Biomechanical effects of posterior lumbar interbody fusion with vertical placement of pedicle screws compared to traditional placement

BACKGROUND The pedicle screw technique is widely employed for vertebral body fixation in the treatment of spinal disorders.However,traditional screw placement methods require the dissection of paraspinal muscles and the insertion of pedicle screws at specific transverse section angles(TSA).Larger TSA angles require more force to pull the muscle tissue,which can increase the risk of surgical trauma and ischemic injury to the lumbar muscles.AIM To study the feasibility of zero-degree TSA vertical pedicle screw technique in the lumbosacral segment.METHODS Finite element models of vertebral bodies and pedicle screw-rod systems were established for the L4-S1 spinal segments.A standard axial load of 500 N and a rotational torque of 10 N/m were applied.Simulated screw pull-out experiment was conducted to observe pedicle screw resistance to pull-out,maximum stress,load-displacement ratio,maximum stress in vertebral bodies,load-displacement ratio in vertebral bodies,and the stress distribution in pedicle screws and vertebral bodies.Differences between the 0-degree and 17-degree TSA were compared.RESULTS At 0-degree TSA,the screw pull-out force decreased by 11.35%compared to that at 17-degree TSA(P<0.05).At 0-degree and 17-degree TSA,the stress range in the screw-rod system was 335.1-657.5 MPa and 242.8-648.5 MPa,separately,which were below the fracture threshold for the screw-rod system(924 MPa).At 0-degree and 17-degree TSA,the stress range in the vertebral bodies was 68.45-78.91 MPa and 39.08-72.73 MPa,separately,which were below the typical bone yield stress range for vertebral bodies(110-125 MPa).At 0-degree TSA,the load-displacement ratio for the vertebral bodies and pedicle screws was slightly lower compared to that at 17-degree TSA,indicating slightly lower stability(P<0.05).CONCLUSION The safety and stability of 0-degree TSA are slightly lower,but the risks of screw-rod system fracture,vertebral body fracture,and rupture are within acceptable limits.

Cadaveric Evaluation of Lumbar Pedicle Morphometry among Nigerians

Pedicle screw is employed in several cases of spine disorders such as fractures, pseudarthrosis, spondylolisthesis, degenerative changes among others. Its essence is to fix the vertebral body in position until fusion is complete. The success of this technique depends on factors like choice of size of screw for a particular pedicle size and shape. Thus, adequate knowledge of the morphometry of lumbar pedicle may avert intraoperative and postoperative complications associated with this technique, especially, neurological impairments. In this study, we determined the vertical and horizontal diameters, interpedicular distance and gender differences of 180 lumbar vertebral pedicles (140 male, 40 female pedicles) using digital vernier calipers. Results revealed a significant increase in pedicle height and width from L2 to L5. Interpedicular distance increased significantly down the vertebrae from L2 to L5. Mean vertical and horizontal diameters, interpedicular distance were not significantly different in both sexes. This study recommends a thorough check of individual’s spinal anatomy in pre-operative assessments.

Successful outcomes of unilateral vs bilateral pedicle screw fixation for lumbar interbody fusion:A meta-analysis with evidence grading

BACKGROUND Whether it’s better to adopt unilateral pedicle screw(UPS)fixation or to use bilateral pedicle screw(BPS)one for lumbar degenerative diseases is still controversially undetermined.AIM To make a comparison between UPS and BPS fixation as to how they work efficaciously and safely in patients suffering from lumbar degenerative diseases.METHODS We have searched a lot in the databases through 2020 with index terms such as“unilateral pedicle screw fixation”and“bilateral pedicle screw fixation.”Only randomized controlled trials and some prospective cohort studies could be found,yielding 15 studies.The intervention was unilateral pedicle screw fixation;Primarily We’ve got outcomes of complications and fusion rates.Secondarily,we’ve achieved outcomes regarding total blood loss,operative time,as well as length of stay.Softwares were installed and utilized for subgroup analysis,analyzing forest plots,sensitivity,heterogeneity,forest plots,publication bias,and risk of bias.RESULTS Fifteen previous cases of study including 992 participants have been involved in our meta-analysis.UPS had slightly lower effects on fusion rate[relative risk(RR)=0.949,95%CI:0.910 to 0.990,P=0.015],which contributed mostly to this metaanalysis,and similar complication rates(RR=1.140,95%CI:0.792 to 1.640,P=0.481),Δvisual analog scale[standard mean difference(SMD)=0.178,95%CI:-0.021 to 0.378,P=0.080],andΔOswestry disability index(SMD=-0.254,95%CI:-0.820 to 0.329,P=0.402).In contrast,an obvious difference has been observed inΔJapanese Orthopedic Association(JOA)score(SMD=0.305,95%CI:0.046 to 0.563,P=0.021),total blood loss(SMD=-1.586,95%CI:-2.182 to-0.990,P=0.000),operation time(SMD=-2.831,95%CI:-3.753 to-1.909,P=0.000),and length of hospital stay(SMD=-0.614,95%CI:-1.050 to-0.179,P=0.006).CONCLUSION Bilateral fixation is more effective than unilateral fixation regarding fusion rate after lumbar interbody fusion.However,JOA,operation time,total blood loss,as well as length of stay were improved for unilateral fixation.

Potential contribution of pedicle screw design to loosening rate in patients with degenerative diseases of the lumbar spine:An observational study

BACKGROUND The majority of published data report the results of biomechanical tests of various design pedicle screw performance.The clinical relevance and relative contribution of screw design to instrumentation stability have been insufficiently studied.AIM To estimate the contribution of screw design to rate of pedicle screw loosening in patients with degenerative diseases of the lumbar spine.METHODS This study is a prospective evaluation of 175 patients with degenerative diseases and instability of the lumbar spine segments.Participants underwent spinal instrumentation employing pedicle screws with posterior only or transforaminal interbody fusion.Follow-up was for 18 mo.Patients with signs of pedicle screw loosening on computed tomography were registered;logistic regression analysis was used to identify the factors that influenced the rate of loosening.RESULTS Parameters included in the analysis were screw geometry,type of thread,external and internal screw diameter and helical pitch,bone density in Hounsfield units,number of levels fused,instrumentation without anterior support,laminectomy,and unilateral and bilateral total facet joint resection.The rate of screw loosening decreased with the increment in outer diameter,decrease in core diameter and helical pitch.The rate of screw loosening correlated positively with the number of fused levels and decreasing bone density.Bilateral facet joint removal significantly favored pedicle screw loosening.The influence of other factors was insignificant.CONCLUSION Screw parameters had a significant impact on the loosening rate along with bone quality characteristics,the number of levels fused and the extensiveness of decompression.The significance of the influence of screw parameters was comparable to those of patient-and surgery-related factors.Pedicle screw loosening was influenced by helical pitch,inner and outer diameter,but screw geometry and thread type were insignificant factors.

Pedicle complex tissue flap transfer for reconstruction of duplicated thumbs with unequal size

BACKGROUND Thumb polydactyly is one of the most common congenital hand deformities,and the Bilhaut-Cloquet procedure or a modified one is often used.However,controversy remains over the rare instances in which both thumbs are not of similar length or far apart in distance.AIM To evaluate the clinical outcomes of pedicle complex tissue flap transfer in the treatment of duplicated thumbs with unequal size.METHODS From January 2014 to December 2020,15 patients underwent duplicated thumb reconstruction by pedicle complex tissue flap transfer at our hand surgery center.The technique was used when it was necessary to combine different tissues from both severed and preserved thumbs that were not of similar length or far apart in distance.Subjective parents’evaluations and functional outcomes(ALURRA and TATA criteria)were obtained.The alignment deviation,instability,range of motion(percent of opposite thumb)of the interphalangeal and metacarpophalangeal joints,and the aesthetic aspects,including circumference,length,nail size,and nail deformity,were used to assess the clinical outcomes.RESULTS The average age of patients at the time of surgery was 13 mo,and the mean final follow-up occurred at 42 mo.An appropriate volume with a stable joint and good appearance was obtained in 14 reconstructed thumbs.An unstable interphalangeal joint occurred in one thumb.The flexion-extension arc at the metacarpophalangeal joint was good,while that at the interphalangeal joint was poor.Most of the parents were satisfied with the cosmetic and functional results of the reconstructed thumbs.The mean ALURRA score was 21.8(range:20-24),and the Tada score was 6.9(range:5-8).Compared with the non-operated side,the length of the operated thumb was approximately 95%,the girth was 89%,and the nail width was 82.9%.The mean ranges of motion were 62.1%of that of the unaffected thumb in the interphalangeal joint and 78.3%in the metacarpophalangeal joint.CONCLUSION Harvesting a pedicle flap from a severed thumb is a safe and reliable procedure.Defects of the preserved thumb,such as the skin,nail,and bone,can be effectively restored using the complex tissue flap.

Central/Inferior Pedicle Technique for Reduction Mammaplasty: A Systematic Review

Background: Intention of reduction mammoplasty is to minimize the breast volume and maintain supply of blood and innervations to NAC (nipple-areola-complex), to lift NAC to higher position in mound of breast using any reliable technique like central pedicle technique. Methods: This research selected and observed 15 patients who underwent central pedicle technique for mammaplasty of breast reduction. Age criterium included for this research is 18 years to 60 years for 5 years from Chinese patients. In addition to these, this study systematically reviewed about central pedicle technique for 25 years. Papers were selected from 1996 to 2021. Results: Using central pedicle technique, shape and projection of breast were reduced. Such changes of measurements showed that postoperative technique leads to long-term satisfactory impact. Conclusion: Central pedicle technique was found to be best, reliable and safe technique for reduction mammaplasty. Reduction mammaplasty is used for reducing the ptotic and large breasts. It provides more satisfactory and good aesthetic outcomes. Majority of patients do not have any complications postoperative. Complications rate is minimal when central pedicle technique is used for reduction mammaplasty. Patients with ptotic and large breasts would have huge advantage postoperative.

Position and complications of pedicle screw insertion with or without image-navigation techniques in the thoracolumbar spine:a meta-analysis of comparative studies

Computer-navigated pedicle screw insertion is applied to the thoracic and lumbar spine to attain high insertion accuracy and a low rate of screw-related complications.However,some in vivo and in vitro studies have shown that no advantages are gained with the use of navigation techniques compared to conventional techniques.Additionally,inconsistent conclusions have been drawn in various studies due to different population characteristics and methods used to assess the accuracy of screw placement.Moreover,it is not clear whether pedicle screw insertion with navigation techniques decreases the incidence of screw-related complications.Therefore,this study was sought to perform a meta-analysis of all available prospective evidence regarding pedicle screw insertion with or without navigation techniques in human thoracic and lumbar spine.We considered in vivo comparative studies that assessed the results of pedicle screw placement with or without navigation techniques.PubMed,Ovid MEDLINE and EMBASE databases were searched.Three published randomized controlled trials（RCTs） and nine retrospective comparative studies met the inclusion criteria.These studies included a total of 732 patients in whom 4,953 screws were inserted.In conclusion,accuracy of the position of grade I,II,III and IV screws and complication rate related to pedicle screw placement were significantly increased when navigation techniques were used in comparison to conventional techniques.Future research in this area should include RCTs with well-planned methodology to limit bias and report on validated,patient-based outcome measures.

Treatment of Thoracolumbar Vertebrate Fracture by Transpedicular Morselized Bone Grafting in Vertebrae for Spinal Fusion and Pedicle Screw Fixation

To enhance the fusion of graft bone in thoracolumbar vertebrae and minimize the postoperative loss of correction, short-segment pedicle screw fixation was reinforced with posterior moselizee bone grafting in vertebrae for spinal fusion in patients with thoracrolumbar vertebrate fractures. Seventy patients with thoracrolumbar vertebrate fractures were treated by short-segment pedicle screw fixation and were randomly divided into two groups. Fractures in group A （n=20） were rein-forced with posterior morselized bone grafting in vertebrae for spinal fusion, while patients group B （n=50） did not receive the morselized bone grafting for bone fusion. The two groups were compared in terms of kyphotic deformity, anterior vertebral height, instrument failure and neurological functions after the treatment. Frankel grading system was used for the evaluation of neurological evaluation and Denis scoring scale was employed for pain assessment. The results showed that the kyphosis correction was achieved in both group A and group B （group A： 6.4 degree; group B： 5.4 degree）/At the end of follow-up, kyphosis correction was maintained in group A but lost in group B （P=0.0001）. Postoperatively, greater anterior height was achieved in group A than in group B （P〈0.01）. During follow-up study, anterior vertebral height was maintained only in Group A （P〈0.001）. Both group A and group B showed good Denis pain scores （P1 and P2） but group A outdid group B in terms of control of severe and constant pain （P4 and P5）. By Frankel criteria, the changes in neurological functions in group A was better than those of group B （P〈0.001）. It is concluded that reinforcement of short-segment pedicle fixation with morselized bone grafting for the treatment of patients with thoracolumbar vertebrae fracture could achieve and maintain kyphosis correction, and it may also increase and maintain anterior vertebral height. Morselized bone grafting in vertebrae offers immediate spinal stability in patients with thoracolumbar vertebrate fractures, decreases the instrument failure and provides better postoperative pain control than without the morselized bone grafting.

Posterior Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis Patients:a Comparison of All Pedicle Screws versus Hybrid Instrumentation

Objective To analyze the influence of segmental pedicle screws versus hybrid instrumentation on the correction results in adolescent idiopathic scoliosis patients undergoing posterior selective thoracic fusion. Methods By reviewing the medical records and roentgenograms of adolescent idiopathic scoliosis patients who underwent selective thoracic fusion from February 2000 to January 2007 in our hospital, the patients were divided into 2 groups according to different instrumentation fashions： Group A was hook-screw-rod （hybrid） internal fixation type, Group B was screw-rod （all pedicle screws） internal fixation type, and the screws were used in every segment on the concave side of the thoracic curve. The parameters of the scoliosis were measured and the correction results were analyzed. Results Totally, 48 patients （7 males, 41 females） were included, with an average age of 14.4 years old and a mean follow-up time of 12.3 months. Thirty and 18 patients were assigned to group A and group B, respectively. The mean preoperative coronal Cobb angles of the thoracic curve were 48.8° and 47.4°, respectively. After surgery, they were corrected to 13.7° and 6.8°, respectively. At final follow-up, they were 17.0° and 9.5°, with an average correction rate of 64.6% and 79.0%, respectively, and the correction rate of group B was significantly higher than that of group A （P=0.003）. The mean preoperative coronal Cobb angles of the lumbar curve were 32.6° and 35.2°, respectively. After surgery, they were corrected to 8.6° and 8.3°, respectively. At final follow-up, they were 10.3° and 11.1°, with an average correction rate of 66.8% and 69.9%, respectively, and the correction rate of group B was significantly higher than that of group A （P=0.003）. The correction loss of the thoracic curve and lumbar curve in the 2 groups were 3.1° and 1.8°, 2.4° and 2.4°, respectively. No significant difference was noted （both P〉0.05）. The decompensation rate at final follow-up in these 2 groups were 4% （1/25） and 7.1% （1/14） respectively, with no significant difference （P〉0.05）.

A new free-hand pedicle screw placement technique with reference to the supraspinal ligament

We sought to compare the safety and accuracy of a new free-hand pedicle screw placement technique to that of the conventional technique. One hundred fifty-three consecutive adult patients with simple fracture in the tho- racic or/and lumbar spine were alternately assigned to either the new free-hand or the conventional group. In the new free-hand technique group, preoperative computerized tomography （CT） images were used to calculate the targeted medial-lateral angle of each pedicle trajectory and the pedicle screw was inserted perpendicular to the corresponding supraspinal ligament. In the conventional technique group, the medial-lateral and cranial-caudal angle of each pedicle trajectory was determined by intraoperatively under fluoroscopic guidance. The accuracy rate of pedicle screw placement, the time of intraoperative fluoroscopy, the operating time and the amount of blood loss during operation were respectively compared. All screws were analyzed by using intraoperative ra- diographs, intraoperative triggered electromyography （EMG） monitoring data, postoperative CT data and clinical outcomes. The accuracy rate of pedicle screw placement in the new free-hand technique group and the conven- tional technique group was 96.3% and 94.2% （P 〈 0.05）, respectively. The intraoperative fluoroscopy time of the new technique group was less than that of the conventional technique group （5.37 seconds vs. 8.79 seconds, P 〈 0.05）. However, there was no statistical difference in the operating time and the amount of blood loss during op- eration （P 〉 0.05）. Pedicle screw placement with the free-hand technique which keeps the screw perpendicular to the supraspinal ligament is an accurate, reliable and safe technique to treat simple fracture in the thoracic or lum- bar spine.

Techniques and accuracy of thoracolumbar pedicle screw placement

Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several decades. Although pedicle screws were originally placed via a freehand technique, there has been a movement in favor of pedicle screw placement with the aid of imaging. Such assistive techniques include fluoroscopy guidance and stereotactic navigation. Imaging has the benefit of increased visualization of a pedicle's trajectory, but can result in increased morbidity associated with radiation exposure, increased time expenditure, and possible workflow interruption. Many institutions have reported high accuracies with each of these three core techniques. However, due to differing definitions of accuracy and varying radiographic analyses, it is extremely difficult to compare studies side-by-side to determine which techniques are superior. From the literature, it can be concluded that pedicles of vertebrae within the mid-thoracic spine and vertebrae that have altered morphology due to scoliosis or other deformities are the most difficult to cannulate. Thus, spine surgeons would benefit the most from using assistive technologies in these circumstances. All other pedicles in thethoracolumbar spine should theoretically be cannulated with ease via a free-hand technique, given appropriate training and experience. Despite these global recommendations, appropriate techniques must be chosen at the surgeon's discretion. Such determinations should be based on the surgeon's experience and the specific pathology that will be treated.

Role of adipose-derived stromal cells in pedicle skin flap survival in experimental animal models

The use of skin flaps in reconstructive surgery is the first-line surgical treatment for the reconstruction of skin defects and is essentially considered the starting point of plastic surgery. Despite their excellent usability, their application includes general surgical risks or possible complications, the primary and most common is necrosis of the flap. To improve flap survival, researchers have used different methods, including the use of adiposederived stem cells, with significant positive results. In our research we will report the use of adipose-derived stem cells in pedicle skin flap survival based on current literature on various experimental models in animals.

Pedicle Screw Fixation with Kyphoplasty Decreases the Fracture Risk of the Treated and Adjacent Non-treated Vertebral Bodies:a Finite Element Analysis

Adjacent vertebral fractures are common in patients with osteoporotic vertebral compression fractures（OVCFs） after kyphoplasty.This finite element study was to examine whether short segment pedicle screw fixation（PSF） with kyphoplasty may decrease the fracture risk of the treated and adjacent non-treated vertebrae after kyphoplasty for OVCFs.By simulating cement augmentation with or without short segment pedicle screw fixation（PSF）,two tridimensional,anatomically detailed finite element models of the T10–L2 functional spinal junction were developed.The insertion of pedicle screws into the intact vertebra apparently decreased the stress distribution of the treated vertebra in vertical compression and other load situations.The stress distribution in the bone structures of the intact vertebra adjacent to the intact-screwed vertebra was much less than that in the one adjacent to the treated vertebra.The insertion of pedicle screws into the intact vertebra greatly decreased the maximum displacement of the cortical bones and cancellous bones of the vertebrae.Our results indicated that short segment PSF with kyphoplasty may decrease the fracture risk of the treated and adjacent non-treated vertebrae in the management of OVCFs.

Clinical outcomes with large macular holes using the tiled transplantation internal limiting membrane pedicle flap technique

AIM: To report the surgical technique and efficacy of the tiled transplantation internal limiting membrane(ILM) pedicle flap technique after vitrectomy for 33 patients with large macular hole(MH). METHODS: This study was a prospective noncontrolled interventional study. All patients were treated by vitrectomy, the tiled transplantation ILM pedicle flap and gas tamponade. All patients underwent visual acuity measurements and optical coherence tomography(OCT), during preoperative and the follow-up visits postoperative. RESULTS: Two high-myopic patient had flap dislocation during surgery. The thorough closure of MH following the tiled transplantation ILM pedicle flap technique was ultimately achieved in 31 patients observed by OCT imaging(93.94%) 1 wk after surgery. Visual acuity improved from 1.51±0.31(logMAR) preoperative to 0.92±0.30 6 mo after surgery(P=0.000). There were no significant changes in OCT finding during the follow-up period from 1 mo to 6 mo after surgery. CONCLUSION: The tiled transplantation ILM pedicle flap technique provides bridge for retinal gliosis to achieve successful closures of the large MHs, and the microenvironment of this technique is more similar to the normal physiological conditions.

Comparison of Clinical Outcomes of Cortical Bone Trajectory and Traditional Pedicle Screw Fixation in Posterior Lumbar Interbody Fusion

Posterior lumbar interbody fusion (PLIF) is a common surgical procedure and widely used in the treatment of lumbar degenerative disc disorders. Traditionally, posterior lumbar interbody fusion is done by using the traditional pedicle screw (PS) which offers great advantages, but at the same time it has some disadvantages which include the risk of superior facet joint violation and muscle damage. Recently, an alternative method of screw insertion via cortical bone trajectory (CBT) has been invented which has less invasive process and can be placed without the drawbacks associated with the traditional pedicle screw. However, it has to remain an interest whether CBT will provide similar or greater clinical outcomes compared to PS in PLIF. So the main aim of this review is to compare the clinical outcomes of cortical bone trajectory and traditional pedicle screw fixation in posterior lumbar interbody fusion based on the articles published on this topic. Compared to the traditional pedicle screw fixation, PLIF with CBT has similar clinical outcome based on pain intensity, ODI status and JOA score, as well as similar fusion rate and radiological evaluated complication such as loosening of screw. In addition PLIF with CBT has advantages of less facet joint violation, less blood loss, less intraoperative muscle damage and perioperative pain. On the basis of this study, we can suggest that PLIF with CBT can be considered as a reasonable alternative to PS in PLIF.

Spinal pedicle subtraction osteotomy for fixed sagittal imbalance patients

In addressing spinal sagittal imbalance through a posterior approach, the surgeon now may choose from among a variety of osteotomy techniques. Posterior column osteotomies such as the facetectomy or Ponte or Smith-Petersen osteotomy provide the least correction, but can be used at multiple levels with minimal blood loss and a lower operative risk. Pedicle subtraction osteotomies provide nearly 3 times the per-level correction of Ponte/Smith-Petersen osteotomies; however, they carry increased technical demands, longer operative time, and greater blood loss and associated significant morbidity, including neurological injury. The literature focusing on pedicle subtraction osteotomy for fixed sagittal imbalance patients is reviewed. The longterm overall outcomes, surgical tips to reduce the complications and suggestions for their proper application are also provided.

Preventing and localizing esophagogastric anastomosis leakage by sleeve-wrapping of the pedicled omentum

AIM: To develop a technique of sleeve-wrapping the pedicled omentum around the esophagogastric anastomosis for preventing and localizing leakage.

Investigation of optical reflectance from different animal vertebra along the fixation trajectory of pedicle screw in frequency domain

Accurate placement of pedicle screw(PS)is crucial in spinal surgery.Developing new real-time intra-operative monitoring and navigation methods is an important direction of clinical appli-cation research.In this paper,we studied the spectrum along the fixation trajectory of PS in frequency domain to tackle the accuracy problem.Fresh porcine vertebrae,bovine vertebrae and ovine vertebrae were measured with the near-infrared spectrum(NIR)device to obtain the reflected spectrum from the vertebrae.Along the fixation trajectory of PS,average energy from different groups was calculated and used for identifying different tissues and compared to achieve the optimal recognition factor.Compared with the time domain approach,the frequency domain method could divide the spectra measured at different tissue points into different groups more stably and accurately,which could serve as a new method to assist the PS insertion.The results gained from this study are significant to the development of hi-tech medical instruments with independent intellectual property rights.

Learning curves of robot-assisted pedicle screw fixations based on the cumulative sum test

BACKGROUND In robot-assisted(RA)spine surgery,the relationship between the surgical outcome and the learning curve remains to be evaluated.AIM To analyze the learning curve of RA pedicle screw fixation(PSF)through fitting the operation time curve based on the cumulative summation method.METHODS RA PSFs that were initially completed by two surgeons at the Beijing Jishuitan Hospital from July 2016 to March 2019 were analyzed retrospectively.Based on the cumulative sum of the operation time,the learning curves of the two surgeons were drawn and fit to polynomial curves.The learning curve was divided into the early and late stages according to the shape of the fitted curve.The operation time and screw accuracy were compared between the stages.RESULTS The turning point of the learning curves from Surgeons A and B appeared in the 18th and 17th cases,respectively.The operation time[150(128,188)min vs 120(105,150)min,P=0.002]and the screw accuracy(87.50%vs 96.30%,P=0.026)of RA surgeries performed by Surgeon A were significantly improved after he completed 18 cases.In the case of Surgeon B,the operation time(177.35±28.18 min vs 150.00±34.64 min,P=0.024)was significantly reduced,and the screw accuracy(91.18%vs 96.15%,P=0.475)was slightly improved after the surgeon completed 17 RA surgeries.CONCLUSION After completing 17 to 18 cases of RA PSFs,surgeons can pass the learning phase of RA technology.The operation time is reduced afterward,and the screw accuracy shows a trend of improvement.