Is open anterior advantageous to posterior decompression and reconstruction in fresh A3 to C3/AO type thoracolumbar junction fractures? A systematic review

INTRODUCTION

Surgical outcomes of open anterior and open posterior approaches, for thoracolumbar A3 to C3/AO type fractures, are compared.

METHODS

A PubMed search was conducted from 1990 to 2024 related to anterior, posterior, and combined approaches. Inclusion criteria: Fresh traumatic T10 to L2 fractures, age ≥13 years, ≥10 cases, minimum follow-up 6 months. Exclusion criteria: Cadaveric studies, pathological fractures, reviews, thoracoscopy-assisted, mini-open lateral (MOLA) and minimal invasive anterior or posterior approaches. Coleman Methodology Scores (CMS) (modified for spinal trauma) indicated potential selection bias in the selected studies. PRISMA guidelines were adapted.

RESULTS

Nineteen studies with 847 participants were selected. The average CMS quality score was fair. The anterior approach, although it better decompresses the compromised spinal canal, it is also associated with increased surgical complications compared to the posterior approach. The neurological outcome, the loss of correction and the reoperation rate, were similar to both approaches. This systematic review favors posterior approach.

CONCLUSIONS

The anterior approach is demanding and is associated with a higher rate of surgical complications compared to the posterior approach. The limitations of the selected studies included inconsistence in the: 1) approaches selection, 2) classifications of the fracture types and the neurological status and 3) variety of instrumentations used.

PROSPERO ID

CRD42023484222.

Extended offset stems are infrequently required in anterior approach total hip arthroplasty and low usage does not compromise stability

INTRODUCTION

Extended offset (EO) stems are commonly used in posterior approach (PA) total hip arthroplasty (THA), but usage rates and complications are not well studied with anterior approach (AA) THA. This study evaluated usage rates, radiographic outcomes and complications following AA THA between patients receiving EO stems and a matched cohort receiving standard offset (SO) stems.

MATERIALS AND METHODS

This retrospective review evaluated 1515 consecutive AA THA performed between 2014 and 2021. The recent 100 EO were included in radiographic and complication analysis and were matched to 100 SO stems based on stem size, procedure (unilateral/bilateral), sex, body mass index (BMI), and age. Data collection included patient demographics; pre- and postoperative radiographic measurements of leg length difference (LLD) and global hip offset difference (GHOD); and complications within 1 year. Independent t-tests and Chi-squared analyses compared EO and SO groups.

RESULTS

EO was utilized in 8% of all AA THA. Despite matching procedures, the distribution of racial groups was different between EO and SO groups, respectively: Caucasian (75% vs. 43%), Asian (12% vs. 35%), Native Hawaiian/Pacific Islander (NHPI) (9% vs. 13%), and other (4% vs. 9%) (p < 0.001). No fractures, dislocations, or revisions occurred within 1 year after surgery in either group. One deep infection was noted in the SO group. The proportions of patients following surgery who had a GHOD < 6 mm (76% vs. 82%; p = 0.193) and LLD < 6 mm (81% vs. 86%; p = 0.223) were not significantly different between EO and SO groups, respectively.

CONCLUSIONS

Prioritizing hip symmetry over stability results in a high proportion of patients achieving hip symmetry without high usage of EO stems in AA THA. Furthermore, low use of EO stems did not result in increased dislocations. Due to racial anatomical differences, Caucasian patients required EO stems to achieve hip symmetry more frequently than Asian and NHPI patients.

Open reduction and internal fixation of crescent fracture-dislocation: anterior or posterior approach?

INTRODUCTION

To date, the approach that prevails in the open reduction and internal fixation of crescent fracture-dislocations (CFD) remains unknown. This study aimed to compare the outcomes of CFD treated via the anterior or posterior approach.

MATERIALS AND METHODS

Data from 64 cases of CFDs openly reduced through an anterior (group A, n = 31) or a posterior (group B, n = 33) approach were retrospectively analyzed. Functional results, reduction quality, residual displacements in the axial and coronal planes, pelvic asymmetry deformity, and correlations between Day's classification were compared. Complications and fracture union were also recorded. All patients were followed up for at least 12 months.

RESULTS

The functional scores were similar between the two groups, and all fractures achieved good or excellent reduction postoperatively. In the coronal plane, the excellent/good ratio in group B was higher than in group A. The mean residual displacement in the coronal plane was significantly higher in group A than in group B, with group A showing greater displacement in both planes for Day I fractures and in the coronal plane for Day II fractures. The residual displacement in both planes for Day III fractures was comparable between the groups. The pelvic asymmetry deformity was equal between the two groups and among the different Day's fracture types.

CONCLUSIONS

Open reduction and internal fixation of CFDs obtained satisfactory outcomes through an anterior or posterior approach. The posterior approach achieved a better sacroiliac joint reduction. The optimal indication for the posterior approach was a Day I fracture, followed by a Day II fracture. No correlation was found between the surgical approach and reduction quality in Day III fractures.

Direct anterior approach with conventional instruments versus robotic posterolateral approach in elective total hip replacement for primary osteoarthritis: a case-control study

BACKGROUND

The purpose of this study is to compare peri-operative and short-term outcomes in patients who underwent elective total hip replacement (THA) for primary osteoarthritis (OA) with direct anterior approach (DAA) versus a pair-matched cohort of patients who underwent robotic-assisted THA with posterolateral approach.

MATERIALS AND METHODS

Data from consecutive patients who underwent elective hip replacement from 2021 to 2023 for primary OA were retrospectively retrieved and divided into two groups: the DAA group, who underwent THA with the DAA approach using conventional instruments, and the robotic posterolateral (R-PL group), who underwent robot arm-assisted THA with the posterolateral approach. Comparative assessed outcomes were: operative time, radiographical implant positioning, intake of rescue analgesics, blood loss, transfusion rate, leg length discrepancy and functional outcomes (Harris hip score and forgotten joint score).

RESULTS

A total of 100 pair-matched patients were retrieved with a mean age of 66.7 ± 10.7 (range: 32-85) years and a mean follow-up of 12.8 ± 3.6 (range: 7-24) months. No differences in patients' characteristics were detected. Patients in the R-PL group required less rescue tramadol (p > 0.001), ketorolac (p = 0.028) and acetaminophen (p < 0.001). There was no significant difference in the operative time between (MD = 5.0 min; p = 0.071). Patients in the DAA group had significantly lower Hb levels at day 1 (p = 0.002) without significant differences in transfusion rate (p = 0.283). Patients in the R-PL group had shorter length of stay (LOS) with a mean difference of 1.8 days [p < 0.001; 95% confidence interval (CI) 1.4-2.3]. No difference in clinical outcomes was found [leg length discrepancy (LLD), p = 0.572; HHS, p = 0.558; forgotten joint score (FJS), p = 0.629]. No radiographical differences were measured in cup inclination (MD = 2.0°, p = 0.069), malpositioning [odd ratio (OR) = 0.2; p = 0.141], stem alignment (OR = 0.3; p = 0.485) and stem sizing (OR = 1.5; p = 1.000). There was no difference in complication rate except for lateral femoral cutaneous nerve damage, which was higher in DAA group (p < 0.001).

CONCLUSIONS

R-PL and DAA THA had comparable short-term clinical and radiological outcomes along with similar complication rates. The R-PL group showed significantly lower Hb drop, rescue analgesic consumption and shorter LOS. This is a preliminary study and no strong recommendation can be provided. Further prospective randomized trials are requested to further investigate the cost-effectiveness of robotic surgery in THA.

LEVEL OF EVIDENCE

Level IV, case-control study.

'On Table' Versus 'Off Table' Direct Anterior Approach Total Hip Arthroplasty: Is There a Difference?

Background

The purpose of this study was to evaluate whether there were differences in patient-reported outcomes, operative times, satisfaction scores, and complications between patients undergoing total hip arthroplasty (THA) performed through a direct anterior approach on a specialized traction table or a regular operating room table.

Methods

Patients who underwent a direct anterior approach THA on a specialized table or a regular table with a minimum 1-year follow-up were included. Patient-reported outcome measures and THA satisfaction were recorded. Demographics, complications, and operative times (both in-room and surgical time) were evaluated. Three hundred twenty-two patients were included with 217 (67.4%) undergoing anterior THA on the specialized table and 105 (32.6%) on a regular table.

Results

Outcome measures were similar at 4 months and 1 year postoperatively. Average operative time was 87 minutes (range, 50-160) and 90 minutes (range, 35-197) for the specialized table and regular table groups (P = .314). Average total in room time was 123 minutes (range, 87-201) and 120 minutes (range, 62-255) for the specialized table and regular table groups (P = .564). Satisfaction rates between groups did not differ (P = .564). No differences were found in complication rates at 4 months (P = .814) or 1 year (P = .547).

Conclusions

This study shows that the direct anterior approach for THA can be safely and efficiently performed on either a specialized traction table or a regular table. Surgeons should continue to utilize the approach and set-up they are most comfortable with to achieve an optimal outcome for the patient.

Approaches in Anterior Column Support in Adult Spinal Deformity Surgery: A Meta-Analysis of Clinical and Radiologic Outcomes

OBJECTIVE

This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence-LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI).

RESULTS

Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF.

CONCLUSIONS

Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach-related comorbidity.

Anterior approach for a stab wound with penetrating rebar injury causing incomplete cauda equina syndrome in lumbosacral spine lesion: a case report and literature review

PURPOSE

To report a unique case of incomplete CES following a rebar penetrating injury in perineal region with retro-pulsed fragment, which was treated with anterior approach and discuss suitable surgical approach.

METHODS

Incomplete cauda equina syndrome caused by non-missile penetrating injury is extremely rare. A 26-year-old male patient presented incomplete cauda equina syndrome due to a penetrating rebar wound from his perineal region to the lumbosacral spine. Computed tomography demonstrated a bony fragment broken from S1 body compressing into the spinal canal.

RESULTS

By anterior approach, we performed partial corpectomy of L5, decompression by retrieving the bony fragment and L5-S1 interbody fusion. The patient had a significant recovery, and no clinical complication was found after over 2-year follow-up.

CONCLUSION

It is challenging to determine the optimal strategy of surgical treatment for penetrating spinal injuries with retained foreign bodies, here we suggest an anterior approach situation that has the advantage of being able to effectively perform decompression and prevent iatrogenic damages of thecal sac and nerve rootlets.

Delayed presentation of lower cervical facet dislocations: What to learn from past reports?

Delayed presentation of lower cervical facet dislocations is uncommon, and there is no standardized way to approach these neglected injuries. The literature on neglected lower cervical facet dislocations is limited to case reports and few retrospective studies. This justifies the need for a comprehensive review of this condition. Our purpose was to elaborate a review on the epidemiology, clinical and radiological presentation, and treatment techniques and approach to these neglected injuries. Middle-aged adults from 30 to 50 represent 73.8% of reported cases, and most of them are males (72.0%). The most affected level is C5-C6 (43.0%). While most delays are due to missed injuries (52.1%) and ineffective non-operative treatment (36.2%), the other reason for delay is negligence in seeking medical care (11.7%). Patients present with variable degrees of neurological deficit, persistent neck pain, and neck stiffness. Reported approaches and techniques to reduce and stabilize these injuries are highly variable and depend on the surgeon's judgment, experience, and preference. Fibrotic tissues and bony fusion around the dislocated facet joint contribute to the reduction challenge, and 77.0% of closed reduction attempts fail. Anterior and posterior approaches to the cervical spine are used selectively or in combination for surgical release, reduction, and stabilization. Despite the lack of standardized treatment guidelines and different approaches, most of the authors reported improvement in pain, balance, and neurology post-surgery. Starting with the posterior surgical approach aims to achieve reduction compared to the anterior approach which largely aims at spinal decompression. Given the existing controversies, the need for quality prospective studies to determine the best treatment approach for lower cervical facet dislocations presenting with delay is evident.

Joint awareness among total hip arthroplasty patients operated through anterior approach versus posterior approach: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to compare joint awareness in patients who underwent total hip arthroplasty (THA) via the anterior approach (AA) versus the posterior approach (PA). The hypothesis was that patients who underwent THA via AA would have better forgetfulness of the artificial joint.

METHODS

A comprehensive search of major literature databases and bibliographic details was conducted to identify studies evaluating the forgotten joint score (FJS-12) in total hip arthroplasty (THA) patients operated through the anterior approach (AA) and posterior approach (PA). Out of 234 studies identified, seven studies met the inclusion criteria for review. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence and the risk of bias in the included studies. The FJS-12 was evaluated at three months, one year, and beyond 2 years.

RESULTS

The mean FJS-12 at > 2 years was 82.03 in the AA group and 80.32 in the PA group. The forest plot analysis (n = 819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI [- 1.17, 5.42], p = 0.21; I2 = 60%). However, the joint awareness was significantly lesser in the AA group at 3 months (MD 12.56, 95% CI [9.58, 15.54], p < 0.00001, I2 = 0%) and 1 year (MD 9.55, 95% CI [7.85, 11.24], p < 0.0001, I2 = 0%).

CONCLUSIONS

After analyzing the available literature, it was found that THA patients operated through the AA approach have significantly lower joint awareness than those operated through the PA approach in the first year of surgery. However, there is no significant difference in joint awareness between these two approaches after 2 years.

LEVEL OF EVIDENCE

III.

Median Sternotomy as a Useful Adjunct to Anterior Cervicothoracic Spine Decompression and Fixation: A Plea for Its Popularity among Spine Surgeons in West Africa

Direct anterior approach to the cervicothoracic spine (C7-T4) for surgery can be challenging via a standard anterior cervical incision as a result of the important neurovascular structures crowding the cervicothoracic junction. Where indicated, median sternotomy provides improved access to this region of the spine for interventions. From the paucity of published literature in West Africa, this adjunct appears to be quite unpopular among spine surgeons in our sub-region. We report the presentation, preoperative evaluation, operative technique and outcome of treatment of a 66-year-old man with multiple myeloma affecting T1 with the same vertebral body collapse, who had full median sternotomy, anterior T1 decompression with C7-T2 Spinal fixation. Where indicated, an anterior trans-sternal approach to the cervicothoracic spine offers good exposure to T2/T3 vertebral body for decompression and instrumentation with minimal risks and morbidity. Spine surgeons in the West African subregion should utilize this important collaboration with thoracic surgeons to achieve satisfactory access to spine surgery within the thoracic cavity.

Comparison of complication rates between anterior versus posterior approaches for treating unstable Hangman's fracture. A systematic review and meta-analysis

Study design

Systematic Review and Meta-analysis.

Objective

To compare the complication rates associated with anterior and posterior approaches for the surgical treatment of unstable hangman's fractures.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed, Web of Science, and Scopus databases to identify comparative studies reporting complications of anterior versus posterior approaches for the treatment of unstable hangman's fractures.

Results

The search yielded 1163 papers from which 5 studies were fully included. One hundred fifteen (115) patients were operated on using an anterior approach versus 65 through a posterior approach. The average complication rates for the anterior and posterior approaches were 26.1 % and 13.8 %, respectively. No complications following the anterior approach required pharmacological or surgical intervention (Clavien-Dindo, Grade 1), while 88.9 % of complications following the posterior approach did (Clavien-Dindo, Grade 2).

Conclusion

No significant differences in the complication rates were found when comparing anterior versus posterior surgery for treating a C2 traumatic spondylolisthesis. However, most of the complications presented in the posterior surgery group were more severe.

Anterior capsulectomy versus repair in direct anterior total hip arthroplasty

BACKGROUND

Utilization of the direct anterior approach for total hip arthroplasty (DAA THA) has increased over the last ten years. The preservation and repair of the anterior hip capsule has been recommended, while anterior capsulectomy has been described by others. In contrast, the higher risk of posterior dislocation using the posterior approach improved significantly after capsular repair. No studies to date have investigated outcome scores based on capsular repair versus capsulectomy for the DAA.

METHODS

Patients randomized to anterior capsulectomy or anterior capsule repair. Patients were blinded to their randomization. Maximum hip flexion was measured both radiographically and clinically with a goniometer. Using a one-sided t test assuming equal variance with an effect size, Cohen's d, of 0.6 and an alpha of 0.05, 36 patients in each group (total 72 patients) needed for a minimum 80% power.

RESULTS

Median goniometer measurements preoperatively were 95° for repair (IQR 85-100) and 91° for capsulectomy (IQR 82-97.5) (p = 0.52). Four-month and one-year goniometer measurements also had no significant difference, 110° (IQR 105-120) and 110° (IQR 105-120) for repair and 105° (IQR 96-116) and 109° (IQR 102-120) for capsulectomy (p = 0.38 and p = 0.26). Median change in flexion as measured by goniometer at 4 months and one year was 12 and 9 degrees for repair and 9.5 and 3 degrees for capsulectomy (p = 0.53 and p = 0.46). X-ray analysis showed no differences in pre-op, 4-month, and one-year flexion with median one-year flexion of 105.5° (IQR 96-109.5) for repair and 100° (IQR 93.5-112) for capsulectomy (p = 0.35). VAS scores were the same for both groups at all three time points. HOOS scores improved equally for both groups. There are no differences in surgeon randomization, age, or gender.

CONCLUSIONS

Both capsular repair and capsulectomy used in direct anterior approach THA result in equal maximum clinical as well as radiographic hip flexion with no change in postoperative pain or HOOS scores.

Accuracy of Preoperative 3D vs 2D Digital Templating for Cementless Total Hip Arthroplasty Using a Direct Anterior Approach

Background

An important aspect of preoperative planning for total hip arthroplasty is templating. Although two-dimensional (2D) templating remains the gold standard, computerized tomography (CT)-based three-dimensional (3D) templating is a novel preoperative planning technique. This study aims to compare the accuracy of a 2D and 3D plan using an anterior approach for the placement of the same uncemented prosthesis.

Methods

Two consecutive cohorts of 100 patients each were retrospectively analyzed. We analyzed the accuracy of the size of the implant (stem, cup, head), the length of head, and offset. As a secondary criterion, we analyzed the rates of stems with more than 3° of varus, fracture, and/or subsidence at 3 months postoperatively.

Results

Within the exact size, the accuracy of the stem and cup size with the 2D plan was 69% and 56%, respectively. With the 3D plan accuracy being 88% (P = .0046) and 96% (P < .0001), respectively. Regarding size and length of the implant head, accuracy was 86% and 82% with the 2D plan and 100% (P < .0001) and 94% (P = .016), respectively, with the 3D plan. The offset of the implants increased beyond 3 mm in 23% of patients in the 2D group and in 5% of patients in the 3D group (P = .0003). The rate of varus stems was 10% in the 2D group and 2% in the 3D group (P = .03). Two fractures and one case of subsidence occurred in the 2D group. None were identified in the 3D cohort.

Conclusions

A CT-based 3D plan is more accurate for implant size selection, allows better prosthetic offset, and reduces the rate of varus stems.

A Randomised Control Trial Comparing the Outcomes of Anterior with Posterior Approach for Transfer of Spinal Accessory Nerve to Suprascapular Nerve in Brachial Plexus Injuries

Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches. Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale. Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier (p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer. Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach. Level of Evidence: Level II (Therapeutic).

Reappraisal of anatomical liver resection for hepatoblastoma in children

Background

The principle of hepatoblastoma (HB) treatment is complete resection. The removal of tumor-bearing section(s) or hemiliver is widely accepted. However, neither the standardized anterior approach for right hepatectomy nor parenchymal sparing anatomical liver resection has been described for HB.

Methods

We retrospectively reviewed the clinical course of two pediatric HB patients who underwent extended right hepatectomy using the anterior approach with the liver hanging maneuver and one who underwent parenchymal sparing anatomical liver resection of S4 apical+S8 ventral/dorsal+S7. The critical aspects of surgical techniques are described in detail.

Results

In all three patients, R0 resection was achieved without complications and are currently alive without recurrence after an average follow-up of 23 months. Intraoperative cardiac hemodynamics were stable, even in a trisomy 18 patient with cardiac disease.

Conclusions

Our findings suggest that these innovative techniques established in adults are safe and feasible for HB in children. These techniques also allow optimal anatomical liver resection to accomplish curative surgery while maintaining the functional reserve of the remnant liver.

Measurement of anatomical parameters of anterior transpedicular root screw intervertebral fusion system of cervical spine

OBJECTIVE

This study aims to investigate the feasibility of the anterior transpedicular root screw (ATPRS) intervertebral fusion system for the cervical spine and provide a basis for the design of the ATPRS intervertebral fusion system.

METHODS

A total of 60 healthy adult cervical spine CT images examined from our hospital were selected, including 30 males and 30 females, with an average age of 39.6 ± 4.8 years. The image data was imported into Mimics 21.0 software in DICOM format for 3D model reconstruction. Simulated screw insertion was performed on both sides of the midline of the intervertebral space. The entry point (P1) was determined when the upper and lower screw paths did not overlap. When the screw was tangent to the medial edge of the Luschka joint, the insertion point was determined as the entry point (P2). Measurements were taken and recorded for the following parameters: distance from the screw entry point to the midline of the intervertebral space (DPM), the simulated screw length, inclination angle, cranial/caudal tilted angle, the anterior-posterior (AP) and mediolateral (ML) diameters of the cervical intervertebral space, the heights of the anterior, middle, and posterior edges of the cervical intervertebral space, and the curvature diameter of the lower end plate of the cervical vertebral body. Statistical analysis was performed on the measurement results.

RESULTS

The screw entry area (P1P2) showed an increasing trend from C3-C7 in both male (2.92-6.08 mm) and female (2.32-5.12 mm) groups. There were statistical differences between men and women at the same level (P < 0.05). The average screw length of men and women was greater than 20 mm, and the upper and lower screw lengths showed an increasing trend from C3 to C7. In the area where screws could be inserted, the range of screw inclination was as follows: male group upper screw (47.73-66.76°), lower screw (48.05-65.35°); female group upper screw (49.15-65.66°) and lower screw (49.42-63.29°); The range of cranial/caudal tilted angle of the screw was as follows: male group upper screw (32.06-39.56°), lower screw (29.12-36.95°); female group upper screw (30.97-38.92°) and lower screw (27.29-37.20°). The anterior-posterior diameter and mediolateral diameter of the cervical intervertebral space showed an increasing trend from C3 to C7 in both male and female groups. The middle height (MH) of the cervical intervertebral space was greater than the anterior edge height (AH) and posterior edge height (PD), with statistical differences (P < 0.05).

CONCLUSIONS

Through the study of CT images of the cervical spine, it was determined that the ATPRS intervertebral fusion system has a feasible area for screw insertion in the cervical intervertebral space.

Selective THA-approach use amongst junior surgeons improves safety of introducing the anterior approach: a prospective, multi-surgeon, comparative, study

BACKGROUND

Learning curves associated with independent practice and anterior approach total hip arthroplasty (AA-THA) has been associated with inferior outcome. This study compared outcome of junior, fellowship-trained, surgeons who perform THA through both anterior and posterior (PA) approach, with senior surgeons who perform either AA or PA, to determine whether: 1. Fellowship training and selective practice allows for safe introduction of AA into practice; and 2. Whether selective approach-use influences outcome.

METHODS

This is a prospective, consecutive study comparing the first 800 THAs of two junior, dual-approach, surgeons (AA/PA: 455/345), with 400 THAs cases of two senior, single-approach, surgeons (AA/PA: 200/200), between 2018 and 2020. Most patients were female (54.4%), mean age was 65 years-old (range 19-96) and mean BMI was 29 kg/m2 (range 16-66). Outcome included radiologic measurements (inclination/anteversion and leg-length), complication- and revision rates, and patient-reported outcomes including Oxford Hip Score (OHS).

RESULTS

At 3.1 years (range 2.0-6.8) follow-up, there were 43 complications (3.6%), including 27 re-operations (2.3%); with no difference between junior and senior surgeons for AA-THA (Junior: 8/455 vs. Senior: 3/200; p = 0.355) or PA-THA (Junior: 11/345 vs. Senior: 5/200; p = 0.400). Amongst juniors, there was no difference in complications (AA:8/455 vs. PA:11/345; p = 0.140) and in ΔOHS (AA:20.5 ± 7.7 vs. PA:20.5 ± 8.0; p = 0.581) between approaches.

CONCLUSION

Contemporary training and selective approach-use minimizes the learning curve, allowing junior staff to have equivalent outcome to established, senior surgeons in both AA and PA. We would advocate for selective approach use amongst junior arthroplasty surgeons when introducing the AA into independent practice.

Anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord via one vertebra with two bony channels for adjacent two-segment cervical spondylotic myelopathy: a technical note

BACKGROUND

The current treatments for adjacent two-segment cervical spondylotic myelopathy (CSM) include two-segment anterior cervical discectomy and fusion (ACDF) and single-segment anterior cervical corpectomy and fusion (ACCF). Long-term follow-up has demonstrated that both procedures have complications such as reduced cervical mobility, accelerated degeneration of adjacent segments and loosening of internal fixation screws. The purpose of this study is to demonstrate the feasibility, safety, and efficacy of anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord (APFETDSC) via one vertebra with two bony channels for the treatment of adjacent two-segment CSM and to present our surgical experience.

METHODS

Anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord (APFETDSC) via one vertebra with two bony channels was performed for 12 patients with adjacent two-segment CSM with follow-up care for at least 12 months. The Visual analog scale (VAS) and the Japanese Orthopedic Association Score (JOA) were recorded, and modified Macnab criteria were used to evaluate the treatment excellence rate. Radiological examinations, including X-ray, computed tomography (CT) and magnetic resonance imaging (MRI), were used to evaluate spinal cord decompression, intervertebral stability and healing of the bony channel.

RESULTS

All 12 patients completed the operation successfully. No postoperative complications, such as dysphagia, Horner's syndrome, or laryngeal recurrent nerve palsy, were found. The postoperative VAS and JOA scores were significantly improved compared with those before surgery(P < 0.001). According to the modified Macnab criteria, the clinical outcome was excellent in 8 cases, good in 3 cases and fine in 1 case at the final follow-up and the excellent and good rate was 91.7%. Postoperative and follow-up imaging showed significant spinal cord decompression, well-healed bony channels and no cervical instability.

CONCLUSIONS

This study is the first report of anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord via one vertebra with two bony channels. This procedure has the advantages of less trauma, faster recovery, fewer complications and no need to implant internal fixators. This is a minimally invasive, feasible and safe surgical procedure for patients with adjacent two-segment CSM.

The Role of Anterior Spine Surgery in Deformity Correction

There are a range of anterior-based approaches to address flexible adult spinal deformity from the thoracic spine to the sacrum, with each approach offering access to a range of vertebral levels. It includes the transperitoneal (L5-S1), paramedian anterior retroperitoneal (L3-S1), oblique retroperitoneal (L1-2 to L5-S1), the thoracolumbar transdiaphragmatic approach (T9-10 to L4-5), and thoracotomy approach (T4-T12). The lumbar and lumbosacral spine is especially favorable for anterior-based approaches given the relative mobility of the peritoneal organs and position of the vasculature.

The Ankle Joint: Updates on Ankle Fusion Approaches and Fixation

Ankle fusion is a well-studied, classical procedure for conditions affecting the ankle joint, and has a long history with predictable results. Although there are many different approaches available, a few options are commonly used. The two main focuses of modern literature are on anterior plating versus traditional screw fixation, and on arthroscopic versus open techniques for fusion. This article discusses recent literature and then presents cases and techniques that are commonly used today. This includes arthroscopic ankle arthrodesis, traditional transfibular approach, anterior plating, and the indications and application of external fixation. Standard recovery and complications are discussed.

Anterior Versus Classical Approach During Right Hepatectomy for Hepatocellular Carcinoma: Inverse Propensity Score Weighted Analysis

BACKGROUND

Eastern data highlight the oncological benefits of the anterior approach (AA) during right hepatectomy (RH) for hepatocellular carcinoma (HCC). However, to our knowledge, previous western data on this topic are scarce. In this study, the oncological outcomes of AA and classical approach (CA) during RH for HCC were compared.

METHODS

A retrospective inverse propensity score-weighted fashion (IPTW) case-control study was performed in two French hepatobiliary surgery departments. Overall survival (OS), disease-free survival (DFS), and early recurrence rate (within 2 years after surgery) were analyzed.

RESULTS

Survival analysis was performed for 114 patients (CA group,60 patients; AA group, 54 patients). Before IPTW adjustment, the 3-year DFS rates were 29.4% (AA group) and 44% (CA group), respectively. No significant differences were found in DFS (HR = 1.1, 95%CI:0.62-1.9, p = 0.77) and OS (HR = 1.2, 95%CI:0.54-2.6, p = 0.66). After IPTW, DFS and OS analyses showed no differences between the two groups (p = 0.77 and p = 0.46, respectively). Early recurrence rates were similar before and after IPTW. Satellite nodules were the only significant independent risk factor for recurrence.

CONCLUSION

AA and CA did not result in significant differences in DFS, OS, or early recurrence after right hepatectomy for HCC before and after IPTW.

Surgical Outcomes and Feasibility of Transvaginal Sacrospinous Ligament Fixation through Anterior Approach for Women with Pelvic Organ Prolapse

Introduction

Supporting vaginal vault or apex is a central component of primary therapy and to prevent recurrence of prolapse. This study aims to review the surgical outcomes and feasibility of the anterior approach following both sacrospinous fixation (SSF) and sacrospinous hysteropexy (SSHP) in a single center over a specific period. And also to review its impact on quality of life.

Materials and Methods

This was a retrospective study that included all women who underwent unilateral SSF or SSHP through anterior approach for pelvic organ prolapse (POP) from May 2021 to May 2023 after institutional ethical approval for the study. The anterior approach was undertaken in 47 patients which were included in final review. A retrospective case note review to assess urinary symptoms was undertaken at baseline and 3 months by urinary distress inventory 6 score. The main outcome measure was recurrence of prolapse, predominant compartment for prolapse, presenting complaints, concomitant surgeries performed, and associated urinary complaints.

Results

The mean age was 56.17 ± 11.95 years and the average body mass index was 26.12 ± 3.11 kg/m2. Except for 4 cases of SSHP, remaining women were postmenopausal at the time of surgery. Ten women presented with urinary complaints as their chief complaint. On examination, POP Quantification evaluation, 35 cases have Ba as leading point, 10 have Ap as their leading point and in two cases C was the leading point.

Conclusion

Anterior unilateral sacrospinous ligament fixation is a safe, effective strategy to treat POP and other concomitant surgery can also be well combined with it.

Pain and rehabilitation after total hip arthroplasty are approach dependent: results 6 weeks and 2 years after surgery in a multisurgeon, single-center, and prospective cohort study

PURPOSE

The aim of this study was the evaluation of pain, function, and overall satisfaction after total hip arthroplasty (THA) using three different standard surgical approaches (DAA (direct anterior approach), lateral, and posterior approach) 2 years postoperatively. Additionally, we compared the results with recently published results of the same study population 6 weeks postoperatively.

METHODS

In a multisurgeon, prospective, single-center cohort study, a total of initial 188 patients who underwent total hip arthroplasty (THA) between February 2019 and April 2019 were analyzed on pain, function, and satisfaction within the first days, 6 weeks, and 2 years postoperatively according to three different approaches (DAA, lateral, and posterior approach). Our research group recently published results directly and 6 weeks postoperatively. We evaluated the same study collectively 2 years postoperatively and compared the results with the data 6 weeks postoperatively. One hundred twenty-five patients could be included. Outcome parameters for the present study were the pain level according to the visual analogue scale (VAS), the modified Harris hip score (mHHS), and an overall satisfaction scale 2 years postoperatively.

RESULTS

Mean overall satisfaction 2 years postoperatively was 9.7 ± 1 (3-10). Satisfaction was significantly better for the DAA than for the lateral approach (p = 0.005). There were no significant differences between the lateral and posterior approaches (p = 0.06) and between the DAA and the posterior approaches (p = 0.11). In total, the mean pain level was 0.4 ± 0.9 (0-5) at 6 weeks and 0.5 ± 1.1 (0-7) at 2 years postoperatively (p = 0.3). Regarding the different approach groups, pain levels 6 weeks and 2 years postoperatively were significantly lower for the DAA than for the lateral approach (p = 0.02). There were no significant differences between DAA and posterior approach (p = 0.05) and the lateral and posterior approach (p = 0.26). The mean mHHS significantly increased from 84.7 + 14.5 (37.4-100) 6 weeks to 95 + 12.5 (23.1-100.1) 2 years postoperatively (p < 0.0001). Regarding the different approaches, mHHS was significantly higher for the DAA than for the lateral approach (p = 0.03). Differences between the DAA and the posterior approach (p = 0.11) and between the lateral and posterior approaches (p = 0.24) were insignificant.

CONCLUSION

At 2 years postoperative, DAA showed significantly better overall satisfaction, pain level, and mHHS than the lateral approach. The differences between DAA and the posterior approach and lateral and posterior approaches were insignificant. Whether the superior results of the DAA to the lateral approach persist over a longer period must be clarified by further studies.

STUDY DESIGN

Prospective cohort study, level of evidence 2.

Laparoscopic right hemi-hepatectomy plus total caudate lobectomy for perihilar cholangiocarcinoma via anterior approach with augmented reality navigation: a feasibility study

BACKGROUND

Right hemi-hepatectomy plus total caudate lobectomy is the appropriate procedure for type IIIa or partial type II pCCA. However, the laparoscopic implementation of this procedure remains technically challenging, especially hilar vascular dissection and en bloc resection of the total caudate lobe. Augmented reality navigation can provide intraoperative navigation to enhance visualization of invisible hilar blood vessels and guide the parenchymal transection plane.

METHODS

Eleven patients who underwent laparoscopic right hemi-hepatectomy plus total caudate lobectomy from January 2021 to January 2023 were enrolled in this study. Augmented reality navigation technology and the anterior approach were utilized in this operation. Routine operative and short-term postoperative outcomes were assessed to evaluate the feasibility of the novel navigation method in this operation.

RESULTS

Right hemi-hepatectomy plus total caudate lobectomy was successfully performed in all 11 enrolled patients. Among the 11 patients, the mean operation time was 454.5 ± 25.0 min and the mean estimated blood loss was 209.1 ± 56.1 ml. Negative surgical margins were achieved in all patients. The postoperative course of all the patients was uneventful, and the mean length of postoperative hospital stay was 10.5 ± 1.2 days.

CONCLUSION

Laparoscopic right hemi-hepatectomy plus total caudate lobectomy via the anterior approach may be feasible and safe for pCCA with the assistance of augmented reality navigation.

The short external rotators in the anterior approach hip arthroplasty: do the tendons heal or not? A prospective MRI study

INTRODUCTION

Release of some of the short external rotator tendons may be needed in the direct anterior approach (DAA) for Total Hip Arthroplasty (THA). It is unknown if these tendons heal. The purpose of this prospective study is to examine short external rotator tendon healing after release and the associated effect on muscle volume. In addition, we examined the relation with external rotation force and patient reported outcome measures (PROMs).

METHODS

In 21 DAA THA patients, preoperative MRI was compared with postoperative MRI at 6 weeks and 12 months. PROMs and rotation force of both hips were assessed. Tendon integrity and muscle volume of the obturator internus and piriformis were assessed on MRI using dedicated software.

RESULTS

In 5 patients all tendons remained intact, in 4 patients only the conjoined tendon was released and in 12 patients both the conjoined and piriformis were released. Obturator externus remained intact in all patients. In patients with tendon release, mean volume of obturator internus and piriformis muscle decreased 27% (SD 11) and 23% (SD 16) 6 weeks after surgery, respectively. Released tendons and muscle volume loss did not recover 12 months after surgery. We found no relation between tendon release and hip rotation force or PROMs.

CONCLUSIONS

We found absent tendon healing and muscle volume loss when the conjoined or piriformis tendons were released. Although we found no relation between tendon detachment and hip force or PROMs, we have adapted our operative technique to make it more preserving for the piriformis.

Both-column Acetabular Fractures with Posterior Wall Involved can be Managed through Single Anterior Approach by Evaluation of Computer-assisted Virtual Surgery Technique

OBJECTIVE

Posterior wall (PW) fractures were sometimes associated in both-column acetabular fractures. How to evaluate pre-operatively the necessity for the performance of the posterior approach was an issue to be solved. In order to solve this issue, the computer-assisted virtual surgery technique was used to evaluate if the involved PW in both-column acetabular fractures (BACF) should be managed through posterior approach and verify the feasibility of this method.

METHODS

Data of a consecutive cohort of 72 patients with both-acetabular fractures from January 2012 to January 2020 was collected for retrospective study, of which 44 patients had concomitant acetabular PW fractures, and patients without PW fractures were labeled as the BCAF group. Computer-assisted virtual surgery technique was performed pre-operatively to evaluate the necessity for performance of posterior approach in 44 patients, and posterior approach was required if more than 3 mm of displacement was still present in the reduced 3D model. The 23 patients without treatment through posterior approach were labeled as the BCAF-PW- group, and the 21 patients with treatment through posterior approach were labeled as the BCAF-PW+ group. Operation-related and post-operative parameters were recorded. The quality of reduction and functional outcomes were assessed by the Matta scoring system and modified Merle d'Aubigné and Postel scoring system. The measurement data were analyzed using the t-test of independent samples and rank-sum test of ranked data between every two groups. Also, the one-way analysis of variance (ANOVA) was used to analyze data between the three groups.

RESULTS

Comparing operation-related and post-operative parameters in the three groups, some PW fractures in both-column acetabular fractures could be ignored, and which could be evaluated pre-operatively for necessity of an additional posterior approach. Operative time (271.2 ± 32.8 mins) and intra-operative blood loss (1176.7 ± 211.1 mL) were significantly higher in the BCAF-PW+ group. The excellent/good of reduction (25/28 of the BCAF group, 21/23 of the BCAF-PW- group, 19/21 of the BCAF-PW+ group) and functional outcomes (24/28 of the BCAF group, 18/23 of the BCAF-PW- group, 18/21 of the BCAF-PW+ group) of three groups were similar. The incidence of complications, such as deep vein thrombosis (4/28 of the BCAF group >3/23 of the BCAF-PW- group >1/21 of the BCAF-PW+ group) and injury of lateral femoral cutaneous nerve (3/23 of the BCAF-PW- group >2/28 of the BCAF group >0/21 of the BCAF-PW+ group), was no significant difference.

CONCLUSION

The partial both-column acetabular fractures with PW involvement could be managed through a single anterior approach without another posterior approach by evaluation of computer-assisted virtual surgery technique.

Anterior approach versus posterior approach for the open reduction of displaced pediatric supracondylar humerus fracture

Background

This study's objective was to compare the results and adverse outcomes of the anterior approach and posterior approach in patients with a type 3 Gartland pediatric supracondylar fracture who failed close treatment and indicated open reduction.

Methods

in this retrospective study patients with Gartland type 3 fracture who failed close reduction and required open reduction were enrolled in the study. Eligible patients underwent open reduction via anterior and posterior triceps sparing approaches. Patients were followed up 3, 6, and 12 months after the surgery. Study variables included age, sex, Bauman's angle, pin site infection, nerve injury, osteonecrosis, and elbow arc of motion.

Results

The study included a total of 83 patients. Surgery was performed on 49 patients using the posterior technique and 34 patients using the anterior approach. The mean age of patients was 6.78 ± 1.40 years. The mean age and the relative frequency of sex didn't differ significantly between study groups (P > 0.05). Two-way repeated measures ANOVA test showed that there was a statistically significant difference in elbow arc of motion in the anterior approach in comparison with the posterior approach, however, this increase was not clinically significant. In terms of adverse events including pin site infection, nerve injury, osteonecrosis, and cubitus varus, there was no statistically significant difference between the two approaches.

Conclusion

There was no clinically significant difference in elbow arc of motion and adverse events between the anterior approach and the posterior approach. Therefore, surgeons should choose the approach with which they are more familiar and comfortable.

Which patient-specific parameters correlate with operation time for total hip arthroplasty? - A retrospective analysis of the direct anterior approach

PURPOSE

The current study aims to identify patient-specific factors that correlate with operation time for total hip arthroplasty (THA) performed via the direct anterior approach (DAA).

METHODS

In this retrospective study, patient-specific factors were tabulated from the charts and measured from preoperative templating radiographs. These factors were correlated with operation time by bivariate analysis. Significant factors were used for stepwise multiple regression analysis.

RESULTS

Nine hundred-sixty procedures were included. BMI (R = 0.283), the distance from the superior iliac spine to the greater trochanter (DAA Plane) (R = - 0.154), patients age (R = 0.152) and the abdominal fat flap (R = 0.134) showed the strongest correlations (p < 0.005) with operation time. The multiple regression model including BMI, Kellgren and Lawrence Score, Age, DAA Plane and the Canal to Calcar ratio had the best predictive accuracy (corrected R2 = 0.122).

CONCLUSIONS

Patient-specific factors that make the entry into the femur difficult correlate significantly with operation time of THA via the DAA.

Muscle recovery after total hip arthroplasty: prospective MRI comparison of anterior and posterior approaches

INTRODUCTION

The direct anterior approach (DAA) and the posterior approach (PA) are 2 common total hip arthroplasty (THA) exposures. This prospective study quantitatively compared changes in periarticular muscle volume after DAA and PA THA.

MATERIALS

19 patients undergoing THA were recruited prospectively from the practices of 3 fellowship-trained hip surgeons. Each surgeon performed a single approach, DAA or PA. Enrolled patients underwent a preoperative MRI of the affected hip and two subsequent postoperative MRIs at around 6 weeks and 6 months after surgery. Clinical evaluations were done by Harris Hip Score at each follow-up interval.

RESULTS

MRIs or 10 DAA and 9 PA patients were analysed. Groups did not differ significantly with regard to BMI, age, or preoperative muscle volume. 1 DAA patient suffered a periprosthetic fracture and was excluded from the study. DAA hips showed significant atrophy in the obturator internus (-37.3%) muscle at early follow-up, with persistent atrophy of this muscle at the final follow-up. PA hips showed significant atrophy in the obturator internus (-46.8%) and externus (-16.0%), piriformis (-8.12%), and quadratus femoris muscles (-13.1%) at early follow-up, with persistent atrophy of these muscles at final follow-up. Loss of anterior capsular integrity was present at final follow-up in 2/10 DAA hips while loss of posterior capsular integrity was present in 5/9 PA hips. There was no difference in clinical outcomes.

DISCUSSION

This study demonstrates that DAA showed less persistent muscular atrophy than PA. Regardless of surgical approach, a muscle whose tendon is detached from its insertion is likely to demonstrate persistent atrophy 6 months following THA. Although the study was not powered to compare clinical outcomes, it should be noted that no significant difference in patient outcomes was observed.

The surgical anatomy of the axillary approach for nerve transfer procedures targeting the axillary nerve

PURPOSE

The exact relational anatomy for the anterior axillary approach, targeting the axillary nerve for nerve transfers/grafts, has not been fully investigated. Therefore, this study aimed to dissect and document the gross anatomy surrounding this approach, specifically regarding the axillary nerve and its branches.

METHODS

Fifty-one formalin-fixed cadavers (98 axilla) were bilaterally dissected simulating the axillary approach. Measurements were taken to quantify distances between identifiable anatomical landmarks and relevant neurovascular structures encountered during this approach. The musculo-arterial triangle, described by Bertelli et al., to aid in identification on localization of the axillary nerve, was also assessed.

RESULTS

From the origin of the axillary nerve till (1) latissimus dorsi was 62.3 ± 10.7 mm and till (2) its division into anterior and posterior branches was 38.8 ± 9.6 mm. The origin of the teres minor branch along the posterior division of the axillary nerve was recorded as 6.4 ± 2.9 mm in females and 7.4 ± 2.8 mm in males. The musculo-arterial triangle reliably identified the axillary nerve in only 60.2% of the sample.

CONCLUSION

The results clearly demonstrate that the axillary nerve and its divisions can be easily identified with this approach. The proximal axillary nerve, however, was situated deep and therefore challenging to expose. The musculo-arterial triangle was relatively successful in localising the axillary nerve, however, more consistent landmarks such as the latissimus dorsi, subscapularis, and quadrangular space have been suggested. The axillary approach may serve as a reliable and safe method to reach the axillary nerve and its divisions, allowing for adequate exposure when considering a nerve transfer or graft.

Anterior unidirectional approach in a uniportal thoracoscopic anterior segmentectomy (S3) of the right upper lobe for a dense fissure

Most types of segmentectomies require dissection of a fissure to expose the pulmonary arteries, which is considered a conventional technique. Therefore, it is necessary to deal with a dense fissure in a pulmonary segmentectomy as well as in a lobectomy. Nevertheless, only a few reports describe the operative technique for managing a dense fissure in a pulmonary segmentectomy. Although a dense fissure is frequently found between the right upper and the middle lobes, only one previous report has described an anterior segmentectomy (S3) of the right upper lobe without the dissection of a dense fissure between the right upper and middle lobes. In this video tutorial, we show the appropriate surgical steps for a right S3 segmentectomy using an anterior unidirectional approach via uniportal thoracoscopy for a patient with a dense fissure.

Extended deltopectoral approach for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock

Background

Severe humeral bone loss in the setting of failed total elbow arthroplasty (TEA) poses a particularly challenging reconstructive problem. The objective of this study was to review the rationale, indications, contraindications, and detailed surgical technique for using an extended anterior deltopectoral approach to perform a revision TEA when substantially long allografts are required in the presence of severely compromised proximal humerus bone stock.

Methods

The authors developed this exposure and reconstructive strategy for failed elbow arthroplasties where the remaining segment of proximal humerus is extremely short, which makes adequate plate fixation of an allograft-prosthetic composite (APC) to the native bone extremely challenging. From an anterior deltopectoral approach, it is possible to use dedicated long, precontoured proximal humerus locking plates to maximize fixation in any remaining proximal humerus. This exposure still makes it possible to provide adequate access to the coupling mechanism of the humeral and ulnar components for implantation of a linked elbow arthroplasty. This exposure also allows for adequate judgment of humeral length and rotation.

Pitfalls and Challenges

Crucial steps in the surgery include extending the dissection past the elbow flexion crease such that one can obtain circumferential exposure of the distal humerus. It is also important to couple the humeral and ulnar components prior to committing to the length of the APC. Special attention must be paid to gauge appropriate APC rotation and length for proper soft tissue tension. When performing fixation of the proximal humeral plate, screw purchase must be maximized in both the remaining native proximal humerus and the APC. Compression across the allograft-host interface is paramount for healing to occur.

Conclusion

An extended anterior deltopectoral approach to perform a revision TEA when very long APCs are required is a viable option to restore humeral bone stock and regain humeral stem fixation in the setting of failed TEA with extensive humeral bone loss.

Treatment of irreducible intertrochanteric femoral fracture with a minimally invasive clamp reduction technique via the anterior approach

OBJECTIVE

To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures.

METHODS

From January 2015 to January 2021, 115 patients (48 males and 67 females) with irreducible intertrochanteric femoral fractures were treated. The average age of the patients was 78.7 (45-100 years old). The types of injuries were falls (91 cases), traffic accidents (12 cases), smashing (6 cases), and high falling (6 cases). The duration between injury and surgery ranged from 1 to 14 days, with an average of 3.9 days. The distribution of AO classification was as follows: 31-A1 in 15 cases, type 31-A2 in 67 cases and 31-A3 in 33 cases.

RESULTS

All patients achieved good reduction, with fracture reduction times ranging from 10 to 32 min (mean of 18 min), and were followed up for 12-27 months after surgery (mean of 17.9 months). Two patients with pronation displacement of the proximal fracture segment died of infection or hypostatic pneumonia after internal fixation failure; one patient with failed internal fixation switched to joint replacement. After internal fixation, the lateral wall of six reversed intertrochanteric femoral fractures showed repronation and abduction displacement, but all fractures achieved bony healing. The rest of the patients did not lose fracture reduction, and all fractures achieved bony healing with a healing time ranging from 3 to 9 months (mean of 5.7 months). While two patients died and one patient exhibited failed internal fixation and thus switched to joint replacement, 91 of the remaining 112 patients had an excellent Harris score of the hip joint function at the final follow-up, while 21 patients had a good Harris score.

CONCLUSION

The minimally invasive clamp reduction technique via the anterior approach for the treatment of irreducible intertrochanteric femoral fractures is simple, effective and minimally invasive. In the case of irreducible intertrochanteric femoral fractures associated with lateral wall displacement, the lateral wall needs to be strengthened after clamp reduction and intramedullary nail fixation to avoid loss of reduction and failure of internal fixation.

Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy

BACKGROUND

Current literature lacks objective criteria to determine surgical management in patients with ankylosing spondylitis who sustain cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in patients, and postulate a management strategy.

METHODS

This was a retrospective study of patients with ankylosing spondylitis who underwent surgery for cervical spine injury with a minimum follow-up of 2 years. Neurological recovery, fracture pattern including translation and angulation, surgical duration, blood loss, and postoperative complications were recorded, and a comparative analysis of these factors with anterior, posterior, and combined surgical approaches was performed.

RESULTS

The study included 43 men with a mean age of 57 years; 49% underwent anterior-only stabilization, 16% underwent posterior-only stabilization, and 35% underwent combined anteroposterior stabilization. Mean operative time was significantly lower in anterior-only (81.4 minutes; P < 0.05) and posterior-only (124 minutes; P < 0.05) approaches compared with combined approach (266.6 minutes). Mean blood loss was significantly lower in anterior-only (87.5 mL, P < 0.05) approach compared with posterior-only (714.7 mL) and combined (912.7 mL) approaches. Mean translation was 1.8 mm, 1.7 mm, and 3.7 mm in anterior, posterior, and combined approaches (P < 0.05), respectively.

CONCLUSIONS

Our study provides insights into management of cervical spine fractures in ankylosing spondylitis patients. A fracture displacement ≤2 mm may be successfully managed by an anterior approach, while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.

Comparison of Long-Term Clinical and Radiographical Outcomes between the Anterior and Combined Anterior and Posterior Approaches for Treating Lumbosacral Tuberculosis

OBJECTIVE

Both anterior and combined anterior and posterior approaches have been used to treat lumbosacral tuberculosis. However, long-term follow-up studies of each approach have not been conducted. We aimed to compare the long-term clinical and radiographical outcomes between the two approaches.

METHODS

In this retrospective cohort study, we included 49 patients with a minimum 6-year follow-up between January 2008 and March 2012. Twenty-four patients underwent the anterior approach (anterior group), and 25 underwent the combined anterior and posterior approach (anterior-posterior group). Student's t test, Mann-Whitney U test, and Pearson's chi-square test were used to compare the two groups regarding clinical data, such as visual analogue scale scores, Oswestry disability index scores and neurological status, and radiographical data, such as lumbosacral angle, lumbar lordosis, and L5-S1 height. Furthermore, operative time, length of stay, and intraoperative and postoperative blood loss (IBL, PBL) were recorded.

RESULTS

Both groups had satisfactory clinical and radiographical outcomes until the final follow-up. All patients achieved bony fusion, and no group differences were found in any of the clinical indices. Both groups corrected and maintained the lumbosacral angle, lumbar lordosis, and L5-S1 height. However, the operative time, length of stay, maximum Hb drop, IBL, and PBL of the anterior group (140.63 ± 24.73 min, 12.58 ± 2.45 days, 28.33 ± 9.70 g/L, 257.08 ± 110.47 ml, and 430.60 ± 158.27 ml, respectively) were significantly lower than those of the anterior-posterior group (423.60 ± 82.81 min, P < 0.001; 21.32 ± 3.40 days, P < 0.001; 38.48 ± 8.03 g/L, P < 0.001; 571.60 ± 111.04 ml, P < 0.001; and 907.01 ± 231.99 ml, P < 0.001).

CONCLUSION

This retrospective study demonstrated long-term efficacy of the anterior approach with a single screw fixation, which was as effective as that of the combined anterior and posterior approach, with the advantage of less trauma.

Incidence and local risk factors of infection after anterior sub-axial cervical spine surgery: retrospective database analysis of 4897 consecutive procedures

INTRODUCTION

The anterior cervical spine approach is safe and effective in many cervical spine pathologies. It is considered one of the most common approaches in spine surgery. Postoperative infections after anterior cervical surgery are rare but serious.

MATERIALS AND METHODS

This study is a retrospective database analysis. In this study, the incidence, and the local risk factors of postoperative infection after anterior-only sub-axial cervical spine surgery in a high-volume spine center were analyzed. The data of patients operated in a teaching hospital is electronically stored in a comprehensive medical database program. Postoperative infection after anterior cervical surgery from C2 to C7 was calculated and analyzed. In the study period, 4897 patients were operated. Twenty-four infections after a primary aseptic operation were detected. Independent local risk factors were estimated.

RESULTS

Postoperative infection occurred in 24/4897 patients (0.49%). The incidence of infection after cervical trauma was 3% (7/229), after spinal cord injury 4.3% (2/46), with myelopathy 1.98% (11/556), and after revision surgery 1.25% (7/560). The incidence showed a significant increase (p = 0.00, 0.01, 0.02). In 14 of the postoperatively infected patients (58.3%) an oesophageal injury was diagnosed. Odds ratios (OR) with a confidence interval (CI) of 95% was calculated. Independent risk factors for the postoperative infections were: Cervical trauma (OR 8.59, 95% CI 3.52-20.93), revision surgery (OR 3.22, 95% CI 1.33-7.82), The presence of cervical myelopathy (OR 6.71, 95% CI 2.99-15.06), and spinal cord injury (OR 9.33, 95% CI 2.13-40.83).

CONCLUSIONS

Postoperative infection after anterior cervical surgery is low (0.49%). In addition to the general risk factor for infection, the local risk factors are trauma, myelopathy, spinal cord injury, and revision surgeries. In the case of postoperative infection, an oesophageal injury should be excluded.

One-stage vs two-stage bilateral THA in Lombardy: a cost-effectiveness analysis

BACKGROUND

Total hip arthroplasty (THA) is the most common treatment for primary and secondary end-stage hip osteoarthritis (OA). Almost 20% of all patients undergoing primary THA suffer from bilateral hip OA and, consequently, will need a contralateral procedure to be performed in the following years. The aim of this study is to evaluate the cost-effectiveness and the reliability of one-stage bilateral THA (1-BTHA) compared to two-stage bilateral THA (2-BTHA), in low-risk patients, performed with anterior minimally invasive surgery (AMIS).

METHODS

Single patient's costs were obtained by dividing the annual costs report by the number of hospitalizations, considering the diagnosis related group (DRG) of the two procedures. Then, 16 patients undergoing 1-BTHA and 8 undergoing 2-BTHA were examined. Hemoglobin (Hb) values before surgery and before discharge, transfusion rate and the occurrence of post-operative complications were observed.

RESULTS

Procedural costs were divided in different subgroups: pre-hospitalization, operating room, hospital stay, post-operative follow-up and other costs. 1-BTHA total costs amount to 5.754,82€, while performing 2-BTHA costs 7.624,32€. However, considering DRG reimbursement, the hospital's profit margin following 1-BTHA is lower than that following 2-BTHA (6.346,18€ versus 9.261,68€). Surgical time was found not to be significantly different between 1-BTHA and 2-BTHA (141,13 ± 26,1 min vs 164,8 ± 44,3 min; p = 0,111). The two groups showed a statistically significant difference in Hb decrease (4,8 ± 1,3 g/dl vs 3,3 ± 0,9; p = 0,001), despite no variances in transfusion rate. No further complications were observed in either group.

CONCLUSIONS

This study demonstrates how, in carefully selected patients, 1-BTHA performed with AMIS is a cost-effective and safe technique compared to 2-BTHA, resulting in a shorter OR time, LOS and lower overall costs.

LEVEL OF EVIDENCE

III.

Iliolumbar vein: a challenge for the exposure of the L4-5 disc in the anterior approach to the lumbar spine

PURPOSE

Anterior lumbar spine arthrodesis has been increasingly prescribed. In order to obtain better exposure of the intervertebral discs, it is necessary to identify vascular structures depending on the level to be approached. Systematic ligation of the iliolumbar vein has been suggested for access to the L4-L5 level, which may be technically challenging. The goal of the present study was to determine a safe limit for separating the iliolumbar vein safely without the need for its ligation.

METHODS

In total, 2284 patients involving the topography of the iliolumbar vein were included. If this vein was up to 5 mm distant from the inferior border of the L4-L5 intervertebral disc, its ligature was performed. In cases that the distance was greater than 5 mm, only the retraction was performed without ligature.

RESULTS

A total of 115 ligatures were necessary (5% of cases). Among the 2169 cases with no ligature, bleeding due to ruptures occurred during traction in only 55 patients (3% of cases). The time taken for ligation ranged from five minutes to thirty-two minutes, with an average of 18.3 min per ligature. In cases in which ligatures were needed (distance less than 5 mm), there was loosening of the ligatures leading to bleeding in 23 cases (20% of ligatures).

CONCLUSIONS

Systematic ligature is not necessary for accessing the anterior route to the L4-L5 level, leading to a reduction in the time of surgery and avoiding serious vascular injuries that can occur.

Comparison of early complications for primary total hip arthroplasty using modified direct anterior approach and lateral approach

BACKGROUND

Total hip arthroplasty is a surgical procedure with reliable results, regardless of the approach used. The anterior approach has advantages by respecting muscle insertions, reflected in the lower number of complications and shorter recovery time compared to other approaches.

OBJECTIVE

The goal of the study was to assess the progression of 150 total hip arthroplasty procedures in the first 90 postoperative days. 75 patients underwent a modified direct anterior approach (MDAA) using a minimally invasive technique with a special table, and 75 patients underwent a direct lateral approach (DLA).

METHODS

An observational retrospective study was conducted, including 150 arthroplasties, performed by the same surgeon, using two surgical approaches. 75 cases with direct lateral approach (DLA) and 75 cases with modified direct anterior approach (MDAA), between January 2007 and December 2020. Baseline characteristics, surgical variables, and postoperative complications were compared between the two groups.

RESULTS

At 90 days, both groups presented a similar percentage of minor complications (32% vs. 42%), however, there was a higher number of major complications due to DLA (40% vs. 12% p < 0.0001) overall, where motor neurological complications have a higher incidence (14 [18.6%]). No differences were found in terms of the Harris functional scale.

CONCLUSION

MDAA is a safe and reliable technique with satisfactory results. It presents predictable early complications, such as other approaches. Although it allows a faster recovery, at 90 days, the evolution and satisfaction are similar between both approaches with excellent and good outcomes in > 90% of cases.

Anterior bilateral sacrospinous ligament fixation with concomitant anterior native tissue repair: a pilot study

INTRODUCTION AND HYPOTHESIS

Anterior bilateral sacrospinous ligament fixation (ABSSLF) was first described in 2000 but only evaluated in a limited number of studies. However, due to the FDA's ban on transvaginal mesh, interest in this technique has re-emerged. The SSLF procedure is known for its inherent high risk for anterior compartment failure; hence, in our center we started performing a preemptive concomitant anterior repair with the intention to reduce such risk. The aim of this study was to review the feasibility and clinical outcomes of this innovative technique.

METHODS

We performed a retrospective cohort study of all the women who had an ABSSLF and a concomitant anterior native tissue repair between May 2019 and July 2020 in a tertiary hospital in France. Our primary endpoint was surgical feasibility, while as secondary endpoints we wanted to explore the perioperative morbidities and clinical outcomes associated with this technique.

RESULTS

A total of 50 women were operated on in the studied period. The median follow-up time was 10 [8.5] months. It was feasible to perform the combined ABSSLF and concomitant anterior native tissue repair in all cases. The most frequent perioperative complications reported were urinary tract infection (14%) and difficulty in resuming voiding (16%). Anatomical and functional results were improved. The rate of anterior compartment recurrence was 37%.

CONCLUSIONS

ABSSLF with a concomitant anterior native tissue repair is feasible and relatively safe for treating anterior and apical pelvic prolapse. However, anterior compartment failure rate is still a limitation. Further larger studies with long-term anatomical and functional results comparing this technique to alternative transvaginal surgical approaches are needed.

Pain and rehabilitation after total hip arthroplasty are approach dependent: a multisurgeon, single-center, prospective cohort study

PURPOSE

The aim of this study was to assess perioperative pain and mobilization after total hip arthroplasty (THA) using three different surgical approaches.

METHODS

This was a multisurgeon, prospective, single-center cohort study. A total of 188 patients who underwent hip arthroplasty (THA) between February 2019 and April 2019 were analyzed according to the surgical approach used (direct anterior, lateral, and posterior approach). Outcome parameters were the daily walking distance during the inpatient stay, the pain level according to the visual analog scale (VAS) at rest and motion during the inpatient stay and at 6-week follow-up and the modified Harris Hips Score (mHHS) preoperatively and at 6 weeks.

RESULTS

The walking distance within the groups increased significantly during the inpatient stay (p < 0.001). The DAA and posterior approach patients had a significantly longer walking distance than the lateral approach patients on the third postoperative day (DAA vs. lateral, p = 0.02; posterior vs. lateral 3, p = 0.03). DAA and posterior approach patients reported significantly less pain during motion on the third postoperative day and at 6-week follow-up than the lateral approach patients (3 postoperative day: DAA vs. lateral, p = 0.011; posterior vs. lateral, p = 0.04; 6 weeks control: DAA vs. lateral, p = 0.001; Posterior vs. lateral 3, p = 0.005). The mHHS demonstrated significant improvement within each group. However, lateral approach patients reported significantly less improvement than the DAA and posterior approach patients (DAA vs. lateral, p = 0.007; posterior vs. lateral, p = 0.021).

CONCLUSION

This study analyzed perioperative pain progression and short-term rehabilitation after THA according to the different surgical approaches. Direct anterior and posterior approaches have shown comparable improvements in pain, walking distance, and mHHS. Whether this effect persists over a longer period of time must be clarified in future studies.

STUDY DESIGN

Prospective cohort study, level of evidence, 2.

Supine versus lateral position for total hip replacement: accuracy of biomechanical reconstruction

BACKGROUND

Restoration of normal hip anatomy and biomechanics is a key surgical goal for success in total hip arthroplasty. The aim of this study was to evaluate the influence, if any, that patient positioning in the supine and lateral decubitus positions has in achieving this goal.

MATERIALS AND METHODS

A single center multi-surgeon case-matched series from a tertiary level referral center of patients undergoing primary unilateral THA for osteoarthritis between April 2018 and December 2019 was retrospectively analyzed. Patients (n = 200) were divided into two matched groups: supine (anterior approach, n = 100) and lateral decubitus (direct lateral or posterior/SuperPATH™ approaches, n = 100). Post-operative anteroposterior pelvic radiographs were analyzed using a previously validated software (SurgiMap, Nemaris Inc., USA) for parameters of reconstruction of the hip in the coronal plane; leg length discrepancy, vertical and horizontal displacement of the center of rotation, femoral offset, and total offset.

RESULTS

Mean absolute leg length discrepancy in the supine group was 0.6 ± 3.3 mm (95% [CI] - 0.1 to 1.2 mm) versus 2.4 ± 3.8 mm (95% [CI] 1.6 to 3.1) in the lateral decubitus position (p < 0.001). The center of rotation was displaced medially by a mean of 3.2 ± 2.7 mm in the supine group versus 1.3 ± 4.0 mm in the lateral decubitus group (p < 0.001). For a surgical target of reconstructing both leg length and total offset within 5 mm of native anatomy, the supine group was more than twice as likely to achieve these goals with fewer outliers (OR 2.631, 95% [CI] 1.901-3.643) (76% v 30%, p < 0.001).

CONCLUSION

Total hip arthroplasty through the anterior approach in the supine position is more consistent and accurate for the restoration of leg length and total offset. Further study is required to assess how this translates with outcome.

LEVEL OF EVIDENCE

III-retrospective cohort study.

Comparative MRI assessment of three minimally invasive approaches in total hip arthroplasty

INTRODUCTION

Minimally invasive approaches (direct anterior approach: DAA; minimally invasive anterolateral: MIAL; piriformis-sparing posterior approach: PSPA) are widely used for total hip arthroplasty (THA), with a muscle-sparing objective. There are no published comparative studies of muscle damage secondary to these approaches. The aim of the present study was to compare fatty infiltration (FI) on MRI induced by DAA, MIAL and PSPA in THA 1) in the tensor fasciae latae (TFL) and sartorius muscles, 2) in the gluteal muscles, and 3) in the pelvitrochanteric muscles.

HYPOTHESIS

Greater FI is induced by DAA in anterior muscles, by MIAL in gluteal muscles and by PSPA in pelvitrochanteric muscles.

MATERIALS AND METHODS

Three continuous prospective series of THA by DAA, MIAL and PSPA included 25 patients each. MRI was performed preoperatively and at 1 year postoperatively. FI was graded on the Goutallier classification in all periarticular hip muscles. Muscles showing ≥2 grade aggravation at 1 year were considered damaged.

RESULTS

Nine patients whose preoperative MRI was uninterpretable were excluded. In all, 66 patients (21 DAA, 24 MIAL and 21 PSPA) with 132 MRI scans were analyzed. TFL was damaged in 2/21 DAA patients (9.5%), 1/24 MIAL patients (4.2%) and 0/21 PSPA patients (0%). There were no sartorius lesions. The anterior third of the gluteus medius was damaged in 8/24 MIAL patients (33.3%) and the gluteus minimus in 10/24 (41.7%), compared to 1/21 DAA patients (4.8%) and 0/21 PSPA patients (0%). The mid and posterior thirds of the gluteus medius and the gluteus maximus were never damaged. The piriformis muscle was damaged in 3/21 DAA patients (14.3%), 2/24 MIAL patients (8.3%) and 2/21 PSPA patients (9.5%). The obturator internus was damaged in 4/21 DAA patients (19%), 1/24 MIAL patients (4.2%) and 16/21 PSPA patients (76.2%). The obturator externus and quadratus femoris were mainly damaged in PSPA patients: respectively, 5/21 (23.8%) and 4/21 patients (19%)).

CONCLUSION

The muscle-sparing properties of minimally invasive hip approaches are only theoretical. In the present series, there were rare TFL lesions with DAA and MIAL. Gluteus medius and minimus lesions were frequent in MIAL. Pelvitrochanteric muscles lesions were more frequent in PSPA, but found in all 3 approaches. These findings should help guide surgeons in their choice of approach and in informing patients about the damage these minimally invasive approaches can cause.

LEVEL OF EVIDENCE

III, prospective comparative study.

A new attempt to treat coronal plane fractures of the elbow joint with salvage via an anterior approach

Background

Existing approaches for treating elbow fractures include lateral, medial, anterior and posterior approaches, though the anterior approach is often not chosen by surgeons to avoid damage to important nerves and blood vessels. However, the anterior approach has unique advantages. The purpose of this study was to report outcomes of 38 patients with coronal plane elbow fractures treated through the anterior approach.

Methods

We retrospectively analyzed 38 cases of coronal plane elbow fracture treated through an anterior approach at our institution between March 2015 and July 2019. The length of the surgical incision, operation time, and postoperative complications were recorded. The range of flexion, extension, and rotation of the affected elbow and the healthy elbow were collected at follow-up. Functional outcomes were evaluated using the Mayo Elbow Function Score (MEPS).

Results

All 38 patients were followed up for a mean of 21.26 months (range 12–36 months). Intraoperatively, the mean surgical incision length was 8 ± 2 cm and the mean operative time was 123 ± 59 min. At the final follow-up, solid osseous union was confirmed for all coronal plane elbow fractures. The mean elbow flexion arc was 129 ± 7°, and the extension arc was 9 ± 6°. The mean pronation arc was 83 ± 3°, and the supination arc was 80 ± 3°. The mean MEPS was 90 ± 8 points, with 18 excellent cases and 20 cases of excellent and good results, respectively. In 31 cases, there was no significant difference in elbow extension, flexion, or pronation between the single-fracture and healthy elbows (P > 0.05), though the arc of supination was slightly worse than that of the healthy elbow (P < 0.05). VAS pain scores before the operation, at three months after the operation, and during follow-up were compared, and pain was significantly reduced after treatment (P < 0.05). Two patients experienced transient postoperative median nerve paralysis, from which they recovered within three months. One patient had mild heterotopic ossification and was not treated because it did not affect the function of the elbow joint. All patients returned to work and were satisfied with the treatment.

Conclusion

The anterior approach has the benefits of simplicity, safety, minimal invasiveness, excellent exposure, and satisfactory prognosis for coronal plane elbow fracture.

Postoperative acetabular component position in revision hip arthroplasty: a comparison of the anterior and posterior approaches

BACKGROUND

While previously considered unsuitable for revision total hip arthroplasty (rTHA), the direct anterior approach (DAA) can be extended to allow for safe acetabular component revision. In primary hip arthroplasty, the DAA and its associated fluoroscopy, has been shown to produce more acceptable component positioning. However, there is little data comparing the DAA to the posterior approach (PA) for rTHA. We hypothesised that, the DAA with intraoperative fluoroscopy would allow for more precise acetabular component positioning when compared to those performed using a PA.

METHODS

50 consecutive patients (25 DAA and 25 PA) undergoing rTHA were included. Radiographic analysis of postoperative acetabular component position was then performed. Univariate and multivariate analyses was performed to assess the contribution of approach on cup positioning inside classically defined "safe zones".

RESULTS

Baseline patient characteristics were similar. The PA was associated with more cups placed outside the Lewinnek (48% vs. 12%, p = 0.005) and the Danoff (52% vs. 28%, p = 0.083) "safe zones" when compared to the DAA. Multivariate analysis revealed that operative approach was the only patient or surgical factor associated with component position outside of the "safe zones" (Lewinnek [OR = 13.6; 95% CI, 2.12-87.9, p = 0.006] and Danoff [OR = 7.7; 95% CI, 1.48-40.1, p = 0.015]).

CONCLUSION

Our results suggest that the DAA allows for more reproducible and precise cup placement in RTHA. The safe-zone paradigm remains a useful index of accurate cup positioning and the DAA, with use of intraoperative fluoroscopy, offers more consistent acetabular component positioning when compared to the PA.

The posterior/medial dry needling approach of the tibialis posterior muscle is an accurate and safe procedure: a cadaveric study

Background

Evidence suggests that tibialis posterior muscle plays an important role in equinovarus foot deformity in patients who had suffered a stroke and it is one of the most frequently injected lower-extremity muscles for the management of spasticity. Our aim was to assess if a needle accurately and safely penetrates the tibialis posterior muscle during the application of dry needling. 

Methods 

We conducted a cadaveric descriptive study. Needling insertion of the tibialis posterior was conducted in 11 cryopreserved cadavers with a 70 mm needle. The needle was inserted using two common approaches, at midpoint (posterior/medial approach) and at upper third (anterior approach) of the leg towards the tibialis posterior. The needle was advanced into the tibialis posterior based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analyzed by photometry. Safety was assessed by calculating the distances from the tip and the path of the needle to proximate neurovascular structures.

Results

Accurate needle penetration of the tibialis posterior muscle was observed in all cadavers with both approaches. In general, distances from the needle to the neurovascular bundles were larger with the posterior/medial approach than with the anterior approach, reaching statistically significance for needle tip to nerve (mean difference: 0.6 cm, 95%CI 0.35 to 0.85 cm) and vascular bundle (mean difference: 0.55 cm, 95%CI 0.3 to 0.8 cm) distances (P < 0.001) and needle path to vascular bundle distance (difference: 0.25 cm, 95%CI 0.1 to 0.4 cm, P = 0.045). Age and gender did not influence the main results.

Conclusions

This cadaveric study suggests that needling of the tibialis posterior muscle can be accurately and safely conducted. Safety seems to be larger with the posterior/medial approach when compared with the anterior approach.

Scar Perception After Two Surgical Approaches for Total Hip Arthroplasty

Background

There is a paucity of literature examining patients’ and health-care providers’ perception of surgical scars after total hip arthroplasty (THA). This study examined perception of surgical scars after direct anterior (DAA) or posterior approach (PA) for THA using validated scar-assessment scales.

Material and methods

Seventy-five DAA and 75 PA THA patients underwent scar assessment using the Patient Observer Scar Assessment Scale (POSAS) and Stony Brook Scar Evaluation Scales. Mean age was different between the cohorts (DAA 67 vs PA 62 years, P = .01). All patients had subcuticular running closure, secured with skin adhesive glue. Mean time from THA to scar assessment was 3.1 and 3.6 years for the DAA and PA groups, respectively (P = .18).

Results

Scar opinion on the POSAS patient-reported scale was graded closer to normal skin more often for DAA than for PA patients (P = .03). More irregularities were graded for the DAA scars on the POSAS observer scale (P = .02) and the Stony Brook Scar Evaluation Scales (P = .04). Age did not predict scar opinion on any of the scales (P > .05). Female gender and a history of keloids predicted poorer scar appearance (P = .001 and P = .02). Overall scar appearance was rated as “good” in 93% of the DAA and 91% of the PA patients (P = .63).

Conclusion

Differences exist in DAA and PA scar perception based on validated scales. Future randomized trials in scar assessment may control for confounding variables such as age and gender, as well as potential biases when using scar assessment scales.

Comparison of the clinical efficacy of two fixation methods combined with OLIF in the treatment of lumbar spondylolisthesis in adult patients

Background

To observe the clinical efficacy of an anterior single rob-screw fixation (ASRSF) combined with the oblique lumbar intervertebral fusion (OLIF) approach compared with a posterior percutaneous screw fixation (PPSF) combined with OLIF in the treatment of lumbar spondylolisthesis.

Method

This is a retrospective case–control study. Patients with degenerative lumbar spondylolisthesis (DLS) treated with either ASRSF combined with OLIF or PPSF combined with OLIF from January 2016 to January 2018 were enrolled in this study. None of the patients had posterior decompression. The visual analog scale (VAS) and Oswestry dysfunction index (ODI) were used for clinical efficacy assessment. The pre- and post-operational disc height, height of foramen, subsidence, and migration of cages, fusion rate and surgery-related complications were compared between the two groups.

Results

Fifty-three patients were included in this single-center study. According to the fixation methods, patients were divided into the ASRSF group (group A, 25 cases) and the PPSF group (group B, 28 cases). There was no statistical difference in surgery-related complications between groups. There was a significant difference in the VAS score at one-week post-surgery (2.3 ± 0.5 vs. 3.5 ± 0.4, P = 0.01), and three months post-operation (2.2 ± 0.3 vs. 3.0 ± 0.3, P = 0.01). Comparison of post-operative imaging data showed that there was a significant difference in the height of the foramen between groups at three months post-surgery(18.1 ± 2.3 mm vs. 16.9 ± 1.9 mm, P = 0.04). At 24 months post-surgery, the ODI was 12.65 ± 3.6 in group A and 19.1 ± 3.4 in group B (P = 0.01). Twelve months after surgery, the fusion rate in group A at 72.0% and 78.6% in group B was not statistically significant (P = 0.75). Fusion was identified in all patients at 24 months post-surgery.

Conclusion

When compared to PPSF, ASRSF combined with OLIF for DLS can reduce post-operative low back pain in the initial stages, maintain the height of the foramen and improve the performance of lumbar function.

Is the anterior approach suitable for laparoscopic right hemihepatectomy in patients with large HCC (5-10 cm)? A propensity score analysis

BACKGROUND

Right hemihepatectomy via the anterior approach was initially employed to improve the survival of patients with large hepatocellular carcinoma (HCC). To date, the safety and feasibility of laparoscopic right hemihepatectomy via the anterior approach (ALRH) for patients with large HCC remains unclear; thus, we compared short-term and long-term outcomes between ALRH and open right hemihepatectomy via the anterior approach (AORH).

METHODS

161 patients with HCC who met the inclusion and exclusion criteria in our department were enrolled in this study between January 2015 and August 2018. Perioperative and oncological outcomes were compared using propensity score matching analysis (PSM).

RESULTS

There were 45 patients in the ALRH group and 116 patients in the AORH group. After 1:3 PSM, 40 ALRH patients and 95 AORH patients were well matched. The intraoperative time was longer in the ALRH group than in the AORH group after PSM (median, 297.5 vs. 205 min, P < 0.001). However, ALRH led to less intraoperative blood loss than AORH after PSM (median, 265 vs. 350 ml, P = 0.049). The rates of overall complications (12.5% vs. 30.5%, P = 0.028) in the ALRH group were significantly lower than those in the AORH group after PSM. Moreover, the survival outcomes were equivalent between the two groups with regard to 1-, 3-, and 5-year overall survival rates (P = 0.698) and disease-free survival rates (P = 0.510).

CONCLUSION

ALRH could be safe and feasible for some patients with large HCCs (5-10 cm) when performed by experienced surgeons, and it had superior perioperative outcomes and equivalent oncological outcomes to AORH.