Analysis of the causes of cage subsidence after oblique lateral lumbar interbody fusion / 中国骨伤

OBJECTIVE@#To observe the cage subsidence after oblique lateral interbody fusion (OLIF) for lumbar spondylosis, summarize the characteristics of the cage subsidence, analyze causes, and propose preventive measures.@*METHODS@#The data of 144 patients of lumbar spine lesions admitted to our hospital from October 2015 to December 2018 were retrospectively analyzed. There were 43 males and 101 females, and the age ranged from 20 to 81 years old, with an average of (60.90±10.06) years old. Disease types:17 patients of lumbar intervertebral disc degenerative disease, 12 patients of giant lumbar disc herniation, 5 patients of discogenic low back pain, 33 patients of lumbar spinal stenosis, 26 patients of lumbar degenerative spondylolisthesis, 28 patients of lumbar spondylolisthesis with spondylolisthesis, 11 patients of adjacent vertebral disease after lumbar internal fixation, 7 patients of primary spondylitis in the inflammatory outcome stage, and 5 patients of lumbar degenerative scoliosis. Preoperative dual-energy X-ray bone mineral density examination showed 57 patients of osteopenia or osteoporosis, and 87 patients of normal bone density. The number of fusion segments:124 patients of single-segment, 11 patients of two-segment, 8 patients of three-segment, four-segment 1 patient. There were 40 patients treated by stand-alone OLIF, and 104 patients by OLIF combined with posterior pedicle screw. Observed the occurrence of fusion cage settlement after operation, conducted monofactor analysis on possible risk factors, and observed the influence of fusion cage settlement on clinical results.@*RESULTS@#All operations were successfully completed, the median operation time was 99 min, and the median intraoperative blood loss was 106 ml. Intraoperative endplate injury occurred in 30 patients and vertebral fracture occurred in 5 patients. The mean follow-up was (14.57±7.14) months from 6 to 30 months. During the follow-up, except for the patients of primary lumbar interstitial inflammation and some patients of lumbar spondylolisthesis with spondylolisthesis, the others all had different degrees of cage subsidence. Cage subsidence classification:119 patients were normal subsidence, and 25 patients were abnormal subsidence (23 patients were gradeⅠ, and 2 patients were gradeⅡ). There was no loosening or rupture of the pedicle screw system. The height of the intervertebral space recovered from the preoperative average (9.48±1.84) mm to the postoperative average (12.65±2.03) mm, and the average (10.51±1.81) mm at the last follow-up. There were statistical differences between postoperative and preoperative, and between the last follow-up and postoperative. The interbody fusion rate was 94.4%. The low back pain VAS decreased from the preoperative average (6.55±2.2 9) to the last follow-up (1.40±0.82), and there was statistically significant different. The leg pain VAS decreased from the preoperative average (4.72±1.49) to the final follow-up (0.60±0.03), and the difference was statistically significant (t=9.13, P<0.000 1). The ODI index recovered from the preoperative average (38.50±6.98)% to the latest follow-up (11.30±3.27)%, and there was statistically significant different. The complication rate was 31.3%(45/144), and the reoperation rate was 9.72%(14/144). Among them, 8 patients were reoperated due to fusion cage subsidence or displacement, accounting for 57.14%(8/14) of reoperation. The fusion cage subsidence in this group had obvious characteristics. The monofactor analysis showed that the number of abnormal subsidence patients in the osteopenia or osteoporosis group, Stand-alone OLIF group, 2 or more segments fusion group, and endplate injury group was higher than that in the normal bone mass group, OLIF combined with pedicle screw fixation group, single segment fusion group, and no endplate injury group, and the comparison had statistical differences.@*CONCLUSION@#Cage subsidence is a common phenomenon after OLIF surgery. Preoperative osteopenia or osteoporosis, Stand-alone OLIF, 2 or more segments of fusion and intraoperative endplate injury may be important factors for postoperative fusion cage subsidence. Although there is no significant correlation between the degree of cage subsidence and clinical symptoms, there is a risk of cage migration, and prevention needs to be strengthened to reduce serious complications caused by fusion of cage subsidence, including reoperation.

Comparison of clinical effect and muscle injury imaging between oblique lateral lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of single-segment degenerative lumbar spinal stenosis / 中国骨伤

OBJECTIVE@#To compare the efficacy and muscle injury imaging between oblique lateral lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis.@*METHODS@#The clinical data of 60 patients with single-segment degenerative lumbar spinal stenosis who underwent surgical treatment from January 2018 to October 2019 was retrospectively analyzed. The patients were divided into OLIF groups and TLIF group according to different surgical methods. The 30 patients in the OLIF group were treated with OLIF plus posterior intermuscular screw rod internal fixation. There were 13 males and 17 females, aged from 52 to 74 years old with an average of (62.6±8.3) years old. And 30 patients in the TLIF group were treated with TLIF via the left approach. There were 14 males and 16 females, aged from 50 to 81 years old with an average of (61.7±10.4) years old. General data including operative time, intraoperative blood loss, postoperative drainage volume, and complications were recorded for both groups. Radiologic data including disc height (DH), the left psoas major muscle, multifidus muscle, longissimus muscle area, T2-weighted image hyperintensity changes and interbody fusion or nonfusion were observed. Laboratory parameters including creatine kinase (CK) values on postoperative 1st and 5th days were analyzed. Visual analogue scale(VAS) and Oswestry disability index(ODI) were used to assess clinical efficacy.@*RESULTS@#There was no significant difference in the operative time between two groups(P>0.05). The OLIF group had significantly less intraoperative blood loss and postoperative drainage volume compared to the TLIF group(P<0.01). The OLIF group also had DH better recovery compared to the TLIF group (P<0.05). There were no significant differences in left psoas major muscle area and the hyperintensity degree before and after the operation in the OLIF group (P>0.05). Postoperativly, the area of the left multifidus muscle and longissimus muscle, as well as the mean of the left multifidus muscle and longissimus muscle in the OLIF group, were lower than those in the TLIF group (P<0.05) .On the 1st day and the 5th day after operation, CK level in the OLIF group was lower than that in the TLIF group(P<0.05). On the 3rd day after operation, the VAS of low back pain and leg pain in the OLIF group were lower than those in the TLIF group (P<0.05). There were no significant differences in the ODI of postoperative 12 months, low back and leg pain VAS at 3, 6, 12 months between the two groups(P>0.05). In the OLIF group, 1 case of left lower extremity skin temperature increased after the operation, and the sympathetic chain was considered to be injured during the operation, and 2 cases of left thigh anterior numbness occurred, which was considered to be related to psoas major muscle stretch, resulting in a complication rate of 10% (3/30). In the TLIF group, one patient had limited ankle dorsiflexion, which was related to nerve root traction, two patients had cerebrospinal fluid leakage, and the dural sac was torn during the operation, and one patient had incision fat liquefaction, which was related to paraspinal muscle dissection injury, resulting in a complication rate of 13% (4/30). All patients achieved interbody fusion without cage collapse during the 6- month follow-up.@*CONCLUSION@#Both OLIF and TLIF are effective in the treatment of single-segment degenerative lumbar spinal stenosis. However, OLIF surgery has obviously advantages, including less intraoperative blood loss, less postoperative pain, and good recovery of intervertebral space height. From the changes in laboratory indexes of CK and the comparison of the left psoas major muscle, multifidus muscle, longissimus muscle area, and high signal intensity of T2 image on imaging, it can be seen that the degree of muscle damage and interference of OLIF surgery is lower than that of TLIF.

Analysis of the causes and clinical results of vertebral fracture during oblique lateral lumbar interbody fusion / 中国骨伤

OBJECTIVE@#To analyze the causes of vertebral fracture during oblique lateral interbody fusion in the treatment of lumbar spondylopathy, summarize the clinical results, and propose preventive measures.@*METHODS@#Retrospective analysis was made on the data of 8 cases of lumbar spondylopathy and vertebral fracture treated by oblique lateral interbody fusion in three medical centers from October 2014 to December 2018. All were female, aged from 50 to 81 years with an average of 66.4 years. Disease types included 1 case of lumbar degenerative disease, 3 cases of lumbar spinal stenosis, 2 cases of lumbar degenerative spondylolisthesis and 2 cases of lumbar degenerative scoliosis. Preoperative dual energy X-ray bone mineral density test showed that 2 cases had T-value >-1 SD, 2 cases had T-value -1 to -2.5 SD, and 4 cases had T-value <-2.5 SD. Single segment fusion was in 5 cases, two segment fusion in 1 case and three segment fusion in 2 cases. Four cases were treated with OLIF Stand-alone and 4 cases were treated with OLIF combined with posterior pedicle screw fixation. Postoperative imaging examination showed vertebral fracture, and all of them were single vertebral fracture. There were 2 cases of right lower edge fracture of upper vertebral body at fusion segment, 6 cases of lower vertebral body fracture at fusion segment, and 6 cases with endplate injury and fusion cage partially embedded in vertebral body. Three cases of OLIF Stand-alone were treated with pedicle screw fixation via posterior intermuscular approach, while one case of OLIF Stand-alone and four cases of OLIF combined with posterior pedicle screw fixation were not treated specially.@*RESULTS@#The 5 cases of initial operation and 3 cases of reoperation did not show wound skin necrosis or wound infection. The follow-up time was from 12 to 48 months with an average of 22.8 months. Visual analogue scale (VAS) of low back pain was preoperative decreased from 4 to 8 points (averagely 6.3 points) and postoperative 1 to 3 points (averagely 1.7 points) at the final follow-up. Oswestry disability index (ODI) was preoperative 39.7% to 52.4% (averagely 40.2%), and postoperative 7.9% to 11.2% (averagely 9.5%) at the final follow-up. During the follow-up, there was no loosening or fracture of the pedicle screw system, and no lateral displacement of the fusion cage;however, the fusion cage at the vertebral fracture segment had obvious subsidence. The intervertebral space height of vertebral fracture segment was preoperaive 6.7 to 9.2 mm (averagely 8.1 mm), and postoperative 10.5 to 12.8 mm (averagely 11.2 mm). The improvement rate after operation was 37.98% compared to preoperative. The intervertebral space height at final follow-up was 8.4 to 10.9 mm (averagely 9.3 mm), and the loss rate was 16.71% compared with that after operation. At the final follow-up, interbody fusion was achieved in all cases except for one that could not be identified.@*CONCLUSION@#The incidence of vertebral fracture during oblique lateral interbody fusion in the treatment of lumbar spondylopathy is lower, and there are many reasons for fracture, including preoperative bone loss or osteoporosis, endplate injury, irregular shape of endplate, excessive selection of fusion cage, and osteophyte hyperplasia at the affected segment. As long as vertebral fracture is found in time and handled properly, the prognosis is well. However, it still needs to strengthen prevention.

Application of oblique lateral interbody fusion in the treatment of lumbar intervertebral disc degeneration in patients with Modic change and endplate sclerosis / 中国骨伤

OBJECTIVE@#To explore the feasibility and clinical effect of Stand-alone oblique lateral interbody fusion (OLIF) in the treatment of lumbar intervertebral disc degeneration with Modic changes and endplate sclerosis.@*METHODS@#A retrospective analysis was performed on 16 cases with lumbar intervertebral disc degeneration with Modic changes and endplate sclerosis admitted to three medical centers from January 2015 to December 2018. There were 6 males and 10 females, the age ranged from 45 to 67 years old with an average of (55.48±8.07) years old, the medical history ranged from 36 to 240 months with an average of (82.40±47.68) months. The lesion sites included L2,3 in 2 cases, L3,4 in 5 cases, and L4,5 in 9 cases. All patients presented with chronic low back pain with lower limb neurological symptoms in 3 cases. All patients were treated by Stand-alone oblique lateral lumbar interbody fusion. Clinical and radiological findings and complications were observed.@*RESULTS@#There was no vascular injury, endplate injury and vertebral fracture during the operation. The mean incision length, operation time, and intraoperative blood loss were(4.06±0.42) cm, (45.12±5.43) min, (33.40±7.29) ml, respectively. The mean visual analogue scale (VAS) of the incision pain was (1.14±0.47) at 72 hours after operation. There was no incision skin necrosis, poor incision healing or infection in patients. Sympathetic chain injury occurred in 1 case, anterolateral pain and numbness of the left thigh in 2 cases, and weakness of the left iliopsoas muscle in 1 case, all of which were transient injuries with a complication rate of 25%(4/16). All 16 patients were followed up from 12 to 36 months with an average of (20.80±5.46) months. The intervertebral space height was significantly recovered after operation, with slight lost during the follow-up. Coronal and sagittal balance of the lumbar spine showed good improvement at the final follow-up. There was no obvious subsidence or displacement of the cage, and the interbody fusion was obtained. At the final follow-up, Japanese Orthopaedic Association(JOA) score and Oswestry disability index(ODI) were significantly improved.@*CONCLUSION@#As long as the selection of case is strict enough and the preoperative examination is sufficients, the use of Stand-alone OLIF in the treatment of lumbar intervertebral disc degeneration with Modic changes and endplate sclerosis has a good results, with obvious clinical advantages and is a better surgical choice.

Short-segment pedicle screw fixation combined with vertebroplasty for the treatment of Kümmell disease with kyphosis / 中国骨伤

OBJECTIVE@#To explore the clinical effects of posterior short-segment pedicle screw internal fixation combined with vertebroplasty for the treatment of Kümmell disease with kyphosis.@*METHODS@#Twenty-four patients with Kümmell disease complicated with kyphosis treated by posterior short-segment pedicle screw internal fixation combined with vertebroplasty from January 2016 to December 2018 were retrospectively analyzed, including 6 males and 18 females, aged 63 to 85 (73.1±6.5) years old. The clinical effect was evaluate by visual analogue scale (VAS), Oswestry Disability Index (ODI), the anterior height of injured vertebral body, and the sagittal Cobb angle of the affected segment beforeoperation, at 3 days and final follow up after operation. And the surgical complications were observed.@*RESULTS@#All 24 patients were followed up from 12 to 24 months with an average of (15.5±3.2) months. The VAS score was decreased from 5.21±1.06 preoperatively to 2.38±0.58 at 3 days postoperatively and 1.71±0.75 at final follow-up;ODI was decreased from (50.4±13.5)% preoperatively to (20.9±8.0)% at 3 days postoperatively and (16.7±9.6)% at final follow-up;the anterior height of injured vertebral body was restored from (8.0±4.2) mm before surgery to (18.1±5.0) mm at 3 days after surgery and (16.8±5.1) mm at final follow up;the sagittal Cobb angle of affected segment was decreased from (19.5±6.3)° preoperatively to (7.6±2.1)° at 3 days after surgery and(8.4±1.7)° at final follow-up. VAS, ODI, anterior height of injured vertebral body, and sagittal Cobb angle of affected segment were significantly improved at 3 days after operation and at final follow-up (@*CONCLUSION@#Posterior short-segment pedicle screw internal fixation combined with vertebroplasty for the treatment of Kümmell disease with kyphosis has relatively small surgical trauma, excellent clinical results, good vertebral height recovery, satisfactory correction of kyphotic angle, and fewer complications, etc. It is a safe and effective surgical method to treat Kümmell disease with kyphosis.

Current advances in research of semaphorin 3A:a potential target for the treatment of nospecific low back pain / 中国骨伤

Nonspecific low back pain is closely associated with afferent nerve ingrowth into degenerated IVDs and increasing the inflammatory response. Members of the class 3 semaphorins signal their response through two prominent receptors; the NRP (Neuropilin-1) and the Plexin A. Sema3A (Semaphorin3A) is primarily known for their role in modulating neuronal survival as well as neurite outgrowth and guidance via regulation of Sema3A-NRP-1-plexinA signal pathway. Also, sema3A is shown to be conductive to innervate the inner painful degenerated IVDs (Intervertebral discs). Furthermore, sema3A is thought to act as a barrier to endothelial cells survival and migration on vascular endothelial growth factor (VEGF) and inhibition of KLF5-induced (Krüppel-like factor 5) inflammatory mediators within degenerated IVDs. Therefore, Sema3A produce a new perspective of dual-action therapeutic agent for attenuating the regulator of innervation and angiogenesis into degenerated IVDs and inhibition of KLF5-induced inflammation.

Establishment of a novel mouse mode of elastase-induced chronic obstructive pulmonary disease related osteoporosis / 中国骨伤

OBJECTIVE@#To establish and evaluate the model of chronic obstructive pulmonary disease (COPD) with osteoporosis induced by elastase in mice.@*METHODS@#Twenty four healthy female 8-week-old C57BL / 6 mice (weighing about 18 g) were randomly divided into three groups. The control group was given intratracheal drip of normal saline, the experimental group 1 and the experimental group 2 were given intratracheal drip of elastase, the control group and the experimental group 1 were kept for 8 weeks and then killed, the experimental group 2 was kept for 12 weeks and then killed. HE staining was used to evaluate the histopathological changes of lung and tibia in the control and experimental groups. The levels of serum inflammatory factors and broncho alveolar lavage factors (BALF) were detected by ELISA. Micro CT was used to detect the bone mass related parameters of mouse femur. The expression of osteoclastic and osteogenic genes was detected by real-time fluorescence quantitative PCR.@*RESULTS@#Lung histopathology showed that the structure of alveoli in the experimental group was disordered, the walls of alveoli became thin or broken, and the alveoli cavity expanded. IL-6 and TNF-α in BALF were significantly higher than those in control group (<0.001), while IL-1β and TNF-α in serum inflammatory factors were significantly higher than those in control group (<0.001). BV / TV(bone volume fraction), TB.Th(average bone trabecular thickness) and TB.N(average bone trabecular number) in the experimental group were significantly lower than those in the control group (<0.05), TB.Sp (average bone trabecular separation) and BS / BV (bone surface area fraction) in the experimental group were significantly higher than those in the control group (<0.01). Compared with the control group, the expression of osteoclast related marker genes increased in the experimental group (<0.05), but decreased in the experimental group(<0.05). The results of experiment 1 and experiment 2 were time-dependent.@*CONCLUSION@#In this study, elastase was used to construct a COPD model with osteoporosis successfully, which provides a suitable animal model for the future study of the pathogenesis of COPD with osteoporosis.

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

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

Current advances on surgical treatment for knee articular cartilage injuries / 中国骨伤

Chondral injuries are short of self-healing ability and need to surgical repair after articular cartilage injury. Conventional treatment includes debridement and drainage under arthroscope, micro-fracture, osteochondral autograft transplantation (OATS), mosaiplasty and osteochondral allografts (OCA), autologous chondrocyte implantation (ACI). Debridement and drainage could remove pain factor, and has advantages of simple operation, wide clinical application and early clinical effect. Micro-fracture and osteochondral autograft transplantation is suitable for small area of cartilage repair, while the further effect showed that fibrous cartilage permeated by drill could decrease postoperative clinical effect. Osteochondral autograft transplantation has better advantages for reconstruction complete of wear-bearing joint. Autologous chondrocyte implantation and allogeneic cartilage transplantation are suitable for large area of cartilage defect, postoperative survival of allogeneic cartilage transplantation is effected by local rejection reaction and decrease further clinical effect. Cartilage tissue engineering technology could improve repair quality of autologous chondrocyte implantation, and make repair tissue close to transparent cartilage, but has limit to combined subchondral bone plate, reactive bone edema, bone loss and bad axis of lower limb. New technology is applied to cartilage injury, and has advantages of less trauma, simple operation, rapid recover, good clinical effect and less cost;and could be main method for treat cartilage injury with surgical repair technology. How to improve repair quality with compression resistance and abrasive resistance are expected to be solved.

Modified Stoppa approach in treatment of bilateral pubic branch fractures / 中国骨伤

<p><b>OBJECTIVE</b>To investigate the feasibility and effectiveness of modified Stoppa approach in treatment of bilateral pubic fractures of pelvic.</p><p><b>METHODS</b>The therapeutic effects of 16 patients with bilateral pubic fractures treated through the modified Stoppa approach from January 2010 to January 2014 were summarized and analyzed, involved 11 males and 5 females with an average age of 40.5 years old ranging from 17 to 59 years. According to Tile classification, there were 8 patients with type A, 6 with type B and 2 with type C. For 16 pelvic fractures, the modified Stoppa approach was used exclusively 11 cases, in combination with the iliac fossa approach in 4 cases, and in combination with the posterior approach in 1 case. The operation incision length, operation time , intra-operative blood loss and postoperative complications were observed. The fracture reduction and post-operative function were assessed by Matta criteria and Majeed system respectively.</p><p><b>RESULTS</b>The incision length of the modified Stoppa approach ranged from 8 to 10 cm (averaged in 9 cm). The operation time ranged from 75 to 135 minutes (averaged in 95 minutes). The intra-operative blood loss ranged from 400 to 900 ml (averaged in 600 ml). Sixteen patients were followed up from 7 to 18 months (averaged in 12.5 months). The fractures were all healed, the fracture healing time was 2.7 to 5 months (means 3.1 months). There were no infections, ectopic ossification, screw loosening, plate breakage and lateral ventral syndrome. According to Matta criteria for pubic fracture reduction, the result was excellent in 9 cases, good in 6, fair in 1. The Majeed function scores at 6 months after operation was 85.32±8.50; the result was excellent in 8 cases, good in 6 cases, fair in 2 cases.</p><p><b>CONCLUSION</b>The modified Stoppa approach has characteristics of convenience and directness of incisions, clear operation field, easy reduction, few complications and fast recovery , it is an ideal choice in surgical treatment of bilateral pubic fractures.</p>

Minimal invasion and closed reduction with external fixation for elderly femoral intertrochanteric fracture / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the clinical effects of minimal invasion and closed reduction with external fixation in treating elderly femoral intertrochanteric fracture.</p><p><b>METHODS</b>From August 2007 and September 2013, 43 patients with elderly femoral intertrochanteric fracture were treated by minimal invasion and closed reduction with external fixation. There were 26 males and 17 females with an average age of 78 years old ranging from 68 to 92 years. Durations from injury to operation ranged from 1 to 8 days with an average of 3 days. According to AO classification, there were 22 cases with type A1, 15 with type A2, 6 with type A3. The time of bone healing were observed after operation and the clinical effects were evaluated by Harris scoring standard.</p><p><b>RESULTS</b>All patients were followed up from 10 to 18 months with an average of 13 months. The incisions obtained one-stage healing after removal of external fixation. All the fractures were healed and the mean healing time was 16 weeks (ranged, 12 to 18 weeks). Two patiens complicated with the thread needle loosening in the femoral trochanteric, 2 cases with the hip varus deformity and 1 case with the delayed union. No bone nonunion, external fixer breakage, blood vessel or nerve damage were found. According to the Harris scoring standard,the average Harris score of hip joint function was 85.89±7.36, and 18 cases got excellent results, 19 good.</p><p><b>CONCLUSION</b>Minimal invasion and closed reduction with external fixation can obtain satisfactory results in treating elderly femoral intertrochanteric fractures. It is a simple and effective method for elderly patients who cannot tolerate anesthesia and surgery trauma.</p>

Accuracy of magnetic resonance imaging signal intensity ratio measurements in the evaluation of multifidus muscle injury and atrophy relative to that of histological examinations.

STUDY DESIGN: A matched-pairs animal study. OBJECTIVE: To confirm the accuracy of magnetic resonance imaging (MRI) as a means of evaluating edema and fat degeneration of the multifidus muscle by comparing measurements made using MRI with those made using histological examination. SUMMARY OF BACKGROUND DATA: MRI is considered a reliable means of evaluating multifidus muscle edema and fat degeneration. However, it is not clear whether its results are always consistent with histological findings. METHODS: Models of different degrees of multifidus injury were created at the L2-L3, L3-L4, and L4-L5 disc levels in 56 New Zealand white rabbits. These were divided into 4 groups and subjected to different processes: sham surgery, dissection and stripping of the multifidus, crushing of the muscle lasting 1 hour, and crushing of the muscle lasting 2 hours. Two rabbits per group were examined at each of the indicated points in time. Multifidus edema was assessed using fat-suppressed T2 signal intensity ratio of gross multifidus to psoas (T2R) on MRI bilaterally, wet weight and wet:dry weight ratio on the left side (edema-left), and visual edema score on the right side (edema-right). Muscle fat degeneration was detected bilaterally using the T1 signal intensity ratio of gross multifidus to psoas with MRI (T1R) and visual fat degeneration score (fat score) with histology. RESULTS: Pearson correlation coefficient analyses showed significant correlations (P < 0.001) between left T2R and edema-left (r = 0.927), right T2R and edema-right (r = 0.868), and T1R and fat score (r = 0.804). A paired t test demonstrated no significant differences between MRI measurements and histological changes (P = 0.999, 1.000, and 0.998). Bland-Altman plots also depicted good agreement between MRI measurements and histological changes (limits of agreement: left multifidus edema, ± 0.75; right multifidus edema, ± 1.01; fat degeneration, ± 1.23). CONCLUSION: The MRI technique is an accuracy means of evaluating multifidus muscle injury and atrophy.

Application of vacuum sealing drainage and cryopreservation technology in hand and foot skin replantation / 中国骨伤

<p><b>OBJECTIVE</b>To summarize the clinical effect of avulsed skin replantation of hand and foot via vacuum sealing drainage (VSD) combing low temperature technique.</p><p><b>METHODS</b>From March 2012 to October 2013,13 cases with avulsed skin replantation of hand foot using combined technique included 8 males and 5 females with an average age of 32 years old ranging from 18 to 62 years. The time from injury to hospital was 1 to 4 hours (2.4 hour in average). The reasons of injury included machine injury in 7 cases and rolling over by cars in 6 cases. The parts of injuried involved finger in 2 cases,back of the hand in 5 cases and dorsum of foot in 6 cases. The area of avulsed skin was 5 cm x 6 cm to 12 cm x 16 cm,tendon and bone exposure was found in 4 cases. VSD was operated in all patients and the avulsed skin was refrigerated in the temperature of -4 °C or -80 °C. After 4 days, the skin stored in the -4 °C was replanted to the wounded place in 5 cases and in 3 cases the skin was planted to the donor site of flap. The skin stored in the -80 °C was replanted in 4 cases after 7 or 8 days, 1 case after 45 days.</p><p><b>RESULTS</b>Of the 13 cases, 1 case of degloved injury from lower leg to dorsal foot,the replanted skin was necrosis completely; 1 case of degloving injury with fourth finger,the skin which replanted after 45 days survived approximately 30%,cured after skin-graft many times. In the other cases, the survival area of replanted skin was more than 85%, all cured after dressing. According to the standard of skin survival area evaluation by Jia et al, 11 cases showed excellent, 1 showed medium and 1 showed inferior. There were no complication about grafted skin rupture after the skin survived in 11 patients,after 4 to 22 months follow-up, the resiliency of grafted skin showed good. Sensation recovery was measured by BMRC standard: 3 cases of S3, 5 cases of S3, 3 cases of S2.</p><p><b>CONCLUSION</b>VSD combining lower temperature technique in skin replantation provides time and space for wound preparation and treatment plan for the patients who need second surgery, especially for the large area skin degloving,this method could utilize the degloved skin efficiently, decrease the donor site area, alleviate the pain and financial burden,reduce the scar formation of donor site and impediment.</p>

Influencing of chronic low back pain on multifidus muscle atrophy / 中国骨伤

<p><b>OBJECTIVE</b>To identify the affect of chronic low back pain on multifidus muscle atrophy and fatty infiltration.</p><p><b>METHODS</b>From March 2010 to August 2013, a retrospective study were carried out in the department of orthopedics of patients with low back pain. Finally 31 cases were selected to this study including 19 males and 12 females with an average age of 36.4 years ranging from 23 to 55 years. The main symptoms of these patients were repeated back pain. Duration was more than 1 year. X-ray, CT, MRI showed no obvious abnormalities. The changes of net cross-sectional area of multifidus and T2 signal ratio of the same patient were measured at different time by MRI. VAS and Oswestry disability scores were recorded in two MRI examination. Correlation between these change of multifidus net area and T2 signal ratio in two times measurement and duration of low back pain, VAS, Oswestry disability scores were analyzed to find the affection of low back pain on paraspinal multifidus muscle.</p><p><b>RESULTS</b>The net multifidus cross-sectional area in same case by the second follow-up MRI is significantly smaller than that of the first follow-up, T2 signal ratio at second was significantly higher than that of the first (P < 0.05). The net cross sectional area of multifidus muscles reduced rate were positively correlated with VAS scores, duration and of Oswestry disabilitry scores (P < 0.001). The rate of increase in T2 signal ratio was not correlated with VAS scores,duration and the Oswestry disability scores (P > 0.05).</p><p><b>CONCLUSION</b>Chronic low back pain is one of the most important reasons of paraspinal multifidus muscle atrophy and fatty. The duration, VAS and Oswestry disability scores of chronic low back pain were positively correlated with the multifidus muscle atrophy.</p>

Locking plate external fixator for the treatment of middle and distal tibial fractures / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the effectiveness of locking plate external fixator in treating middle and distal tibial fractures.</p><p><b>METHODS</b>From January 2010 to January 2013,18 patients suffered from middle and distal tibial fractures were treated by locking plate external fixator,including 11 males and 7 females, with an average age of 53.5 (ranged from 13 to 80) years old,the course of disease ranged from 2 h to 3 d. According to AO classification, 4 cases were type A,11 cases were type B and 3 were type C. Among them,6 patients were open fracture, including 2 cases with type I, 3 cases with type II and 1 case with type III, according to Gustilo classification), 12 patients were close fracture. Operation time, postoperative complications were observed, and Johner-Wruhs scoring were used to evaluate clinical outcomes.</p><p><b>RESULTS</b>All patients were followed up from 6 to 15 (meaned 11) months. Two cases occurred skin necrosis (1 case occurred bone exposure), 2 cases occurred delayed union (all were open fracture), and 1 case occurred nail infection. No screw loosening or broken occurred. According to Johner-Wruhs scoring, 10 cases obtained excellent result,6 cases good,and 2 cases fine.</p><p><b>CONCLUSION</b>Locking plate external fixator for the treatment of middle and distal tibial fractures, which has advantages of lessen damage, shorter operative time, less complications and rapid functional recovery, is one of good choice.</p>

Internal fixation for the treatment of anteromedial facet fracture of the coronoid process of ulna / 中国骨伤

<p><b>OBJECTIVE</b>To investigate the effect of operative treatment for anteromedial facet fracture of the coronoid process of ulna,and to study its surgical exposures and fixation techniques.</p><p><b>METHODS</b>From March 2005 to March 2010,18 patients with anteromedial facet fracture of the coronoid process of ulna were treated with open reduction and internal fixation. There were 12 males and 6 females with an average age of 37.8 years. A single midline posterior incision was used to expose the entire elbow joint. After elevating the full-thickness skin flaps, a lateral incision was made to expose and repair the lateral collateral ligament. Three intervals in the flexor-pronator musculature were used to gain access to the coronoid,depending on the size of the fracture fragment and the planned fixation technique. Fractures were fixed by using mini-plate or with screws. The therapeutic effects were evaluated by Mayo Elbow Performance Score (MEPS) and system of Broberg & Morrey.</p><p><b>RESULTS</b>Seventeen patients were followed up, no patient complained pain and elbow unstable at a mean follow-up period of 38 months(1 to 6 years). The fractures were clinically healed at an average time of 11.6 weeks(ranged from 8 to 16 weeks). The average MEPS was 95.4+/-4.6 (ranged, 82 to 100). The average functional rating of system of Broberg & Morrey was 92.3+/-5.8 (ranged,75 to 100).</p><p><b>CONCLUSION</b>Open reduction and internal fixation is effective to reach anatomical reduction and strong fixation for the treatment of anteromedial facet fracture of the coronoid process of ulna.</p>

Progress on dynamic neutralization system in treating lumbar degenerative diseases / 中国骨伤

Dynamic stabilization technology has increasingly become the hot spot in basic and clinical research for treating lumbar degenerative diseases. As one kind of dynamic stabilization technology,dynamic neutralization system (Dynesys) keeps the spinal motion ability and improve clinical symptoms of patients, moreover, it shows a certain advantage in delaying the degeneration of adjacent segments. From the available documents,the preliminary biomechanical and clinical results of Dynesys were optimistically, it has become another choice in treating the lumbar degenerative diseases besides the lumbar fusion, and it primarily applies to the treatment of mild to moderate lumbar degenerative disease. However, it lacks a mechanism to maintain and restore the lumbar lordosis and patients need active stretching to achieve lordosis. What's more, how to extend the service life and prevent complications remain to be solved, the long-term effect and the mechanism of delaying the adjacent segment degeneration need further investigation. In this article, the design principle, biomechanical research, clinical outcome and clinical application of Dynesys was reviewed.

Case-control study on effects of two approaches on multifidus muscle injuries during lumbar interbody fusion of lumbar vertebrae / 中国骨伤

<p><b>OBJECTIVE</b>To study differences of multifidus muscle injury between Wiltse intermuscular approach and intramuscular stripping approach in one-level small incision transforaminal lumbar interbody fusion (TLIF) surgery.</p><p><b>METHODS</b>A total of 46 patients with unilateral lumbar degenerative disease underwent small incision TLIF from August 2009 to February 2011 by one group of surgeons at a single institution. The decompression side of all patients adopted intra-muscular stripping approach; for the non-decompression side, 22 patients adopted Wiltse intermuscular approach (group A),and 24 patients adopted intra-muscular striping approach (group B). In group A, there were 13 males and 9 females, ranging in age from 36 to 74 years old,averaged 52.7 +/- 9.2; 1 patient had disease in L3, 4 12 in L4,5 and 9 in L5S1. In group B,there were 11 males and 13 females,ranging in age from 32 tio 72 years old, averaged 51.8 +/- 8.7; two patients had disease in L3,4, 14 in L4,5, and 8 in L5S1. The following data were compared between the 2 groups: surgical time from skin incision to completion of pedicle screw placement, suturation time, blood loss. Clinical effects were evaluated by VAS score pre-operatively, as well as 1, 6 and 12 months post-operatively. At the latest follow-up, all the patients were evaluated by MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative level.</p><p><b>RESULTS</b>There was no obvious difference in suturation time, but less surgical time from skin incision to completion of pedicle screw placement, less blood loss, less postoperative back pain in Wiltse intermuscular approach group. For the comparison between the two groups or paired comparison between sides in the Wiltse group, the reduction of lean CSA and increase in the multifidus:psoas T2 signal intensity ratio were all significant lower in Wiltse intermuscular approach group or side.</p><p><b>CONCLUSION</b>The Wiltse intermuscular approach is an easy way for pedicle screw placement, and caused less paraspinal muscle damage than intra-muscular stripping approach, and had positive effects on less back pain.</p>

Effective comparison between improved lateral incision and the traditional L-shaped extension incision in treatment of intra-articular calcaneal fractures / 中国骨伤

<p><b>OBJECTIVE</b>To compare the clinical outcome between the two different approaches of improved lateral incision and the traditional L-shaped extension incision to treat intra-articular calcaneal fractures.</p><p><b>METHODS</b>From January 2005 to January 2008, 36 cases of intra-articular calcaneal fractures were treated by improved lateral incision or the traditional L-shaped extension incision. In improved lateral incision group, there were 19 cases including 12 males and 7 females with an average age of (38.1 +/- 9.1) years; According to Sanders classification: 8 cases were type II, 9 were type III, 2 were type IV; The time from injury to the operation was (10.5 +/- 1.7) days. In the traditional L-shaped extension incision group,there were 17 cases including 11 males and 6 females with an average age of (38.4 +/- 7.3) years; according to Sanders classification of fractures: 7 cases were type II, 9 were type III, 1 was type IV; The time from injury to the operation was (10.6 +/- 1.8) days. Observing and comparing some items of the two groups including (1) operation time, blood loss, incision length, number of graft cases, (2) VAS pain scores after the first day, (3) wound healing, (4) Maryland foot scoring, (5) postoperative imaging results were comparative analyzed.</p><p><b>RESULTS</b>Two groups of patients were followed up from 10 to 15 months with an average of 11 months. The operative time and number of graft cases were compared between two groups with no statistically significant differences. The blood loss were (94.0 +/- 9.5) ml in improved lateral incision group and (109.9 +/- 13.7) ml in L-shaped extension incision group, incision length were (6.8 +/- 1.1) cm in improved lateral incision group and (15.7 +/- 2.2) cm in L-shaped extension incision group with significant differences. Postoperative VAS pain score at the first day were (1.95 +/- 0.71) points in improved lateral incision group and (3.65 +/- 1.00) points in L-shaped incision group with significant difference. In improved lateral incision group there was 1 case of grade B wound healing, and in the traditional L-shaped extension incision group, there were 6 cases of grade B wound healing, these patients were healing by protensive time for change dress.</p><p><b>CONCLUSION</b>These two incision of improved lateral incision and the traditional L-shaped extension incision for treating the intra-articular calcaneal fractures are therapeutic equivalence. However, improved lateral incision has advantage of small incision and operative wound, and fewer wound complications.</p>

Protection of erythropoietin on experimental spinal cord injury by reducing the expression of thrombospondin-1 and transforming growth factor-beta / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Erythropoietin (EPO) functions as a tissue-protective cytokine in addition to its crucial hormonal role in red cell production and neuron protection. This study aimed to determine the neuron protective effect of erythropoietin on experimental rats enduring spinal cord injury (SCI) by assessing thrombospondin-1 (TSP-1) level and transforming growth factor-beta (TGF-beta) in the development of a rat model of SCI.</p><p><b>METHODS</b>Sixty Sprague-Dawley rats were randomly assigned to three groups: sham operation control group, SCI group and EPO treatment group. By using a weight-drop contusion SCI model, the rats in the SCI group and EPO treatment group were sacrificed at 24 hours and 7 days subsequently. The Basso, Beattie, and Bresnahan (BBB) scores were examined for locomotor function. Pathological changes were observed after HE staining. The expressions of thrombospondin-2 (TSP-1) and TGF-beta were determined by immunohistochemical staining and Western blotting.</p><p><b>RESULTS</b>Slighter locomotor dysfunction was discovered and it was recovered abruptly as higher BBB scores were found in the EPO treatment group than in the SCI group (P < 0.01). Pathologically, progressive disruption of the dorsal white matter and regeneration of a few neurons were also observed in SCI rats. TSP-1 and TGF-beta expression increased at 24 hours and 7 days after SCI in the injured segment, and it was higher in the SCI group than in the EPO treatment group. Spinal cord samples from the animals demonstrated a TSP-1 optical density of 112.2 +/- 6.8 and TSP-1 positive cells of 5.7 +/- 1.3 respectively. After injury, the TSP-1 optical density and cell number increased to 287.2 +/- 14.3/mm(2) and 23.2 +/- 2.6/mm(2) at 24 hours and to 232.1 +/- 13.2/mm(2) and 15.2 +/- 2.3/mm(2) at 7 days respectively. When EPO treated rats compared with the SCI rats, the TSP-1 optical density and cell number decreased to 213.1 +/- 11.6/mm(2) and 11.9 +/- 1.6/mm(2) at 24 hours and to 189.9 +/- 10.5/mm(2) and 9.3 +/- 1.5/mm(2) at 7 days, respectively (P < 0.01). In the SCI rats, the TGF-beta optical density and positive neuron number were 291.4 +/- 15.2/mm(2) and 28.8 +/- 4.9/mm(2) at 24 hours and 259.1 +/- 12.3/mm(2) and 23.9 +/- 4.1/mm(2) at 7 days respectively. They decreased in the EPO treated rats to 222.8 +/- 11.9/mm(2) and 13.7 +/- 2.1/mm(2) at 24 hours and to 196.5 +/- 9.7/mm(2) and 8.7 +/- 2.2/mm(2) at 7 days (P < 0.01).</p><p><b>CONCLUSIONS</b>Increased expression of TSP-1 and TGF-beta can be found in the injured segment of the spinal cord at 24 hours and 7 days after injury. EPO treatment can effectively prevent pathological alterations from severe spinal cord injury by reduced expression of TSP-1 and TGF-beta.</p>