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Piña D, Kalistratova V, Boozé Z, Voort WV, Conry K, Fine J, Holland J, Wick J, Ortega B, Javidan Y, Roberto R, Klineberg E, Lipa S, Le H. Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine. J Am Acad Orthop Surg 2023; 31:e675-e684. [PMID: 37311424 DOI: 10.5435/jaaos-d-22-01147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/11/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution. METHODS This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest. RESULTS Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables. DISCUSSION In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI. LEVEL OF EVIDENCE Retrospective case series, Level III evidence.
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Affiliation(s)
- Dagoberto Piña
- From the University of California, Davis School of Medicine, Sacramento, CA (Piña, Kalistratova, and Boozé), University of Louisville, School of Medicine, Louisville, KY (Holland), Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Piña, Voort, Conry, Wick, Ortega, Javidan, Roberto, Klineberg, and Le), Department of Public Health Sciences, University of California, Davis, Sacramento, CA (Fine), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Lipa)
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Liu X, Hu P, Zhai S, Liu X, Wang B, Zhou H, Liu X, Liu Z, Wei F. Surgery for metastatic spinal differentiated thyroid cancer: feasibility, outcome, and prognostic factors. Front Surg 2023; 10:1140150. [PMID: 37273828 PMCID: PMC10232895 DOI: 10.3389/fsurg.2023.1140150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
Study design A retrospective cohort study. Objectives This study aims to report the surgical outcome of metastatic spinal differentiated thyroid cancer (MSDTC) and analyze the factors affecting the prognosis. Methods Thirty-five patients were recruited in our single institution who underwent spinal surgery and adjuvant therapies from 2009 to 2019. Two surgical procedures, total en-bloc spondylectomy and debulking surgery, were undertaken. Their clinical data, postoperative events, and survival data were collected and analyzed. Survival time and associated factors were further analyzed. Results The cohort had a median survival time of 60 months. The mean visual analog scale scores and the Karnofsky performance score improved postoperatively (p < 0.05). The patients' Frankel grade was elevated for cases with preoperative neurological deficits (p < 0.05). In 31 patients who underwent debulking surgery, 41.9% (n = 13) had local recurrences, and radiotherapy reduced the risk of local relapse (p < 0.05). Preoperative and postoperative Frankel grades and radioactive iodine (RAI) therapy were associated with the patients' survival in the univariate analysis (p < 0.05). Furthermore, a multivariate regression analysis showed the postoperative Frankel grade as an independent prognostic factor. Conclusion Pain, quality of life, and neurological status of patients can be effectively improved after surgery. Radiotherapy can reduce the risk of local recurrences, whereas RAI therapy has a limited effect on local and extraspinal tumor control. Neurological status was independently associated with the patients' survival.
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Affiliation(s)
- Xiajun Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
- Department of Spinal Surgery, Baoji Municipal Central Hospital, Baoji, China
| | - Panpan Hu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Shuheng Zhai
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Xiao Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Ben Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Hua Zhou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Zhongjun Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Feng Wei
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
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Multidisciplinary Approach to Spinal Metastases and Metastatic Spinal Cord Compression—A New Integrative Flowchart for Patient Management. Cancers (Basel) 2023; 15:cancers15061796. [PMID: 36980681 PMCID: PMC10046378 DOI: 10.3390/cancers15061796] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/04/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Metastatic spine disease (MSD) and metastatic spinal cord compression (MSCC) are major causes of permanent neurological damage and long-term disability for cancer patients. The development of MSD is pathophysiologically framed by a cooperative interaction between general mechanisms of bone growth and specific mechanisms of spinal metastases (SM) expansion. SM most commonly affects the thoracic spine, even though multiple segments may be affected concomitantly. The great majority of SM are extradural, while intradural-extramedullary and intramedullary metastases are less frequently seen. The management of patients with SM is particularly complex and challenging, with multiple factors—such as the spinal stability status, primary tumor radio and chemosensitivity, cancer biological burden, patient performance status and comorbidities, and patient’s oncological prognosis—influencing the clinical decision-making process. Different frameworks were developed in order to systematize and support this process. A multidisciplinary, personalized approach, enriched by the expertise of each involved specialty, is crucial. We reviewed the most recent evidence and proposed an updated algorithmic approach to patients with MSD according to the clinical scenario of each patient. A flowchart-based approach offers an evidence-based management of MSD, providing a valuable clinical decision tool in a context of high uncertainty and quick-acting need.
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Saha P, Raza M, Fragkakis A, Ajayi B, Bishop T, Bernard J, Miah A, Zaidi SH, Abdelhamid M, Minhas P, Lui DF. Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy. Front Surg 2023; 10:1110580. [PMID: 36969765 PMCID: PMC10033756 DOI: 10.3389/fsurg.2023.1110580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/19/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionTomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery.MethodsFirst-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4–S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4–S1 promontory.ResultsPatient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op.ConclusionThese are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.
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Affiliation(s)
- Priyanshu Saha
- School of Medicine, St George's, University of London, United Kingdom
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
- Correspondence: Priyanshu Saha
| | - Mohsen Raza
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Angelo Fragkakis
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Bisola Ajayi
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Timothy Bishop
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Jason Bernard
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Aisha Miah
- Department of Sarcoma, Royal Marsden NHS Foundation Trust, United Kingdom
| | - Shane H. Zaidi
- Department of Sarcoma, Royal Marsden NHS Foundation Trust, United Kingdom
| | - Mohamed Abdelhamid
- Department of Vascular Surgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Pawan Minhas
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Darren F. Lui
- Department of Complex Neurosurgery, St George's University Hospitals NHS Foundation Trust, United Kingdom
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Gales L, Mitrea D, Chivu B, Radu A, Bocai S, Stoica R, Dicianu A, Mitrica R, Trifanescu O, Anghel R, Serbanescu L. Risk of Myelopathy Following Second Local Treatment after Initial Irradiation of Spine Metastasis. Diagnostics (Basel) 2023; 13:diagnostics13020175. [PMID: 36672985 PMCID: PMC9857541 DOI: 10.3390/diagnostics13020175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
Metastatic lesions of the spine occur in up to 40% of cancer patients and are a frequent source of pain and neurologic deficit due to cord compression. Palliative radiotherapy is the main first-intent local treatment in the form of single-fraction radiotherapy or fractionated courses. Reirradiation is a viable option for inoperable patients where spinal decompression is needed but with an increased risk of radiation-induced myelopathy (RM) and subsequent neurologic damage. This review summarizes reported data on local treatment options after initial irradiation in patients with relapsed spine metastasis and key dosimetric correlations between the risk of spinal cord injury and reirradiation technique, total dose, and time between treatments. The Linear Quadratic (LQ) model was used to convert all the published doses into biologically effective doses and normalize them to EQD2. For 3D radiotherapy, authors used cumulative doses from 55.2 Gy2/2 to 65.5 Gy2/2 EQD2 with no cases of RM mentioned. We found little evidence of RM after SBRT in the papers that met our criteria of inclusion, usually at the median reported dose to critical neural tissue around 93.5 Gy2/2. There is a lack of consistency in reporting the spinal cord dose, which leads to difficulty in pooling data.
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Affiliation(s)
- Laurentia Gales
- Department of Oncology, “Carol Davila” University of Medicine & Pharmacy, 020021 Bucharest, Romania
- Department of Oncology, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
| | - Diana Mitrea
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
| | - Bogdan Chivu
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
| | - Adrian Radu
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
| | - Silvia Bocai
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
| | - Remus Stoica
- Department of Radiotherapy, Centrul Oncologic Sanador, 010991 Bucharest, Romania
| | - Andrei Dicianu
- Department of Radiotherapy, Clinical Emergency County Hospital, 200642 Craiova, Romania
| | - Radu Mitrica
- Department of Oncology, “Carol Davila” University of Medicine & Pharmacy, 020021 Bucharest, Romania
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
- Correspondence: (R.M.); (O.T.); Tel.: +40-741964311 (R.M.); +40-745001224 (O.T.)
| | - Oana Trifanescu
- Department of Oncology, “Carol Davila” University of Medicine & Pharmacy, 020021 Bucharest, Romania
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
- Correspondence: (R.M.); (O.T.); Tel.: +40-741964311 (R.M.); +40-745001224 (O.T.)
| | - Rodica Anghel
- Department of Oncology, “Carol Davila” University of Medicine & Pharmacy, 020021 Bucharest, Romania
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
| | - Luiza Serbanescu
- Department of Oncology, “Carol Davila” University of Medicine & Pharmacy, 020021 Bucharest, Romania
- Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, 022328 Bucharest, Romania
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Li Y, Long Z, Wang X, Lei M, Liu C, Shi X, Liu Y. A novel nomogram to stratify quality of life among advanced cancer patients with spinal metastatic disease after examining demographics, dietary habits, therapeutic interventions, and mental health status. BMC Cancer 2022; 22:1205. [DOI: 10.1186/s12885-022-10294-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Background
It would be very helpful to stratify patients and direct patient selection if risk factors for quality of life were identified in a particular population. Nonetheless, it is still challenging to forecast the health-related quality of life among individuals with spinal metastases. The goal of this study was to stratify patient’s populations for whom the assessment of quality of life should be encouraged by developing and validating a nomogram to predict the quality of life among advanced cancer patients with spine metastases.
Methods
This study prospectively analyzed 208 advanced cancer patients with spine metastases, and collected their general characteristics, food preferences, addictions, comorbidities, therapeutic strategies, and mental health status. The functional assessment of cancer therapy-general (FACT-G) and hospital anxiety and depression scale (HADS) were used to assess quality of life and mental health, respectively. The complete cohort of patients was randomly divided into two groups: a training set and a validation set. Patients from the training set were conducted to train and develop a nomogram, while patients in the validation set were performed to internally validate the nomogram. The nomogram contained significant variables discovered using the least absolute shrinkage and selection operator (LASSO) approach in conjunction with 10-fold cross-validation. The nomogram’s predictive ability was assessed utilizing discrimination, calibration, and clinical usefulness. Internal validation was also completed using the bootstrap method after applying 500 iterations of procedures. A web calculator was also developed to promote clinical practice.
Results
Advance cancer patients with spinal metastases had an extremely low quality of life, as indicated by the average FACT-G score of just 60.32 ± 20.41. According to the LASSO and 10-fold cross-validation, Eastern Cooperative Oncology Group (ECOG) score, having an uncompleted life goal, preference for eating vegetables, chemotherapy, anxiety status, and depression status were selected as nomogram predictors. In the training set, the area under the receiver operating characteristic curve (AUROC) was 0.90 (95% CI: 0.84–0.96), while in the validation set, it was 0.85 (95% CI: 0.78–0.93). They were 0.50 (95% CI: 0.41–0.58) and 0.44 (95% CI: 0.33–0.56), respectively, for the discrimination slopes. The nomogram had favorable capacity to calibrate and was clinically useful, according to the calibration curve and decision curve analysis. When compared to patients in the low-risk group, patients in the high-risk group were above four times more likely to experience a poor quality of life (82.18% vs. 21.50%, P < 0.001). In comparison to patients in the low-risk group, patients in the high-risk group also exhibited significant higher levels of anxiety and depression. The webpage for the web calculator was https://starshiny.shinyapps.io/DynNomapp-lys/.
Conclusions
This study suggests a nomogram that can be applied as a practical clinical tool to forecast and categorize the quality of life among patients with spine metastases. Additionally, patients with poor quality of life experience more severe anxiety and depression. Effective interventions should be carried out as soon as possible, especially for patients in the high-risk group, to improve their quality of life and mental health condition.
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Liu Y, Cao X, Zhao X, Shi X, Lei M, Qin H. Quality of Life and Mental Health Status Among Cancer Patients With Metastatic Spinal Disease. Front Public Health 2022; 10:916004. [PMID: 35865242 PMCID: PMC9294283 DOI: 10.3389/fpubh.2022.916004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
This study aimed to investigate the quality of life and mental health status and further to identify relevant risk factors among advanced cancer patients with spine metastases. This study prospectively included and analyzed 103 advanced cancer patients with spine metastases. Patient's basic information, lifestyles, comorbidities, tumor characteristics, therapeutic strategies, economic conditions, quality of life, anxiety, and depression were collected. Patient's quality of life was assessed using the Functional Assessment of Cancer Therapy-General Scale (FACT-G), and anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS). Subgroup analysis was performed based on different age groups, and a multivariate analysis was performed to test the ability of 20 potential risk factors to predict quality of life, anxiety, and depression. The mean total FACT-G score was only 61.38 ± 21.26. Of all included patients, 52.43% had skeptical or identified anxiety and 53.40% suffered from skeptical or identified depression. Patients had an age of 60 or more and <70 years had the lowest FACT-G score (54.91 ± 19.22), highest HADS anxiety score (10.25 ± 4.22), and highest HADS depression score (10.13 ± 4.94). After adjusting all other potential risk factors, age was still significantly associated with quality of life (OR = 0.57, 95%CI: 0.38–0.86, p < 0.01) and depression (OR = 1.55, 95%CI: 1.00–2.42, p = 0.05) and almost significantly associated with anxiety (OR = 1.52, 95%CI: 0.94–2.43, p = 0.08). Besides, preference to eating vegetables, time since knowing cancer diagnosis, surgical treatment at primary cancer, hormone endocrine therapy, and economic burden due to cancer treatments were found to be significantly associated with the quality of life. A number of comorbidities and economic burden due to cancer treatments were significantly associated with anxiety. Advanced cancer patients with spine metastases suffer from poor quality of life and severe anxiety and depression, especially among patients with an age of 60 or more and <70 years. Early mental health care and effective measures should be conducted to advanced cancer patients with spine metastases, and more attention should be paid to take care of patients with an age of 60 or more and <70 years in terms of their quality of life and mental health status.
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Affiliation(s)
- Yaosheng Liu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
- National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, PLA General Hospital, Beijing, China
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Fifth School of Clinical Medicine, Anhui Medical University, Hefei, China
| | - Xuyong Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xiongwei Zhao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Fifth School of Clinical Medicine, Anhui Medical University, Hefei, China
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xiaolin Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
- Xiaolin Shi
| | - Mingxing Lei
- National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Department of Orthopedic Surgery, Hainan Hospital of PLA General Hospital, Sanya, China
- Mingxing Lei
| | - Haifeng Qin
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- *Correspondence: Haifeng Qin
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