Conventional Lateral Approach Research Articles

Elimination of Lumbar Plexus Injury by Changing the Entry Point and Traction Direction of the Psoas Major Muscle in Transpsoas Lateral Lumbar Spine Surgery.

Background and Objectives: The lateral approach is commonly used for anterior column reconstruction, indirect decompression, and fusion in patients with lumbar degenerative diseases and spinal deformities. However, intraoperative lumbar plexus injury may occur. This is a retrospective comparative study to investigate and compare neurological complications between the conventional lateral approach and a modified lateral approach at L4/5. Materials and Methods: Patients with a lumbar degenerative disease requiring single-level intervertebral fusion at L4/5 were included and categorized into group X and group A. Patients in group X underwent conventional extreme lateral interbody fusion, while those in group A underwent a modified surgical procedure that included splitting of the anterior third of the psoas muscle, which was dilated by the retractor on the anterior third of the intervertebral disc. The incidence of lumbar plexus injury, defined as a decrease of ≥1 grade on manual muscle testing of hip flexors and knee extensors and sensory impairment of the thigh for ≥3 weeks, on the approach side, was investigated. Results: Each group comprised 50 patients. No significant between-group differences in age, sex, body mass index, and approach side were observed. There was a significant between-group difference in intraoperative neuromonitoring stimulation value (13.1 ± 5.4 mA in group X vs. 18.5 ± 2.3 mA in group A, p < 0.001). The incidence of neurological complications was significantly higher in group X than in group A (10.0% vs. 0.0%, respectively, p < 0.05). Conclusions: In our modified procedure, the anterior third of the psoas muscle was entered and split, and the intervertebral disc could be reached without damaging the lumbar plexus. When performing lumbar surgery using the lateral approach, lumbar plexus injury can be avoided by following surgical indication criteria based on the location of the lumbar plexus with respect to the psoas muscle and changing the transpsoas approach to the intervertebral disc.

Clinical application of the modified posterolateral approach for treating posterior tibial plateau fractures.

Objective: To investigate the therapeutic efficacy of the modified posterolateral approach on tibial plateau fractures. Methods: Forty-four patients with tibial plateau fractures were enrolled in the study and divided into two groups-control and observation-according to the different surgical procedures. The control group underwent fracture reduction via the conventional lateral approach, while the observation group underwent fracture reduction via the modified posterolateral strategy. The depth of tibial plateau collapse, active mobility, and the Hospital for Special Surgery (HSS) score and Lysholm score of the knee joint at 12months after surgery were assessed in comparison to the two groups. Results: The amount of blood loss (p < 0.01), duration of surgery (p < 0.05), and depth of tibial plateau collapse (p < 0.001) were significantly less in the observation group compared with the control group. In addition, compared with the control group, the observation group exhibited significantly better knee flexion and extension function and significantly higher HSS and Lysholm scores at 12months after surgery (p < 0.05). Conclusion: The modified posterolateral approach for posterior tibial plateau fractures has less intraoperative bleeding and a shorter operative time compared with the conventional lateral approach. It also effectively prevents postoperative tibial plateau joint surface loss and collapse, promotes the recovery of knee function, and has few postoperative complications and good clinical efficacy. Thus, the modified approach is worth promoting in clinical practice.

Ankle syndesmotic instability assessment using a three-dimensional distance mapping algorithm: a cadaveric pilot WBCT study

Objective: This cadaveric pilot study was to develop a weight bearing computed tomography (WBCT) three-dimensional (3D) distance mapping algorithm that would allow for detection of syndesmotic instability. Methods: Pilot study, two cadaveric specimens. Syndesmotic instability was induced by release of all syndesmotic ligaments through a conventional lateral ankle approach. WBCT imaging under simulated weight bearing was acquired before and after syndesmotic destabilization. Syndesmotic incisura and ankle gutter distances were assessed using a 3D distance mapping WBCT algorithm. Results: We found increases in the overall mean syndesmotic distances in the injured syndesmosis when compared to pre-injury state, and color coded distance maps allowed easy interpretation of the syndesmotic widening following ligament sectioning and destabilization of the syndesmotic joint. Conclusion: The WBCT 3D distance mapping algorithm has the potential to allow detection of mild syndesmotic instability with a relatively ease of interpretation by using color-coded distance maps. Level of Evidence V; Cadaveric Study.

Comparative Study Between the Mini-Open (≤2.5 Cm) Approach and Conventional Open Lateral Approach in the Surgical Treatment of Radial Head Fractures.

PurposeThe conventional lateral approach is widely used to treat radial head fractures with screws. However, the traditional incision may have shortcomings, including excessive exposure and significant scarring. We propose an innovative method – a mini-open lateral approach of less than 2.5 cm for surgical treatment of radial head fractures with screws.MethodsFrom Jan 2017 to Dec 2020, 34 patients diagnosed with closed radial head fracture were treated with open reduction and internal fixation (ORIF) in this study. The novel group (mini-open group) included 15 patients, and the other 19 patients were in the traditional group. The time of operation and the blood loss during operation were recorded. Postoperative clinical outcomes and radiographic results were recorded and compared between the two groups. The range of motion (ROM) in the elbow, the Visual Analogue Scale (VAS), the Mayo Elbow Performance Score (MEPS), Rating Scale of the American Shoulder and Elbow Surgeons (ASES), and the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH) score and complications, such as wound infection, vascular and nerve damage, and fragment redisplacement were observed in the two groups.ResultsIn the comparison between the two groups, there was no significant difference in age, sex, cause of radial head fracture, or other basic information. The operation time, intraoperative blood loss, and VAS score at 3 days postoperation were significantly reduced in the novel group (p < 0.05). The follow-up results showed that there was no significant difference in MEPS, ASES, or Q-DASH scores between the two groups.ConclusionThe mini-open approach reduced intraoperative blood loss, shortened operation time, relieved patient pain, and achieved a satisfactory postoperative clinical result, which demonstrates that the novel approach is a safe and effective option for treating radial head fractures.

Syndesmotic Malreduction Assessment using Three-Dimensional Distance Mapping: A Cadaveric WBCT Study

Category: Sports; Ankle; Ankle Arthritis; Arthroscopy; Trauma Introduction/Purpose: Diagnosing syndesmotic injuries is challenging. Avoiding intra-operative syndesmotic malreduction is even more challenging. Malreduction can be devastating to the long-term health of the ankle joint and has been shown to be more frequent and unforgiving with rigid screw fixation when compared to flexible implants. Syndesmotic position assessment postoperatively is usually performed using bilateral CT. Evaluation is frequently subjective or based on conventional distance, angular, area, and volumetric measurements. Diagnostic accuracy of these measurements is still questionable. The goal of this study was to utilize a 3D Weightbearing CT distance mapping algorithm to objectively assess syndesmotic position in a cadaveric model simulating different patterns of syndesmotic malreduction. We also aimed to evaluate the relative changes in syndesmotic position when fixation was converted from rigid to flexible. Methods: In this cadaveric experimentation, four below-knee specimens were utilized. Specimens were mounted in an external frame simulated weightbearing condition (350N of axial load). Specimens underwent sequential WBCT imaging in four different conditions: native normal ankle, syndesmotic instability, malreduced, and released conditions. In the instability condition, syndesmotic ligaments were surgically released using a conventional limited lateral approach. The malreduced position consisted of controlled 5mm anterior displacement, 5mm posterior displacement, 15o of internal rotation, and over-compressed (160N) states. Fixation was performed with a single implant 20mm proximal to the ankle joint. Implant utilized allowed initial rigid screw- type fixation, followed by implant flexibilization similar to a suture-type fixation (released position). Tibia, fibula, and talus WBCT images were segmented, and syndesmotic incisura and gutter distances were assessed using a 3D distance map algorithm. The syndesmotic position was compared between normal, unstable, malreduced, and released positions. Color-coded representations of the observed differences were presented (Figure). Results: When comparing normal to unstable condition, we observed significant widening of the syndesmotic posterior aspect (average, 13.9%; p=0.004). Overall, all four malreduced positions lead to significantly decreased tibiofibular distances when compared to the unstable state, consistent with syndesmotic over-compression (average, 19.8%; p=0.01), particularly in the posterior aspect of the joint (average, 26.9%; p=0.04). This over-compression was also more pronounced in the anterior displacement (31.5%) and internal rotation malreductions (23.1%). In the released flexible position we found a non-significant trend towards widening of the tibiofibular distances (average, 12%; p=0.08) when compared to the malreduced conditions, indicating partial restoration the syndesmotic relationship. The syndesmotic distances in the released position were also not significantly different from the normal condition. When compared to normal, the lateral gutter demonstrated significant widening in the unstable condition (average 16.7%; p=0.02), narrowing in the malreduced state (average 6.6%; p=0.04), and widening in the released position (average 3.7%; p=0.002). Conclusion: In this study we used 3D WBCT distance mapping to assess syndesmotic position in a cadaveric model simulating syndesmotic instability and multiple syndesmotic malreduction conditions (anterior and posterior displacement, internal rotation and over-compression). We observed significant widening when the syndesmotic ligaments were sectioned, followed by significant tibiofibular narrowing in the malreduced and fixed rigid states. When the implant fixation was released, we observed a trend towards restoration of normal syndesmotic alignment, with relative widening that was however not significantly different from the malreduced rigidly fixed state. Increased sample size cadaveric assessment and clinical studies are necessary to validate our results.

Minimal-invasive anterior approach to the hip provides a better surgery-related and early postoperative functional outcome than conventional lateral approach after hip hemiarthroplasty following femoral neck fractures

IntroductionFemoral neck fractures (FNF) are one of the most frequent fractures among elderly patients and commonly require surgical treatment. Bipolar hip hemiarthroplasty (BHHA) is mostly performed in these cases.Material and methodsIn the present retrospective study geriatric patients with FNF (n = 100) treated either by anterior minimal-invasive surgery (AMIS; n = 50) or lateral conventional surgery (LCS; n = 50) were characterized (age at the time of surgery, sex, health status/ASA score, walking distance and need for walking aids before the injury) and intraoperative parameters (duration of surgery, blood loss, complications), as well as postoperative functional performance early (duration of in-patient stay, radiological leg length discrepancy, ability to full weight-bearing, mobilization with walking aids) and 12 months (radiological signs of sintering, clinical parameters, complication rate) after surgery were analyzed.ResultsPatients in the AMIS group demonstrated a reduced blood loss intraoperatively, while the duration of surgery and complication rates did not differ between the two groups. Further, more patients in the AMIS group achieved full weight-bearing of the injured leg and were able to walk with a rollator or less support during their in-patient stay. Of interest, patients in the AMIS group achieved this level of mobility earlier than those of the LCS group, although their walking distance before the acute injury was reduced. Moreover, patients of the AMIS group showed equal leg lengths postoperatively more often than patients of the LCS group. No significant differences in functional and surgery-related performance could be observed between AMIS and LCS group at 12 months postoperatively.ConclusionsIn conclusion, geriatric patients treated by AMIS experience less surgery-related strain and recover faster in the early postoperative phase compared to LCS after displaced FNF. Hence, AMIS should be recommended for BHHA in these vulnerable patients.

Minimally Invasive Sinus Membrane Elevation Techniques: A Literature Review

Sinus augmentation surgery has become a well-accepted pre-prosthetic procedure for placement of endo-osseous implants in compromised posterior edentulous maxilla. Various procedures for bone augmentation have been used to achieve sufficient bone volume for dental implants with the lateral and crystal surgical approaches being the most common. But these bone augmentation methods, including the conventional lateral maxillary approach and sinus elevation by osteotome, have several limitations. Sinus membrane perforation is one of the most common complications of the sinus lift procedure. Thus, to overcome these limitations various minimally invasive techniques have been introduced. These techniques cause minimal postoperative pain, faster recovery and are more economical due to shorter remission period. Hence, the aim of this review article is to discuss the various minimally invasive maxillary sinus floor elevation techniques introduced.

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BackgroundTotal hip replacement (THR) is clinically and cost-effective. The surgical approach employed influences the outcome; however, there is little generalisable and robust evidence to guide practice.MethodsA total of 723,904 primary THRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient-reported outcome measures (PROMs) data with up to 13.75 years follow-up, were analysed. There were seven surgical approach groups: conventional posterior, lateral, anterior and trans-trochanteric groups and minimally invasive posterior, lateral and anterior. Survival methods were used to compare revision rates and 90-day mortality. Groups were compared using Cox proportional hazards and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, THR fixation, thromboprophylaxis, anaesthetic, body mass index (BMI) and deprivation. PROMs were analysed with regression modelling or non-parametric methods.ResultsUnadjusted analysis showed a higher revision risk than the referent conventional posterior for the conventional lateral, minimally invasive lateral, minimally invasive anterior and trans-trochanteric groups. This persisted with all adjusted FPM and adjusted Cox models, except in the Cox model including BMI where the higher revision rate only persisted for the conventional lateral approach (hazard rate ratio (HRR) 1.12 [95% CI 1.06,1.17] P < 0·001) and trans-trochanteric approaches (HRR 1.48 [95% CI 1.14,1.91] P = 0.003). PROMs demonstrated statistically, but not clinically, significant differences. Self-reported complications were more frequent with the conventional lateral approach, and the risk of 90-day mortality was higher (HRR 1.15 [95%CI 1.01–1.30] P = 0.029).ConclusionsLateral approaches for THR are associated with worse outcomes, including more deaths and revisions, than the posterior approach. We recommend the posterior approach should be considered the current standard approach for THR. Large well-designed studies are needed to assess any potential benefits from using minimally invasive posterior approaches and the conventional anterior approach.

Supracerebellar Approach for Clival Chordomas: Technical Note

The conventional retrosigmoid and lateral supracerebellar approach was used for surgery in 5select cases of large chordomas. Patients were treated during 2011 and 2019. Location of the tumor in the depth from surface, wide tumor extensions, and intimate relationships with critical neural and vascular lesions made the approach selection a formidable challenge. The discussed approach provided a satisfactory and wide exposure that permitted circumferential dissection of the tumor. Maneuvering the angulation of microscope provided access to the part of tumor that extended in the region of cavernous sinus. Radical resection of all the tumors was achieved.

Comparison of laparoscopic left ureterolithotomy between the middle colon and the lateral colon in the early stage of learning

Objective To compare the efficacy of laparoscopic ureterolithotomy via the mid-colon approach and laparoscopic ureterolithotomy via the traditional lateral colon approach for inexperienced surgeons. Methods The data of 59 patients with left ureteropelvic junction stenosis admitted to Luoyang central hospital affiliated to Zhengzhou university from March 2014 to March 2018 were retrospectively analyzed. Thirty-two patients were treated by conventional lateral colon approach and 27 patients were treated by mesocolon approach. The perioperative results and follow-up data were compared between the two approaches. The operative time, intraoperative blood loss, postoperative intestinal function recovery, postoperative pain and so on were compared between the two groups. Results The operation time of the middle colon approach group was significantly shorter than that of the conventional side colon approach group(P 0.05). Conclusions The mesocolon approach is straight through the middle colon. Exposure to ureter can save the time needed for the free colon. Even for surgeons with limited experience, this method is safe and feasible, and has the same success rate as traditional lateral colon surgery. Key words: Ureteral Calculi; Laparoscopy; Lithotripsy

Comparison between thoracoscopic and open approaches in thymoma resection.

To investigate the feasibility and indications of video-assisted thoracic surgery (VATS) in thymoma resection. The clinical data of 103 patients undergoing thymoma resection via different approaches [including conventional lateral thoracotomy approach (LTA) in 41 cases, median sternotomy approach (MSA) in 40 cases, and right-sided VATS in 22 cases] were analyzed. Among them, 59, 13, 25, and 6 patients were in Masaoka stage I, II, III, and IV, respectively. Myasthenia gravis (MG) was also found in 54 cases. The patients were followed up for postoperative survival and the improvement in MG. The prognostic indicators of patients undergoing thymoma resection via different surgical approaches (i.e., LTA, MSA, and VATS) were statistically analyzed. Eight of 103 patients died. Six patients underwent unilateral sacral nerve resection, among whom 4 patients developed respiratory dysfunction, and 3 died. Two patients died of MG after surgery, 1 patient died of tumor recurrence and metastasis, 1 patient died of heart disease, and the cause of death was unknown in the remaining patient. The drainage time was shorter in VATS group than in open groups, along with smaller tumor size. The VATS group also had shorter hospital stay in the whole series and the subgroup without accompanying MG. The improvement in MG showed no significant difference among the three surgical groups. Both 5- and 10-year survival rates were 91% in the entire cohort. VATS is like a conventional surgeries for improving MG in thymoma patients with accompanying MG. VATS resection can still be considered for thymoma that only invades the mediastinal pleura. For thymomas that have intact capsules and have not invaded mediastinal pleura, MSA surgery shall be performed to ensure patient safety if the anteroposterior diameters of the tumors are large and the masses have produced severe compression of the innominate vein, even if the tumors are still in the Masaoka stage II. For thymomas with large left-to-right diameters and with most parts of the tumors located in the left thoracic cavity, a left-sided approach (either VATS or an open approach) may be used in the absence of MG; if MG accompanies the condition, an MT approach or a bilateral VATS may be considered. In patients with unilateral pericardial phrenic nerve and/or local pericardial involvement, right-sided VATS thymectomy may be considered for thymomas located at the right side and bilateral VATS surgery can be performed for tumors located at the left side. In summary, VATS is feasible for the treatment of thymoma complicated by MG. VATS can be performed in patients with Masaoka stage I, II and (a certain portion of) III thymoma; for some patients with Masaoka stage II thymoma, especially those with compression of the innominate vein, the use of VATS should be cautious.

Displaced calcaneal fractures, midterm results of the sinus tarsi approach and screw fixation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; We present the results of displaced intrarticular calcaneal fractures managed by limited sinus tarsi approach with good clinical and radiological outcome and less number of complications seen with conventional lateral approach.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; We operated 42 patients of displaced calcaneal fractures (Sanders type II and III) from April 2016 to March 2018 by open reduction and internal fixation with limited sinus tarsi approach by cannulated screws. All patients were evaluated clinically and radiologically before and after surgery. Final evaluation was done by Maryland Foot and Ankle score.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Patients were followed up for a mean period of 24 months. 30 patients returned to preinjury status activities while 12 patients confined themselves to sedentary schedule. The mean preoperative Bohler’s angle was 3.00 (range -30 to 20) while as mean postoperative Bohler’s angle was 26.4 (range 15 to 40). No wound dehiscence or skin necrosis was seen in our study. One patient developed superficial wound infection. Three patients reported prominent hardware related to screw heads. Four patients developed complex regional pain syndrome which was managed successfully at 6 month’s period.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The limited sinus tarsi approach can be successfully used in displaced intra articular calcaneal fractures with good functional and radiological outcome. It allows good visualisation and reduction and can be used in patients with high risk. It is minimally invasive and undoubtly avoids the major soft tissue problems of extensile approach.&lt;/p&gt;

Treatment of distal humerus fracture with unexposed ulnar nerve medial elbow incision and anatomical locking compression plate

To investigate the feasibility and effectiveness of unexposed ulnar nerve medial elbow incision, open reduction and internal fixation of anatomical locking compression plate (LCP) for distal humerus fractures. Fourteen patients with distal humerus fracture were treated between January 2014 and June 2017. There were 5 males and 9 females, aged 18-85 years (mean, 65.5 years). The causes of injury included falling from height in 12 cases and traffic accident in 2 cases, all were closed fractures. Fractures were classified according to the AO/Association for the Study of Internal Fixation (AO/ASIF): 3 cases of type A2, 2 cases of type A3, 4 cases of type B2, 2 cases of type C1, 2 cases of type C2, and 1 case of type C3; without ulnar nerve damage. The time from injury to operation was 4-15 days, with an average of 7 days. The type B2 fractures were treated with unexposed ulnar nerve elbow medial incision and anatomic LCP internal fixation, the rest patients were all treated with unexposed ulnar nerve medial plus conventional lateral approach and bilateral LCP internal fixation. The operation time was 50-140 minutes (mean, 80 minutes), and the intraoperative blood loss was 20-200 mL (mean, 70 mL). There was no blood vessels or nerve damage during operation. All incisions healed by first intension, and no incision infection occurred. All the 14 cases were followed up 9-24 months (mean, 13 months). X-ray films showed that all fractures healed within 4 months without complications such as nonunion and osteomyelitis. No ulnar nerve injury, cubitus varus deformity, and ossifying myositis occurred during follow-up. At last follow-up, the elbow function was assessed by Mayo Elbow Performance score (MEPS), the results were excellent in 8 cases, good in 4 cases, fair in 1 case, and poor in 1 case (type C3 fracture), with the excellent and good rate of 85.7%. The unexposed ulnar nerve medial elbow incision can be used effectively to reduct the fracture, and it is not prone to ulnar nerve injury. Combined with the lateral approach to treat the distal humerus fracture, which has the advantages of short operation time, few trauma, little bleeding, and reliable effectiveness.

Risk factors concerning postoperative deep wound infection in patients with closed calcaneal fracture

Objective To investigate the risk factors for postoperative deep wound infection after open reduction and internal fixation for closed calcaneal fractures. Methods From January 2014 to January 2017, 190 patients with closed calcaneal fracture were treated at Department of Traumatic Or-thopaedics, Taihe Hospital. They were 118 males and 72 females with an average of 39.8 years (range, from 18 to 73 years). They were divided into a deep infection group and a non deep infection group according to the presence or absence of deep wound infection in the follow-up period. The 2 groups were compared in the general clinical data. In statistical analysis, the related risk factors were first screened by single factor analysis and followed by multivariate logistic regression analysis to identify the independent risk factors associated with the postoperative deep wound infection in patients with closed calcaneal fracture. Results The 190 pa-tients were followed up for an average of 21.3 months(range, from 13 to 31 months). Postoperative deep wound infection occurred in 11 patients, giving an overall incidence of 5.7%(11/190). The single factor analysis showed that the deep infection group incurred significantly longer time for tourniquet and used sig-nificantly more conventional extensile lateral approach than the non deep infection group (P 0.05). The multivariate logistic regression analysis revealed that tourniquet time>80 min (OR=5.949, 95%CI:1.216~29.108, P=0.028) and conventional extensile lateral approach (OR=5.414, 95%CI: 1.507~19.452, P=0.01) were independent risk factors for the post-operative deep wound infection in patients with closed calcaneal fracture after open reduction and internal fixation. Conclusions Tourniquet time and conventional extensile lateral approach may be the indepen-dent risk factors for postoperative deep wound infection in patients with closed calcaneal fracture after open reduction and internal fixation. Therefore, it is important to adopt the sinus tarsi approach and control tourniquet time within 80 minutes for prevention of deep wound infection as long as the surgical quality is ensured. Key words: Calcaneus; Fractures, bone; Infection; Risk factors

Treatment of Malunited Calcaneal Fracture With Posttraumatic Subtalar Osteoarthritis Using Lateral Endoscopic Calcaneoplasty With Posterior Arthroscopic Subtalar Arthrodesis

Malunion of calcaneal fractures is a common complication after improper nonoperative treatment. It may develop into posttraumatic subtalar osteoarthritis, lateral calcaneal wall prominence, and severe foot deformities. This Technical Note reports the technical aspects of lateral endoscopic calcaneoplasty with posterior arthroscopic subtalar arthrodesis for the treatment of malunited calcaneal fracture with lateral calcaneal wall prominence and posttraumatic subtalar osteoarthritis. This technique was chosen because it can reduce the risk of wound complication compared with a conventional lateral extensile approach. This Technical Note describes the use of the technique in a patient with prone position. This offers the advantages of easier access to the lateral surface of the calcaneus and posterior facet of the subtalar joint, and is less invasive to the soft tissue envelope on the lateral side of the foot. Moreover, the concomitant bone void area of the subtalar joint can be dealt with by an arthroscopic procedure.

The evaluation of two different surgical approaches in total hip arthroplasty according to the patient satisfaction, plantar pressure distribution and trendelenburg sign

The aim of this prospective study was to analyze the results of two different surgical aproaches for total hip arthroplasty as Trendelenburg sign, plantar pressure distribution with the help of dynamic pedobarography and clinical results by Harris Hip Score. A total of 28 patients who underwent unilateral total hip arthroplasty using two different types of lateral approach as conventional lateral Hardinge approach and intermuscular Hardinge approach described by Pai were included in this study. Plantar pressures have maesured by EMED-SF pedobarography device and analysed by the help of a commercial software; that seperates the foot to the four different parts which are called masks. TrendelenburgÂ’s sign has been estimated as grade 1 and grade 2 by the method which was described by Hardcastle and Nade. Clinical outcome was measured by comparing Harris Hip Scores pre-operatively and postoperatively at last clinic visit. In both groups after the two years from the surgery; total contact time has increased at the operation side when the results were compared before the surgery at the same side and at the other side after the surgery. Also when we looked at the first and second masks which show the significant part of the stance phase; contact areas have similarly increased and the changes at the peak pressures were similar as contact areas. In both groups Harris Hip score was increased significantly after the operation. This is the first study to compare two different lateral approaches by pedobarographic analysis, clinical evaluation and functional scoring. The fuctional and clinical early results are similar in both lateral hip approaches for total hip arthroplasty when superior gluteal nerve protection, conjuant tendon repair and postoperative rehabilitation have done well.

Minimally invasive sinus tarsal approach versus conventional L-shaped lateral approach in treating calcaneal fractures: a Meta-analysis

To compare efficacy and safety of minimally invasive sinus tarsal approach versus conventional L-shaped lateral approach in treating calcaneal fractures. The studies concerning about randomized controlled trial and non-randomized controlled trial of minimally invasive sinus tarsal approach versus conventional L-shaped lateral approach in treating calcaneal fractures from the time of creating database to March, 2017 were searched from PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMbase, ISI Web of Knowledge databases, VIP, CNKI, CBM and Wan Fang. The literatures which screened by randomized controlled trial and non- randomized controlled trial were extracted and performed quality assessment by two people. Meta analysis were performed by RevMan 5.3 software and GRADE system were used to evaluate quality. Four randomized controlled trial and 4 non-randomized controlled trial were included, totally 493 patients. Meta-analysis results showed compared with conventional L-shaped lateral approach, minimally invasive sinus tarsal approach had shorter operative time [MD=-5.41, 95%CI(-6.71, -4.12), P<0.000 01], lower incidence of postoperative complications[OR=0.10, 95%CI(0.05, 0.21), P<0.000 01], and higher AOFAS score [MD=-3.09, 95%CI(-1.72, 4.46), P<0.000 01] at the final follow-up. Böhler angle in conventional L-shaped lateral approach was better than that of minimally invasive sinus tarsal approach [MD=-0.80, 95%CI(-1.45, -0.14), P<0.05]. While there were no significant differences in postoperative Gissanes angle [MD=0.35, 95%CI(-0.77, 1.47), P>0.05] and Maryland score[MD=2.12, 95%CI(-0.71, 4.95), P>0.05] between two groups. Minimally invasive sinus tarsal approach and conventional L-shaped lateral approach has similar clinical effect for the treatment of calcaneal fractures. However, minimally invasive sinus tarsal approach has advantages of shorter operation time, lower incidence of complication and better safety. For the limited quantity of the original studies, operative approach should be chosen according to the patient.

Suprafloccular approach via the petrosal fissure and venous corridors for microvascular decompression of the trigeminal nerve: technique notes and clinical outcomes.

OBJECTIVE Surgical exposure and decompression of the entire trigeminal nerve in a conventional lateral supracerebellar approach can be challenging because of blockages from the superior petrosal vein complex, cerebellum, and vestibulocochlear nerve. The authors demonstrate a novel suprafloccular approach via the petrosal fissure and venous corridors that can be used as a substitute for the conventional route used to treat trigeminal neuralgia and present a consecutive series of patients and their clinical outcomes. METHODS Preoperative and postoperative clinical data from 420 patients who underwent this modified approach at Hangzhou First People's Hospital between March 2012 and May 2014 were reviewed. The technique expands the working space by opening the petrosal fissure and dissecting adhesions between the vein of the cerebellopontine fissure and the simple lobule as needed. Via 3 surgical corridors, the entire trigeminal nerve is exposed and decompressed thoroughly with minimal retraction of the surrounding vital structures. RESULTS The medial one-third of the trigeminal nerve accounted for the majority (275 [65.5%] cases) of neurovascular conflict sites. The lateral corridor was used in 219 (52.1%) cases, the medial corridor was used in 175 (41.7%) cases, and the intermediate corridor was used in 26 (6.2%) cases. The entire trigeminal nerve in each patient was accessed directly and decompressed properly. At the end of the 24-month follow-up period, the rate of excellent results (Kondo score of T0 or T1) was stable at approximately 90.5%. No complications were related directly to petrosal vein or vestibulocochlear nerve injury. CONCLUSIONS Based on data from the large patient series, the authors found this suprafloccular approach via the petrosal fissure and venous corridors provides full exposure and decompression of the entire trigeminal nerve, a high cure rate, and a low neurovascular morbidity rate.

Modified Lateral Surgical Approach to the Pterygopalatine Fossa.

Oral cancer, especially that originates in the maxillary tuberosity, buccal mucosa, and maxillary alveolus, is apt to invade the pterygopalatine fossa, where an intraoral approach is nearly impossible. There are 2 main types of extraoral approach to the pterygopalatine fossa; the anterior approach and the lateral approach. Although the lateral approach has an advantage compared with the anterior approach in terms of cosmetics, after the operation numbness of the lower lip occurs due to the sacrifice of the mental nerve. In the conventional lateral approach, a vertical incision is made in the center of the lower lip; a lateral flap is then elevated with the sacrifice of the mental nerve. The authors introduce here a new lateral approach to the pterygopalatine fossa with preservation of the mental nerve. In the present technique, a vertical incision was made in the corner of the mouth, and a lateral flap was then elevated with preservation of the mental nerve. This technique could also preserve the marginal mandibular branch of facial nerve in patients without a large metastasis in the submandibular lymph nodes. Additionally, expedient mandibular osteotomy, which is applied in the conventional lateral approach, could be omitted in the present technique, thus helping to prevent postoperative infection. The present approach was applied to 5 patients with oral cancer invading the pterygopalatine fossa. The postoperative numbness of the lower lip was estimated using the current perception threshold. The lesions were successfully resected with little numbness of the lower lip, and no postoperative infection occurred in any of the patients. This technique is available as an approach to the pterygopalatine fossa that preserves the mental nerve and can prevent postoperative infection.

Depth of Pleural Effusion in Thoracentesis: Comparison of Lateral, Posterolateral and Posterior Approaches in the Supine Position.

BackgroundIn patients who have difficulty sitting, thoracentesis is attempted in a supine position via lateral approach. Recently, a new table has been designed for supine thoracentesis. This table has gaps that allow access to the posterolateral and posterior hemithorax.ObjectivesTo compare important safety-related parameters between lateral, posterolateral, and posterior approaches in supine thoracentesis.Materials and MethodsFirst, two cadavers were placed supine on a table featuring gaps allowing access to the posterolateral and posterior hemithorax. Water was administered with sonographic measurement of the depth of pleural effusion (DPE) at the mid-axillary and posterior axillary line. Second, CT images were analyzed in 25 consecutive patients (32 free-shifting, moderate-to-large effusions; mean, 668 (146 - 2020 mL). DPE, craniocaudal distance that effusion can be visualized (CCD), and presence of passive atelectasis at each of the lateral, posterolateral, and posterior routes was assessed.ResultsIn each cadaver, DPE in the posterolateral route was greater than that in the lateral route (P = 0.002, P < 0.001). The amount of pleural fluid enough to spread DPE to higher than 1 cm at the posterior axillary line was less than half the amount at the mid-axillary line (500 mL vs. 1,100 mL; 800 mL vs. 1700 mL). CT showed that the DPEs and CCDs of posterolateral and posterior routes were greater than those of the lateral route (P < 0.001). In thirteen effusions (40.6%), DPE was greater than 1 cm in both posterolateral and posterior routes but less than 1 cm in the lateral route. Frequencies of passive atelectasis in posterolateral and posterior routes (81.3% and 90.6%) were higher (P < 0.001) than that in the lateral route (28.1%).ConclusionSafety-related parameters of posterolateral and posterior approaches in supine thoracentesis are far better than that of the conventional lateral approach.