used for intraoperative hemostasis. This study aims to evaluate the effectiveness and safety of using SHM during UBE-ULBD surgery.

Methods: From October 2023 to July 2024, a total of 96 patients with LSS underwent UBE-ULBD surgery. These 96 patients were randomly divided into two groups: the SHM group (48 patients, using flowable gelatin) and the non-SHM group (48 patients, not using flowable gelatin). The primary outcomes included intraoperative blood loss, postoperative drainage volume, and the 3-min hemostasis success rate. Secondary outcomes included symptomatic postoperative epidural hematoma (SPEH), surgical time, postoperative hospital stay, hospitalization costs, and complications. We used independent sample t-tests to compare continuous data, and chi-square tests or Fisher's exact tests to analyze categorical data.

Results: The intraoperative blood loss and postoperative drainage volume in the SHM group were significantly less than those in the non-SHM group (p < 0.05), and the 3-min hemostasis success rate in the SHM group was significantly higher than that in the non-SHM group (p < 0.05). There were no statistically significant differences between the two groups regarding SPEH, postoperative hospital stay, hospitalization costs, and complications such as thrombosis formation and allergic reactions. However, the surgical time in the SHM group was significantly shorter than that in the non-SHM group (p < 0.05).

Conclusion: When patients with LSS undergo UBE-ULBD, the use of fluid gelatin can effectively reduce intraoperative and postoperative bleeding without introducing additional complications.

Objectives: In patients with lumbar spinal stenosis (LSS), prolonged compression of the epidural venous plexus heightens the risk of bleeding and hematoma during minimally invasive surgery. While absorbable fluid gelatin, an animal protein-based hemostatic agent, is available, its effectiveness in lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD) remains debated. Our research aims to conduct a prospective randomized controlled trial to investigate the effectiveness and safety of this hemostatic material in patients undergoing LE-ULBD for LSS.

Methods: From October 2023 to July 2024, a total of 90 patients with LSS who underwent LE-ULBD were enrolled in this study. The 90 patients were randomly divided into two groups: fluid gelatin group (45 cases, using fluid gelatin) and null-fluid gelatin group (45 cases, not using fluid gelatin). Primary outcomes included the success rate of achieving hemostasis within 3 min and symptomatic postoperative epidural hematoma (SPEH). Secondary outcomes encompassed surgical time, intraoperative blood loss, perioperative blood loss, length of stay, and complications. Independent sample t tests were used to compare continuous data. Chi-squared tests and Fisher's exact probability tests were used to analyze the categorical data.

Results: The success rate of achieving hemostasis within 3 min (p < 0.05) was significantly higher in fluid gelatin group compared to that in the null-fluid gelatin group, and perioperative blood loss (p < 0.05) and surgical time (p < 0.05) were notably lower in the fluid gelatin group. However, there were no statistically significant differences between the two groups regarding intraoperative blood loss, length of stay, and complications, such as SPEH, allergy, and thrombus.

Conclusion: In patients with LSS undergoing LE-ULBD surgery, using fluid gelatin can achieve rapid intraoperative hemostasis, shorten surgical time, and reduce perioperative blood loss without causing complications. Therefore, the conventional use of fluid gelatin in LE-ULBD surgery is an effective and safe strategy.

Objective: The traditional femoral stem is unsuitable for patients with severe proximal femoral bone defects or deformities. However, 3D-printed customized designs offer improved proximal femoral canal contact and enhance the initial stability of the femoral prosthesis. Therefore, this study aims to compare the anatomical parameters, contact parameters, and performance of the 3D-printed customized femoral short (CFS) stem with those of the traditional femoral stem following total hip arthroplasty (THA).

Methods: An in vitro study simulating THA was performed using artificial femur models, with a 3D-printed CFS stem as the experimental group and a Trilock stem as the control group. Anatomical parameters, fitness, filling, micro-motion, and strain distribution were evaluated using artificial femoral models. Micro-motion and strain were recorded under different simulated bodyweight loading using a 3D digital image correlation measurement system.

Results: The neck-shaft angles (NSA) and coronal femoral horizontal offset (CFHO) of the 3D-printed CFS stem (NSA: 125.22°, CFHO: 41.03 mm) were closer to those of the intact femur (NSA: 127.37°, CFHO: 43.27 mm) compare with the Trilock stem (NSA: 132.61°, CFHO: 32.98 mm). In addition, the 3D-printed CFS stem showed improved fitness at cross-sections (The top of the lesser trochanter: 6.31%, the middle of the lesser trochanter: 23.42%, the bottom of the lesser trochanter: 26.61%) and reduced micro-motion under different simulated bodyweight loads (1000: 0.043, 1375: 0.056, 2060 N: 0.061 mm).

Conclusions: The 3D-printed CFS stem provides improved restoration of anatomical parameters, enhanced fitness, and superior biomechanical performance compared with the Trilock stem.

Objective: Duckerley type IIIB distal humerus fractures are rare and complex injuries that pose significant challenges in both diagnosis and treatment. Currently, no consensus exists on the fixation method, with existing approaches often struggling to handle small fragments and associated with issues like elbow instability. The purpose of this study is to evaluate the surgical outcomes of submerged Kirschner wires combined with plate or submerged screw fixation technique for the treatment of Duckerley type IIIB distal humerus fractures.

Methods: A retrospective analysis was conducted on 10 patients with Duckerley type IIIB distal humerus fractures who were treated at our hospital from February 2017 to April 2021. The treatment involved applying buried Kirschner wires combined with microplate or buried screw fixation technique through the olecranon osteotomy approach. The study included six males and four females, with a mean age of 51.4 ± 15.34 years (ranging from 22 to 69 years). During the follow-up, the elbow range of motion, Mayo Elbow Performance Score (MEPS), American Shoulder and Elbow Surgeons (ASES) score, and complications were assessed.

Results: All 10 patients received regular clinical and imaging follow-up for a mean of 39.7 ± 8.8 months (range: 25-50 months). Postoperative incision healing was good for all patients, and no neurovascular injuries were noted. Two patients developed elbow pain. At the last follow-up before the internal fixation removal operation (9.6 ± 1.9 months), X-ray and CT findings confirmed bony healing, and no internal fixation loosening and breakage occurred in any of the patients, except for one case in which there was displacement of the Kirschner wires. The mean range of motion of the elbow before the internal fixation removal operation was extension 15.0° ± 21.6°, flexion 129.5° ± 28.1°, pronation 83.0° ± 9.2°, and supination 81.5° ± 8.0°. The MEPS score was 83.0 ± 8.3, and the ASES was 83.6 ± 7.8. At the last follow-up, the mean range of motion of the elbow was extension 10.0° ± 21.9°, flexion 133.5° ± 16.0°, pronation 88.0° ± 11.2°, and supination 85.0° ± 9.5°. The MEPS score was 84.6 ± 7.6, and the ASES was 84.1 ± 7.4.

Conclusions: The treatment of Duckerley type IIIB low distal humerus fractures using submerged Kirschner wires combined with plate or submerged screw fixation technique has satisfactory advantages in terms of fracture reduction, maintenance of the position of internal fixation, and postoperative recovery.

Objective: Hip and knee OA often occur successively. However, little is known about the relationship between hip and knee OA in unilateral knee OA patients. The aim of the study was to explore the correlation between unilateral knee OA and bilateral hip degeneration to determine the impact unilateral knee OA has on the severity of hip degeneration.

Methods: This retrospective case-control study enrolled 162 patients who were presented with unilateral knee osteoarthritis and hospitalized in Zhongshan hospital, Fudan University, from January 2016 to December 2018. The severity of affected knee joint and bilateral hip joint was evaluated by using the Kellgren-Lawrence (KL) score. Variates, such as gender, age, body mass index (BMI) and Knee Society Score (KSS) at admission, were also recorded. Differences in the severity of OA between ipsilateral, contralateral hip joints and affected knee joints were accessed with chi-square tests. Single-factor and multi-factor logistic regression were applied to determine the risk factors for hip OA in patients with unilateral knee OA.

Results: Gender have no impact on KSS, the length of disease, and BMI of patients. In contralateral hip joints, there was significant difference in the proportion of patients with severe hip degeneration (KL score ≥ 2) compared to those with mild hip degeneration (KL score < 2) when considering length of disease (p < 0.001), KSS symptom score < 70 (p = 0.001) or KSS function score (p < 0.001). The risk factors for contralateral hip degeneration of patients with unilateral knee OA include that long disease course (> 5 years) (OR 3.030 [95% CI 1.476 to 6.220]; p < 0.001), and high KSS function score (≥ 70 year) (OR 0.921 [95% CI 0.878 to 0.967]; p < 0.001), increased risk of contralateral hip degeneration of patients with unilateral knee OA.

Conclusions: The correlation between unilateral knee OA and contralateral hip degeneration was stronger than that between unilateral knee OA and ipsilateral hip degeneration. For knee OA patients with longer course and lower KSS functional score, more attention should be paid to the degeneration process of the contralateral hip joint.

Blocking the infrapatellar branch of the saphenous nerve (IPBSN) can provide analgesic benefits for patients with postoperative acute pain or chronic pain, with minimal adverse effects. To evaluate the analgesic efficacy and potential adverse events associated with IPBSN block in patients suffering from acute or chronic knee pain. We conducted a systematic review across PubMed, Cochrane, Web of Science, and Embase to identify all relevant randomized controlled trials (RCTs) and cohort studies according to predefined selection criteria. The study quality of the RCTs was evaluated using the Cochrane risk of bias assessment tool, while cohort studies were assessed using the ROBINS-I risk of bias tool. The primary outcomes measured were pain intensity and opioid consumption following the nerve block. A total of eight studies were included in this systematic review, encompassing 613 subjects with 276 participants in the control group and 337 participants in the IPBSN block group. The level of evidence was rated high for the RCTs and moderate for the cohort studies. The nerve block was administrated either through the injection of local anesthetic or percutaneous cryoneurolysis targeting the IPBSN. The results indicated that the IPBSN block significantly improved pain relief and reduced opioid consumption in patients with acute postoperative or chronic pain, with no significant difference in the rate of adverse events relating to the procedures or device. The IPBSN block holds promise for improving pain relief and reducing opioid consumption. However, further well-designed randomized controlled trials are needed to confirm these results.

Objectives: The accuracy of dual-energy x-ray absorptiometry (DXA) in predicting proximal humerus osteoporosis in patients with rotator cuff tears (RCTs) undergoing arthroscopic rotator cuff repair (ARCR) is uncertain. The aim of this study was to assess the correlation of computed tomography (CT) Hounsfield units (HU) and the deltoid tuberosity index (DTI) with bone mineral density (BMD), and to evaluate the predictive value of HU values for implant selection.

Methods: This study analyzed the preoperative shoulder CT scans and x-rays of 184 patients who underwent ARCR. Preoperative CT scans were utilized to assess the multiple anatomical parts of the proximal humerus to ascertain the HU values, whereas preoperative x-rays were analyzed to derive the DTI. Among them, 104 patients with preoperative DXA data were grouped according to the WHO diagnostic criteria for osteoporosis to establish the threshold HU values. The correlation between HU values and DTI and the lowest T score on DXA was studied, and the relationship between the HU value and the type of implant selected was discussed. The Pearson correlation coefficient was employed to examine the relationship between HU values, DTI, and T scores. And the Spearman correlation coefficient was employed to examine the relationship between HU values and enhanced fixation.

Results: There was a significant correlation between the HU values and DTI and the lowest T score (r_{HU&T score} = 0.539-0.576, r_{DTI&T score} = 0.288, p < 0.05). On the basis of the lowest T score grouping, the threshold HU values for diagnosing proximal humeral osteoporosis were obtained: proximal humerus = 47.44, humeral head = 97.62, greater tuberosity = 10.9, and lesser tuberosity = 5.38. There was no correlation between HU values and enhanced fixation (using 5.5-mm anchors or metal anchors instead of 4.5-mm anchors or all-suture anchors) (r = -0.143 to -0.027, p > 0.05).

Conclusion: Proximal humeral HU values were significantly correlated with DTI and the lowest T score on DXA. When the HU values in the proximal humerus in patients with RCTs fall below the thresholds, the surgery should be carefully planned. No correlation exists between HU values and enhanced fixation, thus further investigation through group studies is warranted.

Level of evidence: Level III, study of nonconsecutive patients, diagnostic study.

Objective: Spondylolysis, often progressing to spondylolisthesis, commonly defies conservative treatment in refractory cases, indicating a need for surgery. Robot-assisted techniques may provide a stable and effective minimally invasive approach for the treatment of lumbar spondylolysis. To compare the clinical efficacy between robot-assisted percutaneous screw fixation combined with endoscopic bone graft and conventional open screw fixation with bone graft in the treatment of lumbar spondylolysis.

Methods: A cohort study involving 43 individuals with lumbar spondylolysis who underwent surgical treatment was conducted. From January 2022 to June 2023, 20 patients underwent percutaneous screw fixation combined with endoscopic bone graft while 23 patients underwent conventional open screw fixation with bone graft. The demographic data, parameters related to robotic surgery, perioperative indicators, VAS and ODI scores, pedicle screw accuracy, radiographic fusion outcomes, and follow-up results were systematically recorded, analyzed, and then compared between the two groups. Categorical variables were analyzed using chi-square tests, and continuous variables were evaluated with t-tests or Mann-Whitney U tests following normality assessment, with statistical significance at p < 0.05.

Results: Compared with the conventional surgery group, the robot-assisted surgery group had significantly less intraoperative blood loss, less postoperative drainage, shorter hospital stay, less intraoperative fluoroscopy times, and radiation exposure dose (p < 0.05). Nevertheless, the duration of the surgery was longer. Postoperative imaging findings showed high screw accuracy in both groups, with a grade A rate of 95% in the robot-assisted group compared with 91.4% in the conventional open surgery group according to the Gertzbein-Robbins scale. Both groups achieved similar improvements in VAS and ODI during 1-year follow-up, and both groups achieved good bone graft fusion (97.5% fusion rate in the robot-assisted group versus 93.5% in the conventional open surgery group).

Conclusion: Robot-assisted screw fixation combined with endoscopic bone graft provides a safe and reliable minimally invasive treatment of lumbar spondylolysis, with high accuracy of pedicle screw implantation and less radiation exposure dose, less intraoperative trauma, and quicker recovery than conventional open surgery.

Objective: Although endoscopic technologies have been increasingly applied in lumbar fusion surgery in recent years, the advantages and disadvantages of endoscopic posterolateral fusion compared with lateral fusion remain unclear. Six different single-level lumbar interbody fusion procedures were compared to determine whether indirect decompression fusion could achieve levels of efficacy and safety comparable to those of minimally invasive direct decompression fusion in the treatment of lumbar degenerative disease (LDD).

Method: A literature search was conducted in the PubMed, Embase, and Cochrane Library databases, and studies on the treatment of LDD published from 2004 to March 2024 were retrieved. The data of preset clinical outcome measures, including operation time, intraoperative estimated blood loss (EBL), length of hospital stay (LOS), complications, visual analog scale (VAS) score, and the Oswestry Disability Index (ODI), were extracted from the studies.

Results: Thirty-five studies with 3467 patients were included in this review. Network meta-analysis revealed no significant differences in improvements in pain and disability or adverse events among the procedures, except for uniportal endoscopic lumbar interbody fusion (UELIF), which resulted in a lower degree of improvement in the ODI than oblique lateral interbody fusion (OLIF). Stand-alone lateral lumbar interbody fusion (SA-LLIF) exhibited the best performance in terms of indicators of early efficacy, such as surgical time and LOS. OLIF and SA-LLIF had higher fusion rates than did UELIF and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). MIS-TLIF resulted in greater EBL than did OLIF, SA-LLIF, and UELIF.

Conclusion: Minimally invasive lumbar interbody fusion achieves good therapeutic results in LDD patients regardless of the use of indirect or direct decompression, whereas SA-LLIF has better early efficacy.

Objectives: To minimize the risk of V3 segment of vertebral artery (VA) injury in the atlantoaxial dislocation (AAD) patients with C1 pedicle height less than 4.0 mm and provide a strong toggle force in irreducible AAD and revision surgery. We evaluated the feasibility of C1 "Zero Angle" screw (C1ZAS) and safe entry point with "in-out-in" technique as an alternative option for C1 pedicle screw (PS) in cases with AAD.

Methods: Sixty-one patients with AAD or atlantoaxial instability (AAI) (45 male and 16 female) who underwent cervical computed tomography and magnetic resonance imaging scans in our center between January 1, 2022 and December 31, 2023 were retrospectively reviewed. Measurements were made around the ideal trajectory and entry point of C1ZAS using computerized tomography (CT) and magnetic resonance imaging (MRI) in 61 patients. Radiographic measurements included (A) the distance from the recess to the transverse foramen (RTF); (B) the tricortical screw zone (TSZ); (C) the lateral mass height along the C1ZAS trajectory (LMH); (D) the screw length of C1ZAS (ZSL); (E) the screw length of C1 PS (PSL); (F) the distances from the recess to the dura (RD); (G) the distance from the recess to the spinal cord (RSC); (H) the distance from the inner of lateral mass to the spinal cord (ILMSC). During the period of January 1, 2022 to December 31, 2023, C1ZAS placement with "in-out-in" technique was used as an alternative option for C1 PS in 8 patients with AAD and unilateral/bilateral narrow C1 pedicles.

Results: The average RTF, TSZ, LMH, ZSL, RD, RSC, and ILMSC were 7.71, 6.14, 8.32, 33.23, 4.68, 10.02, and 2.91 mm respectively. The entry point of the C1ZAS was defined as the projection point of the inner of the recess to the posterior arch and the trajectory should be angled cephalad by 8.7° and medially by 0°. The 61 patients (122 sides) with AAD or AAI were classified into three groups: the low-risk (76 sides, 62%), the intermedial-risk (18 sides, 15%), and the high-risk (28 sides, 23%) groups. Satisfactory C1ZAS placement and atlantoaxial reduction were achieved in all eight patients with AAD and unilateral/bilateral narrow C1 pedicles. No instance of C1ZAS placement-related VA injury or dural laceration was observed.

Conclusions: When the placement of C1 PS is not feasible in patients with AAD and unilateral/bilateral narrow C1 pedicles, C1ZAS placement with "in-out-in" technique can be considered an effective alternative option, providing tricortical or quadricortical purchase for rigid fixation of the atlas.