A novel nomogram for individualized preoperative prediction of lymph node metastasis in patients with intrahepatic cholangiocarcinoma / 中华外科杂志

Objective: Constructing and validating a nomogram model for preoperative prediction of intrahepatic cholangiocarcinoma (ICC) lymph node metastasis to assist decision making during surgery. Methods: Retrospectively collecting the clinical and pathological data of 1 031 ICC patients who underwent partial hepatectomy at Eastern Hepatobiliary Surgery Hospital of Naval Military Medical University,General Hospital of Eastern Theater Command,or Zhongda Hospital Southeast University from January 2003 to January 2014. There were 682 males and 349 females; mean age was 54.7 years(range:18 to 82 years). There were 562 patients who underwent lymph node dissection and 469 patients who did not. Among the patients in the dissection group,Lasso regression method was used to filtrate preoperative variables related to lymph node metastasis and establish a nomogram. Bootstrap method was used to internally validate the discrimination of the nomogram,and the accuracy of the nomogram was assessed by using calibration curves. Patients were divided into low-moderate and high-risk groups based on model prediction probability. Propensity score matching(PSM) was used to analyze the overall survival (OS) and recurrence-free survival (RFS) of patients with and without lymph node dissection in the two groups,and to judge the importance of lymph node dissection in the two groups. Results: Six factors related to ICC lymph node metastasis were determined by Lasso regression,including hepatitis B surface antigen,CA19-9,age,lymphadenopathy,carcinoembryo antigen and maximum tumor diameter. These factors were integrated into a nomogram to predict ICC lymph node metastasis. The aera under curve value was 0.764,and the C-index was 0.754. Stratified analysis showed that OS and RFS in the high-risk group of lymph node metastasis were significantly lower than those in the low-medium risk group(median OS:14.6 months vs. 27.0 months,P<0.01; median RFS:9.1 months vs. 15.5 months,P<0.01). In the high-risk group,the median OS was 16.7 months and 6.3 months(Log-rank test: P=0.187;Wilcoxon test:P=0.046),and the median RFS was 11.0 months and 4.8 months(P=0.403),respectively in the lymph node dissection group and undissected group after PSM. In the low-medium-risk group,the median OS was 22.7 months and 26.7 months(P=0.288),and the median RFS was 13.0 months and 14.5 months(P=0.306),respectively in the lymph node dissection group and undissected group after PSM. Conclusions: The nomogram could be used for preoperative prediction of lymph node metastasis and prognostic stratification in patients with ICC. For patients with high risk of lymph node metastasis predicted by the model,active dissection should be performed. For patients predicted to be at low-moderate risk,lymph node dissection might be optional in some specific cases.

Treatment strategy and curative effect analysis of os odontoideum complicated with atlantoaxial joint dislocation / 中国骨伤

OBJECTIVE@#To explore the treatment strategy and clinical efficacy for os odontoideum complicated with atlantoaxial dislocation.@*METHODS@#The clinical data of 17 patients with os odontoideum complicated with atlantoaxial dislocation surgically treated from January 2006 to January 2015 were retrospectively analyzed, including 7 males and 10 females, aged 17 to 53 (43.1±11.3) years old;course of disease was 3 to 27(10.2±6.9) months. All patients received cranial traction before operation, 12 of 14 patients with reducible dislocation were treated by posterior atlantoaxial fixation and fusion, and 2 patients with atlantooccipital deformity were treated by posterior occipitocervical fixation and fusion;3 patients with irreducible alantoaxial dislocation were treated by transoral approach decompression combined with posterior atlantoaxial fixation and fusion. The operation time, intraoperative blood loss and perioperative complications were recorded. Visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score were used to evaluate the change of neck pain and neurological function. Atlantoaxial joint fusion rate was evaluated by CT scan.@*RESULTS@#The operation time of posterior fixation and fusion ranged from 86 to 170 (92.2±27.5) min, and the intraoperative blood loss was 200-350 (250.7±65.2) ml. No vertebral artery injury and spinal cord injury were recorded. Among the patients underwent atlantoaxial fixation and fusion, 1 patient with reducible dislocation fixed by C@*CONCLUSION@#Surgical treatment of os odontoideum complicated with atlantoaxial dislocation can achieve satisfactory results, improve the patient's neurological function and improve the quality of life, however the surgical options needs to be individualized.

Minimally invasive direct lateral approach debridement, interbody bone grafting, and interbody fusion combined with posterior percutaneous pedicle screw fixation for lumbar spinal tuberculosis / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy and superiority of direct lateral interbody fusion combined with posterior percutaneous screw fixation in the treatment of lumbar tuberculosis.@*METHODS@#From June 2013 to August 2016, the clinical data of 83 patients with lumbar tuberculosis were retrospectively analyzed, including 55 males and 28 females, aged from 27 to 72 (49.5±13.5) years. These 83 patients were divided into two groups according to different operation methods, 35 cases in group A were treated with direct lateral interbody fusion combined with posterior percutaneous screw fixation;48 cases in group B were treated with anterior traditional extraperitoneal debridement combined with posterior internal fixation. After operation, regular quadruple antituberculosis drugs were continued for 18 months. The operation time, intraoperative blood loss, hospital stay, bone graft fusion time and complications were compared between the two groups. Visual analogue score (VAS) of lumbar pain, Oswestry Disability Index (ODI), sagittal Cobb angle, erythrocyte sedimentation rate (ESR) and C-reactive protein(CRP) values before and after operation were analyzed.@*RESULTS@#The operation was successfully completed in both groups, and the operation mode was not changed during operation. The operation time, intraoperative blood loss and hospital stay were (149.4±13.3) min, (354.3±69.0) ml, (9.4±1.6) d in group A and(116.8±10.0) min, (721.9±172.3) ml, (11.8±1.7) d in group B, respectively, with significant difference between the two groups (@*CONCLUSION@#The two kinds of operation can obtain satisfactory clinical effect. Direct lateral interbody fusion combined with posterior percutaneous screw fixation can reduce intraoperative blood loss and hospital stay, which is conducive to early rehabilitation of patients.

Wiltse approach combined with contralateral transforaminal lumbar interbody fusion and conventional surgery for lumbar disc herniation:a case-control study / 中国骨伤

OBJECTIVE@#To compare the clinical effecty of Wiltse approach combined with contralateral transforaminal lumbar interbody fusion (TLIF) and traditional TLIF in the treatment of lumbar disc herniation and its affect on injury of multifidus muscle.@*METHODS@#From June 2014 to September 2017, 90 patients with lumbar disc herniation combined with lumbar spine instability were divided into two groups (Wiltse approach group and traditional group) depend on the procedure of operation. Wiltse approach group was treated with Wiltse approach screw placement in one side combined with contralateral TLIF. There were 50 patients in Wiltse approach group, including 36 males and 14 females, aged 45 to 72 yearswith an average of (60.4± 3.1) years. The traditional group was treated with traditional TLIF operation. There were 40 patients in the traditional group, including 25 males and 15 females, aged 45 to 74 years with an average of (62.1±3.4) years. The operative time, intraoperative blood loss, accuracy of screw implantation, postoperative drainage volume and drainage tube removal time were recorded in two groups. Visual analogue scale (VAS) and Oswestry Disability Index (ODI)were observed before and 12 months after operation. All patients underwent CT examination preoperative and 12 months postoperative, and the CT values of bilateral multifidus muscle were measured.@*RESULTS@#All the patients were followed up, 40 patients in traditional group were 12 to 18 months with an average of (15.3±4.3) months; and 50 patients in Wiltse approach group were 13 to 24 months with an average of (16.5± 4.1) months. There were no statistically significant differences in operative time and intraoperative blood loss between two groups (@*CONCLUSION@#Compared with traditional surgical procedures, the Wiltse approach nail placement combined with contralateral TLIF has the advantage of accurate nail placement, reducing multifidus muscle damage, and reducing the incidence of postoperative intractable low back pain.

Effect of posterior osteotomy on the sagittal parameters of the spinopelvis in patients with lumbar degenerative kyphosis / 中国骨伤

OBJECTIVE@#To investigate the influence of posterior osteotomy on spinopelvic parameters in lumbar degenerative kyphosis (LDK) patients.@*METHODS@#The clinical data of 21 patients with lumbar degenerative kyphosis who underwent osteotomy from January 2012 to December 2015 were retrospectively analyzed. There were 5 males and 16 females, aged from 55 to 76 years with an average of (66.24±5.13) years. All patients had taken preoperative and postoperative full length spinal X-ray, analyzing the spinopelvic parameters as thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS).@*RESULTS@#All operations were successful, the average operative time was 190 min (160 to 220 min) and intraoperative blood loss was 1 000 ml (800 to 1900 ml). Parameters of the patients between preoperative and period 1-year follow-up were as follows : preoperative TK increased from (31.67±21.13) ° to (34.67±11.60) °, LL corrected from (4.76±3.17) ° to (37.41±6.28) °, PT reduced from (33.94±5.01) ° to (20.12±5.36) °, and SS improved from (18.47±2.60) ° to (31.71±4.30) °, SVA restored from (13.24±3.60) cm to (2.82±1.33) cm. There were significant differences of spinopelvic parameters between preoperation and postoperation (<0.05).@*CONCLUSION@#Posterior osteotomy can effectively reconstruct the sagittal balance of spinopelvis in patients with lumbar degenerative kyphosis. The recovery of lumbar lordosis and sacral slope is closely related to the reconstruction of sagittal balance.

Comparison of the effects of injured vertebra pedicle fixation combined with vertebroplasty and vertebra pedicle screw fixation combined with vertebroplasty in the treatment of osteoporotic thoracolumbar burst fractures / 中国骨伤

OBJECTIVE@#To assess the curative effects of injured vertebra pedicle fixation combined with vertebroplasty and short-segment pedicle screw fixation combined with vertebroplasty in treatment of osteoporotic thoracolumbar burst fractures.@*METHODS@#Seventy patients with osteoporotic thoracolumbar burst fractures who met the inclusion criteria were collected in the study from January 2015 to December 2017. Among them, 35 patients were treated with injured vertebra pedicle fixation combined with vertebroplasty (group A), including 20 males and 15 females, aged from 55 to 74 years with an average of (64.03± 7.82) years. Twenty-six cases were type A3 and 9 cases were type A4 according to the AO typing;another 35 patients were treated with short segment pedicle screw fixation combined with vertebroplasty (group B), including 18 males and 17 females, aged from 54 to 72 years with an average of (62.78±6.40) years. Twenty-eight cases were type A3 and 7 cases were type A4 according to AO typing. Operation length, intraoperative bleeding volume, complication, imaging parameters and clinical effects were compared between the two groups.@*RESULTS@#All the patients were followed up for at least 12 months. There were no significant differences in gender, age, injury site, preoperative VAS, Cobb angle, and injured vertebral height before surgery. There were no significant differences in operation length, intraoperative bleeding volume between two groups. In terms of VAS scores before surgery, 1 week after surgery, and at the final follow up, group A was 5.5 ±2.5, 1.8 ±0.8, 0.9 ±0.4, group B was 5.4 ± 2.3, 1.7±0.6, 1.2±1.8, respectively;injured vertebral height was (40.4±8.8)%, (92.0±4.9)%, (87.1±3.8)% in group A, and (41.2±6.6)%, (93.2±4.6)%, (80.0±4.3)% in group B;Cobb angle was (18.4±6.9) °, (2.8±2.2) °, (4.2±2.6) ° in group A, and (16.8±7.2) °, (2.7±2.5) °, (6.0±2.4) ° in group B. There were significant differences in the 3 parameters above before the operation and at the final follow up in all groups (<0.05). There were significant differences in the Cobb angle and injured vertebral height between 1 week after operation and at the final follow up (<0.05). At the final follow up, injured vertebral height in group A was obviously better than that in group B (<0.05). Internal fixation failure occurred in 2 cases from the group A, and occurred in 4 cases from the group B. There were no neurological complications in both groups.@*CONCLUSION@#For osteoporotic thoracolumbar vertebral burst fractures, injured vertebra pedicle fixation combined with vertebroplasty and vertebra pedicle screw fixation combined with vertebroplasty can achieve good clinical effects. However, injured vertebra pedicle fixation combined with vertebroplasty is better at maintaining postoperative vertebral height and sagittal arrangement, and reducing internal fixation related complications. The treatment strategy is worthy of application and promotion.

Analysis on the causes and prevention strategies of the vascular injury caused by the oblique lateral lumbar fusion / 中国骨伤

OBJECTIVE@#To analyze the causes of vascular injury occurred in oblique lateral interbody fusion for treating lumbar degenerative diseases, and put forward preventive measures.@*METHODS@#There were 235 patients analyzed from October 2014 to May 2017 in five hospitals, who were treated with oblique lateral interbody fusion with or without posterior pedicle screw fixation. There were 79 males and 156 females with an average age of (61.9±13.5) years old (ranged from 32 to 83 years). There were 7 cases of vascular injury, including 4 cases of segmental vessel injury, 1 case of left common iliac artery injury, 1 case of left common iliac veininjury and 1 case of ovarian vein injury.@*RESULTS@#The follow up time ranged from 6 to 36 months, averagely (15.6±7.5) months. There was no pedicle screw loosen or fracture. The low back pain VAS decreased from preoperative 6.7±2.3 to 1.4±0.8 at the latest follow-up, which was statistically difference(@*CONCLUSION@#Oblique lateral interbody fusion technique provides a new method for minimally invasive fusion of lumbar internal fixation. However, it has a risk of vascular injury. In order to effectively prevent the occurrence of vascular injury, the operative indications and careful and meticulous operation should be strictly grasped.

Nomograma prediction of the surgical treatment in triad of elbow / 中国骨伤

OBJECTIVE@#To establish an individualized Nomogram prediction model for predicting the postoperative recovery of patients with triad of elbow (TE) by analyzing risk factors of triad of elbow joint.@*METHODS@#From January 2012 to December 2018, 116 patients with TE who met the criteria were collected. The independent risk factors were screened by univariate Logistic regression analysis. The statistically significant risk factors were included in the multivariate Logistic regression model. The R software was used to establish the Nomogram diagram model to predict the postoperative recovery of TE patients. C index was used to verify the discrimination, Calibration plot of the model, and the decision curve (decision curve analysis, DCA) to verify the net clinical benefit rate of the model.@*RESULTS@#Forty-four of the 116 patients with TE developed symptoms after operation, with an incidence of 37.93%. Age (@*CONCLUSION@#The Nomogram for predicting postoperative results of TE patients based on six independent risk factors:age, work, smoking, Mason classification of radial head, Regan-Morrey classification of coronal process and immobilization time of elbow joint after operation, has good distinguishing capacity and consistency. Thepredictive model could help clinicians to identify high risk population and establish appropriate intervention strategies.

Efficacy of bilateral sagittal cross percutaneous kyphoplasty for preventing recurrent fracture of the cemented vertebrae / 中国骨伤

OBJECTIVE@#To explore the efficacy of bilateral sagittal cross percutaneous kyphoplasty(PKP) for preventing recurrent fracture of the cemented vertebrae.@*METHODS@#From January 2017 to June 2017, 85 patients with single-segment osteoporotic vertebral compression fractures(OVCFs) were treated by bilateral sagittal cross PKP(cross group). There were 35 males and 50 females with an average age of (70.1±8.3) years old in cross group. Another 85 patients with single-segment OVCFs were treated by traditional PKP (traditional group). There were 37 males and 48 females with an average age of (73.3±9.5) years old in traditional group. The cement distribution condition, recurrent fracture of the cemented vertebrae, the anterior vertebral body height and sagittal Cobb angle, visual analogue scale(VAS) were observed in two groups.@*RESULTS@#All patients underwent operation successfully. The follow-up time were (11.8±4.5) months in cross group and (12.1±3.7) months in traditional group. In cross group, all patients' bone cement touched the upper and lower endplates of the vertebral body while 67 cases (78.8%) in traditional group did with significant difference between two groups (0.05).@*CONCLUSIONS@#Bilateral sagittal cross PKP was a simple, safe and effective technique which can make bone cement distribute in the fractured vertebral body and contact the upper and lower endplates of the vertebral body, thus preventing the recurrent fracture of the cemented vertebrae.

One stage temporary atlantoaxial segmental fixation and reduction for Grauer type IIB dens fractures in teenagers / 中国骨伤

OBJECTIVE@#To assess the clinical results of one stage temporary atlantoaxial segmental fixation and reduction for Grauer type IIB dens fractures in teenagers.@*METHODS@#From February 2009 to April 2015, 19 teenagers with Grauer type IIB dens fractures not amenable to anteiror screw fixation were enrolled and treated using one stage temporary atlantoaxial segmental fixation and reduction without fusion. There were 14 males and 5 females, aged from 14 to 32 years with an average of (24.6±5.0 ) years. The internal fixation was removed after bone healing confirmed by CT scan. At the last follow-up (at least 1 year after internal fixation removal), dynamic CT was used to assess the atlantoaxial rotation activity. Visual analogue scale (VAS) was recorded before the first operation, before the second operation (removal of internal fixation) and at the last follow-up. Neck Disability Index(NDI) was used to evaluate the efficacy before the second operation (removal of internal fixation) and the last follow-up.@*RESULTS@#After operation, 2 patients developed the symptoms of occipital nerve stimulation such as numbness and pain in the occipitocervical region, and were treated with drugs such as dehydration and neurotrophic drugs, and the symptoms were relieved after 1 to 2 months. All the internal fixations were removed and all the patients were followed up more than 1 year, with time ranging from 18 to 25 months and an average of (21.47±2.41) months. The time of bone fusion after operation was 6 to 10 months with the mean of(8.21±1.27) months. Secondary surgical removal of internal fixation were performed immediately after fracture healing without internal fixation failure. The symptoms of neck pain improved significantly after operation, VAS score decreased from 6.74±0.65 before operation to 0.42±0.51 at the last follow-up after the second operation (removal of internal fixation), with statistically significant differences(<0.01). The NDI value decreased from (10.58±2.04)% before the second operation (removal of internal fixation) to (3.79±2.23)% at the last follow-up after the second operation (removal of internal fixation), with statistically significant difference(<0.01). At the last follow-up after the second operation (removal of internal fixation), dynamic CT showed that the unilateral rotation of the atlantoaxial spine reached (15.73±5.57)° to the left, (15.55±5.78)° to the right, and the overall rotation of the atlantoaxial spine was (31.28±10.71)°.@*CONCLUSIONS@#One stage temporary atlantoaxial segmental fixation and reduction for the treatment of Grauer type IIB dens fractures not amenable to anteiror screw fixation in teenagers can avoid the loss of atlantoaxial rotation function caused by atlantoaxial fusion, and to some extent retain the rotation activity of atlanto-axial joint.

Percutaneous pedicle screw fixation combined with limited-open decompression technique for thoracolumbar fractures with neurologic deficit / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the clinical effects of percutaneous pedicle screw fixation combined with limited open decompression technique for the treatment of thoracolumbar fractures with neurologic deficit.</p><p><b>METHODS</b>The clinical data of 76 patients with thoracolumbar fractures with neurologic deficit underwent percutaneous pedicle screw fixation combined with limited open decompression technique from June 2010 to June 2014 were retrospectively analyzed. There were 45 males and 31 femals, aged from 17 to 56 years with an average of 32.5 years old. According to the classification of Denis, 33 cases were type A, 26 cases were type B, 17 cases were type C. According to the criterion of American Spinal Injury Association(ASIA), 13 cases were grade A, 9 cases were grade B, 21 cases were grade C, 33 cases were grade D. The operative time, intraoperative blood loss, postoperative internal fixation lossening and breakage were recorded. The informations of the Cobb angle, the anterior height of injured vertebra, canal stenosis were observed before operation, 3 days after operation, and the final follow-up. The improvement of neurologic function were analyzed at final follow-up.</p><p><b>RESULTS</b>All the patients were followed up from 13 to 47 months with an average of 32.1 months. The mean operative time was 159 min (136 to 218 min) and the intraoperative blood loss was 225 ml(150 to 360 ml). The anterior height of injured vertebra was increased from (52.0±5.9)% before operation to (87.2±1.8)% at 3 days after operation, and (86.1±1.5)% at final follow-up (=45.27,=0.000); the Cobb angle was decreased from (29.7±8.2)° before operation to (5.7±2.9)° at 3 days after operation, and (5.9±3.6)° at final follow-up (=34.62,=0.000); the canal stenosis was decreased from (37.5±7.2)% before operation to (12.3±3.3)% at 3 days after operation, and (11.9±3.1)% at final follow-up(=37.02,=0.000); there was no significant differences between postoperative 3 days and the final follow-up about the above parametres(>0.05). According to ASIA criterion, the spinal cord function was classified as grade A in 13 cases, grade B in 0 cases, grade C in 10 cases, grade D in 21 cases and grade E in 32 cases at final follow-up. Internal fixation lossening and breakage occurred in 2 cases.</p><p><b>CONCLUSIONS</b>Percutaneous pedicle screw fixation combined with limited open decompression technique can obtain satisfactory clinical effect for patients with thoracolumbar fractures with neurologic deficit, and have a good recovery of nerve function can be observed.</p>

Treatment of senile spinal tuberculosis with posterior percutaneous pedicle screw fixation combined with local percutaneous endoscopic debridement / 中国骨伤

OBJECTIVE@#To explore the short-term efficacy of posterior percutaneous screw fixation combined with local percutaneous endoscopic debridement in treating senile spinal tuberculosis.@*METHODS@#The clinical data of 19 senile patients with spinal tuberculosis underwent surgical treatment from January 2015 to September 2016 were retrospectively analyzed. There were 13 males and 6 females, aged from 60 to 73 years old with an average of (66.2±4.0) years. All patients have been diagnosed with spinal tuberculosis prior to hospitalization with abscess, dead bone formation but no sinus, neurological symptoms, open surgical indications. All patients were treated with posterior percutaneous screw fixation combined with local percutaneous endoscopic debridement, and were given appropriate chemotherapy for 3 weeks preoperatively. Pre-and post-operative visual analogue score (VAS), Oswestry Disability Index (ODI), sagittal Cobb angle of lesion segment, erythrocyte sedimentation rate(ESR), C-reactive protein(CRP) were analyzed.@*RESULTS@#All the 19 patients successfully completed the operation and passed through the perioperative period safely. The operation method was unchanged during the operation. The average operation time was (153.2±14.0) min. Except for 1 patients who had delayed incision healing, other patients healed at I stage within 2 weeks after operation. All patients were followed up for 15 to 26 months with an average of (19.6±3.2) months.VAS, ODI, sagittal Cobb angle of lesion segment, ESR, CRP were decreased from preoperative(5.9±1.1) points, (80.9±4.0)%, (30.8±5.5)°, (79.6±14.4) mm/h, (56.9±9.5) mg/L to(1.8±0.9) points, (66.4±5.4)%, (15.9±2.5)°, (20.4±4.6) mg/L, (32.0±8.1) mm/h at final follow-up(<0.05).@*CONCLUSIONS@#Senile spinal tuberculosis have more complications and poor general body condition. Posterior percutaneous pedicle screw fixation combined with local percutaneous endoscopic debridement in treating the patients can reduce trauma, got satisfactory effect.

Case control study of unilateral and bilateral intervertebral space release in the treatment of lower lumbar spondylolisthesis / 中国骨伤

OBJECTIVE@#To analyze the clinical efficacy of unilateral and bilateral intervertebral space release in the treatment of lower lumbar spondylolisthesis.@*METHODS@#The clinical data of 41 patients with lumbar spondylolisthesis treated by surgery from October 2012 and May 2016 were retrospcetive analyzed. The patients were divided into two groups, 18 cases were enrolled in unilateral intervertebral release group, there were 7 males and 11 females, aged from 47 to 75 years old with an average of (59.3±6.4) years; according to Meyerding classification, 9 cases of I degree, 7 cases of II degree, 2 cases of III degree. And 23 cases were bilateral release group, there were 11 males and 12 females, aged from 51 to 76 years old with an average of (58.2±5.7) years; according to Meyerding classification, 11 cases of I degree, 10 cases of II degree, 2 cases of III degree. The operation time, intraoperative blood loss, bone graft fusion rate of the patients were recorded in the patients. Pre- and post-operative back and leg pain were evaluated by visual analogue scale (VAS) between two groups. The slip rate, slip angle, posterior height of intervertebral space, height of intervertebral foramen, distance of anterior and posterior displacement of vertex of intervertebral foramen were measured on X-ray and CT. And the above radiographic data were analyzed by intra-group or inter-group.@*RESULTS@#All the patients were followed up from 9 to 24 months with an average of 12 months. The entire 41 patient obtained bone fusion at 12 months after operation. There was no statistical significance in VAS at 12 months after operation, intraoperative blood loss and operation time between two groups(>0.05). There were statistical significance in sliding angle, posterior height of intervertebral space, height of intervertebral foramen, distance of anterior and posterior displacement of vertex of intervertebral foramen of all patients before and after operation(0.05), but there was significant difference in bilateral release group. There was statistical significance in postoperative slip angle, posterior height of intervertebral space, distance of anterior and posterior displacement of vertex of intervertebral foramen between two groups(=0.001, 0.045, 0.001). The height of intervertebral foramen increased and the slippage rate decreased in both groups after operation, but there was no significant difference between two groups(=0.248).@*CONCLUSIONS@#Unilateral and bilateral intervertebral space release for the treatment of lumbar spondylolisthesis can obviously reduce the rate of spondylolisthesis, restore foraminal height and achieve better clinical efficacy. Bilateral release group can better restore the slip angle, increase posterior height of intervertebral space, reduce the distance of anterior and posterior displacement of vertex of intervertebral foramen. Especially for grade II or above degree of slippage is more appropriate.

Case-control study of pedicle screw fixation combined with vertebroplasty and injured vertebra pedicle fixation in treatment of osteoporotic thoracolumbar burst fractures / 中国骨伤

<p><b>OBJECTIVE</b>To compare the curative effect of short-segment pedicle screw fixation combined with vertebroplasty and injured vertebra pedicle fixation in treating osteoporotic thoracolumbar burst fractures.</p><p><b>METHODS</b>A retrospective study was performed for 52 patients with thoracolumbar burst fractures from August 2010 to August 2015. Among them, 27 patients(group A) were treated with short-segment pedicle screw fixation combined with vertebroplasty, including 17 males and 10 females, aged from 54 to 68 years old with an average of(61.01±5.41) years, 16 cases were type A3 and 11 cases were type A4 according the new AO typing. Other 25 patients (group B) were treated with short-segment pedicle screw fixation combined with injured vertebra pedicle fixation, including 12 males and 13 females, aged from 55 to 66 years old with an average of (59.28±6.12) years, 18 cases were type A3 and 7 cases were type A4 according the new AO typing. Operation time, intraoperative bleeding volume, complication, image data and clinical effect were compared between two groups.</p><p><b>RESULTS</b>All the patients were followed up for 12 to 15 months with an average of (12.4±2.1)months. There was no significant difference in general data(including gender, age, injured site, preoperative VAS score, Cobb angle, injured vertebral anterior border height) between two groups. There was no significant differences in operation time, intraoperative bleeding volume between two groups. Preoperative, one week after operation and final follow-up, VAS scores were 5.2±0.5, 1.2±0.2, 0.8±0.1 respectively in group A and 5.0±0.6, 2.5±0.4, 1.3±0.2 in group B; injured vertebral anterior border height were (49.4±6.8)%, ( 94.5±1.2)%, ( 94.1±3.7)% respectively in group A and (48.2±7.0)%, ( 94.3±4.1)%, ( 90.0±2.3)% in group B;Cobb angles were (20.4±5.2) °, (2.5±1.8) °, (4.4±1.7)° respectively in group A and (19.8±6.8)°, (2.4±1.7)°, (7.0±1.2)° in group B. At final follow-up, VAS, Cobb angle, injured vertebral anterior border height in two groups were obviously improved(<0.05). Postoperative at 1 week and final follow-up, VAS score of group A was lower than that of group B(<0.05);and there was no significant difference in Cobb angle between two groups(>0.05); there was significant difference in injured vertebral anterior border height between two groups(<0.05). The complication of internal fixation failure had 1 case in group A and 4 cases in group B.</p><p><b>CONCLUSIONS</b>For the treatment of single osteoporotic thoracolumbar burst fractures, short-segment pedicle screw fixation combined with vertebroplasty is better than combined with injured vertebra pedicle fixation in clinical effect, it can relieve pain, maintain injured vertebral height and sagittal alinement, reduce the complications associated with internal fixation, and be worth spread in clinic.</p>

Surgical methods and curative effect of tibial plateau fracture with medial large block split / 中国骨伤

<p><b>OBJECTIVE</b>To explore the clinical effects of protecting the internal structure of the knee and internal fixation through two different directions for the treatment of tibial plateau fractures with medial large block split.</p><p><b>METHODS</b>From January 2010 to January 2016, data of 21 patients of tibial plateau with medial large block split fractures who were treated with protecting the internal structure of the knee and internal fixation through two different directions were retrospectively analyzed, including 17 males and 4 females, with an average age of (39.2±3.2) years old ranging from 27 to 63 years. Anteroposterior and lateral radiographs as well as computed tomography(CT) images were obtained in the course of preoperative. It was made in the operation to protect medial knee structure, combining with internal fixation via two different directions plates(medial and posteromedial). If the posterolateral condyle fracture was involved, a plate was applied through posterolateral approach. Rasmussen score was used for radiological assessment, and HSS knee score was used for efficacy assessment at 1 year after operation. The fracture healing time was judged by X-ray and clinical examinations, additionally, the complications and corresponding outcomes were also recorded.</p><p><b>RESULTS</b>All patients were followed up for 10 to 24 months with an average of(17.2±1.7) months. All fractures were healed, the healing time was 9 to 16 weeks with an average of(11.1±3.2) weeks. The Rasmussen score after surgery was 1 to 18 points with an average of(16.7±1.5) points. Sixteen cases got excellent, 3 good and 2 fair. At the final follow-up, HSS functional scores ranged from 60 to 100 points with an average of (87.3±6.7) points, the result was excellent in 18 cases, good in 2 cases and fair in 1 case.</p><p><b>CONCLUSIONS</b>For a split fracture of the medial tibial plateau, the medial incision, full protection of the medial knee structure, and two different directions of supporting plate fixation are feasible, and the short-term effect is satisfactory.</p>

French door segmented laminectomy decompression for severe cervical ossification of posterior longitudinal ligament complicated with spinal cord injury / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the clinical effects of French door segmented laminectomy decompression for severe cervical OPLL complicated with spinal cord injury.</p><p><b>METHODS</b>The clinical data of 38 patients with serious cervical OPLL complicated with spinal cord injury were retrospectively analyzed and these patients were treated with French door segmented laminectomy decompression and internal fixation from June 2012 to June 2014. There were 25 males and 13 females, aged from 42 to 78 years with an average of 58.2 years. Of them, 35 cases suffered from aggravating neurological symptoms with a definite precipitating factor. Spinal cord injury was related to minor injury of the neck, such as hyperextension of the neck in 3 cases. Preoperative Japanese Orthopaedic Score (JOA) was 8.1±1.7 and Neck Disability Index (NDI) was 19.8±4.4. Preoperative CT scans showed the range of OPLL was more than three segments. The spinal canal was occupied 50% to 85% with an average of 70.7%.</p><p><b>RESULTS</b>All the patients were followed up for 10 to 24 months with an average of 15.6 months. The operative time was 90 to 150 min with an average of 120 min and blood loss was 300 to 800 ml with an average of (480±80) ml. At final follow-up, NDI and JOA were 7.5±2.5 and 13.5±2.0, respectively, and they were obviously improved compared with preoperation. Preoperative cervical Cobb angle was (8.10±2.70)° and at final follow-up was (15.60±1.80)°, and there was significant difference between preoperative and postoperative (<0.05). Deep infection occurred in 1 case, epidural hematoma in 1 case, C₅ nerve root palsy in 3 cases, and axial symptom in 8 cases after operation. No serious complications, such as vertebral artery injury, cerebrospinal fluid leakage, deterioration of neurological dysfunction, or internal fixation failure was found.</p><p><b>CONCLUSIONS</b>French door segmented laminectomy decompression is safe and feasible for severe cervical OPLL complicated with spinal cord injury, and it is worth to be popularized in future.</p>

Effects of patient-controlled infraclavicular brachial plexus block for postoperative pain and surgical efficacy in patients with terrible tyriad of the elbow / 中国骨伤

<p><b>OBJECTIVE</b>To study the effects of ultrasound guided inter-scalene brachial plexus block and patient-controlled infraclavicular brachial plexus block for postoperative pain and surgical efficacy in patients with terrible tyriad of the elbow.</p><p><b>METHODS</b>From March 2015 to August 2016, 60 patients with terrible tyriad of the elbows were treated in Ningbo No.6 Hospital with ASA I to II internal fixation. There were 32 males and 28 females, ranging in age from 16 to 70 years old, with a mean age of (55.6±18.2) years old. All the patients were divided into two groups(30 cases in each group): controlled intermuscular groove brachial plexus block (group C), infraclavicular brachial plexus block(group I). All catheters were placed using ultra-sound visualization and injected 0.33% ropivacaine 30 ml preoperatively. After regaining consciousness, all patients connected the electronic pump. The solution contained 0.2% ropiva-caine and the pump was setup to deliver a 5 ml bolus dose, with a 15 min lock out interval and background infusion at 5 ml/h. Both analgesia lasted until 5 d after operation. The patients underwent rehabilitation exercise everyday for 5 consecutive days starting from 24 h after operation.VAS score was recorded at 24 h, 48 h, 72 h and 4 d, 5 d after operation during rest and rehabilitation exercise time. The elbow articular range of motion and Mayo elbow performance score (MEPS) were recorded at 6 d after operation. Catheter-related adversereactions (such as oozing from the insertion site, obstruction, prolapse) were recorded.</p><p><b>RESULTS</b>The success rate of blockade was 100% during insertion in both groups. Compared with group C, the VAS score at 3 d during rest time and 3, 4, 5 d after operation during rehabili-tation exercise were decreased(2.5±0.5 vs. 3.8±1.1, 3.0±0.4 vs. 5.0±0.9, 2.5±0.4 vs. 4.5±1.2, 2.1±0.3 vs. 4.1±1.0,<0.05). The elbow articular range of motion and MEPS were increased(-2.19±18.01)° vs.(-8.19±12.16)°, (45.15±11.20)° vs. (22.15±7.02)°, (19.06±6.75)° vs. (9.10±2.48)°, (17.08±5.18)° vs. (10.12±3.15)°, (80.80±9.50) points vs. (64.90±11.21) points. The incidence of insertion site, obstruction, prolapse was 15, 5 and 10 cases respectively in group C, but without any catheter-related adverse reactions happened in group I (<0.05).</p><p><b>CONCLUSIONS</b>Patient-controlled infraclavieular brachial plexus block can be effectively used for postoperative pain after fixation for terrible tyriad of the elbows, and it can increase surgical outcome.</p>

Clinical outcome analysis on using extensor digitorum communis splitting approach for the treatment of radial head fractures / 中国骨伤

<p><b>OBJECTIVE</b>To explore the clinical outcomes of internal fixation or replacement for the treatment of radial head fractures through the extensor digitorum communis splitting approach.</p><p><b>METHODS</b>From July 2012 to May 2015, 25 patients with radial head fractures were reviewed. There were 17 males and 8 females, ranging in age from 20 to 67 years old, with a mean age of 39 years old. Twenty-one patients were treated with reconstruction of plate internal fixation, and 4 patients were treated with radial head replacement. According to Mason classification, 19 cases were type II and 6 cases were type III. All the patients underwent internal fixation or replacement through the extensor digitorum communis splitting approach. The patients were followed up clinically and radiographically until the beginning of fracture union and the entrance of function recovery of elbow motion into a plateau. The functional status of the elbow was evaluated using the Mayo Elbow Performance Index(MEPI). Radiographic signs of post-traumatic arthritis were rated according to the Broberg and Morrey system.</p><p><b>RESULTS</b>All the patients were followed up, and the average duration was 29 months (ranged, 12 to 56 months). The average range of flexion and extension was 120°, the extension was limited by 10°, and the flexion was 135°. The average forearm rotation range was 142°, pronation was 75°, supination was 67°. The mean MEPI was 93±7(ranged, 80 to 100 scores); according to the MEPI scoring criceria, 19 patients got an excellent functional result, 6 good. According to the Broberg and Morrey systems of traumatic arthritis, 19 patients were in grade 0, 6 in grade 1, and no patients in grade 2 or 3. No patients with nonunion of the radial head and failure of internal fixation were found. There were no complications of nerve or vascular injuries, and obvious limitation of elbow rotation. Heterotopic ossification around the elbow occurred in 4 cases, but the motion was not significantly limited. There were no complications such as prosthesis loosening and infection in 4 cases after radial head prosthesis replacement.</p><p><b>CONCLUSIONS</b>The extensor digitorum communis splitting approach is an effective exposure method for internal fixation or replacement in the treatment of radial head fractures.</p>

Research progress on reatment of unstable atlas fracture with single-segment fixation by transoral approach / 中国骨伤

As a common type of fracture in cervical, atlas fracture is frequently unstable due to its special anatomical structure. In a previous treatment, external fixation was likely to bring low bony union rate and long-term neck pain, while occipito-cervical fusion and atlantoaxial fusion sacrifice range of motion in cervical spine. Reduction and single section fixation of atlas by anterior lateral mass screws through the transoral approach were reported by some scholars, and the retrospective study demonstrated the high healing rate, reservation of cervical ROM and less bleeding. But it also has high risks of cervical spinal cord and vertebral artery damage, as well as the post-operation infection. Moreover, the indication and fixation strength require further evidences. As a result, this surgical option provides a new way for spinal surgeons to deal with unstable atlas fractures.

The shor-term clinical outcomes and safety of extreme lateral interbody fusion combined with percutaneous pedicle screw fixation for the treatment of degenerative lumbar disease / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the early efficacy and safety of extreme lateral interbody fusion (XLIF) combined with percutaneous pedicle screw fixation for lumbar degenerative disease.</p><p><b>METHODS</b>From January 2013 to June 2014, 13 patients with degenerative lumbar disease were treated with XLIF combined with percutaneous pedicle screw fixation, including 8 cases of lumbar instability, 5 cases of mild to moderate lumbar spondylolisthesis;there were 5 males and 8 females, aged from 56 to 73 years with an average of 62.1 years. All patients were single segment fusion. Operation time, perioperative bleeding and perioperative complications were recorded. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the clinical efficacy. Interbody fusion rate was observed and the intervertebral foramen area changes were compared preoperation and postoperation by X-rays and CT scanning.</p><p><b>RESULTS</b>The mean operation time and perioperative bleeding in the patients respectively was(62.8±5.2) min and(82.5±22.6) ml. One case occurred in the numbness of femoribus internus and 1 case occurred in the muscle weakness of hip flexion after operation, both of them recovered within 2 weeks. All the patients were followed up from 12 to 19 months with an average of 15.6 months. VAS was decreased from preoperative 7.31±0.75 to 2.31±0.75 at final follow-up(<0.05); ODI was decreased from preoperative (42.58±1.55)% to (12.55±0.84)% at final follow-up(<0.05). At final follow-up, CT scanning confirmed 8 cases completely fused and 5 cases partly fused;the intervertebral foramen area was increased from preoperative (94.86±2.44)mm2 to (150.70±7.02)mm2(<0.05).</p><p><b>CONCLUSIONS</b>Extreme lateral interbody fusion combined with percutaneous pedicle screw fixation is an ideal method and can obtain early good clinical effects in treating lumbar degenerative disease.</p>