Standard Posterolateral Approach Research Articles

Multi-center experience with outpatient total hip arthroplasty via a standard posterolateral approach.

This study sought to evaluate the safety, efficacy, and resource utilization of a pilot outpatient surgery program for total hip arthroplasty compared to traditional inpatient total hip arthroplasty performed via the posterolateral approach. A cohort of 68 patients from two sites were enrolled in a regional pilot project for outpatient total hip arthroplasty (THA) and matched 1:1 against a cohort of patients undergoing routine inpatient THA. Data was extracted retrospectively from patient and hospital charts including adverse events (AE), readmission within 90 days, emergency room (ER) visits, patient calls, patient-reported outcome measures, length of stay, and multiple surgical variables. The outpatient group had a mean hospital stay of 13 hours, whereas the inpatient group had a mean of 58 hours (p<0.001). Three outpatients and four inpatients experienced post-op complications. Three inpatients and one outpatient visited the ER within 8 weeks of surgery. No difference in pre-operative hemoglobin (p = 0.210), or surgical blood loss (p = 0.550) was found between study groups. There was no difference found between groups regarding Oxford-12 Hip Score improvement, nor satisfaction at six months, one and two years (p>0.125). This study demonstrates that outpatient THA using the posterolateral approach is as safe and effective as inpatient THA for overall healthy and carefully screened patients, based on the low rate of AEs observed and similar patient outcomes reported. Significantly reduced time in hospital demonstrates the reduced healthcare resources associated with outpatient THA.

Changes In Serum Creatine Kinase In Patient After Total Hip Arthroplasty

Background : Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation.&#x0D; Objective : This article presents a literature review regarding changes in serum creatine kinase in patients after total hip arthroplasty.&#x0D; Method : Descriptive research with a qualitative approach, systematic literature review study. Researchgate, Google Scholar and ScienceDirect searches reviewed changes in serum creatine kinase in patients after total hip arthroplasty. A total of 5 studies conducted between 2019-2023 were included in this review.&#x0D; Results : A total of 42,890 titles were identified and found 5 studies that met the requirements/criteria which discussed changes in serum creatine kinase in patients after total hip arthroplasty.&#x0D; Conclusions : We analyzed biochemical markers of muscle damage in patients treated with total hip arthroplasty with minimally invasive and standard posterolateral approach to providing objective evidence of the local soft-tissue injury at the time of arthroplasty. The objective measurement of muscle damage marker provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Changes in creatine kinase serum in patient after total hip arthroplasty

Background: Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in post-operative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation. Methods: This study design was a descriptive research with a qualitative approach, systematic literature review study. ResearchGate, Google Scholar and ScienceDirect searches reviewed changes in serum creatine kinase in patients after total hip arthroplasty. A total of 5 studies conducted between 2019-2023 were included in this review to present a literature review regarding changes in serum creatine kinase in patients after total hip arthroplasty. Results: We analyzed biochemical markers of muscle damage in patients treated with total hip arthroplasty with minimally invasive and standard posterolateral approach to providing objective evidence of the local soft-tissue injury at the time of arthroplasty. A total of 42,890 titles were identified and 5 studies that met the requirements/criteria which discussed changes in serum creatine kinase in patients after total hip arthroplasty. Conclusion: The objective measurement of muscle damage markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Is Posterior Femoral Neck Cortex an Obstacle in Achieving Sagittal Plane Balance of Uncemented Straight Femoral Stem?

There is a paucity of the literature that aims to improve sagittal plane balance of femoral stem in hip arthroplasty. We have comparatively evaluated the effect of trimming the posterior cortex left in situ after femoral neck osteotomy and counter-clockwise rotation of starting awl with respect to their ability to achieve neutral alignment of femoral stem in sagittal plane. (1) Which of the two techniques under reference is more reliable in achieving a sagittal plane balance of the femoral stem in the femoral canal? (2) Does either of the two techniques have the potential to adversely affect other parameters for the optimum placement of femoral stem? This prospective study involved a total of 60 patients (age group of 18 to 60years) who underwent primary total hip arthroplasty (THA) through a standard posterolateral approach. They were randomized into groups (1) PNCT (n = 30): femoral canal preparation was done by posterior neck cortex trimming method; (2) CCRA (n = 30): femoral canal preparation was done by counter-clockwise rotation of starting awl. Postoperatively, radiographs and computed tomography were obtained and angle of femoral stem with the femoral canal in coronal and sagittal plane, femoral stem tip deviation in coronal and sagittal plane, anteversion of the femoral stem, duration of canal preparation and blood loss were analyzed between the two groups. Based on our results, there is a significantly better sagittal alignment of the femoral stem within the femoral canal, both in terms of angle of the femoral stem with the femoral canal (p < 0.001) and the deviation of the femoral stem tip from the center of the medullary canal (p < 0.001) when the posterior neck cortex was trimmed. Canal preparation by trimming the posterior neck cortex took a mean of 11.93min (range 8-15min) against the mean duration of 6.87min (range; 5min to 9min) in the other group (p < 0.001). Trimming the posterior femoral neck cortex after neck osteotomy results in better sagittal plane balance of uncemented straight femoral stem. III.

The Supercapsular Percutaneously Assisted Total Hip (SuperPATH) Approach Revisited: Technique Improvements after the Perioperative Experience of 344 Cases.

The SuperPATH approach is a direct superior portal-assisted approach for total hip arthroplasty (THA) that utilizes the interval between the gluteus minimus and the piriformis to access the hip capsule. Patients and Methods: SuperPATH arthroplasty was performed by a single surgeon between December of 2016 and December of 2021 in 344 cases. The technique described by Chow was performed in all cases. The average length of stay was 1.3 days, and all patients were discharged for home. All patients were mobilized on the day of the operation. Six cases presented complications: four intraoperative femur fractures and two peroneal nerve palsies. No infection and no hip dislocation were noticed in any case. Modifications: We recommend that the patient be placed as far from the surgeon as possible as well as the use of a sterilized standard linen pack to elevate the foot and internally rotate the hip. In addition, regarding instrumentation, we recommend the use of a 4.5 mm drill for the first guidance femur drilling and a standard corkscrew for femoral head removal. Finally, we propose a different reduction technique using a hook. The use of the SuperPATH approach allows for maximal tissue sparing through preservation of external rotators and minimizing stretching of the gluteus medius. There is no range of motion restrictions postoperatively and patients can achieve a high level of function with a very low dislocation risk and reduced inpatient stay. Furthermore, an incision extension is possible if needed in complex cases. For surgeons familiar with the standard posterolateral approach, the SuperPATH approach is a reliable and safe method with promising results for the patient. In order to improve the surgical effect and facilitate some steps in the procedure, we share our experience and recommend some modifications.

Does accelerometer-based portable navigation provide more accurate and precise cup orientation without prosthetic impingement than conventional total hip arthroplasty? A randomized controlled study

This prospective randomized controlled study examined whether accelerometer-based navigation resulted in more accurate or precise cup orientation than a conventional mechanical guide. We used a simulation to evaluate how cup orientation affected potential hip range of motion (RoM) and freedom from prosthetic impingement. Sixty hips were randomly allocated 1:1 to accelerometer-based portable navigation or conventional guidance. Procedures were performed through a standard posterolateral approach and combined anteversion technique. Cup inclination, cup anteversion, and stem anteversion were measured using computed tomography (CT). Using CT-based simulation, we evaluated impingement-free potential RoM and the proportion of hips with potential RoM required for daily activities. Absolute cup inclination and anteversion error averaged 4.3° ± 3.2° and 4.4° ± 2.9° for the navigation cohort and 5.6° ± 3.7° and 5.7° ± 4.2° for the conventional cohort, with no significant differences. Navigation resulted in significantly less variation in anteversion error than the conventional guide (p = .0049). Flexion, internal rotation (IR) at 90° of flexion, extension, and external rotation (ER) averaged 123° ± 12°, 46° ± 13°, 50° ± 10°, and 73° ± 23°, respectively, in the navigation cohort and 127° ± 10°, 52° ± 14°, 45° ± 10°, and 63° ± 12°, respectively, in the conventional cohort (p = .15, .15, .03, and .03, respectively). Flexion > 110°, IR > 30° at 90° of flexion, extension > 30°, and ER > 30° were achieved by 93%, 90%, 100%, and 100% of hips, respectively, in the navigation cohort and 97%, 93%, 97%, and 100% of hips, respectively, in the conventional cohort, with no significant differences. Cup anteversion with the navigation system was more precise, but not more accurate, than with the conventional guide. The navigation cohort exhibited greater potential extension and ER than the conventional cohort, but no significant difference in impingement within the potential RoM required for daily activities. 29036. Date of registration: November 14, 2017.

Heterotopic ossification in primary total hip arthroplasty: risk factor analysis

BackgroundAim is to identify if age, sex, type of posterolateral approach (mini vs standard), surgical time and time from surgery to drainage removal were independent risk factors for heterotopic ossifications after total hip arthroplasty.Materials and methodsPatients who underwent a THA with posterolateral approach during a 15 years period were included. The exclusion criteria were absence of X-rays follow-up or HO prophylaxis protocol adoption. The following data were collected: age, sex, type of approach (classical/minimal-invasive), surgical time, time from surgery to drainage removal. Two orthopedic surgeons independently reviewed the 2 years follow-up X-rays and classified the HO according to Brooker classification. Severe HO was defined if HO were classified as major than grade 2. Correlation between severe HO and risk factor has been tested with multivariable analysis.ResultsAbout 1225 patients were included: mean age of 63.8 years, 504 were men. HO were found in 67.6%. Men showed higher severe HO rate than woman (44.1% vs 29.1%, p = 0.001). Patients older than 65 years showed higher severe HO rate (30.3% vs 39.9%, p = 0.002). Standard posterolateral approach was performed in 75.4% and severe HO rate was 32.8% versus 27.1% in those treated with the minimally invasive approach (p = 0.067).In 75.6% of cases surgery lasted less than 90 min and this group showed a severe HO rate in 29.1%, while patient with longer surgical time showed a rate of 35.7% (p = 0.033). In 47.4% of patients, the drainage was removed in the first post-operative day, in this group severe HO rate was significantly lower than the others: 24.8 versus 36.2% (p = 0.001).DiscussionMale sex, age older than 65 years, surgical time longer than 90 min and delayed drainage removal are risk factors for severe HO. Patients with one or more of those risk factors should be identified as good candidates for HO prophylaxis.

New Cementless Total Hip Arthroplasty. A Multicentre Prospective Minimum 2 Year Follow-up Clinical Outcomes Study.

Background: Cementless implants were introduced approximately three decades ago in order to address aseptic loosening of cemented hip prostheses with the aim of early mobilisation, better functional result and bone stock preservation. The primary objective of this study is to introduce a new cementless HA coated implant and report its minimum 2 year follow up results. Material &amp; method: This is a prospective, multi-centre, consecutive series, clinical outcomes study with 75 patients. Inclusion criteria for the study were age 21- 85 years, BMI &lt;40, osteoarthritis of the hip. Patients were operated using a standard posterolateral approach. The Paragon stem and the Global cup were implanted in a cementless method. Patients were reviewed at 6 weeks, 6 months and two years postoperative. At each visit AQoL 6D, VAS Pain, Oxford Hip Score were recorded. Post-operative X-Rays were reviewed at immediate post-operative, 6 months and two years. Results: Mean duration of surgery was 63.1 min with range of 40-120 min. AQoL over time changed from pre-op mean 50.51, at 6 weeks and at 2 years mean 35.06. Oxford hip score had upward trend from pre-op to post-op 6wks assessments and a plateau in following assessments. VAS pain trajectories, showing a clear downward trend from pre-op to post-op 6wks and a plateau in the following postoperative assessments. Discussion &amp; conclusion: The combination of Paragon stem and Global cup incorporates proven features of successful implants. The unique feature of lateral tension grooves and progressive neck dimension with dual offset options. This combination has shown promising early results with early follow up of a minimum of 2 years, with a 100% survivorship of the stem and 98.7% survivorship overall for any reason and is a good cementless option in THA.

Direct superior approach for total hip arthroplasty.

The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs. The DSA patients had a shorter length of hospital stay (mean 2.09 days (SD 1.20) DSA vs 2.74 days (SD 1.17) PLA; p < 0.001) and shorter time to discharge from the inpatient physiotherapy teams (mean 1.44 days (SD 1.17) DSA vs 1.93 days (SD 0.96) PLA; p < 0.001). There were no differences in operating time (p = 0.505), pain levels up to postoperative day 1 (p = 0.106 to p =0.242), OHS (p = 0.594 to p = 0.815), satisfaction levels (p = 0.066 to p = 0.299), stem alignment (p = 0.240), acetabular component inclination (p < 0.001) and anteversion (p < 0.001), or leg length discrepancy (p = 0.134). While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. Cite this article: Bone Joint J2021;103-B(3):500-506.

Time efficiency of direct anterior hip arthroplasty compared to postero-lateral approach in elderly patients.

IntroductionPrimary arthroplasty of the hip joint is currently one of the most commonly performed procedures in orthopedics. In Poland we are observing significant changes in the age structure. With the prolonged life more and more elderly patients require musculoskeletal surgery to maintain comfortable and painless mobility. Reducing the duration of the procedure reduces the costs of anesthesiology, surgical and instrument teams, as well as the operating room technical team. The aim of the study was to compare the time required to perform hip joint arthroplasty by the direct anterior approach (DAA) with the postero-lateral approach (PLA) in our hospital.Material and methodsA retrospective analysis of 559 total and bipolar cemented and cementless hip replacement procedures based on two operative approaches – the minimally invasive DAA over the course of 2 years, and the standard PLA over the course of 3 years – was performed.ResultsStatistically significant differences were observed between the approaches used for cementless total arthroplasty with regard to the mean treatment times: 51.9 min for the 272 DAA cases, and 78.3 min for the 190 PLA cases (p < 0.0001). For the cementless hemi-arthroplasty procedure, the mean treatment times were 46.9 min in 36 patients for DAA, and 48.2 min for 61 patients for PLA (p = 0.57).ConclusionsMinimally invasive DAA significantly shortens the time of the procedure in elderly patients compared to PLA. Further study is needed to analyze other aspects of those two approaches.

Assessment of the Learning Curve of Supercapsular Percutaneously Assisted Total Hip Arthroplasty in an Asian Population

The supercapsular percutaneously assisted total hip (SuperPATH) approach is a microinvasive approach that was developed to minimize surgical disruption of soft tissue during routine total hip arthroplasty (THA). This study was aimed at assessing early outcomes and learning curves of the SuperPATH approach in one Chinese hospital's experience. Early outcomes of the first consecutive 78 SuperPATH cases (80 hips) performed by the same surgeon were evaluated. The patients were divided into 4 groups according to the surgical order. The incision, intraoperative blood loss, hospital stay, Harris hip score, and complication occurrence in each group were evaluated. Learning curves were assessed using operative time and intraoperative blood loss as surrogates. The operation time and intraoperative blood loss of groups A and B were more than those of groups C and D, and the difference was statistically significant (P < 0.05); however, there was no statistically significant difference between the two groups (group A vs. group B, P = 0.426; group A vs. group B, P = 0.426). There was no statistically significant difference in terms of incision length and hospital stay, and Harris hip score at the last follow-up was increased with statistically significant difference when compared with that preoperatively among the 4 groups. One case of periprosthetic fracture occurred in group A. No other complication, such as joint dislocation, sciatic nerve injury, prosthesis loosening, periprosthetic infection, and deep vein thromboembolism, occurred in the 4 groups. In summary, for surgeons who are familiar with the standard posterolateral approach, they could achieve more familiarity with SuperPATH after 40 cases of surgery.

Comparison of clinical and economic outcomes between the direct anterior approach and the posterolateral approach for primary total hip arthroplasty

IntroductionTotal hip arthroplasty (THA) is one of the most frequently performed surgical procedures in orthopedics. The most commonly employed approaches are the posterolateral approach (PLA) and the lateral approach. Minimally invasive techniques such as direct anterior approach (DAA) and MIS DAA (minimal invasive surgery direct anterior approach) are used more and more often. The aim of the study was to compare the two approaches DAA and PLA in terms of length of stay, economic outcomes, quality of life, hip joint function and hip joint awareness.Material and methodsThe study was performed as a retrospective analysis of 52 cementless total hip arthroplasty procedures performed by MIS DAA and 56 cementless THA performed by classic standard PLA. The evaluation of hip joint awareness, quality of life, hip joint fitness assessment and economic indicators were evaluated.ResultsThe mean duration of the anterior approach procedure (48.96 minutes) was found to be around half that of the posterior approach (102.52 minutes) (Levene’s test: F = 2.37; p &gt; 0.005). The mean durations of the two types of approaches were found to be significantly different (Student’s t test: t (106) = –16.15; p &lt; 0.005). The shorter mean duration of stay and shorter procedure duration associated with the anterior approach result in mean savings of PLN 5465.96 per procedureConclusionsThe MIS DAA procedure is a safe and less traumatizing surgical approach for hip arthroplasty which allows faster post-operative primary mobilization, shorter procedure time and sooner discharge from hospital than standard PLA. Significant reduction in costs of hospitalization was observed in the MIS DAA procedure.

Primary bipolar hemiarthroplasty as a treatment option for unstable intertrochanteric fractures.

Management of unstable intertrochanteric fractures is challenging, especially in patients with osteoporosis. Comminuted unstable intertrochanteric fractures require postoperative immobilization. Several recent reports have recommended hemiarthroplasty for treatment of unstable intertrochanteric fractures to avoid various immobilization-associated complications. The purpose of this study was to evaluate the functional and clinical outcomes of bipolar hemiarthroplasty for unstable intertrochanteric fractures in older persons. Sixty patients aged over 75 years underwent hemiarthroplasty to treat unstable intertrochanteric fractures and were followed up over 12 months. All surgeries were performed by the same surgical team using the standard posterolateral approach. Wires, cables, and plates were used as required. Use of cemented protheses was considered when the lesser trochanter had been displaced. All patients were allowed full weight-bearing as tolerated. Clinical evaluation was based on Harris Hip Scores. The cohort comprised 16 men and 44 women (aged 75-96 years). According to the Jensen classification, 24 fractures were type III, 14 type IV, and 22 type V. Cement was used in 24 patients. At 12 months follow-up, Harris Hip Scores were excellent in 18%, good in 42%, fair in 25%, and poor in 15%. No radiological abnormalities were detected. Primary bipolar hemiarthroplasty for treating unstable intertrochanteric fractures eliminates the need for prolonged immobilization and permits early ambulation. As reported by others, hip hemiarthroplasty is an effective treatment choice for unstable intertrochanteric femoral fracture in older patients.

Direct Superior Approach to the Hip for Total Hip Arthroplasty.

Traditional posterior approaches to the hip, posterolateral and mini-posterior, violate the iliotibial band and the short external rotators, specifically the quadratus femoris and obturator externus muscles1-4. The direct anterior approach does not violate the iliotibial band or the quadratus femoris, resulting in earlier ambulation and lower dislocation rates1,5-9. The direct superior (DS) is a posterior approach that spares the iliotibial band, obturator externus tendon, and quadratus femoris muscle. The goal of minimally invasive surgery (MIS) is to disrupt the least amount of tissue necessary to adequately expose the hip and correctly place implants. Although MIS total hip arthroplasty (THA) has not lived up to all of its promises10-13, MIS-THA may enable early ambulation and decrease length of stay14-16. The patient is positioned in the lateral decubitus position. An 8 to 10-cm incision is made at a 60° oblique angle starting from the posterior-proximal corner of the greater trochanter. Only the gluteus maximus fascia is incised; the Iliotibial band is completely spared. The gluteus maximus muscle is split bluntly, exposing the gluteus medius muscle, piriformis tendon, and triceps coxae (the obturator internus and superior and inferior gemellus muscles). The piriformis and conjoined tendon are released from the greater trochanter and tagged. The gluteus minimus is elevated, exposing the posterior hip capsule. An arthrotomy is performed prior to dislocating the hip with flexion, adduction, internal rotation, and axial compression. The femoral neck is resected, the acetabulum is reamed, and components or trials are impacted into position. Hip stability is assessed. Final implants are placed. The posterior capsule, piriformis, and obturator internus tendons are repaired anatomically. The fascia and skin are closed. Posterolateral approach.Mini-posterior approach.Direct lateral approach.Anterolateral approach.Percutaneously assisted total hip (PATH).Supercapsular PATH (SuperPath). The DS approach to the hip differs from the traditional posterior and mini-posterior approaches because it preserves the iliotibial band, quadratus femoris muscle, and obturator externus tendon1, potentially suppressing dislocation. The DS approach to the hip causes less soft-tissue destruction, especially to the gluteus minimus and tensor fasciae latae muscles, compared with the direct anterior approach to the hip, suggesting DS-THA may enhance postoperative mobility1,3,14-16. DS-THA is extensile by extending the incision distally, incising the iliotibial band, and releasing the quadratus femoris muscle. This converts a DS approach to a standard posterolateral approach, providing additional visualization.

Transtrochanteric approach can provide better postoperative care and lower complication rate in the treatment of hip fractures.

PurposeDislocation is an important complication that increases the mortality, morbidity, and postoperative care following bipolar hemiarthroplasty. It is thought that the transtrochanteric approach that enables access to the femoral neck directly from the fracture line at the coronal plane of the greater trochanter without opening the posterior and anterior capsules could reduce the risk of dislocation. Additionally, it is argued that preservation of the external rotators could also be advantageous for patient rehabilitation and muscle strength. The aim of this study is to compare the effectiveness of the standard posterolateral approach and transtrochanteric approach performed from the fracture line, primarily the rate of dislocation, in osteoporotic Evans Type IV–V unstable intertrochanteric fractures on which bipolar hemiarthroplasty was performed.Patients and methodOne hundred and twelve patients had Type IV–V fracture according to Evans classification and underwent hemiarthroplasty were enrolled in the study. Patients operated using the posterolateral approach, that is, Group 1 (n=48), and patients operated using the transtrochanteric (transfracture) approach, that is, Group 2 (n=64), were compared in terms of dislocation, surgical duration, amount of blood transfusion, infection, mortality, and trochanteric nonunion. Factors that could affect the development of dislocation from the patient, surgery, and implant were also analyzed.ResultsIt was found that the rate of dislocation was statistically significantly higher in Group 1 in comparison to Group 2 (P<0.05). It was also observed that the surgical duration was statistically significantly shorter in Group 2 (P<0.05). It was found that the presence of a cognitive disorder, trochanteric nonunion, and use of posterolateral surgical approach resulted in a statistically significant increase in the rate of dislocation (P<0.05).ConclusionTranstrochanteric (transfracture) approach is an effective method for minimizing possible complications following hemiarthroplasty, especially dislocation.

Changes of the serum creatine phosphokinase in total hip arthroplasty in Vietnamese patients

BackgroundWe analyzed biochemical markers of muscle damage in patients treated with total hip arthroplasty with minimally invasive and standard posterolateral approach to providing objective evidence of the local soft-tissue injury at the time of arthroplasty. MethodsSixty-one patients in group one treated with minimally invasive total hip arthroplasty through an approach less 9 cm length and fifty-three patients in group two treated with the same procedure through an approach more than 9 cm length. Serum creatine phosphokinase (CPK) levels were measured preoperatively and on postoperative days 1, day 2 and 5. ResultsThe levels of the markers of muscle damage were increased in both group. The rise in the CPK level on postoperative day 1 in both group was 2.5–3 times higher than preoperative CPK and were slightly decreased on the next few days. There were no significant differences between the two cohorts of changes of CPK level. ConclusionsThe objective measurement of muscle damage marker provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Total hip arthroplasty performed with a tissue-preserving technique using superior capsulotomy.

We present a minimally invasive tissue-sparing posterior superior (TSPS) approach that intends to protect the abductor muscles during total hip arthroplasty, prevents the release of the short rotator muscles, and provides the surgeon with the option to repair the posterior capsule. We hypothesized that the TSPS technique would produce a better clinical outcome, faster recovery, and lower complication rates, and that it would not jeopardize acetabular component position. A retrospective, observational study was conducted in a consecutive series of patients. A cohort of 130 patients (130 hips) operated with a standard posterolateral approach were compared with a cohort of 132 patients (132 hips) operated with a TSPS approach. Patients were assessed with the Harris hip score (HHS) and Western Ontario and McMaster Universities index (WOMAC), which were carried out preoperatively, one month (HHS only), three months, one year, and at four years post-operatively. Compared with the standard group, patients in the TSPS group showed a faster return to ambulation as reflected in better post-operative HHS and WOMAC scores up until one year (p < 0.05). No significant differences in HHS (p = 0.564) and WOMAC (p = 0.796) scores were found at the four-year follow-up. No major adverse events were observed in either group. The TSPS approach yielded better early clinical outcomes and appears to be a safe and reliable technique. However, these early differences do not appear to be sustained over time, as comparable mid-term clinical outcomes with similar complications rates were observed.

An evolution in the management of fractures of the ankle

There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety. We performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracture which was fixed using a posteromedial approach. Five patients underwent initial temporary spanning external fixation. The outcome was assessed at a median follow-up of 29 months (interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were assessed for the quality of the reduction. The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm (IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting the medial forefoot, which resolved within three months. We found that the posteromedial approach to the ankle for the surgical treatment of Haraguchi type 2 posterior malleolar fractures is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. Cite this article: Bone Joint J 2017;99-B:1496-1501.

Minimally invasive bronchoplastic resections

Background: Minimally invasive lung surgery has recently proven to be superior to anterolateral thoracotomy in terms of postoperative pain and quality of life for early stage lung cancer. With these advantages, it is not surprising that surgeons all around the world try to push the limits of Video-assisted thoracoscopic surgery (VATS). Aim of this study was to explore the feasibility of a minimally invasive approach to bronchoplastic resection and to point out specific technical considerations. Methods: Between 2009 and 2015, 15 minimally invasive bronchoplastic resections were performed using a standard 3 port VATS technique. During the same time, 463 patients underwent some form of anatomic VATS lung resection (lobectomy, segmentectomy, bilobectomy or pneumonectomy) and 21 open bronchoplastic resections using a standard posterolateral thoracotomy approach. Perioperative results of the minimally invasive group were collected in a prospectively maintained database. Results: Median age of the patients was 57 years (17–75 years). There were 8 (53.3%) female patients. Reason for resection was primary lung cancer in all patients. Final pathology was adenocarcinoma in 4, squamous cell cancer in 5, carcinoid tumors in 4 and other types of histology in 2 patients (mucoepidermoid tumor and large cell tumor). Type of bronchoplastic procedure was simple closure of the bronchus in two patients, wedge bronchoplasty in 12 patients and circumferential sleeve in one patient. Median operative time was 217 minutes (141–390 minutes). Median chest tube duration and hospital stay was 4 days (2–50 days) and 9 days (6–63 days), respectively. Postoperative complications occurred in 2 patients (13.3%), with one atelectasis prompting bronchoscopy and one chylothorax who needed re-thoracoscopy and ligation of the cystic duct. Conclusions: Minimally invasive bronchoplastic lung resections are feasible with a low perioperative morbidity and mortality in an experienced center. Surgeons should share their experience to clarify technical considerations like optimal sewing technique.

Acetabular component orientation in total hip arthroplasty: the impact of obesity.

Acetabular component position can be an important determinant of joint stability and bearing surface wear after THA. Nonetheless, the incidence of malpositioning is high. Patient obesity, low surgeon volume, and minimally invasive approaches are known risk factors for malposition. As the incidence of obesity continues to increase, it is important to recognise its effect on intraoperative component positioning in THA. Our goal was to assess the impact of obesity on component position for a high-volume surgeon using a standard postero-lateral approach. A consecutive series of 120 obese (BMI >30, mean BMI 34.4) and 120 non-obese patients (mean BMI 25.4), who had undergone primary THA by a single surgeon, were included in our retrospective study. AP pelvis and cross-table radiographs obtained at the first postoperative visit were analysed using EBRA software to determine inclination and anteversion angles. Optimal position was defined as 30-45º of inclination and 5-25º of anteversion. Mean inclination and anteversion were 40.6 (+/-5.4º) and 16.6 (+/-5.5º) respectively, in the obese group and 39º (+/-5.0º) and 16.2º (+/-7.5º) in the non-obese group. In the obese group 89 (74%) patients were within the desired range for both measurements, 31 (26%) were out of range in at least one, compared to 91 (76%) and 29 (24%) in the non-obese group, respectively. The overall incidence of malpositioning was 25% for both groups. Among outliers, mean deviation from the optimal range was ≤3.8º in both groups. The risk of component malpositioning in THA may be reduced when surgery is performed by an experienced, high volume surgeon utilising a standard posterolateral approach. In this setting the deleterious effect of obesity may be overcome.