Surgical Approaches to Petrous Apex Cholesterol Granulomas: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the outcomes of different surgical approaches to petrous apex cholesterol granulomas (PACG).

DATA SOURCES

PubMed, Embase, Google Scholar, Cochrane, and Web of Science.

REVIEW METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Network Meta-analyses guidelines, databases were searched from inception to November 31, 2022. Studies comparing two or more approaches were included. Reviews and population studies were excluded. The main outcome measures were the resolution of symptoms, serviceable hearing, complication, and revision rates.

RESULTS

The search yielded 2132 studies. After applying inclusion and exclusion criteria, 15 studies remained, consisting of 214 patients treated with lateral approaches (n = 182) or anterior endonasal approaches (n = 32). The efficacy of lateral and anterior endonasal approaches in achieving symptom resolution was comparable (73% vs. 68%, p = 0.5). Both exhibited similar rates of complications (33% vs. 37%, p = 0.3), albeit with distinct profiles. Lateral approaches were associated with higher rates of facial palsy and sensorineural hearing loss (44% vs. 18%, p = 0.03). Anterior endonasal approaches demonstrated higher rates of epistaxis and cerebrospinal fluid leak (15% vs. 1%, p = 0.001). Anterior endonasal approaches exhibited lower revision rates (OR: 0.35, 95% CI: 0.14-0.88). The placement of a stent in both approaches was associated with higher symptom resolution (OR: 5.12, 95% CI: 1.05-9.97) and lower revision rates (OR: 0.71, 95% CI: 0.33-0.92).

CONCLUSIONS

Anterior endonasal approaches yield lower revision rates compared to lateral approaches for PACG. Both approaches demonstrate similar effectiveness in symptom resolution and comparable rates of complications, with distinct profiles. Facial nerve and hearing status are important factors that should be addressed when selecting the approach. Stenting is beneficial.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1540-1550, 2024.

Further investigation of the lateral approach for the resection of Knosp grade 4 pituitary adenomas in endoscopic endonasal surgery

OBJECTIVE

The authors performed a further in-depth study of the lateral compartment of the cavernous sinus (LCCS) by the endoscopic endonasal approach to improve the safety and efficacy of the lateral approach for the removal of Knosp grade 4 pituitary adenomas (KG4PAs).

METHODS

Twenty-three cadaveric specimens were used for endoscopic endonasal dissection, and the LCCS was exposed to observe the neurovascular and fibrous structures within. A subclassification of the lateral approach based on further knowledge of the LCCS was proposed and used to resect 86 KG4PAs, and the surgical outcomes of these cases were reviewed. Type A KG4PAs represent tumor that was mainly distributed in the posterosuperior and superolateral compartments, type B KG4PAs represent tumor that was mainly distributed in the anteroinferior compartments, and type AB KG4PAs represent tumor that extended into each compartment with characteristics of types 4A and 4B.

RESULTS

The authors identified multiple fibers that anchored the horizontal segment of the internal carotid artery (ICA) to the abducens nerve. The fibers, the sympathetic nerve, and the inferior lateral trunk form a partition-like structure in the LCCS named the abducens nerve-ICA complex (AIC), and the LCCS can be divided into the superolateral and inferolateral compartments by the AIC. Accordingly, the lateral approach was subclassified into the lateral superior (LS) approach and the anterior inferior (AI) approach. The LS approach was mainly used to resect type A KG4PAs, whereas the AI approach was used to resect type B KG4PAs, and a combination of the two was used to resect type AB KG4PAs. The gross-total, subtotal, and partial resection rates were 81.4%, 12.8%, and 5.8%, respectively. The numbers of cases of postoperative transient cranial nerve palsy, postoperative permanent cranial nerve palsy, ICA injury, and CSF leakage were 6 (6.9%), 2 (2.3%), 1 (1.2%), and 1 (1.2%), respectively.

CONCLUSIONS

This study revealed that the LCCS is divided by the AIC into the superolateral and inferolateral compartments, avoiding the misconception that the LCCS has vertical communication. Therefore, the lateral approach was subclassified into the LS approach and the AI approach for the resection of KG4PAs, which allowed a high gross-total resection rate with acceptable safety in the surgical treatment of KG4PAs.

Sequential Depth Stimulation Within the Psoas Offers No Benefit for Localization of the Lumbar Plexus During Lateral Lumbar Fusion Surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

In this study we aim to assess the difference in triggered EMG readings throughout different depths in the psoas muscle during the lateral approach to the lumbar spine and their effect on surgeon decision making.

METHODS

Three surgeons, practicing at different institutions, assessed triggered EMG readings during the trans psoas approach at the level of the disc and 5,10 and 15 millimeters into the psoas muscle with sequential dilators. Measurement of distance into the psoas muscle was done with a specially designed instrument. Results of anterior and posterior directed stimulation as well as the delta value between these were recorded and underwent statistical analysis. Patients who had partial readings were excluded from the study.

RESULTS

A total of 40 levels in 35 patients were included in the study. There was no significant difference found between means of anterior or posterior threshold readings along the different distance groups. A significant difference was found (P = .024) in the mean difference between the distance groups with a decrease in the difference between anterior and posterior threshold values found as the distance from the disc space increased. None of the surgeons reported a decision to abort the fusion of a spinal level.

CONCLUSIONS

In the trans-psoas approach to the lumbar spine, the assessment of the location of the femoral nerve using directional neuromonitoring when advancing in the psoas muscle shows no clear benefit as opposed to stimulating solely when adjacent to the disc space.

Biomechanics and finite element analysis comparing posterior T-plates with LCP for fixation of posterolateral tibial plate fractures

Objective: The treatment for posterolateral tibial plateau fractures (PTPF) have been subjects of controversy. We conducted a study to improve the fixation of PTPF through a lateral approach. Methods: We utilized 40 synthetic tibias and categorized the fracture models into five groups based on the locking compression plate (LCP) and T-distal radius plate (TPP) via various forms of fixation with screws through the posterolateral (PL) fracture fragments. I: Two-screw fixation using two locking screws (LPTL). Ⅱ: Two-screw fixation with both variable angle locking screws (LPTV). Ⅲ: One-screw fixation with one locking screw (LPOL). Ⅳ: One-screw fixation with one locking screw and two anteroposterior lag screws (LPOLTL). Ⅴ: a distal radius plate with three locking screws (TPP). Biomechanical tests were conducted to observe the axial compression displacement of the PL fracture fragments at force levels of 250 N, 500 N, and 750 N, as well as to determine the failure load and the axial stiffness for each respective group. Results: Under a 750 N load condition, the displacements within the five experimental groups exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. However, there were no significant differences between Group V and Group II, Group I and Group IV (p > 0.05), and only Group Ⅲ demonstrated a displacement exceeding 3 mm. The failure load and the axial stiffness exhibited the same trend. Conversely, statistical significance was identified among the remaining group compared with Group Ⅲ (p < 0.05). Regarding the finite element analysis, the maximum displacements for the five models under the load of 750 N exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. The following trends were observed in maximum von Mises stresses for these models under the load of 750 N: Ⅴ < Ⅱ < Ⅳ< Ⅰ < Ⅲ. Conclusion: It is crucial to address the inadequate mechanical strength associated with single screw fixation of LCP for fixing PL fractures in a clinical setting. The biomechanical strength of two-screw fixation surpasses that of single-screw fixation. Introducing variable-angle screws can further enhance the fixation range. Furthermore, the addition of two lag screws threaded from anterior to posterior can compensate the mechanical stability, when PL fracture is fixed with single screw in clinic.

Robot-Assisted Radical Prostatectomy by Lateral Approach: Technique, Reproducibility and Outcomes

BACKGROUND

Radical prostatectomy by lateral approach allows performing a prostatectomy through a buttonhole, with direct access to the seminal vesicle and fully sparing the anterior pubovesical complex. Our aim is to show the results of reproducing the technique of robotic radical prostatectomy by lateral approach, in terms of intraoperative, postoperative, oncological and functional parameters.

METHODS

We analyzed 513 patients submitted to robotic radical prostatectomy by lateral approach from January 2015 to March 2021, operated on by two surgeons in our institution. The oncological and functional results of both surgeons were compared.

RESULTS

When comparing both surgeons, the rate of positive surgical margins (PSM) was 32.87% and 37.9% and significant surgical margins (PSM > 2 mm) were 5.88% and 7.58% (p = 0.672) for surgeon 1 and surgeon 2, respectively. Immediate continence was 86% and 85% and sexual potency at one year 73% and 72%, with a similar rate of complications for surgeon 1 and 2.

CONCLUSIONS

Radical prostatectomy by the lateral approach technique with preservation of the anterior pubovesical complex is reproducible and offers good oncological and functional results.

The Effectiveness and Practicality of a Novel Barrier Membrane for the Open Window in Maxillary Sinus Augmentation with a Lateral Approach, with Risk Indicators for Bone Graft Displacement and Bone Height Decrease: A Prospective Study in Humans

Maxillary sinus augmentation with a lateral approach (MSA) is a well-established treatment. In this prospective study, we evaluated risk factors for postoperative bone graft displacement and reported the clinical application of long-term resorbable L-lactic acid/-caprolactone (PLA/PCL) as a barrier membrane to cover the open window in the lateral wall in MSA. Twenty-four patients underwent MSA according to the relevant criteria; CT data obtained before and 1 week (1 w) and 5-6 months (5 m) post-MSA, bone height changes, bone height reduction rates at 1 w and 5 m post-MSA, bone graft displacement measurements, and risk factors were examined. All patients showed bone height increments (p < 0.005). However, no difference was observed between 1 w and 5 m post-MSA. Bone graft displacement was observed in eight patients; the reduction rate from 1 w to 5 m post-MSA was 8.38% ± 4.88%. Sex, septa, maxillary sinus floor-palatal bone distance, and maxillary sinus floor-maxillary ostium distance were associated with bone graft displacement (p < 0.05). The height from the maxillary sinus floor to the palatal bone and the sinus angle influenced the augmentation degree (p < 0.05). The PLA/PCL membrane is compared favorably with other membranes and may be useful as a barrier membrane for the MSA open window.

Surgical Approach Does Not Affect Chronic Opioid Usage After Total Hip Arthroplasty

BACKGROUND

Three different surgical approaches (the direct anterior, antero-lateral, and posterior) are commonly used for total hip arthroplasty (THA). Due to an internervous and intermuscular approach, the direct anterior approach may result in less postoperative pain and opioid use, although all 3 approaches have similar outcomes 5 years after surgery. Perioperative opioid medication consumption poses a dose-dependent risk of long-term opioid use. We hypothesized that the direct anterior approach is associated with less opioid usage over 180 days after surgery than the antero-lateral or posterior approaches.

METHODS

A retrospective cohort study was performed including 508 patients (192 direct anterior, 207 antero-lateral, and 109 posterior approaches). Patient demographics and surgical characteristics were identified from the medical records. The state prescription database was used to determine opioid use 90 days before and 1 year after THA. Regression analyses controlling for sex, race, age, and body mass index were used to determine the effect of surgical approach on opioid use over 180 days after surgery.

RESULTS

No difference was seen in the proportion of long-term opioid users based on approach (P = .78). There was no significant difference in the distribution of opioid prescriptions filled between surgical approach groups in the year after surgery (P = .35). Not taking opioids 90 days prior to surgery, regardless of approach, was associated with a 78% decrease in the odds of becoming a chronic opioid user (P < .0001).

CONCLUSION

Opioid use prior to surgery, rather than THA surgical approach, was associated with chronic opioid consumption following THA.

Case Report: A spinal infection with bilateral psoas abscesses was treated with NPWT to enhance the local infection by increasing the infiltration of neutrophil cells and draining the pus

Treatment of spinal brucellosis with bilateral psoas abscess is a challenging clinical endeavor. We retrospectively evaluated a case of lumbar infection and bilateral psoas abscess, and was effectively managed through a unilateral extreme lateral approach with the aid of NPWT for bilateral drainage. We hypothesize that NPWT can influence the Piezo1 receptor of neutrophils and further influence the interaction between neutrophils and endothelial cells to promote the clearance of infected lesions, and this phenomenon is also observed in pathological slides. This proves that NPWT can rapidly enhance the recruitment of neutrophils in the infected area and improve the local immune response, and after a year of reassessment and tracking, Bilateral drainage using NPWT via a unilateral Extreme Lateral Approach could acquire satisfactory surgical outcomes, can be used as a treatment modality for lumbar infection with bilateral psoas abscesses.

Evaluation of Total Hip Arthroplasty Performed from a Lateral Approach as Optimal Treatment for Femoral Neck Fractures in Elderly, Active Patients

BACKGROUND

The aim of the study was to evaluate total hip arthroplasty in terms of clinical and functional outcomes, rate of complications and hospitalization, as a treatment of choice for displaced femoral neck fractures.

MATERIALS AND METHODS

We retrospectively reviewed the data of 526 patients with THA operated on in our department between January 2017 and December 2021. Clinical examinations, functional outcome assessment and radiographic evaluation were performed during follow-up. Patients were evaluated at the following time points: postoperatively at 3 days, 6 weeks, 12 weeks and 1 year, and we recorded surgery related data, complications, Visual Analogue Scale pain score, Harris Hip Score, the Western Ontario McMaster Osteoarthritis Index, and range of motion.

RESULTS

Low intraoperative blood loss, short surgical time, short hospitalization, early mobilization of the patient and a good range of motion testify that the modified direct lateral approach is a valuable procedure for the patients with THA. A VAS score evaluated at 3 days and 6 weeks indicated a very good overall postoperative experience. The HHS and Womac scores were evaluated at 6 weeks, 12 weeks and 1 year and showed excellent results.

CONCLUSION

THA for active patients with a displaced fracture of the femoral neck is an excellent treatment option which provides lasting pain relief, a high level of function and very low rates of reoperation.

Does Surgical Approach Influence Complication Rate of Hip Hemiarthroplasty for Femoral Neck Fractures? A Literature Review and Meta-Analysis

Background: Femoral neck fractures are an epidemiologically significant issue with major effects on patients and health care systems, as they account for a large percentage of bone injuries in the elderly. Hip hemiarthroplasty is a common surgical procedure in the treatment of displaced femoral neck fractures. Several surgical approaches may be used to access the hip joint in case of femoral neck fractures, each with its own benefits and potential drawbacks, but none of them has consistently been found to be superior to the others. This article aims to systematically review and compare the different approaches in terms of the complication rate at the last follow-up. Methods: an in-depth search on PubMed/Scopus/Web of Science databases and a cross-referencing search was carried out concerning the articles comparing different approaches in hemiarthroplasty and reporting detailed data. Results: A total of 97,576 hips were included: 1030 treated with a direct anterior approach, 4131 with an anterolateral approach, 59,110 with a direct lateral approach, and 33,007 with a posterolateral approach. Comparing the different approaches, significant differences were found in both the overall complication rate and the rate of revision surgery performed (p < 0.05). In particular, the posterolateral approach showed a significantly higher complication rate than the lateral approach (8.4% vs. 3.2%, p < 0.001). Furthermore, the dislocation rate in the posterolateral group was significantly higher than in the other three groups considered (p < 0.026). However, the posterolateral group showed less blood loss than the anterolateral group (p < 0.001), a lower intraoperative fractures rate than the direct anterior group (p < 0.035), and shorter mean operative time than the direct lateral group (p < 0.018). Conclusions: The posterolateral approach showed a higher complication rate than direct lateral approach and a higher prosthetic dislocation rate than the other three types of surgical approaches. On the other hand, patients treated with posterolateral approach showed better outcomes in other parameters considered, such as mean operative time, mean blood loss and intraoperative fractures rate. The knowledge of the limitations of each approach and the most common associated complications can lead to choosing a surgical technique based on the patient's individual risk.

Approaches for Total Hip Arthroplasty: A Systematic Review

These surgical procedures have their own challenges, limitations, and success rate. The choice of surgical approach will depend on many factors including the surgeon's choice, type of pathology, bone stock, age of the patient, and experience of the surgeon. Whichever approach is used for total hip arthroplasty (THA), the primary goals of the surgery would be pain relief and enhancement in the quality of the patient's life suffering from hip pathologies. To further understand the advantages and potential pitfalls associated with different surgical approaches, we conducted a review study comparing different surgical approaches for THA in terms of their clinical and functional outcomes. All the studies done on surgical approaches used in THA published articles in the English language and from 2015 onward were included in the review. The databases searched were COCHRANE, MEDLINE, PEDRO, CINHAL, etc. Search engines that were searched were Google Scholar, Pub Med, and Science Direct. As per the inclusion criteria, out of 50 studies, 26 studies were included in the study which underwent critical analysis. Considering all the factors reviewed from the literature, the posterior approach or posterolateral approach is optimally beneficial.

Long-term follow-up results of surgically treated patients with foraminal and far lateral disc herniations

PURPOSE

Foraminal and far lateral disc herniations are rarer cause of nerve root compression. There are reports regarding the outcome, however long-term follow-up results of surgically treated patients are few. The purpose of this retrospective study is to analyze the clinical characteristics and long-term surgical outcomes of the foraminal and far lateral disc herniations.

MATERIALS AND METHODS

The 114 patients who underwent an operation for foraminal and far lateral disc herniaitions were reviewed. Visual analogue scale of back and leg pain, the ocurrence of motor deficit and sensory dysesthesia before and after operations were used to compare the results of early and long-term outcome.

RESULTS

A total of 114 telephone interviews were conducted. The mean follow up was 134 months. Complete relief of symptoms were reported by 77 patients (67.1%). The average VAS of radicular leg pain was 7.5 Post-operatively the average VAS of radicular pain decreased to 2.2. Preoperatively, 9 patients (7.6%) had motor deficit and 17 (14.4%) patients had sensory dysesthesia. Post-operatively 9 (100%) of the patients showed motor, and 12 (70.6%) of the patients showed sensory improvement. In 17 patients with hypoesthesia the complaints continued during 2 weeks to 6 months. They were given gabapentin as medical treatment, however 5 of these patients still have sensory dysesthesia. The outcome was: 67.1% excellent (77 patients), 26.3% good (30 patients), 6.1% fair (7 patients).

CONCLUSION

The far lateral approach is a minimally invasive and safe procedure with low complication rates.

The Prone Lateral Approach for Lumbar Fusion-A Review of the Literature and Case Series

Lateral lumbar interbody fusion is an evolving procedure in spine surgery allowing for the placement of large interbody devices to achieve indirect decompression of segmental stenosis, deformity correction and high fusion rates through a minimally invasive approach. Traditionally, this technique has been performed in the lateral decubitus position. Many surgeons have adopted simultaneous posterior instrumentation in the lateral position to avoid patient repositioning; however, this technique presents several challenges and limitations. Recently, lateral interbody fusion in the prone position has been gaining in popularity due to the surgeon's ability to perform simultaneous posterior instrumentation as well as decompression procedures and corrective osteotomies. Furthermore, the prone position allows improved correction of sagittal plane imbalance due to increased lumbar lordosis when prone on most operative tables used for spinal surgery. In this paper, we describe the evolution of the prone lateral approach for interbody fusion and present our experience with this technique. Case examples are included for illustration.

Surgical Strategy for Hemispherotomy

Hemispherotomy is a radical treatment for drug-resistant epilepsy that targets developmental, acquired, and progressive diseases with widespread epileptogenic regions in one cerebral hemisphere. Currently, two main approaches are utilized after repeated improvements: lateral and vertical approaches. With the lateral approach, the surgical field is wide, and the approach to the lateral ventricle is relatively easy. On the other hand, the vertical approach has the advantage of reducing intraoperative bleeding and operating time as the resection line of the radial fiber is short, and understanding the three-dimensional anatomy is relatively easy. The lateral approach is generally used for atrophic lesions, whereas the vertical approach is for hypertrophic lesions. Hemispherotomy is expected to not only suppress epileptic seizures but also improve psychomotor development by protecting the unaffected cerebral hemisphere. However, this method is one of the most invasive surgeries in epilepsy surgery, and it is important to fully consider its indications. Furthermore, understanding the neural fiber pathway is important for actual surgery.

Lateral approach for insertional Achilles tendinitis with Haglund deformity

Objective

The study aims to investigate the functional outcome of the lateral approach for insertional Achilles tendinitis (IAT) with Haglund deformity.

Methods

From January 2016 to September 2019, 14 cases of IAT with Haglund deformity that resisted conservative treatment received surgery in our department. A lateral approach was used to debride the bony and soft tissue and reattach the insertion of the Achilles tendon. The Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Score (AOFAS), and Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A) were used to evaluate clinical outcomes.

Result

The mean patient age was 39.57 years at the time of surgery. The mean follow-up was 14.74 months. The mean VAS score significantly decreased from 4.86 ± 0.86 preoperatively to 1.21 ± 1.58 postoperatively (P < 0.001). The mean AOFAS score significantly improved from 66.64 ± 6.23 preoperatively to 90.21 ± 11.50 postoperatively (P < 0.001). The mean preoperative and the last follow-up VISA-A were 66 (range 56.75-69.25) and 86 (range 75.75-97.00) points, respectively (P < 0.05).

Conclusion

The lateral approach was effective and safe for IAT with Haglund deformity. Moreover, the mid-term functional outcome was promising.

Level of Clinical Evidence

IV.

Radiographic comparison of L5-S1 lateral anterior lumbar interbody fusion cage subsidence and displacement by fixation strategy: anterior plate versus integrated screws

OBJECTIVE

The aim of this study was to radiographically compare cage subsidence and displacement between L5-S1 lateral anterior lumbar interbody fusion (ALIF) cages secured with an anterior buttress plate and cages secured with integrated screws.

METHODS

Consecutive patients who underwent L5-S1 lateral ALIF with supplemental posterior fixation by a single surgeon from June 2016 to January 2021 were reviewed. Radiographs were analyzed and compared between the two groups based on the type of fixation used to secure the L5-S1 lateral ALIF cage: 1) anterior buttress plate or 2) integrated screws. The following measurements at L5-S1 were analyzed on radiographs obtained preoperatively, before discharge, and at latest follow-up: 1) anterior disc height, 2) posterior disc height, and 3) segmental lordosis. Cage subsidence and anterior cage displacement were determined radiographically.

RESULTS

One hundred thirty-nine patients (mean age 60.0 ± 14.3 years) were included for analysis. Sixty-eight patients were treated with an anterior buttress plate (mean follow-up 12 ± 5 months), and 71 were treated with integrated screws (mean follow-up 9 ± 3 months). Mean age, sex distribution, preoperative L5-S1 lordosis, preoperative L5-S1 anterior disc height, and preoperative L5-S1 posterior disc height were statistically similar between the two groups. After surgery, the segmental L5-S1 lordosis and L5-S1 anterior disc heights significantly improved for both groups, and each respective measurement was similar between the groups at final follow-up. Posterior disc heights significantly increased after surgery with integrated screws but not with the anterior buttress plate. As such, posterior disc heights were significantly greater at final follow-up for integrated screws. Compared with patients who received integrated screws, significantly more patients who received the anterior buttress plate had cage subsidence cranially through the L5 endplate (20.6% vs 2.8%, p < 0.01), cage subsidence caudally through the S1 endplate (27.9% vs 0%, p < 0.01), and anterior cage displacement (22.1% vs 0%, p < 0.01).

CONCLUSIONS

In this radiographic analysis of 139 patients who underwent lateral L5-S1 ALIF supplemented by posterior fixation, L5-S1 cages secured with an anterior buttress plate demonstrated significantly higher rates of cage subsidence and anterior cage displacement compared with cages secured with integrated screws. While the more durable stability afforded by cages secured with integrated screws suggests that they may be a more viable fixation strategy for L5-S1 lateral ALIFs, there are multiple factors that can contribute to cage subsidence, and, thus, definitive presumption cannot be made that the findings of this study are directly related to the buttress plate.

Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study

Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2−10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student’s t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value—0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression.

METHODS

A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance.

RESULTS

A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m². For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8^o to 48.7^o, while the indirect decompression cohort LL increased 8.9%, from 41.9^o to 45.5^o. Difference in LL improvement between cohorts was insignificant (P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant (P = .053).

CONCLUSIONS

Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.

Perioperative Positioning in Neurosurgery: A Technical Note on Park Bench Positioning for the Obese Patient Using the "Arrowhead" Technique

Complex neurosurgical procedures, such as those traversing the posterior fossa, require optimization of the operative corridor with advanced patient positioning methods. Even seemingly small changes in the location of intracranial mass lesions can require a more dramatic operative trajectory. Modifications of traditional lateral, semi-sitting, and park-bench approaches have been described in the literature to access these lesions; however, technical considerations with respect to enlarged body habitus have yet to be fully explored. Herein, we describe a technique for positioning obese patients in the park bench position, which is referred to as the “Arrowhead technique,” along with a literature review of positional complications and considerations in the setting of obesity.

Percutaneous Transforaminal Endoscopic Decompression for Lumbar Lateral Recess Stenosis

Objective: The aim of this study was to evaluate the treatment efficacy of lateral spinal stenosis through the decompression of the nerve root under a multiple planar endoscope.

Methods: From January 2017 to March 2019, 52 patients with lumbar spinal stenosis or lumbar spinal stenosis combined with intervertebral disc herniation had been treated via transforaminal approach spinal endoscopy. Our study retrospectively analyzed the treatment outcome. All patients experienced complications with different degrees of facet joint hyperplasia and ligamentum flavum hyperplasia and hypertrophy. Some patients suffered disc herniation. All patients were treated with percutaneous transforaminal approach multiple planar endoscopic decompression. The visual analog scale (VAS) and the Oswestry Disability Index (ODI) were compared before and after the operation, as were the horizontal foramen areas of the medial margins of the upper and lower pedicles of the vertebral arch. The treatment effectiveness was evaluated.

Results: VAS and ODI scores were significantly improved at postoperative 3 days, 3 months, 6 months, and the last follow-up (P < 0.05). The area of the intervertebral foramen was 422.5 ± 159.2 mm² preoperatively and 890.8 ± 367.7 mm² postoperatively, the difference was statistically significant (P < 0.05).

Conclusion: Percutaneous transforaminal approach multiple planar endoscopic decompression could achieve an accurate and effective decompression of the lumbar lateral spinal canal. This procedure has good short-term effects, and is especially suitable for elderly patients.

Lateral versus posterior surgical approach for the treatment of supracondylar humeral fractures in children: a systematic review and meta-analysis

Background: Supracondylar humeral fracture (SHF) is the most common type of fracture in children. Moreover, lateral and posterior surgical approaches are the most frequently chosen approaches for open reduction surgery in displaced SHF when C-arm is unavailable. However, previous literature showed mixed findings regarding functional and cosmetic outcomes. Currently, no systematic review and meta-analysis has compared these two procedures.  Methods: Our protocol was registered at PROSPERO (registration number  CRD42021213763). We conducted a comprehensive electronic database search in MEDLINE, EMBASE, and CENTRAL. Two independent reviewers screened the title and abstract, followed by full-text reading and study selection based on eligibility criteria. The quality of the selected studies was analyzed with the ROBINS-I tool. Meta-analysis was carried out to compare the range of motion (functional outcome) and cosmetic outcome according to Flynn's criteria. This systematic review was conducted based on PRISMA and Cochrane handbook guidelines.  Results: Our initial search yielded 163 studies, from which we included five comparative studies comprising 231 children in the qualitative and quantitative analysis. The lateral approach was more likely to result in excellent (OR 1.69, 95% CI [0.97-2.93]) and good (OR 1.12, 95% CI [0.61-2.04]) functional outcomes and less likely to result in fair (OR 0.84, 95% CI [0.34-2.13]) and poor (OR 0.42, 95% CI [0.1-1.73]) functional outcomes compared to the posterior approach. In terms of cosmetic results, both approaches showed mixed findings. The lateral approach was more likely to result in excellent (OR 1.11, 95% CI [0.61-2.02]) and fair (OR 1.18, 95% CI [0.49-2.80]) but less likely to result in good (OR 0.79, 95% CI [0.40-1.55]) cosmetic outcomes. However, none of these analyses were statistically significant (p> 0.05).  Conclusion: Lateral and posterior surgical approaches resulted in satisfactory functional and cosmetic outcomes. The two approaches are comparable for treating SHF in children when evaluated with Flynn's criteria.

Lateral versus posterior surgical approach for the treatment of supracondylar humeral fractures in children: a systematic review and meta-analysis

Background: Supracondylar humeral fracture (SHF) is the most common type of fracture in children. Moreover, lateral and posterior surgical approaches are the most frequently chosen approaches for open reduction surgery in displaced SHF when C-arm is unavailable. However, previous literature showed mixed findings regarding functional and cosmetic outcomes. Currently, no systematic review and meta-analysis has compared these two procedures.  Methods: Our protocol was registered at PROSPERO (registration number  CRD42021213763). We conducted a comprehensive electronic database search in MEDLINE, EMBASE, and CENTRAL. Two independent reviewers screened the title and abstract, followed by full-text reading and study selection based on eligibility criteria. The quality of the selected studies was analyzed with the ROBINS-I tool. Meta-analysis was carried out to compare the range of motion (functional outcome) and cosmetic outcome according to Flynn's criteria. This systematic review was conducted based on PRISMA and Cochrane handbook guidelines.  Results: Our initial search yielded 163 studies, from which we included five comparative studies comprising 231 children in the qualitative and quantitative analysis. The lateral approach was more likely to result in excellent (OR 1.69, 95% CI [0.97-2.93]) and good (OR 1.12, 95% CI [0.61-2.04]) functional outcomes and less likely to result in fair (OR 0.84, 95% CI [0.34-2.13]) and poor (OR 0.42, 95% CI [0.1-1.73]) functional outcomes compared to the posterior approach. In terms of cosmetic results, both approaches showed mixed findings. The lateral approach was more likely to result in excellent (OR 1.11, 95% CI [0.61-2.02]) and fair (OR 1.18, 95% CI [0.49-2.80]) but less likely to result in good (OR 0.79, 95% CI [0.40-1.55]) cosmetic outcomes. However, none of these analyses were statistically significant (p> 0.05).  Conclusion: Lateral and posterior surgical approaches resulted in satisfactory functional and cosmetic outcomes. The two approaches are comparable for treating SHF in children when evaluated with Flynn's criteria.

Lateral versus posterior surgical approach for the treatment of supracondylar humeral fractures in children: a systematic review and meta-analysis

Background: Supracondylar humeral fracture (SHF) is the most common type of fracture in children. Moreover, lateral and posterior surgical approaches are the most frequently chosen approaches for open reduction surgery in displaced SHF when closed reduction fails. However, previous literature showed mixed findings regarding functional and cosmetic outcomes. Currently, no systematic review and meta-analysis has compared these two procedures.  Methods: Our protocol was registered at PROSPERO (registration number  CRD42021213763). We conducted a comprehensive electronic database search in MEDLINE, EMBASE, and CENTRAL. Two independent reviewers screened the title and abstract, followed by full-text reading and study selection based on eligibility criteria. The quality of the selected studies was analyzed with the ROBINS-I tool. Meta-analysis was carried out to compare the range of motion (functional outcome) and cosmetic outcome according to Flynn's criteria. This systematic review was conducted based on PRISMA and Cochrane handbook guidelines.  Results: Our initial search yielded 163 studies, from which we included five comparative studies comprising 231 children in the qualitative and quantitative analysis. The lateral approach was more likely to result in excellent (OR 1.69, 95% CI [0.97-2.93]) and good (OR 1.12, 95% CI [0.61-2.04]) functional outcomes and less likely to result in fair (OR 0.84, 95% CI [0.34-2.13]) and poor (OR 0.42, 95% CI [0.1-1.73]) functional outcomes compared to the posterior approach. In terms of cosmetic results, both approaches showed mixed findings. The lateral approach was more likely to result in excellent (OR 1.11, 95% CI [0.61-2.02]) and fair (OR 1.18, 95% CI [0.49-2.80]) but less likely to result in good (OR 0.79, 95% CI [0.40-1.55]) cosmetic outcomes. However, none of these analyses were statistically significant (p> 0.05).  Conclusion: Lateral and posterior surgical approaches resulted in satisfactory functional and cosmetic outcomes. The two approaches are comparable for treating SHF in children when evaluated with Flynn's criteria.

A novel endoscope-assisted technique for lateral lumbar interbody fusion: feasibility study, technical note, and operative video

The lateral approach to the spine is generally well tolerated, but reports of debilitating injury to the lumbar plexus, iliac vessels, ureter, and abdominal viscera are increasingly recognized, likely related to the lack of direct visualization of these nearby structures. To minimize this complication profile, the authors describe here a novel, minimally invasive, endoscope-assisted technique for the LLIF and evaluate its clinical feasibility. Seven consecutive endoscope-assisted lateral lumbar interbody fusion (LLIF) procedures by the senior authors were reviewed for the incidence of approach-related complications. One patient had a postoperative approach-related complication. This patient developed transient ipsilateral thigh hip flexion weakness that resolved spontaneously by the 3-month follow-up. No patient experienced visceral, urological, or vascular injury, and no patient sustained a permanent neurological injury related to the procedure. The authors' preliminary experience suggests that this endoscope-assisted LLIF technique may be clinically feasible to mitigate vascular, urological, and visceral injury, especially in patients with previous abdominal surgery, anomalous anatomy, and revision operations. It provides direct visualization of at-risk structures without significant additional operative time. A larger series is needed to determine whether it reduces the incidence of lumbar plexopathy or visceral injury compared with traditional lateral approaches.

Extreme Lateral Interbody Fusion for Thoracic and Thoracolumbar Disease: The Diaphragm Dilemma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Complication profiles for lateral approaches to the spine are well established. However, the influence of level of surgery on complication rates and subtypes are less well established. To determine risk factors for complications as determined by level and surgery type in patients undergoing a lateral (retroperitoneal or retropleural approach) to the thoracolumbar spine.

METHODS

All adult patients undergoing a lateral thoracolumbar fusion with or without posterior instrumentation performed at a single institution were identified. Primary outcomes assessed were presence of complication, complication subtype, and need for reoperation. The primary independent variables were spinal level (thoracic, thoracolumbar, or lumbar) and type of surgery (discectomy or corpectomy). Categorical outcomes were compared using chi-square test. Unadjusted and adjusted odds ratios for corpectomy status were calculated to determine risk of complication by level. P < .05 was considered statistically significant.

RESULTS

A total of 165 patients aged 18 to 75 years were identified as having undergone a lateral fusion. Complication rates were 28.6%, 36.4%, and 11% for thoracic, thoracolumbar, and lumbar lateral approach fusions, respectively. Under univariate analysis, patients undergoing lateral approach in the thoracic spine group had significantly higher rates of postoperative complications than those in the lumbar group (P = .005). After adjusting for corpectomy status, there was no difference in complication rates.

CONCLUSIONS

Lateral (retroperitoneal or retropleural) approaches to the thoracic and thoracolumbar spine may be used with complication rates comparable to well-established lumbar approaches. Extent of surgery (corpectomy vs discectomy) rather than level of surgery may represent the primary driver of complications.

Lateral maxillary sinus floor elevation in the presence of a sinus osteoma: A case report

Eventhough the lateral sinus floor elevation is a well-documented procedure, many factors can increase its difficulty. The presence an osteoma can be very challenging and must be managed with caution taking in consideration the lesions's size and extension.

Does surgical approach affect early outcomes following primary total hip replacement in obese patients?

AIM

The aim of this study was to assess whether obese patients undergoing primary total hip replacement (THR) via a posterior approach had superior revision rates and Oxford Hip Scores (OHS) compared to those via a lateral approach.

PATIENTS AND METHODS

This is a retrospective cohort study using prospective data from the New Zealand Joint Registry applying STROBE and RECORD guidelines. Patients undergoing THR since 2010 were stratified by body mass index (BMI) into obese (BMI 30-39 kg/m²), and morbidly obese (BMI ⩾40 kg/m²) groups. All-cause revision rates, and 6-month OHS post-surgery were compared between groups. Multivariate analysis was performed.

RESULTS

12,109 unilateral THRs in obese patients were identified. The mean follow-up was 2.8 years (range 0.01-6.95 years). Univariate analysis in the BMI ⩾ 40 group showed the posterior approach had a significantly lower all-cause revision rate (0.99/100 observed component years (ocys); 95% CI, 0.65-1.44/100 ocys) than the lateral approach (1.71/100 ocys (95% CI, 0.98-2.77/100 ocys), p < 0.05). There was no significant difference in dislocation rates between the surgical approaches. OHS was statistically higher in the posterior approach group in BMI 30-39 patients (p < 0.001) but not clinically significant. Multivariate analysis showed femoral head size significantly influenced all-cause revision rates and mitigated against the increased risk associated with the surgical approach.

CONCLUSION

The choice of surgical approach in obese patients conveys no advantage in overall revision rates in the short-term. Choosing an appropriate size of femoral head may be of greater importance than choice of surgical approach for obese patients in primary THR.

Lateral approach improves surgical access to the superior pole in giant endemic goiters

Background

Surgical management of mega-goiters in endemic areas with extreme iodine deficiency presents unique challenges. Based on our initial 5-year experience (2007 to 2011) operating on mega-goiters in Gitwe, Rwanda, Africa, we modified our technique to a lateral approach which affords better exposure of the superior pole vessels and other vital neurovascular structures, thereby improving safety. We describe this lateral approach technique and review outcomes compared to the standard technique.

Methods

From 2007 to 2019, we have conducted 13 annual surgical missions to low resource setting in Gitwe, Rwanda. Retrospective chart review of surgeries between 2012 and 2019 was performed to study outcomes using standard approach and lateral technique during the same time period.

Results

Over a period of 8 years (2012 to 2019), out of 192 total cases, lateral approach was used in 35 patients. No patient experienced significant intra-operative blood loss requiring transfusion. One patient had a post-operative hematoma requiring surgical intervention. Vocal cord mobility testing by transcutaneous laryngeal ultrasound was implemented in 2016. Of all patients, incidence of vocal cord weakness was 8.0% (11/137 patients tested) with less than 1/3 of these symptomatic. There was no statistically significant difference in vocal cord weakness noted in the two approaches (3/23 in lateral approach and 8/114 in standard approach) by Fisher's exact test (P=0.34).

Conclusions

Lateral approach, by affording optimal exposure of the great vessels and the laryngeal nerves, reduces the risk of bleeding and nerve injury. Furthermore, inferiorly based strap muscle flap provides excellent coverage and cosmetic outcome.

Posterior-Based Approaches to Open Reduction Internal Fixation of Bimalleolar and Trimalleolar Fractures: A Systematic Review and Meta-analysis

Although there is growing evidence supporting posterior-based surgical approaches to open reduction internal fixation (ORIF) of malleolar fractures, the lateral approach still remains the standard of care for this injury. The purpose of this review was to integrate the results of several studies investigating outcomes following posterior-based approaches to the ORIF of malleolar fractures. The literature search was undertaken using PubMed, the Cochrane Library, and Embase. Crude event rates for fracture healing and postoperative complications were calculated. When possible, meta-analyses were conducted to estimate the relative risk of these outcomes between patients treated by posterior-based approaches versus other approaches to ORIF of malleolar fractures. Twenty-two studies were eligible, and 4 studies were included in the meta-analyses. The healing rate was 100% in all patients, regardless of the surgical approach. Overall, 1.26% of patients developed an infection, 0.63% required reoperation, 1.13% experienced aseptic loosening, 5.53% experienced pain after treatment, and 2.52% experienced symptomatic hardware. No malunion or heterotopic ossification was reported in any study. Among patients treated with a posterior-based approach, the most frequently reported complication was infection (2.50%), with lower rates of reoperation and postoperative pain. Patients with trimalleolar fractures experienced slightly poorer outcomes. Patients treated by posterior-based approaches had a significantly increased risk of infection (p = .010) relative to those treated by the lateral approach; patients treated by the lateral approach had a significantly increased risk of pain after surgery (p = .004) and symptomatic hardware (p = .007). This study brought together evidence that posterior-based surgical approaches and non-posterior-based approaches to ORIF are effective in healing malleolar fractures, with significant differences in specific postoperative complications that need to be further explored.

[Application of elbow arthrography through lateral approach in treatment of elbow fractures in infants]

Objective

To evaluate the effectiveness of elbow arthrography through lateral approach in the treatment of elbow fractures in infants.

Methods

The clinical data of 24 infants with elbow fractures admitted between May 2016 and May 2018 were retrospectively analyzed. There were 14 boys and 10 girls with an average age of 1.8 years (range, 2 months to 3 years). The time from injury to admission ranged from 1 hour to 7 days, with an average of 6.7 hours. The preoperative carrying angle was (30.8±4.5)° (range, 24°-41°), and the elbow range of motion was (128.5±4.5)° (range, 125°-134°). Elbow arthrography through lateral approach was used in all cases, including 10 cases of humeral lateral condylar fracture, 6 cases of distal humeral epiphysis fracture, 3 cases of fresh Monteggia fracture, and 5 cases of radial neck fracture. According to fracture types, open reduction with Kirschner wire fixation, closed reduction with plaster cast fixation, or closed reduction with percutaneous Kirschner wire fixation were used.

Results

None of the children had adverse reactions such as drug allergy. All patients were follow-up 14-38 months, with an average of 19.6 months. The skin irritation around the needle tail occurred in 2 cases after operation, and the symptoms disappeared after the Kirschner wire was pulled out. The anteroposterior and lateral X-ray films of elbow joint showed that the fractures healed well and no mulunion at the fracture site or premature epiphysis closure was observed. At last follow-up, the carrying angle was (5.2±1.9)° (range, 2°-8°) and the elbow range of motion was (137.1±4.7)° (range, 133°-141°), which were significantly improved when compared with those before operation ( t=22.670， P=0.000； t=11.910， P=0.000). According to Flynn clinical function evaluation standard of elbow joint, 22 cases were excellent, 1 case was good, and 1 case was fair. The excellent and good rate was 95.8%.

Conclusion

Elbow arthrography through lateral approach can clearly judge the cartilage damage of the elbow joint surface in infants, and minimize the occurrence of misdiagnosis and missed diagnosis, and can guide the choice of treatment.

Direct Lateral Minimally Invasive Approach for Excision of a L1/L2 Neurofibroma-A Technical Note and Literature Review

A case of resection of a large dumbbell-shaped nerve sheath tumor at L1/L2 via a direct lateral minimally invasive approach is described. The tumor was removed via a lateral, subdiaphragmatic, rib-sparing, retropleural, retroperitoneal approach. The thoracolumbar junction can be challenging via the lateral approach and to the best of our knowledge this is the first report of excision of a paravertebral tumor via this approach. We believe this provided the benefits of direct operative trajectory and exposure, excellent tumor access, and avoided the need for facetectomy and extended spinal instrumentation across the thoracolumbar junction. Complete tumor excision was achieved with preserved motor function and improvement in radicular pain and sensory neurological deficit.

Mini-open lateral retropleural/retroperitoneal approaches for thoracic and thoracolumbar junction anterior column pathologies

OBJECTIVE

Advancements in less invasive lateral retropleural/retroperitoneal approaches aim to address the limitation of posterolateral approaches and avoid complications associated with anterior open thoracotomy or thoracoabdominal approaches.

METHODS

Consecutive patients treated with a mini-open lateral approach for thoracic or thoracolumbar anterior column pathologies were analyzed in a retrospective case series including clinical and radiographic outcomes. Special attention is given to operative techniques and surgical nuances.

RESULTS

Eleven patients underwent a mini-open lateral retropleural or combined retropleural/retroperitoneal approach for thoracic or thoracolumbar junction lesions. Surgical indications included chronic fracture/deformity (n = 5), acute fracture (n = 2), neoplasm (n = 2), and osteomyelitis (n = 2). The mean length of postoperative hospital stay was 7.2 days (range 2-19 days). All patients ultimately had successful decompression and reconstruction with a mean follow-up of 16.7 months (range 6-29 months). Axial back pain assessed by the visual analog scale improved from a mean score of 8.2 to 2.2. Complications included 1 patient with deep venous thrombosis and pulmonary embolism and 1 with pneumonia. One patient developed increased leg weakness, which subsequently improved. One patient undergoing corpectomy with only lateral plate fixation developed cage subsidence requiring posterior stabilization.

CONCLUSIONS

Mini-open lateral retropleural and retroperitoneal corpectomies can safely achieve anterior column reconstruction and spinal deformity correction for various thoracic and thoracolumbar vertebral pathologies.

Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Total Knee Arthroplasty for Valgus Deformity via a Lateral Approach: Clinical Results, Comparison to Medial Approach, and Review of Recent Literature

BACKGROUND

Total knee arthroplasty (TKA) for valgus deformity is a challenge. The standard medial parapatellar approach may not be universally useful for this. We have adopted the lateral approach to valgus knees. Here we describe our experience with this approach, present early results, and compare them to the medial approach.

METHODS

Our institutional registry was queried for all patients with valgus deformity who underwent a TKA via a lateral approach between 2013 and 2016. The registry was also queried for patients with valgus deformity who underwent a TKA through a medial approach in previous years and this data was compared to the study group.

RESULTS

Seventy-nine valgus knees in 72 patients were operated through a lateral approach. Deformity was corrected by 10.8°, from 16.2° to 5.4° (P < .001). Patellar tilt improved from -2.3° to 0.3° (P = .037). Seven implants (9%) were constrained. Mean operating time was 87 minutes (range 53-137). Twenty-five knees in 23 patients were operated via the medial approach. Deformity was corrected by 7.3°, from 13.2° to 5.9° (P < .001). Mean operating time was 137 minutes (range 90-230). Constrained implants were used in 16% of cases. The lateral approach allowed better correction of valgus deformity (10.8 vs 7.3, P = .03) and shorter operative times (87 vs 137 minutes, P < .001).

CONCLUSION

A lateral approach TKA for valgus deformity improves knee alignment and patellar tilt. Compared to the medial approach, it allows better correction of the deformity, shorter operating times, and perhaps less use of constrained implants.

Open reduction and internal fixation of Gustilo type-I and type-II open pilon fractures using a lateral approach

BACKGROUND

Traditional anteromedial incision for pilon fractures would further increase the damage to the subcutaneous tissues anterior and medial to tibia. In this study, we retrospectively evaluated the method and the outcomes of lateral approach for surgical treatment of Gustilo type-I and type-II open pilon fractures with medial soft tissue injuries.

METHODS

From May 2014 to September 2017, 35 patients with Gustilo type-I and type-II open pilon fractures were treated with standard protocol using a lateral approach. The initial wound debridement and application of a spanning external fixator or traction of calcaneal tubercle were performed within 24 h and a definitive fixation was performed when the wound was healed. The mean time from primary surgery to definite surgery was 11.8 (range: 8-16) days. Postoperative radiographs, complications, bone union, and American Orthopedic Foot and Ankle Society (AOFAS) ankle/hind foot score were recorded.

RESULTS

The mean follow-up period was 17 months (range: 13-23). The average time to bone union was 22 weeks (range: 18-25). In 35 patients, 2 patients had a superficial wound infection and another 1 patient showed limitation of ankle joint motion. No cases of deep infection, skin necrosis, and symptomatic implant reported. The mean AOFAS score was 89.8 (range: 84-95). On final outcome, 25 patients come under excellent and 10 patients had good result.

CONCLUSION

From the results of this study, we can conclude that the lateral approach to treat Gustilo type-I and type-II open pilon fractures was a safe option with a low complication rate. On the other hand, it provides sufficient exposure to restore anatomic articulation, which is worthy of clinical recommendation.

Long-term effectiveness of maxillary sinus floor augmentation: A systematic review and meta-analysis

AIM

To assess the long-term effectiveness (≥5 years) of maxillary sinus floor augmentation (MSFA) procedures applying the lateral window technique and to determine possible differences in outcome between simultaneous and delayed implant placement, partially and fully edentulous patients and grafting procedures.

MATERIALS AND METHODS

MEDLINE (1950-May 2018), EMBASE (1966-May 2018) and Cochrane Central Register of Controlled Trials (1800-May 2018) were searched. Inclusion criteria were prospective studies with follow-up ≥5 years and a residual bone height ≤6 mm. Outcome measures included implant loss, peri-implant bone level change, suprastructure survival, patient-reported outcome measures and overall complications. Data were pooled and analysed using a random effects model.

RESULTS

Out of 2,873 selected articles, 11 studies fulfilled all inclusion criteria. Meta-analysis revealed a weighted annual implant loss of 0.43% (95% CI: 0.37%-0.49%). Meta-regression analysis did not reveal significant differences in implant loss neither between edentulous and dentate patients nor implants placed simultaneously with or delayed after MSFA, nor implants placed in MSFA using solely autologous bone or bone substitutes. The results of the other outcome measures were favourable, and overall complications were low.

CONCLUSION

MSFA is a reliable procedure in the partially and fully edentulous maxilla for support of dental implants.

Risk factors in lateral window sinus elevation surgery

Maxillary sinus augmentation is the most predictable of the pre-prosthetic surgical procedures. There are, however, known and well-documented complications that can and do occur. The most common are the intraoperative complications of sinus membrane perforation and bleeding, and the postoperative complications of sinus graft infections, sinus infections, and sinusitis. The majority of these complications can be prevented, or their incidence greatly reduced, through a thorough understanding of maxillary sinus anatomy, the multifaceted etiologies of these conditions, and the steps that can be taken to avoid them. This volume of Periodontology 2000 will discuss both the preoperative and intraoperative procedures that will prevent these untoward outcomes and the necessary treatment modalities that will limit their adverse effects.

Laparoscopic Adrenalectomy for the Treatment of Isolated Large Adrenal Gland Metastases from Malignant Melanoma: A Case Report

The adrenal gland is a common site for metastatic disease. However, isolated adrenal metastases (AM) are rare. We present a case of a rapidly enlarging adrenal mass with solitary distant metastasis from primary malignant melanoma. To our knowledge, the present case is the largest solitary mass that involves the adrenal gland from malignant melanoma in the literature. The present patient with a large adrenal mass (14 cm) was successfully operated by a transperitoneal laparoscopic approach. The surgeon's laparoscopic experience is more important than the lesion size for laparoscopic indications in selected patients.

Lateral or medial approach for valgus knee in total knee arthroplasty - which one is better? A systematic review

Objective

To identify whether the medial or lateral approach is superior for patients with valgus knees undergoing primary total knee arthroplasty (TKA).

Methods

Studies evaluating the 2 approaches were sourced from the PUBMED, EMBASE, Web of Science, and OVID databases. The quality of included studies was assessed using a modified quality evaluation method, and differences between approaches were systematically reviewed.

Results

Seventeen observational studies were included. The studies were published between 1991 and 2016, and included 5 retrospective studies and 12 prospective studies. Sixteen evaluation methods for the study outcomes were identified. Twelve and eight complication types were identified by studies reporting the lateral and medial approaches for valgus knee, respectively. Several studies showed that pain scores and knee function were superior using a lateral approach.

Conclusion

The lateral approach (combined with a tibial tubercle osteotomy or proximal quadriceps snip) was more useful and safer than the medial approach in the treatment of severe uncorrectable valgus knee deformity in patients undergoing TKA. Most of the available evidence supports the use of a lateral approach provided that the surgeon is familiar with the pathological anatomy of the valgus knee.

A comparison of the effectiveness of lateral versus posterior approach to shoulder injection in patients with subacromial impingement syndrome: A pragmatic randomized controlled trial

OBJECTIVE

The aim of the study was to determine the effectiveness of the lateral approach to subacromial injection, compared with the posterior approach, for the treatment of subacromial impingement syndrome.

METHOD

A pragmatic randomized controlled trial was carried out in an outpatient community musculoskeletal service. The sample comprised 80 adults, aged 18 years or over, with subacromial impingement syndrome. The intervention group received a single subacromial injection, using a 21-gauge green needle, of 40 mg/ml triamcinolone acetonide (Kenalog) and 4 ml 1% lignocaine using a lateral approach. The control group received identical treatment, with the exception that the injection was given using a posterior approach. The outcome measures were pain measured using 0-10 numerical pain scale and shoulder pain and disability index (SPADI) scores at 8 and 12 weeks' follow-up.

RESULT

A moderate but statistically and clinically significant difference in improvement in daytime pain (mean change in score) occurred in favour of the lateral group (mean = 4.0) compared with the posterior group (mean = 2.0) between weeks 0 and 8 (1.4 points [95% confidence interval 0.3, 2.6; p = 0.018]). However, there were no statistically significant differences between the groups in night-time pain, shoulder function and SPADI scores. There was a statistically and clinically significant difference (p = 0.001) within the groups for all clinical outcomes between weeks 0 and 8, and between weeks 0 and 12.

CONCLUSION

There were no significant differences in the treatments; however, both forms of treatment were associated with a significant improvement in shoulder pain, function and disability.

Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication.

METHODS

All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes.

RESULTS

A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days).

CONCLUSIONS

We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.

Report of two cases

Recurrent radiculopathy after anterior cervical discectomy with fusion (ACDF) occurs in approximately 4% of cases. The main obstacles of revision surgery after ACDF via the same approach are scar tissue and arthrodesis. We present two patients with recurrent symptoms after ACDF who underwent revision surgery using an alternative, less invasive lateral approach (LA). These two patients both presented with recurrent unilateral cervical radiculopathy due to progression of intervertebral foraminal stenosis. The second patient also presented with paraparesis of the lower limbs and central stenosis. Anterior foraminotomy in the first case and oblique corpectomy in the second were performed via the LA. The previously implanted interbody cages were left intact and no new fusion procedures were needed. No spinal instability or symptom relapse was observed in follow-up. The lateral approach to the cervical spine enables direct and effective decompression of neural structures without violation of previously achieved interbody fusion.

Lateral versus central tendon-splitting approach to insertional Achilles tendinopathy: a retrospective study

INTRODUCTION

This study aimed to compare operative outcomes between the lateral approach (LA) and the central approach (CA) to insertional Achilles tendinopathy (IAT).

METHODS

We retrospectively reviewed patients who underwent surgical treatment for IAT using the LA or CA. Patients' demographic data, postoperative complications and satisfaction rate were reviewed. Clinical outcomes were prospectively assessed preoperatively, at three months postoperatively and at the last visit, including patients' visual analogue scale (VAS) scores for pain, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores and 36-item Short Form Health Survey (SF-36) scores.

RESULTS

There were 39 patients in the LA group and 32 in the CA group. In each group, average VAS and AOFAS Scale scores improved significantly. SF-36 scores improved in most parameters. No significant difference in baseline score; average AOFAS Scale score at each visit; and mean VAS score preoperatively and at last visit; satisfaction rate; and overall complication rate were observed between the groups. The mean VAS score in the LA group at postoperative three months was significantly lower than that in the CA group (2.7 ± 2.5 vs. 4.4 ± 3.0; p = 0.016). There were significantly more cases of delayed wound healing in the LA group than in the CA group (2.6% vs. 15.6%; p = 0.049).

CONCLUSION

Both approaches had comparable outcomes for IAT in terms of functional improvement, pain relief, overall enhancement of patients' health condition and overall postoperative complication rate. The LA provided better short-term pain relief and reduced delayed wound healing compared with the CA.

Laparoscopic Splenectomy: Postero-Lateral Approach

In paediatric population, the laparoscopic splenectomy has been preferred to the open surgery during the last years. Due to the improvement of the technique and the devices, the indications to the laparoscopic splenectomy have been increased, even though there is still a variety of conditions in which the execution of this technique is arduous. During the preoperative consult there is the need to carefully evaluate the existence of cholecystic lithiasis, the haemoglobin level in patients with SCA, platelet count in children with ITP and the vaccination status. An anterior and a lateral or hanging spleen approach are primarily used for laparoscopic splenectomy. In the last four years, near the Section of Pediatric Surgery of the Department of Pediatrics, Obstetrics and Medicine of the Reproduction of Siena University, 8 cases of splenomegaly have been treated, 7 by lateral videolaparoscopic splenectomy (5 males and 2 females, with medium age of 10,5 years) and 1 by anterior approach (10 years). The advantages shown by these techniques allow the laparoscopic splenectomy to be considered as a valid alternative to the open surgery. In children's laparoscopic splenectomy, the rate of complications is considerably low and the the major problem is the intraoperative hemorrhage. With increasing surgical experience, the minimally invasive approach appears to be superior in terms of faster postoperative recovery, shorter hospital stay, perioperative and postoperative advantages. Therefore, the laparoscopic technique may soon be accepted as the standard method in patients requiring splenectomy.

Clinical and Radiological Outcomes of Transfibular Total Ankle Arthroplasty

BACKGROUND:

Ankle arthritis is a highly limiting pathology that causes pain and functional limitation with subsequent deterioration of quality of life. With recent advances in surgical instrumentation and techniques, prosthetic replacement of the ankle has proven to be a valid alternative to arthrodesis with comparable outcomes. The purpose of this study was to evaluate clinical and radiological findings in a transfibular total ankle replacement with follow-up of at least 2 years.

METHODS:

This prospective study included 89 patients who underwent transfibular total ankle arthroplasty from May 2013 to February 2016. The mean age was 53.2 ± 13.5 years. All patients were followed for at least 24 months postoperatively with an average follow-up of 42.0 ± 23.5 months. Patients were assessed clinically and radiographically preoperatively and at 6, 12, and 24 months postoperatively.

RESULTS:

At 24 months postoperatively, patients demonstrated statistically significant improvement in the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score from 33.8 ± 14.3 to 88.5 ± 6.6 ( P < .001), visual analog scale (VAS) from 80.5 ± 17.0 to 14.1 ± 9.2 ( P < .001), and Short Form-12 Physical and Mental Composite Scores from 29.9 ± 6.7 and 43.3 ± 8.6 to 47.0 ± 7.6 and 53.3 ± 8.1, respectively ( P < .001). In addition, ankle dorsiflexion and plantarflexion improved from 6.2 ± 5.5 and 9.6 ± 5.8 degrees to 24.2 ± 7.9 and 18.1 ± 7.6 degrees, respectively ( P < .001). Radiographically, patients demonstrated maintained neutral alignment of the ankle at 24 months. No patient demonstrated any radiographic evidence of tibial or talar lucency at final follow-up. Seven patients underwent reoperation for removal of symptomatic hardware (6 fibular plates, 1 syndesmotic screw); 2 patients experienced delayed wound healing. The first one was treated with plate removal and flap coverage. The second one required fibular plate removal. One patient developed a postoperative prosthetic infection requiring operative debridement, removal of implants, and placement of an antibiotic spacer.

CONCLUSION:

This study found that transfibular total ankle replacement was a safe and effective option for patients with ankle arthritis resulting in improvements in patient-reported outcomes, range of motion, and radiographic parameters. However, further studies are required to determine the mid- and long-term performance of these implants.

LEVEL OF EVIDENCE:

Level IV, case series.

Surgical Approaches and Hemiarthroplasty Outcomes for Femoral Neck Fractures: A Meta-Analysis

BACKGROUND

The lateral approach (LA), posterior approach (PA), and anterior approach (AA) are conventional surgical access routes for hemiarthroplasty in proximal femoral fractures. This meta-analysis assesses and compares the outcomes and attempts to identify the best approach for hemiarthroplasty in the treatment of proximal femoral fractures.

METHODS

An electronic search was performed from inception to October 25, 2017, for comparative studies including at least 2 of the conventional approaches. Outcomes including operation time, surgical blood loss, perioperative fractures, wound infections, dislocations, and hospital length of stay were plotted in forest plots.

RESULTS

Twenty-one eligible studies were selected including 3 randomized, controlled trials, 7 prospective and 11 retrospective cohort studies. The odds ratio (OR) for dislocations was significantly higher for the PA compared with the AA (OR, 2.61; 95% confidence interval [CI], 1.26 to 5.43; P = .01) and the LA (OR, 2.90; 95% CI, 1.63 to 5.14; P = .0003). The PA had a higher risk of reoperation compared to the AA (OR, 1.25; 95% CI, 1.12 to 1.41; P < .0001). No significant differences were found concerning perioperative fractures, wound infections, and hospital length of stay. Some studies suggest a better short-term functional outcome using the AA compared to the PA.

CONCLUSION

The PA for hemiarthroplasty in proximal femoral fractures poses an increased risk of dislocation and reoperation compared to the LA and AA. There are no evident advantages of the PA and its routine use for fracture-related hemiarthroplasty should be questioned.

Complication Risk in Secondary Thyroid Surgery

Objectives

Secondary thyroid surgery is rare, compared with primary thyroid surgery. However, secondary surgery has a greater risk of complications due to the formation of scar tissue as well as increased fragility of the tissues following the previous surgery. Several surgical techniques and strategies have been recommended to decrease the complication rate associated with secondary surgery. The aim of this study was to evaluate the complication rate in patients who underwent secondary thyroid surgery using a lateral approach and intraoperative nerve monitoring (IONM).

Methods

The data of 44 patients who underwent secondary surgical intervention after thyroid surgery performed for benign or malignant thyroid disease (Group 1), and of 44 patients who underwent primary surgery (Group 2) were compared. Lobectomy patients with a histopathological result of malignant disease, whom were applied completion thyroidectomy were excluded from the study. Secondary surgery was performed using a lateral approach. Access was achieved between the anterior edge of the sternocleidomastoid muscle and the strap muscles. In primary surgery, the thyroid lodge was entered through the midline. Standard IONM was applied in all cases. Hypocalcemia was defined as a serum calcium level of ≤8 mg/dL within the first postoperative 48 hours, regardless of clinical symptoms. Transient and permanent recurrent laryngeal nerve paralysis was evaluated based on the number of nerves at risk. The lobectomy was considered to be high-risk with the presence of recurrence, Graves' disease, substernal goiter, and application of central dissection.

Results

The mean age of Group 1 and 2 was 49.9±14.1 years and 45±12.6 years , respectively (range: 22-90 years; p=0.69). Female patients constituted 90.9% (n=40) of the population in Group 1 and 75% (n=33) of the patient population in Group 2 (p=0.87). In Group 1, 11 (25%) patients, and 7 (15.9%) patients in Group 2 underwent surgical intervention due to the presence of a malignant disease (p=0.29). Bilateral intervention was applied in 26 (59.1%) patients in Group 1 and 28 (63.6%) patients in Group 2. The rate of transient and permanent hypocalcemia in Groups 1 and 2 was 34.1% (n=15) vs 22.5%, and 2.5% (n=1) vs 0%, respectively, without any significant intergroup difference (p=0.237, p=1). In Group 1, 71 lobes were operated on, and there were 72 in Group 2. All of the interventions in Group 1 (100%), and 31.9% (n=23) of those in Group 2 were high-risk, and there was a significant intergroup difference (p<0.0001). The rate of transient and permanent vocal cord paralysis were 4.2% (n=3) vs 2.8% (n=2) and 6.9 % (n=5) vs 0% in Groups 1 and 2, respectively (p=0.719; p=0.245).

Conclusion

When performed with a meticulous and attentive technique, secondary surgical intervention can be applied without increasing the incidence of permanent complications. Though there is substantial risk associated with all of these procedures, the rate of vocal cord paralysis was similar to that seen after primary intervention, and was thought to be related to surgical experience and technique, as well as the use of IONM.

Lateral and Posterior Approaches in Hemiarthroplasty

PURPOSE

Hemiarthroplasty is a common treatment for patient with a fragility displaced femoral neck fracture. We compared lateral and posterior approaches with respect to need for mobility aids, mobility level, living arrangements, pain, hip dislocation, and survival 12 months after hip fracture.

METHODS

A total of 393 fragility femoral neck fracture patients aged 65 years or more who underwent hemiarthroplasty were observed for 12 months. Patient information was collected on admission, during hospitalization, and by telephone interview 1 year after the hip fracture. A total of 269 patients were included in the final analysis.

RESULTS

At 1 year after hip fracture, more patients undergoing hemiarthroplasty with the posterior approach (22%) survived without mobility aids compared to those with the lateral approach (12%; p = 0.026). Multivariate logistic regression analysis revealed that the need for mobility aids 1 year after hip fracture was significantly predicted by the use of mobility aids before the fracture (odds ratio = 13.46, 95% confidence interval = 4.29-42.25), age ≥85 years (odds ratio = 3.85, 95% confidence interval = 1.09-13.44), male sex (odds ratio = 3.59, 95% confidence interval = 1.05-12.22), and lateral approach (odds ratio 2.73, 95% confidence interval 1.15-6.50). The posterior approach resulted in four (3.4%) dislocated hips, compared with none by the lateral approach. Survival, mobility level, pain in the operated hip, and living arrangements 1 year postoperatively were not significantly different between groups.

CONCLUSION

Hemiarthroplasty using a lateral approach predisposed to the need for ambulatory aids 1 year after hip fracture. The posterior approach, however, predisposed to hip dislocation. Patient selection must be considered when deciding the appropriate surgical approach.

Comparison of Posterior Approach With Intramedullary Nailing Versus Lateral Transfibular Approach With Fixed-Angle Plating for Tibiotalocalcaneal Arthrodesis

BACKGROUND

A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. The intramedullary (IM) nail and lateral, fixed-angle plating are commonly used because of ease of use and favorable biomechanical properties. A lateral, transfibular (LTF) approach allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PATS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either a PATS approach with IM nailing or LTF approach with fixed-angle plating.

METHODS

A retrospective review was performed on all patients who underwent simultaneous TTC arthrodesis with minimum 1 year clinical and radiographic follow up. Patients were excluded if they underwent TTC arthrodesis through an approach other than PATS or LTF, and received fixation without an IM nail or fixed-angle plate. Primary outcomes examined were union rate, revisions, and complications. Thirty-eight patients underwent TTC arthrodesis with a PATS approach and IM nailing, and 28 with a LTF approach and lateral plating.

RESULTS

The overall union rate was 71%; 76% (29 of 38 patients) for the PATS/IM nail group, and 64% (18 of 28) for LTF/plating group ( P = .41). Symptomatic nonunion requiring revision arthrodesis occurred in 16% (6 of 38) of the PATS/IM nail group versus 7% (2 of 28) in the LTF/lateral plating group ( P = .45). There were no significant differences in individual tibiotalar or subtalar union rates, superficial wound problems, infection, symptomatic hardware, stress fractures, or nerve irritations.

CONCLUSION

Union, revision, and complication rates were similar for TTC arthrodesis performed with a PATS approach and IM nail compared with an LTF approach and fixed-angle plate in a complex patient population. Both techniques were adequate, especially when prior incisions, preexisting hardware, or deformity preclude options.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Early Complications and Secondary Procedures in Transfibular Total Ankle Replacement

BACKGROUND

A new transfibular total ankle arthroplasty (TAA) system has not been assessed for potential early complications.

METHODS

We retrospectively assessed prospectively collected data on the initial cohort of patients undergoing TAA with this implant. We evaluated visual analog scale (VAS) pain and function, range of motion, and early radiographic outcomes.

RESULTS

Twenty consecutive TAAs (19 patients) were treated with the implant from January 2013 through June 2014. Average patient age was 63.7 (range, 41-80) years, with an average follow-up of 18 (range, 12-27) months. No fibular nonunion or implant failure was found at 12 months postoperatively. One patient had asymptomatic mild tibial lucency. Four of 20 TAAs underwent additional surgery for anterior impingement (1 ankle), deep infection and symptomatic fibular hardware (1 ankle), and symptomatic fibular hardware (2 ankles).

CONCLUSION

Of 20 ankles treated with a new transfibular arthroplasty system, no fibular nonunion, delayed union, or implant failure was noted at 12 months postoperatively. Two complications were resolved with secondary treatment, and 2 other ankles underwent secondary surgery for symptomatic fibular hardware with good outcome. The findings suggest that this total ankle system is safe and effective at short-term follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.