[Accuracy and safety of robot assisted pedicle screw placement].

OBJECTIVE: To investigate the accuracy and safety of pedicle screw placement assisted by orthopedic robot and C-arm fluoroscopy. METHODS: The clinical data of 36 patients with spinal diseases underwent surgical treatment from January 2019 to August 2020 was retrospectively analyzed. Among them, 18 cases were implanted pedicle screws assisted by orthopaedic robot(observation group), including 12 males and 6 females, aged from 16 to 61 years with an average of (38.44±3.60) years;there were 1 case of adolescent scoliosis, 1 case of spinal tuberculosis, 7 cases of lumbar spondylolisthesis, 4 cases of thoracic fracture and 5 cases of lumbar fracture. Another 18 cases were implanted pedicle screws assisted by C-arm fluoroscopy(control group), including 10 males and 8 females, aged from 18 to 58 years with an average of (43.22±2.53) years;there were 1 case of adolescent scoliosis, 6 cases of lumbar spondylolisthesis, 6 cases of thoracic fracture and 5 cases of lumbar fracture. The intraoperative fluoroscopy times, nail placement time and postoperative complications were recorded in two groups. CT scan was performed after operation. The Gertzbein-Robbins standard was used to evaluate the accuracy of pedicle screw placement which was calculated. RESULTS: The number of intraoperative fluoroscopy in observation group was(6.89±0.20) times, which was significantly higher than that in control group(14.00±0.18)times(P<0.05). The placement time of each screw in observation group was(2.56±0.12) min, which was significantly different from that in control group(4.22±0.17) min (P<0.05). One case of incision infection occurred in control group after operation, and recovered after active dressing change. During the follow-up period, no serious complications such as screw loosening and fracture occurred in two groups, and there was no significant difference in complications between two groups(P>0.05). A total of 107 screws were placed in observation group, including 101 screws in class A, 4 in class B, 2 in class C, 0 in class D and 0 in class E, the accuracy rate of pedicle screw placement=[(number of screws in class A+B) / the number of all screws placed in the group] ×100%=98.1%(105/107); and a total of 104 screws were placed in control group, including 90 screws in class A, 4 in class B, 5 in class C, 5 in class D and 0 in class E, the accuracy rate of pedicle screw implantation=[(number of screws in class A+B/the number of all screws placed in the group]×100%=90.3% (94/104); there was significant difference between two groups (P<0.05). CONCLUSION: Orthopaedic robot assisted pedicle screw placement has the advantages of less fluoroscopy times, shorter screw placement time and higher accuracy, which can further improve the surgical safety and has a broad application prospect in the orthopaedic.

[Clinical application of Orthopedic Tianji Robot in surgical treatment of thoracolumbar fracture].

OBJECTIVE: To explore the clinical application of Orthopedic Tianji Robot in the treatment of thoracolumbar fractures with minimally invasive percutaneous pedicle screw internal fixation. METHODS: The clinical data of 46 patients with thoracolumbar fractures treated by minimally invasive percutaneous pedicle screw internal fixation from June 2018 to January 2020 in Gansu Provincial People's Hospital was retrospectively analyzed. According to the different aided equipments, the patients were divided into a C-arm X-ray plus robot assisted nail placement group (observation group) and simple C-arm X-ray assisted nail placement group (control group). Twenty-two patients in observation group, including 12males and 10 females, aged from 24 to 61 years old, with a mean of(40.23±12.19) years, 3 cases were T11 vertebrae fracture, 8 cases were T12, 9 cases were L1, and 2 cases were L2. And there were 24 cases in control group, including 15 males and 9 females, aged from 26 to 58 years old, with a mean of (42.88±10.31) years, 3 cases were T11 vertebrae fracture, 10 cases were T12, 7 cases were L1, and 4 cases were L2. The operation time, the number of intraoperative fluoroscopy, intraoperative blood loss, the days of hospitalization, and postoperative complications were recorded. Preoperative and postoperative VAS at 3 days, 1 week and 3 months were compared between two groups. The sagittal Cobb angle of the injured vertebral body and the percentage of the anterior edge height of the vertebral body were observed before and after operation, and evaluate the accuracy of nail placement according to the Gertzbein-Robbins classification criteria with collected postoperative CT images. RESULTS: All patients were followed up for 5 to 12 months with an average of (7.07±0.83) months. There was no significant differences in intraoperative blood loss, operation time and hospitalization days between two groups (P>0.05). The number of intraoperative fluoroscopy was (5.62±0.51) times in observation group and (12.54±0.52) in control group, the difference between two groups was statistically significant (P<0.05). The VAS, the percentage of the height of the injured vertebra anterior edge and the Cobb angle of the injured vertebral plane at each time point after operation were improved(P<0.05), but the difference between two groups was not statistically significant (P>0.05). One case of postoperative incision infection occurred in the control group, which was cured after active dressing changes. There were no serious complications such as screw loosening and breakage in all patients, and there was no statistically significant difference in the incidence of complications between two groups(P>0.05). The postoperative nail placement accuracy ratesof the observation group and the control group were 98.4% (126/128) and 90.3% (121/134), respectively, and the difference was statistically significant (P<0.05). CONCLUSION: In the surgical treatment of thoracolumbar fractures, compared with simple C-arm fluoroscopy, the pedicle screw placement assisted by Orthopedic Tianji Robot overcomes the shortcomings of surgeon's physiological tremor, fatigue and multiple intraoperative fluoroscopy, improves the accuracy of screw placement, and is a more accurate and safer way of pedicle screw placement for thoracolumbar fractures.

[Clinical study of modified one stage posterior approach total en block spondylectomy and spinal reconstruction in the treatment of invasive thoracic vascular tumor].

OBJECTIVE: To explore the surgical method and safety of modified one stage posterior approach total en block spondylectomy combined with pedicle screw fixation and titanium mesh reconstruction for the treatment of invasive thoracic vascular tumor. METHODS: The clinical data of 12 patients with invasive thoracic vasculay tumor from December 2012 to May 2015 was retrospectively analyzed. There were 8 males and 4 females, aged from 40 to 62 years with an average of 51.2 years, the course of disease was 2 months to 8 years with an average of 3.4 years. The lesions involved vertebral bodies:1 case of T2, 4 cases of T4, 1 case of T5, 2 cases of T6, 2 cases of T8, and 2 cases of T10. According to Tomita classification, there were 3 cases of typeⅠ, 3 cases of typeⅡ, 1 case of type Ⅲ, and 5 cases of type Ⅳ. The Japanese Orthopaedic Association (JOA) score was 8.0±2.7 before operation. One patient with T10 lesions had sensory dyskinesia below the umbilicus, and the muscle strength of both lower limbs was grade Ⅰ-Ⅱ, and the others 11 patients were grade Ⅲ-Ⅳ. All 12 patients underwent one stage posterior approach total en block spondylectomy and the pedicle screw fixation combined with titanium mesh reconstruction under general anesthesia and continuous motor evoked potential (MEP) spinal cord electrophysiological monitoring throughout the operation. The operation time, intraoperative blood loss and transfusion, postoperative pain and recovery of spinal cord function, bone graft fusion, tumor recurrence and other complications were followed up. RESULTS: All the operations were successful. The average operation time, intraoperative blood loss and blood transfusion were 5.5 h (4.5 to 6.0 h), 1 850 ml (1 650 to 2 500 ml), 1 050 ml (600 to 1 500 ml), respectively. All 12 patients were followed up for 5 months to 2.5 years with an average of 21 months. Local pain and lower limb muscle strength were improved to varying, and the nerve compression symptoms disappeared. The JOA score at 6 months after operation was 12.0±3.4, which was statistically significant difference compared with the preoperative 8.0±2.7 (t=3.20, P<0.05). Titanium mesh bone grafts were all fused in phaseⅠ, with an average fusion time of 4.5 months (3 to 7 months). During the follow-up period, there was no tumor recurrence, loosening or breaking of nails, sinking and displacement of titanium mesh. CONCLUSION: Modified one stage posterior approach total en block spondylectomy is an ideal surgical method for the treatment of invasive thoracic vascular tumors, which has a safe, reliable and long lasting efficacy.

[Halo-pelvic traction combined with stageâ ¡surgical correction for the treatment of severe and rigid scoliosis].

OBJECTIVE: To investigate the clinical effects of the Halo-pelvic traction combined with posterior instrumentation correction and internal fixation for the treatment of severe and rigid scoliosis. METHODS: From January 2015 to 2019 May, 16 patients with severe and rigid scoliosis were treated by the Halo-pelvic traction combined with posterior instrumentation correction. There were 7 males and 9 females, aged 14 to 28 years with an average of 17.6 years, Cobb angle was 90° to 140° with an average of (108.84±17.93) °. Including congenital scoliosis in 10 cases (6 cases of dyssegmented scoliosis, 3 cases of dysplasia, 1 case of mixed scoliosis), idiopathic scoliosis in 4 cases and neurofibromatosis in 2 cases. All patients in group had scoliosis corrected by Halo-pelvic distraction combined with posterior instrumentation correction and internal fixation. Among them, 7 cases were treated with self-made guide device for iliac bone puncture, and the other cases with traditional bare hands. The height, scoliosis Cobb angle, kyphosis Cobb angle and correction rate of 16 patients before and after surgery were observed. RESULTS: The body height was corrected from (144.88±6.32) cm to (154.56±7.87) cm ; Cobb angle of scoliosis was corrected from (108.84±17.93) ° to (42.12±7.29) °, Cobb angle of kyphosis was corrected from (64.18±16.39) ° to (33.81±6.06) °. After the Halo pelvic traction, the body height increase, Cobb angle of scoliosis and kyphosis were changed with the mean of (7.06± 5.65) cm, (41.50±9.09)%, (30.52±9.66)%, respectively. After the stage Ⅱ surgical correction, the body height increase, Cobb angle of scoliosis and kyphosis were changed with the mean of (2.63±1.78) cm, (32.47±10.80)%, (15.55±9.47)% (The baseline Cobb angle referenced by the correction rate was the Cobb angle of the previous treatment). The body height increase and correction rate of Cobb angle of scoliosis and kyphosis with staged traction combined with surgery was (9.69±5.42) cm, (61.09 ± 5.03)%, (46.07±8.60)%. There was significant difference in body height increase, correction rate of Cobb angle of scoliosis and kyphosis between before and after each period of treatment (P<0.05). CONCLUSION: Treatment of severe and rigid scoliosis with Halo-pelvic traction combined with stage Ⅱ surgical correction can significantly correct deformities and improve appearance, and has fewer surgical complications and strong clinical operability.

[Treatment of grade I and II degree degenerative lumbar spondylolisthesis with minimally invasive surgery-transforaminal lumbar interbody fusion under Quadrant channel].

OBJECTIVE: To investigate the advantages of minimally invasive surgery-transforaminal lumbar interbody fusion(MIS-TLIF) under Quadrant channel in the treatment of grade I and II degree degenerative lumbar spondylolisthesis. METHODS: The clinical data of 100 patients with grade I and II degree degenerative lumbar spondylolisthesis treated from March 2014 to March 2017 were retrospectively analyzed. Among them, 50 patients were treated with MIS-TLIF, including 19 males and 31 females, aged from 44 to 73 years old with an average of (49.83±15.46) years old; course of disease from 6 months to 7 years with the mean of (22.18±4.74) months; L4 slippage was in 30 cases and L5 slippage was in 20 cases, the slippage vertebral pedicles were intact; according to Meyerding classification, 29 cases of I degree slip and 21 cases of II degree slip. Other 50 patients were treated with open-transforaminal lumbar interbody fusion(OPEN-TLIF), including 23 males and 27 females, aged from 40 to 77 years old with an average of(50.67±14.36) years old; course of disease from 6 months to 10 years with the mean of (20.56±5.37) months; L4 slippage was in 33 cases and L5 slippage was in 17 cases, the slippage vertebral pedicles were intact; according to Meyerding classification, 34 cases of I degree slip and 16 cases of II degree slip. The operation time, length of surgical incision, intraoperative blood loss, postoperative drainage, and serum creatine kinase(CK-MM) levels before surgery and 1 day after surgery were observed. Visual analogue scale(VAS), Japanese Orthopedic Association Score (JOA), and Oswestry dysfunction index (ODI) were compared between the two groups before and after surgery. According to the imaging data, the slip rate, intervertebral space height and slip angle of the two groups before and 12 months (last follow-up) were compared. Intervertebral fusion was evaluated according to lumbar X-ray and CT at 6 and 12 months postoperatively. The clinical effect was evaluated according to the MacNab criteria at 12 months after surgery. RESULTS: All the patients were followed up for 12 months. In MIS-TLIF group, operation time, length of surgical incision, intraoperative blood loss, postoperative drainage were (118.48±21.97) min, (3.74±0.74) cm, (148.78±32.32) ml, (84.85±16.37) ml, respectively, CK-MM level was (72.31±9.79) µ/L before surgery and (415.12±25.89) µ/L at the first day after surgery. In OPEN-TLIF group, operation time, length of surgical incision, intraoperative blood loss, postoperative drainage were (115.40±11.94) min, (8.46±0.69) cm, (219.27±48.33) ml, (157.69±31.61) ml, respectively, CK-MM level was (75.48±10.73) µ/L before surgery and (506.69±37.86) µ/L at the first day after surgery. The intraoperative blood loss, postoperative drainage volume, length of surgical incision, and CK-MM level on the first postoperative day were lower in MIS-TLIF group than in OPEN-TLIF group(P<0.05), but the operation time and preoperative CK-MM levels were compared between two groups, the difference was not statistically significant (P>0.05). There were no significant differences in ODI, VAS, and JOA scores before surgery(P>0.05). The ODI, VAS, and JOA scores were significantly improved after surgery(P<0.05), and the scores of MIS-TLIF group were better than those of OPEN-TLIF group(P<0.05). At the last follow-up, the slip rate, slip angle and intervertebral space height were significantly improved in the same group(P<0.05), but there was no significant difference between two groups(P>0.05). There was no significant difference in intervertebral fusion between groups at 6 and 12 months after operation(P>0.05). According to the MacNab standard, 40 cases got excellent results, 7 good, 3 fair in MIS-TLIF group, and 35 cases got excellent results, 10 good, 5 fair in OPEN-TLIF group. One patient had incision exudation and delayed healing in MIS-TLIF group. And in OPEN-TLIF group, 1 patient had local muscle necrosis on the right side of L5 and the bacterial culture of the secretions was negative in the different three times and the right internal fixation device was taken out after the second operation completely debridement, and finally obtained delayed healing. CONCLUSIONS: The MIS-TLIF under Quadrant channel has advantage of minimally invasive trauma, less bleeding, faster function recovery and better effect in surgical treatment of grade I and II degree degenerative lumbar spondylolisthesis.

[Minimal invasive surgery-transforaminal lumbar interbody fusion combined with expanded pedicle screw through Mast Quadrant channel for the treatment of senile pyogenic discitis and vertebral osteomyelitis].

OBJECTIVE: To investigate the feasibility and clinical efficacy of minimal invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) combined with expanded pedicle screw (EPS) in the treatment of elderly patients with pyogenic discitis and vertebral osteomyelitis (PDVO). METHODS: The clinical data of 11 elderly patients with pyogenic discitis and vertebral osteomyelitis treated from January 2016 to June 2017 were retrospectively analyzed, including 7 males and 4 females, aged from 59 to 79 years old with an average of (68.09±5.34) years. The MIS-TLIF technique was used assisted by the Quadrant channel under general anesthesia for the debridement and bone fusion of these 11 elderly patients. The posterior fixation was performed with EPS. The operation time, intraoperative blood loss, intraoperative blood transfusion, and postoperative time of out of bed, postoperative complications and erythrocyte sedimentation rate(ESR)were recorded. Visual analogue scale (VAS) was used to evaluate the clinical effects and the imaging data were used to observe lumbar fusion. RESULTS: All the operations were successfully performed, the debridement was thorough, bone fusion was adequate, and no complications such as dural sac and nerve root injury were found. The operation time and intraoperative blood loss was(179.55±59.05) min and (174.55±49.22)ml, respectively. Concentrated red blood cells of (109.09±97.00) ml and plasma of (72.73±100.91) ml were given during operation. The time of out of bed was(1.19±0.83) d. All the incisions obtained healing at the first stage. The average follow-up time was(19.27±11.63) months. VAS scoring at 1 week and 6 months after surgery was 3.73±1.01 and 2.18±0.40;ESR at 6 weeks after surgery was(19.27±2.61) mm/h(decreased by more than 50%), at 6 months after surgery was (9.55±1.01) mm/h, both within normal range. During the follow-up period, all patients reached the clinical cure standard, and the bone fusion time was(5.54±1.51) months. CONCLUSIONS: MIS-TLIF combined with EPS through Quadrant channel in the treatment of elderly patients with PDVO has achieved minimally invasive surgery. The feasibility of this method also has been verified and satisfactory clinical results have been achieved. It is a safe and reliable treatment for elderly patients with spinal suppurative osteomyelitis.

[Application of total en bloc spondylectomy in spinal tumors].

Total en bloc spondylectomy is a surgical technique cutting off tumors of spine and its satellite. Previous studies have shown that this technique could reduce postoperative recurrence rate of spinal tumor, but surgical indications are not unified. Wide application of spinal tumor surgical staging and life expectancy system make it more clear for surgery. However, it is difficult to carry out extensive operation for the characteristics of more bleeding, great difficulty and high risk. As for continuous improvement of TES technology, application of endoscopy and appearance of 3D printing artificial vertebral body could push the operation becoming mature.

[Progress on research of Madelung's deformity].

Madelung deformity is a rare deformity of forearm and wrist caused by growth disorders of distal radius ulnar and palmar epiphyseal. Current studies showed that its incidence mainly associated with trauma, epiphyseal developmental abnormalities, nutritional disorders and genetic deletion or mutation. The early clinical presentation is not typical, in middle and late time, wrist deformity and weak can appear. Plain film considered as the main means of diagnosis is often lack of early diagnosis significance. Although wrist joint magnetic resonance imaging showing early soft tissue and skeletal abnormalities were used for the early diagnosis of the disease, current domestic study in magnetic resonance imaging of this deformity is less. According to the size of the distal ulnar inclination angle and palm angle, this deformity can be divided into different types. The patients with severe deformity and symptoms usually need surgical intervention including ulna revision and osteotomy of the distal radius at present. Although the two operation can achieve good clinical results, the surgical trauma, infection and postoperative risk of joint activities are more.

[Clinical application of anterior thoracoscopically assisted surgery with posterior one-stage total en block spondylectomy for thoracic spinal tumor].

OBJECTIVE: To investigate the clincial effects and feasibility of anterior thoracoscopically assisted surgery (TAS) with posterior one-stage total en block spondylectomy(TES) for thoracic spinal tumour. METHODS: From October 2014 to January 2016, 4 patients with thoracic spinal tumour were treated by anterior thoracoscopically assisted surgery with posterior one-stage total en block spondylectomy. There were 2 males and 2 females, aged 16, 35, 46, 60 years. Courses of disease were 1, 4, 6, 9 months. The tumor occurred at T4, T6, T130 segment in 1 case respectively, at double T7/T8 segments in 1 case. Preoperative visual analogue scores(VAS) were 4, 5, 6, 8 points. Frankel grade of neurologic function was grade B in 2, D in 1, and E in 1. SF-36 quality of life scores were 38, 65, 35, 29 points, including 2 cases of primary spinal tumors, 2 cases of metastatic spinal tumors. According to the classification of Tomita, 1 case was type III, 2 cases were type IV, 1 case was type VI. And according to the WBB staging, 4-9/ABCD was in 2 cases, 5-8/ABC compliated with 1-3 was in 1 case, 6-7/ABC was in 1 case. Surgical procedure: With lateral position, the thoracoscope channel was inserted. The involved intervertebral vessels and corresponding intercostal vessels were ligated, while the prevertebral large vessels were completely separated and protected. The front halves of superior and inferior involved vertebral discs were removed. Then the patients were changed to prone position, posterior one-stage total en block spondylectomy, titanium cage bone graft (allograft bone), pedicle screw fixation were performed. RESULTS: All of the operations were successful and the patients were followed up for 34, 10, 11, 12 months. Pleural effusion occurred in 1 case after operation, and pleural closed drainage was done. All incisions got primary healing; and all patients showed significant pain relief (P<0.005), with the VAS score decreasing to 2(2 cases) and 3(2 cases) scores, 2 months after surgery. No nerve functional injury aggravated. SF-36 quality of life score obviously improved with postoperative scores for 88, 92, 71, 80 at 3 months after operation. No recurrent vertebral tumor, internal fixation lossening or breakage was found at follow-up points of 3, 6, 12 months. One patient with lung cancer died of multiple organ failure at 11 months after operation. CONCLUSIONS: With anterior TAS, vertebral anterior vessels, intervertebral blood vessels, intercostal vessels were successfully separated or ligated, intraoperative bleeding was effectively controlled, lung and esophagus were effectively protected, and the tumor received wide excision. Anterior TAS and one-stage posterior TES could significantly reduce the surgical trauma and the risk of surgery.

[Intraosseous lipoma: retrospective analysis of 19 patients].

OBJECTIVE: To investigate the diagnostic and therapeutic procedures of intraosseous lipoma. METHODS: From June 1986 to January 2016, 19 patients with intraosseous lipoma were treated including 12 males and 7 females, aged from 24 to 76 years, a predilection aged was from 40 to 50 years in 13 cases. Symptoms presented with pain or swelling in 15 patients, the lesions were found incidentally in 3 patients, another case was bone defect lipoma replacement after curettage of bone cyst for 4 years. On plain X-ray flims of all bones showed a well-circumscribed radiolucent area. Diagnosis was established with CT or MRI. Among them, 16 cases were treated by surgical operation, 3 cases were treated by concervative treatment. All patients' clinical data, histologic findings and X-ray, CT and MRI were analysed. RESULTS: Total 19 patients were followed up from 9 to 42 months with an average of 15 months. There was no local tumor recurrence in 16 patients after excising the tumors, the remaining 3 patients showed no enlargement of the lesion. CONCLUSIONS: Surgical intervention is considered as an unnecessary in the patients diagnosied intraosseous lipoma by MRI or CT. Patients with symptomatic should adopt surgical treatment with curettage and bone grafting.

[Curative effect analysis on closed reduction and external fixator under local anesthesia for the treatment of intertrochanteric fracture in elderly patients with high-risk].

OBJECTIVE: To explore clinical efficacy of closed reduction and external fixation under local anesthesia for the treatment of high-risk elderly patients with intertrochanteric fracture. METHODS: From March 2013 to March 2015, 10 patients with intertrochanteric fractures treated with closing reduction and external fixator under local anesthesia were analyszed, including 4 males and 6 females, aged from 69 to 88 years old with an average of 75.2 years old. All fractures were caused by injury and classified to type I (5 cases), II (3 cases), and V (2 cases) according to Evans classification. According to American Society of Anesthesiologists (ASA), 6 cases were type III and 4 cases were type IV. Blood loss,operative time,hospital stays, postoperative complications, ambulation time and fracture healing time were observed, and Harris scoring were used to evaluate hip joint function. RESULTS: All patients were followed up from 3 to 23 months with an average of 13.1 months. One patient with chronic obstructive pulmonary disease died for non-operation reason at 4 months after operation, the other fractures were healed at stage I, the mean fracture healing time was 5.6 months. There were no coxa vara, lower limb venous thrombosis, loosen and remove of needle passage. The average operative time was 46 min, blood loss was (35.00 ± 8.46) ml without blood transfusion. One patient was occurred pulmonary infection and stent-tract infection on the 2 nd and 3 rd day after operation, and improved with active anti-infection and dressing change; the other patients gone to ground activity at 4.2 d after operation. The patients stayed hospital for 10.6 d on average. According to Harris scoring at final following-up, the total score was 83.42 ± 3.27, 3 cases obtained excellent results, 5 cases good and 1 case poor. CONCLUSION: Closed reduction and external fixation under local anesthesia in treating high-risk elderly patients with intertrochanteric fracture,which has advantages of shorter operative time, less blood loss, good recovery of postoperative function, is a safe, stable and economic method.