中国修复重建外科杂志最新文献

Clavicle fracture is a common orthopedic injury, accounting for approximately 2.6%-4% of all adult skeletal fractures. In 2023, the American Academy of Orthopaedic Surgeons (AAOS) developed evidence-based treatment guidelines for clavicle fractures, which include 4 recommendations and 10 options. This article, based on a thorough review of the guidelines, discusses the clinical treatment of clavicle fractures, aiming to share advancements and the latest diagnostic and therapeutic considerations with orthopedic colleagues to enhance treatment outcomes.

Spinal robotics has rounded out twenty years in clinical, is mainly used for pedicle screw placement at present, can significantly increase the accuracy of screw placement and reduce radiation exposure to the patient and the surgeon. In the future, haptic feedback, automatic collision avoidance, and other technologies will further expand its application to complete precise operations such as decompression and correction, providing safety guarantee for the implementation of complex spinal surgery.

Spanning two decades since the 1st generation spinal robotics inception, the robot-assisted spine surgery (RSS) technology has evolved through generations, culminating in the 4th generation characterized by real-time visual navigation and wire-free screw placement. The fundamental principles of RSS technology include surgical planning, tracking, image registration, and robotic arm control technologies. Currently, RSS technology is maturely employed in thoracolumbar procedures and is progressively being applied in cervical surgeries, spinal tumor resections, and percutaneous operations, offering advantages in reducing tissue trauma and exposure to radiation, thereby improving patient outcomes. Emerging research also focuses on the cost-effectiveness of clinical applications and robot-specific complications. With the integration of artificial intelligence into surgical planning, RSS technology is poised to further incorporate emerging technologies and expand its application across a broader clinical spectrum.

Objective: To compare the effectiveness of robot-assisted and traditional freehand screw placement in the treatment of atlantoaxial dislocation.

Methods: The clinical data of 55 patients with atlantoaxial dislocation who met the selection criteria between January 2021 and January 2024 were retrospectively analyzed. According to different screw placement methods, they were divided into the traditional group (using the traditional freedhand screw placement, 31 cases) and the robot group (using the Mazor X robot-assisted screw placement, 24 cases). There was no significant difference in gender, age, body mass index, etiology, and preoperative visual analogue scale (VAS) score, cervical spine Japanese Orthopaedic Association (JOA) score between the two groups ( P>0.05). The operation time, intraoperative blood loss, operation cost, and intraoperative complications were recorded and compared between the two groups. The VAS score and cervical spine JOA score were used to evaluate the improvement of pain and cervical spinal cord function before operation and at 1 month after operation. CT examination was performed at 3 days after operation, and the accuracy of screw placement was evaluated according to Neo grading criteria.

Results: All the 55 patients successfully completed the operation. The operation time, intraoperative blood loss, and operation cost in the robot group were significantly higher than those in the traditional group ( P<0.05). A total of 220 C ₁ and C ₂ pedicle screws were inserted in the two groups, and 94 were inserted in the robot group, with an accuracy rate of 95.7%, among them, 2 were inserted by traditional freehand screw placement due to bleeding caused by intraoperative slip. And 126 pedicle screws were inserted in the traditional group, with an accuracy rate of 87.3%, which was significantly lower than that in the robot group ( P<0.05). There were 1 case of venous plexus injury in the robot group and 3 cases in the traditional group, which improved after pressure hemostasis treatment. No other intraoperative complication such as vertebral artery injury or spinal cord injury occurred in both groups. All patients were followed up 4-16 months with an average of 6.6 months, and there was no significant difference in the follow-up time between the two groups ( P>0.05). Postoperative neck pain significantly relieved in both groups, and neurological symptoms relieved to varying degrees. The VAS score and cervicle spine JOA score of both groups significantly improved at 1 month after operation when compared with preoperative scores ( P<0.05), and there was no significant difference in the score change between the two groups ( P>0.05).

Conclusion: In the treatment of atlantoaxial dislocation, the accuracy of robot-assisted screw placement is superior to the traditional freedhand screw

Objective: To explore effectiveness of minimally invasive internal fixation with locking plates for mid-shaft clavicle fractures.

Methods: Between October 2022 and August 2023, 28 patients with mid-shaft clavicle fractures were treated by minimally invasive internal fixation with locking plates. There were 10 males and 18 females with a mean age of 46.2 years (range, 18-74 years). The fractures were caused by traffic accident in 16 patients, sports-related injury in 7 patients, and other injuries in 5 patients. According to Robinson classification, the fractures were classified as type 2A1 in 1 case, type 2A2 in 6 cases, type 2B1 in 15 cases, and type 2B2 in 6 cases. The interval between fracture and operation ranged from 5 hours to 21 days (median, 1.0 days). The pain visual analogue scale (VAS) score was 8.1±1.6. The VAS score at 3 days after operation and the occurrence of complications after operation were recorded. During follow-up, X-ray films were re-examined to observe the healing of the fracture; the shoulder joint function was evaluated according to the Constant-Murley score at 6 months, and the length of the incision scar (total length of the distal and proximal incisions) was measured.

Results: All operations were successfully completed without any subclavian vascular or nerve damage. All incisions healed by first intention. The VAS score was 1.2±0.7 at 3 days after operation, and there was a significant difference in VAS score between pre- and post-operation ( t=8.704， P<0.001). At 1 week after operation, the patient's shoulder was basically painless, and they resumed normal life. All patients were followed up 12-20 months (mean, 13.3 months). X-ray films showed that the bone callus began to form at 2-4 months after operation (mean, 2.7 months). There was no delayed healing or non healing of the fracture, and no loosening or fracture of the internal fixators during follow-up. At 6 months after operation, the mean total incision length was 1.5 cm (range, 1.1-1.8 cm); no patient complained of numbness or paresthesia on subclavicular region or anterior chest wall. The Constant-Murley score of shoulder joint function was 93-100 (mean, 97.6).

Conclusion: Minimally invasive internal fixation with locking plates is a good surgical method for treating mid-shaft clavicle fractures, with simple operation, minimal trauma, good postoperative results, and high satisfaction.

Objective: To explore the clinical value of metagenomic next-generation sequencing (mNGS) in diagnosis and treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA).

Methods: Between April 2020 and March 2023, 10 patients with PJI after TKA were admitted. There were 3 males and 7 females with an average age of 69.9 years (range, 44-83 years). Infection occurred after 8-35 months of TKA (mean, 19.5 months). The duration of infection ranged from 16 to 128 days (mean, 37 days). The preoperative erythrocyte sedimentation rate (ESR) was 15-85 mm/1 h (mean, 50.2 mm/1 h). The C reactive protein (CRP) was 4.4-410.0 mg/L (mean, 192.8 mg/L). The white blood cell counting was (3.4-23.8)×10 ⁹/L (mean, 12.3×10 ⁹/L). The absolute value of neutrophils was (1.1-22.5)×10 ⁹/L (mean, 9.2×10 ⁹/L). After admission, the joint fluid was extracted for bacterial culture method and mNGS test, and sensitive antibiotics were chosen according to the results of the test, and the infection was controlled in combination with surgery.

Results: Seven cases (70%) were detected as positive by bacterial culture method, and 7 types of pathogenic bacteria were detected; the most common pathogenic bacterium was Streptococcus lactis arrestans. Ten cases (100%) were detected as positive by mNGS test, and 11 types of pathogenic bacteria were detected; the most common pathogenic bacterium was Propionibacterium acnes. The difference in the positive rate between the two methods was significant ( P=0.211). Three of the 7 patients who were positive for both the bacterial culture method and the mNGS test had the same results for the type of pathogenic bacteria, with a compliance rate of 42.86% (3/7). The testing time (from sample delivery to results) was (4.95±2.14) days for bacterial culture method and (1.60±0.52) days for mNGS test, and the difference was significant ( t=4.810, P<0.001). The corresponding sensitive antibiotic treatment was chosen according to the results of bacterial culture method and mNGS test. At 3 days after the one-stage operation, the CRP was 6.8-48.2 mg/L (mean, 23.6 mg/L); the ESR was 17-53 mm/1 h (mean, 35.5 mm/1 h); the white blood cell counting was (4.5-8.1)×10 ⁹/L (mean, 6.1×10 ⁹/L); the absolute value of neutrophils was (2.3-5.7)×10 ⁹/L (mean, 4.1×10 ⁹/L). All patients were followed up 12-39 months (mean, 23.5 months). One case had recurrence of infection at 6 months after operation, and the remaining 9 cases showed no signs of infection, with an infection control rate of 90%.

Conclusion: Compared with bacterial culture method, mNGS test can more rapidly and accurately detect pathogenic bacteria for PJI after TKA, which is important for guiding antibiotics combined with surgical treatment of PJI.

Objective: To explore the application of improved carpal shoot through view (ICSTV) method in the treatment of distal radius fractures with volar plate internal fixation.

Methods: The clinical data of 67 patients with distal radius fractures who met the selection criteria between January 2020 and January 2023 was retrospectively analyzed. There were 30 males and 37 females with an average age of 53.6 years (range, 18-75 years). According to the AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 25 cases of type B and 42 cases of type C. The time from injury to operation ranged from 2 to 6 days, with an average of 3.8 days. During the operation, bilateral cortical drilling was performed, and the length of the implanted screw was 1-2 mm shorter than that measured by the depth ruler. Standard anteroposterior and lateral (AAL) fluoroscopy and ICSTV fluoroscopy were performed after volar anatomic locking plate fixation, respectively. If the dorsal cortex of the distal radius was detected to be penetrated, the short screw was replaced and ICSTV fluoroscopy was performed again until no screw was penetrated. The detection rate of dorsal cortical screw penetration was compared between AAL fluoroscopy and ICSTV fluoroscopy. Postoperative CT scan was performed to confirm the presence or absence of dorsal cortical screw penetration.

Results: Intraoperative AAL fluoroscopy found 5 screws penetrating the dorsal cortex in 4 patients (6.0%), and ICSTV fluoroscopy found 19 screws penetrating the dorsal cortex in 15 patients (22.4%) including the above 4 patients, with a significant difference in the detection rate between the two fluoroscopy methods [ OR=0.267 (0.084, 0.845), P=0.018]; 15 patients were replaced with short screws during operation. At the same time, ICSTV fluoroscopy detected 2 screws penetrating into the distal radioulnar joint in 2 cases (3.0%), which could not be found in AAL fluoroscopy, and the direction of the screws was adjusted and replaced. All patients were reexamined by wrist CT within 3 days after operation, and no dorsal cortical screw penetration or screw penetration into the distal radioulnar joint was found. All the 67 patients were followed up 6-18 months, with an average of 11.3 months. Extensor tendon irritation occurred in 2 patients at 3 months after operation, and no extensor tendon rupture occurred in all patients during follow-up. All fractures healed well, and the healing time was 8-13 weeks, with an average of 10.8 weeks. There was no complication such as internal fixation loosening or fracture displacement. The Gartland-Werley score at last follow-up ranged from 0 to 15, with an average of 5.6.

Conclusion: ICSTV fluoroscopy can effectively detect occult dorsal cortical screw penetration of the distal radius that can not be revealed by AAL fluoroscopy.

Objective: To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S ₂ nerve root for relieving spastic equinus foot.

Methods: Anatomical studies were performed on 12 adult cadaveric specimens. The S ₂ nerve root and its branches were exposed through the posterior approach. Located the site where S ₂ joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S ₂ nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S ₂ joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading.

Results: The distance between the location where S ₂ joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S ₂ nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs.

Conclusion: HSN of triceps branches combined with partial neurotomy of S ₂ nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.

Objective: To compare the short-term effectiveness of arthroscopic suture of triangular fibrocartilage complex (TFCC), arthroscopic suture of TFCC combined with open reduction and internal fixation, and simple open reduction and internal fixation in the treatment of distal radius fractures combined with ulnar styloid base fractures and TFCC injury.

Methods: A clinical data of 97 patients with distal radius fractures combined with ulnar styloid base fracture and TFCC injury, who were admitted between September 2019 and September 2022 and met the selective criteria, was retrospectively analyzed. After reduction and internal fixation of distal radius fractures, 37 cases underwent arthroscopic suture of TFCC (TFCC group), 31 cases underwent arthroscopic suture of TFCC combined with open reduction and internal fixation of ulnar styloid base fractures (combination group), and 29 cases underwent simple open reduction and internal fixation of ulnar styloid base fractures (internal fixation group). There was no significant difference in baseline data between groups ( P>0.05), such as gender, age, injury side, time from injury to operation, and preoperative radius height, palm inclination, ulnar deviation, grip strength, wrist range of motion (ROM) in rotation, ulnar-radial deviation, and flexion-extension. The differences (change value) in radius height, metacarpal inclination angle, ulnar deviation angle, grip strength, and wrist ROM in rotation, ulnar-radial deviation, and flexion-extension between preoperative and 12 months after operation in 3 groups were compared. The effectiveness was evaluated according to the modified Gartland-Werley score at 12 months after operation.

Results: All incisions healed by first intention. All patients were followed up 12-18 months (mean, 14 months). X-ray films showed that there were 4 patients with non-union of ulnar styloid base fracture in TFCC group, and the remaining patients had fracture healing at 3 months after operation. The radius height, palm inclination, and ulnar deviation of 3 groups at 12 months after operation were significantly better than those before operation ( P<0.05); however, the differences in the change values of the above indexes between groups was not significant ( P>0.05). At 12 months after operation, the change values of wrist ROM in rotation, ulnar-radial deviation, and flexion-extension in the TFCC group and the combination group were significantly greater than those in the internal fixation group ( P<0.05), and there was no significant difference between the TFCC group and the combination group ( P>0.05). The change values of grip strength was significantly greater in the combination group than in the internal fixation group ( P<0.05); there was no significant difference between the other groups ( P>0.05). The excellent and good rates according to the modified Gartland-Wer

Objective: To investigate the feasibility and effectiveness of robot-assisted posterior minimally invasive access in treatment of thoracolumbar tuberculosis via transforaminal expansion approach.

Methods: A clinical data of 40 patients with thoracolumbar tuberculosis admitted between January 2017 and May 2022 and met the selection criteria was retrospectively analyzed. Among them, 15 cases were treated with robot-assisted and minimally invasive access via transforaminal expansion approach for lesion removal, bone graft, and internal fixation (robotic group), and 25 cases were treated with traditional transforaminal posterior approach for lesion removal and intervertebral bone grafting (traditional group). There was no significant difference in the baseline data between the two groups ( P>0.05) in terms of gender, age, lesion segment, and preoperative American Spinal Injury Association (ASIA) grading, Cobb angle, visual analogue scale (VAS) score, erythrocyte sedimentation rate (ESR), and C reactive protein (CRP). The outcome indicators were recorded and compared between the two groups, including operation time, intraoperative bleeding volume, hospital stay, postoperative bedtime, complications, ESR and CRP before operation and at 1 week after operation, the level of serum albumin at 3 days after operation, VAS score and ASIA grading of neurological function before operation and at 6 months after operation, the implant fusion, fusion time, Cobb angle of the lesion, and the loss of Cobb angle observed by X-ray films and CT. The differences of ESR, CRP, and VAS score (change values) between pre- and post-operation were calculated and compared.

Results: Compared with the traditional group, the operation time and intraoperative bleeding volume in the robotic group were significantly lower and the serum albumin level at 3 days after operation was significantly higher ( P<0.05); the postoperative bedtime and the length of hospital stay were also shorter, but the difference was not significant ( P>0.05). There were 2 cases of poor incision healing in the traditional group, but no complication occurred in the robotic group, and the difference in the incidence of complication between the two groups was not significant ( P>0.05). There were significant differences in the change values of ESR and CRP between the two groups ( P<0.05). All Patients were followed up, and the follow-up time was 12-18 months (mean, 13.0 months) in the traditional group and 12-16 months (mean, 13.0 months) in the robotic group. Imaging review showed that all bone grafts fused, and the difference in fusion time between the two groups was not significant ( P>0.05). The difference in Cobb angle between the pre- and post-operation in the two groups was significant ( P<0.05); and the Cobb angle loss was significant more in the traditional group than in the robotic group (