ObjectiveTo evaluate the long-term effectiveness of patients received surgical treatment under the guidance of “West China Classification” of desmoid-type fibromatosis (DTF) in the shoulder girdle.MethodsThe clinical data of 32 patients with DTF in the shoulder girdle admitted between June 2003 and December 2016 were retrospectively analyzed, including 14 males and 18 females, aged 14-56 years with an average age of 36.8 years. The maximum diameter of the tumor was 7-19 cm, with an average of 11.1 cm. According to the “West China Classification” of DTF in the shoulder girdle, there were 4 cases of region Ⅰ, 3 cases of region Ⅱ, 6 cases of region Ⅲ, 3 cases of region Ⅳ, 5 cases of regions Ⅰ+Ⅱ, 5 cases of regions Ⅱ+Ⅲ, and 6 cases of regions Ⅰ+Ⅱ+Ⅲ. In addition, the involvement of blood vessels and nerves was also taken into consideration for choosing a surgical approach. Finally, 12 cases were operated via anteroposterior approach (group A), 14 via posterior approach (group B), and 6 via combined anterior-posterior approach (group C). The 1993 Musculoskeletal Tumor Society (MSTS93) score (including pain, limb function, satisfaction, hand position, hand flexibility, and lifting ability), Japanese Orthopedic Association (JOA) score, range of motion (ROM) of shoulder joint (including flexion, extension, abduction, and adduction), and complications of patients in the 3 groups were recorded and compared.ResultsAll the 32 patients were followed up 30-190 months, with an average of 94.6 months. At last follow-up, complications occurred in 5 cases (15.6%), including 2 cases (16.6%) in group A, 2 (14.3%) in group B, and 1 (16.6%) in group C. There was no significant difference in the incidence of complications among the 3 groups (P=1.000). Tumor recurrence occurred in 5 (15.6%) cases, including 1 (8.3%) case in group A, 2 (14.3%) in group B, and 1 (16.6%) in group C. No significant difference was found in the recurrence rate among the 3 groups (P=1.000). At last follow-up, MSTS93 score of pain, limb function, satisfaction, hand flexibility, and hand position in groups A and B were significantly better than those in group C (P<0.05), even though no significant difference existed between group A and group B (P>0.05). The lifting ability score in group C was significantly lower than in group A (P<0.05), and no significant difference was found between other groups (P>0.05). The JOA score and flexion, extension, abduction, and adduction activities of shoulder in groups A and B were significantly better than those in group C (P<0.05). The extension activity in group A was significantly better than that in group B (P<0.05), the flexion activity in group B was significantly better than that in group A (P<0.05). There was no significant difference in other indexes between groups A and B (P>0.05).ConclusionTaking a rational approach to fully expose and completely remove the tumor is the key point of surgical treatment for patients with DTF in the shoulder girdle. At the same time, preservation of vital structures and reconstruction of soft tissues should also be taken into consideration. Overall, surgical treatment under the guidance of “West China Classification” of DTF in the shoulder girdle has achieved satisfactory long-term effectiveness.
ObjectiveTo compare the clinical and radiographic results between primary total knee arthroplasty (TKA) via mini-subvastus or conventional approach through a prospective randomized controlled study.MethodsNinety-four patients (104 knees) undergoing primary TKA between January 2011 and April 2012 were evaluated and randomly divided into 2 groups. Forty-six patients (52 knees) underwent TKA via conventional approach (conventional approach group), and 48 patients (52 knees) underwent TKA via mini-subvastus approach (mini-subvastus approach group). In these patients, 45 cases (51 knees) in conventional approach group and 45 cases (49 knees) in mini-subvastus approach group were followed up and recruited in the final analysis. There was no significant difference in age, gender, body mass index, sides, osteoarthritis grading, American Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, visual analogue scale (VAS), range of motion (ROM) of knee between 2 groups (P>0.05). The clinical indexes were recorded and analyzed, including the operation time, length of incision, total blood loss, blood transfusion after operation, hospital stay time, the time of performing straight leg raise, incision condition, VAS score, ROM of knee, HSS score, and KSS score, hip-knee-ankle angle (HKA), femoral anatomic axis and the femoral prosthesis joint angle (femoral angle), tibia anatomic axis and tibial prosthesis joint angle (tibial angle), femoral prosthesis flexion angle (FPFA), and posterior slope angle (PSA) of the tibial plateau.ResultsAll patients were followed up. The average follow-up time was 66.4 months (range, 60.0-72.5 months) in conventional approach group and 65.6 months (range, 60.0-71.2 months) in mini-subvastus approach group. Compared with the conventional approach group, the incision of mini-subvastus approach group shortened, the operation time prolonged, and the time when patients started straight leg raise exercises was earlier; showing significant differences between 2 groups (P<0.05). There was no significant difference in hospital stay time, total blood loss, and numbers of blood transfusion between 2 groups (P>0.05). The complication rate was 8.2% (4/49) in mini-subvastus approach group and 0 in conventional approach group, showing no significant difference between 2 groups (P=0.054). At 1 and 3 days, the VAS and the ROM of knee in mini-subvastus approach group were significantly better than those in conventional approach group (P<0.05); but there was no significant difference in above indexes between 2 groups at 14 day (P>0.05). There was no significant difference in HSS and KSS scores between 2 groups at the 1, 3, 6, 12 months and 3, 5 years (P>0.05). X-ray film showed no aseptic loosening in all cases. There was no significant difference in the measured values and incidence of abnormal patient of HKA, femoral angle, tibial angle, FPFA, and PSA at last follow-up between 2 groups (P>0.05).ConclusionTKA via mini-subvastus approach is helpful to the early function recovery of knee, but the long-term effectiveness is consistent with TKA via conventional approach. As the limited exposure, TKA via mini-subvastus spproach may has high risk of operative complications.
Objective To explore decompression strategies for lateral lumbar spinal stenosis under unilateral biportal endoscopy (UBE) assistance. Methods A clinical data of 86 patients with lateral lumbar stenosis treated with UBE-assisted intervertebral decompression between September 2022 and December 2023 was retrospectively analyzed. There were 42 males and 44 females with an average age of 63.6 years (range, 45-79 years). The disease duration ranged from 6 to 14 months (mean, 8.5 months). Surgical levels included L2, 3 in 3 cases, L3, 4 in 26 cases, L4, 5 in 42 cases, and L5, S1 in 15 cases. According to Lee’s grading system, there were 21 cases of grade 1, 37 cases of grade 2, and 28 cases of grade 3 for lumbar spinal stenosis. Based on the location of stenosis and clinical symptoms, the 33 cases underwent interlaminar approach, 7 cases underwent interlaminar approach with auxiliary third incision, 26 cases underwent contralateral inclinatory approach, and 20 cases underwent paraspinal approach; then, the corresponding decompression procedures were performed. Visual analogue scale (VAS) score was used to evaluate lower back/leg pain before operation and at 1 and 3 months after operation, while Oswestry disability index (ODI) was used to evaluate spinal function. At 3 months after operation, the effectiveness was evaluated using the modified MacNab evaluation criteria. The spinal stenosis and decompression were evaluated based on Lee’s grading system using lumbar MRI before operation and at 3 months after operation. ResultsAll procedures were successfully completed with mean operation time of 95.1 minutes (range, 57-166 minutes). Dural tears occurred in 2 cases treated with interlaminar approach with auxiliary third incision. All incisions healed by first intention. All patients were followed up 3-10 months (mean, 5.9 months). The clinical symptoms of the patients relieved to varying degrees. The VAS scores and ODI of lower back and leg pain at 1 and 3 months after operation significantly improved compared to preoperative levels (P<0.05), and the indicators at 3 months significantly improved than that at 1 month (P<0.05). According to the modified MacNab evaluation criteria, the effectiveness at 3 months after operation was rated as excellent in 52 cases, good in 21 cases, and poor in 13 cases, with an excellent and good rate of 84.9%. No lumbar instability was detected on flexion-extension X-ray films during follow-up. The Lee’s grading of lateral lumbar stenosis at 2 days after operation showed significant improvement compared to preoperative grading (P<0.05). ConclusionFor lateral lumbar spinal stenosis, UBE-assisted decompression of the spinal canal requires the selection of interlaminar approach, interlaminar approach with auxiliary third incision, contralateral inclinatory approach, and paraspinal approach based on preoperative imaging findings and clinical symptoms to achieve better effectiveness.
ObjectiveTo investigate the effectiveness of the extended Carlson approach in the treatment of lateral femoral condylar Hoffa fractures.MethodsThe clinical data of 17 patients with lateral femoral condyle Hoffa fractures between September 2012 and January 2019 were retrospectively analyzed. There were 10 males and 7 females, with a mean age of 43 years (range, 32-68 years). Fractures were caused by traffic accident in 9 cases, by falling from height in 6 cases, and by the other mechanism in 2 cases. According to the Letenneur’s classification, there were 8 cases of typeⅠ, 6 cases of type Ⅱ, and 3 cases of type Ⅲ. The mean time from injury to operation was 7 days (range, 3-32 days). All patients were treated with extended Carlson approach. Patients with Letenneur types Ⅰ and Ⅲ were fixed by a posterior antigliding plate combined with headless compression screws from anteroposterior direction, and patients with Letenneur typeⅡ were fixed by headless compression screws from anteroposterior direction. The anteroposterior and lateral X-ray films, CT and three-dimensional reconstruction of the knee joint were taken after operation to assess fracture healing and position of the internal fixators. The knee function was evaluated according to Letenneur’s functional assessment system.ResultsAll patients were followed up 13-28 months (mean, 15 months). All the incisions healed by first intention, and no complication such as fracture redisplacement, fracture nonunion, internal fixator fracture, and common peroneal nerve injury occurred. The mean time of fracture healing was 18 weeks (range, 16-32 weeks). At last follow-up, according to Letenneur’s functional assessment system, the knee function was excellent in 12 cases and good in 5 cases, with an excellent and good rate of 100%.ConclusionThe extended Carlson approach for the treatment of lateral femoral condylar Hoffa fractures has the advantages of clear exposure, easy reduction and fixation, high fracture healing rate, few complications, and good recovery of knee joint function.
ObjectiveTo investigate the effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space.MethodsTwelve patients with lower cervical interlocking fracture and dislocation were analyzed retrospectively between January 2013 and June 2015. There were 7 males and 5 females, aged 25-59 years with an average age of 38.4 years. The disease duration was 9.6 hours to 100 days with an average of 7.3 days. There were 8 cases of unilateral locking and 4 cases of bilateral locking; 4 cases of old injury and 8 cases of fresh injury. The injured segments were 2 cases of C3, 4, 5 cases of C4, 5, 3 cases of C5, 6, and 2 cases of C6, 7. According to Meyerding classification, there were 9 cases of grade Ⅰ and 3 cases of grade Ⅱ. According to the functional classification of American Spinal Injury Association (ASIA), there were 2 cases of grade C, 6 cases of grade D, and 4 cases of grade E. The interlocking facet was released through the Luschka joint and anterior lamina space, and the anterior cervical fusion and internal fixation were used to treat the fracture and dislocation of the lower cervical spine. The recovery of spinal cord function was judged by the functional classification of ASIA; visual analogue scale (VAS) score, neck disability index (NDI) score, modified Japanese Orthopaedic Association (m-JOA) score were used to evaluate the clinical efficacy; the Cobb angle of fusion segment were observed by X-ray film. The intervertebral bone graft fusion was evaluated at 6 months after operation.ResultsThe average operation time was 78.30 minutes, the average intraoperative blood loss was 167.30 mL, and the average postoperative drainage volume was 58.12 mL. No blood transfusion was given during or after operation. During the operation, there was no accidental injury of large blood vessels, esophagus, and trachea; no laryngo edema, dysphagia, hoarseness, and cerebrospinal fluid leakage occurred after operation; no spinal cord injury or nerve root injury aggravated; the incision healed by first intention, and no infection occurred. All 12 cases were followed up 15-20 months, with an average of 16.5 months. The symptoms and function of the nerve injury were significantly improved when compared with that before operation. Re-examination of the cervical spine X-ray film at 6 months after operation showed that the Cage or bone graft was not displaced or broken, the screw was not loosened or detached, and the intervertebral graft fusion rate was up to 100%. At last follow-up, the ASIA grade, Cobb angle of fusion segment, neck pain VAS score, m-JOA score, and NDI score were significantly improved when compared with preoperative one (P<0.05).ConclusionThe effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space is clear, which not only can make the injured segment get satisfactory reduction, immediate stability and reconstruction, and full decompression, but also can effectively prevent the secondary injury of spinal cord.
Objective To explore the clinical value of preoperative neoadjuvant chemotherapy (NAC) combined with laparoscopic pancreatoduodenectomy (LPD) with multiple surgical approaches in the treatment of borderline resectable pancreatic head cancer. Methods The clinicopathologic data of 35 patients with critical resectable pancreatic head carcinoma admitted to the Department of Hepatobiliary and Pancreatic Surgery of Luoyang Central Hospital Affiliated to Zhengzhou University and the Department of Hepatobiliary and Pancreatic Surgery of the Fifth Affiliated Hospital of Zhengzhou University from January 2017 to June 2022 were retrospectively analyzed. All patients received NAC before operation (AG protocol). At the end of the course of treatment, according to the type of borderline resectable pancreatic cancer (BRPC) [venous invasion type (BRPC-V type) and arterial invasion type (BRPC-A type)], take the individualized surgical approach for LPD (BRPC-V type: inferior mesenteric vein approach; BRPC-A type: left posterior approach, medial uncinate process approach, anterior approach, or lower mesocolon approach). The intraoperative condition, R0/R1 resection rate, lymph node dissection, postoperative complications, average hospital stay, recovery, follow-up and survival were recorded. Results① Efficacy evaluation of NAC: 13 patients were partially relieved , 17 patients were stable and 5 patients were progressive after 4 weeks of treatment. Five progressive patients continued to receive comprehensive internal medicine treatment, and the remaining 30 patients underwent LPD. ② Intraoperative situation: LPD were successfully completed in 30 patients, 2 patients underwent extended pancreaticoduodenectomy combined with superior mesenteric vein (or) portal vein reconstruction among them. Among the 30 patients with LPD, there were 10 cases of inferior mesenteric vein approach, 10 cases of left posterior approach, 6 cases of medial uncinate process approach, 1 case of left posterior approach+medial uncinate process approach, 2 cases of anterior approach, and 1 case of inferior mesocolon approach. The mean operative time was (379.4±77.3) min, the intraoperative blood loss was (436.9±95.1) mL. ③ Postoperative situation: The incidence rate of postoperative surgery-related complications was 33.3% (10/30), including 4 cases of Clavien-Dindo grade Ⅰ [biliary fistula in 1 case (3.3%), A-grade pancreatic fistula in 1 case (3.3%), gastric draining dysfunction in 1 case (3.3%), diarrhea in 1 case (3.3%)], 5 cases of grade Ⅱ [pulmonary infection in 2 cases (6.6%), B-grade pancreatic fistula in 2 cases (6.6%), abdominal infection in 1 case (3.3%)], and 1 case of grade Ⅲ [gastroduodenal artery stump bleeding (3.3%)]. Among the 10 patients with complications, 9 cases recovered after symptomatic treatment, and 1 case died, with a fatality rate of 3.3% (1/30). The mean postoperative hospital stay was (17.3±5.5) days. ④ Excision rate and pathological results: R0 resection rate was 90.0% (9/10) in 10 patients with BR-PV type LPD, and R1 resection was performed in 1 patient. R0 resection rate was 75.0% (15/20) in 20 patients with BR-A type, and R1 resection was performed in 5 patients (2 patients with medial uncinate process approach; Left posterior approach in 2 cases; Submesocolon approach was used in 1 case). In 30 patients with LPD, the total R0 removal rate was 80.0% (24/30), the number of lymph nodes dissected was (11±5). Pathological type: There were 26 cases (86.7%) of ductal adenocarcinoma in 30 patients, 1 case of adeno-squamous carcinoma (3.3%), 1 case of mucinous carcinoma (3.3%), 2 cases of acinocytic cell carcinoma (6.7%). 23 cases (76.7%) of medium-high differentiation and 5 cases (16.6%) of low differentiation, two cases (6.7%) were undifferentiated. ⑤ Postoperative follow-up and survival: 30 patients were completely followed-up for 6-39 months, with a median follow-up time of 17 months. The median survival time of BRPC-V and BRPC-A patients was 24.0 months and 17.0 months, respectively. The overall survival rates of 30 patients at 1, 2 and 3 years after operation were 77.3%、46.5% and 13.7%, respectively. Conclusion The selection of preoperative NAC combined with individualized surgical approach for patients with borderline resectable pancreatic head cancer is beneficial to improve the radical resection rate and clinical therapeutic effect, and has good clinical application value.
ObjectiveTo summarize the advantages and disadvantages of different surgical approaches in thyroidectomy using the da Vinci robotic surgical system. MethodThe relevant to articles about da Vinci robotic thyroidectomy via different surgical approaches at home and abroad were retrieved and reviewed. ResultsThe robot-assisted transaxillary thyroidectomy had a definite curative effect and was a mature technology. The bilateral axillary-breast approach thyroidectomy had a wide range of applications and was suitable for beginners. The robotic retroauricular approach thyroidectomy had great advantages in the dissection of lateral cervical lymph nodes. The transoral robotic thyroidectomy was a surgical approach that conformed to the minimally invasive concept. Conclusions Da Vinci robotic thyroidectomy via different surgical approaches has its corresponding application scope and advantages. Clinical surgeons should choose an optimal surgical approach according to the tumor location, size and number of patients and the advantages of the operator, so as to achieve the therapeutic effect of radical cure of tumors and reduction of injury.
Objective To review the research on different surgical approaches and MRI evaluation of total hip arthroplasty (THA), to clarify the possible muscle damage caused by different approaches, and to help clinicians avoid intraoperative muscle damage and identify the causes of certain muscle-related complications after operation. MethodsThe research literature on different surgical approaches and MRI evaluation of THA at home and abroad was extensively reviewed to summarize the MRI performance of the posterior approach, modified direct lateral approach, direct anterior approach, and minimally invasive anterolateral approach (also called Orthopadische Chirurgie Munchen approach). Results The traditional posterior approach mainly damages the short external rotator muscle group and increases the incidence of postoperative dislocation; the piriformis-keeping posterior approach significantly improves the quality of the pyriformis tendon in the postoperative period, but it may lead to damage to the intrapelvic portion of the piriformis muscle. The modified direct lateral approach mainly damages the gluteus medius muscle, which increases the risk of postoperative claudication. The direct anterior approach mainly damages the vastus tensoris muscle and may result in damage to the short external rotator muscle group and the muscles around the incision. The minimally invasive anterolateral approach primarily damages the superior gluteal nerve, which subsequently leads to denervation of the broad fascial tensor fasciae latae, and this approach may also result in injury to the gluteus medius and gluteus minimus muscles. The muscle damage status significantly affects prognosis, and the minimally invasive approach is more suitable for elderly patients. ConclusionMRI can clarify the different types of muscle damage caused by different surgical approaches. Minimally invasive approaches can reduce muscle damage and improve postoperative function compared with traditional approaches, and can benefit elderly patients more, but due to the small field, forcing to expand the surgical field will lead to unintended muscle damage and reduce postoperative function.
Objective To investigate the effectiveness of posterior minimally invasive approach in the treatment of posterior wall acetabular fractures. Methods The clinical data of 17 patients with posterior wall acetabular fractures treated with posterior minimally invasive approach between March 2019 and June 2023 were retrospectively analyzed. There were 14 males and 3 females with an average age of 41 years ranging from 28 to 57 years. The causes of injury were traffic accident in 12 cases and falling from height in 5 cases. There were 3 cases complicated with posterior hip dislocation and 2 cases complicated with sciatic nerve injury. According to AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 11 cases of type A1.1 and 6 cases of type A1.2. The time from injury to operation was 5-8 days, with an average of 6.2 days. The incision length, intraoperative blood loss, and operation time were recorded. The quality of posterior wall fracture reduction were evaluated by Matta criteria, and hip function were evaluated by modified Merle d’Aubign-Postel score criteria at 6 months after operation and last follow-up. Results The operation was successfully completed in 17 cases. The length of incision ranged from 7 to 9 cm, with an average of 8.3 cm, and all incisions healed by first intention. The intraoperative blood loss ranged from 200 to 350 mL, with an average of 281 mL. The operation time ranged from 45 to 70 minutes, with an average of 57 minutes. Two patients had sciatic nerve injury before operation, and the sciatic nerve function recovered completely at 3 months after operation; the other 15 patients had no symptoms of sciatic nerve injury after operation. All the 17 patients were followed up 14-27 months, with an average of 19.5 months. At 1 week after operation, according to the Matta criteria, anatomical reduction was achieved in 12 cases and satisfactory reduction in 5 cases, with a satisfaction rate of 100%. According to the modified Merle d’Aubign-Postel scoring system, the hip function score was 13-18 (mean, 16.1) at 6 months after operation. Among them, 5 cases were excellent, 9 were good, and 3 were fair, with an excellent and good rate of 82.4%. At last follow-up, the hip function score was 7-18 (mean, 13.7), of which 3 cases were excellent, 9 were good, 3 were fair, and 2 were poor, with an excellent and good rate of 70.6%. During the follow-up, there was no infection, failure of internal fixation, and femoral head necrosis, and heterotopic ossification occurred in 2 cases. ConclusionThe posterior minimally invasive approach has the advantages of less trauma, shorter operation time, less blood loss, without cutting off the external rotator muscle. Exposure through the gluteus medius-piriformis space and piriformis-supercilium space can provide sufficient safe exposure for the posterior wall acetabulum fracture, which is a reliable alternative approach for the posterior acetabular fracture.
ObjectiveTo review the research progress of different surgical approaches in the treatment of acetabular both-column fractures.MethodsThe domestic and foreign related research literature on surgical approaches for acetabular both-column fractures was extensively consulted. The anatomical characteristics, exposure ranges, advantages, disadvantages, and indications of various common surgical approaches for both-column fractures were mainly summarized.ResultsThe ilioinguinal approach is more suitable for both-column fractures if the anterior column fracture is complicated or combined with the anterior wall fracture while the posterior column fracture is simple and stable. The modified Stoppa approach or the lateral (para) rectus abdominal approach is the preferred choice when both-column fractures are combined with a quadrilateral fracture or femoral head dislocation. What’s more, the Kocher-Langenbeck approach is required when the posterior column fractures are complicated or combined with posterior wall fractures. In addition, the simultaneous ilioinguinal and Kocher-Langenbeck approaches are the first choices when the both-column fractures possessing extremely severe and obvious displacement.ConclusionThe reasonable choice of surgical approach is extremely important for acetabular both-column fractures. Each surgical approach has its advantages and limitations. It is necessary to take the precise reposition of the acetabular joint surface as the principle, and comprehensively judge the fracture types and severity of anterior column, posterior column, and square area, and then select the optimal surgical approach for surgical treatment.