Clinical Research and Technique Note of TLIF by Wiltse Approach for the Treatment of Degenerative Lumbar

ObjectiveTo assess the clinical efficacy and share the technique notes of Wiltse Approach TLIF for the treating single segment degenerative lumbar spinal disease.MethodIn this retrospective controlled study, 780 patients with single segment degenerative lumbar disease who were operated in our hospital from January 2016 to December 2020 were analyzed retrospectively. The patients were randomly assigned to Wiltse approach group (group A, 410 cases) and conventional open approach group (group B, 370 cases). Patient''s assessment of pain and disability were evaluated by the visual analogue scale (VAS) and the Oswestry disability index (ODI) before and after surgery. The incision length, operative time, exposure time, intraoperative blood loss, hidden blood loss, time to ambulation, total length of hospitalization, serum creatine kinase, X‐rays, CT and MRI were also evaluated.ResultsThere were no differences in sex, age, pre‐operative ODI score, VAS score between the two groups (P > 0.05). The Wiltse approach group had a shorter incision length with 7.69 ± 0.44 cm compared to the conventional group with 11.13 ± 0.36 cm (P < 0.01). The average operative time was 119.20 ± 14.64 min with exposure time of 16.20 ± 3.42 min in the Wiltse approach group and 145.65 ± 16.98 min with 29.20 ± 3.42 min in the conventional group (P < 0.05, P < 0.01). Comparing the intraoperative blood loss, hidden blood loss, serum creatine kinase, time to ambulation, total length of hospitalization, the Wiltse approach group was less than the conventional open approach group (P < 0.05). The VAS score of the two groups decreased significantly with time, and the VAS score of the Wiltse group was significantly lower than that of the conventional open approach group (P < 0.05). At last investigation after operation, ODI scores of the two groups were significantly decreased compared with that before operation. Wiltse approach group was significantly lower than that of the conventional open approach group (P < 0.05). The multifidus of the two groups of patients had a certain degree of atrophy. But the Wiltse approach group multifidus muscle atrophy rate is significantly lower than the conventional open approach group.ConclusionThe Wiltse approach TLIF significantly reduces the damage to the paravertebral muscles and the postoperative incidence of chronic low back pain.     

Comparison of the Wiltse Approach and Percutaneous Pedicle Screw Fixation Under O‐arm Navigation for the Treatment of Thoracolumbar Fractures

ObjectivesThe aim of this study was to evaluate the clinical outcomes of the Wiltse approach and percutaneous pedicle screw placement under O‐arm navigation for the treatment of thoracolumbar fracture.MethodsWe enrolled a total of 54 patients with neurologically intact thoracolumbar fracture who received minimally invasive treatments between October 2014 and October 2018 in this retrospective study. Among these, 28 patients (22 males and six females, with a mean age of 48.6 ± 9.6 years) were treated with pedicle screw fixation through the Wiltse approach (WPSF), and another 26 (15 males and 11 females, with a mean age of 45.7 ± 10.6 years) received percutaneous pedicle screw fixation under O‐arm navigation (OPSF). Statistical methods were used to perform a detailed comparison of clinical outcomes, radiologic findings, and complications between the two groups obtained preoperatively, postoperatively, and at last follow‐up.ResultsAll patients underwent surgery successfully and finished a follow‐up of more than 12 months. No serious complications, such as infection, blood vessel injury, or spinal cord or nerve root injury occurred. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, local Cobb angle (LCA), vertebral wedge angle (VWA), and R value were notably improved after surgery, though there was no clear discrepancy between the groups at each time point (P > 0.05). During the follow‐up period, no patients developed neurological impairment or implant‐related complications, and no patients underwent revision surgery. The WPSF group had a significantly shorter operation time than the OPSF group (68.1 ± 9.8 vs 76.1 ± 9.0 minutes, P = 0.005). Moreover, the WPSF group showed less cost of surgery than the WPSF group (48142.1 ± 1430.1 vs 59035.4 ± 1152.7 CNY, P < 0.001). There were no significant differences between the two groups in terms of the intraoperative bleeding, length of incision, or postoperative hospitalization time (P > 0.05). The accuracy of pedicle screw placement was 95.2% (160/168) in the WPSF group and 96.8% (151/156) in the OPSF group, with no significant difference between the groups (P = 0.432).ConclusionBoth WPSF and OPSF were safe and effective for the treatment of thoracolumbar fracture. Although the two groups showed favorable clinical and radiologic outcomes through to final follow‐up, we recommended the minimally invasive WPSF given its shorter operation time and lower cost of surgery.     

Comparison of Outcomes between Robot‐Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single‐Level Lumbar Spondylolisthesis

ObjectiveTo compare the safety and effectiveness of robot‐assisted minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single‐level lumbar degenerative spondylolisthesis (LDS).MethodsThis is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single‐level lumbar degenerative spondylolisthesis and treated with robot‐assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot‐assisted Mis‐TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient''s satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively.ResultsThere were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis‐TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis‐TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow‐ups. ODI score was also significantly lower in OLIF group than Mis‐TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis‐TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis‐TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis‐TLIF, P = 0.263).ConclusionRobot‐assisted OLIF and Mis‐TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.     

Robot‐Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis

ObjectiveTo compare the clinical efficacy between robot‐assisted minimally invasive transforaminal lumbar interbody fusion (robot‐assisted MIS‐TLIF) and traditional open TLIF surgery in the treatment of lumbar spondylolisthesis.MethodsAccording to the inclusion and exclusion criteria, 48 cases with lumbar spondylolisthesis who received surgical treatment from June 2016 to December 2017 in the spinal surgery department of Beijing Jishuitan Hospital were analyzed in this study, including 23 patients who received robot‐assisted MIS‐TLIF and 25 patients who received traditional open TLIF surgery. The two groups were compared in terms of pedicle screw accuracy evaluated by Gertzbein‐Robbins classification on postoperative computed tomography (CT), operation time, blood loss, postoperative drainage, hospitalization, time to independent ambulation, low back pain evaluated by visual analog scale (VAS), lumbar function evaluated by Oswestry Disability Index (ODI), paraspinal muscles atrophy on magnetic resonance imaging (MRI), and complications.ResultsPostoperative CT showed that the rate of Grade A screws in the robot‐assisted MIS‐TLIF group was significantly more than that in the open surgery group (χ ² = 4.698, P = 0.025). Compared with the open surgery group, the robot‐assisted MIS‐TLIF group had significantly less intraoperative blood loss, less postoperative drainage, shorter hospitalization, shorter time to independent ambulation, and lower VAS at 3 days post‐operation (P < 0.05). However, the duration of surgery was longer. The VAS of the robot‐assisted MIS‐TLIF group decreased from 6.9 ± 1.8 at pre‐operation to 2.1 ± 0.8 at post‐operation, 1.8 ± 0.7 at 6‐month follow‐up and 1.6 ± 0.5 at 2‐year follow‐up. The VAS of the open surgery group decreased from 6.5 ± 1.7 at pre‐operation to 3.7 ± 2.1 at post‐operation, 2.1 ± 0.6 at 6‐month follow‐up and 1.9 ± 0.5 at 2‐year follow‐up. The ODI of the robot‐assisted MIS‐TLIF group decreased from 57.8% ± 8.9% at pre‐operation to 18.6% ± 4.7% at post‐operation, 15.7% ± 3.9% at 6‐month follow‐up and 14.6% ± 3.7% at 2‐year follow‐up. The ODI of the open surgery group decreased from 56.9% ± 8.8% at pre‐operation to 20.8% ± 5.1% at post‐operation, 17.3% ± 4.2% at 6‐month follow‐up and 16.5% ± 3.8% at 2‐year follow‐up. Paraspinal muscle cross‐sectional area in 2‐year follow‐up in patients of the open surgery group decreased significantly compared to patients of robotic‐assisted MIS‐TLIF group (P = 0.016).ConclusionIn the treatment of lumbar spondylolisthesis, robot‐assisted MIS‐TLIF may lead to more precise pedicle screw placement, less intraoperative blood loss, less postoperative drainage, less postoperative pain, quicker recovery, and less paraspinal muscle atrophy than traditional open surgery.     

Psychological and Functional Comparison between Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Single‐Level Lumbar Spinal Stenosis

ObjectiveThe aim of this study was to investigate whether treatment with minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) causes patients suffering from lumbar spinal stenosis (LSS) to experience less anxiety and better clinical efficacy than open transforaminal lumbar interbody fusion (TLIF).MethodsIn this retrospective cohort study, we analyzed 86 patients, including 46 male patients and 41 female patients, who suffered from single‐segmental lumbar spinal stenosis in our department between January 2016 and January 2018. They were divided into two groups: a control group (n = 46), for patients who underwent open TLIF surgery, and an experimental group (n = 40), for patients who underwent Mis‐TLIF surgery. All patients were evaluated based on operation time, intraoperative blood loss, hospital stay, visual analogue scale (VAS), Oswestry disability index (ODI), hospital anxiety depression scale (HADS), fusion rate, and complications (screw misplacement and loosening, cerebrospinal fluid leakage, infection, and delayed wound healing). Patient characteristics were compared within and between groups.ResultsThe average incision length was 3.64 ± 0.476 cm in the experimental group, which was smaller than that (8.11 ± 2.406 cm) in the control group (P < 0.05). The operation time of the experimental group was a little longer than that of the control group. The intraoperative blood loss and hospital stay in the experimental group were less than those in the control group.The mean preoperative low back pain VAS score was 7.525 ± 1.432 in the experimental group and 7.087 ± 1.799 in the control group (P > 0.05). The low back pain VAS scores on postoperative day 3 and at 3, 6, and 12 months postoperatively were 5.000 ± 0.987, 4.075 ± 0.997, 2.150 ± 0.834, and 1.450 ± 0.639 in the experimental group, respectively; these scores were lower than those in the control group (6.870 ± 1.572, P < 0.05; 4.630 ± 1.103, P < 0.05; 2.630 ± 1.103, P < 0.05; and 2.326 ± 1.034, P < 0.05, respectively). There was no obvious difference in the leg pain VAS scores between the two groups at all follow‐up points.The mean preoperative ODI score was 58.700% ± 19.703% in the experimental group and 61.696% ± 17.583% in the control group (P > 0.05). The ODI scores at postoperative months 3, 6, and 12 were 25.225% ± 5.554%, 20.150% ± 7.698%, and 16.125% ± 9.565% in the experimental group; these scores were lower than those in the control group (49.130% ± 14.805%, P < 0.05; 34.044% ± 15.148%, P < 0.05; and 29.282% ± 132.567%, P < 0.05, respectively).The mean preoperative HADS score was 14.475 ± 3.113 in the experimental group and 13.391 ± 2.824 in the control group (P > 0.05). However, the mean HADS scores on postoperative day 3 in the experimental group was 8.500 ± 2.000, decreasing obviously compared to the preoperative scores (P < 0.05). The mean postoperative HADS score on postoperative day 3 in the control group was 12.734 ± 1.949, which had not decreased significantly compared to the preoperative score (P > 0.05). The HADS scores in the experimental group was lower than that in the control group on postoperative day 3 (P < 0.05).In the correlation analysis, the incision length was correlated to the HADS scores on postoperative day 3 (r = 0.527, P < 0.05). The HADS scores on postoperative day 3 were positively correlated with the low back pain VAS scores on the same day (r = 0.388, P < 0.05). The HADS scores on postoperative day 3were positively correlated with the ODI scores at 3‐month (r = 0.460, P < 0.05), 6‐month (r = 0.429, P < 0.05), and 12‐month follow up (r = 0.349, P < 0.05).Fusion rates were not significantly different between the two groups. There was no screw misplacement and loosening, infection, or delayed wound healing in either group. The cerebrospinal fluid leakage rate in the control group was higher than that in the experimental group.ConclusionPatients undergoing Mis‐TLIF experience less anxiety and have better outcomes than those who undergo open TLIF. The lower level of anxiety experienced by patients undergoing Mis‐TLIF is positively correlated with postoperative VAS and ODI scores.     

Application of Triggered EMG in the Intraoperative Neurophysiological Monitoring of Posterior Percutaneous Endoscopic Cervical Discectomy

ObjectiveTo describe the rationale and application of triggered EMG (T‐EMG) in intraoperative neurophysiological monitoring, and to explore the efficacy and safety of posterior percutaneous endoscopic cervical discectomy (PPECD) in the treatment of cervical spondylotic radiculopathy (CSR) under multimodal intraoperative neurophysiological monitoring (IOM).MethodsThis study was a retrospective cohort control study. The clinical data of 74 patients with single‐segment CSR from June 2015 to August 2018 were analyzed retrospectively, of whom 35 underwent IOM‐assisted PPECD with triggered EMG (T‐EMG group), while 39 were subjected to IOM‐assisted PPECD alone (IOM group). Operation time, hospital stay, and complications were recorded for both groups. The curative effect was evaluated according to the Visual Analog Scale (VAS) of neck and arm pain, Japanese Orthopaedic Association (JOA) score, and modified MacNab scale.ResultsOperations were successful and all patients were followed up for at least 24 (average 31.77 ± 9.51) months with no patient lost to follow‐up. No significant difference was found in preoperative baseline data between the T‐EMG and the IOM group (P > 0.05). Also, no significant difference was found in the operation time between the T‐EMG (108.29 ± 11.44 min) and the IOM (110.13 ± 12.70 min) (P > 0.05) group, but the difference in hospital stay (T‐EMG: 5.66 ± 0.99 days; IOM: 7.10 ± 1.43 days) was statistically significant (P < 0.05). The VAS for the neck and upper limbs in the two groups at 1 month post‐operation (T‐EMG: 2.09 ± 1.07, 2.26 ± 0.92; IOM:2.18 ± 1.05, 2.31 ± 0.77) and the last follow‐up (T‐EMG: 0.83 ± 0.62, 0.86 ± 0.55; IOM: 0.90 ± 0.50, 0.87 ± 0.61) were significantly different from the preoperative scores (T‐EMG: 6.14 ± 1.09, 7.17 ± 1.04; IOM: 6.18 ± 1.28, 7.15 ± 1.23) (P < 0.05). However, no significant difference was found between the two groups (P > 0.05). The 1‐month postoperative JOA scores for the two groups (12.69 ± 0.76; 12.59 ± 0.82) and those at the last follow‐up (14.60 ± 0.77; 14.36 ± 0.78) were significantly different from the preoperative scores (11.09 ± 0.98; 11.05 ± 0.89) (P < 0.05), but the difference between the two groups was not significant (P > 0.05). One patient in the T‐EMG group developed a transient aggravation of symptoms on the first day after surgery. In the IOM group, three patients had intraoperative cerebrospinal fluid leakage, and symptoms of C5 nerve root paralysis were presented in four patients following surgery. Compared with the IOM group, the T‐EMG group had fewer complications (1/35; 7/39, P < 0.05). At the last follow‐up, the modified MacNab criteria were 91.43% (32/35) and 89.7% (35/39) for the T‐EMG group and IOM group, respectively.ConclusionsTriggered EMG prevents the occurrence of neurological complications, which not only aids PPECD for CSR treatment in achieving satisfactory results, but also reduces average hospital stay and complication rates.     

Symmetry in Paraspinal Muscles as a Predictor of the Development of Pregnancy‐Related Low Back and Pelvic Pain: A Prospective Study

ObjectiveTo determine the asymmetry in the paraspinal muscle before pregnancy and evaluate its association with pregnancy‐associated lumbopelvic pain (LPP).MethodsThis was a prospective case–control study conducted from January 2017 and December 2018. A total of 171 subjects (mean age ± SD, 27.4 ± 5.8 years) were finally divided into the LBP group, PGP group, and no LPP group. Each subject was asked to follow a standardized clinical imaging protocol before the pregnancy. The area of muscles (multifidus, erector spinae, and psoas muscles) on the axial slice at mid‐disc of L₄–L₅ and L₅–S₁ were segmented and then the cross‐sectional area (CSA) of a particular muscle was measured by outlining the innermost fascial border surrounding each muscle. The mean value of F‐CSA''s ratio to T‐CSA (F/T CSA) was used to determine whether the bilateral paraspinal muscle was asymmetrical. Total muscle CSA (T‐CSA) represents the sum of CSA of interested three muscles. The signal intensity can distinguish fat and muscle tissue in a different range. Based on this, functional CSA (F‐CSA), represented by fat‐free area, was evaluated quantitively by excluding the signal of the deposits of intramuscular fat. Total muscle CSA (T‐CSA), functional CSA (F‐CSA), and the ratio of F‐CSA to T‐CSA (F/T CSA) were measured unilaterally and compared between groups. Logistic regression was performed to determine the risk factors for pregnancy‐associated LPP. The Pearson correlation coefficient was performed to test the relationship between asymmetry in F/T‐CSA and pain rating.ResultsA total of 124 subjects (72.5%) (28.5 ± 5.2 years) had LPP during pregnancy. Forty‐eight (38.7%) individuals had low back pain (LBP) and 76 (61.3%) had pelvic girdle pain (PGP). Seventy‐six women (44.4%) were determined to have asymmetry in paraspinal muscle according to the definition in this methods section. The duration of follow‐up was 24 months postpartum. A total of 39 (31.5%) women unrecovered from LPP. F/T‐CSA was significantly decreased for LBP in the PGP group than in the and control group (0.03 ± 0.02 vs 0.05 ± 0.03 vs 0.12 ± 0.05, P < 0.001). Meanwhile, significant differences were detected in both groups (all P < 0.001). In patients with LBP, the level of paraspinal asymmetry, represented by the difference in F/T‐CSA, was positively correlated with pain scores (r = 0.52, P < 0.01). However, no statistically significant correlation between pain scores and paraspinal asymmetry was found in PGP (r = 0.42, P > 0.05). Asymmetry in the paraspinal muscle (adjusted OR = 1.5), LBP (adjusted OR = 1.6), LPP in a previous pregnancy (adjusted OR = 1.4), sick leave ≥90 days (adjusted OR = 1.2), and heavy labor (adjusted OR = 1.2) were risk factors for the unrecovered LPP during pregnancy.ConclusionsAsymmetrical muscular compositions could lead to abnormal biomechanics for the segmental motions. Lateral‐directed physical training and stretching may help decrease the occurrence and severity of this condition.     

Efficacy and Safety of Postoperative Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Study

ObjectiveTo assess the efficacy and safety of postoperative intravenous tranexamic acid (TXA) in patients undergoing total knee arthroplasty (TKA).MethodsFrom March 2020 to August 2020, all patients undergoing primary unilateral TKA in our hospital were considered in prospective randomized controlled study. Included patients were randomized into three groups to receive either two doses of 15 mg/kg intravenous TXA postoperatively, at 2 and 24 h after closing the incision (group A), or a single dose of 15 mg/kg intravenous TXA 2 h postoperatively (group B), or placebo (group C). The calculated total blood loss (TBL) and hidden blood loss (HBL), incidence of venous thromboembolism (VTE), and transfusion rate were compared among groups. The levels of prothrombotic state parameters including thrombomodulin (TM), thrombin‐anti‐thrombin complex (TAT), plasmin‐anti‐plasmin complex (PIC), and tissue‐type plasminogen activator‐plasminogen activator inhibitor complex (t‐PAI·C) in plasma were measured during the perioperative period. Patients were compared depending on the Kellgren‐Lawrence classification (K‐L types III and IV).ResultsAll patients were followed up for at least 4 weeks. The mean TBL and HBL in group C (1,182.45 ± 160.50; and 965.47 ± 139.61 mL, respectively) were significantly higher than those in groups A (944.34 ± 130.88 mL, P < 0.05; and 712.45 ± 129.82mL, P < 0.05, respectively) or B (995.20 ± 154.00 mL, P < 0.05; and 757.20 ± 134.39 mL, P < 0.05, respectively), but no significant differences were found between groups A and B (P > 0.05 and P > 0.05, respectively). None of the patients of three groups received blood transfusion, so there were no significant differences in blood transfusion rate among groups. Similar results were obtained with subgroups of patients who had the K‐L types III and IV. The DVT frequencies were four, three, and three in groups A, B, and C, respectively, with no significant differences after comparison (P > 0.05). There were no significant differences in the levels of prothrombotic state parameters (TM, TAT, PIC, t‐PAI·C) or incidence of VTE among groups (P > 0.05). Wound leakage was observed in five patients during the hospital stay (two patients in group A, one patient in group B, and two patients in group C), and no statistical difference was found in wound leakage or other complications among groups (P > 0.05).ConclusionsShort‐term application of postoperative intravenous TXA in TKAs resulted in reduced HBL without a measured increase in the actual incidence of VTE or the potential risk of thrombosis, but administration of TXA after the first 24 h had no significant effect.     

Anterior Cervical Discectomy and Fusion Combined with Foraminotomy Assisted by High‐Definition 3‐Dimensional Exoscope in the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis

ObjectiveTo evaluate the outcomes of cervical spondylotic radiculopathy secondary to bony foraminal stenosis treated with anterior cervical discectomy and fusion (ACDF) combined with anterior cervical foraminotomy (ACF) assisted by High‐Definition 3‐Dimensional Exoscope.MethodsIn this retrospective study, a total of 19 consecutive patients (12 males and seven females, with an average of 49.2 years, range from 40 to 59 years) with spondylotic radiculopathy caused by bony foraminal stenosis underwent ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope in our hospital between January 2019 and December 2019 were included in this study. All patients signed the consent form before the surgery. The patient baseline information such as gender, age, body mass index (BMI), surgery time, blood loss, hospital stay, lesion segment, side, follow‐up time and postoperative complications were recorded. The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were measured and compared before surgery, 1 months and final follow‐up after surgery. The radiographic outcomes were evaluated using the C₂‐C₇ angel, disc height, foraminal height, superior diagonal distance, inferior diagonal distance, and foraminal area.ResultsThe involved levels included C₄‐C₅ (six cases), C₅‐C₆ (10 cases), C₆‐C₇ (three cases). The mean duration of the surgery, mean blood loss, mean hospital stay, and mean follow‐up were 100 ± 11.10 min, 19.4 ± 7.05 mL, 7.1 ± 0.99 days, and 12.1 ± 2.25 months, respectively. The average preoperative JOA score was 11.9 ± 1.31, then improved to 15.7 ± 0.73 (t = −13.45, P < 0.001) and 16.2 ± 0.74 (t = −14.39, P < 0.001) at 1 month after operation and at last follow‐up, respectively. The average preoperative NDI score was 27.3 ± 3.36, then decreased to 5.1 ± 1.79 (t = 20.63, P < 0.001) and 4.5 ± 1.21 (t = 25.53, P < 0.001) 1 month after operation and at last follow‐up, respectively. The average preoperative VAS score was 6.7 ± 0.93, then decreased to 2.4 ± 0.69 (t = 15.05, P < 0.001) and 1.9 ± 0.78 (t = 16.40, P < 0.001) 1 month after operation and at last follow‐up, respectively. As compared with the condition before surgery, there was a significant improvement in the C₂‐C₇ angel, disc height, foraminal height, and foraminal area (P < 0.05). None of the patients developed postoperative vascular injury, nerve injury, loosening and rupture of the internal fixation, displacement of interbody fusion cage, and pseudarthrosis.ConclusionACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope is effective and safe for the treatment of CSR caused by secondary to bony foraminal stenosis.     

Treatment of Degenerative Lumbar Scoliosis with Oblique Lumbar Interbody Fusion in Conjunction with Unilateral Pedicle Screw Fixation via the Wiltse Approach

ObjectiveTo evaluate the clinical outcomes of oblique lumbar interbody fusion (OLIF) in conjunction with unilateral pedicle screw fixation (UPSF) via the Wiltse approach in treating degenerative lumbar scoliosis (DLS).MethodsThe article is a retrospective analysis. Twelve patients with DLS who underwent combined OLIF and UPSF between July 2017 and December 2018 were included. The study included 2 male and 10 female patients, with a mean age at the time of the operation of 67.2 ± 9.1 years. The surgical characteristics and complications were evaluated. The clinical and radiological data such as the correction of deformity, coronal and sagittal profile were analyzed.ResultsThe mean follow‐up time of the study was 26.8 ± 1.8 months. At the final follow‐up, all patients who underwent combined OLIF and UPSF achieved statistically significant improvements in coronal Cobb angle (from 19.6° ± 4.8° to 6.9° ± 3.8°, P < 0.01), distance between the C7 plumb line and central sacral vertebral line (from 2.5 ± 1.7 cm to 0.9 ± 0.6 cm, P < 0.01), sagittal vertebral axis (from 4.3 ± 4.3 cm to 1.5 ± 1.0 cm, P = 0.03), lumbar lordosis (from 29.4° ± 8.6° to 40.8° ± 5.8°, P < 0.01), pelvic tilt (from 27.6° ± 10.8° to 18.3° ± 7.0°, P < 0.01), pelvic incidence‐lumbar lordosis mismatch (from 23.3° ± 10.5° to 11.9° ± 8.4°, P < 0.01), and cross‐sectional area of the dural sac (from 87.33 ± 39.41 mm² to 124.70 ± 39.26 mm², P < 0.01). The visual analogue score for back and leg pain and Oswestry Disability Index of all patients significantly improved postoperatively (P < 0.01). One case of lumbar plexus injury was found after surgery. During the follow‐up period, one patient had cage subsidence. A fusion rate of 100% and good positioning of the pedicle screws were achieved in all patients at the final follow‐up.ConclusionOLIF in conjunction with UPSF is a safe and effective minimally invasive procedure for correcting both coronal and sagittal deformities, as it results in an improved quality of life in patients with DLS.     

Simultaneous or Staged Decompressions for Patients with Tandem Spinal Stenosis

ObjectiveTo compare the clinical effects of cervical decompression first, lumbar decompression first, or simultaneous decompression of both lesions in the treatment of tandem spinal stenosis (TSS).MethodsThis is a retrospective analysis. From January 2013 to December 2018, 51 TSS patients underwent our surgery and postoperative investigation. Among the 51 subjects, 27 females and 24 males, aged 49–77 years with an average age of 66.3 ± 6.8, were selected. According to the different operation sequences, all patients were divided into three groups. In simultaneous operation group, five patients underwent cervical and lumbar vertebrae surgery at the same time. In first cervical surgery group, 28 patients underwent cervical vertebra surgery first, followed by lumbar spine surgery after a period of recovery. And in first lumbar surgery group, 18 patients underwent lumbar vertebrae surgery first. The choice for neck surgery is posterior cervical single‐door vertebroplasty, the surgery of lumber is plate excision and decompression needle‐rod system internal fixation. The outcome measures are visual analogue scale (VAS), Japanese Orthopaedic Association cervical (JOA‐C) and lumbar (JOA‐L) scores, which were assessed at 3 months and 1 year after the operation by telephone interview. In addition, operative time, estimated blood loss, and hospital stay were also recorded.ResultsAll the patients in the study had surgery performed successfully by the same group of orthopaedic surgeons. The preoperative VAS scores of simultaneous operation group, first cervical surgery group, and first lumbar surgery group were 8.00 ± 1.00, 8.36 ± 0.68, and 8.17 ± 0.71 (P > 0.05). The preoperative JOA‐C scores were 7.00 ± 2.35, 6.54 ± 1.53, and 7.83 ± 1.04 (P < 0.05). And the preoperative JOA‐L scores were 7.20 ± 2.17, 4.64 ± 2.36, and 5.78 ± 1.22 respectively (P < 0.05). During the final 1‐year follow‐up, the JOA‐C improvement rates of simultaneous operation group, first cervical surgery group, and first lumbar surgery group were 85.68% ± 5.44%, 84.27% ± 5.02%, and 83.34% ± 10.25%, respectively (P > 0.05), and the JOA‐L improvement rates were 80.04% ± 3.35%, 81.65% ± 3.74%, and 80.21% ± 4.76% (P > 0.05). The difference among them was not statistically significant. In addition, operation time (OP), blood loss (BL), and hospital stay (HS) in the simultaneous operation group were 245.00 ± 5.00 min, 480.00 ± 27.39 mL, and 16.60 ± 0.55 days, respectively. While those parameters in the first cervical surgery group were 342.50 ± 18.18 min, 528.21 ± 43.97 mL, and 22.75 ± 2.15 days, and in the first lumbar surgery group they were 346.11 ± 24.77 min, 519.44 ± 43.99 mL, and 22.89 ± 1.64 days. The average blood loss in simultaneous operation group was less (P > 0.05); meanwhile, the operation time and hospital stay time were significantly shorter in the simultaneous operation group than in the first cervical surgery group and first lumbar surgery group (P < 0.05). Only one case of fat liquefaction occurred in first cervical surgery group, which healed spontaneously after a regular change of dressing for 1 month.ConclusionsUnder the condition of ensuring the surgical effect, the choice of staged surgery or concurrent surgery according to the patients'' own symptoms of cervical and lumbar symptoms could both obtain satisfactory results, and the damage of simultaneous surgery was less than that of staged surgery.     

Percutaneous Endoscopic Lumbar Discectomy via Transforaminal Approach Combined with Interlaminar Approach for L4/5 and L5/S1 Two‐Level Disc Herniation

ObjectiveThe purpose of the present study was to discuss a new surgical strategy that combines percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) for L4/5 and L5/S1 two‐level disc herniation.MethodsThis was a retrospective study. A total of 19 patients with L4/5 and L5/S1 two‐level lumbar disc herniation (LDH) who underwent percutaneous endoscopic lumbar discectomy (PELD) in our hospital from January 2015 to June 2016 were retrospectively examined. The average age of these 19 patients was 42.21 ± 14.88 years old, including 12 men and 7 women. One experienced surgeon who had carried out more than 3000 lumbar surgeries performed PELD for these patients. During the PELD surgery, the transforaminal approach was adopted for L4/5 level disc herniation and the interlaminar approach was adopted for L5/S1 level disc herniation. The demographic data, operation time (min), fluoroscopy times, hospital stay (days), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate the surgical outcomes. MRI was conducted to evaluate the radiographic improvement.ResultsAll patients underwent PELD via the transforaminal approach combined with the interlaminar approach successfully and achieved satisfactory efficacy. The follow‐up points were 3, 12, and 18 months. The average hospital stay (days) and the average follow up (months) were 3.32 ± 0.98 and 18.63 ± 3.84, respectively. The operation time and fluoroscopy times were 85.79 ± 12.90 min and 39.05 ± 4.59 times, respectively. The fluoroscopy times (frequency) for L4/5 and L5/S1 were 26.95 ± 6.41 and 12.11 ± 3.49 (t = 7.00, P < 0.05). Furthermore, there was no significant difference for fluoroscopy times between male and female patients (t = 0.89, P = 0.99). The preoperative back pain (VAS‐Back) and the last follow‐up VAS‐Back were 5.58 ± 2.01 and 2.37 ± 1.01, respectively (t = 7.14, P < 0.05). The preoperative leg pain (VAS‐Leg) and the last follow‐up VAS‐Leg were 7.00 ± 1.56 and 1.63 ± 1.01, respectively (t = 20.97, P < 0.05). There were significant differences between preoperative VAS‐Back and the last follow‐up VAS‐Back in men (t = 4.61, P < 0.05) and women (t = 6.57, P < 0.05). In addition, there was significant differences between preoperative VAS‐Leg and the last follow‐up VAS‐Leg in men (t = 13.48, P < 0.05) and women (t = 26.87, P < 0.05). There were significant differences between preoperative ODI scores (44.84 ± 10.82%) and the last follow‐up ODI scores (11.12 ± 5.80%) (t = 10.92, P < 0.05). Preoperative ODI scores and the last follow‐up ODI scores were significantly different for men (t = 8.80, P < 0.05) and women (t = 6.63, P < 0.05). All patients received significant pain relief and functional improvement after the surgery. Except for two cases of postoperative dysesthesia and one dural tear, no severe complications occurred. The dysesthesia symptoms of these two patients disappeared within 1 week with the application of dexamethasone and neurotrophic drugs and the dural tear case also recovered well as the dural laceration was small. No poor results were reported and 89.47% of patients achieved excellent or good recovery.ConclusionPercutaneous endoscopic lumbar discectomy via the transforaminal approach combined with the interlaminar approach under epidural anesthesia can treat L4/5 and L5/S1 two‐level disc herniation safely and effectively.     

Anterior Selective Lumbar Fusion Saving More Distal Fusion Segments Compared with Posterior Approach in the Treatment of Adolescent Idiopathic Scoliosis with Lenke Type 5: A Cohort Study with More Than 8‐Year Follow‐up

ObjectiveTo investigate whether anterior selective fusion (ASF) could save more distal fusion segments compared with posterior approach in the treatment of Lenke type 5 adolescent idiopathic scoliosis with long term follow‐up.MethodsA retrospective cohort study. From 2008 to 2011, 22 AIS girls with Lenke type 5 who underwent ASF or posterior selective fusion (PSF) with more than 8‐year follow‐up, were extracted from the database. 13 girls in the ASF group had an average age of 14.3 ± 1.3 years and Risser sign of 3.3 ± 1.1; 9 PSF girls had an average age of 16.2 ± 3.6 years and Risser sign of 3.8 ± 1.5. The radiographic outcome was compared between groups preoperatively, 6‐month postoperatively, 8‐year postoperatively and at last follow‐up (>8 years).ResultsThe average follow‐up duration was 8.7 ± 0.4 (ASF) and 8.8 ± 0.5 (PSF) years, respectively. There was no significant difference at baseline in age, Risser sign and preoperative curve pattern in the coronal and sagittal plane between the groups (P > 0.05). The ASF group had significantly shorter fusion segments (5.1 ± 0.6 vs. 7.0 ± 1.3) and decreased upper instrumented vertebra (UIV) (T₁₁ ± 0.8 vs. T₁₀ ± 0.8) than the PSF (P < 0.05); while no significant difference was found in the lower instrumented vertebra (LIV) and distal reserved segments (P > 0.05), which suggested that ASF could shorten the fusion segments by lowering UIV. The distal compensatory curve in the ASF group (9.0° ± 3.9°) was significantly larger than in the PSF group (3.3° ± 2.4°, P = 0.003), despite of no significant difference in the incidence of coronal imbalance (P > 0.05), indicating that both two approaches could obtain satisfactory correction in the coronal plane. In the sagittal plane, PSF patients had significantly larger lumbar lordosis (LL, 59.1° ± 10.5°), thoracic kyphosis (TK, 37.2° ± 13.3°) and proximal junctional angle (PJA, 13.3° ± 6.1°) at the last follow‐up than the ASF (LL: 43.4° ± 9.4°; TK: 20.7° ± 8.4°; PJA: 4.7° ± 3.4°; P < 0.05), but without significant difference in proximal junctional kyphosis (PJK) and sagittal vertical axis (SVA) (P > 0.05). After controlling for age, Risser sign, and radiographic parameters related to the primary curve pattern, shorter fusion segments and more distal reserved segments still remained significant in the ASF group with greater Risser sign (P < 0.05). No major intra‐ or post‐operative complications occurred.ConclusionsBoth ASF and PSF could obtain satisfactory coronal and sagittal correction for Lenke 5 AIS; compared with PSF, ASF could shorten the fusion segments by lowering UIV, and save more distal fusion segments only in patients with greater skeletal maturity.     

Posteromedial Corner Release with the Knee in Figure‐of‐Four Position vs Conventional Position for Varus Knee Arthroplasty

ObjectiveTo introduce posteromedial corner release with the knee in the figure‐of‐four position versus the conventional position for varus knee arthroplasty.MethodsThis is a retrospective study. From March 2015 to September 2019, a series of 123 patients (139 knees) with varus knee were randomly and blindly allocated to experimental group (60 patients; 68 knees) and control group (57 patients; 65 knees). Patients in experimental group underwent posteromedial corner release with the knee in the figure‐of‐four position; and patients in control group with the knee in the conventional position. If soft tissue balance was not completely achieved or the medial gap was still tight, an additional loosening technique were used to achieve symmetric medial and lateral space in both groups. Time for soft tissue balancing was defined as the time from the start of the spacer test to the end of the balance test. Length of release was defined as the distance from the osteotomy surface of the tibial plateau to the farthest structures released. The rating system of Hospital for Special Surgery (HSS) knee score was used to evaluate the clinical results. Quantitative variables were described as mean and standard deviation, and compared by one‐way analysis of variance.ResultsThe mean age of experimental group and control group was 70.2 ± 8.7 years and 68.7 ± 6.2 years, respectively (P > 0.05). Preoperatively, the mean HSS score of the groups was 38.2 ± 11.3 and 39.1 ± 10.7, respectively (P > 0.05). The mean varus knee angle was 19.7° ± 9.3° and 19.3° ± 10.7°, respectively (P > 0.05). The mean time for soft tissue balancing was 8.4 ± 3.3 min and 11.3 ± 6.9 min in experimental and control group, respectively (P < 0.05). The mean length of releasing posteromedial corner structures was 35.5 ± 13.4 mm and 27.3 ± 9.7 mm in experimental and control group, respectively (P < 0.05). Additional special loosening techniques were performed in eight knees in experimental group and seven knees in control group. The HSS scores 5 years after surgery were 95.1 ± 16.9 and 94.8 ± 17.2 respectively (P > 0.05). No complications were found during the follow‐up time, and the clinical symptoms were observed to be significantly improved in the patients.ConclusionThe posteromedial corner can be released more extensively and thoroughly when the knee is placed in the figure‐of‐four position during varus knee arthroplasty.     

CircCDR1as Suppresses Bone Microvascular Endothelial Cell Activity and Angiogenesis Through Targeting miR‐135b/ FIH‐1 Axis

ObjectiveThe current study investigated the role of CircCDR1as on angiogenesis of bone microvascular endothelial cells (BMECs) isolated from non‐traumatic ONFH.MethodsForty corticosteroid‐induced ONFH patients received THA were enrolled in our study. Expressions of CircCDR1as, miR‐135b, and FIH‐1 were detected by qRT‐PCR in affected necrosis tissue and non‐affected normal tissue. Bone microvascular endothelial cells (BMEC) were isolated from six patients and treated with 0.1 mg/mL hydrocortisone to establish a GC‐damaged model of BMECs. Circ CDR1as plasmid and miR‐135b mimic were transfected into BMECs. BMEC proliferation was assessed using MTT assays. The migration ability of cells was detected by scratch‐wound assays. Matrigel assay was performed to detect angiogenesis in vitro. Western blot assay was used to detect HIF‐1α, VEGF, and FIH‐1 expressions. FISH, RNA pull down, RIP, and luciferase assay were carried out to determine the interaction of CircCDR1as, miR‐135b, and FIH‐1.ResultsCircCDR1as was upregulated(2.02 ± 0.30 vs. 1.00 ± 0.10,P < 0.001) whereas miR‐135b was downregulated (0.55 ± 0.12 vs. 1.00 ± 0.10,P < 0.001) in affected tissues than in non‐affected tissues. Expression of CircCDR1as and FIH‐1 were negatively associated with miR‐135b in affected tissues (CircCDR1as with miR‐135b: r = −0.506, P < 0.001; FIH‐1 with miR‐135b r = −0.510, P < 0.001). Total blood tubule density was increased when CircCDR1as was silenced compared with NC (P < 0.01 vs. NC). The number of migrated BMECs were significantly increased in CircCDR1as silencing group compared with NC group (P < 0.05 vs. NC). In addition, CircCDR1as plasmids transfection increased the protein expressions of FIH‐1 (P < 0.05 vs. NC) and reduced the HIF‐1α as well as VEGF expression compared with NC group (P < 0.05 vs. NC). FISH, RNA pull down, RIP, and luciferase assay identified that FIH‐1 was a target of miR‐135b and could be modulated by CircCDR1as.ConclusionCircCDR1as decreases angiogenesis and proliferation of BMECs by sponging miR‐135b and upregulate FIH‐1.     

Comparison of Clinical and Radiological Outcomes Between Upper Fibular Curvature and Non‐Curvature with Medial Knee Osteoarthritis Following Proximal Fibular Osteotomy: A Retrospective Cohort Study with Minimum 2‐Year Follow‐up

ObjectiveTo evaluate and compare the clinical and radiographic outcomes of proximal fibular osteotomy (PFO) in treating medial knee osteoarthritis (KOA) patients with upper fibular curvature and non‐curvature.MethodsA retrospective cohort study was performed. From January 2016 to January 2017, a total of 51 patients (nine males and 42 females) at a mean age of 63.7 years (range 48–79 years) with medial KOA who underwent PFO procedure at the Third Hospital of Hebei Medical University were included in the study. The patients were divided into the two groups, namely curvature group (28 patients, six males and 22 females, aged 62.6 ± 7.7 years) and non‐curvature group (23 patients, three males and 20 females, aged 64.5 ± 7.6 years). Perioperative parameters and Kellgren‐Lawrence classification were recorded and analyzed in the two groups, respectively. All patients were followed up at 1, 3, 6, and 12 months at the first year of post‐operation, and then every 6 months from the second year of post‐operation. A telephone survey with standard questionnaire survey, including Visual Analog Scale (VAS) score and Hospital for Special Surgery (HSS) scoring system, was used to evaluate postoperative clinical outcomes. Radiological results were assessed using the femorotibial angle (FTA), hip‐knee‐ankle angle (HKA), and settlement value of medial tibial platform (MTP) in the two groups.ResultsThe average follow‐up periods of the curvature group and the non‐curvature group were 34.8 ± 6.1 and 33.9 ± 5.4 months, respectively. There were no significant differences between the two groups of demographic data in terms of number of patients, age, body mass index (BMI), gender, KOA side, and Kellgren‐Lawrence classification (P > 0.05). The VAS scores of the curvature group and non‐curvature group were (3.53 ± 1.62 vs 3.68 ± 1.43 at 1 month, 3.46 ± 0.79 vs 3.57 ± 0.66 at 3 months, and 2.43 ± 0.88 vs 2.83 ± 0.94 at 6 months, both P > 0.05), while significant differences were found from 12 months post‐operation (1.54 ± 0.72 vs 2.03 ± 0.85 at 12 months, and 1.04 ± 0.69 vs 1.74 ± 0.75 at 24 months, both P < 0.05). The HSS scores of the curvature group and non‐curvature group were (79.67 ± 5.14 vs 78.25 ± 6.37 at 1 month, 84.65 ± 3.76 vs 83.18 ± 3.64 at 3 months, and 86.27 ± 3.13 vs 85.49 ± 3.25 at 6 months, both P > 0.05), while significant differences were found from 12 months post‐operation (90.64 ± 4.32 vs 87.71 ± 5.63 at 12 months, and 92.93 ± 2.07 vs 90.06 ± 2.08 at 24 months, both P < 0.05). In addition, the FTA and settlement value of the curvature group were lower than the non‐curvature group (177.18 ± 1.52 vs 178.35 ± 1.86, and 5.29 ± 1.74 vs 6.49 ± 2.09, both P < 0.05) while the HKA were higher than the non‐curvature group (175.32 ± 2.34 vs 173.83 ± 2.64, P < 0.05) at the final follow‐up.ConclusionsMedial KOA patients with upper fibular curvature is an optimal surgical indication for PFO surgery, with the advantages of pain relief, better functional recovery, and alignment correction.     

Original Designed Uniportal‐Bichannel Spinal Endoscopic System (UBiSES) for Foraminoplasty in Percutaneous Endoscopic Transforaminal Discectomy

ObjectiveThe study introduced uniportal‐bichannel spinal endoscopic system (UBiSES) and explored the feasibility of applying UBiSES to conduct lumbar foraminoplasty in percutaneous endoscopic transforaminal discectomy (PETD).MethodsThis is a cohort study. 36 patients confirmed as L5/S1 lumbar disc herniation (LDH) in our hospital from March, 2019 to November, 2019 were enrolled. 36 patients were divided into two groups named the UBiSES group (n = 18, male: female = 8:10) and the TESSYS group (n = 18, male: female = 10:8). The average age of the UBiSES group and the TESSYS group were 40.94 ± 12.39 years old and 39.78 ± 13.02 years old respectively. PETD via uniportal‐bichannel foraminoplasty assisted by UBiSES was adopted on the UBiSES group while PETD via conventional foraminoplasty was performed on the TESSYS group. One experienced surgeon with more than 4000 cases of lumbar surgery performed PETD on all patients. The demographic data, the duration of working cannula placement (minutes), decompression time (minutes), radiation exposure time (seconds), complications, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores and modified MacNab criteria were recorded and analyzed. The magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to evaluate the radiographic improvement.ResultsPETD via lumbar foraminoplasty was successfully performed in all cases. The follow‐up points were 3 months, 6 months, and 12 months. The average follow‐up period of all patients was 15.78 ± 2.29 months. There was no statistic difference in age (P = 0.81), sex (P = 0.51) and follow‐up (P = 0.14) between two groups. The duration of working cannula placement was 19.08 ± 2.30 min in the UBiSES group and 24.90 ± 4.71 min in the TESSYS group and there was significant difference between two groups (P < 0.05). There was no statistic difference in decompression time between the UBiSES group (44.18 ± 5.70 min) and the TESSYS group (47.46 ± 5.96 min) (P = 1.70). The radiation exposure time was 28.00 ± 4.70 s in the UBiSES group and 40.50 ± 5.73 s in the TESSYS group respectively, and has significant difference between two groups (P < 0.05). Furthermore, there was significant different in the duration of working cannula placement and radiation exposure time in male or female between the UBiSES group and the TESSYS group (P < 0.05). For male or female, no difference observed in decompression time and follow‐up period between two groups. Postoperative VAS of low back and leg at every follow‐up point (1 day, 3 months, 6 months, 12 months) was improved significantly in both groups compared with their preoperative VAS (P < 0.05). The postoperative ODI (3 months, 6 months, 12 months) has decreased significantly in both the UBiSES group and the TESSYS group compared with their preoperative ODI (P < 0.05). 94.44% patients received an excellent or good recovery in the UBiSES group and 88.89% for the TESSYS group. There was no poor result reported in both groups. The radiographic images showed satisfactory foraminoplasty and sufficient decompression of nerve in both groups. No postoperative complications were observed during follow‐ups in the UBiSES group. Two patients in the TESSYS group experienced postoperative dysesthesia and the symptom was disappeared in 5 days and 7 days respectively with dexamethasone and neurotrophic drugs treatment.ConclusionsThe original designed UBiSES could effectively and safely enlarge the foramen with an extensive surgical view and space under full‐time and real‐time visualization and get satisfactory efficacy.     

Comparison of Tri‐Lock Bone Preservation Stem and the Conventional Standard Corail Stem in Primary Total Hip Arthroplasty

ObjectiveTo compare the clinical and radiographic outcomes between the Tri‐Lock Bone Preservation Stem (BPS) and the conventional standard Corail stem in primary total hip arthroplasty (THA).MethodsFrom March 2012 to May 2014, we retrospectively reviewed 84 patients (104 hips) who received Tri‐Lock (BPS) and 84 patients (115 hips) who received conventional standard Corail stem in THA. Their mean ages were 53.12 ± 2.32 years and 52.00 ± 2.11 years, respectively. The clinical outcomes were assessed by Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Pain Visual Analogue Scale (VAS) and Harris Hip Score (HHS). The radiological outcomes were evaluated by the radiological examination. Accordingly, Intraoperative and postoperative complications were observed as well.ResultsThe mean follow‐up time was 48.23 ± 2.91 months in the Tri‐Lock (BPS) group and 49.11 ± 2.11 months in the Corail group, respectively. The bleeding volumes in two groups were comparable (169.22 ± 58.11 mL vs 179.30 ± 59.14 mL, P = 0.003), with more bleeding volume in Corail group patients, while no statistically significance with respect to operation time was observed (65.41 ± 6.24 min vs 63.99 ± 6.33 min, P = 0.567). The rates of intraoperative fracture was 8% for the Corail group while 1% for the Tri‐Lock (BPS) group (8% vs 1%, P = 0.030). At final follow‐up, no statistical differences in regard to HHS, WOMAC, and Pain VAS were revealed between the two groups (P > 0.05). The rate of thigh pain was higher in Corail group than in Tri‐lock (BPS) group (5% vs 0%, P = 0.043). However, incidence of stress shielding in grade 1 was higher in Tri‐Lock (BPS) than in the Corail group (76% vs 23%, P < 0.01), while those in grade 2 and 3 were lower compared to the Corail stem (15% vs 28%, P < 0.01; 9% vs 16%, P = 0.008, respectively). Intriguingly, other assessments in relation to radiographic outcomes and postoperative complications were not comparable between the two groups. The Kaplan–Meier survival rate (revision surgery performed for any reason was defined as the end point) was similar between the two groups (P = 0.57), with 98.8% (95% confidence interval, 92.3%–100%) in Tri‐lock (BPS) group and 97.6% (95% confidence interval, 94.6%–100%) in Corail group.ConclusionsThe Tri‐Lock (BPS) has similar clinic performances compared to the Corail stem. Furthermore, the Tri‐lock (BPS) stem has some advantages in achieving lower incidence of thigh pain, stress shielding and intra‐operative fracture. Therefore, we recommend the Tri‐lock (BPS) stem as a good alternative in primary total hip arthroplasty, especially taking into account patient factors, including bone deficiency and convenience of extraction of the stem in hip revision.     

Comprehensive Interventions Including Vitamin D Effectively Reduce the Risk of Falls in Elderly Osteoporotic Patients

ObjectiveTo evaluate the effects of different intervention measures to prevent falls in elderly osteoporotic patients.MethodsA randomized controlled trial was conducted in our outpatient ward from August 2014 to September 2015. A total of 420 patients over 60 years of age were assigned to four groups. NA VitD group took 800 mg calcium and 800 IU non‐active vitamin D. P‐NA VitD group took 800 mg calcium, 800 IU non‐active vitamin D, and received physical exercise. A VitD group took 800 mg calcium and 0.5 μg active vitamin D. P‐A VitD took 800 mg calcium, 0.5 μg active vitamin D, and received physical exercise. Physical exercise includes guidance in improving muscle strength and balance ability. Short physical performance battery (SPPB), grip strength, modified falls efficacy scale (MFES), blood calcium, and 25‐hydroxyl vitamin D were measured before interventions and at 3, 6, and 12 months after interventions. Bone mineral density (BMD) was detected before interventions and at 12 months after interventions. The incidence of falls and fractures, adverse events, and drug reactions were recorded for 12 months.ResultsA total of 420 patients were allocated in the four groups: 98 cases into the NA VitD group (11 males, 87 females), 97 cases into the P‐NA VitD group (13 males, 84 females), 99 cases in the A VitD group (15 males, 84 females), and 98 cases into the P‐A VitD group (11 males, 87 females). At 6 months after interventions, the SPPB of A VitD group significantly increased from 6.9 ± 1.9 to 8.0 ± 2.4 (P < 0.05), and the SPPB of A VitD group significantly increased from 7.2 ± 2.1 to 8.6 ± 1.7 (P < 0.05). At 6 months after interventions, MFES of P‐NA VitD group 7.0 ± 1.6 to 7.6 ± 1.6 (P < 0.05), and MFES of P‐A VitD group significantly increased from 6.7 ± 1.6 to 7.5 ± 1.6 (P < 0.05). At 12 months after interventions, SPPB of all groups, grip strength, and MFES of P‐NA VitD group, A VitD group, P‐A VitD group were significantly improved (P < 0.05). The BMD of lumbar vertebrae of A VitD group significantly increased from 0.742 ± 0.042 to 0.776 ± 0.039, and P‐A VitD group significantly increased from 0.743 ± 0.048 to 0.783 ± 0.042 (P < 0.05). No serious adverse events occurred during the 12 months of follow‐up.ConclusionActive vitamin D is better than non‐active vitamin D to improve physical ability and the BMD of lumbar vertebrae and reduce the risk of falls.     

Analysis of Combined Indicators for Risk of Osteoporotic Hip Fracture in Elderly Women

ObjectiveTo compare the accuracy of combined independent risk factors in assessing the risk of hip fractures in elderly women.MethodsNinety elderly females who sustained hip fractures (including femoral neck fractures and intertrochanteric fractures) and 110 female outpatients without a hip fracture were included in our cross‐sectional study from 24 November 2017 to 20 May 2019. The age of subjects in the present study was ≥65 years, with the mean age of 78.73 ± 7.77 and 78.09 ± 5.03 years for women with and without elderly hip fractures, respectively. Bone mineral density (BMD), Beta‐carboxy terminal telopeptide (β‐CTX), N‐terminal/mid region (N‐MID), and 25(OH)D levels were analyzed. A novel evaluation model was established to evaluate combined indicators in assessing hip fractures in elderly women.ResultsCompared with the control group, taller height (155.68 ± 6.40 vs 150.97 ± 6.23, P < 0.01), higher levels of β‐CTX (525.91 ± 307.38 vs 330.94 ± 289.71, P < 0.01), and lower levels of total hip BMD (0.662 ± 0.117 vs 0.699 ± 0.111, P = 0.022), femoral neck BMD (0.598 ± 0.106 vs 0.637 ± 0.100, P = 0.009), and 25(OH)D (15.67 ± 7.23 vs 29.53 ± 10.57, P < 0.01) were found in the facture group. After adjustment for confounding factors, logistic regression analysis revealed that 25(OH)D (adjusted OR 0.837 [95% CI 0.790–0.886]; P < 0.01), femoral neck BMD (adjusted OR 0.009 [95% CI 0.000–0.969]; P = 0.048) and height (adjusted OR 1.207 [95% CI 1.116–1.306]; P < 0.01) remained risk factors for hip fractures in elderly women. Then a model including independent risk factors was established. A DeLong test showed the area under the receiver operator characteristic (ROC) (Area under the curve [AUC]) of 25(OH)D was significantly greater than that for femoral neck BMD (P < 0.01) and height (P < 0.01). The AUC of model including 25(OH)D and height was significantly greater than that of other combinations (P < 0.01).Conclusion25(OH)D, femoral neck BMD and height were associated with the occurrence of hip fractures in elderly women even after adjustment for confounding factors, and a model including 25(OH)D and height could provide better associated power than other combinations in the assessment of elderly hip fractures.