Anterolateral Approach Research Articles

Leg length discrepancy after total hip arthroplasty performed by direct anterior approach: a systematic review comparing surgical approaches and strategies for prevention.

Leg length discrepancy (LLD) is a common complication following total hip arthroplasty (THA). The direct anterior approach (DAA) for THA is gaining popularity due to its advantages, but there is limited research on the incidence and size of LLD. This systematic review aims to explore the differences in LLD between DAA and other approaches, as well as the techniques to control LLD in DAA. A comprehensive literature search was conducted to identify relevant studies comparing THA by DAA with other surgical approaches and investigating methods to control LLD in DAA, following PRISMA guidelines and a priori registration on PROSPERO (CRD42023412644). The quality of the included studies was assessed. Data on preoperative and postoperative LLD and other relevant outcomes were extracted and analyzed descriptively. In total, 29 studies were included in this systematic review. The majority (86%) were classified as level IV evidence. Comparisons between DAA and posterior approach (PA) or anterolateral approach (ALA) showed DAA had lower rates of LLD >10 mm compared to PA and ALA. Different pre- and intra-operative techniques were evaluated, but no consensus on the best method for preventing LLD in DAA was reached. DAA shows comparable or superior results in the prevention of LLD compared to other surgical approaches. Supine patient placement, direct leg measurement, and the use of IF contribute to these outcomes. Intraoperative fluoroscopy with a grid and preoperative planning offers a good option, especially for training purposes, but its role in preventing LLD by experienced DAA surgeons needs further investigation.

A Cadaveric Study: Does Ankle Positioning Affect the Quality of Anatomic Syndesmosis Reduction?

The objective of this study was to compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position). Baseline computed tomography (CT) imaging of 10 cadaveric ankle specimens from 5 donors was obtained with the ankles placed in normal resting position. Two fellowship-trained orthopaedic surgeons disrupted the syndesmosis of each ankle specimen. All ankles were then placed in neutral plantarflexion and were subsequently reduced with thumb pressure under direct visualization through an anterolateral approach and stabilized with one 0.062-inch K-wire placed from lateral to medial in a quadricortical fashion across the syndesmosis. Postreduction CT scans were then obtained with the ankle in normal resting position. This process was repeated with the ankles placed in maximal dorsiflexion during reduction and stabilization. Postreduction CT scans were then obtained with the ankles placed in normal resting position. All postreduction CT scans were compared with baseline CT imaging using mixed-effects linear regression with significance set at P < 0.05. Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared with baseline scans [13.0 ± 5.4 degrees (mean ± SD) vs. 7.5 ± 2.4 degrees, P = 0.002]. There was a tendency toward lateral translation of the fibula with the ankle reduced in maximal dorsiflexion (3.3 ± 1.0 vs. 2.7 ± 0.7 mm, P = 0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion compared with baseline were present (P > 0.05). Reducing the syndesmosis with the ankle in maximal dorsiflexion may lead to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion compared with baseline. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.

The temperature profile in elbow arthroscopy using radiofrequency ablation.

Over the last decades, arthroscopic surgery has become increasingly relevant as its minimally invasive approach offers many benefits. To investigate the risks of orthoscopic surgery at the elbow, this study aimed to investigate the development of temperatures in elbow joints while performing radiofrequency ablation in arthroscopic surgery. We performed standard arthroscopic surgeries with posterolateral, transtricipital and anterolateral approaches on seven cadaveric elbows and performed ablation on predefined locations with or without irrigation. Two temperature probes were positioned into the olecranon fossa and between the ulnar nerve and the medial joint capsule. The temperature data were recorded using a real-time data logger. A bipolar radiofrequency ablation (bRFA) device was used at the medial and lateral recess and in the fossa olecrani over a defined period. Data was then analyzed using Matlab. Using bRFA without irrigation results in rapidly increasing temperature within the joint. A significant temperature increase was found within only 5s without irrigation (p = 0.0052) in the fossa olecrani. We did not observe critical temperatures above 41°C close to the ulnar nerve within 30s under constant irrigation (p = 0.0747). Radiofrequency ablation (RFA) can be safely used in elbow arthroscopy with irrigation. The continuous use without irrigation should be limited to 3s. Despite the anatomical proximity of the ulnar nerve and capsule, we were able to show that a possible rise in temperature most likely does not affect the ulnar nerve.

Anterior Spinal Fusion for Thoraco-Lumbar Idiopathic Scoliosis Comparing Less Invasive Concave versus Traditional Convex Approach: A Pilot Study.

Background/Objectives: Anterior spinal fusion for primary thoracolumbar or lumbar (TL/L) adolescent idiopathic scoliosis, AIS, has advantages over posterior fusion, particularly in saving motion segments below the fusion construct. Traditionally, the approach is anterolaterally from the convexity. In adult degenerative scoliosis, the lateral or anterolateral approach may be performed from the traditional or from the concave approach which is less invasive and gives comparable outcomes. The purpose of the present pilot study was to assess the feasibility of the less invasive concave approach for younger AIS patients and compare it to the traditional convex approach over a 5-year follow-up period. Methods: The two cohorts were assessed by comparing pre- to postoperative radiographs, and clinical outcomes for pain, function, self-perception of appearance, and opinion of surgical success were prospectively obtained. Results: Radiographs found that primary TL/L scoliosis significantly improved from 53° to 18° (65%) for both the concave and convex cohorts. Sagittal alignments remained stable and there was no difference between cohorts. Coronal balance improved in both cohorts and sagittal balance was stable for both. Clinically, VAS back pain improved significantly for both cohorts initially and remained improved in the concave group. Leg pain, pain drawing, ODI disability, and VAS appearance scores improved and there was no difference between cohorts. The self-rating of success of the procedure was 100% at early and late follow-up periods. There were no neurological/surgical complications. Conclusions: The concave approach for anterior fusion for TL/L AIS is feasible with comparable radiographic and clinical outcomes to the traditional approach.

Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury

ObjectivesTo compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery.MethodsThe online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches.ResultsFifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p > 0.05).ConclusionIntramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation.Level of evidenceLevel IV.

Minimally Invasive Lateral Transorbital Approach for Clipping of Right Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video.

The lateral transorbital approach is a minimally invasive approach that was first described for accessing the cavernous sinus.1 Although other minimally invasive approaches have been broadly applied to aneurysm surgery,2 the use of transorbital keyholes for this is still quite rare.3,4 We present a 72-year-old man with an incidentally discovered 5-mm middle cerebral artery aneurysm. Despite a low rupture risk,5 the patient himself opted for treatment, and because of the complex shape of the aneurysm, he chose surgical clipping as the treatment of choice. Two unique aspects of the patient's anatomy brought forth transorbital approach for consideration. He had a wide fissure, which opened to the orbital wall, and a giant frontal sinus made its avoidance difficult with any anterolateral transcranial approach. The lateral transorbital approach was started with a transpalpebral incision.4,6,7 Both wings of the sphenoid bone were drilled until the frontal and temporal dura was exposed. Opening this through the orbit gained direct access to the large Sylvian fissure. Two specific challenges were specific to this opening: the aneurysm dome pointed straight at the surgeon, and the M1 segment, needed for proximal control, was directly behind the aneurysm. Despite these, the aneurysm was successfully eliminated through the transorbital approach with no residual or normal branch compromise. Given the specific anatomical provisions, the lateral transorbital approach was an effective and safety alternative to the pterional approach for middle cerebral artery aneurysms. No Institutional Review Board approval was sought or necessary as the patient provided consent for the procedure, publication of his image, and this submission.

Endoscopy-assisted high cervical anterolateral retropharyngeal approach to clivus: a cadaveric study.

The surgical management of pathologies involving the clivus and craniocervical junction has always been considered a complex procedure because of the deeply located surgical targets and the surrounding complex neural and vascular anatomical structures. The most commonly used approaches to reach this area are the transnasal, transoral, and transcervical approaches. This approach was performed unilaterally on five cadaver heads and bilaterally on one cadaver head. We described a modified endoscope-assisted high cervical anterolateral retropharyngeal approach in which each stage of the procedure was demonstrated on human cadavers in a step-by-step manner using endoscopic camera views. This approach was broken down into nine steps. The neurovascular structures encountered at each step and their relationships with each other are demonstrated. The advantages and disadvantages of our modified approach were compared to the conventional transcervical, transoral, and endoscopic endonasal approaches.

Total Hip Arthroplasty Complications in Sickle Cell Disease: Systematic Review and Meta-Analysis.

Background: Microvascular occlusions caused by sickle-shaped erythrocytes in patients with sickle cell disease (SCD) can lead to increased intraoperative and postoperative complications during total hip arthroplasty (THA). This systematic review and meta-analysis aimed to estimate the overall rate of complications following THA in patients with SCD and to identify the predictors of these complications including the surgical approach. Methods: The search was conducted across the grey literature, Google Scholar, and seven databases: Scopus, MEDLINE Central/PubMed, ProQuest, SciELO, SAGE, and Web of Science. All observational studies reporting the proportional THA complications in SCD were included. The Newcastle-Ottawa Scale quality assessment tool was used to assess the quality of the studies. The random effect model was applied to estimate the pooled outcomes. A sub-group analysis for the different approaches was performed. A sensitivity analysis and meta-regression were used to explain heterogeneity and to identify the THA complication predictors. Results: Of 3230 citations, only 23 studies were eligible for the meta-analysis. The pooled proportion of total primary THA complications in patients with SCD was 42% (95% CI: 30-56%, I2 = 95%). The sub-group analysis highlighted the anterolateral approach as the approach accompanied with the least complications. The meta-regression revealed that the anterolateral approach decreases the complications significantly, -28.67 (95%CI, -56.45--0.88, p = 0.044), while the number of hips increased the complications by 0.43 (95%CI, 0.30-0.57, p < 0.001). Male gender, age, lateral approach, and HbSS non-significantly affect the THA complications in SCD 52.05, 0.18, 6.06, and 55.78, respectively. The pooled proportions for an SCD crisis 9% (95%CI, 5-14%, I2 = 61%), dislocation 4% (95%CI: 2-7%, I2 = 66%), aseptic loosening 12% (95%CI, 7-20%, I2 = 91%), revision 6% (3-11, I2 = 92%), heterotopic ossification 12% (95%CI, 3-35%, I2 = 95%), and prosthetic joint infection (PJI) 6% (95%CI, 3-11%, I2 = 92%). The most fitted model of meta-regression illustrated that HbSS significantly increases PJI, 0.05 (95%CI: 0.02-0.08, p = 0.009), and male gender and age non-significantly increase PJI, 2.28 (95%CI: -4.99-13.56, p = 0.311) and 0.001 (95%CI: -0.27-0.27, p = 0.990), respectively. Meanwhile, the anterolateral, lateral, and posterior approaches non-significantly decrease PJI, -3.55, -0.92, and -1.27, respectively. The pooled proportion for a sickle cell disease crisis after revision was 16% (95%CI: 6-36%, I2 = 0) and for aseptic loosening after revision, it was 24% (95%CI: 12-43%, I2 = 0). Conclusions: This study revealed the high rate of complications in patients with SCD and highlighted that the anterolateral approach was associated with the lowest rate of complications. Furthermore, this study illustrated that homozygous (HbSS) individuals are more susceptible to prosthetic joint infection.

Cementless short stem total hip arthroplasty in patients older than 75 years: is it feasible?

BackgroundIn recent years, the indication for cementless short stem total hip arthroplasty (THA) has been widened to elderly patients as they might profit by the advantages of the short-curved implant design as well. Therefore, this study was conducted to evaluate the clinical and radiological outcome of a cementless short stem in elderly patients (≥ 75 years) compared to a young control group (≤ 60 years).MethodsA retrospective cohort of 316 THAs performed between 2014 and 2017 was prospectively examined. In all patients a cementless, curved short stem and press-fit cup (Fitmore® stem; Allofit®/-S cup; both ZimmerBiomet, Warsaw, IN, USA) were implanted via a minimally-invasive anterolateral approach. Clinical and radiological outcome as well as rate of complications and revision were assessed.ResultsIn total, 292 patients have been included for analysis of complications and revisions (Øfollow-up: 4.5 years) and 208 patients for clinical and radiological outcome (Øfollow-up: 4.4 years). Complication rate was significantly increased in elderly patients (13.7% vs. 5.8%, p = 0.023), while the revision rate was increased without statistical significance (5.2% vs. 2.2%, p = 0.169). Periprosthetic fractures occurred significantly higher in the elderly patients (5.2% vs. 0.7%; p = 0.026). Both groups showed a comparable clinical outcome in the Harris Hip Score (93.7 vs. 91.9; p = 0.224), Oxford Hip Score (44.5 vs. 43.7; p = 0.350), Forgotten Joint Score (81.7 vs. 81.5; p = 0.952) and WOMAC (7.4 vs. 9.3; p = 0.334).ConclusionCementless short stem total hip arthroplasty shows a comparable clinical and radiological outcome in patients over 75 years of age compared to younger patients under 60 years of age. However, cementless shorts stem THA shows an increased rate of overall complications and periprosthetic fractures in elderly patients over 75 years of age. Cemented fixation of the femoral component should be considered in patients over 75 years of age.Level of evidenceIII Case-controlled study.Trial registrationObservational study without need for trial registration due to ICMJE criteria.

Use of a Monopolar Stimulator to Preserve the Frontotemporal Branches of the Facial Nerve During a Pterional Approach: 2-Dimensional Operative Video.

Preservation of the frontotemporal branches of the facial nerve is essential to obtain good cosmetic outcomes after anterolateral cranial base approaches.1,2 Since the description of the interfacial dissection, most nerve injuries are due to retraction of the nerve fibers and not direct transection.3-5 In this video, we showcase the use of a monopolar stimulator to guide the placement of hook retractors and assess no undue retraction is applied to the nerve fibers during a pterional craniotomy. This simple tool can help in preserving frontalis function after anterolateral skull base craniotomies. Institutional review board approval was not required; the patient consented to the procedure and to the publication of his/her image.

Reversed proximal humeral internal locking system (PHILOS) plate for distal humeral shaft fractures through an Anterolateral Approach

Reversed proximal humeral internal locking system (PHILOS) plate for distal humeral shaft fractures through an Anterolateral Approach

Extensor Retinaculum Syndrome of the Ankle: An Adult Case Series.

Extensor retinaculum syndrome (ERS) is a relatively rarely diagnosed compartment syndrome-like entity caused by elevated pressures in the tissues deep to the superior extensor retinaculum (SER). ERS is identified as out-of-proportion anterior ankle pain, pain with passive toe plantarflexion, elevated SER pressures (>40 mm Hg), and ultimately toe extension weakness and first web space numbness. Although previously described in a pediatric population, this case series is the first to our knowledge in an adult population. Seven nonconsecutive cases over 18 years from 2 surgeons are reported who underwent complete SER release for ERS either through the direct lateral approach to the fibula or the anterolateral approach to the distal tibia. All were associated with traumatic injuries including 3 bimalleolar ankle fractures, 3 tibial pilon fractures, and 1 distal tibial/fibular shaft fracture. All patients developed writhing anterior ankle pain worsened with passive toe plantarflexion. SER compartment pressures ranged from 50 to >135 mm Hg. Five cases displayed decreased first web space sensation. The diminished or absent first web space sensation uniformly improved post-release. Complications included 1 patient with complex regional pain syndrome type 1, 1 patient required hardware removal, and 2 had persistent but improved first web space sensation changes. Clinical suspicion for possible ERS should arise after distal tibial/fibular fractures when the excruciating pain localizes to the ankle instead of the classic anterior leg muscle bellies. If pain is worsened with passive toe plantarflexion, this diagnosis should be considered. Recommended treatment involves complete release of the SER anywhere on the anterior surface between the tibia and fibula depending on the approach needed for fixation of the associated fracture. Level IV, case series.

Percutaneous Approaches to Hypoglossal Nerve Stimulation: A Pilot Study During Drug-Induced Sleep Endoscopy.

Hypoglossal nerve stimulation (HNS) is a surgical treatment option for select patients with obstructive sleep apnea that currently requires intraoperative dissection of the hypoglossal nerve (HGN) for implantation of an electrode array. Most HNS strategies target select HGN protrusor muscle branches and exclude undesirable retractor branches. We hypothesized that the target HGN branches could instead be selectively stimulated with a percutaneously delivered electrode array under ultrasound guidance via several anatomic approaches. Five different anatomic approaches were iteratively developed and evaluated during drug-induced sleep endoscopy across 14 patients: posterior, intraoral, anteromedial, anterolateral, and paracoronal. The paracoronal and anterolateral approaches were the most successful, with comparable changes in pharyngeal critical closing and opening pressures. Our data suggest that percutaneous delivery of an HGN electrode is feasible and may decrease the morbidity of HNS therapy implantation. Further work is necessary to ascertain what anatomic approach is optimal for percutaneous electrode delivery.

V2 Vertebral Artery Transposition for Microvascular Decompression of C5 Nerve Root: A 2-Dimensional Operative Video.

Vertebral artery tortuosity is a common phenomenon with an estimated incidence of 2.7%. However, it is symptomatic in very rare instances, with only 21 cases reported in the literature. When a neurovascular conflict can be clearly identified, microsurgical decompression should be the treatment of choice. This can be performed through a variety of different strategies which can achieve either direct or indirect decompression. We present the case of a 68-year-old female who suffered from progressive right-sided C5 radiculopathy and deltoid weakness for over a year secondary to a neurovascular conflict between a V2 vertebral artery loop and the C5 nerve root. Microvascular decompression with vertebral artery transposition using an anterolateral approach was recommended for pain management and arrest of her neurological deficit, and the patient consented to the procedure. Institutional Review Board approval was not necessary given that this treatment was necessary and indicated. The longus colli is mobilized, and the anterior wall of the foramen transversarium is exposed. The foramen transversarium is drilled to unroof the vertebral artery. The neuroforamen is identified. A tailored foraminotomy is performed to expose the neurovascular conflict. The vertebral artery loop is dissected away from the C5 nerve root and transposed outside the neuroforamen. The transposition is maintained with Teflon felts. The patient had immediate resolution of her pain and weakness. Surgeons should be aware of this rare cause of radiculopathy and should be familiar with the surgical technique for vertebral artery mobilization. Direct decompression should be the goal of treatment when possible.

Comparative Study of Union Rate in Closed Humerus Shaft Fracture After Operative Fixation with Anteromedial Versus Anterolateral Surface Plating Using the Anterolateral Approach: A Randomized Controlled Study

Purpose: Plate osteosynthesis is considered the gold standard for treating humeral shaft fractures, and orthopedic surgeons widely use the anterolateral approach with anterolateral surface placement. However, surgeons may have difficulties with the non-smooth surface and proximity to the radial nerve during their use. To address this challenge, we propose introducing the anterolateral approach with anteromedial surface placement. This study aimed to compare the outcomes between anteromedial and anterolateral surface plating using the anterolateral approach. Methods: This study included 74 patients who sustained a mid-shaft humerus fracture (AO 12) and underwent open reduction internal fixation between December 2020 and December 2022. Twelve patients were excluded based on the exclusion criteria. Among the remaining patients, 30 were randomized and allocated to surgery with anteromedial surface plating, while 32 patients were treated with anterolateral surface plating through an anterolateral approach. Postoperative clinical and radiographic results were recorded and analyzed. Results: The union rate, blood loss, operative time, and complications were not significantly different between the two groups. All the patients healed radiographically except for two in the anterolateral surface plating group, who required reoperation. Although anteroposterior alignment was significantly better in the anteromedial surface plating group, it was not clinically significant. Conclusions: Anteromedial plating demonstrated a commendable union rate, offered assured alignment, and presented itself as a secure option for addressing fractures of the humerus shaft.

ABORD ANTEROLATERAL DE LA CHARNIERE THORACO-LOMBAIRE : EXPERIENCE D’UN CAS AVEC CHYLOTHORAX PAR PLAIE IATROGENE DU CANAL THORACIQUE.

Despite its advantages, the anterolateral approach to the thoracolumbar spine can present several complications including chylothorax. We present a rare case of thoracic duct injury secondary to an anterolateral surgical approach to the thoracolumbar spine post-vertebromedullary trauma which was successfully treated non-surgically. Observation: This is a 35-year-old patient, hospitalized for the treatment of a spinal trauma whose radiological assessment revealed a type A3 fracture of the 12th thoracic vertebra according to the Ao-spine classification. He had benefited from a corpectomy of the same vertebra followed by the placement of an interbody implant via an anterolateral approach with thoraco-phrenotomy. The immediate aftermath of the operation was marked by the presence in the chest drain of a white lactescent liquid, the chemical study of which revealed the presence of chylomicrons by electrophoresis, lipoproteins and a triglyceride level of 80 g/l, confirming the diagnosis of chylothorax. Conservative medical treatment was instituted consisting of chest drainage for 3 weeks and parenteral nutrition which allowed complete recovery. Conclusion: Iatrogenic chylothorax represents a rare cause of pleural effusion. This case reflects a successful approach to the management of post-dorsal spine surgery lymph leak via anterolateral approach, using drainage and strict dietary changes, which precluded the need for thoracic duct repair surgery. Keywords: Anterolateral approach, Chylothorax, Conservative treatment,

A Comparison of Surgical Approaches for Hip Hemiarthroplasty Performed for the Treatment of Femoral Neck Fracture: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

Multiple hemiarthroplasty (HA) approaches exist for femoral neck fracture (FNF) treatment. However, there is no consensus on the superiority of one approach for postoperative outcomes. This study assessed outcomes among randomized controlled trials (RCTs) comparing the posterior approach (PA), direct lateral approach (DLA), anterolateral approach (ALA), and the direct anterior approach (DAA) in HA for FNF. PubMed, Ovid/MEDLINE, Scopus, Cochrane Central Registry of Controlled Trials, and Cochrane Database of Systematic Reviews were queried in February 2024. A frequentist model network meta-analysis of eligible prospective RCTs compared outcomes among approaches using P-scores. Of 1,481 retrieved studies, 11 RCTs totaling 1,513 FNF patients who underwent HA through a PA (n = 446; 29.5%), DLA (n = 481; 31.8%), ALA (n = 296; 19.6%), or DAA (n = 290; 19.2%) with median (interquartile range) follow-up of 6 (4.5-12.0) months were included for meta-analysis. DAA was associated with statistically increased operative duration (mean difference [MD], 1.89 minutes; 95% CI, 0.08 to 3.69 minutes; p < 0.001) compared with a PA, whereas an ALA was associated with statistically greater blood loss compared with a PA (MD, 5.81 mL; 95% CI, 4.11 to 7.50 mL; p < 0.001). There were no differences in the incidence of fracture, dislocation, infection, complications, revision, nor 1-year mortality among approaches. There were also no differences in hip nor pain score improvement at latest follow-up, although with high heterogeneity (I2 = 85.7% and 94.2%, respectively). This study found no clinical difference in improvement in pain, function, nor in revision outcomes and operative characteristics among HA approaches for FNF, and each approach had a similar adverse event profile. Despite limited randomized evidence, these findings suggest comparable short-term efficacy and safety of all approaches. Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence.

Displaced humeral shaft fractures: Assessment of fracture union and complications following dual plate fixation using an anterior approach

The humeral bone is subject to torsional forces. In case of displaced shaft fractures, internal fixation remains the standard of care. This retrospective two-center study assessed the fracture union rate and complications after dual 3.5 mm locking compression plate (LCP) fixation using an anterolateral approach. Over a 9-year period, 38 patients underwent surgery in two centers. They had a mean age of 53.7 years (15–97, ± standard deviation (SD) 26) and there were three open fracture cases (7.9 %). The dominant side was affected in 21 cases (55.3 %) and there were 11 polytrauma patients (29 %). Mean operative time was 78 min (40–124, ± 19.8 SD). Patients were treated with dual 3.5 mm LCP fixation (6 screws on either side of the fracture line, anterolateral approach without a tourniquet). The first two orthogonal views showing at least 3 cortical bridges out of 4 determined fracture healing, as assessed by two independent raters. Pre- and postoperative complications were tabulated. Clinical outcomes included range of motion (ROM) and return to activities, while functional outcomes were assessed with the Disability of the Arm Shoulder and Hand (DASH), the Constant score, the Subjective Shoulder Score (SSV) and the Mayo Elbow Performance Score (MEPS). Minimum follow-up was 1 year. Four patients were given a shoulder immobilizer to wear for 3 weeks; immediate mobilization was the standard of care for the other patients. Fracture union was achieved in all cases within a mean of 11.7 weeks (6–28 ± 7.1 SD) without any heterotopic ossification of the brachialis muscle. There were eight patients with preoperative radial nerve palsy and two cases of postoperative palsy. There was one surgical site infection (2.6 %). Return to work for active patients was possible in 87 % of cases within a mean of 23 weeks (6–72 ± 11 SD). The Constant score was 84.6 (35–100, ± 13.4 SD), the SSV score was 80.7 (60–100, ± 8.2 SD), the DASH score was 13.5 (0–38.3, ± 8.8 SD) and the MEPS score was 85 (55–100, ± 11.9 SD). Traditional fixation methods provide little control over torsional forces, leading to non-union rates between 3 % and 12 % and delayed union (12 to 20 weeks). The simplicity of the technique described here, and the short operative time, may help explain the low infection rate. Dual plate fixation makes it possible to use more screws and allows nerve exploration and decompression in case of preoperative nerve palsy. Dual plate fixation to treat humeral shaft fractures is a simple and reliable technique.

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review.

Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures. A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled. Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%). The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

Single Versus 3-incision Triple Pelvic Osteotomy: Comparison of Clinical and Radiologic Results.

Triple pelvic osteotomy (TPO) is indicated when the anatomic and functional realignment of the hip joint is needed. Although the traditional approach for TPO involves a separate incision for ischial cut, there has been a trend for single-incision TPO in recent years. This study aims to compare the clinical and radiologic results of 2 different approaches. Forty-two hips of 39 patients treated using TPO with a minimum of 24 months of follow-up were included in our cohort. Demographics, perioperative, and radiologic parameters were evaluated. Harris Hip Score and International Hip Outcome Tool were used for clinical evaluation. A single anterolateral incision approach was used in 18 hips (17 patients), whereas a 3-incision approach was used in 24 hips (22 patients). The mean follow-up was 4.7 years in the 3-incision group and 3.8 years in the single-incision group ( P =0.43), with mean surgery age at 8.7 years (range, 5.4 to 12) for single-incision and 9.7 years (range, 7.7 to 11.7) for 3e-incision ( P =0.22). There were no significant differences observed between the 2 groups concerning radiographic measurements, complications, and functional scores. The mean surgical time was 118.6 minutes in the single-incision group and 97.9 minutes in 3-incision group ( P =0.036). Mean intraoperative blood loss was 181.7ml in the single-incision group and 243.4ml in 3-incision group ( P =0.028). Three-incision group demonstrated significantly higher intraoperative blood loss, leading to lower hemoglobin values ( P =0.042). The single-incision TPO demonstrated similar outcomes compared with the traditional 3-incision approach in terms of radiologic correction and functional improvement. The single-incision technique exhibited advantages such as reduced intraoperative blood loss and potential benefit of decreased pain due to fewer scars. However, it required a longer surgical time compared with the 3-incision approach. Surgeons should consider patient-specific factors and their expertise when selecting the most appropriate approach for each case. Level III-retrospective comparative series.