ObjectiveTo evaluate the effectiveness and safty of posterior popliteal fossa S-shaped incision with double-window approach for the treatment of posterior column of tibial plateau fractures.MethodsA retrospective analysis was made on the clinical data of 13 patients with complex tibial plateau fractures involving both posteromedial and posterolateral columns between May 2015 and July 2017. There were 9 males and 4 females, aged 33-64 years (mean, 46.5 years). The causes of injury included traffic accident in 5 cases, falling from height in 2 cases, falling from electric bicycle in 4 cases, and falling because of skiing in 2 cases. The preoperative range of motion of the affected knees was (35.1±9.2)°. The time from injury to surgery was 7-19 days (mean, 13.3 days). All patients underwent a posterior popliteal fossa S-shaped incision through the window of medial heads of gastrocnemius muscle (medial window) and the window between medial and lateral head of gastrocnemius muscle (popliteal fossa window) approaches. After a good visual control of fracture reduction, both posteromedial and posterolateral columns of tibial plateau fractures were fixed with buttress plate respectively. Bone union, limb alignment, articular surface, and range of motion were estimated after operation. The American Hospital for Special Surgery (HSS) score was used to evaluate functional outcomes of knees.ResultsAfter operation, 1 patient had fat liquefaction and dehiscence of incision, which healed after expanding the wound; the other patients’ incisions healed by first intention, and no vascular or nerve injury occurred during operation. All the 13 patients were followed up 12-18 months (mean, 16 months). The X-ray films showed that all patients obtained good fracture unions, the fracture healing time was 14-22 weeks (mean, 18 weeks). At 12 months after operation, the articular surface was smooth without collapse, and the knee range of motion was (109.5±13.6)°, showing significant difference when compared with preoperative value (t=18.879, P=0.000). No complication of infection, re-displacement of fracture, or secondary varus/valgus deformity was observed during follow-up. The HSS score was 82-96 (mean, 89.6) at 12 months after operation, with the result of excellent in 10 cases and good in 3 cases.ConclusionThe posterior column fracture of tibial plateau involving both posteromedial and posterolateral columns treated by double-window approach through posterior popliteal fossa S-shaped incision is safe and effective, with satisfactory results and good recovery of knee joint function.
ObjectiveTo evaluate the safety and effectiveness of one-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis.MethodsBetween August 2011 and October 2014, 13 patients with lumbosacral tuberculosis were treated by one-stage posterior reserved posterior ligament complex, lesion debridement, bone graft fusion, and internal fixation via unilateral musculussacrospinalis iliac flap approach. There were 8 males and 5 females, aged from 22 to 57 years, with an average age of 35 years. The disease duration ranged from 2 to 19 months, with an average of 6.7 months. According to the American Spinal Injury Association (ASIA) classification criteria, the patients were graded as grade B in 2 cases, grade C in 4 cases, grade D in 5 cases, and grade E in 2 cases before operation. The preoperative Oswestry disability index (ODI) was 36.4±5.7; the preoperative lumbosacral angle was (20.7±0.7)°; the preoperative erythrocyte sedimentation rate (ESR) was (63.4±8.4) mm/1 h; and the preoperative C-reactive protein (CRP) was (38.8±5.2) mmol/L. The operation time and intraoperative blood loss were recorded. The ODI, ASIA grade, lumbosacral angle, and ESR were recorded at last follow-up. Bridwell criterion was used to judge the interbody fusion.ResultsThe operation time was 150-240 minutes (mean, 190 minutes), and the intraoperative blood loss was 420-850 mL (mean, 610 mL). No major blood vessel, dural sac, nerve root, and lumbosacral plexus injuries occurred during the operation. Delayed wound healing occurred in 3 cases, and primary wound healing achieved in the other patients. No wound infection or sinus formation was found. All 13 patients were followed up 1.5-6.1 years (mean, 2.8 years). During the follow-up period, there was no tubercular symptom, cerebrospinal fluid leakage, loosening and rupture of internal fixator; and no complications such as retrograde ejaculation and erectile dysfunction occurred in 8 male patients. Solid spinal fusion obtained in all patients with the mean fusion time of 6.4 months (range, 4.2-9.9 months); and all iliac osteotomies healed. At last follow-up, the ODI was 7.2±3.5, the lumbosacral angle was (31.2±0.5)°, and ESR was (9.8±2.5) mm/1 h, all of which improved significantly when compared with pre-operative ones (P<0.05). The patients were classified as grade D in 2 cases and grade E in 11 cases, which improved significantly when compared with preoperative ones (Z=–3.168, P=0.002).ConclusionOne-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis is effective and safe.
ObjectiveTo investigate the feasibility of one-stage total spondylectomy by anterior and posterior approaches for treating solitary plasmacytoma (SP) of cervical spine.MethodsBetween June 2000 and March 2015, the clinical data, diagnosis, and treatment of 12 patients with SP of cervical spine were retrospectively analyzed. There were 8 males and 4 females, with a mean age of 46 years (range, 28-74 years). The mean disease duration was 8.4 months (range, 3-15 months). There were 2 cases in C2 segment, 4 cases in C3, 2 cases in C4, 1 recurrent case in C5, C6, and 3 cases in C7. According to WBB (Weinstein-Boriani-Biagini) surgical staging system, the tumor mainly occupied the vertebral body areas and expanded outside to 4 or 9 radiating zone in 8 cases, expanded both outsides to 4 or 9 radiating zones in 4 cases; 7 cases of them affected A to D layers, other 5 cases affected B to D layers. Preoperative Frankel system showed grade B in 1 case, grade C in 6 cases, and grade D in 5 cases. One vertebra segment was involved in 11 cases, and 2 vertebra segments were involved in 1 case. The unilateral vertebral artery was involved in 4 cases and bilateral vertebral artery in 1 case. One-stage total spondylectomy by anterior and posterior approaches for SP of cervical spine was applied in all patients, which all received adjuvant radiotherapy postoperatively. The operation time, intraoperative blood loss, complications, Frankel system, and visual analogue scale (VAS) score were recorded and analyzed.ResultsThe operation time was 6.8-9.3 hours (mean, 7.2 hours), and the intraoperative blood loss was 1 100-2 600 mL (mean, 1 600 mL). Esophageal leakage occurred in 1 patient with C5, C6 recurrent SP at 1 week after operation and 1 case presented with fat liquefaction of wound, who were cured by symptomatic treatment. Other patients showed no neurological deficit, major vascular injury (especially vertebral artery), phrenic nerve injury, superior laryngeal nerve injury, laryngeal nerve injury, respiratory failure, or other complications. All the 12 patients were followed up 27-98 months (mean, 58 months). The symptoms of spinal cord compression disappeared or improved after operation. At last follow-up, the nerve function was recovered to Frankel grade E in all patients; the VAS score decrease to 1.1±0.7, showing significant difference when compared with preoperative value (6.7±2.7) (t=2.485, P=0.014). Two patients had local recurrence at 29 months and 37 months after operation respectively, which were treated with adjuvant chemotherapy. One of them finally progressed to multiple myeloma and died of multiple organ failure after 43 months, the other one survived with residual tumor. One case presented with internal fixator loosening and breaking at 4 years after operation, who was performed revision surgery. The other patients had no tumor recurrence or malignant change during the follow-up, no complication such as internal fixator loosening or breaking occurred.ConclusionFor patients with SP of cervical spine, surgical intervention is an acceptable treatment option. One-stage total spondylectomy by anterior and posterior approaches can decline the local recurrence and relieve the symptoms of spinal cord compression, so as to improve patients’ life quality. However, patients with progression to multiple myeloma should be treated with individualized therapeutic regimen, and the prognosis may be poor.
ObjectiveTo investigate the surgical outcome of combined posterior and anterior approaches for the resection of thoracolumbar spinal canal huge dumbbell-shaped tumor. MethodsBetween January 2009 and March 2015, 12 patients with thoracolumbar spinal canal huge dumbbell-shaped tumor were treated by posterior approach and anterolateral approach through diaphragmatic crura and thoracoabdominal incision for complete resection. There were 9 males and 3 females, with an average age of 45 years (range, 30-65 years). The disease duration was 8-64 weeks (mean, 12.7 weeks). The tumor was located at T12, L1 in 6 cases, at L1, 2 in 5 cases, and at L2, 3 in 1 case. The tumor size ranged from 4.3 cm×4.0 cm×3.5 cm to 7.5 cm×6.3 cm×6.0 cm. According to tumor outside the spinal involvement scope and site and based on the typing of Eden, 5 cases were rated as type b, 2 cases as type d, 4 cases as type e, and 1 case as type f in the transverse direction; two segments were involved in 8 cases, and more than two segments in 4 cases. The degree of tumor excision, tumor recurrence, and the spine stability were observed during follow-up. The verbal rating scale (VRS) was used to evaluate pain improvement. ResultsThe average surgical time was 170 minutes (range, 150- 230 minutes); the average intraoperative blood loss was 350 mL (range, 270-600 mL). All incisions healed by first intention, and no thoracic cavity infection and other operation related complication occurred. Of 12 cases, 10 were histologically confirmed as schwannoma, and 2 as neurofibroma. The patients were followed up 6 months to 6 years (mean, 31 months). Neurological symptoms were significantly improved in all patients, without lower back soreness. The thoracolumbar X-ray film and MRI showed no tumor residue. No tumor recurrence, internal fixator loosening, scoliosis, and other complications were observed during follow-up. VRS at last follow-up was significantly improved to grade 0 (10 cases) or grade I (2 cases ) from preoperative grade I (2 cases), grade II (8 cases), and grade III (2 cases) (Z= —3.217, P=0.001). ConclusionCombined posterior approach and anterolateral approach through diaphragmatic crura and thoracoabdominal incision for complete resection of thoracolumbar spinal canal huge dumbbell-shaped tumor is feasible and safe, and can protect the stability of thoracolumbar spine and paraspinal muscle function. It can obtain satisfactory clinical result to use this method for treating the complex type of thoracolumbar spinal canal dumbbell-shaped tumor.
Objective To explore the advantage of reconstruction belt for treating complicated acetabular fracture by combined anterior and posterior approaches through the comparison with reconstruction plate. Methods A retrospective analysis was made on the clinical data of 39 patients with acetabular fractures who met the selection criteria. After open reduction by combined anterior and posterior approaches was performed, fracture was fixed by reconstruction belt in 20 cases (trial group), and by reconstruction plate in 19 cases (control group). There was no significant difference in gender, age, cause of injury, time from injury to hospital, type of fracture, and preoperative visual analogue scale (VAS) score between 2 groups (P > 0.05). The number of plate shaping, plate shaping time, operation time, bleeding amount, perspective times, VAS score, modified Merled’Aubigne-Postel hip score, and related complications were recorded and compared. According to Matta standard, the fracture displacement was measured to evaluate the fracture reduction and fracture healing. Results The number of plate shaping, plate shaping time, operation time, bleeding amount, and perspective times in the trial group were significantly less than those in the control group (P < 0.05). The patients were followed up 12-29 months (mean, 21.1 months) in the trial group, and 12-27 months (mean, 20.5 months) in the control group. The VAS score was significantly lower at 7 days and 6 months after operation than at pre-operation, and at 6 months than at 7 days in 2 groups (P < 0.05), but difference was not significant between 2 groups (P > 0.05). At 6 months after operation, the Merled’Aubigne-Postel score of hip function in the trial group was 15.950±1.504, showing no significant difference when compared with the control group (15.895±1.629) (t= -0.110, P=0.913). The fracture displacement was (0.750±1.070) mm in the trial group and was (0.842±1.068) mm in the control group, showing no significant difference (t= -0.269, P=0.789). The X-ray films showed that all fractures healed in 2 groups. The healing time was (16.10±2.07) weeks in the trial group and was (15.84±2.14) weeks in the control group, showing no significant difference (t =0.382, P=0.075). Conclusion Reconstruction belt for complicated acetabular fracture by combined anterior and posterior approaches has similar effectiveness to reconstruction plate, but the number of plate shaping, plate shaping time, and perspective times are fewer.
ObjectiveTo compare the effectiveness between modified ilioinguinal approach combined with Kocher-Langenbeck (K-L) approach and Stoppa approach combined with K-L approach for the treatment of complicated acetabular fractures.MethodsBetween May 2011 and May 2016, Sixty-two patients with complicated acetabular fractures were treated with operation via combined anterior and posterior approaches. Thirty-four cases (group A) were treated with modified ilioinguinal approach combined with K-L approach, and 28 cases (group B) were treated with Stoppa approach combined with K-L approach. There was no significant difference in gender, age, injury causes, the type of fracture, time from injury to operation, and associated injury between 2 groups (P>0.05). The operation time, intraoperative blood loss, and hospitalization time were recorded. X-ray film was performed to evaluate the fracture reduction according to the Matta reduction criteria and observe the fracture healing, osteoarthritis, and heterotopic ossification. Clinical results were evaluated according to the grading system of modified d’Aubigne and Postel.ResultsThere was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups (P>0.05). Postoperative incision fat liquefaction occurred in 2 cases in group A and group B respectively, and deep vein thrombosis of lower extremity occurred in 1 case in group A. No iatrogenic injury was found in 2 groups. Fifty-six patients were followed up after operation. Thirty patients in group A were followed up 12-48 months (mean, 31.8 months). Twenty-six patients in group B were followed up 12-46 months (mean, 30.2 months). At 12 months after operation, according to the grading system of modified d’Aubigne and Postel, the hip function was rated as excellent in 9 cases, good in 16 cases, fair in 3 cases, and poor in 2 cases, with the excellent and good rate of 83.3% in group A; the hip function was rated as excellent in 7 cases, good in 14 cases, fair in 2 cases, and poor in 3 cases, with the excellent and good rate of 80.8% in group B. There was no significant difference in the hip function between 2 groups (Z=0.353, P=0.724). The X-ray films showed that there were 23 cases of anatomical reduction, 6 cases of satisfactory reduction, and 1 case of unsatisfactory reduction in group A, and 20 cases, 5 cases, and 1 case in group B, respectively. There was no significant difference in the results of fracture reduction between 2 groups (Z=0.011, P=0.991). Fracture healing was observed in both groups. There was no significant difference in fracture healing time between 2 groups (t=0.775, P=0.106). During follow-up, 5 cases of osteoarthritis changes, 2 cases of heterotopic ossification, and 2 cases of avascular necrosis of femoral head occurred in group A, and 4 cases, 2 cases, and 1 case in group B, respectively. The difference between 2 groups was not significant (P>0.05).ConclusionAccording to the location and type of fracture, making a choice between the modified anterior approach and Stoppa approach, and then combined with K-L approach for treatment of complicated acetabular fracture, can obtain satisfactory effectiveness.
Objective To explore the effectiveness and related issues in the treatment of multiple segments of thoracolumbar tuberculosis through posterior unilateral debridement with bone graft and internal fixation. Methods The clinical data of 29 patients with multiple segments of thoracolumbar tuberculosis who met the selection criteria were retrospective analyzed between January 2012 and July 2015. There were 17 males and 12 females, with age of 21-62 years (mean, 37.4 years). Lesions contained 3-8 vertebral segments, including 3 segments in 6 cases, 4-6 segments in 17 cases, and 7-8 segments in 6 cases. The center lesions located at thoracic spine in 8 cases, lumbar spine in 10 cases, and thoracolumbar segment in 6 cases, and thoracic lumbar skip lesions in 5 cases. The complications included vertebral abscess in 7 cases, psoas major abscess in 6 cases, sacral spine muscle abscess in 7 cases, iliac fossa and the buttocks abscess in 1 case, spinal canal abscess in 2 cases. Preoperative neurological function was assessed according to the American Spinal Injury Association (ASIA) classification: 1 case of grade B, 3 cases of grade C, 8 cases of grade D, and 17 cases of grade E. The disease duration was 6-48 months (mean, 19.3 months). All the patients were treated with posterior unilateral transpedicular or transarticular debridement with bone graft fusion and internal fixation under general anesthesia. Pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), and sagittal Cobb angle were recorded and compared. Bridwell classification standard was used to evaluate bone graft fusion. According to the number and the center of the lesion, the necessity to placement of titanium mesh cage was analyzed. Results All the patients were followed up 18-30 months (mean, 24 months). Cerebrospinal fluid leakage occurred in 3 cases, intercostal neuralgia in 2 cases, wound unhealed and fistula formation in 1 case, and ofiliac fossa abscess recurred in 1 case, and all recovered after symptomatic treatment. During follow-up, no fracture or loosing of internal fixation was found and all the lesions were cured at last follow-up. According to Bridwell classification standard, bone graft achieved bony fusion during 4-9 months after operation. The VAS score, ODI, and Cobb angle at immediate after operation and at last follow-up were significantly improved when compared with preoperative ones (P<0.05). At last follow-up, the neural function of all patients improved significantly when compared with preoperative one (Z= –3.101, P=0.002). The ratio of no placement of titanium mesh cage was significantly higher in patients with more than 6 lesion segments (6/6, 100%) than in patients with less than 6 lesion segments (4/23, 17.4%) (χ2=14.374, P=0.000). And the ratio of placement of titanium mesh cage was not significantly different between the patients with the different locations of center focus (χ2=0.294, P=0.863). Conclusion For treating multiple segments of thoracolumbar tuberculosis, the method of posterior unilateral debridement with bone graft and internal fixation can decrease the damage of posterior spinal structures and surgical trauma.
Objective To investigate the effectiveness of radical debridement, reconstruction with bone allograft, and pedicle screw-rod internal fixation via combined anterior and posterior approach in the treatment of lumbosacral tuberculosis. Methods Between January 2005 and May 2010, 16 patients with lumbosacral tuberculosis were treated. Radical debridement wasperformed via extraperitoneal approach, then tricortical il iac bone allograft was placed and pedicle screw-rod internal fixation was used to reconstruct the spinal column. There were 12 males and 4 females aged 38-65 years (mean, 48 years). The disease duration ranged from 6 to 24 months (mean, 10 months). The main cl inical symptom was persistent pain in lumbosacral area. The involved segments included L4, 5 (3 cases), L5, S1 (8 cases), and L4-S1 (5 cases). The lumbosacral angle was 18-32° (mean, 22°). The erythrocyte sedimentation rate (ESR) was 15-55 mm/1 hour (mean, 25 mm/1 hour). All the patients were given antituberculosis chemotherapy for 12 months after operation. Results The operation time was 120-240 minutes (mean, 180 minutes). The amount of bleeding was 300-600 mL (mean, 420 mL). All wounds healed by first intention, and no relative compl ication occurred. All 16 cases were followed up 12-24 months (mean, 16 months). No recurrence occurred and ESR recovered to normal. Persistent pain in lumbosacral area and radicular pain in lower extremities disappeared. The X-ray films demonstrated that bony fusion was obtained in all patients at 8-12 months postoperatively. The lumbosacral angle was 16-31° (mean, 21°) at last follow-up. Conclusion The extraperitoneal approach can provide direct and safe access to the lesion. The structural il iac bone allograft and posterior instrumentation could reconstruct effectively the stabil ity of the lumbosacral junction.
ObjectiveTo evaluate the effectiveness of arthroscopic treatment of superior labrum anterior and posterior (SLAP) injury by absorbable anchors through anterior and posterior approach. MethodsBetween January 2010 and August 2012, 28 patients with Snyder II type of SLAP injury underwent arthroscopic operation by absorbable anchors through anterior and posterior approach. There were 15 males and 13 females, aged from 30 to 45 years (mean, 36.5 years). The left shoulder was involved in 12 cases and the right shoulder in 16 cases. All patients had a clear history of trauma. The disease duration ranged from 2 weeks to 3 years (median, 13 months). The results of O'Brien test and Speed test were positive in 25 cases and 26 cases respectively. Shoulder pain visual analogue scale (VAS) was 7.6±1.4. The Constant score of shoulder joint function was 60.2±4.3. ResultsOperation was successfully completed, and the incision healed well in all cases, with no complication. The follow-up time ranged from 12 to 36 months (mean, 24.5 months). The symptoms of shoulder joint interlocking, snapping, and instability disappeared. The joint pain was significantly improved. At 12 months after surgery, Constant score of shoulder joint function was 92.7±4.5, showing significant difference when compared with preoperative score (t=-30.279, P=0.000); the shoulder pain VAS score was 1.1±0.9, showing significant difference when compared with preoperative score (t=23.810, P=0.000). At 1 year after operation, MRI examination showed complete healing in 25 cases, and high signal in 3 cases, but the pain and activity were significantly improved. ConclusionArthroscopic treatment of SLAP injury by absorbable anchors through anterior and posterior approach has the advantages of less injury, small incision, and quick recovery, so it is an ideal operation method.
ObjectiveTo investigate the effectiveness of two surgical approaches in the treatment of type Ⅳ Pipkin fracture.MethodsThe clinical data of 15 patients with type Ⅳ Pipkin fracture treated surgically between July 2013 and June 2018 were retrospectively analyzed. According to different surgical approaches, they were divided into group A (8 cases, using K-L posterior approach) and group B (7 cases, using greater trochanter osteotomy approach). There was no significant difference in gender, age, cause of injury, and interval from injury to operation between the two groups (P>0.05). The incision length, operation time, intraoperative blood loss, hospital stay, fracture healing time, and complications of the two groups were recorded. Hip joint function recovery was evaluated according to Thompson-Epstein functional evaluation system.ResultsAll the 15 patients were followed up 1-5 years, with an average of 2.5 years. There was no significant difference in operation time between the two groups (t=14.681, P=0.100); the incision length, intraoperative blood loss, and fracture healing time in group A were all greater than those in group B, and the hospital stay was shorter than that in group B, showing significant differences (P<0.05). In group A, 1 patient presented hip pain, clasthenia, and limited mobility after operation, 1 patient presented ossifying myositis, 1 patient presented osteonecrosis of the femoral head, 1 patient presented fat liquefaction of incision, and 1 patient presented sciatica, with a complication incidence of 62.5%. Postoperative hip pain occurred in 1 patient and ossifying myositis in 2 patients in group B, with a complication incidence of 42.9%. There was no significant difference in the incidence of complications between the two groups (χ2=−0.735, P=0.462). At last follow-up, according to Thompson-Epstein functional evaluation system, the results in group A were excellent in 3 cases, good in 2 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 62.5%; in group B, the results were excellent in 4 cases, good in 2 cases, and fair in 1 case, and the excellent and good rate was 85.7%. There was no significant difference in good and fair rate between the two groups (χ2=−0.990, P=0.322).ConclusionK-L posterior approach is more convenient in the fracture treatment during operation, but it has greater trauma, greater vascular damage, and more blood loss. The greater trochanter osteotomy approach can better protect the blood supply of femoral head, shorten the operation time, reduce intraoperative blood loss, and reduce postoperative complications. It is an ideal way in the surgical treatment of type Ⅳ Pipkin fracture.