BACKGROUND:The high rate of postoperative hypoproteinemia in patients undergoing hip revision is associated with severe trauma,which affects the rapid recovery of patients. OBJECTIVE:To investigate the risk factors of perioperative hypoproteinemia in patients with hip revision,and to provide guidance for early screening of high-risk patients with postoperative hypoproteinemia. METHODS:According to the inclusion and exclusion criteria,161 patients who underwent hip revision were divided into hypoproteinemia group(76 cases)and normal group(85 cases).The rate of hypoproteinemia was 47.2%.Data such as age,gender,body mass index,osteoporosis,operation time,preoperative erythrocytes,preoperative hemoglobin,preoperative leukocytes,preoperative platelets,preoperative fibrinogen,preoperative C-reaction protein,preoperative sedimentation rate,preoperative blood calcium,preoperative albumin,postoperative drainage tube placement,American Society of Anesthesiologists score,and postoperative hypoproteinemia were collected.SPSS software was used to analyze the independent risk factors of hypoproteinemia after hip revision using multivariate binary logistic regression analysis.R software was used to construct the nomogram prediction model.Receiver operating characteristic curve and calibration curve and decision curve were drawn to evaluate the model. RESULTS AND CONCLUSION:(1)Univariate analysis results showed that body mass index,preoperative erythrocytes,preoperative hemoglobin,preoperative platelets,preoperative fibrinogen,preoperative C-reaction protein,and operation time were significantly different between the two groups(P<0.05).(2)Multivariate binary Logistic regression analysis results showed that body mass index(OR=0.859,P=0.021),operation time(OR=1.010,P=0.002),preoperative erythrocytes(OR=0.424,P=0.036),and preoperative C-reaction protein(OR=1.043,P=0.032)levels were independent risk factors for postoperative hypoproteinemia in patients with hip revision.(3)Based on four independent risk factors:body mass index,operation time,preoperative erythrocytes and preoperative C-reaction protein,the nomogram can effectively predict the risk of hypoproteinemia after hip revision.This nomogram prediction model has good differentiation and accuracy,and may lead to better clinical net benefits for patients.

Ankylosing spondylitis (AS) combined with lower cervical fracture is often categorized into unstable fracture, with a high incidence of neurological injury and a high rate of disability and morbidity. As factors such as shoulder occlusion may affect the accuracy of X-ray imaging diagnosis, it is often easily misdiagnosed at the primary diagnosis. Non-operative treatment has complications such as bone nonunion and the possibility of secondary neurological damage, while the timing, access and choice of surgical treatment are still controversial. Currently, there are no clinical practice guidelines for the treatment of AS combined with lower cervical fracture with or without dislocation. To this end, the Spinal Trauma Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate Clinical guidelines for the treatment of ankylosing spondylitis combined with lower cervical fracture in adults ( version 2024) in accordance with the principles of evidence-based medicine, scientificity and practicality, in which 11 recommendations were put forward in terms of the diagnosis, imaging evaluation, typing and treatment, etc, to provide guidance for the diagnosis and treatment of AS combined with lower cervical fracture.

The incidence of osteoporotic thoracolumbar vertebral fracture (OTLVF) in the elderly is gradually increasing. The kyphotic deformity caused by various factors has become an important characteristic of OTLVF and has received increasing attention. Its clinical manifestations include pain, delayed nerve damage, sagittal imbalance, etc. Currently, the definition and diagnosis of OTLVF with kyphotic deformity in the elderly are still unclear. Although there are many treatment options, they are controversial. Existing guidelines or consensuses pay little attention to this type of fracture with kyphotic deformity. To this end, the Lumbar Education Working Group of the Spine Branch of the Chinese Medicine Education Association and Editorial Committee of Chinese Journal of Trauma organized the experts in the relevant fields to jointly develop Clinical guidelines for the diagnosis and treatment of osteoporotic thoracolumbar vertebral fractures with kyphotic deformity in the elderly ( version 2024), based on evidence-based medical advancements and the principles of scientificity, practicality, and advanced nature, which provided 18 recommendations to standardize the clinical diagnosis and treatment.

Objective:To investigate the clinical efficacy of percutaneous kyphoplasty (PKP) assisted by intuitive visual navigation orthopaedic surgery robot in the treatment of osteoporotic vertebral compression fracture (OVCF).Methods:A retrospective analysis was conducted in Peking University Third Hospital from June 2021 to November 2022, 78 patients with OVCF were treated by the intuitive visual navigation orthopaedic surgery robot or freehand surgery with a "C" arm X-ray machine. According to the method of puncture, they were divided into robot group and freehand group. In the robot group, there were 36 cases, including 7 males and 29 females, aged 74.50±5.87 years, 32 cases of single vertebral fractures, 4 cases of double vertebral fractures, 1 case of T 8, 2 cases of T 10, 2 cases of T 11, 11 cases of T 12, 10 cases of L 1, 8 cases of L 2, 2 cases of L 3, 3 cases of L 4, and 1 case of L 5. Bone mineral density T value was -2.94±0.50; In the freehand group, there were 42 cases, including 9 males and 33 females, aged 72.86±8.84 years, 36 cases of single fracture and 6 cases of double fracture, 1 case of T 6, 2 cases of T 7, 3 cases of T 11, 9 cases of T 12, 8 cases of L 1, 9 cases of L 2, 5 cases of L 3, 6 cases of L 4, and 5 cases of L 5. Bone mineral density T value was -3.00±0.50. The effectiveness evaluation indexes of the two groups were compared, which included surgery duration, X-ray fluoroscopy times, hospitalization time, lumbar pain visual analogue scale (VAS), Oswestry disability index (ODI) and height of fractured anterior vertebrae (HFAV). Results:Both groups of patients successfully received surgical treatment. The mean operating time of the robot group was 33.44±2.50 min, which was significantly longer than that of the free hand group, which was 29.69±2.40 min ( t=6.491, P<0.001). Meanwhile, the intraoperative blood loss of the robot group was 3.54±0.89 ml, which was significantly less than that of the freehand group, which was 6.72±1.89 ml ( t=9.110, P<0.001). In terms of radiographic fluoroscopy times, the average of the robot group was 26.81±7.76 times, which was significantly less than the freehand group's 42.61±6.62 times ( t=9.294, P<0.001). The postoperative vertebral front edge height in the free hand group was 18.64±0.32 mm and in the robot group was 18.79±0.36 mm. The difference was not statistically significant ( t=2.673, P=0.067). All patients were followed up for 8.3±2.9 months (range, 6-13 months). The VAS scores of low back pain in the two groups at 1 day and 6 months after operation were significantly improved compared with those before operation ( P<0.05), and there was no significant difference between the two groups in VAS score after operation ( P>0.05). Six months after surgery, the ODI of the free hand group and the robot group were 11.67%±2.13% and 12.11%±2.33%, respectively. The ODI scores of the two groups were significantly lower at 6 months postoperative follow-up than that before surgery, and the postoperative follow-up at all had significant differences compared with that before surgery ( P<0.05), and there was no difference between the two groups in postoperative ODI scores ( P>0.05). No obvious bone cement leakage was found in all patients during operation. Conclusion:Compared with the traditional C-arm X-ray for PKP treatment of OVCF by free hand, intuitive visual navigation orthopedic robot can safely and effectively assist in the completion of the operation process, and has the advantages of less intraoperative blood loss, fewer fluoroscopy times.

Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.

The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.

Objective:To evaluate the specialty of the clinical features, treatment procedure, clinical outcome, and prognosis in the patients with "sandwich" atlantoaxial dislocation (AAD).Methods:From 2008 to 2018, 160 cases with "sandwich" AAD were retrospectively selected from the case series of AAD in Peking University Third Hospital. The case series had 80 males and 80 females. The mean age at the initial visit was 35.5±14.6 years (range, 5-77). The clinical courses, treatment methodology and prognosis were reviewed. And the surgical approach, posterior fixation segment and the recovery of neurological function were mainly summarized. The atlantodental interval (ADI), the distance by which the odontoid exceeded the Chamberlain line and the cervical-medullary angle were analyzed.Results:The most common symptoms included weakness or numbness of the limbs (67.5%, 108/160), unstable gait (30%, 48/160) and vertigo (20%, 32/160). Among all, 130 cases (81.3%, 130/160) had myelopathy, with the Japanese Orthopaedic Association (JOA) scores from 4 to 16 (mean JOA scores 13.5±2.5). Cranial neuropathy was involved in 20 cases (12.5%). Radiological findings showed brainstem and/or cervical-medullar in 130 cases (81.3%), syringomyelia in 37 cases (23.1%) and Chiari malformation in 30 cases (18.8%). Computed tomography angiography (CTA) was performed in 90 cases, which showed vertebral artery anomalies in 55 cases (61.0%) and excessive medialized internal carotid artery in 5 cases (5.6%). All cases had no spinal cord or vertebral artery injury. The surgery included posterior occipito-cervical fusion (reducible dislocation, 145 cases), and transoral release followed by posterior fusion (irreducible dislocation, 15 cases). Fifty-seven cases were treated using alternative fixation technique. The average follow-up time was 50.5±22.4 months (range, 24 to 120 months). All of 152 cases (95.0%) achieved solid atlantoaxial fusion; there was no obvious osseous fusion formation on postoperative images in 6 cases (3.8%), but no atlantoaxial instability was found on dynamic radiographs; screw loosening happened in 2 patients (1.2%). Nine patients (5.6%) suffered complications, including 4 cases with recurrent dislocation, 2 screw loosening, 2 cases with bulbar paralysis and 1 wound infection. The mean postoperative JOA was 15.1±1.8 (range, 5-17), and the mean neurological improvement rate was 42.9%±33.3% in the patients with myelopathy.Conclusion:"Sandwich" AAD, a subgroup of AAD, has unique clinical features: earlier onset age and more severe myelopathy. The incidence of bone and vascular malformation is higher. So alternative surgical plan and hybrid fixation should be prepared for this subgroup of AAD.

Objective:To compare the technique between concave distraction and convex resection in the treatment of congenital cervicothoracic scoliosis and evaluate its curative effect.Methods:Data of congenital cervicothoracic scoliosis patients from January 2010 to January 2020 were collected, among which 5 were males and 3 were females. The patients' age was 12.5±4.5 years old (range 6-20 years old). One case had C 7 wedged vertebra, 4 cases had T 1 hemivertebra and unbalanced vertebra, 2 cases had T 2 hemivertebra and 1 case had fused facet joint and wedged lamina in T 1. All patients had different degrees of vertebra fusion. Convex resection technique (one stage anterior and posterior combined hemivertebrae resection and annular osteotomy) was used to treat 4 cases before 2015; Concave distraction technique (A combination of anterior and posterior release, intervertebral space and facet space distraction, cage placed and fusion) was used to treat 4 cases after 2015 and 2 of them had 2 segments distraction. Perioperative neurological, vascular and wound related complications were recorded. The main parameters were structure Cobb angle, cephalic and caudal compensatory Cobb angle, mandibular incline, neck tilt, shoulder balance and head shift were measured pre-operation, post-operation and at the last follow-up. Results:All patients' surgeries were completed successfully. In convex resection group, the duration of surgery was 201±100 min (range 113-300 min) per vertebra, the estimated blood loss was 294±153 ml (range 100-450 ml) per vertebra, the hospital stay was 14±3 d (range 11-18 d) and follow up time was 51±11 months (range 36-60 months). In concave distraction group, the duration of surgery was 117±14 min (range 101-129 min) per vertebra, the estimated blood loss was 119±36 ml (range 85-167 ml) per vertebra, hospital stay was 17±3 d (range 14-20 d) and follow up time was 28±21 months (range 12-60 months). Convex resection group had longer operation time and more blood loss per vertebra than concave distraction group. In convex resection group, structural Cobb angle was 45.1°±21.0° pre-operation and 22.7°±15.3° post-operation, which was corrected significantly ( Z=6.53, P=0.038). The correction rate was 54.8%±30.9%. Cephalic compensatory Cobb angle was 22.1°±8.2° pre-operation and 8.2°±5.8° post-operation, which was corrected significantly ( F=6.01, P=0.049). The correction rate was 66.8%±15.1%. Mandible incline was 7.8°±3.1° pre-operation and 3.5°±1.5° post-operation, which was corrected significantly ( F=8.02, P=0.018). The correction rate was 51.0%±29.7%. In concave distraction group, structural Cobb angle was 32.2°±27.2° pre-operation and 16.3°±16.7° post-operation, which was corrected significantly ( F=7.43, P=0.024) . The correction rate was 59.0%±24.7%. Caudal compensatory Cobb angle was 18.9°(17.2°, 32.1°) pre-operation and 9.5°±10.3° post-operation, which was corrected significantly ( Z=6.00, P=0.049). The correction rate was 64.0%±24.1%. Clavicle angle was 3.9°±2.3° pre-operation and 0.3°±0.4° post-operation, which was corrected significantly ( F=1.75, P=0.040). The correction rate was 97.0% (48.5%, 99.8%). There was no significant difference in the correction rate of all radiographic parameters between the two groups. At the last follow-up, the patients' appearance of head, neck and shoulder were improved compared with those before surgery. In convex resection group, 2 patients showed nerve root stimulation symptoms postoperatively on convex side. One patient developed C 5 nerve root palsy which weakened deltoid muscle and the other patients presented with reduced triceps muscle strength. In concave distraction group, one patient developed C 5 nerve root palsy on convex side. All these symptoms recovered by conservative treatment 3 months after operation. Conclusion:It is safe and effective to treat congenital cervicothoracic scoliosis with convex resection technique and concave distraction technique. The concave distraction technique has the advantages of more safety, less operating time, less blood loss and easier to perform and has a wider application prospect.

Objective:To explore the safety, feasibility, and short-term outcome ofdistraction on the concave side in the treatment of patients with congenital cervical scoliosis.Methods:Between August 2015 and December 2019, 11 patients with congenital cervical scoliosis underwent distraction technique on concave side, among which 5 were males and 6 were females. Age was 9.9±3.1 years old (range 6-16 years old). The primary cervical spine deformity was hemi-vertebra with different degrees of vertebra fusion. 7 cases were in C 3, 3 cases were in C 4 and 1 case was in C 5. Anterior-posterior combined approach was used. Firstly, discectomy and soft tissue release on concave side were made through anterior approach, then distraction on concave side and fusion with internal fixation were made through posterior approach and at last fixation and fusion in anterior approach were made. In this study we measured structure Cobb angle, compensatory Cobb angle, mandibular incline, shoulder balance and the angle difference of trapezius muscle preoperation and post operation. Perioperative neurological,vascular and wound related complicationswere recorded. Results:All patients' surgeries were completed successfully. Eight patients received single site distraction and 3 patients received distraction in two sites. The duration of surgery was 466±141 min (range 150-659 min), the estimated blood losswas 387±191 ml (range 100-660 ml) and follow up time was 12.2±9.5 months (range 3-24 months). Structural Cobb angle was 28.9°±13.1° pre-operation and 7.4°(3.0°, 27.7°) post-operation at 3 months, which was corrected significantly ( Z=-2.934, P=0.003). The correction rate was 58.1±26.1% (range 18.8%-97.6%). Structural Cobb angle was 13.2°±12.3°at 1 year post operation and had no significant difference compared with 3 months post operation ( t=1.960, P=0.107). Compensatory Cobb angle was 18.3°±6.1° pre-operation and 9.4°±7.3° post-operation at 3 months, which was corrected significantly ( t= 5.071, P<0.001) and the correction rate was 51.3%±28.3% (range 2.4%-94.7%). Compensatory Cobb angle was 8.9°±7.7° at 1 year follow up and was corrected significantly ( t=5.253, P=0.003) compared to 3 months after surgery and the correction rate was 61.4%±26.9%. Two patients developed C 5 nerve root dysfunction and 1 patient developed numbness on the index and middle fingers after surgery. All of them occurred on the concave side and recovered by conservative treatment. Conclusion:The application of distraction on the concave side in the treatment of congenitalcervical scoliosis is with good feasibility and clinical safety. Short-term follow-up showed excellent resultswith a promising future.

Distal junctional problem (DJP) is one of the severe complications after spinal correction, fixation and fusion. As the number of patients receiving spinal surgery increased recently, the incidence of DJP also increased dramatically. Compared with proximal junctional problem, the incidence of DJP is low. However, the clinical symptoms are severe, and the rate of surgical revision is high in patients with distal junctional problems. DJP include distal junctional kyphosis (DJK) and distal junctional failure(DJF). The definition of DJK is confusing, however, and the most commonly used was that the distal junction Angle at the last follow-up was greater than 10° and increased by 10° compared with that before surgery. There are 6 DJF modes: progressive loss of lumbar lordosis,acute wedging in the disc below the instrumentation, fracture of LIV, osteoporotic fracture below the long rigid fixation, failure of the instrumentation at LIV, spinal stenosis and or segmental instability underneath the instrumentation. Possible risk factors for DJP include weight, age, type of spinal deformity, osteoporosis, choice of LIV, hip disease, deformity location, surgical approach, surgical procedure, fusion segments, fixation devices, LIV at L5, fixed to S1 with no iliac screws, poor restoration of spinal alignment, et al. Currently, there are some controversies in DJP, mainly including the incidence, risk factors whether needs to and how to revise. The review intends to conduct a simple literature review of the current DJP diagnostic criteria, incidence, risk factors, and other research progress, in order to improve the understanding of the distal junction problem.