ObjectiveTo review the research progress of the diagnosis and treatment of Hangman fracture.
MethodsThe original articles about the diagnosis and treatment of Hangman fracture were extensively reviewed and analyzed.
ResultsNot only X-ray, but also MRI and CT scans are necessory for the diagnosis and assessment of Hangman fractures. The treatment of unstable Hangman fracture included posterior C2, C3 fixation, anterior C2, C3 fixation, and anterior C2, C3 fixation combined with posterior C2 pedicle screw fixation. The anterior surgical fixation is used by the anterior retropharyngeal approach or subaxial anterior approach, and it has the advantages of directly resecting the injured C2, C3 discs, getting a satisfactory cervical spine alignment, and avoiding the postoperative axial pain. However, posterior surgical fixation using C2 pedicle screw has the risks of neurovascular injuries.
ConclusionThe surgical technique of Hangman fracture should be determined based on the patient's injury and surgeon's experience. Randomized control trials of different surgical techniques should be performed.
ObjectiveTo investigate clinical application value of totally laparoscopic splenectomy via anterior approach.
MethodsThe clinical data of 26 consecutive patients underwent totally laparoscopic splenectomy via anterior approach from March 2012 to June 2015 in this hospital were analyzed retrospectively. There were 11 males and 15 females. These patients included 2 cases of traumatic spleen ruptures, 4 cases of idiopathic thrombocytopenic purpuras, 1 case of hereditary spherocytosis, 3 cases of splenic cysts, 5 cases of autoimmunity hemolytic anemias, 2 cases of splenic hemangioma, 1 case of hematolymphangioma, 8 cases of cirrhosis portal hypertensions. The operative time, intraoperative bleeding, postoperative time to out-of-bed activity, the first flatus/bowel motion time, complications, and hospital stay were analyzed retrospectively.
ResultsTwenty-six patients were successfully carried out totally laparoscopic splenectomy via anterior approach. The average operation time was 93 min (72-120 min). The average blood loss was 60 mL (10-80 mL). The postoperative time to out-of-bed activity was 24 h. The first flatus/bowel motion time was 2-3 d. The average hospital stay was 7 d (6-9 d). The postoperative pancreatic fistula (Grade A) occurred in 1 patient, who recovered well on day 6 by postoperative drainage management. After 5-32 months of following-up, all patients recovered smoothly without any long-term complications.
ConclusionThe preliminary results of limited cases in this study show that totally laparoscopic splenectomy via anterior approach is feasible, safe, and minimally invasive.
Objective To evaluate the cl inical outcomes of anterior decompression, bone graft and internal fixation in treating fourth lumbar burst fractures with il iac fenestration. Methods From February 2001 to May 2006, 8 cases of fourth lumbar burst fractures were treated by anterior decompression, correction, reduction, il iac autograft, Z-plate internal fixation with il iac fenestration. Of them, there were 7 males and 1 female, aging 24-46 years with an average of 29.3 years, including 3 cases of Denis type A and 5 cases of Denis type B. The decompression, intervertebral height were compared betweenpreoperation and postoperation by CT scanning. According to Frankel assessment for neurological status, 2 cases were at grade C, 5 at grade D and 1 at grade E before operation. Four cases had different degrees of disturbance of sphincter. Time from injury to operation was 8 hours to 11 days. The preoperative height of the anterior border of the L4 vertebral body was (13.8 ± 2.3) mm, the Cobb angel of fractured vertebral body was (13.2 ± 2.5)°, the vertebral canal sagittal diameter of L4 was (10.6 ± 3.5) mm. The bone graft volume was (7.5 ± 1.3) cm3 during operation. Results Operations were performed successfully. The mean operative time was (142 ± 25) minutes and the mean amount of blood loss was (436 ± 39) mL. The incisions obtained heal ing by first intention after operation. Two cases suffered donor site pain and recevied no treatment. The follow-up time of 8 cases was from 21 months to 52 months (mean 24.5 months). At one week after operation, the height of the anterior border of the L4 vertebral body was (32.5 ± 2.6) mm, the Cobb angel of fractured vertebral body was (6.8 ± 3.7)°, and the vertebral canal sagittal diameter of L4 was (19.8 ± 5.1) mm, showing significant difference when compared with those of preoperation (P lt; 0.01). At the final follow-up, the results showed that the pressure was reduced sufficiently, all autograft fused well, the neurological status improved at Frankel grade from C to D in 1 patient, from D to E in 3 patients, but the others had no improvement. In 4 patients who had disturbance of sphincter, 3 restored to normal and 1 was better off. Conclusion Cl inical outcomes of anterior surgery for fourth lumbar burst fractures with il iac fenestration are satisfactory. It can facil icate operation, reduce the pressure sufficiently, maintenance intervertebral height and recover the neurological function.
Objective To evaluate the effectiveness of operation via anterior approach in treating pelvic crescent fra cture. Methods Between June 2007 and December 2009, 18 patients with pelvic crescent fracture were treated, including 11 males and 7 females with an average age of 32 years (range, 19-52 years). The locations were the right in 8 cases and the leftin 10 cases. Fractures were caused by traffic accident in 10 cases, by fall ing from height in 5 cases, and by crushing with heavy weights in 3 cases. All patients suffered lateral compression injuries of the pelvis. The mean time from injury to operation was 7.8 days (range, 3-22 days). The preoperative mean displacement of the posterior pelvic ring was 13.7 mm (range, 5-24 mm) according to the method described by Matta et al. The operation time, intraoperative blood loss, displacement correction of the posterior pelvic ring, fracture heal ing time, and Hannover pelvic score were recorded. Results The average operation time was 175 minutes (range, 110-230 minutes); the average intraoperative blood loss was 561.7 mL (range, 300-1 100 mL); the postoperative mean displacement of the posterior pelvic ring was 1.2 mm (range, 0-3 mm); and the mean displacement correction of the posterior pelvic ring was 12.6 mm (range, 4-23 mm). No intraoperative lumbosacral nervous injury occurred. Superficial wound infection occurred in 2 cases and was cured after 1 week of wound drainage and appl ication of antibiotic. The others achieved heal ing of incision by first intention. Fifteen patients were followed up 16.1 months on average (range, 13-22 months). The X-ray films showed fracture heal ing in all patients. The fracture heal ing time was 3.6 months on average (range, 3-4 months). No patient had loss of reduction or failure of internal fixation. The cl inical outcome was excellent in 10 cases (66.7%) and good in 5 cases (33.3%) according to Hannover pelvic score; social reintegration was complete in 13 cases (86.7%) and incomplete in 2 cases (13.3%). Conclusion Operation via anterior approach is a good choice in the treatment of pelvic crescent fracture.
ObjectiveTo compare the effectiveness of anterior and lateral approaches of minimally invasive plate osteosynthesis (MIPO) in the treatment of humeral shaft fractures.
MethodsThe clinical data were retrospectively analyzed and compared from 35 cases of humeral shaft fractures between January 2010 and December 2012. The patients underwent MIPO by anterior approach in 17 patients (group A) and by lateral approach in 18 patients (group B). There was no significant difference in gender, age, injury causes, type of fractures, and time from injury to operation between 2 groups (P>0.05). The operation time, fracture healing time, intra- or postoperative complications, and shoulder and elbow range of motion (ROM) values were recorded and analyzed. The functions of the affected shoulder and elbow were assessed with the University of California Los Angeles (UCLA) and Mayo elbow performance score system respectively.
ResultsThe operation time was (91.35±8.00) minutes and (95.56±7.92) minutes in groups A and B respectively, showing no significant difference (t=-1.561, P=0.128). Incision healed by first intention in all patients of 2 groups. No iatrogenic radial nerve palsy occurred in group A, 2 cases had postoperative iatrogenic radial nerve palsy in group B, showing no significant difference (P=0.486). The patients were followed up 15.4 months on average (range, 11-24 months) in group A and 16.8 months on average (range, 10-23 months) in group B. The X-ray films showed bony healing in all patients. The fracture union time was (13.5±2.1) weeks in group A and (14.0±2.2) weeks in group B, showing no significant difference (t=-0.696, P=0.491). The UCLA scores were 33.4±1.9 in group A and 30.6±2.0 in group B, and the Mayo elbow performance scores were 100 in group A and 96.4±2.8 in group B; all showed significant differences (t=4.231, P=0.000; t=5.293, P=0.000).
ConclusionGood clinical outcomes could be obtained when humeral shaft fractures are treated with MIPO either by anterior approach or by lateral apporach. However, anterior approach could offer better shoulder and elbow functional results.
Objective To investigate and compare the effects of restoring and maintaining the cervical curvature and height of the fused segment by using three different anterior cervical plate systems. Methods From January 2002 to June 2004, 122 patients underwent anterior cervical decompression,autogenous iliac bone graft and plate fixation. Of the 122 patients (85 males, 37 females, aged 14-70), 37 underwent surgery involving the fixation with the Orion plate system, 39 with the Zephir plate system, and 46 with the Codman platesystem. The cervical curvature and height of the fused segment were measured onthe lateral X-ray films so as to compare the changes of the conditions preoperatively,1 week after surgery, and during the follow-up, and also to compare the difference among the three groups. Results The follow-up of the patients for 6-35 months (average 17.3 months) showed that all the patients developed the bone fusion 6 months after operation. There was a significant improvement in the cervical curvature and height of the fused segment before operation versus 1 week after operation（Plt;0.05）; however, there were no significant changes 1 week after operation versus during the followup in each group（Pgt;0.05）; there was no significant difference among the three groups（Pgt;0.05）. Conclusion The three plate systems can effectively reconstruct and maintain the cervical curvature and height of the fused segment, with a satisfactory effect in a short term.
ObjectiveTo explore the effectiveness and safety of tranexamic acid (TXA) in anterior approach surgery for thoracolumbar fractures.MethodsFrom January 2017 to January 2020, a total of 68 thoracolumbar fracture patients undergoing anterior approach surgery were included and randomly divided into TXA group (n=33) and control group (n=35). Patients in the TXA group were given a dose of 15 mg/kg of TXA by intravenous infusion during 30 min before skin incision and an additional 15 mg/kg of TXA intravenously at 8 h after the first infusion, while the ones in the control group were given 15 mg/kg of normal saline at the same time. Basic data of the patients were collected. The hemoglobin concentration, hematocrit, coagulation and fibrinolysis indexes of the patients were monitored preoperatively, 24-hour postoperatively, and 72-hour postoperatively. The intraoperative blood loss and wound drainage of the patients were recorded. The incidence of blood transfusion and thrombotic events were collected. Statistical analysis was performed.ResultsThere was no significant difference in age, sex, body mass index, operation time, fracture location distribution, anesthesia classification of American Society of Anesthesiologists, neurologic grade of American Spinal Injury Association, injury time, or length of hospital stay between the two groups (P>0.05). Compared with those in the control group, the total blood loss [(1 398.49±312.24) vs. (1 642.30±357.78) mL, P=0.003], intraoperative blood loss [(432.83±74.76) vs. (486.31±86.51) mL, P=0.008], and wound drainage [(276.73±89.42) vs. (389.24±125.71) mL, P<0.001] in the TXA group reduced. No statistically significant difference was found between the two groups in the preoperative hemoglobin or hematocrit (P>0.05), but the 24-hour postoperative hemoglobin concentration [(112.67±20.59) vs. (102.64±19.41) g/L, P=0.042] and hematocrit [(32.25±4.12)% vs. (30.13±4.28)%, P=0.042] in the TXA group were higher than those in the control group. The incidence of allogeneic blood transfusion in the TXA group was lower than that in the control group (6.1% vs. 25.7%, P<0.05). There was no statistically significant difference in preoperative, 24-hour postoperative, or 72-hour postoperative prothrombin time, international standardized ratio, activated partial prothrombin time, platelet count, fibrinogen, d-dimer, or fibrinogen degradation products between the two groups (P>0.05), and no thrombotic complications were found.ConclusionTXA has good efficacy and safety in the anterior approach surgery for thoracolumbar fractures.
Objective To explore an improved surgical approach to the superior posterior partial resection of the fractured vertebral body followed by the single segmental fusion to treat lumbar burst fracture and to evaluate its preliminary clinical application. Methods From June to October 2006, 4 patients (2 males, 2 females; age, 17-39 years) with Denis B type lumbar burst fracture underwent the superior posterior partial resection of the fractured vertebral body followed by the single segmental fusion. The fracture occurred in 2 patients at L1 and 2 at L2. According to the Frankel scales assessment, before operation, 2patients were at Grade B and the other 2 at Grade C, and the visual analogue scale (VAS) was 7.00±0.82. Radiological evaluation was performed, which revealed the kyphosis Cobb angel of 22.94±11.21°, the adjacent superior and the inferiorintervertebal disc heights of 12.78±1.52 mm and 11.68±1.04 mm, espectively, and the vertebral canal sagittal diameter of 9.56±2.27 mm on the computer tomography (CT) scan. The neurological and the radiological evaluations were also made immediately and 3 months after operation. Results The anterior single segmental decompression and fusion operations were performed successfully in all the patients. The average operating time was 166±29 min and the average amount of blood loss was 395± 54 ml. The Frankel scales assessment showed that at the time immediately after operation, one of the 2 Grade B patients had an improvement to Grade C, but the other patient had no improvement. One of the 2 Grade C patientshad an improvement to Grade D, but the other patient had no improvement. Three months after operation, the 2 Grade B patients had an improvement to Grade C. The 2 grade C patients had an improvement to Grade D or E. The VAS score was significantly decreased to 3.50±1.29 after operation and to 1.25±0.50 3 months later （P＜0.05）. The vertebral canal sagittal diameter was significantly increased to 19.76±3.82 mm (Plt;0.01), but it was maintained to 19.27±3.41 mm3 months later, with no significant difference（Pgt;0.05）. The patients’ kyphosis Cobb angle was significantly improved to 8.71±5.41° (P＜0.05) , but it was maintained to 9.52±5.66° 3 months later, with no significant difference（Pgt;0.05）. The heights of the adjacent discs remained unchanged. No complication was observedduring and after operation, and the radiological and the CT scanning evaluations 3 months later showed no failure of the internal fixation. Conclusion The superior and posterior partial resection of the fractured vertebral body followedby the single segmental fusion can effectively decompress the vertebral canal and maintain the spine stability in treatment of the Denis B type fracture thoughthe longterm effectiveness requires a further follow-up.
ObjectiveTo investigate the application value of totally laparoscopic associating liver tourniquet and portal ligation for staged hepatectomy (ALTPS) using the anterior approach technique for hepatocellular carcinoma (HCC) with hepatitis B cirrhosis.
MethodsIn September, 2014, a patient suffered cirrhotic hepatocellular carcinoma in the right liver scheduled for two-stage liver resection, in whom the future liver remnant (FLR) was considered too small (FLR/standard liver volume:29.1%, FLR/body wight:0.49%). In the first stage, using totally laparoscopic technique, a tourniquet was placed around the parenchymal transection line on the Cantlie's line via an anterior approach through retrohepatic tunnel for staged right hepatectomy, and the right portal vein was ligated. In the second stage, totally laparoscopic right hemihepatectomy was carried out on 10 days after the first-stage operation that achieved sufficient hypertrophy of the FLR.
ResultsThe FLR on postoperative day 4 of the first stage increased from 301.48 to 496.45 mL (FLR/standard liver volume:47.9%, FLR/body wight:0.81%), with a 64.67% hypertrophy. And the FLR on postoperative day 8 of the first stage increased to 510.96 mL (FLR/standard liver volume:49.3%, FLR/body wight:0.84%), with a 69.48% hypertrophy. The remnant liver volume on postoperative day 5 of the second stage increased to 704.53 mL. The duration of the first stage was 180 min, intraoperative blood loss was 50 mL, and patient did not received a blood transfusion. The duration of the second stage was 220 min, intraoperative blood loss was 400 mL, and patient did not required a blood transfusion. No serious complications happened. The patient was discharged on 7 days after the second stage.
ConclusionsAs a effective, safe, simple, and "non-touch" technique which provided a less aggressive modification of the ALPPS procedureto achieve oncological efficacy, the totally laparoscopic ALTPS using the anterior approach technique also could achieve sufficient hypertrophy of the FLR in several days. A proper expansion of the indications for the procedure is safe and feasible in HCC patients with cirrhosis.
ObjectiveTo investigate the effects of anterior single segment fixation on the spinal biomechanical stabilization in the treatment of thoracolumbar burst fracture of Denis type B with pedicle injury.
MethodsSix fresh human cadaveric spine specimens (T11-L3) were harvested as normal control (group A). Then the L1 Denis type B fracture model was created by the hemi-corpectomy method. Each specimen was tested in 3 different scenarios: anterior single segment (T12, L1) fixation with the integrity of the pedicle (group B), anterior single segment fixation with the resection of the unilateral pedicle (group C), and anterior single segment fixation with the resection of the bilateral pedicles (group D). Range of motion (ROM) in flexion/extension, bilateral bending, and bilateral axial rotation was measured by spinal three-dimensional measuring system under pure moments of 8.0 N·m.
ResultsThe ROM values of T12, L1 in flexion, extension, and right/left lateral bending of groups B, C, and D were significantly lower than those of group A (P<0.05); group D was significantly higher than groups B and C (P<0.05); but groups B and C showed no significant difference (P>0.05). The ROM values of T12, L1 in right/left axial rotation of groups B and C were significantly lower than those of groups A and D (P<0.05), but there was no significant difference (P>0.05) between groups B and C and between groups A and D. The ROM values of L1, 2 in flexion, extension, right/left lateral bending, and right/left axial rotation showed no significant difference between groups (P>0.05).
ConclusionResection of the unilateral pedicle has litter effects on the spine biomechanical stabilization of the anterior single segment fixation in the 6 degrees of freedom. However, the bilateral resection results show significant decrease in flexion, extension, lateral bending, and rotation motion stability by the single segment fixation devices, especially in the axial rotation aspect.
