BACKGROUND:The addition of traditional rod-rod fixation for atlantoaxial joint disease to C1-C2 pedicle screw-rod fixation(C1-C2 PSR)can provide stronger anti-rotation stability for screw/rod fixation,but there is a risk of installation difficulties,impact on bone graft bed,and spinal cord injury.The new horizontal screw-screw crosslink(hS-S CL)designed by the authors can effectively overcome the above shortcomings,but its biomechanical properties are unclear. OBJECTIVE:To analyze biomechanical properties of new horizontal screw-screw crosslink in C1-C2 PSR by three-dimensional finite element analysis. METHODS:CT thin layer scanning data were collected from the occipital base to the axis(C0-2)of one adult healthy male volunteer.The atlantoaxial finite element models were established respectively:the normal group,the unstable group,the non-crosslink group(unstable+C1-C2 PSR),and the crosslink group(C1-C2 PSR+hS-S CL).Range of motion and Von Miss Stresses in flexion and extension,lateral flexion and rotation of the four groups were calculated by applying 1.5 Nm torque to each finite element model,and the stress cloud was extracted. RESULTS AND CONCLUSION:(1)Range of motion of the unstable group was increased by 43.8%-78.7%compared with the normal group,and the range of motion of the internal fixation groups was 90.2%-98.7%lower than that of the unstable group under six conditions.The range of motion of the crosslink group and the non-crosslink group was basically the same in flexion and extension states,but in lateral flexion and rotation states,the range of motion of the crosslink group decreased 34.3%-43.8%and 78.6%-79.1%,respectively,compared with the non-crosslink group,and range of motion decreased most obviously in rotation state.(2)The stress peak of the internal plant model:The maximum stress of the crosslink group was generally smaller than that of the non-crosslink group,and the stress peak value of all the internal fixation groups was the lowest when the extension was carried out.(3)The stress cloud of internal plants showed that there was no obvious stress concentration phenomenon in the internal fixation,and the main stress distribution areas were the screw root and bone joint,and the crosslink ends were the screw tail groove or the joint rod joint.(4)The new horizontal screw-screw crosslink can obviously improve the anti-rotation stability of internal fixation and it can share part of the pressure in the three-dimensional motion direction of the internal fixation system and reduce the maximum stress of the internal plants.However,the stress distribution is obvious at both ends of the crosslink,and this part may be prone to fracture of the crosslink.

BACKGROUND:Posterior atlantoaxial pedicle screw rod internal fixation is the main method for treating atlantoaxial dislocation,and the horizontal crosslink plays an important role in the antirotation ability of the internal fixation system.The new horizontal screw-screw crosslink can effectively overcome the disadvantages of traditional horizontal crosslink,such as inconvenient installation,impact on bone grafting bed,and potential spinal cord injury.However,the biomechanical properties of the new horizontal screw-screw crosslink with different installation modes are still unclear. OBJECTIVE:To investigate the biomechanical characteristics of new different installation modes of horizontal screw-screw crosslink in the C1-C2 pedicle screw-rod fixation and to provide a theoretical basis for optimal installation mode. METHODS:Six fresh human occipitocervical specimens were divided into the intact state group(group A),and the atlantoaxial instability model of type Ⅱ odontoid fracture was established based on the intact state group as the instability group(group B).The C1-C2 pedicle screw-rod fixation was performed on each specimen based on the instability group(group C).In group C,different installation modes of horizontal screw-screw crosslink were successively installed in each specimen,including upper transverse connection(two atlas screw tails)as group D,lower transverse connection(two axis screw tails)as group E,diagonal transverse connection(upper left and lower right for group F,lower left and upper right for group G),and cross transverse connection as group H.The specimen models were tested in order of flexion,extension,lateral flexion and lateral rotation on a three-dimensional motion machine,and the atlantoaxial range of motion of each group of specimens was obtained.Repeated measure analysis of variance was used to evaluate the biomechanical properties of each group. RESULTS AND CONCLUSION:(1)Under six states,the range of motion of groups A,C,D,E,F,G and H was smaller than that of group B,and there were statistically significant differences(P＜0.05).(2)In the flexion and extension states,there was no significant difference among the five types of horizontal screw-screw crosslink groups(P＞0.05).(3)In the left and right rotation directions,there were significant differences in D and E groups compared with F,G and H groups(P＜0.05);there were no significant differences between D and E groups,and F and G groups(P＞0.05),and there were no significant differences in F and G groups compared with H group(P＞0.05).(4)In conclusion,under flexion-extension states,the biomechanical stability of five types of horizontal screw-screw crosslink groups was similar,but under the rotation state,the stability of diagonal horizontal screw-screw crosslink group and cross horizontal screw-screw crosslink group was obviously better than that of transverse horizontal screw-screw crosslink group;however,the stability of diagonal horizontal screw-screw crosslink group is similar to the cross horizontal screw-screw crosslink group,so the former is more worthy of clinical recommendation.

Objective: To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. Methods: From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. Results: Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). Conclusion Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Objective: To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. Methods: From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. Results: Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). Conclusion Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Objective: To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. Methods: From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. Results: Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). Conclusion Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Objective: To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. Methods: From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. Results: Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). Conclusion Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Objective: To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. Methods: From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. Results: Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). Conclusion Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.

Objective:To evaluate the preliminary clinical application of our self-designed posterior reduction forceps for atlantoaxial dislocation in the reduction and fixation of irreducible atlantoaxial dislocation with simple posterior screw-rod system.Methods:Our posterior reduction forceps was self-designed and developed to assist simple posterior screw-rod system in the treatment of irreducible atlantoaxial dislocation based on the posterior atlantoaxial screw-rod system. A retrospective study was conducted to analyze the clinical data of 5 patients with irreducible atlantoaxial dislocation who had been treated from January 2021 to October 2022 at Department of Spine Surgery, General Hospital of Southern Theatre Command of PLA with our self-designed posterior reduction forceps. There were 2 males and 3 females, aged 53, 62, 45, 32 and 48 years, respectively. Diagnosis: 1 case of free odontoid process combined with atlantoaxial dislocation, 2 cases of atlantoaxial dislocation, and 2 cases of old odontoid process fracture combined with atlantoaxial dislocation. Respectively, their preoperative Japanese Orthopaedic Association (JOA) scores were 9, 11, 12, 13 and 10 points and their atlanto-dental intervals (ADI) 9.8, 7.4, 6.6, 6.4 and 8.5 mm. Postoperatively, atlantoaxial reduction and spinal cord compression were evaluated by X-ray, CT, and MRI examinations, and internal fixation, atlanto-axial sequence, and bone graft fusion by X-ray and CT examinations. One week after surgery, the JOA scores were used to evaluate the patients' neurological function and the ADI was measured to evaluate the atlantoaxial reduction.Results:The surgery was successfully performed in the 5 patients, with no intraoperative complications like neurovascular injuries to the spinal cord. The postoperative atlantoaxial reduction was satisfactory, the position of internal fixation was good, the compression to the spinal cord was relieved, and the clinical symptoms were significantly improved. At 1 week after surgery, respectively, the JOA score: 13, 14, 14, 15 and 13; the ADI: 2.6, 2.1, 1.8, 1.5 and 2.2 mm; the follow-up time: 3, 6, 12, 9 and 6 months; the bone fusion time: 3, 3, 6, 6 and 3 months. Follow-ups revealed no loosening or fracture of internal fixation, good atlanto-axial sequence, and no recurrence of dislocation.Conclusion:Our self-designed posterior reduction forceps for atlantoaxial dislocation can assist the simple posterior screw-rod system to treat irreducible atlantoaxial dislocation, leading to good preliminary clinical outcomes.

OBJECTIVE To analyze the research status， hotspot and development trend of tyrosine kinase inhibitors （TKIs） in the treatment of human epidermal growth factor receptor 2 （HER2） positive breast cancer. METHODS The literature related to TKIs in the treatment of HER2 positive breast cancer were searched from the Web of Science core collection database； the author， country/region， institution， subject field， journal and keywords was visualized by CiteSpace 6.1.R3 software. RESULTS A total of 732 pieces of literature were included， and the number of literature published showed an increasing trend year by year. The number of literature published in the United States was the largest （center degree 0.10）， and the number of literature published in China ranked second （center degree 0.05）. The most published and cited authors were Crown from St. Vincent’s University Hospital in Australia and Slamon from University of California， Los Angeles in the United States； the institution with the highest number of literature was the University of Texas MD Anderson Cancer Center， and the journal with the highest number of literature was the Journal of Clinical Oncology. The research mainly focused on five aspects： HER2 positive breast cancer treatment drugs， TKIs receptor， TKIs mechanism of action， HER2 positive breast cancer brain metastasis， and TKIs clinical trials. The main frontier areas and development trends were the combination of TKIs with other drugs or therapies to enhance targeting and reduce toxic side effects. CONCLUSIONS The study of TKIs in the treatment of HER2 positive breast cancer has attracted the attention of scholars at home and abroad. Chinese scholars and research teams need to strengthen cooperation and communication in the future， and cooperation with other countries should be strengthened in terms of the efficacy and safety of TKIs alone and combined with other drugs in the treatment of HER2 positive breast cancer.

Objective:To subdivide clinical classification of refractory atlantoaxial dislocation, and evaluate the reliability of new subdivide clinical classification of refractory atlantoaxial dislocation.Methods:From January 2010 to December 2018, 48 patients with refractory atlantoaxial dislocation were treated, including 19 males and 29 females, aged 16 to 65 years, with an average of 39.2±13.3 years. According to the changes of relative anatomical position of C 1 and C 2 under general anesthesia with heavy traction of 1/6 body weight, subdivide clinical classification of refractory atlantoaxial dislocation were proposed, and refractory atlantoaxial dislocation was divided into traction loosening type (atlantoaxial angle≥5°) and traction stabilization type (atlantoaxial angle<5°). The traction loosening type was directly reduced by posterior atlantoaxial screw-rod fixation and fusion without anterior or posterior soft tissue release. For traction stabilization type, transoral soft tissue release was performed first, and then transoral anterior reduction plate fixation and fusion or posterior atlantoaxial screw-rod fixation and fusion were performed. Atlantodental interval (ADI) and atlantoaxial angle (AAA) were measured and collected before and after surgery to evaluate atlantoaxial reduction. The space available for the spinal cord (SAC) were measured to evaluate spinal cord compression. Visual analogue score (VAS) was used to evaluate the neck pain levels, and Japanese Orthopaedic Association (JOA) scores was used to evaluate the neurological function. American Spinal Cord Injury Association impairment scale (AIS) was used to evaluate the degree of spinal cord injury. One week, 3, 6, 12 months postoperatively and the annual review of the X-ray and CT scan were checked, in order to evaluate the reduction, internal fixation and bone graft fusion. Results:Among all 48 cases, 22 cases were traction loosening type, of which posterior atlantoaxial screw-rod fixation and fusion were performed in 16 cases and occipitocervical fixation and fusion in 6 cases. 26 cases were traction stabilization type, and they all underwent anterior transoral release, and then, anterior TARP fixation and fusion were performed in 24 cases and posterior screw-rod fixation and fusion in the other 2 cases. X-ray, CT and MRI images and of all patients 1 week after surgery showed good atlantoaxial reduction and decompression of spinal cord. In each of the two types, there was one case lost to follow-up. For 46 cases in follow-up, the follow-up time ranged from 6 to 72 months, with an average of 38.0±17.2 months. Among 46 cases, 21 cases of traction loosening type showed that, ADI reduced from preoperative 9.9±2.2 mm to 2.3±0.9 mm at 3 months after surgery and 2.3±1.0 mm at the last follow-up, AAA increased from preoperative 57.9°±12.3° to 91.0°±2.2° at 3 months after surgery and 90.9°±2.2° at the last follow-up, SAC increased from preoperative 9.8±1.3 mm to 15.1±0.7 mm at 3 months after surgery and 14.9±0.7 mm at the last follow-up, VAS score reduced from preoperative 1.5±2.1 to 0.7±1.0 at 3 months after surgery and 0.3±0.6 at the last follow-up, and JOA score increased from preoperative 10.2±1.7 to 13.3±1.3 at 3 months after surgery and 14.9±1.5 at the last follow-up. Twenty-five cases of traction stabilization type presented that, ADI reduced from preoperative 9.7±2.0 mm to 2.1±1.4 mm at 3 months after surgery and 2.1±1.3 mm at the last follow-up, AAA increased from preoperative 55.8°±9.2° to 90.9°±1.4° at 3 months after surgery and 90.9°±1.3° at the last follow-up, SAC increased from preoperative 10.5±1.0 mm to 15.4±0.5 mm at 3 months after surgery and 14.8±2.8 mm at the last follow-up, VAS score reduced from preoperative 1.7±2.1 to 0.7±0.9 at 3 months after surgery and 0.3±0.5 at the last follow-up, and JOA score increased from preoperative 10.1±1.3 to 12.9±1.5 at 3 months after surgery and 14.4±1.3 at the last follow-up. In the traction loosening type, all the 10 grade D patients were improved to grade E at the last follow-up. In the 2 grade C patients of traction stabilization type before surgery, 1 patient was improved to grade E, 1 patient was improved to grade D, and all 11 patients with grade D were improved to grade E at the last follow-up. Bony fusion was obtained in all patients from 3 to 6 months, with an average of 4.4±1.5 months. During follow-up period, no looseness of internal fixation or redislocation happened.Conclusion:Refractory atlantoaxial dislocation can be divided into traction loosening type and traction stabilization type. For traction loosening type, satisfactory reduction can be achieved by using posterior atlantoaxial screw-rod system without soft tissue release. For traction stabilization type, anterior release is preferable, and then anterior TARP or posterior screw-rod can be used to achieve satisfactory reduction.