There has been increasing application of autologous costal chondral/osteochondral transplantation (ACCT/ACOT) and costa-derived chondrocyte implantation (ACCI) for articular cartilage repair over the past three decades. This review presents the major evidence on the properties of costal cartilage and bone and their qualifications as grafts for articular cartilage repair, the major clinical applications, and the risks and strategies for costal chondral/osteochondral graft(s) harvest. First, costal cartilage has many specific properties that help restore the articular surface. Costa, which can provide abundant cartilage and cylindrical corticocancellous bone, preserves permanent chondrocyte and is the largest source of hyaline cartilage. Second, in the past three decades, autologous costal cartilage-derived grafts, including cartilage, osteochondral graft(s), and chondrocyte, have expanded their indications in trauma and orthopaedic therapy from small to large joints, from the upper to lower limbs, and from non-weight-bearing to weight-bearing joints. Third, the rate of donor-site complications of ACCT or ACOT is low, acceptable, and controllable, and some skills and accumulated experience can help reduce the risks of ACCT and ACOT. Costal cartilage-derived autografting is a promising technique and could be an ideal option for articular chondral lesions with or without subchondral cysts. More high-quality clinical studies are urgently needed to help us further understand the clinical value of such technologies.
Osteoarthritis (OA) is the most common chronic degenerative joint disease in middle-aged and elderly people, characterized by joint pain and dysfunction. Macrophages are key players in OA pathology, and their activation state has been studied extensively. Various studies have suggested that macrophages might respond to stimuli in their microenvironment by changing their phenotypes to pro-inflammatory or anti-inflammatory phenotypes, which is called macrophage polarization. Macrophages accumulate and become polarized (M1 or M2) in many tissues, such as synovium, adipose tissue, bone marrow, and bone mesenchymal tissues in joints, while resident macrophages as well as other stromal cells, including fibroblasts, chondrocytes, and osteoblasts, form the joint and function as an integrated unit. In this study, we focus exclusively on synovial macrophages, adipose tissue macrophages, and osteoclasts, to investigate their roles in the development of OA. We review recent key findings related to macrophage polarization and OA, including pathogenesis, molecular pathways, and therapeutics. We summarize several signaling pathways in macrophage reprogramming related to OA, including NF-κB, MAPK, TGF-β, JAK/STAT, PI3K/Akt/mTOR, and NLRP3. Of note, despite the increasing availability of treatments for osteoarthritis, like intra-articular injections, surgery, and cellular therapy, the demand for more effective clinical therapies has remained steady. Therefore, we also describe the current prospective therapeutic methods that deem macrophage polarization to be a therapeutic target, including physical stimulus, chemical compounds, and biological molecules, to enhance cartilage repair and alleviate the progression of OA.
Objective: Clinical and radiographic degenerative spondylolisthesis (CARDS) classification was proposed to differentiate homogenous lumbar degenerative spondylolisthesis (LDS) subgroups. The sitting radiograph exhibited lumbar malalignment with maximum lumbar kyphosis, intervertebral kyphosis, and spondylolisthesis.This study aimed to assess the sitting radiograph for distribution of clinical and radiographic degenerative spondylolisthesis classification, and to elucidate its significance for exhibiting kyphotic alignment (CARDS type D) and segmental instability.
Methods: A cohort of 101 patients with symptomatic lumbar degenerative spondylolisthesis (LDS) between September 2018 and December 2020 were recruited. The distribution and relibility of CARDS classification with or without sitting radiograph was assessed. The translational and angular range of motion and segmental instability was also evaluated. Univariate analysis of variance was used for multiple groups, and the least significant difference for two groups. Kappa consistency test of intrarater and interrater was evaluated for CARDS classification with or without sitting radiograph. Chi-square test was used to compare paried categorical data.
Results: Utility of sitting radiographs for CARDS classification revealed higher percentage of type D than that without the sitting radiograph (p < 0.001). The sitting radiograph revealed a larger slip distance than the flexion radiograph (p = 0.003), as well as a lower slip angle than flexion radiograph (p < 0.001). The sitting-supine modality demonstrated the largest translational range of motion compared to the sitting-extension (p < 0.001) and flexion-extension modalities (p < 0.001). The sitting-supine modality showed larger angular range of motion than the flexion-extension modality (p < 0.001). The percentage of flexion, extension, upright, supine, and sitting radiograph to identify translational instability was higher than that without sitting radiograph (p < 0.001), as well as taking angular motion ≥10° as an additional criterion for segmental instability (p < 0.001).
Conclusion: The CARDS classification was reliable for LDS. The sitting radiograph showed maximal slip distance and kyphotic slip angle. Application of the sitting radiograph was necessary for evaluating segmental instability and kyphotic alignment of LDS.
Objective: Cable-dragged reduction and cantilever beam internal fixation can provide promising results in the treatment of atlantoaxial dislocation or instability. However, bilateral atlantoaxial joints bone autografting has not been conducted in this technique. We aim to evaluate the safety and effectiveness of bilateral atlantoaxial joints bone autografting in posterior cable-dragged reduction and cantilever-beam internal fixation.
Methods: In this retrospective study, we included 14 patients with a minimum 24-month follow-up from December 2019 to September 2020. The granular bone harvested from the iliac crest was packed into the bilateral atlantoaxial joints of 14 patients in posterior cable-dragged reduction and cantilever-beam internal fixation. X-ray imaging and cervical computed tomography (CT) were performed during follow-up. The time required for bone fusion was recorded. The clinical outcomes were evaluated using the JOA scores, NDI, and VAS scores. Mann–Whitney U test, the chi-squared test, or the Fisher exact test were used to compare the two groups regarding patient characteristics, clinical outcomes, bone fusion rates, and cervical sagittal alignment.
Results: The operations were successfully performed in all patients without any intraoperative complications. The mean operation time was (169.64 ± 20.91) minutes, and the intraoperative blood loss was (130.71 ± 33.62) mL. All patients received satisfactory reductions and firm bony fusion at the final follow-up. The fusion rates were 64.29% in the atlantoaxial joints and 21.43% in post bone graft area at 3 months postoperatively, and a significant difference was observed (p = 0.022). Besides, the cervical sagittal alignment in all patients was well maintained in the last follow-up compared to preoperatively. Importantly, a complete bony fusion in the atlantoaxial joints was observed in all patients. Moreover, the JOA, NDI, and VAS scores had improved significantly at the last follow-up.
Conclusion: Bone autografting of the bilateral atlantoaxial joints is a safe and effective technique to increase bone fusion rates, shorten bone fusion time, and reduce complication rates when the cable-dragged reduction and cantilever beam internal fixation approach is used. Therefore, it is a cost-effective surgical procedure for treating patients with atlantoaxial dislocation or instability.
Objective: Endobutton technique could provide flexible coracoclavicular (CC) stabilization for acromioclavicular joint (ACJ) dislocation and achieved good clinical outcomes. However, the difficult part of this technique was placement of the Endobutton to the coracoid base. In this study, we designed an Endobutton installation device to place the Endobutton at the coracoid base. And we examined the clinical and radiographic outcomes of patients with acute Rockwood type III ACJ dislocation repaired with Endobutton using this device.
Methods: We designed an Endobutton installation device to place the Endobutton at the coracoid base to achieve CC stabilization. We retrospectively reviewed 42 patients with acute Rockwood type III ACJ dislocation who underwent CC stabilization with Endobuttons placed either using this novel device (group I, n = 19) or the traditional technique (CC stabilization without using special device, group II, n = 23) from January 2015 to April 2020. The two groups were compared regarding the operative time, intraoperative blood loss, and clinical and radiologic outcomes at final follow-up. The operation-related complications were also evaluated. The Student's t test and the Mann–Whitney U-test were used to compare differences in continuous variables. Differences in categorical variables were assessed with either the Pearson's chi-squared test or Fisher's exact test.
Results: Forty-two patients were clinically followed up for a minimum of 12 months. Compared with group II, group I had a significantly shorter mean operative time (56.05 ± 7.82 min vs. 65.87 ± 7.43 min, p < 0.01) and significantly lesser mean intraoperative blood loss (67.89 ± 14.75 mL vs. 94.78 ± 25.01 mL, p < 0.01). At final follow-up, there were no significant differences between the two groups in the visual analog scale score for pain, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand score, and postoperative CC distance of the affected side. Loss of reduction occurred in four patients in group I and three patients in group II (p = 0.68); there were no other operation-related complications in either group.
Conclusions: The Endobutton installation device makes placement of the Endobutton at the coracoid base easier and achieves satisfactory clinical and radiologic outcomes without additional complications in acute Rockwood type III ACJ dislocation.
Objective: Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients.
Methods: We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months.
Results: The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively.
Conclusion: Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.
Objectives: Osteoporotic vertebral fractures (OVFs) are a critical public health concern requiring urgent attention, and severe OVFs impose substantial health and economic burdens on patients and society. Analysis of the risk factors for severe OVF is imperative to actively prevent the occurrence of this degenerative disorder. This study aimed to investigate the risk factors associated with the severity of OVF, with a specific focus on changes in the paraspinal muscles.
Methods: A total of 281 patients with a first-time single-level acute OVF between January 2016 and January 2023 were enrolled in the study. Clinical and radiological data were collected and analyzed. The cross-sectional area (CSA) and degree of fatty infiltration (FI) of the paraspinal muscles, including the multifidus muscles (MFMs), erector spinae muscles (ESMs), and psoas major muscles (PSMs), were measured by magnetic resonance imaging (MRI) of the L4/5 intervertebral discs. According to the classification system of osteoporotic fractures (OF classification) and recommended treatment plan, OVFs were divided into a low-grade OF group and a high-grade OF group. Univariate and multivariate logistic regression analyse s were performed to identify risk factors associated with the severity of OVF.
Results: Ninety-eight patients were included in the low-grade OF group, and 183 patients were included in the high-grade OF group. Univariate analysis revealed a significantly higher incidence of a high degree of FI of MFMs (OR = 1.71, p = 0.002) and ESMs (OR = 1.56, p = 0.021) in the high-grade OF group. Further multivariate logistic regression analysis demonstrated that a high degree of FI of the MFMs (OR = 1.71, p = 0.002) is an independent risk factor for the severity of OVF.
Conclusion: A high degree of FI of the MFMs was identified as an independent risk factor for the severity of OVF. Decreasing the degree of FI in the MFMs might lower the incidence of the severity of OVF, potentially reducing the necessity for surgical intervention in OVF patients.
Objectives: There is no consensus on the treatment of moderate-to-severe rigid scoliosis. Anterior release and three-column osteotomy are excessively traumatic, whereas posterior column osteotomy (PCO) alone results in poor outcomes. An emerging surgical technique, posterior intervertebral release (PR), can release the rigid spine from the posterior approach. This study was performed to compare the multi-segment apical convex PR combined with PCO and PCO alone in patients with moderate-to-severe rigid scoliosis.
Methods: From June 2021 to June 2022, this prospective study of moderate-to-severe (Cobb: 70–90°) rigid scoliosis (flexibility of main curve <25%) involved two groups defined by surgical procedure: the PR group, the patients undergoing PR combined with PCO; and the PCO group, the patients undergoing PCO alone. Follow-up was at least 12 months. Radiographic results mainly included main curve Cobb, correction of per PR/PCO segment, apical vertebra rotation (AVR) and apical vertebra translation (AVT). Demographics, surgical data, complications were also recorded. Student's independent samples t test and Pearson's chi-square test were used to compare the differences between groups.
Results: Forty patients with an average age of 16.65 years were included (PR group, n = 20; PCO group, n = 20). The main curves averaged 77.56° ± 5.86° versus 78.02° ± 5.72° preoperatively and 20.07° ± 6.73° versus 33.58° ± 5.76° (p < 0.001) at the last follow-up in the PR and PCO groups, respectively. The mean correction rates were 74.30% and 56.84%, respectively (p < 0.001). The average coronal curve correction was 13.49° per release segment, which was significantly higher than the PCO correction of 6.20° (p < 0.001). The correction of apical vertebra rotation and translation in the main thoracic curve was significantly better in the PR group than in the PCO group (p < 0.05). Several minor complications in the two groups improved after conservative treatment.
Conclusion: The multi-segment apical convex PR combined with PCO offers more advantages than PCO alone in the treatment of patients with moderate-to-severe rigid scoliosis. Owing to its excellent corrective effect and few complications, this is a high benefit–risk ratio surgical strategy for rigid scoliosis.
Objective: Osteonecrosis of the femoral head (ONFH) is a disease that occurs frequently in young and middle-aged people. Because of its high disability rate, it affects the ability to work, so the early treatment of this disease is particularly important. This retrospective study aimed to evaluate the clinical efficacy of hip arthroscopy combined with multiple small-diameter fan-shaped low-speed drilling decompression (MSFLD) in treating early-mid stage ONFH (ARCO II-IIIA) compared to MSFLD, with at least 10-year follow-up.
Methods: A total of 234 patients who underwent hip arthroscopy and MSFLD for ONFH from 1998 to 2012 were analyzed retrospectively. This study enrolled patients between 18 and 60 years old with ARCO stage II-III A, diagnosed clinically and through imaging, in accordance with the 2021 guidelines for the treatment of ONFH. Clinical data, including demographics, operation mode, BMI, pre- and postoperative Harris score, and femoral head survival rate, were collected. Patients were divided into hip arthroscopy + MSFLD and MSFLD groups based on the operation mode. The t-test was used to compare the postoperative efficacy, Harris scores, and survival rates of the femoral head between the two groups.
Results: Among the 234 patients, 160 cases were followed up, including 92 cases in the hip arthroscopy + MSFLD group and 68 cases in MSFLD group, the follow-up rate was 68.38%, and the follow-up time was (10–22)14.11 ± 3.06 years. The Harris score (80.65 ± 6.29) in the hip arthroscopy + MSFLD group was significantly higher than that in the MSFLD group (p = 0.00), and the survival rate of femoral head (5-year survival rate was 84.78%, 10-year survival rate was 23.91%) was also higher than that in the MSFLD group (5-year survival rate was 63.24%, 10-year survival rate was 8.82%). The 5-year and 10-year survival rates of patients with ARCO II were 82.11% and 28.42%, which were better than 54% and 33% for ARCO III A. The femur head survival rate of alcoholic ONFH (5-year survival rate 61.54%, 10-year survival rate 9.23%) was significantly higher than that of other types of ONFH.
Conclusion: Clinical follow-up of at least 10 years suggests that hip arthroscopy combined with MSFLD is an effective treatment for early-mid stage ONFH, with good clinical effect and high survival rate of femoral head.
Objective: Re-resection of spinal giant cell tumors is an exceedingly difficult procedure. Moreover, the prognosis of patients with en bloc resection or intralesional excision for re-resection has rarely been reported. This study aimed to compare the prognostic value of en bloc resection with that of intralesional excision in patients undergoing re-resection for giant cell tumors of the spine.
Methods: This retrospective analysis evaluated patients who underwent revision surgeries for relapse of giant cell tumors of the spine at our center between January 2005 and January 2021. Local progression-free survival represents the duration between en bloc resection or intralesional excision and tumor recurrence. Neurological recovery, survival rates, local control, and complications were evaluated. The Kaplan–Meier estimator was used for survival analysis.
Results: A total of 22 patients (nine men and 13 women) with a mean age of 34.1 (range 19–63) years were included. Significant statistical differences were found in the local tumor recurrence rate between patients treated with en bloc resection and those treated with intralesional excision (p < 0.05). The 5- and 10-year local progression-free survival rates were both 90% in the en bloc resection group, while in the intralesional excision group, the 5-year local progression-free survival rate was 80% with a 10-year rate of 45.7%. The en bloc resection group had a lower local tumor recurrence rate than that of the intralesional excision group (p < 0.05), but the former had a higher rate of complications (p = 0.015).
Conclusions: This study revealed a low local recurrence rate in patients who underwent en bloc resection for giant cell tumors, while the perioperative complication rate was high.
Objective: The floating calcified tissue in floating calcified lumbar disc herniation (FCLDH) is hard and often adheres to the dura mater, which can easily cause nerve root damage during surgery, making the operation challenging. We proposed the classification of FCLDH and a new technique for removing floating calcified tissue and reported the clinical efficacy and safety of this new technique in clinical practice.
Methods: From January 2019 to October 2021, 24 patients (13 males and 11 females, 46.4 ± 7.72 years) with L5-S1 floating calcified lumbar disc herniation were treated with percutaneous endoscopic interlaminar discectomy (PEID). According to FCLDH classification, a total of Type Ia: nine cases, Type Ib: five cases, Type IIa: four cases, and Type IIa: six cases were included. The visual analogue scale (VAS) and Oswestry disability index (ODI) were recorded pre-operatively and 3 days postoperatively, 6 months postoperatively, and at the last follow-up. The postoperative curative effect was evaluated according to the modified MacNab criteria. Computed tomography (CT) and magnetic resonance imaging (MRI) of the lumbar spine were performed 3 days after surgery to evaluate the efficacy of the surgery.
Results: All patients successfully underwent PEID. The VAS and ODI scores at 3 days postoperatively, 6 months postoperatively, and at the last follow-up were significantly improved and statistically significant compared to those of the preoperative period (p < 0.05). All the patients were followed up for 12–24 months (mean, 16.6 ± 4.6 months). At the last follow-up, according to the modified MacNab criteria, 15 cases were excellent, eight were good, and one was fair. The combined excellent and good rate was 95.83% (23/24). Postoperative review revealed that all floating calcified tissues were effectively removed and the nerve roots were adequately decompressed without complications such as cerebrospinal fluid leakage and lumbar spine infection.
Conclusion: The classification of FCLDH we proposed can well guide the selection of surgical plans. PEID combined with floating calcified tissue removal technology has good efficacy in the treatment of L5-S1 FCLDH, ensuring accurate removal of calcified tissue, reducing complications and improving the quality of life of affected individuals.
Objective: Patients who undergo a biplanar ascending medial open-wedge high tibial osteotomy with an excessive correction angle might experience patella infera and even knee pain after surgery. The purpose of this study was to identify the cut-off points for the degree of knee varus correction of open-wedge high tibial osteotomy, which is related to the symptomatic patellar position change.
Methods: This retrospective study included 124 patients (mean age 61.69 ± 6.28 years; 78 women, 46 men) with varying degrees of varus knee osteoarthritis. All patients had undergone standard biplanar medial open-wedge high tibial osteotomy. They were divided into nine groups according to the change in hip–knee–ankle angle. Plain radiographs and three-dimensional CT images were obtained preoperatively and 18 months postoperatively. Patellar height was assessed using the Caton–Deschamps index, the Insall–Salvati index, and the Blackburne–Peel index. The patellofemoral index and patellar tilt were used to evaluate the degree of horizontal displacement of the patella. The varus correction, medial–proximal tibial angles, joint line convergence angles, and hip–knee–ankle angles were also measured. The subjective score was evaluated using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC).
Results: There were significant changes in patella indexes in each group after surgery, among which there was no significant difference in patellar height changes for Groups A to F (p > 0.05), which were significantly lower than those in Group G, H, and I (p < 0.001). The patellar tilt and patellofemoral index also followed the same trend. The improvement in WOMAC scores for Groups G, H, and I was also significantly less for Groups A to F (p < 0.001).
Conclusion: The patellar height, patellar tilt, and patellofemoral index all changed significantly in parallel with increasing degrees of osteotomy correction. The cut-off points for correction angle are 12.5° to 13.4°. When the correction angle is larger than this range, the patellar position can be significantly affected. Postoperative patellofemoral joint pain may be related to the changes in patella position.
Objective: Three-dimensional (3D)-CT data is currently insufficient for classifying femoral trochanter fractures. Fracture classification based on fracture stability analysis is helpful to evaluate the prognosis of patients after internal fixation. Currently, there is a lack of fracture classification methods based on 3D-CT images and fracture stability analysis. The aim of this study was to propose a new six-part classification method for intertrochanteric fractures of femur based on 3D-CT images and fracture stability analysis to improve the diagnosis rate of unstable fractures.
Method: From January 2009 to December 2019, 320 patients receiving intramedullary nail surgery for femoral intertrochanteric fractures at Chengdu University's Affiliated Hospital were studied retrospectively. AO and six-part classifications were undertaken according to the 3D-CT image data of the patients, and the stability rates of two classifications were compared. According to the six-part classification stability criteria, the patients were divided into a stable and an unstable fracture group. The perioperative and follow-up indicators of the two groups were statistically analyzed, and the six-part classification's inter-observer and internal reliability was examined.
Results: There were 107 men and 213 females women the 320 patients, with an average age of 79.32 ± 11.26 years and an osteoporosis rate of 55.63% (178/320). The fracture stability rate of 39.69% (127/320) was studied using a six-part classification method. The AO classification fracture stability rate was 42.50% (136/320), with no significant difference (χ2 = 0.523, p = 0.470 > 0.05). There is no statistically significant difference between the two classification techniques in the examination of fracture stability (McNemer difference test p = 0.306 > 0.05; Kappa consistency test p < 0.001). According to the six-part classification, fracture stability and instability group were divided into two groups. The following indicators were compared between the two groups: The surgery time (p = 0.280), fracture reduction quality (p = 0.062); function independent measurement (p = 0.075); timed up and go test (TUG) (p = 0.191), and Parker-Palmer score (p = 0.146). Were as compared according to the six-part classification of stable and unstable fracture groups. Perioperative blood loss (p < 0.001), the Harris score excellent and good rate (p = 0.043), fracture healing time (p < 0.001), and the entire weight-bearing duration (p = 0.002) were statistically significant. The difference in femoral head height (FHH) (p = 0.046), the change in femoral neck shaft angle (p = 0.003), the change in medial cephalic nail length (p = 0.033), and the change in tip–apex distance (TAD) (p = 0.002) were statistically significant compared to the relevant markers of imaging stability. Fracture stability had a substantial influence on Harris ratings at 3, 6, and 12 months following surgery, according to repeated measures analysis of variance (F(1,126) = 32.604, p < 0.001). The effect of time on the Harris score was similarly significant (F(1.893,238.508) = 202.771, p < 0.001). The observer intra-observer inter-group correlation coefficient (ICC) value was 0.941 > 0.75, the inter-observer ICC value was 0.921 > 0.75, and the intra-observer and inter-observer reliability were both good.
Conclusion: The six-part classification of femoral intertrochanteric fractures based on 3D-CT images has broader guiding relevance for femoral intertrochanteric fracture stability analysis. Clinicians will find this classification simpler and more consistent than the AO classification.
Objective: Symptomatic venous thromboembolism (VTE) and prosthesis failure are the most serious complications after total knee arthroplasty (TKA). However, whether knee valgus deformity aggravates these complications has not been fully clarified. To study the difference between perioperative symptomatic VTE and prosthesis revision rate in patients with valgus knee osteoarthritis by comparing with patients undergoing TKA for varus deformity and analyze the reasons for revision. At the same time, the distribution and radiographic features of lower extremity deep venous thrombosis were recorded.
Methods: The data of patients who underwent TKA in two tertiary hospitals from January 2016 to December 2020 were retrospectively reviewed, and a total of 8917 patients were included. According to preoperative manifestations of knee malformations, all patients were divided into two groups: valgus group (n = 412) and varus group (n = 8505). Main indicators included the incidence of symptomatic VTE and prosthesis revision. Secondary outcomes included general information on operative time, Kellgren and Lawrence score, total hospital stay, and total costs. The patient data of the two groups were analyzed by Pearson chi-square test, Student t test, or Mann–Whitney U test. The revision was evaluated using Kaplan–Meier survival analysis.
Results: The proportion of valgus knees in TKA patients was 4.62% (412/8917). The incidence of VTE was 6.23‰ (53/8505) and 16.99‰ (7/412) in the varus and valgus groups, and the results were statistically different (p = 0.009). There was no significant difference in echogenicity, number of occluded vessels, and thrombus length between the valgus group (p = 0.102; p = 0.645; p = 0.684). Patients with valgus deformity had 12.14‰ (5/412) prosthesis revision, the incidence of varus deformity was 4.82‰ (41/8505), and the revision risk of valgus group was 2.5 times higher than varus group, and the results were statistically different (p = 0.043). The operation time and hospital stay in the valgus group were longer than those in the varus group, and the results were statistically different (p = 0.018; p < 0.001).
Conclusions: Valgus deformity increases risk of symptomatic VTE and prosthesis revision after TKA. These results have guiding significance for the prevention of complications after TKA in patients with valgus deformity.
Objective: The incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients.
Method: The clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty-four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot-assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24-week follow-up. Repeated-measures analysis of variance (ANOVA) and effect sizes were used as analysis methods.
Results: A total of 90 screws were implanted, 51 screws in the TiRobot-assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw-related complications or revision surgeries in any group. The Matta value of the TiRobot-assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot-assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot-assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow-up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow-up, with statistical significance (p < 0.001).
Conclusion: TiRobot-assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.
Objectives: The current clinical pulse lavage technique for flushing fresh osteochondral allografts (OCAs) to remove immunogenic elements from the subchondral bone is ineffective. This study aimed to identify the optimal method for removing immunogenic elements from OCAs.
Methods: We examined five methods for the physical removal of immunogenic elements from OCAs from the femoral condyle of porcine knees. We distributed the OCAs randomly into the following seven groups: (1) control, (2) saline, (3) ultrasound, (4) vortex vibration (VV), (5) low-pulse lavage (LPL), (6) high-pulse lavage (HPL), and (7) high-speed centrifugation (HSC). OCAs were evaluated using weight measurement, micro-computed tomography (micro-CT), macroscopic and histological evaluation, DNA quantification, and chondrocyte activity testing. Additionally, the subchondral bone was zoned to assess the bone marrow and nucleated cell contents. One-way ANOVA and paired two-tailed Student's t-test are used for statistical analysis.
Results: Histological evaluation and DNA quantification showed no significant reduction in marrow elements compared to the control group after the OCAs were treated with saline, ultrasound, or VV treatments; however, there was a significant reduction in marrow elements after LPL, HPL, and HSC treatments. Furthermore, HSC more effectively reduced the marrow elements of OCAs in the middle and deep zones compared with LPL (p < 0.0001) and HPL (p < 0.0001). Macroscopic evaluation revealed a significant reduction in blood, lipid, and marrow elements in the subchondral bone after HSC. Micro-CT, histological analyses, and chondrocyte viability results showed that HSC did not damage the subchondral bone and cartilage; however, LPL and HPL may damage the subchondral bone.
Conclusion: HSC may play an important role in decreasing immunogenicity and therefore potentially increasing the success of OCA transplantation.
Purpose: Multilevel cervical spondylotic myelopathy poses significant challenges in selecting optimal surgical approaches, warranting a comprehensive understanding of their biomechanical impacts. Given the lack of consensus regarding the most effective technique, this study aims to fill this critical knowledge gap by rigorously assessing and comparing the biomechanical properties of three distinct surgical interventions, including anterior controllable antedisplacement and fusion (ACAF), anterior cervical corpectomy decompression and fusion (ACCF), and anterior cervical discectomy and fusion (ACDF). The study offers pivotal insights to enhance treatment precision and patient outcomes.
Methods: The construction of the cervical spine model involved a detailed process using CT data, specialized software (Mimics, Geomagic Studio, and Hypermesh) and material properties obtained from prior studies. Surgical instruments were modeled (titanium mesh, anterior cervical plate, interbody cage, and self-tapping screws) to simulate three surgical approaches: ACAF, ACCF, and ACDF, each with specific procedures replicating clinical protocols. A 75-N follower load with 2 Nm was applied to simulate biomechanical effects.
Results: The range of motion decreased more after surgery for ACAF and ACDF than for ACCF, especially in flexion and lateral bending. ACCF have higher stress peaks in the fixation system than those of ACAF and ACDF, especially in flexion. The maximum von Mises stresses of the bone–screw interfaces at C3 of ACCF were higher than those of ACAF and ACDF. The maximum von Mises stresses of the bone–screw interfaces at C6 of ACDF were much higher than those of ACAF and ACCF. The maximum von Mises stresses of the grafts of ACCF and ACAF were much higher than those of ACDF. The maximum von Mises stresses of the endplate of ACCF were much higher than those of ACAF and ACDF.
Conclusion: The ACAF and ACDF models demonstrated superior cervical reconstruction stability over the ACCF model. ACAF exhibited lower risks of internal fixation failure and cage subsidence compared to ACCF, making it a promising approach. However, while ACAF revealed improved stability over ACCF, higher rates of subsidence and internal fixation failure persisted compared to ACDF, suggesting the need for further exploration of ACAF's long-term efficacy and potential improvements in clinical outcomes.
Objective: Osteonecrosis of the femoral head (ONFH) is a common orthopedic disease with a high disability rate. The clinical effect of BuShenHuoXue decoction (BSHX) for ONFH is satisfactory. We aimed to elucidate the potential angiogenic mechanisms of BSHX in a rat femoral osteonecrosis model and bone marrow mesenchymal stem cells (BMSCs).
Methods: With in vivo experiments, we established the steroid-induced osteonecrosis of the femoral head (SONFH) model using Sprague–Dawley (SD) rats (8-week-old). The rats were randomly divided into five group of 12 rats each and given the corresponding interventions: control, model (gavaged with 0.9% saline), BSHX low-, medium- and high-dose groups (0.132 3, 0.264 6, and 0.529 2 g/mL BSHX solution by gavage). After 12 weeks, haematoxylin and eosin (H&E) staining was preformed to evaluate rat osteonecrosis. the expression of angiogenic factors (CD31, VEGFA, KDR, VWF) in rat femoral head was detected by immunohistochemistry, qPCR and western blotting. In cell experiment, BMSCs were isolated and cultured in the femoral bone marrow cavity of 4-week-old SD rats. BMSCs were randomly divided into eight groups and intervened with different doses of BSHX-containing serum and glucocorticoids: control group (CG); BSHX low-, medium-, and high-dose groups (CG + 0.661 5, 1.323, and 2.646 g/kg BSHX gavage rat serum); dexamethasone (Dex) group; and Dex + BSHX low-, medium-, and high-dose groups (Dex + 0.661 5, 1.323, and 2.646 g/kg BSHX gavaged rat serum), the effects of BSHX-containing serum on the angiogenic capacity of BMSCs were examined by qPCR and Western blotting. A co-culture system of rat aortic endothelial cells (RAOECs) and BMSCs was then established. Migration and angiogenesis of RAOECs were observed using angiogenesis and transwell assay. Identification of potential targets of BSHX against ONFH was obtained using network pharmacology.
Results: BSHX upregulated the expression of CD31, VEGFA, KDR, and VWF in rat femoral head samples and BMSCs (p < 0.05, vs. control group or model group). Different concentrations of BSHX-containing serum significantly ameliorated the inhibition of CD31, VEGFA, KDR and VWF expression by high concentrations of Dex. BSHX-containing serum-induced BMSCs promoted the migration and angiogenesis of RAOECs, reversed to some extent the adverse effect of Dex on microangiogenesis in RAOECs, and increased the number of microangiogenic vessels. Furthermore, we identified VEGFA, COL1A1, COL3A1, and SPP1 as important targets of BSHX against ONFH.
Conclusion: BSHX upregulated the expression of angiogenic factors in the femoral head tissue of ONFH model rats and promoted the angiogenic capacity of rat RAOECs and BMSCs. This study provides an important basis for the use of BSHX for ONFH prevention and treatment.
Introduction: Patients with hemophilia (PWH) constantly suffer hemarthrosis, which leads to deformity of the hip joint. Therefore, PWH who are going to receive total hip arthroplasty (THA) should be exclusively treated before the surgery with careful measurement of their proximal femur. Hence, we conducted a retrospective study to explore the anatomical parameters of and differences in the proximal femur in hemophilic patients who underwent THA.
Methods: The retrospective study comprised data of adult patients who received total hip arthroplasty from 2020 to 2022 in the research center. Patients having a diagnosis of hemophilic arthritis and received THA were included in experimental group, and patients with hip arthritis or femoral head necrosis were taken as control group. Parameters including femoral offset, neck-shaft angle (NSA), medullary cavity of 20 mm above mid-lesser trochanter level (T+20), mid-lesser trochanter level (T), and 20 mm blow it (T−20), and canal flare index (CFI), femoral cortical index (FCI) were measured on X-ray and CT images with PACS by two independent doctors. Data was analyzed by SPSS 20. Kolmogorov–Smirnov test was used to test data normality. Student's t-test was performed between PWH and control group. p < 0.05 was considered statistically significant.
Results: Among the 94 hips, 39 (41.5%) were included in group hemophilia and 55(58.5%) in control group. The mean age of the patients was 49.36 ± 12.92 years. All cases were male patients. Data demonstrated significantly smaller femoral cortical index (FCI), femoral offset, medullary cavity of 20 mm above mid-lesser trochanter level, mid-lesser trochanter level, and 20 mm below it, and neck-shaft angle (NSA) was obviously larger in PWH than control group (p < 0.05). No significant difference was found in canal flare index (CFI).
Conclusion: Hemophilic patients undergoing THA were prone to longer and thinner proximal femur. Preoperative morphological analysis of femur is recommended.
Objective: Spinal endoscopy radiofrequency is a minimally invasive technique for lumbar disc herniation (LDH) and low back pain (LBP). However, recurring LDH/LBP following spinal endoscopy radiofrequency is a significant problem. Paravertebral musculature plays a crucial role in spine stability and motor function, and the purpose of the present study was to identify whether patients’ baseline lumbar muscular electrophysiological function could be a predictor of recurring LDH/LBP.
Methods: This was a prospective follow-up and case-control study focusing on elderly patients with LDH who were treated in our department between January 1, 2018, and October 31, 2021. The end of follow-up was recurring LBP, recurring LDH, death, missing to follow-up or 2 years postoperation. The surface electromyography test was performed before the endoscopy C-arm radiofrequency (ECRF) operation to detect the flexion–relaxation ratio (FRR) of the lumbar multifidus (FRRLM) and the longissimus erector spinae (FRRES), and the other baseline parameters included the general characteristics, the visual analogue scale, the Japanese Orthopaedic Association score, and the Oswestry Disability Index. Intergroup comparisons were performed by independent t-test and χ2-test, and further binary logistic regression analysis was performed.
Results: Fifty-four patients completed the 2-year follow-up and were retrospectively divided into a recurring LDH/LBP group (Group R) (n = 21) and a no recurring group (Group N) (n = 33) according to their clinical outcomes. FRRLM and FRRES in Group N were much higher than those in Group R (p < 0.001, p = 0.009). Logistic regression analysis showed that only the FRRLM (odds ratio [OR] = 0.123, p = 0.011) and FRRES (OR = 0.115, p = 0.036) were independent factors associated with the ECRF outcome.
Conclusions: Lumbar disc herniation patients’ baseline FRRLM and FRRES are independent outcome predictors of recurring LDH/LBP after ECRF. For every unit increase in baseline FRRLM, the risk of recurring LDH/LBP is decreased by 87.7%, and for every unit increase in baseline FRRES, the risk of recurring LDH/LBP is decreased by 88.5%.
Objective: Glucocorticoid (GC) overuse is strongly associated with steroid-induced osteonecrosis of the femoral head (SINFH). However, the underlying mechanism of SINFH remains unclear. This study aims to investigate the effect of dexamethasone (Dex)-induced oxidative stress on osteocyte apoptosis and the underlying mechanisms.
Methods: Ten patients with SINFH and 10 patients with developmental dysplasia of the hips (DDH) were enrolled in our study. Sixty rats were randomly assigned to the Control, Dex, Dex + N-Acetyl-L-cysteine (NAC), Dex + Dibenziodolium chloride (DPI), NAC, and DPI groups. Magnetic resonance imaging (MRI) was used to examine edema in the femoral head of rats. Histopathological staining was performed to assess osteonecrosis. Immunofluorescence staining with TUNEL and 8-OHdG was conducted to evaluate osteocyte apoptosis and oxidative damage. Immunohistochemical staining was carried out to detect the expression of NOX1, NOX2, and NOX4. Viability and apoptosis of MLO-Y4 cells were measured using the CCK-8 assay and TUNEL staining. 8-OHdG staining was conducted to detect oxidative stress. 2′,7′-Dichlorodihydrofluorescein diacetate (DCFH-DA) staining was performed to measure reactive oxygen species (ROS). The expression of NOX1, NOX2, and NOX4 in MLO-Y4 cells was analyzed by Western blotting. Multiple comparisons were performed using one-way analysis of variance (ANOVA).
Results: In patients and the rat model, hematoxylin–eosin (HE) staining revealed a significantly higher rate of empty lacunae in the SINFH group than in the DDH group. Immunofluorescence staining indicated a significant increase in TUNEL-positive cells and 8-OHdG-positive cells in the SINFH group compared to the DDH group. Immunohistochemical staining demonstrated a significant increase in the expression of NOX1, NOX2, and NOX4 proteins in SINFH patients compared to DDH patients. Moreover, immunohistochemical staining showed a significant increase in the proportion of NOX2-positive cells compared to the Control group in the femoral head of rats. In vitro, Dex significantly inhibited the viability of osteocyte cells and induced apoptosis. After Dex treatment, the intracellular ROS level increased. However, Dex treatment did not alter the expression of NOX proteins in vitro. Additionally, NAC and DPI inhibited the generation of intracellular ROS and partially alleviated osteocyte apoptosis in vivo and in vitro.
Conclusion: This study demonstrates that GC promotes apoptosis of osteocyte cells through ROS-induced oxidative stress. Furthermore, we found that the increased expression of NOXs induced by GC serves as an important source of ROS generation.
Background: Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint.
Operative Technique: A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension.
Conclusion: Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.
Objective: In clinical practice, noncontinuous two-segment spinal cord cervical spondylosis is a particular form of cervical degenerative disease. Traditional anterior open surgery frequently comes with severe trauma, risks, and debatable treatment options. This study aimed to describe for the first time a novel minimally invasive technique, namely, anterior full-endoscopic single-port double transcorporeal spinal cord decompression for the treatment of patients with noncontinuous two-segment cervical spondylotic myelopathy.
Method: From February 2020 to May 2021, five patients with noncontinuous two-segment cervical spondylotic myelopathy were treated with anterior full-endoscopic single-port double transcorporeal spinal cord decompression. Two bone channels were established by the trephine through the vertebral body oblique upward and downward to the herniated disc osteophyte complex, and the full-endoscopic system could decompress the spinal cord through the channels. All cases were followed up for over 2 years. The modified Japanese Orthopaedic Association (mJOA) score and visual analogue scale (VAS) score before and after operation and during follow-up were used to evaluate the clinical effectiveness. Radiological examinations, including CT and MRI, were utilized to evaluate the efficacy of spinal cord decompression and bone channel repair.
Results: All operations were successfully completed and the average operation time was 185 min, with no operation-related complications. Compared with the preoperative evaluation, the mJOA score and VAS score were improved at each time point after operation and follow-up. Postoperative CT and MRI scans showed that the intervertebral disc-osteophyte complex was removed through the vertebral bone passage, and the spinal cord was fully decompressed. After 24 months of follow-up, CT and MRI scans showed that the bone channel was almost repaired and healed.
Conclusion: Anterior full-endoscopic single-port double transcorporeal spinal cord decompression is an effective minimally invasive technique for noncontinuous two-segment cervical spondylosis. It provides precise and satisfactory spinal cord decompression under endoscopic visualization with minimum trauma.
For Crowe IV dysplasia, the clinical efficacy and surgical technique of subtrochanteric osteotomy (SO) within the direct anterior approach total hip arthroplasty (DAA-THA) was a subject of debate. This study aimed to describe the surgical technique and clinical outcomes in 11 cases of SO in DAA-THA and to summarize the relevant literature on this topic. Between June 2016 and June 2023, we retrospectively evaluated patients diagnosed with Crowe IV hip dysplasia at our institution. Criteria identified 11 patients who underwent SO during DAA-THA. Comprehensive data encompassing demographic information, radiological data, prosthetic implant type, and surgical intricacies were collected. In addition, an exhaustive review of existing case series literature was undertaken utilizing the PubMed databases. There were no revisions, deaths, dislocations, or infections. One hip (9.09%) had an intraoperative proximal split fracture, two hips (18.2%) had lower limb deep vein thrombosis, and one hip (9.09%) had symptoms of femoral nerve injury. Radiological data showed improved bilateral femoral offset, leg length discrepancy, and anatomical acetabular. During the mean follow-up of 2.18(1.06-2.46) years, patients demonstrated enhanced functional outcomes, with average changes of 25.2 in the Harris hip score and 47 in the WOMAC score. Reviewing the literature, most studies have favored S-ROM prostheses and transverse osteotomy techniques. Intraoperative fractures were notably frequent, with rates peaking at 25%. Nonunion and nerve injury were secondary common complications. SO via DAA-THA may offer satisfactory clinical and radiographic outcomes, but the literature review underscores the need for heightened awareness of intraoperative fracture risk. Proximal detachment of the vastus intermedius plays a pivotal role in SO exposure through the DAA.
Background: The repair and reconstruction of medial meniscus posterior root tears (MMPRTs) is an important issue in the field of orthopedic sports medicine. This study reports the first application of arthroscopic linear chain fixation for the treatment of MMPRTs.
Case presentation: A 78-year-old female patient presented with a 1.5-month history of right knee pain accompanied by a locked facet joint. The patient underwent surgery with the new linear chain fixation method. In this method, the suture and the loop part of the buckle-strap titanium plate were combined into a linear chain mechanical complex, and the tension of the posterior root stump was gradually increased by pulling on the two attachment lines at the external mouth of the tibial tunnel. The postoperative Lysholm score was 89, and the visual analogue scale score was 0.9, indicating a significant improvement in knee joint function. At the 7-month and 1-year post-surgery follow-up, physical and MRI examinations confirmed satisfactory healing of the MMPRTs.
Conclusion: This surgical approach offers several benefits, including a simplified instrumentation setup, preservation of natural anatomical structures, and reliable residual stump fixation. It has the potential for clinical implementation.
Background: Fibrodysplasia ossificans progressiva (FOP) is an extremely rare disease characterized by malformation of the bilateral great toes and progressive heterotopic ossification. The clinical features of FOP occur due to dysfunction of the bone morphogenetic protein (BMP) signaling pathway induced by the mutant activin A type I receptor/activin-like kinase-2 (ACVR1/ALK2) which contributes to the clinical features in FOP. Dysregulation of the BMP signaling pathway causes the development of osteochondroma. Poor awareness of the association between FOP and osteochondromas always results in misdiagnosis and unnecessary invasive operation.
Case Presentation: In this study, we present a case of classical FOP involving osteochondroma. An 18-year-old male adolescent, born with deformity of bilateral big toes, complained multiple masses on his back for 1 year. The mass initially emerged with a tough texture and did not cause pain. It was misdiagnosed as an osteochondroma. After two surgeries, the masses became hard and spread around the entire back region. Meanwhile, extensive heterotopic ossification was observed around the back, neck, hip, knee, ribs, and mandible during follow-up. Osteochondromas were observed around the bilateral knees. No abnormalities were observed in the laboratory blood test results. Whole exome sequencing revealed missense mutation of ACVR1/ALK2 (c.617G > A; p.R206H) in the patient and confirmed the diagnosis of FOP.
Conclusion: In summary, classical FOP always behaves as a bilateral deformity of the big toes, as well as progressive ectopic ossification and osteochondromas in the distal femur and proximal tibia. An understanding of the association between osteochondromas and FOP aids in diagnosis and avoids unnecessary invasive management in patients.