Comparison between anterior-to-posterior screw fixation versus posterolateral approach plate fixation for posterior malleous fracture: A systematic review and meta-analysis.

PURPOSE: There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach utilizing a buttress plate. This review aims to compare the clinical outcome between the AP screw fixation and the PL plate fixation for treating PMFs. METHODS: We searched all relevant publications about PMFs treated with AP screws or PL plates through electronic databases including the PubMed, the Cochrane Library, the Embase, the Wiley online library and the Web of Science. The meta-analysis was conducted to evaluated clinical outcomes including reduction quality, post-operative function and complications. RESULTS: Six studies (one single randomized controlled trial and five retrospective cohort studies) were enrolled. 172 patients underwent AP screw fixation and 214 patients underwent PL plate fixation with a total of 386 patients (169 males and 217 females). The PL plating group yielded better AOFAS scores(MD = 6.97, 95 % CI=[4.68, 9.27], P＜0.00001, I2 =0 %) and was more likely to achieve excellent anatomical reduction(OR=5.49, 95 % CI=[1.06, 28.42], P = 0.04, I2 =80 %). No differences were found in the bad reduction quality, incidences of complications (arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. CONCLUSION: We suggest that the PL plate fixation method has the clinical benefit of achieving anatomical reduction and better AOFAS scores over the AP screw fixation for treating PMFs. No differences were found in the incidences of complications ( arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. The posterior approach and the direct reduction are recommended for the treatment of the PMFs. LEVEL OF CONFIDENCE: Ⅱb.

Excision of a Distal Tibial Interosseous Osteochondroma Through Posterolateral Approach: A Case Report.

Osteochondromas arising from the interosseous border of the distal tibia are rare, but cases have been reported previously in the literature. In long-standing cases, they can cause a "mass effect" resulting in the deformation of the bones around the ankle joint, mechanical restriction of joint movement, and even degenerative joint disease. Hence, they need to be resected if patients present with such impending complications. Several surgical techniques have been described previously for tumor resection including the anterior approach and the trans-fibular approach, the latter of which required a fibular osteotomy with or without fibular reconstruction. The surgical technique described here utilizes the posterolateral approach to the ankle joint for tumor excision, thus avoiding the need for any osteotomy or fibular reconstruction and reducing the risk of injury to major neurovascular structures. It also reduces the need for long-term immobilization and promotes a faster return to activity.

Accuracy of two-dimensional digital planning in uncemented primary hip arthroplasty: monocentric analysis of eight hundred implants.

PURPOSE: In the last decades, there has been a refinement in total hip arthroplasty, which allowed surgeons to achieve the highest performance and better patient outcomes. Preoperative planning in primary hip arthroplasty is an essential step that guides the surgeon in restoring the anatomy and biomechanics of the joint. This study aims to evaluate the accuracy of the 2D digital planning, considering cup sizing, stem sizing, and limb length discrepancy. Additionally, we conducted a multivariable analysis of demographic data and comorbidities to find factors influencing preoperative planning. METHODS: This retrospective study analyzed the planning accuracy in 800 consecutive uncemented primary total hip arthroplasty. We compared the preoperatively planned total hip arthroplasty with postoperative results regarding the planned component size, the implanted size, and the lower limb length restoration. Therefore, we investigated factors influencing planning accuracy: overweight and obesity, sex, age, past medical history, comorbidities, and implant design. All the surgeries were performed in the posterolateral approach by one expert surgeon who did the preoperative planning. The preoperative planning was determined to be (a) exact if the planned and the implanted components were the same size and (b) accurate if exact ± one size. The restoration of postoperative limb length discrepancy was classified into three groups: ± 3 mm, ± 5 mm, and ± 10 mm. This assessment was performed through a digital method 2D based on a standard hip X-ray. RESULTS: This court of 800 implants showed that planning was exact in 60% of the cups and 44% of the stems and was accurate in 94% of the cups and 80% of the stems. The postoperative limb length discrepancy was ± 3 mm in 91% and ± 5 mm in 97%. CONCLUSIONS: This study showed preoperative 2D digital planning great precision and reliability, and we demonstrated that it was accurate in 94% of the cups and 80% of the stems. Therefore, the preoperative limb length discrepancy analysis was essential to guarantee the recovery of the operated limb's correct length.

The Effect of Prone and Supine Limb Positioning on the Radiographic Evaluation of Posterolateral Plate Fixation of the Posterior Malleolus.

Aim: To facilitate the posterolateral approach to the posterior malleolus patients are often positioned prone initially, then turned supine to complete fixation at the medial malleolus. We sought to define observed differences in the radiographic appearance of implants relative to the joint line, in prone and supine positions. Methods: A 3.5 mm tubular plate and a 3.5 mm posterior distal tibial periarticular plate were applied sequentially to 3 individual cadaveric legs, via a posterolateral approach. The tubular plate was positioned to simulate buttress fixation and the posterolateral plate placed more distally. Each limb was secured on a custom jig and radiographs were taken on a mobile c-arm fluoroscopy machine with a calibration ball. A series of prone AP, supine PA and mortise radiographs were taken. Prone radiographs were also taken in different degrees of caudal tilt to simulate knee flexion which occurs in practice, during intraoperative positioning. Plate tip-joint line distances were measured and Mann-Whitney U tests performed. Results: There was no statistically significant difference in plate tip-joint line distance when comparing equivalent prone and supine views (PA/AP or mortise). However, significant differences in apparent implant position were noted with alterations in caudal tilt. When taking a prone image, when the knee is flexed to 20 degrees, the plate tip will appear 6.5-8.5 mm more proximal than in the equivalent supine image where the knee is extended and the fluoroscopy beam is orthogonal to the anatomic axis of the tibia. Conclusion: Observed differences in radiographic appearance of metalwork in the prone and supine position are most likely due to knee flexion and the resulting variation in the angle of the fluoroscopy beam, rather than projectional differences between supine and prone views. Surgeons should be alert to this when analysing intraoperative images.

Bipolar hip arthroplasty using conjoined tendon preserving posterior lateral approach in treatment of displaced femoral neck fractures.

BACKGROUND: Hip fractures account for 23.8% of all fractures in patients over the age of 75 years. More than half of these patients are older than 80 years. Bipolar hemiarthroplasty (BHA) was established as an effective management option for these patients. Various approaches can be used for the BHA procedure. However, there is a high risk of postoperative dislocation. The conjoined tendon-preserving posterior (CPP) lateral approach was introduced to reduce postoperative dislocation rates. AIM: To evaluate the effectiveness and safety of the CPP lateral approach for BHA in elderly patients. METHODS: We retrospectively analyzed medical data from 80 patients with displaced femoral neck fractures who underwent BHA. The patients were followed up for at least 1 year. Among the 80 patients, 57 (71.3%) were female. The time to operation averaged 2.3 d (range: 1-5 d). The mean age was 80.5 years (range: 67-90 years), and the mean body mass index was 24.9 kg/m2 (range: 17-36 kg/m2). According to the Garden classification, 42.5% of patients were type Ⅲ and 57.5% of patients were type Ⅳ. Uncemented bipolar hip prostheses were used for all patients. Torn conjoined tendons, dislocations, and adverse complications during and after surgery were recorded. RESULTS: The mean postoperative follow-up time was 15.3 months (range: 12-18 months). The average surgery time was 52 min (range: 40-70 min) with an average blood loss of 120 mL (range: 80-320 mL). The transfusion rate was 10% (8 of 80 patients). The gemellus inferior was torn in 4 patients (5%), while it was difficult to identify in 2 patients (2.5%) during surgery. The posterior capsule was punctured by the fractured femoral neck in 3 patients, but the conjoined tendon and the piriformis tendon remained intact. No patients had stem varus greater than 3 degrees or femoral fracture. There were no patients with stem subsidence more than 5 mm at the last follow-up. No postoperative dislocations were observed throughout the follow-up period. No significance was found between preoperative and postoperative mean Health Service System scores (87.30 ± 2.98 vs 86.10 ± 6.10, t = 1.89, P = 0.063). CONCLUSION: The CPP lateral approach can effectively reduce the incidence of postoperative dislocation without increasing perioperative complications. For surgeons familiar with the posterior lateral approach, there is no need for additional surgical instruments, and it does not increase surgical difficulty.

Does Approach Matter in Robotic-Assisted Total Hip Arthroplasty? A Comparison of Early Reoperations Between Direct Anterior and Postero-Lateral Approach.

BACKGROUND: There is no consensus on whether direct anterior approach (DAA) or postero-lateral approach (PLA) total hip arthroplasty (THA) confers a lower risk of postoperative complications. Robotic assistance in THA results in a more consistently accurate component position compared to manual THA. The objective of this study was to compare rates of dislocation, reoperation, revision, and patient-reported outcome measures between patients undergoing DAA and PLA robotic-assisted primary THA. METHODS: We identified 2,040 consecutive robotic-assisted primary THAs performed for primary osteoarthritis, using DAA (n = 497) or PLA (n = 1,542) between 2017 and 2020. The mean follow-up was 18 months. Kaplan-Meier analysis estimated survivorship free of dislocation, reoperation, and revision. Achievement of patient acceptable symptom state and minimum clinically important difference were used to compare changes in the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) and Visual Analog Scale. RESULTS: Dislocation was rare in this series (14 in 2,040, 0.7%), including 1 of 497 (0.2%) in the DAA cohort and 13 of 1,542 (0.8%) in the PLA cohort (P = .210). There was no difference in 2-year reoperation-free survivorship (97.8 versus 98.6%, P = .59) or revision-free survivorship (98.8 versus 99.0%, P = .87) at any time point. After controlling for age, sex, and body mass index, there was no difference in dislocation, reoperation, or revision. At 6-week follow-up, after controlling for age, sex, and body mass index, patients in the DAA cohort had higher odds of achieving HOOS JR minimum clinically important difference (odds ratio = 2.01, P = .012) and HOOS JR patient acceptable symptom state (odds ratio = 1.72, P = .028). There were no differences in patient-reported outcome measures by 3 months. CONCLUSIONS: For robotic-assisted primary THA, DAA may confer enhanced early (<6 weeks) functional recovery compared to the PLA, but there was no significant difference in postoperative dislocation, reoperation, or revision rates.

Evolution and current status of surgical management of thoracic disc herniation - A review.

Thoracic disc herniations (TDH) are uncommon compared to cervical and lumbar disc herniations. Surgical treatment of TDH can be challenging due to the anatomical constraints and the high risk of morbidity due to proximity to the thoracic spinal cord. Moreover, the selection of appropriate surgical approach depends on various factors such as the size and location of disc herniation within the spinal canal, spinal level, presence or absence of calcification, degree of spinal cord compression, and familiarity with various approaches by the treating surgeon. While there is agreement that posterolateral approaches can be used to treat posterolateral and central soft disc herniation, there is a lack of consensus on the best surgical approach for central calcified and giant calcified TDH where an anterior approach is perceived as the best option. There is increasing evidence that support the safety and efficacy of posterolateral approaches even for central calcified and giant calcified TDH. This review highlights the evolution of surgical management for TDH based on the past and current literature and the author's experience at his institution.

Percutaneous Endoscopic Posterior Lateral Approach for the Treatment of Central Cervical Disc Herniation.

BACKGROUND: To design percutaneous endoscopic surgery via a posterolateral approach for the treatment of central cervical disc herniation. METHODS: From October 2019 to October 2020, 12 consecutive patients with central cervical disc herniation underwent percutaneous endoscopic posterior lateral cervical surgery. The imaging examination (dynamic X-ray, computed tomography, and magnetic resonance imaging of the cervical spine) was conducted after the operation. Visual analog scale score and the modified Japanese Orthopaedic Association score was performed before and after the operation. RESULTS: Twelve patients (6 men and 6 women; mean age 52.08 ± 9.3 years) were included, and the average operation time was 105.00 ± 10.55 minutes. Postoperative computed tomography and magnetic resonance imaging results showed that the treatment segment of all patients was prominent, the cervical intervertebral disc was completely removed, the cervical spinal cord was fully decompressed, and there were no cases of infection, cerebrospinal fluid leakage or neurological complications. The average follow-up time after the operation was 22.83 ± 3.13 months. One year after the operation, there was no cervical instability in the X-ray examination of cervical flexion and extension position. Preoperative visual analog scale score and the modified Japanese Orthopaedic Association score were significantly improved at the last follow-up. CONCLUSION: Percutaneous endoscopic posterior lateral cervical discectomy provides a new surgical method for the endoscopic treatment of central cervical disc herniation. This treatment has a better surgical field and easier operation, which can remove the protruding cervical disc under the endoscope and make sure that the cervical spinal cord is fully decompressed. The clinical effect is satisfactory. A small amount of pedicle resection will not cause cervical instability.

Femoral Nerve Palsy Post Total Hip Arthroplasty (THA) via a Posterolateral Approach.

Femoral nerve palsy (FNP) is a debilitating and relatively rare complication of total hip replacement, which can worsen the functional prognosis. Various surgical approaches, including posterior, lateral, and anterior, are employed in total hip arthroplasty (THA), and the chosen approach can influence which nerve is affected. There is currently a lack of recent research on the prevalence of FNP and its typical course of recovery. In this clinical case, we report a rare incidence of FNP that presented as a complication of primary THA in a patient with end-stage osteoarthritis secondary to developmental dysplasia of the hip (DDH). A 35-year-old female presented with groin pain and restricted movement in her hip joint. She had a history of undergoing complex open-reduction surgery for hip dysplasia. During the physical examination, a positive Trendelenburg gait was identified, along with end-stage osteoarthritis (OA) secondary to the dysplasia. She subsequently underwent THA using a posterolateral approach. Following the procedure, she experienced neurological symptoms, leading to the diagnosis of FNP, a rare occurrence.

[Comparison of early clinical effects between direct superior approach and posterolateral approach in hemiarthroplasty of femoral neck fracture in the elderly].

OBJECTIVE: To compare and analyze the early clinical effect of direct superior approach(DSA) and posterior lateral approach (PLA) in hemiarthroplasty for elderly patients with femoral neck fracture. METHODS: The clinical data of 72 elderly patients with femoral neck fracture who underwent hemiarthroplasty from January 2020 to December 2021 were retrospectively analyzed. Among them, 36 patients were operated through minimally invasive DSA including 10 males and 26 females with an average age of (82.82±4.05) years old; the other 36 patients underwent traditional PLA including 14 males and 22 females with an average age of (82.79±3.21) years old. The perioperative related indexes and Harris scores during follow-up between two groups were compared. RESULTS: Comparison of operation time between two groups, (79.41±17.39) min of DSA group was shorter than(98.45±26.58) min of PLA group;incision length (8.33±2.69) cm was shorter than (11.18±1.33) cm of PLA group;intraoperative blood loss (138.46±71.58) ml was less than (173.51±87.17) ml of PLA group, initial landing time (3.04±0.95) d was earlier than (4.52±1.10) d of PLA group, hospitalization time (8.70±1.89) d was shorter than (10.67±2.35) d of PLA group(P<0.05). There was no statistical difference in Harris score between two groups before operation(P>0.05), but Harris score in DSA group was higher than that of PLA group at 1 month after operation(P<0.05), but at 12 months after operation, the difference was not statistically significant between two groups(P>0.05). CONCLUSION: Compared with PLA, DSA is superior in clinical indexes such as operation time, intraoperative blood loss, incision length, first landing time, length of hospitalization and Harris score in the first month after operation in hemi hip replacement, and has comparative advantages in promoting early postoperative rehabilitation of elderly patients with femoral neck.

[Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture].

Objective: To compare the effectiveness between the posterolateral approach and the posterolateral combined posteromedial approaches in the treatment of Mason type 2B posterior malleolar fracture. Methods: A retrospective analysis was performed on the clinical data of 79 patients with posterior ankle fracture who met the selection criteria between January 2015 and January 2022. There were 62 cases of Mason 2B Pilon subtype and 17 cases of avulsion subtype. Among Mason 2B Pilon subtype patients, 35 were treated with posterolateral approach (group A), 27 patients were treated with combined approach (group B). There was no significant difference in gender, age, injured side, cause of injury, time from injury to operation, preoperative hospital stay, preoperative visualanalogue scale (VAS) score, and intraoperative internal fixation between the two groups ( P>0.05). All patients with Mason 2B avulsion subtype were treated by posterolateral approach, including 7 males and 10 females, aged from 25 to 68 years, with an average of 46.1 years. The operation time, intraoperative blood loss, postoperative hospital stay, and complications were recorded. The reduction quality was evaluated by Ovadia deals radiographic score, and the ankle function and pain were evaluated by VAS score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and ankle range of motion. Results: Mason 2B Pilon subtype: There was no significant difference in operation time, intraoperative blood loss, postoperative hospital stay, and follow-up time between the two groups ( P>0.05). The radiological evaluation of Ovadia deals in group A was significantly worse than that in group B ( P<0.05). The VAS score in the two groups significantly improved at each time point after operation, and the VAS score and AOFAS score further improved with the extension of time after operation, and the differences were significant ( P<0.05). Except that the AOFAS score of group A was significantly lower than that of group B at last follow-up ( P<0.05), there was no significant difference in VAS score and AOFAS score between the two groups at other time points ( P>0.05). At last follow-up, the ankle range of motion in group A was significantly less than that in group B ( P<0.05). There was no significant difference in the incidence of sural nerve injury, deep tissue infection, limitation of toe movement, and traumatic ankle arthritis between the two groups ( P>0.05). Mason 2B avulsion subtype: The operation time was (119.47±20.61) minutes and the intraoperative blood loss was 50 (35, 55) mL. Seventeen patients were followed up 13-25 months, with an average of 18 months. The Ovadia deals score was excellent in 10 cases, good in 6 cases, and poor in 1 case at 1 week after operation, and the excellent and good rate was 94.1%. All fractures healed in 8-18 weeks with an average of 12.35 weeks. There were 1 case of sural nerve injury and 3 cases of traumatic ankle arthritis after operation. No deep tissue infection or limitation of toe movement occurred. The VAS score decreased significantly and AOFAS score increased significantly with time, and the differences were significant between different time points before and after operation ( P<0.05). The ankle range of motion at last follow-up was (56.71±2.47)°. Conclusion: Compared with the posterolateral approach, the combined approach is a better choice for the treatment of Mason 2B Pilon subtype. If the posteromedial bone block does not affect the reduction of the medial malleolus, the posterolateral approach can achieve good effectiveness for Mason 2B avulsion subtype.

Outcomes of direct anterior approach for uncemented total hip replacement in medial femoral neck fractures: a retrospective comparative study on the first 100 consecutive patients.

BACKGROUND: With the aging of the population, the incidence of medial femoral neck fractures is likely to increase, and along them the need for total hip replacement. The present study aimed to analyze whether the use of the direct anterior hip approach, compared with posterolateral approach in medial proximal femur fracture patients, results in any advantage in terms of complications rate and functional recovery. METHODS: A total of 162 patients were included in the study, and divided by approach: 100 performed with direct anterior approach (group A) and 62 with posterolateral approach (group B). The two populations were overlapping in age (75 vs 74 years; p = 0.13), sex (58F 42M vs 46F 16M; p = 0.12) and BMI (24 vs 24; p = 0.77). RESULTS: Group A showed a higher ASA score compared to group B (3 vs 2; p = 0.04). Similar hospital stays (7 vs 7 days; p = 0.55) and complication rates (6% vs 8%; p = 0.61) were observed among groups, the most frequent being periprosthetic fractures, and need for allogeneic blood transfusion (20% vs 13%; p = 0.25). Patients in group A (96 vs 85 min; p = 0.10) showed a slightly, longer surgical time and a faster postoperative functional recovery witnessed by the ability to climb stairs at hospital discharge (37% vs 21%; p = 0.041). CONCLUSION: The use of the direct anterior hip approach was effective in the management of frail patients with medial femoral neck fractures managed by total hip arthroplasty, allowing faster functional recovery in the elderly population.

[Effectiveness analysis of posterolateral approach lumbar interbody fusion assisted by one-hole split endoscope for L4, 5 degenerative lumbar spondylolisthesis].

Objective: To compare the effectiveness of posterolateral approach lumbar interbody fusion assisted by one-hole split endoscope (OSE) and traditional posterior lumbar interbody fusion (PLIF) in the treatment of L4, 5 degenerative lumbar spondylolisthesis (DLS). Methods: The clinical data of 58 patients with DLS who met the selection criteria admitted between February 2020 and March 2022 were retrospectively analyzed, of which 26 were treated with OSE-assisted posterolateral approach lumbar interbody fusion (OSE group) and 32 were treated with PLIF (PLIF group). There was no significant difference between the two groups in terms of gender, age, body mass index, Meyerding grade, lower limb symptom side, decompression side, stenosis type, and preoperative low back pain visual analogue scale (VAS) score, leg pain VAS score, Oswestry disability index (ODI), and the height of the anterior and posterior margins of the intervertebral space (P>0.05). The operation time, intraoperative blood loss, postoperative hospital stay, and complications were compared between the two groups. The low back pain and leg pain VAS scores and ODI before operation, at 1 month, 6 months after operation, and last follow-up, the height of anterior and posterior margins of the intervertebral space before operation, at 6 months after operation, and last follow-up, the modified MacNab criteria at last follow-up after operation were used to evaluate the effectiveness; and the Bridwell method at last follow-up was used to evaluate the interbody fusion. Results: Both groups successfully completed the operation. Compared with the PLIF group, the OSE group showed a decrease in intraoperative blood loss and postoperative hospital stay, but an increase in operation time, with significant differences (P<0.05). In the OSE group, no complication such as nerve root injury and thecal sac tear occurred; in the PLIF group, there were 1 case of thecal sac tear and 1 case of epidural hematoma, which were cured after conservative management. Both groups of patients were followed up 13-20 months with an average of 15.5 months. There was no complication such as loosening, sinking, or displacement of the fusion cage. The low back pain and leg pain VAS scores, ODI, and the height of anterior and posterior margins of the intervertebral space at each time point after operation in both groups were significantly improved when compared with those before operation (P<0.05). Except for the VAS score of lower back pain in the OSE group being significantly better than that in the PLIF group at 1 month after operation (P<0.05), there was no significant difference in all indicators between the two groups at all other time points (P>0.05). At last follow-up, both groups achieved bone fusion, and there was no significant difference in Bridwell interbody fusion and modified MacNab standard evaluation between the two groups (P>0.05). Conclusion: OSE-assisted posterolateral approach lumbar interbody fusion for L4, 5 DLS, although the operation time is relatively long, but the postoperative hospitalization stay is short, the complications are few, the operation is safe and effective, and the early effectiveness is satisfactory.

The arterial risk posed by the posterolateral approach: An anatomical cadaveric study of the fibular artery and its variability.

The posterior malleolus of the tibia is commonly accessed surgically through the posterolateral approach. This approach gives good access to the fibula and lateral aspect of the posterior tibia, however; there is little known on the vascular risks with this approach. The aim of this study was to assess and describe the anatomy of the fibular artery and its branches at the ankle region and relate it to the surgical access of the posterior malleolus. Eleven cadaveric foot and ankle specimens were dissected in layers, preserving the fibular artery, anterior tibial artery (ATA), and posterior tibial artery (PTA). Five distinct variations were found in the fibular artery: variable terminal branching with a hyperplastic fibular artery; a superficially located fibular artery; variation in the level and number of anastomoses; variation in the muscular branches; and a variable anterior perforating branch. The mean proximal distance from a horizontal line drawn through the medial protuberance of the medial malleolus of the tibia (horizontal line reference point-HLRP) to the posterior communicating branch of the fibular artery was 37.93 mm (range 19.03-85.43 mm). The mean proximal distance between HLRP and the anterior perforating branch of the fibular artery was 44.23 mm (range 35.44-62.32 mm). In 10 specimens, the fibular artery was immobile distal to its anterior perforating branch. The posterolateral approach specifically puts the fibular artery at risk and knowledge of its anatomy and variability is important when undertaking this approach. Understanding the common variations within the ankle's arterial anatomy can help surgeons protect these vessels from damage during the surgical approach.

In primary total hip arthroplasty, the direct anterior approach leads to higher levels of creatine kinase and lower levels of C-reactive protein compared to the posterolateral approach: a propensity score matching analysis of short-term follow-up data.

BACKGROUND: This retrospective study compares the invasiveness of the direct anterior approach (DAA) and the posterolateral approach (PLA) in total hip arthroplasty (THA) by assessing three widely used inflammation-related serum markers in the first ten post-operative days. METHODS: The database of our institution was mined for primary THAs conducted by the DAA or the PLA from February 2020 to June 2022. Demographics and creatine kinase (CK), C-reactive protein (CRP), and white blood cells were compared. Propensity Score Matching (PSM) analysis (1:1 ratio) was conducted based on multiple variables. RESULTS: PSM analysis yielded 44 pairs of DAA and PLA patients. CK was significantly higher (p < 0.001) in the DAA than in the PLA group on postoperative day (POD) 2, 5 and 10. The POD2, POD5 and POD10 CK/preoperative CK ratio was 12.9, 5.0 and 0.8 in DAA and 8.8, 3.3 and 0.6 in PLA (p = 0.017, p = 0.012 and p = 0.025, respectively). The POD2, POD5 and POD10 CRP/preoperative CRP ratio was 95.1, 65.6 and 22.8 in PLA and 34.7, 23.3 and 8.9 in DAA (p < 0.001, p = 0.002 and p < 0.001, respectively). CONCLUSION: PSM analysis of early postoperative CK and CRP values demonstrated that the DAA should be considered as a less stressful approach, not as a muscle-sparing or a minimally invasive THA approach.

Transperitoneal laparoscopic retrievement of a migrated prosthetic head after total hip arthroplasty: a case report.

The migration of a prosthetic head during total hip arthroplasty (THA) is a rare complication. Few cases are described in the literature, offering different solutions and surgical approaches for prosthetic head retrievement. Here, we present a case of successful laparoscopic transperitoneal retrieval of a prosthetic head migrated above the right iliac vein after THA with a posterolateral approach.

Which patient benefit most from minimally invasive direct anterior approach total hip arthroplasty in terms of perioperative blood loss? A retrospective comparative study from a cohort of patients with primary degenerative hips.

INTRODUCTION: Total hip arthroplasty (THA) is a successful surgery, but despite the advancements in anesthesiology and orthopedics, sometimes blood transfusions are required to manage the anemia due to the blood loss, involving a substantial number of patients. The aim of this retrospective comparative study is to define how the choice of the surgical approach, either direct anterior (DA) or posterolateral (PL), may influence the postoperative blood loss and the need for transfusion in THA. MATERIALS AND METHODS: Data collection was carried out retrospectively of THAs performed between 2016 and 2021 on primary hip osteoarthritis treated by DA or with PL approach. Clinical and perioperative anesthetic data were collected. Preoperative hemoglobin levels were compared with the lowest detected level by calculating ΔHb (hemoglobin decrease). Then, data from the two groups were cross-checked: duration of surgery, whether premedication with tranexamic acid, duration of the hospitalization, rate of need for hemotransfusions, and amount of blood transfused. The two samples were subdivided into subgroups according to age, BMI, tranexamic acid prophylaxis, and chronic treatment with drugs that alter coagulative properties. RESULTS: Time of surgery was longer for patients treated with DA access (mean DA: 78.8 min; mean PL: 74.8 min; p: 0.05; 95% CI), but the length of hospitalization was shorter for patients treated with DA group with a mean time of 6.23 days versus 7.12 days for the PL group (p < 0.01). DA THA resulted advantageous mainly in patients between 66 and 75 years, showing a reduced postoperative transfusion requirement in the postoperative period (DA: 13.43%-mean: 1.33 units; PL: 26.82%-mean: 1.18 units; p: 0.044, 95% CI). Patients that assume blood-altering drugs showed a higher transfusion rate (p < 0.01), but comparison of the two subgroups showed that the choice of the surgical approach did not significantly affect the transfusion rate in these patients (p: 0.512). Prophylaxis with tranexamic acid reduced the transfusion rate (p < 0.01). CONCLUSION: Patients treated by minimally invasive direct anterior approach undergo a significantly shorter hospitalization. From the analysis of patient's subgroups those aged between 66- and 75-years benefit from the DA approach mainly for the minor blood loss with less frequent transfusion requirement.

Clinical effects of 3D printing-assisted posterolateral incision in the treatment of ankle fractures involving the posterior malleolus.

Objective: To explore the clinical outcomes of a 3D printing-assisted posterolateral approach for the treatment of ankle fractures involving the posterior malleolus. Methods: A total of 51 patients with ankle fractures involving the posterior malleolus admitted to our hospital from January 2018 to December 2019 were selected. The patients were divided into 3D printing group (28 cases) and control group (23 cases). 3D printing was performed for ankle fractures, followed by printing of a solid model and simulation of the operation on the 3D model. The operation was then performed according to the preoperative plan, including open reduction and internal fixation via the posterolateral approach with the patient in the prone position. Routine x-ray and CT examinations of the ankle joint were performed, and ankle function was evaluated using the American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score. Results: All patients underwent x-ray and CT examinations. All fractures healed clinically, without loss of reduction or failure of internal fixation. Good clinical effects were achieved in both groups of patients. The operation time, intraoperative blood loss and intraoperative fluoroscopy frequency in the 3D printing group were significantly less than those in the control group (p < 0.05). There was no significant difference between the two groups in the anatomical reduction rate of fractures or the incidence of surgical complications (p > 0.05). Conclusion: The 3D printing-assisted posterolateral approach is effective in the treatment of ankle fractures involving the posterior malleolus. The approach can be well planned before the operation, is simple to perform, yields good fracture reduction and fixation, and has good prospects for clinical application.

Early Practice All-Cause Complications for Fellowship-Trained Anterior Hip Surgeons Are Not Increased When Compared to "Gold Standard" Experienced Posterior Approach Surgeons.

BACKGROUND: Increased complication rates have been reported during the learning curve for direct anterior approach (DAA) total hip arthroplasty (THA). However, emerging literature suggests that complications associated with the learning curve may be substantially reduced with fellowship training. METHODS: Our institutional database was queried to identify 2 groups: (1) 600 THAs comprised of the first 300 consecutive cases performed by 2 DAA fellowship-trained surgeons; and (2) 600 posterolateral approach (PA) THAs, including the most recent 300 primary cases performed by 2 experienced PA surgeons. All-cause complications, revision rates, reoperations, operative times, and transfusion rates were evaluated. RESULTS: Comparing DAA and PA cases, there were no significant differences in rates of all-cause complications (DAA = 18, 3.0% versus PA = 23, 3.8%; P = .43), periprosthetic fractures (DAA = 5, 0.8% versus PA = 10, 1.7%; P = .19), wound complications (DAA = 7, 1.2% versus PA = 2, 0.3%; P = .09), dislocations (DAA = 2, 0.3% versus PA = 8, 1.3%, P = .06), or revisions (DAA = 2, 0.3% versus PL = 5, 0.8%; P = .45) at 120 days postoperatively. There were 4 patients who required reoperation for wound complications, all within the DAA group (DAA = 4, 0.67% versus PA = 0; P = .045). Operative times were shorter in the DAA group (DAA <1.5 hours = 93% versus PA <1.5 hours = 86%; P < .01). No blood transfusions were given in either group. CONCLUSION: In this retrospective study, DAA THAs performed by fellowship-trained surgeons early in practice were not associated with higher complication rates compared to THAs performed by experienced PA surgeons. These results suggest that fellowship training may allow DAA surgeons to complete their learning curve period with complication rates similar to experienced PA surgeons.

Comparison of Perioperative Outcomes and Early Complications Between a Direct Anterior Approach or Posterolateral Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Study.

Background: Controversies remain on the best surgical approaches for unilateral total hip arthroplasty (THA). There are little data on simultaneous bilateral THA via direct anterior approach (SimBDAA-THA) or posterolateral approach (SimBPA-THA). Purpose: We sought to assess differences in perioperative outcomes and early medical and surgical complications between SimBDAA-THA and SimBPA-THA. Methods: This retrospective study involved patients who underwent either SimBDAA-THA in a supine position (n = 73) or SimBPA-THA in a lateral position (n = 162) at our institution from January 2015 to November 2021. The 2 groups were compared in terms of clinical and demographic characteristics, surgical parameters, and complications during 6-months of follow-up. Results: There were no differences in clinical and demographic characteristics between the 2 groups prior to surgery. Simultaneous bilateral THA via direct anterior approach significantly shortened the length of both the operation (117.50 ±19.42 vs 143.97 ± 32.20 min) and the hospitalization (140.64 ± 43.22 vs 156.24 ± 56.64 h) but increased perioperative loss of hemoglobin (3.28 ± 1.01 vs 3.21 ± 2.26 g/dL). There were no significant differences between the two groups in transfusion rate; levels of interleukin-6, C-reactive protein or creatine kinase; or complications. Conclusion: This retrospective study of patients at a single institution found minimal differences in perioperative outcomes or early medical and surgical complications between SimBDAA-THA and SimBPA-THA except operative time and length of hospitalization. Larger studies with longer follow-up should be conducted to identify whether a direct anterior approach is superior to a posterolateral one.