Posterior Lateral Approach Research Articles

A COMPARATIVE STUDY OF ANTERO-POSTERIOR SCREW VERSUS POSTERO-ANTERIOR SCREW FOR POSTERIOR MALLEOLUS FRACTURE

ntroduction: Optimal treatment of ankle fractures with posterior malleolus fragment is controversial. Posterior malleolus is signicant stabilizer preventing posterior subluxation of ankle. Posterior malleolus fracture have generally been neglected because of these fragment is considered to be reduce spontaneously after open reduction of the lateral malleolus by ligamentotaxis by posterior-inferior tibiobular ligament. Fixation of this fragment is important in the role of ankle mechanics. WeObjectives: compare in this study better surgical & functional outcome for this posterior malleolus fracture xation by AP SCREW and PA SCREW Methods: We prospectively evaluated 30 patients (15 patients for AP screw xation and 15 patients for PA screw xation who underwent for xation by anterior posterior screw by percutaneous method and posterior lateral approach for posterior anterior screw xation. We assigned alternating patient who received AP SCREW xation VS PA SCREW xation based on order in which they presented to our institution.We use American Orthopedics foot and ankle society (AOFAS) score, range of motion of ankle and X-Ray nding. The mean Follow up was 15 Months(Range 12-20 Months). Full union without any loss of reduction was obtained in 27 out of 30 patients. As anteriorResult & Discussion: posterior screw is a blind procedure, the risk of injury to anterior tibial artery & nerve, purchase of screws distal threads for fragment is debatable. In posterior plating better visualization of fragment and anatomy will help in better xation of posterio malleoi fragment. Assessment of treatment outcome using the AOFAS demonstrated signicant high score of 97.4 in group with posterior antero screw xation with posterior lateral approach compare to score of 80 in group anterior posterior screw xation. In comparison to the anterior-posterior screwConclusions: xation,open reduction and xation of the, posterolateral key fragment of the ankle using posterolateral approach via Posterior anterior screw resulted in a more accurate fracture reduction outcome 12 months after surgery.

A comparative study of a rabbit spinal tuberculosis model constructed by local direct infection via the posterior lateral approach

The present study aims to establish a method of constructing a New Zealand rabbit spinal tuberculosis model by direct local infusion of M. tuberculosis H37Rv strain into the intervertebral disc space through the posterior lateral approach. Sixty-six New Zealand rabbits were pretreated with complete Freund's adjuvant and randomly divided into 4 group: the posterolateral approach model group (Group A, 25), ventral transverse process approach model group (Group B, 25), control group (Group C, 10), and blank group (Group D, 6). In Groups A and B, the bone holes were filled with gelatin sponge after drilling, and the local area was directly infused with 0.1 ml of M. tuberculosis H37Rv strain suspension. In Group C, the gelatin sponge was filled through the posterolateral approach and the local area was infused with 0.1 ml of normal saline suspension. In Group D, No specific treatment was performed. The general conditions of the experimental rabbits in each group were compared to those of a control group; the degree of vertebral body exposure, incision length, and complications of the two methods were compared; and the tuberculosis models were evaluated by imaging, histopathology, and bacterial culture. In Group A, the lateral side of the vertebral body was well exposed, the damage was mild, and no peritoneal rupture or gastrointestinal complications were observed. In Group B, the ventral side of the vertebral body and the intervertebral disc were exposed, and abdominal complications were more likely to occur. The survival rates of the experimental rabbits at 8 weeks after surgery were 92.0% in Group A, 88.00% in Group B, 90.0% in Group C, and 100% in Group D. MRI examinations showed that in Group A, the positive rate of radiographic bone findings was 86.9% at 4 weeks after surgery and 100% at 8 weeks after surgery; in Group B, the positive rate of radiographic bone findings was 78.2% at 4 weeks after surgery and 95.4% at 8 weeks after surgery. There was no significant difference between Groups A and B in the radiographic bone findings rate detected by the same imaging method at the same time point (P > 0.05). Eight weeks after surgery, bone destruction, paravertebral abscess, and caseous necrosis occurred in the vertebral bodies of surviving rabbits in Groups A and B. The BacT/ALERT 3D rapid culture system was used to culture the pus in the lesion, and the results showed that the positive rate of tuberculosis was 52.17% in Group A and 54.54% in Group B, and the difference was not statistically significant (P > 0.05). After pretreatment with complete Freund's adjuvant, direct infusion of the H37Rv strain of M. tuberculosis into the intervertebral disc space of New Zealand rabbits via the posterolateral approach and the ventral transverse process approach can successfully establish rabbit spinal tuberculosis models.

Giant cell tumor of dorsal spine: A rare case report

Giant cell tumor is a relatively rare neoplasm. In GCT the axial skeleton is extremely rarely involved. Most GCT arises in the meta-epiphyseal ends of the long bones. Peak incidence is between 30 to 40 years of age. GCT is usually classified as benign, but shows aggressive behavior and occasionally undergo transformation to malignancy. The patients with GCT in the spine often complain of the lower back pains, as the tumors primarily involve the sacrum. We report a case of an adolescent female complaining of the upper back pain with a sudden weakness of the lower extremities, later diagnosed with the GCT of the D8 vertebra. The present patient was operated using posterior lateral approach of spine and proper rehabilitation was done. Subsequent follow up revealed improvement in carrying out her daily activities.

STUDY OF FUNCTIONAL OUTCOMES OF TOTAL HIP ARTHROPLASTY THROUGH HARDINGE'S APPROACH

Introduction: Degenerative hip disorders are one of the most common and debilitating musculoskeletal disorders with increased morbidity and decreased quality of life. Total hip arthroplasty is a modern surgical procedure which has relieved patients from incapacitating pain arising from the hip joint. Many surgical approaches to hip have evolved over the period of time for Total hip arthroplasty. Surgical approaches differs mainly in position of patient in supine or lateral and whether the hip is dislocated anteriorly or posteriorly. The choice of surgical approaches is largely depending on personal preference and training. Gibsons posterior and hardinges direct lateral approach are the two most commonly used surgical approaches. To evaluate the Clinical and Functional outcomes of Total Hip Replacement after Harding's approach Harris Hip Score and radiological assessment was used. Harris Hip Score comprised of Pain, Functional disabilities, Deformity, Range of movements Objective: To study the clinical, radiological and fuctional outcome and complications associated with total hip arthroplasty through hardinge approach. Materials And Methods: A Prospective study was carried out from July 2019 to December 2020 under Department of Orthopaedics, SRG Hospital and Medical College, Jhalawar including 58 patients who fullled the inclusion criteria operated for total hip arthroplasty through hardinge approach. Patient's follow up was up to 12 months. Results: The functional assessments were made with modied Harris Hip scores. The results showed excellent in 41 patients (70.68%), good in 15 patients (25.86%), Fair in 2 patients (3.44%). There are no poor results in our study. Hardinge's approach has no incidence of prosthesis dislocation. Conclusion: The Hardinge's approach provides easy access to the hip joint and provides excellent exposure of both acetabular and proximal femur. Hardinge's approach is a good approach for the outcome of the Harris hip score with no major complication with satisfactory clinical, functional and radiological outcomes. Hardinge's approach has no incidence of prosthesis dislocation.

Large Paraspinal Schwannoma Removal via the Retroperitoneal Approach: A Case Report

Schwannomas are benign tumors originating from the Schwann cells of the peripheral nerve sheath; these tumors usually occur in the head, neck, and extremities and account for almost 40% of extra-medullary tumors occurring in the human spine. The general consensus for the treatment of these tumors is gross total resection. However, due to differences in volume and the complex location involving both the spinal canal and the para-spinal area including the foramen, no consensus exists regarding the choice of a surgical approach. The classic surgical method is usually through the posterior or posterior-lateral approach. Here, we present a case of paraspinal schwannoma removed via the retroperitoneal approach.

Management of Thoracic Disc Pathology via the Lateral Approach: Advances Using the Minimally Invasive Approach and Navigation.

Historically, thoracic disc pathology has been treated via open thoracotomy or open posterior costotransversectomy or lateral extracavitary approaches. However, these approaches are associated with approach-related morbidity. With advancement in such minimally invasive approaches as the lateral interbody fusion coupled with navigation, the morbidity of approaching anterior thoracic spinal pathology may be reduced. There are subtleties and nuances in the thoracic approaches that are different from the lateral lumbar interbody approaches. We discuss our technique of the minimally invasive approach to the thoracic spine, management of the rib and pleura, and incorporation of navigation into the procedure.

Dislocation of Total Hip Replacement in Femoral Neck Fracture: Do Surgical Approach and Dual Mobility Implant Matter?

Introduction: Total hip replacement (THR) in the neck of femur fracture in the elderly is associated with a higher risk of dislocation compared to hemiarthroplasty of hip or total hip replacement in the native hip. There is uncertainty regarding combining surgical approach, femoral head size, and the usage of single bearing or dual mobility to reduce the risk of dislocation. This study looks into the bearing of the prosthesis for posterior or lateral surgical hip approach as well as their head size to give a stable hip to these vulnerable groups of patients.Methods: Initial data were collected retrospectively from February 2017 till May 2019 from the electronic records database and clinical notes. Patients included in the study had a femoral neck fracture (age >60 years) who underwent a total hip replacement. Subsequent data were collected prospectively from June 2019 to July 2020.Results: High rate of dislocation was found with posterior approach and single bearing prosthesis. However, if dual mobility prosthesis was used while using the posterior approach the dislocation rate was very low. Also, with lateral approach and single bearing prosthesis using large femoral head size, the dislocation rate was negligible.Conclusions: We recommend a dual mobility prosthesis for posterior approach THR and lateral approach with single-bearing hip replacement with large size femoral head. The dislocation rate is low using this principle irrespective of the surgical approach.

Instability in Patients with Lumbar Spine Disease or Fusion Undergoing Posterior Approach vs. Lateral Approach Primary Total Hip Arthroplasty

Background and Hypothesis: 
 Dislocation rates after total hip arthroplasty (THA) in patients with fixed spinopelvic motion due to lumbar spine disease or fusion have been reported as high as 20%. Few studies exist that compare dislocation rates in patients with spine pathology undergoing THA via different surgical approaches. The purpose of this study was to compare postoperative dislocation rates in patients with lumbar spine disease or fusion between those undergoing a primary THA using a posterior versus direct lateral surgical approach. 
 
 Experimental Design or Project Methods: 
 With IRB approval, 1,205 primary THAs performed by two surgeons were retrospectively reviewed. One surgeon routinely performs THAs with a posterior approach while the other surgeon routinely uses a direct lateral approach. Chart review from the electronic medical record was conducted to identify patients who have lumbar spine disease or a lumbar spine fusion. Dislocations for patients with and without lumbar spine disease were compared by posterior approach and direct lateral approach. 
 
 Results: 
 767 posterior approach and 431 direct lateral approach THAs were available for analysis. 43.6% of all THAs had lumbar spine pathology (337/767 posterior and 185/431 direct lateral). The overall dislocation rate was 1.26% (15/1195). The main predictors of dislocation in binary logistic regression were the presence of lumbar spine pathology (OR 5.24, 95% CI: 1.47–18.69, p=0.018) and posterior surgical approach (OR 7.93, 95% CI: 1.04–60.6, p=0.046). The dislocation rate for direct lateral approach THAs with lumbar spine pathology was significantly lower compared to posterior approach THAs with lumbar spine pathology (0.0% vs 3.6%, p=0.011). 
 
 Conclusion and Potential Impact: 
 Although there were few dislocations, the study results suggest a direct lateral approach for primary THA may be beneficial to reduce postoperative dislocation for patients with limited spinopelvic motion due to lumbar spine pathology.

Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures.

Evidence demonstrates comparable clinical outcomes across the various surgical approaches to primary total hip arthroplasty (THA). However, high-quality contemporary data regarding periprosthetic joint infection (PJI) risk between direct anterior approach (DAA) and other (THA) approaches is lacking. This systematic review and meta-analysis evaluated PJI rates reported in the literature between the DAA and other approaches. Five online databases were queried for all studies published from January 1st, 2000 through February 17th, 2021 that reported PJI rates between DAA and other surgical approaches. Studies reporting on primary THAs for osteoarthritis (OA) and that included PJI rates segregated by surgical approach were included. Articles reporting on revision THA, alternative THA etiologies, or minimally invasive techniques were excluded. Mantel-Haenszel (M-H) models were utilized to evaluate the pooled effect of surgical approach on infection rates. Validated risk of bias and methodological quality assessment tools were applied to each study. Multiple sensitivity analyses were conducted to evaluate the robustness of analyses. 28 articles reporting on 653,633 primary THAs were included. No differences were found between DAA cohorts and combined other approaches (OR: 0.95; 95% CI 0.74-1.21; p = 0.67) as well as segregated anterolateral approach cohorts (OR: 0.82, 95% CI 0.64-1.06; p = 0.13). However, DAA patients had a significantly reduced risk of infection compared to those undergoing posterior (OR: 0.66, 95% CI 0.58-0.74; p < 0.0001) and direct lateral (OR: 0.56, 95% CI 0.48-0.65; p < 0.00001) approaches. The DAA to primary THA had comparable or lower PJI risk when compared to other contemporary approaches. The results of the most up-to-date evidence available serve to encourage adult reconstruction surgeons who have already adopted the DAA. Additionally, orthopaedic surgeons considering adoption or use of the direct anterior approach for other reasons should not be dissuaded over theoretical concern for a general increase in the risk of PJI. Level III.

Inveterate elbow dislocation: surgical reduction with triceps lengthening

Inveterate elbow dislocations remain common in developing countries. We report the case of a 17-year-old child who consulted us after six months of trauma to the left elbow. Clinical examination revealed a deformed elbow, locked in extension with a mobility sector of 5°. The Mayo Clinic Elbow performance score was sixty-six; the downstream vasculo-nervous examination was normal. The face and profile X-ray of the elbow showed a pure posterolateral elbow dislocation. We used the posterior medial para-tricipital and lateral approach, a first stage of arthrolysis was performed. A complete reduction was achieved by progressive and non-traumatic gentle maneuvers. Intraoperative elbow flexion was less than 80°, indicating a retraction of the triceps muscle, so a Z-lengthening plasty was necessary. This reduction was then fixed with two olecranon-humeral K-wires. At the third week, the plaster cast and K-wires were removed. The patient was subsequently referred to a physical therapist. After a ten-month follow-up, an undistorted and functional elbow with a gain of twenty-one points according to the Mayo Clinic score was obtained. Surgical reduction of a neglected elbow dislocation with triceps lengthening plasty, followed by a codified physical therapy program, results in a remarkable restoration of elbow function and stability. Keyword : elbow, dislocation, inveterate, reduction, triceps.

Short-term outcomes vary by surgical approach in total hip arthroplasty: a network meta-analysis

The direct anterior approach (DAA) has increased in popularity in recent years. Proponents cite its muscle-sparing approach and purported reduction in pain and improvement in function when compared to the traditional surgical approaches. There remains controversy surrounding the validity of these claims. The objective of this study was to compare the common total hip surgical approaches in terms of pain scores, functional outcomes, opioid use and complications within the first 12weeks postoperatively. A network meta-analysis of randomized controlled trials (RCT) comparing postoperative outcomes of different surgical approaches in primary THA up to 12weeks was performed. PubMed, MEDLINE, Embase, Web of Science and SCOPUS were systematically searched from inception to May 2020. Outcomes included pain scores, functional outcome scores, length of stay (LOS), complications and opioid consumption. Twenty-five RCTs (n = 2339) were included. The DAA demonstrated statistically significant improvement in Harris Hip Scores at 6weeks when compared to the posterior and direct lateral approaches. The DAA reduced pain scores on postoperative day 2 and at 2weeks compared to the direct lateral approach. The anterolateral approach was found to have a significantly shorter LOS compared to the other major surgical approaches. The differences in functional outcomes or pain scores did not surpass conventional cutoffs for a minimal clinically important difference. The DAA led to functional improvements at 6weeks compared to the posterior and direct lateral approaches and reduced postoperative pain compared to the direct lateral approach. However, these improvements failed to reach clinical significance. All major surgical approaches led to large improvements in function by 12weeks with relatively low complication rates. Whether a short-term statistically significant improvement in function is sufficiently patient important to recommend DAA as a standard remains uncertain.

Comparision of the early functional outcome between lateral and posterior approaches in total hip arthroplasty

Background: The choice of surgical approach for THA remains a contentious issue with regards to restoration of patient function and optimization of clinical outcome. In this study we planned to compare early functional outcome between posterior and lateral approaches using Harris Hip score and Trendelenburg test.Methods: Patients undergoing THA were assigned to the two groups to be operated by either Lateral or the posterior approach for the procedure of Total Hip Arthroplasty. Function of the hips was assessed at 2 week, 3 & 6 months after surgery using Harris hip score and Trendelenburg Test.Results: We included 30 patients in our analysis (15 Lateral and 15 posterior). The groups were similar with respect to age (p=.79), Gender (p=.705). Temporal parameters were similar among the groups at all time points. At 2 weeks, there is negative trendelenburg test in all the patients operated by posterior approach as well as lateral approach. At 3 and 6 Months, there is negative trendelenburg test in all the patients operated by posterior approach, while 13.33% patients operated with lateral approach had positive trendelenberg test. No significant difference was seen in pain at 2 weeks, at 3 months, at 6 months between posterior approach and lateral approach (p value >.05). Conclusion: From this study the functional outcome and Trendelenburg test have statistically no significant difference in both lateral and posterior approach. Good surgical technique and awareness of the anatomy of the nerve supply are key factors in preserving good abductor strength.

Microsurgical resection of foramen magnum meningioma: multi-institutional retrospective case series and proposed surgical risk scoring system.

Foramen magnum meningiomas (FMMs) are a major surgical challenge, due to relevant surgical morbidity and mortality. The paper aims to review the clinical (symptomatic improvement, complication rate, length of hospital stay) and radiological outcome (completeness of resection) of microsurgical resection of FMMs, and to identify predictors of complications. A multi-institutional retrospective review of prospectively maintained database of FMMs included 51 patients (74.5% females) with a median tumor volume of 8.18cm3 (range, 1.77-57.9cm3) and median follow-up of 36months (range, 0.30-180.0months). Tumors were resected though suboccipital approach (58.8%) or posterior-lateral approaches (39.3%), including far-lateral, extreme lateral and transcondylar approaches. Gross-total resection (GTR) was achieved in 80.4% and 98% of cases did not present tumor regrowth or recurrence. Clinical symptoms improved in 34 patients (66.7%) and worsened in 5 (9.8%). The median length of hospital stay was 5days. Mortality was null. Postoperative complications developed in 15 patients (29.4%), with cerebrospinal fluid leak (7.8%) and lower cranial nerves deficits (7.8%) as the most frequent. Craniospinal location (p = 0.03), location anterior to the dentate ligament (DL) (p = 0.02), involvement of vertebral artery (VA) (p = 0.03) were significantly associated with complication rate. These three elements allow calculating the Foramen Magnum Meningioma Risk Score (FRMMRS), to estimate the risk of post-operative complications. Microsurgical resection allows for high GTR rate and low rate of tumor regrowth or recurrence, despite complications in one third of the patients. The FMMRS allows classifying FMMs and estimating the risk of post-operative complications.

Evaluation of different surgical approaches to remove dental implants from the maxillary sinus

Dental implant surgery on atrophied maxilla has many risks; in some patients, simultaneous sinus lifting with implant placement must be performed to increase the chances of successful implantation; this procedure can cause implant migration. Eleven patients were diagnosed with implant migration into the maxillary sinus in four anatomical areas: the sinus floor above the alveolar bone, near the junction of the sinus and nasal floor, near the floor of the orbit, and the most posterior aspect of the sinus. Surgical removal was performed through four different direct non-endoscopic transoral approaches depending on the location of the displaced implant. Surgical challenges, surgery duration and postoperative complications were reported. The least challenging surgical intervention was noted when removing the displaced implants from the floor of the sinus through the crestal approach. More challenges were experienced during the surgical removal of anteriorly displaced implants near the roof of the orbital floor due to surgical access and the proximity of vital anatomical structures. Bleeding from the pterygoid venous plexus was profound with the posterior lateral approach. The choice of an appropriate surgical approach to retrieve displaced dental implants from the maxillary sinus depends on the location of the implant and the surrounding vital anatomical structures.

Imaging Analysis of Prosthesis Angle after Hip Replacement with Direct Anterior Approach in Lateral Position.

The use of lateral DAA-THA for the treatment of end-stage hip disorders has good recent clinical efficacy, does not require special surgical beds and traction equipment, uses traditional surgical instruments, reduces the requirements for surgical beds and surgical instruments, enters through the nerve and muscle anatomical gap without cutting any muscle or nerve tissue, is minimally invasive, and has good surgical maneuverability, low bleeding, low postoperative pain, short hospitalization time, and rapid recovery. It is a safe and effective minimally invasive procedure because of its light weight, short hospital stay, and rapid recovery. In this paper, we used imaging to observe the angle of the posterior prosthesis. And the results showed that hip arthroplasty using the direct anterior approach improved hip mobility in early stages compared with other approaches and reduced pain. The direct anterior approach and length between total hip arthroplasty using direct lateral and posterior lateral approach and partial data (surgical time, blood loss, etc.) were significantly worse than those using direct forward approach. In addition, the direct anterior approach to total hip arthroplasty is subject to a learning curve and requires at least 33 cases of experience to achieve a lower complication rate.

A Complication-Based Comparison Between the Posterior and Direct Lateral Approaches to Total Hip Arthroplasty: A Single-Center Experience.

IntroductionMany approaches to performing total hip arthroplasty (THA) exist, primarily due to an insufficient amount of research that would favor one approach over the other. This study aimed to compare the risk of nerve injury, dislocation, Trendelenburg gait, and stem malposition between the direct lateral and posterior approaches to THA.MethodsThe study was a retrospective cohort study, and it was conducted in King Abdulaziz Medical City. It was directed toward adult patients who underwent THA from November 1, 2003, to November 1, 2018. All figures were obtained through the BESTCare system (ezCareTech, Saudi Arabia). Categorical variables were presented as frequencies and proportions. Quantitative variables were measured as mean and standard deviation. Fisher's exact test was used to compare the risk of complications between the two approaches.ResultsThe posterior approach displayed a greater risk of stem malposition (p< 0.001) when compared with the direct lateral approach. However, neither approach showed a higher risk of dislocation, nerve injury, or Trendelenburg gait.ConclusionsA higher risk of stem malposition was observed in the posterior approach, and there were no remarkable variances between the two approaches in the risk of dislocation, nerve injury, and Trendelenburg gait. Until more meticulous nationwide studies are available to provide evidence that would favor an approach over the other, the choice of surgical approach for THA remains to depend on the patient's characteristics and the surgeon's prior experience. Regardless of the approach, preoperative, intraoperative, and postoperative factors that increase the risk of complications should also be identified and addressed adequately.

Effectiveness of simultaneous and staged minimally invasive dorsal decompression-stabilization procedures in patients with lumbar spine degenerative diseases

To compare the effectiveness of simultaneous and staged minimally invasive dorsal decompression-stabilization procedures in patients with lumbar spine degenerative diseases. A prospective study included 67 patients (41 men and 26 women) aged 48 (34; 56) years who underwent a single-level minimally invasive spinal root decompression and transforaminal interbody fusion via Wiltse posterior-lateral approach. Two study groups were distinguished: group I (simultaneous surgical interventions, SiSI) (n=29), in which guide spokes and transpedicular screws were installed simultaneously by two surgeons within one x-ray session from two sides; group II (staged surgical interventions, StSI) (n=38), in which staged transpedicular stabilization was performed (decompression side followed by contralateral side). Mean follow-up was 14 months in group I and 20 months in group II. We considered intraoperative fluoroscopy and irradiation dose, duration of surgery and anesthesia with calculation of doses of opioid drugs, blood loss, time of activation, hospital-stay and perioperative morbidity. Clinical outcomes were studied in long-term postoperative period. Simultaneous approach ensured less time of intraoperative fluoroscopy (p=0.029) and irradiation dose (p=0.035), duration of surgery (p=0.01) and anesthesia (p=0.02), amount of opioid drugs during anesthesia (p=0.017). Blood loss, duration of activation and hospitals-stay were similar in both groups (p=0.35, p=0.12 and p=0.57, respectively). There was comparable improvement in VAS score of pain in the lumbar spine and lower extremities in both groups (p=0.63 and p=0.31, respectively). According to SF-36 questionnaire, there was no between-group difference in physical and psychological components (p=0.44 and p=0.72, respectively). There was significantly greater number of adverse effects of anesthesia in the StSI group (26.2% vs. 6.8%, p=0.003). At the same time, the number of surgical postoperative complications was similar in both groups (3.4% vs. 5.3%, p=0.62). Simultaneous minimally invasive dorsal decompression-stabilization procedures have some significant advantages over staged approach regarding intraoperative parameters and adverse effects of anesthesia in patients with lumbar spine degenerative diseases. Nevertheless, there were similar clinical data and small incidence of surgical perioperative complications.

Ceramic-on-metal bearing in short stem total hip arthroplasty: ions, functional and radiographic evaluation at mid-term follow-up.

The aim of this study is to evaluate clinical, radiographic and laboratory results of ceramic-on-metal (CoM) (hybrid hard bearing) in total hip arthroplasty (THA), associated with a short stem implant. From a cohort of 37 patients suffering from primary or secondary hip osteoarthritis who underwent THA using CoM bearing, 19 were suitable for this study. All procedures were performed by the same surgeon using a posterior-lateral approach. All patients were compared clinically using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analogue scale (VAS), 12-item Short Form Health Survey (SF12F/M), and radiographically (offset, CD angle, limb length discrepancy, cup inclination and anteversion, subsidence, osseointegration, heterotopic ossification). Blood samples were collected in order to evaluate chromium (Cr) and cobalt (Co) ions level. Radiographic evaluations were carried out by 3 different blinded surgeons. A statistical analysis was performed. At a mean follow-up of 97 (73-125) months all implanted stems were well-positioned and osseointegrated. Clear improvements were observed for clinical scores comparing preoperative and postoperative values. Radiographic evaluation showed a good ability to restore proper articular geometry. Cr ion analysis revealed values below the safety threshold except for 1 case. Serum levels of Co were below the threshold in all patients. There was a statistically significant correlation only between Cr metal ions and length of follow-up. CoM bearing has proven to be reliable and safe at a mean 8-year follow-up for patients in whom the components were correctly implanted. The rise of blood metal ions was minimal and involved neither systemic or local toxicity nor influenced clinical results.

Treatment of Posterior Cruciate Ligament Tibial Avulsion: A New Modified Open Direct Lateral Posterior Approach.

The optimal operative technique for the treatment of the tibial-side avulsion injuries of the posterior cruciate ligament (PCL) is debatable. This study was aimed to evaluate the postoperative outcomes and complications if any after an open direct, posterolateral approach using cannulated cancellous screw fixation of a PCL tibial avulsion. From January 2016 to June 2018, 17 patients (14 males and 3 females) with PCL avulsion fraction treatment-who underwent open reduction and internal fixation using cannulated cancellous screws-were included in this prospective study. A direct posterolateral approach in the prone position was used in all cases. The Lysholm's knee score and International Knee Documentation Committee (IKDC) score were assessed preoperatively and during regular follow-up examinations for at least 1 year (12-20 months) postoperatively. All patients had fracture union and all of their knees were stable upon physical examination. No nerve or blood vessel injuries occurred. The mean Lysholm's scores and mean IKDC scores were improved significantly at the last follow-up. This study provides evidence that open direct posterolateral approach may be reliable for the treatment of tibial-sided bony PCL avulsion fractures. This approach can provide direct visualization of the posterior capsule and PCL avulsion site associated with good reduction and stable fixation, easy application of the screws directly from posterior to anteriorly without extensive soft tissue damage. Nevertheless, long-term follow-up is recommended.

Does Medial Overhang of the Greater Trochanter Influence Femoral Stem Position During Cemented Hip Arthroplasty? A Retrospective Radiological Review.

PurposeWe investigate the effect that variation in the anatomy of the greater trochanter (GT), in particular the medial overhang, can have on femoral stem alignment in total hip arthroplasty (THA).MethodsPre- and post-operative anteroposterior pelvic radiographs of 576 consecutive patients undergoing THA were retrospectively analysed. Medial overhang of the GT relative to the lateral femur diaphysis was measured. The femoral morphology was classified according to Dorr classification. The alignment of the femoral stem axes on post-operative radiographs was recorded.ResultsFollowing exclusions, 500 THAs performed by six surgeons all using the same cemented polish tapered stems were analysed: 320 THAs were performed via the posterior-lateral approach and 180 via the direct-lateral approach. Mean stem varus was 0.53° (range: -7 to 7°). Mean medial overhang was 21 mm (range: 8-43 mm). An overhang of <20 mm had a mean varus of -0.1°, an overhang of 20-30 mm had a mean varus of 0.8° and an overhang of >30 mm had a mean varus of 2.33°. Those with an overhang of <20 mm had a 2% chance of significant varus (≥4°), increasing to 9.5% for 20-30 mm and 44.4% for >30 mm. One-way analysis of variance comparison of these groups returned a p-value of <0.0001. Dorr type A femora had a mean varus of 0.52°, Dorr B had a mean varus of 0.54° and Dorr C had a mean varus of 0.46°. The posterior-lateral approach had a mean varus of 1.05° (range: -7 to 7°) compared to -0.40° (range: -5 to 5°) for direct-lateral approach. The t-test comparing approach was p < 0.0001.DiscussionThe extent of medial overhang of the GT can adversely affect the final stem position in THA, resulting in a statistically significant increase in mean stem varus. There is a linear relationship between stem position and GT overhang, with an increased chance of significant varus malposition (44.4% with >30 mm of overhang).ConclusionsScrutiny of pre-operative radiographs to determine high-risk patients is important, and we propose a classification system of GT anatomy to aid assessment.