Anterolateral Research Articles

Comparison of mitral valve apparatus anomalies between sarcomeric hypertrophic cardiomyopathy and Fabry disease cardiomyopathy

Abstract Background Despite different etiopathogenesis, Fabry disease (FD) cardiomyopathy and sarcomeric hypertrophic cardiomyopathy (HCM) share a similar hypertrophic phenotype. Cardiac magnetic resonance (CMR) plays a pivotal role in distinguishing between these two clinical conditions, thanks to the thorough morphological definition of the phenotype and non-invasive tissue characterization. A high prevalence of mitral apparatus anomalies has been previously described both in sarcomeric HCM and FD cardiomyopathy. Purpose This study systematically compares the morphology of the mitral apparatus in sarcomeric HCM and FD cardiomyopathy, to add new insights into differential diagnosis. Methods CMR images of 120 patients were retrospectively analyzed and divided as follows: healthy controls CTRL (n=40), HCM (n=40), and FD (n=40) with left ventricular hypertrophy (LVH). The analyses included the measurement of I) papillary muscles’ hypertrophy, expressed as the maximum diameter (D max) of the anterolateral (AL) and posteromedial (PM) papillary muscles (see Figure 1 A and B); II) the anteriorization of the anterolateral papillary muscle defined as the distance between the anterolateral papillary muscle and the anterior interventricular junction (Anteriorization of AL) (Fig. 1 C); III) the length of the anterior mitral leaflet (MVL length) (Fig. 1 D). All measurements were performed on cine-SSFP sequences in diastole. Results Compared to healthy controls, HCM and FD patients showed significant hypertrophy of both papillary muscles (p<0.001) and elongation of the anterior mitral leaflet (p<0.001). Both papillary muscles in FD patients showed greater hypertrophy compared to HCM patients (D max AL p=0.017 and D max PM p=0.039). No significant differences were observed between FD and HCM regarding MVL length (p=0.078). Compared to FD (p=0.028) and healthy controls (p<0.001), HCM patients showed greater anteriorization of the anterolateral papillary muscle. (Results are summarized in Table 1). Conclusions From the comparison of mitral valve apparatus anomalies between HCM and FD, it emerged that patients with FD cardiomyopathy show a higher degree of papillary muscle hypertrophy, while patients with sarcomeric HCM display a greater anterior displacement of the anterolateral papillary muscle. The systematic analysis of the morphology of mitral apparatus can be integrated in the differential diagnosis between these two pathologies.Fig.1 Representation of MeasurementsTable 1.Summary results table

Comprehensive Dynamic 3-Dimensional Analysis of the Tricuspid Valve in Functional Tricuspid Regurgitation: Implications for Prophylactic Tricuspid Valve Intervention

ObjectivesUnderstanding of changes in tricuspid annulus (TA) during secondary or functional tricuspid regurgitation (TR) is currently limited and its surgical management relies on limited 2-dimensional (2D) imaging. The aims of the study were to: 1) track and measure changes in TA using 3-dimensional (3D) echocardiography during complete cardiac cycle in patients with functional TR when compared to no TR, and 2) compare TAPSE derived from 2D and 3D coordinates as a measure of RV function when compared to standard method of fractional area change (FAC). DesignIntraoperative 3D echocardiography data was collected prospectively followed by post processing software analysis to track and reconstruct changes throughout the cardiac cycle. SettingData was collected from 108 patients undergoing left sided heart surgery at two large academic centers – Beth Israel Deaconess Medical Center in Boston, MA and Rhode Island Hospital, Providence, RI between from November 2018 to April 2020. ParticipantsFinal dataset (n=92) included two groups: no significant functional tricuspid regurgitation (NTR) group (n=74), defined as ≤ mild tricuspid regurgitation (TR) and TA < 35 mm, and a significant functional TR (FTR) group (n=18), defined as ≥ moderate TR. Interventions3D TEE datasets were analyzed, and the motion of TA coordinates was tracked during complete cardiac cycle in 2D and 3D planes using post-processing and software analysis. Computational modeling of TA motion was performed using computer-aided design. In further analysis, reconstructed and 3D printed models of TV were developed for the two groups. Measurements and Main ResultsPatients in FTR group had larger TA size during the cardiac cycle with less overall excursion and reduced annular dynamism. 3D motion of TA for lateral (L), anterolateral (AL) and posterolateral (PL) coordinates was lower in FTR group compared to NTR group [(18±6.8 vs 13.6±8.5, p=0.02), (15.2±5.5 vs 11.3±6.0, p=0.009) and (17.6±6.6 vs 12.3±5.2, p=0.002) respectively]. TAPSE derived from 3D planes was more accurate for RV function assessment (AUC 0.704, p = 0.011) than 2D TAPSE (AUC 0.625, p = 0.129). Finally, in the FTR group, the anteroseptal-posterolateral (AS-PL) diameter was consistently larger during all phases of cardiac cycle, in comparison with septo-lateral (S-L) diameter. Conclusion3D echocardiographic assessment of TA helps better understand its geometry and dynamism in functional TR, and is more accurate than 2D measurements for RV function assessment.

An in-vitro three-dimensional surgical simulation technique to predict tibial tunnel length in transtibial posterior cruciate ligament reconstruction

BackgroundDuring the transtibial posterior cruciate ligament (PCL) reconstruction, drilling depth excessively longer than the tibial tunnel length (TTL) is an important reason to cause popliteal neurovascular bundle injury when preparing the tibial tunnel. This study aims to develop an in-vitro three-dimensional surgical simulation technique to determine the TTL in anteromedial (AM) and anterolateral (AL) approaches.MethodsA total of 63 knees’ 3-dimensional (3D) computed tomography models were included in this study. The SuperImage system was used to reconstruct the 3D knee model and locate the tibial PCL site. The established 3D knee model and the coordinates of the tibial PCL site were imported into Rhinoceros 3D modeling software to simulate AM and AL tibial tunnel approaches with different tibial tunnel angles (TTA). The TTL and the tibial tunnel height (TTH) were measured in this study.ResultsIn AM and AL tibial tunnel approaches, the TTL showed a strong correlation with the TTA (for AM: r = 0.758, p < 0.001; for AL: r = 0.727, p < 0.001). The best fit equation to calculate the TTL based on the TTA was Y = 1.04X + 14.96 for males in AM approach, Y = 0.93X + 17.76 for males in AL approach, Y = 0.92X + 14.4 for females in AM approach, and Y = 0.94X + 10.5 for females in AL approach.ConclusionMarking the TTL on the guide pin or reamer could help to avoid the drill bit over-penetrated into the popliteal space to damage the neurovascular structure.

Incidence and impact on arrhythmia recurreces of atrial fibrillation termination during linear radiofrequency ablation in the left atrium

Abstract Atrial Fibrillation Termination During Linear Radiofrequency Ablation in the Left Atrium: Incidence and Impact on Arrhythmia Recurrences Background Termination of atrial fibrillation (AF) during persistent atrial fibrillation (peAF) ablation is infrequent and has shown no clear association with reduced recurrences during follow-up. Linear ablation, often considered to have minimal impact on efficacy, has been primarily explored through creating ablation lines from the mitral annulus to the inferior pulmonary vein or by isolating the posterior wall. Purpose This study aims to assess the incidence of AF termination using an alternative linear ablation approach and its correlation with arrhythmia recurrence during follow-up. Methods Patients enrolled in the PowerFast III trial (a multicenter randomized trial comparing high- power short-duration radiofrequency (RF) application to conventional RF application) with peAF and undergoing linear ablation were included in this sub-study. Conventional pulmonary vein isolation (PVI) was performed using two different RF settings along with a set of RF lines, including anteroseptal (AS), anterolateral (AL), posterior wall isolation between the pulmonary veins, and between the two anterior lines. Patients were categorized into two groups based on AF termination or flutter organization (Group 1) or no AF termination (Group 2) during RF application. All patients were monitored with EKG transmission for one year. Results Fifty-one consecutive patients (mean age 61 years, male 39) were included. AF terminated in 21 patients (41%) during RF application (9 converting to AF and 12 to atrial flutter). AF did not terminate during RF application for PVI, except for one patient during right PV ablation following left PVI. AF termination occurred by posterior wall lines in three patients, roof line in three, and anterior line in two. AF converted into atrial flutter during ablation by a roof line in 5 patients and by an anterior line in 7. No significant differences in atrial arrhythmia recurrence were observed between the two groups (three patients in Group 1 vs. eleven in Group 2, P = 0.11). However, Group 1 exhibited fewer AF recurrences (zero patients) than Group 2 (eight patients, P = 0.015). Conclusions Extensive linear RF ablation resulted in a substantial proportion of patients experiencing AF termination or conversion into atrial flutter. AF termination or conversion did not appear to be correlated with atrial arrhythmia freedom during follow-up but was associated with fewer AF recurrences.Any arrhythmia recurrenceAF recurrence

Different radius of curvature at the talus trochlea from northern Chinese population measured using 3D model

BackgroundTo analyze the curvature characteristics of the talus trochlea in people from northern China in different sex and age groups.MethodsComputed tomography scanning data of talus from 61 specimens were collected and constructed as a three-dimensional model by Materialise’s Interactive Medical Image Control System(MIMICS) software, anteromedial(AM), posteromedial(PM), anterolateral(AL), and posterolateral(PL) edge, anterior edge of medial trochlea, posterior edge of medial trochlea and anterior edge of lateral trochlea were defined according to the anatomical landmarks on trochlear surface. The curvature radii for different areas were measured using the fitting radius and measure module.ResultsThere were significant differences among the talus curvatures in the six areas (F = 54.905, P = 0.000), and more trends in the analytical results were as follows: PM > PL > MP > AL > MA > AM. The average PL radius from specimens aged > 38 years old was larger than that from specimens aged < = 38 years (t=-2.303, P = 0.038). The talus curvature of the AM for males was significantly larger than that for females (t = 4.25, P = 0.000), and the curvature of the AL for males was larger than that for females (t = 2.629, P = 0.010). For observers aged < = 38 years, the AM curvature of the right talus in the male group was significantly larger than that in the female group (P < 0.01). In age < = 38years group, the MA curvature of right talus in male was significantly larger than in female group(P < 0.01), fitting radius of talus for male (21.90 ± 1.97 mm) was significantly greater than female of this(19.57 ± 1.26 mm)(t = 6.894, P = 000). The average radius of the talus in the male population was larger than that in the female population.ConclusionThere was no significant relationship between age and talus curvature for males and females. The radius of curvature in the posterior area was significantly larger than that in the anterior area. We recommend that this characteristic of the talus trochlea should be considered when designing the talus component in total ankle replacement (TAR).

Anterolateral versus anteromedial plate osteosynthesis of midshaft humeral fractures; is there a difference in the rates of iatrogenic radial nerve palsy?

The anterolateral (AL) and anteromedial (AM) surfaces of the humerus are typically used for plate placement during plate osteosynthesis of midshaft humeral fractures via the anterolateral approach. The purpose of this study was to determine if a significant difference exists in the rates of iatrogenic radial nerve palsy (IRNP) following either AL or AM humeral fracture plating. The research question is stated as follows: is anteromedial plating of humeral fractures associated with lower rates of IRNP when compared with anterolateral plating? This multicenter prospective randomized study was undertaken following ethical review and approval with eligible patients who had midshaft humeral fractures or nonunions randomized into 2 groups, viz AL plate osteosynthesis group and AM plate osteosynthesis group. Following diagnostic and preoperative evaluation, patients had open plate osteosynthesis through the anterolateral approach with plate placement according to their study groups. Post-operatively, they were assessed for IRNP while obtained data was analyzed with SPSS version 23 and inter-group differences with P values less than 0.05 were considered statistically significant. Eighty-five eligible patients participated in the study with 43 patients in Group A (AL plate osteosynthesis group) and 42 patients in Group B (AM plate osteosynthesis group). The observed inter-group differences with regard to gender distribution, mean age and clinical diagnosis; acute fracture (AF) versus nonunion were not statistically significant. Furthermore, four (9.3%) patients amongst the 43 patients in Group A (AL plate osteosynthesis group) developed IRNP while two (4.8%) patients amongst the 42 patients in Group B (AM plate osteosynthesis group) had IRNP. The inter-group difference with regard to rates of IRNP was not statistically significant (P = 0.694). This study found that (in contrast to previous studies) there was no significant difference in the rates of IRNP following either open anterolateral or anteromedial plate osteosynthesis of midshaft humeral fractures through the anterolateral approach. Orthopaedic surgeons should therefore remain cautious when obtaining consent for surgery as well as when performing internal fixation of midshaft humeral fractures to limit medicolegal disputes that may arise from IRNP.

Long-Term Outcome Analysis of Surgically Treated Talus Fractures in a Tertiary Care Hospital.

Aim The present study aims to look at the long-term clinical and radiological outcomes of surgically treated talus fractures. We have compared the outcomes and complications between simple and complex talar fracture patterns. Additionally, patients' ability to return to activity following surgical treatment of these fractures was also analysed. Materials and methods Retrospective analysis of surgically treated talus fractures at the PSG Institute of Medical Sciences and Research from 2012 to 2015. The fractures were classified as neck and body fractures. The fractures were classified anatomically (neck and body) based on their severity (simple and complex) fracture patterns. A radiological assessment was done at follow-up to assess for complications of malunion, avascular necrosis (AVN), and arthritis. The outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Maryland foot score (MFS). Results Twenty patients were included in the analysis. There were 12 talar neck and eight body fractures, subclassified into simple (10) and complex fracture patterns (10). The surgical approach involved either a medial malleolus osteotomy/via fractured medial malleolus (55%) or a non-osteotomy-based approach (anteromedial (AM)/anterolateral (AL)/combined AM and AL) (45%). The average AOFAS score was 71.34, while the MFS was 74.35. The outcomes were consistently unfavourable for patients with complex fractures with a higher propensity for complications, but no difference was observed when comparing neck and body fractures. There was a 10% incidence of malreduction in the non-osteotomy-based approach group. AVN was found in 35% of cases, and post-traumatic arthritis occurred in 75% of cases during the five-year follow-up period. Conclusion The findings of the present study consistently reiterate the propensity for complex talus fractures to develop complications like AVN and post-traumatic arthritis in the long term. This study serves to help predict talus fractures based on their severity, with poor outcomes noted with more complex fracture types. We also advocate a more extensile medial malleolus osteotomy-based approach to better visualise complex body fractures of the talus and obtain more anatomical reduction.

Impact of Selective Posterior Cruciate Ligament Fiber Release on Femoral Rollback in Cruciate-Retaining Total Knee Arthroplasty: A Computational Study

BackgroundPartial or total release of the posterior cruciate ligament (PCL) is often performed intraoperatively in cruciate-retaining total knee arthroplasty (CR-TKA) to alleviate excessive femoral rollback. However, the effect of the release of selected fibers of the PCL on femoral rollback in CR-TKA is not well understood. Therefore, we used a computational model to quantify the effect of selective PCL fiber releases on femoral rollback in CR-TKA. MethodsComputational models of 9 cadaveric knees (age: 63 years, range 47 to 79) were virtually implanted with a CR-TKA. Passive flexion was simulated with the PCL retained and after serially releasing each individual fiber of the PCL, starting with the one located most anteriorly and laterally on the femoral notch and finishing with the one located most posteriorly on the medial femoral condyle. The experiment was repeated after releasing only the central PCL fiber. The femoral rollback of each condyle was defined as the anterior-posterior distance between tibiofemoral contact points at 0° and 90° of flexion. ResultsRelease of the central PCL fiber in combination with the anterolateral (AL) fibers, reduced femoral rollback a median of 1.5 [0.8, 2.1] mm (P = .01) medially and by 2.0 [1.2, 2.5] mm (P = .04) laterally. Releasing the central fiber alone reduced the rollback by 0.7 [0.4, 1.1] mm (P < .01) medially and by 1.0 [0.5, 1.1] mm (P < .01) laterally, accounting for 47 and 50% of the reduction when released in combination with the AL fibers. ConclusionsReleasing the central fibers of the PCL had the largest impact on reducing femoral rollback, either alone or in combination with the release of the entire AL bundle. Thus, our findings provide clinical guidance regarding the regions of the PCL that surgeons should target to reduce femoral rollback in CR-TKA.

Impact of liver cirrhosis, severity of cirrhosis and portal hypertension on the difficulty of laparoscopic and robotic minor liver resections for primary liver malignancies in the anterolateral segments

IntroductionWe performed this study in order to investigate the impact of liver cirrhosis (LC) on the difficulty of minimally invasive liver resection (MILR), focusing on minor resections in anterolateral (AL) segments for primary liver malignancies. MethodsThis was an international multicenter retrospective study of 3675 patients who underwent MILR across 60 centers from 2004 to 2021. Results1312 (35.7%) patients had no cirrhosis, 2118 (57.9%) had Child A cirrhosis and 245 (6.7%) had Child B cirrhosis. After propensity score matching (PSM), patients in Child A cirrhosis group had higher rates of open conversion (p = 0.024), blood loss >500 mls (p = 0.001), blood transfusion (p < 0.001), postoperative morbidity (p = 0.004), and in-hospital mortality (p = 0.041). After coarsened exact matching (CEM), Child A cirrhotic patients had higher open conversion rate (p = 0.05), greater median blood loss (p = 0.014) and increased postoperative morbidity (p = 0.001). Compared to Child A cirrhosis, Child B cirrhosis group had longer postoperative stay (p = 0.001) and greater major morbidity (p = 0.012) after PSM, and higher blood transfusion rates (p = 0.002), longer postoperative stay (p < 0.001), and greater major morbidity (p = 0.006) after CEM. After PSM, patients with portal hypertension experienced higher rates of blood loss >500 mls (p = 0.003) and intraoperative blood transfusion (p = 0.025). ConclusionThe presence and severity of LC affect and compound the difficulty of MILR for minor resections in the AL segments. These factors should be considered for inclusion into future difficulty scoring systems for MILR.

Posterior Proximal Cartilage of the Lateral Femoral Condyle as a Reference for Positioning the Femoral Tunnel in ACL Reconstruction

Background: Due to the similarity among specimens in the height of the anterior cruciate ligament (ACL) on the distal proximal axis in relation to the proximal posterior cartilage of the lateral femoral condyle (point C), it is known this point can be used as an arthroscopic intraoperative parameter to define the position of the femoral tunnel in ACL reconstruction. Indications: For ACL reconstruction, point C can be used as an arthroscopic intraoperative parameter to define the position of the femoral tunnel on the distal proximal and anteroposterior axes. Technique Description: For access to the joint, standard arthroscopic ports, both anterolateral (AL) and anteromedial (AM), are used. By directing the camera toward the posterior region of the lateral femoral condyle through the AM port, it is possible to visualize the end of the posterior and proximal articular cartilage, the so-called C point. In this case, we sought to position the center of the femoral tunnel in the center of the AM band of the ACL. Holding the camera through the AM portal and visualizing point C, a millimeter-scale femoral guide is introduced through the AL portal toward the posterior femoral cartilage (point C) and positioned over it, creating a line between point C and the lateral distal femoral cartilage. The distance between point C and the distal femoral cartilage is measured. At this time, an accessory AM portal 1.5 cm from the AM port is constructed. Through it, with the aid of an ice pick or radiofrequency tip, a marking is made in the deep to shallow axis at 35% of this distance. Then, approximately 2 mm above the imaginary line formed by the union of point C and the lateral distal femoral cartilage, the center of the femoral tunnel is marked. Results: Point C is an anatomical landmark that is easy to view and is present in all knees; thus, it can be used as a reference during surgery for positioning the femoral tunnel. Discussion/Conclusion: Point C can be used as an arthroscopic intraoperative parameter to define the position of the femoral tunnel in ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Efficacy of three different techniques in the fluoroscopy-guided intra-articular steroid injection of the hip: a randomized controlled trial

Fluoroscopy-guided injection via the anterior (A), anterolateral (AL), or proximal anterolateral (PAL) approaches are the common hip injection techniques without comparing the efficacy of the three techniques. The prospective randomized controlled trial was conducted from August 2020 to March 2022. Included patients with intra-articular hip disorders indicated an intra-articular steroid injection. Excluded significant spine pathology with radiculopathy or significant neurological deficits, previous hip surgery of the injection side, suspected tumor or infection origins, steroid or contrast media allergy, and body mass index > 35 kg/m2. The primary outcome was the injection attempt defining one attempt and multiple attempts. 90 patients were recruited and allocated to 30 per group. There were no differences between A, AL, and PAL respectively regarding the success in one attempt rate (80%, 80%, 90%; p = 0.533), VAS during local anesthetic injection (4.33 ± 1.99, 3.70 ± 2.34, 4.27 ± 2.49; p = 0.500), VAS during intra-articular injection (4.27 ± 1.87, 4.70 ± 2.37, 4.13 ± 2.37; p = 0.587), radiation doses (0.558 ± 0.313, 0.526 ± 0.485, 0.492 ± 0.275 mGy; p = 0.788), radiation time (0.043 ± 0.017, 0.039 ± 0.021, 0.041 ± 0.015 seconds; p = 0.723), and complications. The post-injection mHHS was improved in all three approaches without significant differences.

Combined subtarsal contralateral transmaxillary retroeustachian and endoscopic endonasal approaches to the infrapetrous region.

The eustachian tube (ET) limits endoscopic endonasal access to the infrapetrous region. Transecting or mobilizing the ET may result in morbidities. This study presents a novel approach in which a subtarsal contralateral transmaxillary (ST-CTM) corridor is coupled with the standard endonasal approach to facilitate access behind the intact ET. Eight cadaveric head specimens were dissected. Endoscopic endonasal approaches (EEAs) (i.e., transpterygoid and inferior transclival) were performed on one side, followed by ST-CTM and sublabial contralateral transmaxillary (SL-CTM) approaches on the opposite side, along with different ET mobilization techniques on the original side. Seven comparative groups were generated. The length of the cranial nerves, areas of exposure, and volume of surgical freedom (VSF) in the infrapetrous regions were measured and compared. Without ET mobilization, the combined ST-CTM/EEA approach provided greater exposure than EEA alone (mean ± SD 288.9 ± 40.66 mm2 vs 91.7 ± 49.9 mm2; p = 0.001). The VSFs at the ventral jugular foramen (JF), entrance to the petrous internal carotid artery (ICA), and lateral to the parapharyngeal ICA were also greater in ST-CTM/EEA than in EEA alone (p = 0.002, p = 0.002, and p < 0.001, respectively). EEA alone, however, provided greater VSF at the hypoglossal canal (HGC) than did ST-CTM/EEA (p = 0.01). The SL-CTM approach did not increase the EEA exposure (p = 0.48). The ST-CTM/EEA approach provided greater exposure than EEA with extended inferolateral (EIL) or anterolateral (AL) ET mobilization (p = 0.001 and p = 0.02, respectively). The ST-CTM/EEA also increased the VSF lateral to the parapharyngeal ICA in comparison with EEA/EIL ET mobilization (p < 0.001) but not with EEA/AL ET mobilization (p = 0.36). Finally, the VSFs at the HGC and JF were greater in EEA/AL ET mobilization than in ST-CTM/EEA without ET mobilization (p = 0.002 and p = 0.004, respectively). Combining the EEA with the more laterally and superiorly originating ST-CTM approach allows greater exposure of the infrapetrous and ventral JF regions while obviating the need for mobilizing the ET. The surgical freedom afforded by the combined approaches is greater than that obtained by EEA alone.

Comparative Analysis of Surgical Working Corridors for Meckel Cave Trigeminal Schwannomas: A Quantitative Anatomic Study.

Volumetric analysis of the working corridors of the interdural approach to the Meckel cave may lead to a selection of routes which are anatomically more advantageous for trigeminal schwannoma resection. The herein-reported anatomic study quantitively compares the infratrochlear (IT) transcavernous, anteromedial (AM), and anterolateral (AL) corridors, highlighting their feasibility, indications, advantages, and limitations. Anatomic boundaries and depth of Meckel cave, porus trigeminus, IT transcavernous, AM, and AL corridors were identified in 20 formalin-fixed latex-injected cadaveric heads and were subsequently measured. The corridor areas and volumes were derived accordingly. Each opening angle was also calculated. Angles and volumes were compared using analysis of variance. Statistical significance was set at a P -value <.05. The IT transcavernous corridor volume was greater than that of the AM and AL. The opening angle of the AM middle fossa triangle was wider than the other 2. The IT corridor can be advantageous for Meckel cave schwannomas invading the cavernous sinus and those with a notable extension into the posterior fossa because the transcavernous approach maximizes the working space into the retrosellar area. The AM middle fossa corridor is strategic in schwannomas confined to the Meckel cave with a minor extension into the posterior fossa. It raises the chance of total resection with a single approach involving the porus trigeminus opening.

Descending the reconstructive ladder: Salvage reconstruction by tissue expansion to revise a free flap-based forehead reconstruction

Abstract Background: Forehead defects pose a reconstructive challenge and multiple revisions are often required to achieve satisfactory outcomes. Materials and Methods: The case history of a 20-year-old woman undergoing radical resection of a forehead arteriovenous malformation and reconstruction with an anterolateral (ALT) free flap is described. Results: Although free tissue transfer with an ALT was successful, its color and texture mismatch were unacceptable to the patient. The esthetic result and patient satisfaction were improved by subsequent tissue expansion of the contralateral forehead, removal of the free flap and advancement of the contralateral forehead skin. Conclusion: Complex reconstructions utilize a breadth of techniques. We illustrate a dynamic use of the reconstructive ladder, implementing a descending approach to achieve a satisfactory reconstruction objectively and subjectively from the patient perspective.

Paper 65: Novel CT-Derived 3D Modeling Assessing Dysplastic Hips Versus Controls Demonstrates Decreased 2D Lateral Center Edge Angle, but not Tönnis Angle, Predicts Decreased 3D Anterolateral Coverage

Paper 65: Novel CT-Derived 3D Modeling Assessing Dysplastic Hips Versus Controls Demonstrates Decreased 2D Lateral Center Edge Angle, but not Tönnis Angle, Predicts Decreased 3D Anterolateral Coverage

Accuracy of Femoral Tunnel Placement between Anteromedial and Anterolateral Visualisation Portals in Anterior Cruciate Ligament Reconstruction - Outcomes of a CT based Cross-Sectional Study.

Anatomical femoral tunnel placement is critical for anterior cruciate ligament reconstruction (ACLR). Tunnel placement may vary with different surgical techniques. The aim of this study was to compare the accuracy of femoral tunnel placement between the Anteromedial (AM) and Anterolateral (AL) visualisation portals on post-operative CT scans among a cohort of ACLR patients. This cross-sectional study was conducted from January 2018 to March 2020 after obtaining ethics clearance. Patients who went for arthroscopic ACLR in our institute were divided into an AM (group 1) and an AL (group 2) based on the visualisation portal for creating the femoral tunnel and a 3D CT scan was done. The femoral tunnel position was calculated in deep to shallow and high to low direction using the Bernard Hertel grid. Femoral tunnel angle was measured in the 2D coronal image. Statistical analysis was done with the data collected. Fifty patients with an average age of 26.36 (18-55) years ±7.216 SD were enrolled in the study. In this study, the AM technique was significantly more accurate (p<0.01) than the AL technique in terms of femoral tunnel angle. Furthermore, the deep to the shallow position was significantly (p= 0.018) closer to normative values, as determined by the chi-square test. The chances of error in tunnel angle in femoral condyle are 2.6 times greater in the AL technique (minimal clinical difference). To conclude, in ACLR the anteromedial visualisation portal can facilitate accurate femoral tunnel placement compared to the anterolateral visualisation portal.

Double-Bundle PCL Reconstruction in the Multiple-Ligament Injured Knee

Background: Multi-ligament knee injuries and knee dislocations are potentially devastating injuries that typically result in injury to both cruciate ligaments and variable injury to collateral ligament complexes. Indications: Surgical intervention typically leads to better patient outcomes than nonoperative management. We describe our preferred technique for bicruciate ligament reconstruction with a focus on double-bundle posterior cruciate ligament (PCL) reconstruction. Technique Description: A transtibial approach is used to drill the PCL tibial tunnel. A safety incision on the proximal medial tibia, which may incorporate the distal aspect of a medial-sided incision for medial collateral ligament (MCL) reconstruction, allows palpation of the PCL fovea for anatomic tunnel placement, protection of the posterior neurovascular structures, and egress of arthroscopic fluid during the case. This technique uses an inside-out approach for creation of the 2 femoral sockets to recreate the 2 PCL bundles. The grafts are passed in antegrade fashion, with passage and femoral fixation of the posteromedial (PM) bundle followed by the anterolateral (AL) bundle. After passage of the anterior cruciate ligament (ACL) graft and fixation on the femur in standard fashion, attention is turned to PCL tibia-sided fixation. We use a screw and spiked washer to fix the AL bundle at 90° of flexion with an anterior drawer maneuver. The PM bundle is then fixed with a polyetheretherketone (PEEK) interference screw in near full extension. Fixation of the ACL on the tibia in standard fashion completes the bicruciate ligament reconstruction. Results: In biomechanical cadaveric studies, double-bundle PCL reconstruction has been shown to more closely approximate native knee kinematics, with more restraint to posterior translation at all knee flexion angles and less internal rotation laxity at higher knee flexion angles. In clinical results, both single-bundle and double-bundle reconstructions improve knee stability and patient-reported outcomes. Double-bundle PCL reconstruction may provide improved objective posterior tibial stability and objective International Knee Documentation Committee (IKDC) scores. Discussion: Double-bundle PCL reconstruction can be performed efficiently with good outcomes and potentially less residual posterior translation or internal rotation laxity than single-bundle PCL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up

Background: Lateral extra-articular procedures have been effective in reducing graft rupture rates after anterior cruciate ligament (ACL) reconstruction (ACLR), but the evidence supporting their role in ACL repair is sparse. Purpose/Hypothesis: The purpose was to compare clinical and radiological outcomes of ACLR and lateral extra-articular tenodesis (LET) (ACLR+LET) against combined repair of the ACL and anterolateral (AL) structures (ACL+AL Repair). It was hypothesized that patients undergoing ACL+AL Repair would have noninferior clinical and radiological outcomes with respect to International Knee Documentation Committee (IKDC) scores, knee laxity parameters, and magnetic resonance imaging (MRI) characteristics. Furthermore, it was hypothesized that patients undergoing repair would have significantly better Forgotten Joint Score–12 (FJS-12) values and shorter times to return to the preinjury level of sport, without any increase in the rate of ipsilateral second ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: Consecutive patients evaluated with an acute ACL tear were considered for study eligibility. ACLR+LET was only performed when intraoperative tear characteristics contraindicated ACL repair. Patient-reported outcome measures such as the IKDC score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS); reinjury rates; anteroposterior side-to-side laxity difference; and MRI characteristics were reported at a minimum follow-up of 2 years. The noninferiority study was based on the IKDC subjective score; side-to-side anteroposterior laxity difference; and signal-to-noise quotient (SNQ). The noninferiority margins were defined using the existing literature. An a priori sample size calculation was performed using the IKDC subjective score as the primary outcome measure. Results: A total of 100 patients (47 ACLR+LET, 53 ACL+AL Repair) with a mean follow-up of 25.2 months (range, 24-31 months) were enrolled and underwent surgery within 15 days of injury. At the final follow-up, the differences between groups with respect to the IKDC score, anteroposterior side-to-side laxity difference, and SNQ did not exceed noninferiority thresholds. ACL+AL Repair was associated with a shorter time to return to the preinjury level of sport (ACL+AL Repair: mean, 6.4 months; ACLR+LET: mean, 9.5 months; P < .01), better FJS-12 values (ACL+AL Repair: mean, 91.4; ACLR+LET: mean, 97.4; P = .04), and a higher proportion of patients achieving the Patient Acceptable Symptom State (PASS) for the KOOS subdomains studied (Symptoms: 90.2% vs 67.4%, P = .005; Sport and Recreation: 94.1% vs 67.4%, P < .001; Quality of Life: 92.2% vs 73.9%, P = .01). There were no significant differences between groups with respect to ipsilateral second ACL injury rates (ACL+AL Repair group, 3.8% and ACLR+LET group, 2.1% [n = 1]; P = .63). Conclusion: ACL+AL Repair yielded clinical outcomes that were noninferior to (or not significantly different from) ACLR+LET with respect to IKDC subjective, Tegner activity level, and Lysholm scores; knee laxity parameters; graft maturity; and rates of failure and reoperation. However, there were significant advantages of ACL+AL Repair, including a shorter duration of time to return to the preinjury level of sport, better FJS-12 values, and a higher proportion of patients achieving PASS for KOOS subdomains studied (Symptoms, Sport and Recreation, Quality of Life).

DOES YOUR APPROACH MATTER?

There is controversy regarding the effect of different approaches on recovery after THR. Collecting detailed relevant data with satisfactory compliance is difficult. Our retrospective observational multi-center study aimed to find out if the data collected via a remote coaching app can be used to monitor the speed of recovery after THR using the anterolateral (ALA), posterior (PA) and the direct anterior approach (DAA).771 patients undergoing THR from 13 centers using the moveUP platform were identified. 239 had ALA, 345 DAA and 42 PA. There was no significant difference between the groups in the sex of patients or in preoperative HOOS Scores. There was however a significantly lower age in the DAA (64,1y) compared to ALA (66,9y), and a significantly lower Oxford Hip Score in the DAA (23,9) compared to PA(27,7). Step count measured by an activity tracker, pain killer and NSAID use was monitored via the app. We recorded when patients started driving following surgery, stopped using crutches, and their HOOS and Oxford hip scores at 6 weeks.Overall compliance with data request was 80%. Patients achieved their preoperative activity level after 25.8, 17,7 and 23.3 days, started driving a car after 33.6, 30.3 and 31.7 days, stopped painkillers after 27.5, 20.2 and 22.5 days, NSAID after 30.3, 25.7, and 24.7 days for ALA, DAA and PA respectively. Painkillers were stopped and preoperative activity levels were achieved significantly earlier favoring DAA over ALA. Similarly, crutches were abandoned significantly earlier (39.9, 29.7 and 24.4 days for ALA, DAA and PA respectively) favoring DAA and PA over ALA. HOOS scores and Oxford Hip scores improved significantly in all 3 groups at 6 weeks, without any statistically significant difference between groups in either Oxford Hip or HOOS subscores.No final conclusion can be drawn as to the superiority of either approach in this study but the remote coaching platform allowed the collection of detailed data which can be used to advise patients individually, manage expectations, improve outcomes and identify areas for further research.

Abductor muscle function after anterolateral approach in patients with unilateral end-stage hip osteoarthritis undergoing total hip arthroplasty: A prospective study.

Total hip arthroplasty (THA) is a successful procedure for treating end-stage hip osteoarthritis (OA). Regarding the surgical approach for THA, the anterolateral (AL) approach, which requires anterior hemimyotomy of the gluteus medius muscle, has shown a long-term favorable outcome. However, to date, complete information related to hip abductor muscle outcomes after the AL approach is unavailable. This study therefore aimed to evaluate the postoperative outcome of patients who undergo THA using the AL approach in terms of hip abductor muscle recovery, pain, function, and muscle healing status. Twenty patients diagnosed with unilateral end-stage hip OA underwent cementless THA with the AL approach. All patient procedures were performed by a single surgeon. Preoperative and postoperative data were collected at 2-week, 6-week, 3-month, and 6-month follow-up periods. Hip abductor muscle power was measured via handheld dynamometer. The healing of the musculotendinous repair was evaluated with magnetic resonance imaging at 9 months. After THA, hip abductor muscle power in the operated hip significantly increased as early as 3 months post-procedure when compared with the preoperative value (p < 0.05). The other parameters-including pain score, Harris hip score, and WOMAC score-significantly improved as early as 2 weeks post-operation (p < 0.05). In all patients, MRI scans showed good healing of the muscle repair site without a gap in the gluteus medius muscle. However, three patients (15%) had some fibrosis and tendon swelling at the repair site. This study demonstrated that patients with end-stage hip OA could experience significantly improved hip abductor motor function as early as 3 months after undergoing THA with the AL approach. Moreover, despite patients experiencing anterior hemimyotomy of the gluteus medius muscle, no significant complications emerged at the muscle repair site in the AL approach.