ObjectiveThe volume based procurement (VBP) program in China was initiated in 2022. The cost‐effectiveness of robotic arm assisted total knee arthroplasty is yet uncertain after the initiation of the program. The objective of the study was to investigate the cost‐effectiveness of robotic arm‐assisted total knee arthroplasty and the influence of the VBP program to its cost‐effectiveness in China.MethodsThe study was a Markov model‐based cost‐effectiveness study. Cases of primary total knee arthroplasty from January 2019 to December 2021 were included retrospectively. A Markov model was developed to simulate patients with advanced knee osteoarthritis. Manual and robotic arm‐assisted total knee arthroplasties were compared for cost‐effectiveness before and after the engagement of the VBP program in China. Probability and sensitivity analysis were conducted.ResultsRobotic arm‐assisted total knee arthroplasty showed better recovery and lower revision rates before and after initiation of the VBP program. Robotic arm‐based TKA was superior to manual total knee arthroplasty, with an increased effectiveness of 0.26 (16.87 vs 16.61) before and 0.52 (16.96 vs 16.43) after the application of Volume‐based procurement, respectively. The procedure is more cost‐effective in the new procurement system (17.13 vs 16.89). Costs of manual or robotic arm‐assisted TKA were the most sensitive parameters in our model.ConclusionBased on previous and current medical charging systems in China, robotic arm‐assisted total knee arthroplasty is a more cost‐effective procedure compared to traditional manual total knee arthroplasty. As the volume‐based procurement VBP program shows, the procedure can be more cost‐effective.

Background To investigate the influence of osteophytes on postoperative gap balancing, and to work out a predictive model of the relationship between osteophyte size and gap gaining in primary total knee replacement. Methods One hundred and ten patients were enrolled in the study. Pre- and postoperative radiographs were collected and analyzed. They were assigned to the training dataset and test dataset randomly at a ratio of 9:1 by using the statistical package R (version 4.0.5). Size and marginal distances of osteophytes, planned bone cut planes, predicted bone cuts and joint gaps were labeled on the preoperative standing anteroposterior and lateral views, while actual bone cuts and joint gaps were recorded on the postoperative plain films, respectively. Statistical analysis was performed. Results Actual joint gaps were significantly related to the distances of medial and lateral predictive bone cutting lines, bone cut thickness on tibial side and posterior condylar, as well as size and marginal distances of osteophytes ( P < 0.05). A predictive equation was generated, with a root mean square error (RMSE) of 3.4761 in validation. A 2-D planning system with adjustable input parameters and dim predictive outputs on joint gap was developed. The equation is S (Joint Gap)=1.82+0.15*y+0.552*Tibial cut+0.953*Femoral cut+0.197*Post Condyle Conclusion Postoperative joint gap can be predicted on the basis of preoperative measurements on 2-D plain films. Larger sample size may help improve the effectiveness and accuracy of the predictive equation.

AbstractBackgroundSpinopelvic dissociation (SPD) is generally caused by high-energy injury mechanisms, and, in the absence of timely diagnosis and treatment, it can lead to chronic pain and progressive deformity. However, SPD is difficult to manage because of its rarity and complexity. In this study, we re-defined SPD according to the mechanism of injuries and biomechanical characteristics of the posterior pelvic ring and developed new classification criteria and treatment principles based on the classification for SPD.MethodsBetween June 2015 and September 2020, 30 patients with SPD which were selected from 138 patients with pelvic fractures were enrolled. Physical examination was performed, classification criteria (301 SPD classification) were developed, and specific treatment standards were established according to the classifications.ResultsThe injury mechanisms and co-existing injuries did not significantly differ between the classical SPD patients and expanded SPD patients. The 301 SPD classification criteria covered all the patients. Fixation by biplanar penetration screws was used in 7 patients, 11 patients received fixation by uniplanar penetration screws, 6 patients used sacroiliac compression screws, 3 patients received uniplanar screws combined with sacroiliac compression screws, and open spondylopelvic fixation was used in only 3 patients. According to the Matta criteria, 19, 7, and 4 patients achieved excellent, good, and fair reduction. The Majeed function score of the patients ranged from 9 to 96 points, and the mean score was 72.9 ± 24.6 points.ConclusionThe expanded definition for SPD is particularly significant for definite diagnosis and prevention of missing diagnosis, based on which the 301SPD classification criteria can more systemically guide the clinical treatment of SPD, increase the treatment efficacy, and reduce surgical trauma.Chinese Clinical Trial Registry: ChiCTR-IPR-16009340.

Background: The intramedullary fixation for the management of intertrochanteric fractures has replaced the extramedullary fixation without strong evidence regarding its effect on survival and hospital readmission. We sought to determine the effect of two fixation method on mortality and readmission rate among elder intertrochanteric fracture patients.Methods: We did a retrospective cohort study of intertrochanteric fracture patients (≥60 years) who underwent intramedullary or extramedullary fixation, using two population-based samples of 26988 patients in Beijing from 2008 to 2016 and 61401 patients in USA from 2013 to 2016. The primary outcome measure was mortality and the incidence of hospital readmissions. Association between internal fixation methods and outcomes were examined by multivariate analysis, propensity score matching, and inverse probability of treatment weighting (IPTW). We did subgroup analyses of death by age and comorbidities, and re-created the PS model in each subgroup.Findings: The proportion of intramedullary fixation increased from 21·23% to 77.79% in Beijing from 2008 to 2016, while proportion of intramedullary fixation was 98·26% in USA. After adjusted, extramedullary fixation had significantly lower in-hospital mortality than intramedullary fixation in Beijing, opposite to the result gained from USA database. Follow-up data on long-term outcomes (1-month, 6-month and 1-year) only were available in Beijing. 1-year mortality was 4·96% among patients who underwent intramedullary fixation and 3·66% among those who underwent extramedullary fixation (risk difference, 1·30%, 95% confidence interval [CI], -1·79% to -0·81%; hazard ratio, 0·82, 95% CI, 0·72 to 0·93). Extramedullary fixation was also associated with lower hospital readmission rate (hazard ratio, 0·88, 95% CI, 0·81 to 0·97). Results were similar after propensity score matching (PSM) and inverse probability weighting (IPTW) matching, as well as in two sensitivity analyses. Subgroup analyses identified the characteristics of specific patients who still had significantly lower risk of death when underwent extramedullary fixation, including advanced age (>70 years old), comorbidities ≥5 or ≤2, or comorbidity of pulmonary disease/heart disease/stroke.Interpretation: Compared to the intramedullary fixation, the extramedullary fixation was associated with lower postoperative mortality and readmission rate. Overwhelming application of intramedullary fixation would bring more difficulties and bias to further real-world study.Funding: National Key R&D Program of China (2020YFC2004906); Beijing Natural Science Foundation-Haidian original Innovation Joint Foundation (L192016)Declaration of Interest: The authors declare support from the National Natural Science Foundation of China and the Program of Beijing Municipal Science and Technology Commission.Ethical Approval: This study was approved by the biomedical ethics board of the Chinese PLA General Hospital (Ethical Approval No.: S2019-014-01)

Abstract Background To explore the risk factors involved in the induction of thoracolumbar fascia (TLF) injury by osteoporotic vertebral compression fracture (OVCF), and the association between the residual pain after percutaneous vertebroplasty (PVP) and fascial injury. Methods A total of 81 patients with single-segment OVCF, treated between January 2018 and January 2020 were included. The patients were grouped according to the existence of TLF injury. The patients’ general, clinical, and imaging data were accessed. Results There were 47 patients in the TLF group and 34 in the non-injury group (NTLF group). In the TLF group, BMI (Body mass index) was significantly lower, while the prevalence of hypertension and sarcopenia were significantly higher (P < 0.05). The vertebral compression degree was higher, and the kyphosis angle of the injured vertebra was greater in the TLF group (P < 0.05). Cobb’s angle was not significantly different between groups. At 3-d after the operation, the VAS (Visual analogue scale) was 4.64 ± 1.78 and 3.00 ± 1.71, and the ODI (Oswestry disability index) was 67.44 ± 11.37% and 56.73 ± 10.59% in TLF and NTLF group, respectively (P < 0.05). However, at 3-m after the operation, the differences in the VAS score and the ODI between groups were not statistically significant. The area of fascial edema was not significantly associated with the pre- and post-operative VAS or ODI, but was positively correlated with the vertebral body compression degree (R = 0.582, P = 0. 029). Conclusion Residual back pain after PVP is associated with TLF injury. Low BMI, hypertension and sarcopenia are risk factors of TLF injury, and sarcopenia may be the major factor.

OBJECTIVE:To evaluate clinical efficacy of single-tunnel double-line technique with tendoscopy in treating tibial intercondylar eminence fractures.METHODS:From January 2016 to April 2020, 22 patients with tibial intercondylar eminence fractures were admitted, including 14 males and 8 females with a mean age of (34.8±5.9) years old ranging from 26 to 45 years old. The mean duration from injury to surgery was(11.2±4.1) days(ranged, 5 to15 d). All patients were treated with arthroscopic single-tunnel double-line technique. The fracture healing was evaluated according to X-ray. The Lysholm score, IKDC 2000 score and the anterior drawer test were used to evaluate efficacy before operation and at the latest follow-up.RESULTS:All patients were followed up, and the duration ranged from 12 to 75 months, with an average of(34.6±13.0) months. Lysholm score was (89.60±2.89) points at the latest follow-up, showing significant difference when compared with preoperative score which was (30.80±9.55)points(t=9.67, P<0.01). IKDC 2000 score was(80.00±6.17) points at the latest follow-up, showing significant difference when compared with preoperative score which was(24.60±7.21)points(t=11.41, P<0.01). One patient showed weakly positive of drauer test.CONCLUSION:Single-channel double-line technique could effectively fix bone block of intercondylar eminence with advantage of easy operation and minimally invasive, which could be applied to various types of tibial intercondylar eminence fractures.

Background: Intertrochanteric fracture is a significant risk factor for elder death and disability. Though current guidelines remain controversial for the treatment strategies by limited evidence, intramedullary fixation has overtaken the use of extramedullary fixation as the preferred technique. We aimed to assess the effect of different treatments on death and secondary fracture, and evaluate their cost-effectiveness.Methods: We conducted a population-based cohort study of all intertrochanteric fracture patients (≧60 years) in Beijing from 2008 to 2016, using population-based health database from the Beijing Municipal Health Commission and Beijing Center for Disease Control and Prevention (CDC) . We used multivariable Cox-regression analysis and semi-competing risk model to calculate the clinical effects and determine whether surgical technique was an independent and significant risk factor for death and secondary fracture. We further used inverse probability of treatment propensity-score weighting and did subgroup analyses by age and comorbidities. A Markov model was constructed to evaluate the incremental cost-effectiveness ratios and determine the most cost-effective treatment.Findings: During a median 5.49 years follow-up, a total of 36488 intertrochanteric fracture patients were included. From 2008 to 2016, the proportion of intramedullary fixation increased from 27.7% to 54.4%, while the extramedullary fixation decreased from 42.5% to 20.7%. After adjusted, extramedullary fixation had significantly lower mortality than intramedullary fixation by 8.8% (hazard ratio [HR] 0.839, 95% CI 0.789-0.891), especially for elder patients with fewer comorbidities. After adjusted, extramedullary fixation had significantly lower secondary fracture incidence than intramedullary fixation by 7.4% (hazard ratio [HR] 0.791, 95% CI 0.715-0.875). Extramedullary fixation was the most cost-effective strategy with an incremental cost-effectiveness ratio of $31,354.20 per QALY compared with conservative treatment.Interpretation: Compared to other operative treatments, the extramedullary fixation was associated with lower mortality and secondary fracture incidence, and was the most cost-effective strategy. Funding: National Natural Science Foundation of China (61771489), Program of Beijing Municipal Science and Technology Commission (Z191100004419008). Declaration of Interest: None to declare. Ethical Approval: This study was approved by the biomedical ethics board of the Chinese PLA General Hospital (Ethical Approval No.: S2019-014-01)