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Abstract To illustrate the surgical technique and explore clinical outcomes of the reconstruction for the malignant and metastatic bone tumour of proximal femur with metallic modular intercalary prosthesis. Sixteen patients who underwent modular intercalary prosthetic reconstruction after tumour resection were included from April 2012 and October 2020. Prosthesis and screws parameters, resected bone length and residual bone length, clinical outcomes and survivorship were analyzed. All patients were followed up for an average of 19 months (range 1–74). In our series, 12 patients died of the progression of the primary disease at the final follow-up. The cumulative survivorship since the treatment of proximal femoral metastasis was 78.6% (11 patients) at 6 months and 38.5% (5 patients) at 1 year. The mean MSTS score was 22.25 ± 4.55 among all patients. There were no cases of loosening or breakage of the prostheses, plates or screws, despite the various measurements of prostheses and residual bones. Modular intercalary prosthetic reconstruction was an effective method for malignant tumour of the proximal femur, including the advantages of providing early pain relief, quickly restoring postoperative function, required a short operation time, and preserving the adjacent joints.

Calcium sulfate and calcium sulfate-based biomaterials have been widely used in non-load-bearing bone defects for hundreds of years due to their superior biocompatibility, biodegradability, and non-toxicity. However, lower compressive strength and rapid degradation rate are the main limitations in clinical applications. Excessive absorption causes a sharp increase in sulfate ion and calcium ion concentrations around the bone defect site, resulting in delayed wound healing and hypercalcemia. In addition, the space between calcium sulfate and the host bone, resulting from excessively rapid absorption, has adverse effects on bone healing or fusion techniques. This issue has been recognized and addressed. The lack of sufficient mechanical strength makes it challenging to use calcium sulfate and calcium sulfate-based biomaterials in load-bearing areas. To overcome these defects, the introduction of various inorganic additives, such as calcium carbonate, calcium phosphate, and calcium silicate, into calcium sulfate is an effective measure. Inorganic materials with different physical and chemical properties can greatly improve the properties of calcium sulfate composites. For example, the hydrolysis products of calcium carbonate are alkaline substances that can buffer the acidic environment caused by the degradation of calcium sulfate; calcium phosphate has poor degradation, which can effectively avoid the excessive absorption of calcium sulfate; and calcium silicate can promote the compressive strength and stimulate new bone formation. The purpose of this review is to review the poor properties of calcium sulfate and its complications in clinical application and to explore the effect of various inorganic additives on the physicochemical properties and biological properties of calcium sulfate.

Abstract Background The present study aimed to evaluate the indications, feasibility, clinical effectiveness and complications of the treatment with microwave in situ inactivation followed by curettage and bone grafting assisted with internal fixation, for the proximal humerus tumors. Methods The clinical data of 49 patients with primary or metastatic tumor of the proximal humerus who received intraoperative microwave inactivation in situ with curettage and bone grafting in our hospital from May 2008 to April 2021 were retrospectively analyzed. Results There were 25 males and 24 females, with an average age of 57.6 ± 19.9 years (range, 20–81). All patients were followed up for 7 to 146 months, with an average period of 69.2 ± 39.8 months. Up to the last follow-up, 14 patients died. The 5-year overall survival was 67.3%, and 5-year tumor-specific survival was 71.4%. The 5-year tumor-specific survival rates were 100% for aggressive benign tumors or low potential malignancy tumors, 70.1% for primary malignancies, and 36.9% for metastatic tumors. The average preoperative MSTS, constant-Murley and VAS scores were 16.81 ± 3.85, 62.71 ± 12.56 and 6.75 ± 2.47, which were all significantly improved at 6 weeks after operation and at the final follow-up (P

Objective To explore the potential effect of three allogenic bone substitute configurations on the viability, adhesion, and spreading of osteoblasts in vitro. Methods Freeze‐dried cortical bone were ground and fractions were divided into three groups with different sizes and shapes, defined as bone fiber (0.1 mm × 0.1 mm × 3 mm), bone powder (0.45–0.9 mm), and bone granule group (3–6 mm). MC3T3‐E1 cells were divided and co‐cultured within groups to induce cell adhesion. The configuration of allogenic bone was captured by scanning electron microscopy and confocal laser scanning microscopy, and substrate roughness values were quantified. Cell adhesion rate was assessed using the hemocyte counting method, cell viability was determined by CCK‐8 assay and live/dead staining, and cell morphology was visualized by Phalloidin and DAPI, and the mRNA expression of adhesion‐related gene (vinculin) of different substitutes were determined with quantitative real‐time polymerase chain reaction. Results The roughness values of bone fiber, bone powder, and bone granule group were 1.878 μm (1.578–2.415 μm), 5.066 μm (3.891–6.162 μm), and 0.860 μm (0.801–1.452 μm), respectively (bone powder group compared with bone granule group, H = 18.015, P 0.05). In addition, representative cell adhesion rates at 24 h showed significantly lower cell adhesion rate in bone fiber group (20.3 ± 1.6%) compared to bone powder (29.3 ± 4.4%) and bone granule group (27.3 ± 3.2%) (F = 10.51，P = 0.009 and P = 0.034, respectively), but there was no significant difference between the latter two groups (P > 0.05). Interestingly, the expression of vinculin mRNA steadily decreased in a time‐dependent manner. The vinculin expression reached its peak at 6 h in each group, and the vinculin levels in bone fiber, bone powder, and bone granule group were 2.119 ± 0.052, 3.842 ± 0.108, and 3.585 ± 0.068 times higher than those in the control group, respectively (F = 733.643, all P

Objective For reconstructing the posterior cervical muscular–ligament complex, attachment points and various modified techniques were designed and applied in clinical practice. This study investigated the clinical and radiographic outcomes of open door laminoplasty with modified centerpiece mini‐plate fixation and extensor attachment point reconstruction in the treatment of cervical spondylotic myelopathy (CSM). Methods Sixty‐nine patients with CSM who underwent C3–C7 open door laminoplasty at our hospital from January 2016 to May 2018 were divided into two groups: 37 and 32 patients underwent laminoplasty with modified and conventional centerpiece titanium plate fixation (MPF and CPF groups), respectively. Changes in cervical spinal angle (CSA), cervical range of motion (ROM), posterior cervical muscle atrophy, neurological function (Japanese Orthopaedic Association [JOA] score), Neck Disability Index (NDI), and axial symptom severity were compared between the two groups. Results There were no significant differences in operative duration (136.7 ± 23.9 vs 128.3 ± 21.5 min, t = 1.525, p > 0.05), volume of intraoperative blood loss (275.9 ± 33.1 vs 268.2 ± 31.6 ml, t = 0.984, p > 0.05), lamina open angle (41.2° ± 4.5° vs 39.4° ± 4.1°, t = 1.726, p > 0.05), and spinal cord drift distance (2.4 ± 0.3 vs 2.3 ± 0.4 mm, t = 1.184, p > 0.05) between the two groups. After surgery, JOA score significantly increased (p 0.05). The NDI score was significantly decreased in both the groups (p 0.05). CSA decreased from 21.7° ± 2.8° to 18.3° ± 2.1°, and posterior cervical muscle cross‐sectional area decreased from 35.2 ± 4.9 cm2 to 31.0 ± 4.1 cm2 in the CPF group (p 0.05). Postoperative axial symptom severity was significantly worse in the CPF group than in the MPF group (Z = −2.357, p

Objective Pre‐implantation sterilization procedures for tendons are important measures to reduce the risk of disease transmission, however these procedures may compromise tendon microarchitecture and biomechanical properties to varying degrees. We explore the effects of different sterilization procedures on the micro‐histology, biomechanical strength and biochemical properties of human tendon allografts in vitro study. Methods The tendon allografts were harvested from cadaveric donors after the donors were serologically screened by antibody or nucleic acid testing of infectious agents. All samples were divided into five groups, which were fresh‐frozen group (control group), 15 kGy gamma irradiation group, 25 kGy gamma irradiation group, 70% ethanol group, and peracetic acid‐ethanol group. Each group included 10 tendons for testing. Histological staining and transmission electron microscopy were applied to observe the internal structure and arrangement of tendon collagen fibers, while the machine learning classifier was trained to distinguish the darker cross‐sections of collagen fibers and brighter backgrounds of the electron micrograph to detect the distribution of diameters of tendon collagen fibers. The viscoelasticity, mechanical properties and material properties of tendon allografts were examined to detect the influence of different intervention factors on the biomechanical properties of tendons. Results Histological staining and transmission electron microscopy showed that the structure of fresh‐frozen tendons was similar to the structures of other experimental groups, and no obvious fiber disorder or delamination was observed. In the uniaxial cyclic test, the cyclic creep of 25 kGy irradiation group (1.5%) and peracetic acid‐ethanol group (1.5%) were significantly lower than that of the control group (3.6%, F = 1.52, P = 0.039) while in the load‐to‐failure test, the maximum elongation and maximum strain of the peracetic acid‐ethanol group were significantly higher than those of the control group (F = 4.60, P = 0.010), and there was no significant difference in other biomechanical indicators. According to the experimental results of denatured collagen, it could be seen that no matter which disinfection procedure was used, the denaturation of the tendon sample would be promoted (F = 1.97, P = 0.186), and high‐dose irradiation seemed to cause more damage to collagen fibers than the other two disinfection procedures (296.2 vs 171.1 vs 212.9 μg/g). Conclusion Biomechanical experiments and collagen denaturation tests showed that 15 kGy gamma irradiation and 70% ethanol can preserve the biomechanical strength and biochemical properties of tendons to the greatest extent, and these two sterilization methods are worthy of further promotion.

Objectives The restoration of as much normal function as possible has become an important goal following the endoprosthetic reconstruction. The objective of this study was to assess the functional outcome after endoprosthetic reconstruction for tumors around the knee and to explore prognostic factors of functional outcome. Methods We retrospectively collected data on patients who underwent tumor prosthetic replacements consecutively. Musculoskeletal Tumour Society score and Toronto Extremity Salvage Score were used to assess the functional outcome at 1, 3, 6, 12, and 24 months after surgery. The logistic model was used to select factors that had potential predictive value for postoperative function. Potential prognostic factors included age, gender, tumor site, type of tumor, length of bone resection, type of prosthesis, length of prosthetic stem, chemotherapy, pathological fracture, and body mass index. Results At the 24 months after surgery, the mean musculoskeletal tumor society (MSTS) score was 81.4% and the mean Toronto extremity salvage score (TESS) was 83.6%. At the last follow-up, 68% of patients and 73% of patients received perfect or good MSTS score and TESS score, respectively. The multivariate analysis according to ordered-logit model showed that age

Unicompartmental knee osteoarthritis (UKOA) is the early stage of knee joint degeneration, which is characterized by unicompartmental degeneration and mostly occurs in medial compartment. Pain and limited motion are main symptoms, which affect patients' life quality. Periarticular knee osteotomy (PKO) for lower extremity alignment correction is an effective treatment for UKOA with abnormal alignment, which could relieve pain and improve joint function by adjusting lower extremity alignment. At present, no clinical guidelines are available for the treatment of UKOA by PKO for lower extremity alignment correction. Experts from the Clinical New Technology Application Committee of the Chinese Hospital Association, Joint Surgery Study Group of the Chinese Orthopaedic Association of the Chinese Medical Association, and Osteoarthritis Study Group of the Chinese Association of Orthopaedic Surgeons of the Chinese Medical Doctor Association formulated these guidelines. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) grading system and the Reporting Items for Practice Guidelines in Healthcare (RIGHT) were adopted to select 25 most concerning questions. Finally, 25 recommendations were formulated through evidence retrieval, evidence quality evaluation, and the determination of directions and strength of recommendations. Recommendation items 1–5 are indications and contraindications for PKO for lower extremity alignment correction, items 6–21 are surgical methods and principles, item 22 describes 3D printing corrective osteotomy technique, and items 23–25 address the perioperative period, follow‐up management, and other content. These guidelines are designed to improve the normalization and standardization of KOA treatment by PKO for lower extremity alignment correction.

Objective To propose a simple and practical clinical classification for tenosynovial giant cell tumor (TGCT) of the knee. Methods A retrospective study was conducted to verify the value and significance of this clinical classification. TGCT growth patterns, knee joint capsule, and bone erosion were applied to establish this novel clinical classification. Seventy‐eight patients who underwent surgery for TGCT from 2008 to 2016 were identified. This novel clinical classification was retrospectively applied to patients' existing classification, and patients with different TGCT types were statistically compared to verify the significance of the clinical classification. Results The clinical classification included three types and four subtypes. Type 1: localized TGCT, Subtype 1a: localized intra‐articular TGCT, Subtype 1b: localized extra‐articular TGCT. Type 2: diffuse TGCT, Subtype 2a: diffuse intra‐articular TGCT with bone normal, Subtype 2b: diffuse intra‐articular TGCT with bone destruction. Type 3: diffuse TGCT across the knee joint capsule. The mean follow‐up time for the 78 patients was 59.6 months. Twenty‐one patients were in Subtype 1a, four were Subtype 1b, 38 were Subtype 2a, seven were Subtype 2b, and eight were Type 3. Oncological results and surgical complications differed significantly (P = 0.000, P = 0.000). The mean Musculoskeletal Tumor Society functional scores differed significantly at 27.8 for Type 1 patients, 22.9 for Type 2 patients, and 17.0 for Type 3 patients (P = 0.000). Conclusions This clinical classification can be easily used to evaluate TGCT of all knees prior to surgery or other treatments and can help determine surgical options.

Objective To investigate the correlation between computed tomography (CT) values and bone mineral density (BMD) in elderly Chinese patients with proximal humeral fractures. Methods This was a single‐center retrospective study involving 166 elderly patients with proximal humeral fractures between January and June 2015 in our hospital. Following the inclusion and exclusion criteria, 89 patients were finally enrolled in this study. The spiral CT scanning was performed on these patients, and the CT images were obtained by using MIMICS software. The CT values in axial, coronal, and sagittal images of healthy proximal humeri were measured using a circular region of interest (ROI) by Image J. The bone mineral density (BMD) of the lumbar spine and femoral neck was measured using dual‐energy X‐ray absorptiometry (DXA). Spearman rank correlation methods were used for analysis of the association between the proximal humerus average CT value (CTMean) and the lumbar spine as well as femoral neck BMD in patients with proximal humeral fractures, or osteoporotic patients. Results Among the included 89 patients, there were 26 males and 63 females, 69% and 84% of whom were diagnosed with osteoporosis, respectively. The lumbar spine and femoral neck BMD and the CTMean of the proximal humerus were higher in males than females with proximal humeral fractures (P

Abstract Background Prosthesis-related complications, after knee reconstruction with endoprosthesis during operation for tumors around the knee, remain an unresolved problem which necessitate a revision or even an amputational surgery. The purpose of the current study was to identify significant risk factors associated with implant failure, and establish a novel model to predict survival of the prosthesis in patients operated with endoprostheses for tumor around knee. Methods We retrospectively reviewed the clinical database of our institution for patients who underwent knee reconstruction due to tumors. A total of 203 patients were included, including 123 males (60.6%) and 80 (39.4%) females, ranging in age from 14 to 77 years (mean: 34.3 ± 17.3 years). The cohort was randomly divided into training (n = 156) and validation (n = 47) samples. Univariable COX analysis was used for initially identifying potential independent predictors of prosthesis survival with the training group (p

According to the Global Cancer Statistics 2020 report, breast cancer is the most commonly diagnosed cancer worldwide. Patients with mammary cancer live longer due to the continuous optimization of chemotherapy, targeted drugs, and hormone therapy, which will inevitably lead to an increase in the prevalence of metastatic bone tumors. Bone metastasis affects approximately 8% of patients with mammary cancer, with the spine being the most common site. Metastatic neoplasms can invade the centrum and its attachments, leading to local pain, spinal instability, vertebral pathological fractures, spinal cord compression, impaired neurological function, and paralysis, ultimately reducing the quality of life. Multidisciplinary and personalized management using analgesic drugs, endocrine therapy, corticosteroid therapy, chemotherapy, bisphosphonates, immunotherapy, targeted drugs, radiotherapy, and surgery has been advocated for the treatment of spinal metastases. Multiple paradigms and systems have been proposed to determine suitable treatments. In the early stages, the occurrence of metastasis indicates a terminal stage of the tumor process in patients with malignant tumors, implying that their lifespan is limited. As a result, the choice of treatment is heavily influenced by longevity. However, with the development of treatment methods, the lifespan of patients with tumors has considerably increased in recent years. This leads to the choice of patient’s treatment, which depends not only on the patient’s survival, but also on the radiotherapy or postoperative functional outcomes. Nevertheless, they fall short of determining the variables that affect survival and functional outcomes in histology-specific subgroups of breast cancer. To accurately predict the bone survival and functional outcomes of patients with breast cancer spine metastases a review of prognostic factors was performed.

Objectives To describe the technique of the aorta balloon occlusion, and evaluate the blood loss in lumbar spine tumor surgery assisted by aortic balloon occlusion, and to observe the balloon‐related complications. Methods Six patients with lumbar spine tumor underwent resuscitative endovascular balloon occlusion of the aorta prior to tumor resections in our institution between May 2018 to January 2021. Medical records including demographic, diagnosis, tumor location, surgical approach, intraoperative blood loss, surgical duration, and perioperative balloon‐related complication were evaluated retrospectively. Results This series included four males and two females, with a median age of 50 years (range 22 to 69). Of these, three primary tumors were plasmacytoma, giant cell tumor of bone, and osteosarcoma, while recurrence of undifferentiated pleomorphic sarcoma (UPS), recurrence of giant cell tumor of bone (GCT), and metastatic thyroid cancer were diagnosed in cases 1, 6, and 2, respectively. L2 was involved in cases 1 and 5. L3 was involved in case 6. L4 was involved in case 2, 3, and 6. L5 was involved in case 4. One‐stage total en bloc resection surgery (TES) was accomplished in all patients; of this series, signal anterior approach was conducted in case 1, signal posterior approach was utilized in cases 2, 3, and 6, while combined anterior and posterior approach was performed in cases 4 and 5. The median intraoperative blood loss was 1683 mL and ranged from 400 to 3200 mL with a median surgical duration of 442 min and a range from 210 to 810 min. During the perioperative period, no serious balloon‐related complications occurred. Conclusions Endovascular balloon occlusion of the aorta successfully controls intraoperative exsanguination, contributing to a more radical tumor resection and a low rate of tumor cell contamination in lumbar tumor surgery.

Although the structure and composition of collagen have been studied by polarized light microscopy since the early 19th century, many studies and reviews have paid little or no attention to the morphological problems of histopathological diagnosis. The morphology of collagen fibers is critical in guiding mechanical and biological properties in both normal and pathological tendons. Highlighting the organization and spatial distribution of tendon‐containing collagen fibers can be very useful for visualizing a tendon's ultrastructure, biochemical and indirect mechanical properties, which benefits other researchers and clinicians. Picrosirius red (PSR) staining, relying on the birefringence of collagen fibers, is one of the best understood histochemical methods that can highly and specifically underline fibers better than other common staining techniques when combined with polarized light microscopy (PLM). Polarized light microscopy provides complementary information about collagen fibers, such as orientation, type and spatial distribution, which is important for a comprehensive assessment of collagen alteration in a tendon. Here, this brief review serves as a simplistic and important primer to research developments in which differential staining of collagen types by the Picrosirius‐polarization method is increasing in diverse studies of the medical field, mainly in the assessment of the morphology, spatial distribution, and content of collagen in tendons.

Objective The objective of the present paper was to explore the clinical effect of one approach anterior decompression and fixation with posterior unilateral pedicle screw fixation for thoracolumbar osteoporosis vertebral compression fractures (OVCF). Methods This is a single‐center retrospective analysis. A total of six thoracolumbar OVCF patients (four women and two men) with an average age of 65.2 years (58–72 years) who were treated between June 2016 and May 2018 were enrolled in the present study. The lesion segments included: 1 case at T11, 1 case at T12, 3 cases at L1, and 1 case at L2. The six thoracolumbar OVCF patients were treated with one approach anterior decompression and fixation with posterior unilateral pedicle screw fixation. After general anesthesia, patients were placed in the right lateral decubitus position, an approximately 10–15‐cm oblique incision was made along corresponding ribs, and the conventional left retroperitoneal and/or the extrapleural approach was performed for anterior lateral exposure. First, anterior decompression and fixation were performed, and then through the unilateral paraspinal muscle approach, posterior pedicle screw fixation was performed under the same incision. The back pain visual analogue scale (VAS), the Oswestry disability index (ODI), and the MacNab criteria were used to evaluate the clinical outcome. The radiographic analysis included the regional kyphosis angle and the fusion rate. Neurological status, operation time, intraoperative bleeding, the time of ambulation, hospital stay, and surgical complications were also assessed. Results Surgery was successful in all six patients, who were followed up for 31.6 months (range, 23–46 months). The operation time was 125–163 min, with a median of 135 min. The preoperative blood loss was 580–1230 mL, with a median of 760 mL. The time of ambulation was 3–5 days, with a median of 4.2 days. The hospital stay was 8–15 days, with the median of 10.5 days. According to the Frankel classification of neurological deficits, of two patients with grade C preoperatively, one had improved to grade D and one had improved to grade E at final follow up; among four patients with grade D preoperatively, at the final follow up one remained the same and three had improved to grade E. The postoperative back pain VAS score decreased significantly, from 6.17 ± 0.75 preoperatively to 0.83 ± 0.41 postoperatively (P

The life expectancy of patients with advanced cancer has been prolonged with the development of systemic treatment technology. Spinal metastasis is one of the common ways of metastasis of advanced tumors, leading to spinal cord compression and compression fractures, which often lead to a significant reduction in patients’ quality of life and physical function. Therefore, surgical treatment is still needed for functional recovery and local control. Separation surgery has been known since 2014 when it was purposed. Combined with radiotherapy, it can achieve an ideal goal of local control. This paper gives a brief introduction to separation surgery, hoping to increase the reader's understanding and consider this method in the course of treatment.

With advances in tumor treatment, metastasis to bone is increasing, and surgery has become the only choice for most terminal patients. However, spinal surgery has a high risk and is prone to heavy bleeding. Controlled hypotension during surgery has outstanding advantages in reducing intraoperative bleeding and ensuring a clear field of vision, thus avoiding damage to important nerves and vessels. Antihypertensive drugs should be carefully selected after considering the patient's age, different diseases, etc, and a single or combined regimen can be used. Hypotension also inevitably leads to a decrease in perfusion of important organs, so the threshold of hypotension and the maintenance time of hypotension should be strictly limited, and the monitoring of important organs during the operation is particularly important. Information such as blood perfusion, blood oxygen saturation, cardiac output, and neurophysiological conduction potential changes should be obtained in a timely fashion, which will help to reduce the risk of hypotension. In short, when applying controlled hypotension, it is necessary to choose an appropriate threshold and duration, and appropriate monitoring should be conducted during the operation to ensure the safety of the patient.

Objective To investigate the surgical strategy, safety, and efficacy of close reduction and robot‐aided minimally invasive lumbopelvic fixation in treatment of traumatic spinopelvic dissociation. Methods Data of 32 patients (21 males and 11 females) with traumatic spinopelvic dissociation treated by lumbopelvic fixation with robot‐aided minimally invasive technique or conventional open procedure in our institution from March 2010 to April 2019 were retrospectively analyzed, and divided into robot group and control group. Intraoperative blood loss, surgical time, fluoroscopy frequency, total drilling times, infection rate, hospitalization time, and sacral fracture healing time were reviewed. Radiographs and computed tomography (CT) scans were totally acquired to evaluate the reduction quality, residual fracture displacement, and Gras classification on screws insertion after surgery. According to the Majeed scoring system, functional outcome was assessed for each patient at the final follow‐up. Results There were 12 patients in the robot group and 20 patients in the control group with no significant difference about the demographic data. The average surgical time was 148.3 ± 40.5 min with intraoperative blood loss of 142.5±36.7 mL in the robot group and 185.0 ± 47.8 min with 612.5 ± 182.7 mL in the control group (P = 0.034, P = 0.000). The robot group had a shorter mean hospitalization time at 19.9 ± 7.0 days compared to the control group with 28.6 ± 5.4 days (P = 0.010). The fluoroscopy frequency was 35.4 ± 3.0 in the robot group and 45.5 ± 3.6 in the control group (P = 0.000) and total drilling times were 7.1 ± 1.1 and 9.6 ± 1.3 (P = 0.000), respectively. The infection rate was 0% (0/12) in the robot group and 15% (3/20) in the control group (P = 0.159). According to the Gras classification on screw positioning, there were 11 cases in Grade I and 1 case in Grade II in the robot group, and 14 cases in Grade I and 6 cases in Grade II in the control group. All the patients were followed up consecutively for at least 12 months, with an average follow‐up period of 17.1 ± 3.6 months. All sacral fractures healed with an average time of 3.8 ± 0.6 months in the robot group and 4.7 ± 0.7 months in the control group (P = 0.000). According to Majeed functional assessment investigation, the mean score of the patients was 87.2 ± 4.0 in the robot group and 83.1 ± 4.5 in the control group (P = 0.015). Conclusions Robot‐aided minimally invasive lumbopelvic fixation for traumatic spinopelvic dissociation is a safe and feasible option with advantages of less intraoperative blood loss, less radiation damage, less hospitalization time, and better functional outcome.

Abstract Background Aseptic loosening of distal femoral tumor implants significantly correlates with the resection length. We designed a new “sleeve” that is specially engaged in the metaphysis at least 5 cm proximal to the knee joint line to preserve as much bone stock as possible. This study investigates the influence of a metaphyseal sleeve on the stress-strain state of a bone tumor implant system in the distal femur. Methods Cortex strains in intact and implanted femurs were predicted with finite element (FE) models. Moreover strains were experimentally measured in a cadaveric femur with and without a sleeve and stem under an axial compressive load of 1000 N. The FE models, which were validated by linear regression, were used to investigate the maximal von Mises stress and the implanted-to-intact (ITI) ratios of strain in the femur with single-legged stance loading under immediate postoperative and osseointegration conditions. Results Good agreement was noted between the experimental measurements and numerical predictions of the femoral strains (coefficient of determination (R 2) ≥ 0.95; root-mean-square error (RMSE%) ≈ 10%). The ITI ratios for the metaphysis were between 13 and 28% and between 10 and 21% under the immediate postoperative and osseointegration conditions, respectively, while the ITI ratios for the posterior and lateral cortices around the tip of the stem were 110% and 119% under the immediate-postoperative condition, respectively, and 114% and 101% under the osseointegration condition, respectively. The maximal von Mises stresses for the implanted femur were 113.8 MPa and 43.41 MPa under the immediate postoperative and osseointegration conditions, which were 284% and 47% higher than those in the intact femur (29.6 MPa), respectively. Conclusions This study reveals that a metaphyseal sleeve may cause stress shielding relative to the intact femur, especially in the distal metaphysis. Stress concentrations might mainly occur in the posterior cortex around the tip of the stem. However, stress concentrations may not be accompanied by periprosthetic fracture under the single-legged stance condition.

Osteosarcoma is the most common primary malignant bone tumor, occurring mainly in children and adolescents, and the limbs are the main affected sites. At present, limb‐salvage treatment is considered as an effective basic standard treatment for osteosarcoma of the limb. China has a vast territory, but the development of technology is not balanced,which requires sufficient theoretical coverage, strong technical guidance and the application of limb‐salvage treatment guidelines to the treatment of osteosarcoma. Therefore, to standardize and promote the development of limb‐salvage surgery technology and improve the success rate of limb‐salvage treatment, this guide systematically introduces limb‐salvage techniques for the treatment of patients with limb osteosarcoma through definition of limb‐salvage treatment, surgical methods, efficacy evaluation, postoperative treatment and prevention of complications, rehabilitation guidance, and follow‐up advice.

Objectives To evaluate the mechanical properties and provide a theoretical basis of a diaphyseal prosthesis with tooth mechanism using the finite element analysis method from the point of view of biomechanics. Methods A 3D digital femur model was generated based on a 28‐year‐old healthy man's femoral computed tomography (CT) data in Mimics 17.0 and the customized diaphyseal prostheses with/without tooth mechanism were designed in SolidWorks 2016. The 3D femur model after 8 cm osteotomy in the middle of its shaft and the prostheses with/without tooth mechanism was imported into Abaqus 2016 and the finite element analysis models were established. Three biomechanical tests (compression test, torsion test, and 3P‐bending test) under broken load were simulated in FEA to evaluate the performance of the prostheses. Results The stress distributions of the two prostheses were similar and the maximum von Mises stresses placed on them were very close in each test. The maximum von Mises stresses on the prosthesis with tooth mechanism were 31.55, 319.7, and 447.4 MPa, respectively, and those on the prosthesis without tooth mechanism were 26.26, 300.4, and 455.2 MPa, respectively, in the compression, torsion, and 3P‐bending tests. The maximum von Mises stresses on them were far below the ultimate tensile strength or ultimate compressive strength of the titanium alloy. Conclusions The diaphyseal prosthesis with tooth mechanism is helpful to adjust the rotation of the long bone during operation. Compared with the conventional diaphyseal prosthesis (without tooth mechanism), the diaphyseal prosthesis with tooth mechanism also has a good biomechanical performance and does not increase the risk of prosthetic failure.

Objectives To investigate the contact stress and the contact area o tibial inserts and bushings with respect to different congruency designs in a spherical center axis and rotating bearing hinge knee prosthesis under gait cycle loading conditions using finite element analysis. Methods Nine prostheses with different congruency (different degrees of tibiofemoral conformity and different distances between the spherical center and the bushing) designs were developed with the same femoral and tibial components. The models were transferred to finite element software. The peak contact stresses and contact areas on tibial inserts and bushings under the gait cycle loading conditions were investigated and compared. Results For tibial insert, the peak contact stress was the highest in the low conformity‐long group (61.4486 MPa), and it was 1.88 times higher than that in the group with the lowest stress (moderate conformity‐short group, 32.754 MPa). The contact area was the largest in the low conformity‐long group (420.485 mm2), and it was 1.19 times larger than that in the group with the smallest area (moderate conformity‐middle group, 352.332 mm2). For bushing, the peak contact stress was the highest in the high conformity‐long group (72.8093 MPa), and it was 3.21 times higher than that in the group with the lowest stress (high conformity‐short group, 22.6928 MPa). The contact area was the largest in the low conformity‐short group (2.41 mm2), and it was 2.27 times larger than that in the group with the smallest area (high conformity‐middle group, 1.063 mm2). Conclusion The results of our study showed that the congruency of the tibiofemoral surface and bushing surface should be considered carefully in the design of the spherical center axis and rotating bearing hinge knee prosthesis. Different levels of contact performance were observed with different congruency designs. In addition, the influence of contact stress and contact area on the polyethylene wear of rotating hinge knee prostheses should be confirmed with additional laboratory tests.

Objective To assess the defatting efficacy of high pressure washing and gradient alcohol and biomechanical properties of defatted bone. Methods Fresh cancellous bone was obtained from the femoral condyle and divided into six groups according to different defatting treatments, which were: high pressure washing for 10 s (10S group), 20 s (20S group), and 30 s (30S group), gradient alcohol immersion (Alcohol group), acetone immersion (Acetone group), and non‐defatted (Fresh group). The appearance of six groups was observed, and the appearance of defatted bone and fresh bone was compared. The residual lipid content and infrared spectrum were used to compare the efficacy of defatting, the DNA content was used to compare the cell content after defatting, and the maximum stress and elastic modulus were used to compare the effects of defatting treatment on biomechanical properties. Results The fresh bone was yellow and the pores contained a lot of fat. The defatted bone was white and the porous network was clear. There was no difference in residual lipid content among the three groups with high pressure washing (1.45% ± 0.16%, 1.40% ± 0.13%, and 1.46% ± 0.11%, respectively) (P = 0.828). There was no difference in residual lipid content among the 10S, alcohol, and acetone groups (1.45% ± 0.16%, 1.28% ± 0.07%, and 1.13% ± 0.22%, respectively) (P = 0.125). Infrared spectra showed that the fat content of the five defatting groups was significantly lower than that of the fresh group. There was no difference in residual lipid content among the three groups with high pressure washing (4.53 ± 0.23 ug/mL, 4.61 ± 0.18 ug/mL, and 4.66 ± 0.25 ug/mL, respectively) (P = 0.645). There was no difference in residual lipid content among the 10S, alcohol, and acetone groups (4.53 ± 0.23 ug/mL, 4.29 ± 0.24 ug/mL, and 4.27 ± 0.29 ug/mL, respectively) (P = 0.247). The maximum stress of the bone decreased significantly with the increase of the washing time (9.95 ± 0.31 Mpa, 9.07 ± 0.45 Mpa, and 8.17 ± 0.35 Mpa, respectively) (P = 0.003). The elastic modulus of the bone decreased significantly with the increase of the washing time (116.40 ± 3.54 Mpa, 106.10 ± 5.29 Mpa, and 95.63 ± 4.08 Mpa, respectively) (P = 0.003). There was no statistical difference in the maximum stress between the fresh group, the 10S group, the alcohol group, and the acetone group (10.09 ± 0.67 Mpa, 9.95 ± 0.31 Mpa, 10.11 ± 0.07 Mpa, and 10.09 ± 0.39 Mpa, respectively) (P = 0.963). There was no statistical difference in the maximum stress between the fresh group, the 10S group, the alcohol group and the acetone group (119.93 ± 4.94 Mpa, 116.40 ± 3.54 Mpa, 118.27 ± 0.85 Mpa, 118.10 ± 4.52 Mpa, respectively) (P = 0.737). Conclusion The defatting efficiency was satisfactory at a time of 10 s under high pressure washing. In terms of defatting efficiency and its effect on biomechanical properties of bone, high pressure washing and gradient alcohol were similar to conventional acetone solvent extraction defatting.

Objective To characterize the visceral metastasis as a predictive tool for the survival of patients with spinal metastases through an exploratory meta‐analysis. Methods Two investigators independently searched PubMed and Embase databases for eligible studies from 2000–2016. The effect estimates for the hazard ratio (HR) or risk ratio (RR) and 95% confidence interval (CI) were collected and pooled with a random‐ or fixed‐effect model. Results In total, 18 eligible studies were retrieved with 5468 participants from nine countries. The overall pooled effect size for HR and RR was 1.50 and 3.79, respectively, which was proved to be statistically significant. In the subgroup of prostate cancer (PCa) and non‐small cell lung cancer (NSCLC), statistical significance and marginal statistical significance was presented for the pooled HR (HR = 1.76, 95% CI 1.35–2.29) and (RR = 1.56, 95% CI 0.99–2.48), respectively. However, in the subgroup of thyroid cancer, breast cancer, and renal cancer, statistical significance was not achieved (HR = 1.17, 95% CI 0.75–1.83, Z = 0.70, P = 0.486). The results did not show any evidence of publication bias. Conclusions This study demonstrated that visceral metastasis was a significant prognostic factor in patients with spinal metastases as a whole. Interestingly, the onset of visceral metastases differentially impacted the survival in different primary tumors. Therefore, the prognostic value of visceral metastasis might be related to the type of primary tumor.

Objectives To summarize the epidemiological characteristics of patients following surgery for spinal metastases retrospectively and make a univariate analysis to identify independent variables that could affect the operation decision making. Methods This was a multicenter retrospective review of patients with spinal metastasis who were treated with surgery from 1 January 2007 to 31 July 2019. Basic clinical data were analyzed retrospectively by univariate analysis to identify independent variables that could affect the decision of operation modalities, including gender, age, spinal metastatic site, Frankel score, Karnofsky performance score (KPS), spinal instability neoplastic score (SINS), visual analogue scale (VAS), Tokuhashi score, urinary and fecal incontinence, spinal pathological fracture, primary tumor, extraspinal metastasis, visceral metastasis, and bone lesion (osteolytic, osteoblastic or mixed). Results A total of 580 patients including 332 males and 248 females were enrolled in the study with an average age of 58.26 years old (range, 13–86 years old). The most common spinal metastatic level was the thoracic vertebra (190 [32.76%]), followed by the lumbar vertebra (146 [25.17%]), cervical vertebra (47 [8.10%]), and sacral vertebra (35 [6.03%]). Metastases involving more than two sites of the cervical, thoracic, lumbar, and sacral vertebrae arose in 162 (27.93%) patients. For primary tumor, there were 198 (34.14%) cases of lung cancer, 41 (7.07%) cases of kidney cancer, 39 (6.72%) cases of breast cancer, 38 (6.55%) cases of gastrointestinal cancer, 35 (6.03%) cases of lymphoma and myeloma, 25 (4.31%) cases of prostate cancer, 24 (4.14%) cases of liver cancer, 23 (3.97%) cases of mesenchymal tissue sarcoma, 20 (3.45%) cases of thyroid cancer, and 84 (14.48%) cases were tumor with unknown origin. Sixty‐three (10.86%) patients received minimally invasive surgery, 460 (79.31%) patients received palliative surgery, and the remaining 57 (9.83%) received tumor resection. According to the univariate analysis, the KPS score, SINS score, VAS score, Tokuhashi score, urinary and fecal incontinence, spinal pathological fracture, and bone lesion (osteolytic, osteoblastic or mixed) were independent and favorable factors affecting the surgery modalities. Conclusions Surgical treatment for spinal metastases was mainly to relieve pain, rebuild spinal stability, improve nerve function, control local tumors, and improve the quality of life of patients. For middle‐aged and elderly patients with good general conditions, severe pain, spinal pathological fracture, spine instability and without urinary and fecal incontinence, early surgical treatment should be actively carried out.

Objectives To describe the epidemiological characteristics of patients with spinal metastases between 2007 and 2019. Methods Patients with spinal metastases were identified from several clinical centers in China between January 2007 and July 2019. Demographics, primary tumor types, spinal involvement, and Clinical indicators of each patient were reviewed. Results A total of 1196 patients were included in this study, 717 males (59.95%) and 479 females (40.05%), with a male to female ratio of 1.50:1. Most patients (63.71%) were in the ages range of 50 to 69 years. The mean age was 58.6 ± 11.6 (range 13–89) years and the median age was 59.0 years. The average age of females was younger than that of males, and the difference was statistically significant. The proportion of male patients over 60 years old was higher than that of females, and the difference was statistically significant. The most common primary tumor was lung cancer (n = 437, 36.54%), followed by unknown origin (n = 194, 16.22%), kidney cancer (n = 78, 6.52%), breast cancer (n = 76, 6.35%), and liver/biliary cancer (n = 75, 6.27%). The most common primary tumor was lung cancer in both males and females, followed by unknown origin in males and breast cancer in females. There were 730 patients (61.04%) in the subgroup of the number

Abstract Background Aseptic loosening has become the main cause of prosthetic failure in medium- to long-term follow-up. The objective of this study was to establish and validate a nomogram model for aseptic loosening after tumor prosthetic replacement around knee. Methods We collected data on patients who underwent tumor prosthetic replacements. The following risk factors were analyzed: tumor site, stem length, resection length, prosthetic motion mode, sex, age, extra-cortical grafting, custom or modular, stem diameter, stem material, tumor type, activity intensity, and BMI. We used univariate and multivariate Cox regression for analysis. Finally, the significant risk factors were used to establish the nomogram model. Results The stem length, resection length, tumor site, and prosthetic motion mode showed a tendency to be related to aseptic loosening, according to the univariate analysis. Multivariate analysis showed that the tumor site, stem length, and prosthetic motion mode were independent risk factors. The internal validation indicated that the nomogram model had acceptable predictive accuracy. Conclusions A nomogram model was developed for predicting the prosthetic survival rate without aseptic loosening. Patients with distal femoral tumors and those who are applied with fixed hinge and short-stem prostheses are more likely to be exposed to aseptic loosening.

IntroductionVenous thromboembolism can be divided into deep vein thrombosis and pulmonary embolism. These diseases are a major factor affecting the clinical prognosis of patients and can lead to the death of these patients. Unfortunately, the literature on the risk factors of venous thromboembolism after surgery for spine metastatic bone lesions are rare, and no predictive model has been established.MethodsWe retrospectively analyzed 411 cancer patients who underwent metastatic spinal tumor surgery at our institution between 2009 and 2019. The outcome variable of the current study is venous thromboembolism that occurred within 90 days of surgery. In order to identify the risk factors for venous thromboembolism, a univariate logistic regression analysis was performed first, and then variables significant at the P value less than 0.2 were included in a multivariate logistic regression analysis. Finally, a nomogram model was established using the independent risk factors.ResultsIn the multivariate logistic regression model, four independent risk factors for venous thromboembolism were further screened out, including preoperative Frankel score (OR=2.68, 95% CI 1.78-4.04, P=0.001), blood transfusion (OR=3.11, 95% CI 1.61-6.02, P=0.041), Charlson comorbidity index (OR=2.01, 95% CI 1.27-3.17, P=0.013; OR=2.29, 95% CI 1.25-4.20, P=0.017), and operative time (OR=1.36, 95% CI 1.14-1.63, P=0.001). On the basis of the four independent influencing factors screened out by multivariate logistic regression model, a nomogram prediction model was established. Both training sample and validation sample showed that the predicted probability of the nomogram had a strong correlation with the actual situation.ConclusionThe prediction model for postoperative VTE developed by our team provides clinicians with a simple method that can be used to calculate the VTE risk of patients at the bedside, and can help clinicians make evidence-based judgments on when to use intervention measures. In clinical practice, the simplicity of this predictive model has great practical value.

Reconstruction of massive bone defects is challenging for orthopaedic clinicians, especially in cases of severe trauma and resection of tumors in various locales. Autologous iliac crest bone graft (ICBG) is the “gold standard” for bone grafting. However, the limited availability and complications at donor sites resulted in seeking other options like allografts and bone graft substitutes. Demineralized bone matrix (DBM) is a form of allograft using acidic solution to remove mineral components, while leaving much of the proteinaceous components native to bone, with small amounts of calcium‐based solids, inorganic phosphates, and some trace cell debris. It is an osteoconductive and osteoinductive biomaterial and is approved as a medical device for use in bone defects and spinal fusion. To pack consistently into the defect sites and stay firmly in the filling parts, DBM products have various forms combined with biocompatible viscous carriers, including sponges, strips, injectable putty, paste, and paste infused with chips. The present review aims to summarize the properties of various kind of viscous carriers and their clinical use combined with DBM in commercially available products. Given DBM'mercially available products. Given DBM;s long clinical track record and commercial accessibility in standard forms, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopaedic repair and regenerative medicine contexts are attractive.

Abstract Background Core decompression (CD) is an important method for the treatment of osteonecrosis of the femoral head (ONFH). Few articles investigate the influence of core decompression on outcomes of ONFH. This study was carried out to observe the safety and effectiveness of core decompression in the treatment of ONFH. Methods A comprehensive literature search of databases including PubMed, Embase, and Cochrane Library was performed to collect the related studies. The medical subject headings used were “femur head necrosis” and “Core decompression.” The relevant words in title or abstract included but not limited to “Osteonecrosis of the Femoral Head,” “femoral head necrosis,” “avascular necrosis of femoral head,” and “ischemic necrosis of femoral head.” The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. Results Thirty-two studies included 1865 patients (2441 hips). Twenty-one studies (1301 hips) using Ficat staging standard, 7 studies (338hips) using Association Research Circulation Osseous (ARCO) staging standard, and University of Pennsylvania system for staging avascular necrosis (UPSS) staging criteria for 4 studies (802 hips). All the studies recorded the treatment, 22 studies (1379 hips) were treated with core decompression (CD) alone, and 7 studies (565 hips) were treated with core decompression combined with autologous bone (CD Autologous bone). Nine subjects (497 hips) were treated with core decompression combined with autologous bone marrow (CD Marrow). Twenty-seven studies (2120 hips) documented the number of conversion to total hip replacement (THA), and 26 studies (1752hips) documented the number of radiographic progression (RP). Twenty-one studies recorded the types of complications and the number of cases, a total of 69 cases. The random-effect model was used for meta-analysis, and the results showed that the overall success rate was 65%. The rate of success showed significant difference on the outcomes of different stages. The rate of success, conversion to THA, and radiographic progression showed significant difference on the outcomes of ONFH using different treatments. Conclusions Core decompression is an effective and safe method of treating ONFH. The combined use of autologous bone or bone marrow can increase the success rate. For advanced femoral head necrosis, the use of CD should be cautious. High-quality randomized controlled trials and prospective studies will be necessary to clarify the effects of different etiology factors, treatments, and postoperative rehabilitation. Until then, the surgeon can choose core decompression to treat ONFH depending on the patient’s condition. Level of evidence I Meta-analysis

Purpose: Undisplaced subtle ligamentous Lisfranc injuries are easy to miss or underestimate, and many cases are treated without surgical fixation. It has not yet widely known whether conservative treatment for undisplaced subtle ligamentous Lisfranc injuries may lead to a poor outcome. The purpose of this study is to compare the outcomes of conservative versus surgical management (percutaneous position screw) of undisplaced subtle ligamentous Lisfranc injury. Methods: We analysed 61 cases in this retrospective study, including 38 males and 23 females. Forty-one patients were managed conservatively, while 20 patients received surgical treatment involving minimal invasive percutaneous position screw. American orthopaedic foot &ankle society (AOFAS), foot function index (FFI, including FFI disability, FFI pain score and activity limitation scale) scores, Maryland foot score and short form-36 (SF-36) were recorded and compared after a follow-up of 10–16 months (average 12.3). Results: Patients in the surgical management group had higher scores in all evaluation methods (p

Objectives To establish a dynamic three‐dimensional (3D) model of upper cervical spine instability and to analyze its biomechanical characteristics. Methods A 3D geometrical model was established after CT scanning of the upper cervical spine specimen. The ligament of the specimen was fatigued to establish the upper cervical spine‐instability model. A 100‐N preloaded stress was applied to the upper surface of the occipital bone, and then a 1.5‐Nm moment was applied in the occipital‐sagittal direction to simulate upper cervical spine flexion and extension. Subsequently, the 3D dynamic model was established based on trajectory data that were measured using a motion‐capture system. The stress on the main ligament and the relative motion angle of the joint were analyzed. Results The shape of the model grid was regular and the total number of its units was 627 000. After finite‐element analysis was conducted, results of the ligament stress and relative movement angle were obtained. After the upper cervical spine instability, the pressure of the alar ligament during the upper cervical spine extension was increased from 2.85 to 8.12 MPa. The pressure of the flavum ligament was increased during the upper‐cervical spine flexion, from 0.90 to 1.21 MPa. The pressure of the odontoid ligament was reduced during the upper cervical spine flexion and extension, from 10.46 to 6.67 MPa and 25.66 to 16.35 MPa, respectively. The pressure of the anterior longitudinal ligament and cruciate ligament was increased to a certain degree during upper cervical spine flexion and extension. The pressure of the anterior longitudinal ligament was increased during flexion and extension, from 7.70 to 10.10 MPa and 10.45 to 13.75 MPa, respectively. The pressure of the cruciate ligament was increased during flexion and extension, from 2.29 to 4.34 MPa and 2.32 to 4.40 MPa, respectively. In addition, after upper cervical spine instability, the articular‐surface relative‐movement angle of the atlanto‐occipital joint and atlanto‐axial joint had also changed. During upper cervical spine flexion, the angle of the atlanto‐occipital joint was increased from 3.49° to 5.51°, and the angle of the atlanto‐axial joint was increased from 8.84° to 13.70°. During upper cervical spine extension, the angle of the atlanto‐occipital joint was increased from 11.16° to 12.96°, and the angle of the atlanto‐axial joint was increased from 14.20° to 17.20°. Therefore, the movement angle of the atlanto‐axial joint was most obvious after induction of instability. Conclusion The 3D dynamic finite‐element model of the upper cervical spine can be used to analyze and summarize the relationship between the change of ligament stress and the degree of instability in cervical instability. Frequent or prolonged flexion activities are more likely to lead to instability of the upper cervical spine.

Abstract Background The optimal reconstructive method after diaphyseal malignant bone tumor resection remains controversial. This multicenter clinical study was designed to investigate the clinical value and complications of segmental prosthesis in the repair of diaphyseal defects. Methods We present 49 patients from three clinical centers treated with wide resection for primary or metastatic bone tumors involving the diaphysis of the femur, tibia, humerus, or ulna, followed by reconstruction using a modular intramedullary segmental prosthesis. Results Enrolled patients included 23 men and 26 women with a mean age of 63.3 years. Of these, seven patients had primary bone tumors and 42 patients had metastatic lesions. At the mean follow-up of 13.7 months, 17 patients were alive, 31 patients were deceased due to tumor progression, and one patient was dead of another reason. There were eight nononcologic complications (two with radial nerve injury, three with delayed incision healing, two with aseptic loosening in the proximal humerus prosthetic stem and one with structural failure) and three oncologic complications (three with primary tumor recurrence) among all patients. The incidence of complications in primary tumor patients (4/7, 57.1%) was higher than that in patients with metastatic tumors (7/42, 16.7%) (p = 0.036). Aseptic loosening and mechanical complications were not common for patients with primary tumors, although the reconstruction length difference was statistically significant (p = 0.023). No statistically significant differences were observed in limb function, while the mean musculoskeletal tumor society score was 21.2 in femora, 19.6 in humeri, and 17.8 in tibiae (p = 0.134). Conclusions Segmental prostheses represent an optional method for the reconstruction of diaphyseal defects in patients with limited life expectancy. Segmental prostheses in the humerus experienced more complications than those used to treat lesions in the femur.

Objectives To investigate the association between the number of metastases to the spine and survival in patients with metastatic spinal cord compression (MSCC), as well as the prognosis difference between patients with solitary spinal metastasis (SSM) and multiple spinal metastases (MSM). Methods Three institutional databases were searched to identify all patients who had undergone spinal surgery for metastatic spinal tumors between March 2002 and June 2010. As well as age and gender, preoperative medical conditions were collected from medical records, including primary tumor, preoperative Frankel score, other bone metastases, preoperative Karnofsky performance status (KPS), number of involved vertebrae, pathological fracture metastasis site, serum albumin, sphincter dysfunction and the time of developing motor deficits before surgery. Survival data were obtained from medical records or via telephone follow‐ups. Univariate and multivariate predictors of overall survival for each group were assessed using the Cox proportional hazards model. Results The median postoperative survival time was 6.0 ± 0.6 months (95% confidence interval [CI] 4.8–7.2) in patients with SSM and 7.0 ± 1.0 months (95% CI 5.1–8.9) in patients with MSM (P = 0.238). The difference in survival was not significant between groups. Furthermore, univariate analysis showed that the number of spinal metastases had no significant association with survival (P = 0.075). Primary tumor (P = 0.004) and preoperative KPS (P

Objective To investigate whether visceral metastases have a significant impact on survival in patients with metastasis‐related spinal cord compression (MSCC), and to determine the difference in prognosis between patients with and without visceral metastases. Methods Three institutional databases were searched to identify all patients who had undergone spinal surgery for spinal metastases between March 2002 and June 2010. Data on patient characteristics including pre‐ and post‐operative medical conditions, were collected from medical records or by telephone follow‐up. Survival data were obtained either from medical records or by searching a governmental cancer registry. Results The mean age of study patients was 59.6 ± 10.5 years (range, 18–84 years), of whom 102 were male and 67 female. The median and mean postoperative survival times were 7.0 ± 0.5 (95% CI 6.0–8.0) months and 12.6 ± 1.2 (95% CI 10.1–15.0) months, respectively, in all patients, being 5.0 ± 0.5 (95% CI 4.0–6.0) months and 10.8 ± 2.4 (95% CI 6.1–15.5) months, respectively, for patients with visceral metastases and 7.0 ± 0.8 (95% CI 5.4–8.6) months and 13.0 ± 1.4 (95%CI 10.3–15.6) months, respectively, for patients without visceral metastases (P = 0.87). These survival times did not differ significantly between groups. Multivariate Cox proportional hazard regressions showed that visceral metastases had no statistically significant association with survival (P = 0.277), whereas rate of growth of primary tumor (P = 0.003), preoperative Karnofsky performance status (KPS) (P

Bosworth ankle fracture-dislocation is rare, known to be an irreducible type of ankle injury, with a high incidence of complication. We present two cases of even rarer variants of Bosworth ankle fracture-dislocation. The first case is a type of supination external rotation adduction, and the second case is a type of supination external rotation adduction. These types have not been described before. In both of the cases we failed to achieve close reduction, and therefore proceeded with emergency surgeries, with open reduction and internal fixation. Both of the cases were performed with a postero-lateral approach to reduce the dislocations, and fix the fractures successfully. Unfortunately in one of the cases, acute compartment syndrome developed post-surgically. However, both cases showed good functional outcomes. Keywords: Fracture dislocation, Supination, Rotation, Ankle injuries, Complications

Abstract Background Cancer patients’ survival time has obviously improved, with the development of systemic treatment techniques. However, the probability of metastases to the vertebrae has also been increased which makes some adverse effects on patients’ quality of life. The prediction of survival plays a key role in choosing therapeutic modality, and Tokuhashi Score was established as one of the most commonly used predictive systems for spinal metastases. Thus, this study was conducted to identify the prognostic effect of factors involved in revised Tokuhashi Score (RTS). Methods Two investigators independently retrieved relevant literature on platforms of PubMed, Embase and Cochrane Library. We identified eligible studies through title/abstract and full-text perusing. Data was extracted including general information of studies, participants’ characteristics, therapeutic modality, overall survival and prognostic effect of factors. Hazard ratio (HR) for each factor was synthesized if available through fixed- or random-effect models as appropriate. Results A total of 63 eligible studies with 10,411 participants were identified. Overall, cases with thyroid cancer had the highest survival rate, while the ones with non-small cell lung cancer and hepatocellular carcinoma lived for the shorted survival time. Performance status, bone metastasis, number of involved vertebrae, visceral metastasis, primary tumor and neurological status were regarded as significant predictors in 71.4, 40.0, 18.2, 63.4, 73.1 and 44.7% of the involved studies respectively. Thirty-eight articles were included in meta-analysis, and prognostic effects of five factors (apart from primary tumor) were analyzed. Factors were all proved to be significant except comparisons between KPS (Karnofsky Performance Status) 10–40 VS. 50–70 and single VS. multiple spinal metastases. Conclusion All factors of RTS were significant on prognosis predicting and should be considered when choosing therapeutic modality for spinal metastases. What’s more, we believe that more accurate prognosis may be obtained after removal of the cut-offs for KPS 10–40 VS. 50–70 and single VS. multiple involved vertebrae.

Spinal metastases are a common manifestation of malignant tumors that can cause severe pain, spinal cord compression, pathological fractures, and hypercalcemia, and these clinical manifestations will ultimately reduce the health-related quality of life and even shorten life expectancy in patient with cancer. Effective management of spinal bone metastases requires multidisciplinary collaboration, including radiologists, surgeons, radiation oncologists, medical oncologists, and pain specialists. In the past few decades, conventional radiotherapy has been the most common form of radiotherapy, which can achieve favorable local control and pain relief; however, it lacks precise methods of delivering radiation and thus cannot provide sufficient tumoricidal dose. The advent of stereotactic radiosurgery has changed this situation by using highly focused radiation beams guided by 3-dimensional imaging to deliver a high biologic equivalent dose to the target region, and the spinal cord can be identified and excluded from the target volume to reduce the risk of radiation-induced myelopathy. Separation surgery can provide a 2- to 3-mm safe separation of tumor and spinal cord to avoid radiation-induced damage to the spinal cord. Targets for separation surgery include decompression of metastatic epidural spinal cord compression and spinal stabilization without partial or en bloc tumor resection. Combined with conventional radiotherapy, stereotactic radiosurgery can provide better local tumor control and pain relief. Several scoring systems have been developed to estimate the life expectancy of patients with spinal metastases treated with radiotherapy. Thorough understanding of radiotherapy-related knowledge including the dose-fractionation schedule, separation surgery, efficacy and safety, scoring systems, and feasibility of combination with other treatment methods is critical to providing optimal patient care.

Background: Intralesional excision with curettage is the standard method of giant cell tumor (GCT) treatment, but the ideal filling material after curettage remains controversial. The purpose of this study was to compare the oncological and functional outcomes which underwent cementation or bone grafting after GCT curettage around the knee. Methods: We reported 136 cases with GCTs in distal femur or proximal tibia who accepted curettage from five clinical centers during the last 15 years. All patients were divided into two groups according to filling materials. Recurrence-free survival proportions were used to evaluate oncological outcomes while the Musculoskeletal Tumor Society (MSTS) 93 functional score was used to evaluate functional outcomes. Other parameters including surgical complication, general condition, and radiological classification had been analyzed. The valid statisitical data was analyzed using SPSS 13.0 software. Results: After GCT curettage, 86 patients (63.2%) accepted bone grafting while 50 patients (36.8%) accepted cementation. There was no statistical difference in age, gender, tumor location, radiological classification, fixation, follow-up time, and MSTS 93 functional score between cementation group and bone grafting group. The recurrence-free survival proportions showed that the recurrence rate in bone grafting group was higher than it in cementation group (P = 0.034). Surgical complication was lower in cementation group than that in bone grafting group but without statistically significant difference (P = 0.141). Conclusions: Parameters including patients' age, gender, tumor location, and radiological classification did not affect surgeons' treatments in cavity filling after GCT curettage. Cementation should be recommended because of easy usage, the similar postoperative knee function with bone grafting, and the better local tumor control than bone grafting.

The purpose of this article is to introduce and analyze the feasibility of simultaneously combined anterior‐posterior approaches for subaxial cervical circumferential reconstruction in sitting position. A retrospective case review was performed for above surgery procedure. A 79‐year‐old man was confirmed subaxial cervical fracture and dislocation with facet locked by radiological examination, and the involved levels were C5‐6. According to American Spinal Injury Association (ASIA) classification, the impairment scale was grade B. And the Subaxial Cervical Spine Injury and Severity Score (SLIC) were 9. The patient was restricted in sitting position with traction on a halo in extension to immobilize the head during the operation. A posterior laminectomy and pedicle screws insertion to the involved cervical spine was performed firstly. And then the anterior discectomy and strut graft were accomplished through an anterior cervical approach. The final fixation was finished by clamping the strut graft with pedicle screw system. Total blood loss was 600 ml and the total operating time was 150 min. The patient was followed up for 6 months. The symptom of neck pain improved distinctly and no evidence about implant failure was noted. Neurological status improvement was confirmed and the ASIA scale was improved to grade C. We believed that the simultaneously combined anterior‐posterior approach in sitting position was safe and more advantageous for appropriate cases.