ObjectiveTo investigate the effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space.MethodsTwelve patients with lower cervical interlocking fracture and dislocation were analyzed retrospectively between January 2013 and June 2015. There were 7 males and 5 females, aged 25-59 years with an average age of 38.4 years. The disease duration was 9.6 hours to 100 days with an average of 7.3 days. There were 8 cases of unilateral locking and 4 cases of bilateral locking; 4 cases of old injury and 8 cases of fresh injury. The injured segments were 2 cases of C3, 4, 5 cases of C4, 5, 3 cases of C5, 6, and 2 cases of C6, 7. According to Meyerding classification, there were 9 cases of grade Ⅰ and 3 cases of grade Ⅱ. According to the functional classification of American Spinal Injury Association (ASIA), there were 2 cases of grade C, 6 cases of grade D, and 4 cases of grade E. The interlocking facet was released through the Luschka joint and anterior lamina space, and the anterior cervical fusion and internal fixation were used to treat the fracture and dislocation of the lower cervical spine. The recovery of spinal cord function was judged by the functional classification of ASIA; visual analogue scale (VAS) score, neck disability index (NDI) score, modified Japanese Orthopaedic Association (m-JOA) score were used to evaluate the clinical efficacy; the Cobb angle of fusion segment were observed by X-ray film. The intervertebral bone graft fusion was evaluated at 6 months after operation.ResultsThe average operation time was 78.30 minutes, the average intraoperative blood loss was 167.30 mL, and the average postoperative drainage volume was 58.12 mL. No blood transfusion was given during or after operation. During the operation, there was no accidental injury of large blood vessels, esophagus, and trachea; no laryngo edema, dysphagia, hoarseness, and cerebrospinal fluid leakage occurred after operation; no spinal cord injury or nerve root injury aggravated; the incision healed by first intention, and no infection occurred. All 12 cases were followed up 15-20 months, with an average of 16.5 months. The symptoms and function of the nerve injury were significantly improved when compared with that before operation. Re-examination of the cervical spine X-ray film at 6 months after operation showed that the Cage or bone graft was not displaced or broken, the screw was not loosened or detached, and the intervertebral graft fusion rate was up to 100%. At last follow-up, the ASIA grade, Cobb angle of fusion segment, neck pain VAS score, m-JOA score, and NDI score were significantly improved when compared with preoperative one (P<0.05).ConclusionThe effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space is clear, which not only can make the injured segment get satisfactory reduction, immediate stability and reconstruction, and full decompression, but also can effectively prevent the secondary injury of spinal cord.
Objective To investigate the microscope-assisted anterior cervical surgery and traditional open surgery for the treatment of cervical myelopathy with ossification of the posterior longitudinal ligament (OPLL). Methods Retrospective selection of patients with OPLL who underwent microscope-assisted and traditional open anterior cervical surgery in West China (Airport) Hospital Sichuan University were selected between January 2016 and August 2020. The patients who underwent traditional open anterior cervical surgery between January 2016 and August 2018 were classified as the conventional group, and the patients who underwent microscope-assisted anterior cervical surgery between September 2018 and August 2020 were classified as the microscope group. The baseline characteristics, operative time, intraoperative blood loss, length of hospital stay, Visual Analogue Scale (VAS) of pain before and after surgery, and surgical complications were collected. Neurological function was assessed using the Japanese Orthopaedic Association (JOA) score. Result A total of 46 patients were included. There were 24 cases in the conventional group and 22 cases in the microscope group. There was no significant difference in baseline characteristics between the two groups (P>0.05). The operation time, intraoperative blood loss and length of hospital stay in the microscope group were lower than those in the conventional group (P<0.001). There was no significant difference in VSA score and JOA score between the two groups before operation (P>0.05). There were statistically significant differences in VAS score and JOA score between the two groups 18 months after operation (P<0.001). The comparison of VAS score and JOA score in the two groups before and after operation showed that there was a statistically significant difference between 18 months after operation and before operation (P<0.05). In the microscope group, the average improvement rate of neurological function [(79.90±16.67)% vs. (58.12±17.47)%, t=4.317, P<0.001], excellent and good rate [95.45% (21/22) vs. 66.67% (16/24), χ2=4.354, P=0.037] were higher than those in the conventional group. The total number of complications in the microscope group was lower than that in the conventional group (P=0.024). Conclusion Compared with the traditional open anterior cervical surgery, the microscope-assisted anterior cervical surgery for OPLL can reduce intraoperative blood loss and length of hospital stay, reduce the incidence of postoperative complications.
ObjectiveTo investigate the effectiveness of the extended Carlson approach in the treatment of lateral femoral condylar Hoffa fractures.MethodsThe clinical data of 17 patients with lateral femoral condyle Hoffa fractures between September 2012 and January 2019 were retrospectively analyzed. There were 10 males and 7 females, with a mean age of 43 years (range, 32-68 years). Fractures were caused by traffic accident in 9 cases, by falling from height in 6 cases, and by the other mechanism in 2 cases. According to the Letenneur’s classification, there were 8 cases of typeⅠ, 6 cases of type Ⅱ, and 3 cases of type Ⅲ. The mean time from injury to operation was 7 days (range, 3-32 days). All patients were treated with extended Carlson approach. Patients with Letenneur types Ⅰ and Ⅲ were fixed by a posterior antigliding plate combined with headless compression screws from anteroposterior direction, and patients with Letenneur typeⅡ were fixed by headless compression screws from anteroposterior direction. The anteroposterior and lateral X-ray films, CT and three-dimensional reconstruction of the knee joint were taken after operation to assess fracture healing and position of the internal fixators. The knee function was evaluated according to Letenneur’s functional assessment system.ResultsAll patients were followed up 13-28 months (mean, 15 months). All the incisions healed by first intention, and no complication such as fracture redisplacement, fracture nonunion, internal fixator fracture, and common peroneal nerve injury occurred. The mean time of fracture healing was 18 weeks (range, 16-32 weeks). At last follow-up, according to Letenneur’s functional assessment system, the knee function was excellent in 12 cases and good in 5 cases, with an excellent and good rate of 100%.ConclusionThe extended Carlson approach for the treatment of lateral femoral condylar Hoffa fractures has the advantages of clear exposure, easy reduction and fixation, high fracture healing rate, few complications, and good recovery of knee joint function.
ObjectiveTo compare the clinical and radiographic results between primary total knee arthroplasty (TKA) via mini-subvastus or conventional approach through a prospective randomized controlled study.MethodsNinety-four patients (104 knees) undergoing primary TKA between January 2011 and April 2012 were evaluated and randomly divided into 2 groups. Forty-six patients (52 knees) underwent TKA via conventional approach (conventional approach group), and 48 patients (52 knees) underwent TKA via mini-subvastus approach (mini-subvastus approach group). In these patients, 45 cases (51 knees) in conventional approach group and 45 cases (49 knees) in mini-subvastus approach group were followed up and recruited in the final analysis. There was no significant difference in age, gender, body mass index, sides, osteoarthritis grading, American Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, visual analogue scale (VAS), range of motion (ROM) of knee between 2 groups (P>0.05). The clinical indexes were recorded and analyzed, including the operation time, length of incision, total blood loss, blood transfusion after operation, hospital stay time, the time of performing straight leg raise, incision condition, VAS score, ROM of knee, HSS score, and KSS score, hip-knee-ankle angle (HKA), femoral anatomic axis and the femoral prosthesis joint angle (femoral angle), tibia anatomic axis and tibial prosthesis joint angle (tibial angle), femoral prosthesis flexion angle (FPFA), and posterior slope angle (PSA) of the tibial plateau.ResultsAll patients were followed up. The average follow-up time was 66.4 months (range, 60.0-72.5 months) in conventional approach group and 65.6 months (range, 60.0-71.2 months) in mini-subvastus approach group. Compared with the conventional approach group, the incision of mini-subvastus approach group shortened, the operation time prolonged, and the time when patients started straight leg raise exercises was earlier; showing significant differences between 2 groups (P<0.05). There was no significant difference in hospital stay time, total blood loss, and numbers of blood transfusion between 2 groups (P>0.05). The complication rate was 8.2% (4/49) in mini-subvastus approach group and 0 in conventional approach group, showing no significant difference between 2 groups (P=0.054). At 1 and 3 days, the VAS and the ROM of knee in mini-subvastus approach group were significantly better than those in conventional approach group (P<0.05); but there was no significant difference in above indexes between 2 groups at 14 day (P>0.05). There was no significant difference in HSS and KSS scores between 2 groups at the 1, 3, 6, 12 months and 3, 5 years (P>0.05). X-ray film showed no aseptic loosening in all cases. There was no significant difference in the measured values and incidence of abnormal patient of HKA, femoral angle, tibial angle, FPFA, and PSA at last follow-up between 2 groups (P>0.05).ConclusionTKA via mini-subvastus approach is helpful to the early function recovery of knee, but the long-term effectiveness is consistent with TKA via conventional approach. As the limited exposure, TKA via mini-subvastus spproach may has high risk of operative complications.
Objective To review the research on different surgical approaches and MRI evaluation of total hip arthroplasty (THA), to clarify the possible muscle damage caused by different approaches, and to help clinicians avoid intraoperative muscle damage and identify the causes of certain muscle-related complications after operation. MethodsThe research literature on different surgical approaches and MRI evaluation of THA at home and abroad was extensively reviewed to summarize the MRI performance of the posterior approach, modified direct lateral approach, direct anterior approach, and minimally invasive anterolateral approach (also called Orthopadische Chirurgie Munchen approach). Results The traditional posterior approach mainly damages the short external rotator muscle group and increases the incidence of postoperative dislocation; the piriformis-keeping posterior approach significantly improves the quality of the pyriformis tendon in the postoperative period, but it may lead to damage to the intrapelvic portion of the piriformis muscle. The modified direct lateral approach mainly damages the gluteus medius muscle, which increases the risk of postoperative claudication. The direct anterior approach mainly damages the vastus tensoris muscle and may result in damage to the short external rotator muscle group and the muscles around the incision. The minimally invasive anterolateral approach primarily damages the superior gluteal nerve, which subsequently leads to denervation of the broad fascial tensor fasciae latae, and this approach may also result in injury to the gluteus medius and gluteus minimus muscles. The muscle damage status significantly affects prognosis, and the minimally invasive approach is more suitable for elderly patients. ConclusionMRI can clarify the different types of muscle damage caused by different surgical approaches. Minimally invasive approaches can reduce muscle damage and improve postoperative function compared with traditional approaches, and can benefit elderly patients more, but due to the small field, forcing to expand the surgical field will lead to unintended muscle damage and reduce postoperative function.
ObjectiveTo review the research progress of different surgical approaches in the treatment of acetabular both-column fractures.MethodsThe domestic and foreign related research literature on surgical approaches for acetabular both-column fractures was extensively consulted. The anatomical characteristics, exposure ranges, advantages, disadvantages, and indications of various common surgical approaches for both-column fractures were mainly summarized.ResultsThe ilioinguinal approach is more suitable for both-column fractures if the anterior column fracture is complicated or combined with the anterior wall fracture while the posterior column fracture is simple and stable. The modified Stoppa approach or the lateral (para) rectus abdominal approach is the preferred choice when both-column fractures are combined with a quadrilateral fracture or femoral head dislocation. What’s more, the Kocher-Langenbeck approach is required when the posterior column fractures are complicated or combined with posterior wall fractures. In addition, the simultaneous ilioinguinal and Kocher-Langenbeck approaches are the first choices when the both-column fractures possessing extremely severe and obvious displacement.ConclusionThe reasonable choice of surgical approach is extremely important for acetabular both-column fractures. Each surgical approach has its advantages and limitations. It is necessary to take the precise reposition of the acetabular joint surface as the principle, and comprehensively judge the fracture types and severity of anterior column, posterior column, and square area, and then select the optimal surgical approach for surgical treatment.
Objective To investigate the effectiveness of posterior minimally invasive approach in the treatment of posterior wall acetabular fractures. Methods The clinical data of 17 patients with posterior wall acetabular fractures treated with posterior minimally invasive approach between March 2019 and June 2023 were retrospectively analyzed. There were 14 males and 3 females with an average age of 41 years ranging from 28 to 57 years. The causes of injury were traffic accident in 12 cases and falling from height in 5 cases. There were 3 cases complicated with posterior hip dislocation and 2 cases complicated with sciatic nerve injury. According to AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 11 cases of type A1.1 and 6 cases of type A1.2. The time from injury to operation was 5-8 days, with an average of 6.2 days. The incision length, intraoperative blood loss, and operation time were recorded. The quality of posterior wall fracture reduction were evaluated by Matta criteria, and hip function were evaluated by modified Merle d’Aubign-Postel score criteria at 6 months after operation and last follow-up. Results The operation was successfully completed in 17 cases. The length of incision ranged from 7 to 9 cm, with an average of 8.3 cm, and all incisions healed by first intention. The intraoperative blood loss ranged from 200 to 350 mL, with an average of 281 mL. The operation time ranged from 45 to 70 minutes, with an average of 57 minutes. Two patients had sciatic nerve injury before operation, and the sciatic nerve function recovered completely at 3 months after operation; the other 15 patients had no symptoms of sciatic nerve injury after operation. All the 17 patients were followed up 14-27 months, with an average of 19.5 months. At 1 week after operation, according to the Matta criteria, anatomical reduction was achieved in 12 cases and satisfactory reduction in 5 cases, with a satisfaction rate of 100%. According to the modified Merle d’Aubign-Postel scoring system, the hip function score was 13-18 (mean, 16.1) at 6 months after operation. Among them, 5 cases were excellent, 9 were good, and 3 were fair, with an excellent and good rate of 82.4%. At last follow-up, the hip function score was 7-18 (mean, 13.7), of which 3 cases were excellent, 9 were good, 3 were fair, and 2 were poor, with an excellent and good rate of 70.6%. During the follow-up, there was no infection, failure of internal fixation, and femoral head necrosis, and heterotopic ossification occurred in 2 cases. ConclusionThe posterior minimally invasive approach has the advantages of less trauma, shorter operation time, less blood loss, without cutting off the external rotator muscle. Exposure through the gluteus medius-piriformis space and piriformis-supercilium space can provide sufficient safe exposure for the posterior wall acetabulum fracture, which is a reliable alternative approach for the posterior acetabular fracture.
ObjectiveTo analyze the relation between preoperative staging and surgical decision-making in rectal cancer patients from the West China Colorectal Cancer Database (DACCA) and to identify key factors influencing the selection of surgical approach. MethodsBased on the updated DACCA dataset as of April 24, 2024, the patients with rectal cancer were included. Chi-square tests and logistic regression analyses were performed to evaluate the correlation between preoperative staging [(y)cTNM stage] and the selection of sphincter-preserving surgery or intersphincteric resection (ISR). Additional factors, including age, body mass index (BMI), tumor location, and nutritional score, were assessed for their impact on surgical choices. ResultsA total of 2 733 rectal cancer patients were included. Preoperative (y)cTNM staging distribution was as follows: 23 (0.8%) at stage 0, 388 (14.2%) at stage Ⅰ, 760 (27.8%) at stage Ⅱ, 873 (31.9%) at stage Ⅲ, and 689 (25.2%) at stage Ⅳ. The preoperative stage Ⅱ–Ⅳ were the independent risk factors for both the choices of sphincter-preserving surgery and ISR [stage Ⅱ: sphincter-preserving surgery: OR(95%CI)=13.634 (4.952, 37.540), P<0.001; ISR: OR (95%CI)=3.097 (2.108, 4.551), P<0.001. stage Ⅲ: sphincter-preserving surgery: OR (95%CI)=14.677 (5.339, 40.345), P<0.001; ISR: OR (95%CI)=2.985 (2.042, 4.363), P<0.001. stage Ⅳ: OR (95%CI)=25.653 (9.320, 70.610), P<0.001; ISR: OR (95%CI)=4.445 (3.015, 6.555), P<0.001]. The low/ultra-low tumor location was an independent risk factor for choice of sphincter-preserving surgery [OR (95%CI)=2.038 (1.489, 2.791), P<0.001], but which was an independent protective factor for the choice of ISR [OR (95%CI)=0.013 (0.009, 0.019), P<0.001]. ConclusionsResults of this study are consistent with clinical practice, indicating that preoperative staging is the core basis for surgical decision-making in rectal cancer. With the progression of staging, patients are more inclined to choose non-sphincter-preserving and non-ISR procedures. Although low/ultralow tumors pose great challenges for anal preservation, the proportion of ISR selection remains relatively high. The anatomical location of the tumor and nutritional status also significantly affect surgical selection, necessitating comprehensive preoperative evaluation.
ObjectiveTo compare the short-term effectiveness and safety of unipedicular versus bipedicular percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fracture (OVCF) with posterior wall broken.MethodsThe clinical data of 68 patients with OVCF with posterior wall broken and without posterior ligament complex injury and spinal cord nerve injury between June 2013 and December 2018 were retrospectively analyzed. According to the different operative approaches, the patients were divided into two groups: group A (36 cases received PKP via bilateral pedicle puncture) and group B (32 cases received PKP via unilateral pedicle paracentesis). There was no significant difference between the two groups in gender, age, fracture vertebra distribution, time from injury to operation, preoperative pain visual analogue scale (VAS) score, Oswestry disability index (ODI), and height of injured vertebra (P>0.05). The operation time, intraoperative fluoroscopy times, and bone cement volume were recorded and compared between the two groups. The VAS score and ODI score were used to evaluate the effectiveness before operation, at 1 day and 6 months after operation; the height of injured vertebra was measured on the lateral X-ray film, and the recovery height of injured vertebra at 1 day after operation and the loss height of injured vertebra at 6 months after operation were calculated; the intraoperative and postoperative complications of the two groups were recorded.ResultsThe operation time, intraoperative fluoroscopy times, and bone cement volume of group B were significantly less than those of group A (P<0.05). All patients were followed up 10-35 months, with an average of 18 months. During the operation, there were 2 cases (5.56%) of cement leakage in group A and 9 cases (28.13%) in group B, showing significant difference (χ2=4.808, P=0.028). There was no adverse reactions of bone cement, iatrogenic spinal cord injury, infection of puncture port, or other complications in the two groups. During the follow-up period, there were 3 cases (8.3%) of adjacent vertebral fractures in group A and 2 cases (6.3%) in group B, showing no significant difference between the two groups (χ2=0.027, P=0.869). The height of injured vertebra of the two groups at 1 day and 6 months after operation were significantly improved when compared with preoperative ones (P<0.05). There was no significant difference in the height of injured vertebrae and the recovery height of injured vertebra at 1 day after operation between the two groups (P>0.05). However, at 6 months after operation, the height of injured vertebra in group B was significantly lower than that in group A (P<0.05), and the loss height of injured vertebra in group B was significantly higher than that in group A (P<0.05). The VAS score and ODI score at 1 day and 6 months after operation were significantly improved when compared with preoperative ones in both groups (P<0.05), but there was no significant difference between the two groups (P>0.05).ConclusionBoth bipedicular and unipedicular PKP can obtain satisfactory effectiveness for the treatment of OVCF with posterior wall broken, but the former may have advantages of lower cement leakage rate and less height loss.
ObjectiveTo analyze the clinical outcomes of extended thymectomy for myasthenia gravis (MG) patients under different surgical approaches, and to determine the factors affecting the prognosis of MG. MethodsThe MG patients who underwent extended thymectomy from January 2014 to March 2021 in our hospital were retrospectively collected. According to the surgical approach, they were divided into a subxiphoid group and an intercostal group, and the perioperative results and prognosis were compared between the two groups. A “good outcome” was defined as complete stable remission (CSR), pharmacological remission (PR) or minimal manifestations state (MMS); a “poor outcome” was defined as outcomes worse than MMS. Univariate and multivariate logistic regression analyses were performed to assess the factors associated with the good outcomes. ResultsA total of 187 MG patients were included in the study, including 82 males and 105 females, with a median age of 50 (36, 60) years. There were 134 patients in the intercostal group and 53 patients in the subxiphoid group. Compared with the intercostal group, although the operation time of the subxiphoid group was longer [200.0 (172.0, 232.0) min vs. 141.0 (118.0, 169.0) min, P<0.001], the intraoperative blood loss was less [10.0 (10.0, 20.0) mL vs. 20.0 (10.0, 50.0) mL, P<0.001], the postoperative hospital stay was shorter [3.0 (2.5, 4.0) d vs. 5.0 (3.0, 7.0) d, P<0.001], and the incidence of complications was lower [1 (1.9%) vs. 26 (19.4%), P=0.001]. A total of 159 (85.0%) patients were followed up for a median period of 46 (13, 99) months, with a good outcome rate of 90.6% and CSR rate of 33.3%. There were no statistical differences in PR, MMS or overall good outcome rates between the two groups (P>0.05). Multivariate logistic analysis showed that age≤50 years was an independent predictor for "good outcome" of MG patients. ConclusionExtended thymectomy via subxiphoid for MG is a safe, feasible and effective surgical approach.